Health care access, concentrated poverty, and pediatric asthma hospital care use in California's San Joaquin Valley: A multilevel approach

Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies

STUDY OBJECTIVE

Social determinants of health contribute to disparities in pediatric health and health care. Our objective was to synthesize and evaluate the evidence on the association between social determinants of health and emergency department (ED) outcomes in pediatric populations.

METHODS

This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity Extension guidelines. Observational epidemiological studies were included if they examined at least 1 social determinant of health from the PROGRESS-Plus framework in relation to ED outcomes among children <18 years old. Effect direction plots were used for narrative results and pooled odds ratios (pOR) with 95% confidence intervals (CI) for meta-analyses.

RESULTS

Fifty-eight studies were included, involving 17,275,090 children and 103,296,839 ED visits. Race/ethnicity and socioeconomic status were the most reported social determinants of health (71% each). Black children had 3 times the odds of utilizing the ED (pOR 3.16, 95% CI 2.46 to 4.08), whereas visits by Indigenous children increased the odds of departure prior to completion of care (pOR 1.58, 95% CI 1.39 to 1.80) compared to White children. Public insurance, low income, neighborhood deprivation, and proximity to an ED were also predictors of ED utilization. Children whose caregivers had a preferred language other than English had longer length of stay and increased hospital admission.

CONCLUSION

Social determinants of health, particularly race, socioeconomic deprivation, proximity to an ED, and language, play important roles in ED care-seeking patterns of children and families. Increased utilization of ED services by children from racial minority and lower socioeconomic status groups may reflect barriers to health insurance and access to health care, including primary and subspecialty care, and/or poorer overall health, necessitating ED care. An intersectional approach is needed to better understand the trajectories of disparities in pediatric ED outcomes and to develop, implement, and evaluate future policies.

Differences in Health Care Utilization for Asthma by Children with Medicaid versus Private Insurance

Asthma is the most common chronic disease in children, disproportionately affects families with lower incomes, and is a leading reason for acute care visits and hospitalizations. This retrospective cohort study used the Massachusetts All Payer Claims Database (2014-2018) to examine differences in acute care utilization and quality of care for asthma between Medicaid- and privately insured children in Massachusetts. Outcomes included acute care use (emergency department [ED] or hospitalization), ED visits with asthma, routine asthma visits, and filled prescriptions for asthma medications. Multivariable logistic regression was used to account for differences in demographics, ZIP codes, health status, and asthma severity. Overall, 10.0% of Medicaid-insured children and 5.6% of privately insured were classified as having asthma. Among 317,596 child-year observations for children with asthma, 64.4% were insured by Medicaid. Medicaid-insured children had higher rates of any acute care use (50.4% vs. 30.0%) and ED visits with an asthma diagnosis (27.2% vs. 13.3%) compared to privately insured children. Only 65.4% of Medicaid enrollees had at least one routine asthma visit compared to 74.3% of privately insured children. Most children received at least one asthma medication (88.6% Medicaid vs. 83.3% privately insured), but a higher percentage of Medicaid-insured children received at least one rescue medication (84.0% vs. 73.7%), and a lower percentage of Medicaid-insured (46.1% vs. 49.2%) received a controller medication. These results suggest that opportunities for improvement in childhood asthma persist, particularly for children insured by Medicaid.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Telehealth as a Tool to Transform Pediatric Care: Views from Stakeholders

Background and Objectives: The 2020 COVID-19 pandemic generated rapid telehealth expansion. Most prior telehealth studies focus on a single program or health condition, leaving a knowledge gap regarding the most appropriate and effective means of allocating telehealth services and funding. This research seeks to evaluate a wide range of perspectives to inform pediatric telehealth policy and practice. Methods: In 2017, the Center for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation (Innovation Center) issued a Request for Information to inform the Integrated Care for Kids model. Researchers identified 55 of 186 responses that addressed telehealth and analyzed them based on grounded theory principles overlaid with a constructivist approach to contextualize Medicaid policies, respondent characteristics, and implications for specific populations. Results: Respondents noted several health equity issues that telehealth could help to remedy, including timely care access, specialist shortages, transportation and distance barriers, provider-to-provider communication, and patient and family engagement. Implementation barriers reported by commenters included reimbursement restrictions, licensure issues, and costs of initial infrastructure. Respondents raised savings, care integration, accountability, and increased access to care as potential benefits. Discussion and Conclusions: The pandemic demonstrated that the health system can implement telehealth rapidly, although telehealth cannot be used to provide every aspect of pediatric care such as vaccinations. Respondents highlighted the promise of telehealth, which is heightened if telehealth supports health care transformation rather than replicating how in-office care is currently provided. Telehealth also offers the potential to increase health equity for some populations of pediatric patients.

The Affordable Care Act and child asthma: Lowering health care barriers by raising our voices

BACKGROUND

This policy discussion addresses the provisions of the Affordable Care Act (ACA) that impact children with asthma.

PURPOSE

The purpose of this policy paper is to inform health care professionals and lawmakers about ACA provisions affecting pediatric asthma care and provide recommendations for policy changes that can improve equitable care for children with asthma.

METHODS

The issues addressed involve discrimination, Medicaid policy oversight, quality improvement stategy, data collection, school-based health care funding, accountable care organization reimbursement, and the extension of dependent coverage.

DISCUSSION

Health care policy development that focuses on human rights, and not market valuation, could reduce health inequity among children with asthma.

CONCLUSION

Policy recommendations are presented to improve asthma care for a population that is largely vulnerable due to age, socioeconomic status, and discrimination.

Population-level SDOH and Pediatric Asthma Health Care Utilization: A Systematic Review

CONTEXT

Spatial analysis is a population health methodology that can determine geographic distributions of asthma outcomes and examine their relationship to place-based social determinants of health (SDOH).

OBJECTIVES

To systematically review US-based studies analyzing associations between SDOH and asthma health care utilization by geographic entities.

DATA SOURCES

Pubmed, Medline, Web of Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Empirical, observational US-based studies were included if (1) outcomes included asthma-related emergency department visits or revisits, and hospitalizations or rehospitalizations; (2) exposures were ≥1 SDOH described by the Healthy People (HP) SDOH framework; (3) analysis occurred at the population-level using a geographic entity (eg, census-tract); (4) results were reported separately for children ≤18 years.

DATA EXTRACTION

Two reviewers collected data on study information, demographics, geographic entities, SDOH exposures, and asthma outcomes. We used the HP SDOH framework's 5 domains to organize and synthesize study findings.

RESULTS

The initial search identified 815 studies; 40 met inclusion criteria. Zip-code tabulation areas (n = 16) and census-tracts (n = 9) were frequently used geographic entities. Ten SDOH were evaluated across all HP domains. Most studies (n = 37) found significant associations between ≥1 SDOH and asthma health care utilization. Poverty and environmental conditions were the most often studied SDOH. Eight SDOH-poverty, higher education enrollment, health care access, primary care access, discrimination, environmental conditions, housing quality, and crime - had consistent significant associations with asthma health care utilization.

CONCLUSIONS

Population-level SDOH are associated with asthma health care utilization when evaluated by geographic entities. Future work using similar methodology may improve this research's quality and utility.

The Moderating Role of Housing Quality on Concentrated Poverty and Asthma-Related Emergency Department Visits Among Hispanics/Latinos

Background. Rates of asthma-related emergency department visits have been shown to vary significantly by place (i.e., neighborhood) and race/ethnicity. The moderating factors of asthmatic events among Hispanic/Latino-specific populations are known to a much lesser degree. Objective. To assess the extent to which housing moderates the effect of poverty on Hispanic/Latino-specific asthma-related emergency department (ED) visits at an ecological level. Methods. Using data from the Office of Statewide Health Planning and Development (OSHPD) and the 2016-2017 U.S. Census, a cross-sectional ecological analysis at the census tract-level was conducted. Crosswalk files from the U.S. Department of Housing and Urban Development were used to associate zip codes to census tracts. Negative binomial regression was used to estimate rate ratios. Results. The effect of poverty on asthma-related ED visits was significantly moderated by the median year of housing structures built. The effect of mid-level poverty (RR= 1.57, 95% CI 1.27, 1.95) and high-level poverty (RR= 1.47, 95% CI 1.22, 1.78) in comparison to low-level poverty, was significantly greater among census tracts with housing built prior to 1965 in comparison to census tract with housing built between 1965-2020. Conclusion. Communities with older housing structures tend to be associated with increased Hispanic/Latino ED visits apart from affluent communities.

Beliefs about marijuana use during pregnancy and breastfeeding held by residents of a Latino-majority, rural region of California

Marijuana use among pregnant and breastfeeding women is on the rise and carries risks for infant health and well-being. Decisions to use marijuana while pregnant and breastfeeding are motivated by beliefs that use poses minimal risk to infants and offers benefits to maternal users. Misperceptions and usage trend higher among disadvantaged populations. This study surveyed 401 community residents on beliefs about risks and benefits of marijuana use by pregnant and breastfeeding women. The study utilized techniques to enhance recruitment of Latino and disadvantaged residents of rural communities in California, a state where recreational marijuana use is legal. Analyses revealed substantial endorsement of beliefs about benefits and low risks of marijuana use while pregnant and breastfeeding, many of which run counter to current evidence. Misperceptions were particularly prevalent for cannabis users and male respondents. Trends in valid beliefs, while modest, were higher for Latinos and parents.

Ten year trends in hospital encounters for pediatric asthma: an Indiana experience

INTRODUCTION

Pediatric asthma is a common cause of emergency department visits, hospital admissions, and mortality. Population incidence studies have historically used large-scale survey data. We measured these epidemiologic trends using a health information exchange.

METHODS

In this retrospective cohort study, we used electronic health record data from a regional health information exchange to study clinical trends in pediatric patients presenting to the hospital for asthma in the State of Indiana. Data was obtained from 2010 to 2019 and included all patients ages 2-18 years. Study participants were identified using international classification of disease codes. The measured outcomes were number of hospital encounters per year, percentage of admissions per year, and mortality rates.

RESULTS

Data included 50,393 unique patients and 88,772 unique encounters, with 57% male patients. Over the ten-year period, hospital encounters ranged from 5000 to 8000 per year with no change in trajectory. Between 2010 and 2012, the percent of encounters admitted to the hospital was ∼30%. This decreased to ∼20-25% for 2015-2019. Patient mortality rates increased from 1 to 3 per 1000 patient encounters in 2010-2014 to between 5 and 7 per 1000 patient encounters from 2016 to 2019. White patients had a significantly higher admission percentage compared to other racial groups, but no difference in mortality rate.

CONCLUSIONS

Asthma continues to be a common condition requiring hospital care for pediatric patients. Regional health information exchanges can enable public health researchers to follow asthma trends in near real time, and have potential for informing patient-level public health interventions.

Health insurance, pediatric asthma, and emergency department usage

This study synthesized current research on the relationships between type of insurance and emergency department usage for children with asthma in the United States. Thematic analysis is in the context of the Affordable Care Act (ACA). A systematic mapping review yielded 20 articles published in the last 10 years on topics of insurance, emergency department usage, and pediatric asthma. Analysis indicates continued trends of increased emergency department use among asthmatic children since enactment of the ACA, running counter to the goal of fiscal efficiency for the healthcare system and reduction of health inequities. Barriers to care persist, particularly among communities of color, despite provisions to improve access to primary and preventive care. Inadequate access to primary care is associated with poor adherence among asthmatic children with public insurance. Those with health insurance through their parents' employer experience barriers due to cost-sharing expenses. This leads to increased asthma severity and low medication adherence, resulting in the need for emergency care. A disconnect between increased health insurance coverage and utilization of primary care in some populations implies unmet service needs that warrant further investigation. Findings inform policymakers and public health leaders of persistent health inequities resulting in preventable emergency department usage.

Risk Factors for Acute Urticaria in Central California

At least 15–20% of the population in the world suffers from urticaria. Allergy triggers contribute to the development of urticaria. Not much is known about the demographic and environmental risk factors that contribute to the occurrence of acute urticaria. Methods: We utilized emergency department data on acute urticaria-related visits managed by the California Office of Statewide Planning and Operations for 201 zip codes located in southern central California (San Joaquin Valley) collected during the years 2016 and 2017. Census data from the same zip codes were considered as a population at risk. Socioeconomic and environmental parameters using CalEnviroScreen (Office of Environmental Health Hazard Assessment, Sacramento, CA, USA) database for the zip codes were evaluated as risk factors. Results: The incidence rate of acute urticaria in San Joaquin Valley during 2016–2017 was 1.56/1000 persons (n = 14,417 cases). Multivariate Poisson analysis revealed that zip codes with high population density (RR = 2.81), high percentage of farm workers (RR = 1.49), and the composite of those with high and medium percentage of poverty and those with high and medium percentage of non-white residents (RR = 1.59) increased the likelihood of the occurrence of acute urticaria. Conclusion: High population density, farm work, poverty and minority status is associated with a high risk of having acute urticaria.

The joint effect of ambient air pollution and agricultural pesticide exposures on lung function among children with asthma

BACKGROUND

Ambient environmental pollutants have been shown to adversely affect respiratory health in susceptible populations. However, the role of simultaneous exposure to multiple diverse environmental pollutants is poorly understood.

OBJECTIVE

We applied a multidomain, multipollutant approach to assess the association between pediatric lung function measures and selected ambient air pollutants and pesticides.

METHODS

Using data from the US EPA and California Pesticide Use Registry, we reconstructed three months prior exposure to ambient air pollutants ((ozone (O₃), nitrogen dioxide (NO₂), particulate matter with a median aerodynamic diameter < 2.5 μm (PM_2.5) and <10 μm (PM₁₀)) and pesticides (organophosphates (OP), carbamates (C) and methyl bromide (MeBr)) for 153 children with mild intermittent or mild persistent asthma from the San Joaquin Valley of California, USA. We implemented Bayesian kernel machine regression (BKMR) to estimate the association between simultaneous exposures to air pollutants and pesticides and lung function measures (forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), and forced expiratory flow between 25% and 75% of vital capacity (FEF_25-75)).

RESULTS

In BKMR analysis, the overall effect of mixtures (pollutants and pesticides) was associated with reduced FEV₁ and FVC, particularly when all the environmental exposures were above their 60th percentile. For example, the effect of the overall mixture at the 70th percentile (compared to the median) was a -0.12SD (-50 mL, 95% CI: -180 mL, 90 mL) change in the FEV₁ and a -0.18SD (-90 mL, 95% CI: -240 mL, 60 mL) change in the FVC. However, 95% credible intervals around all of the joint effect estimates contained the null value.

CONCLUSION

At this agricultural-urban interface, we observed results from multipollutant analyses, suggestive of adverse effects on some pediatric lung function measures following a cumulative increase in ambient air pollutants and agricultural pesticides. Given the uncertainty in effect estimates, this approach should be explored in larger studies.

Cumulative Impact of Environmental Pollution and Population Vulnerability on Pediatric Asthma Hospitalizations: A Multilevel Analysis of CalEnviroScreen

The CalEnviroScreen created by the Office of Environmental Health Hazard Assessment, Sacramento, USA, is a place-based dataset developed to measure environmental and social indicators that are theorized to have cumulative health impacts on populations. The objective of this study was to examine the extent to which the composite scores of the CalEnviroScreen tool are associated with pediatric asthma hospitalization. This was a retrospective analysis of California hospital discharge data from 2010 to 2012. Children who were hospitalized for asthma-related conditions, were aged 0–14 years, and resided in California were included in analysis. Rates of hospitalization for asthma-related conditions among children residing in California were calculated. Poisson multilevel modeling was used to account for individual- and neighborhood-level risk factors. Every unit increase in the CalEnviroScreen Score was associated with an increase of 1.6% above the mean rate of pediatric asthma hospitalizations (rate ratio (RR) = 1.016, 95% confidence interval (CI) = 1.014–1.018). Every unit increase in racial/ethnic segregation and diesel particulate matter was associated with an increase of 1.1% and 0.2% above the mean rate of pediatric asthma, respectively (RR = 1.011, 95% CI = 1.010–1.013; RR = 1.002, 95% CI = 1.001–1.004). The CalEnviroScreen is a unique tool that combines socioecological factors and environmental indicators to identify vulnerable communities with major health disparities, including pediatric asthma hospital use. Future research should identify mediating factors that contribute to community-level health disparities.

Cost barriers to asthma care by health insurance type among children with asthma

Objective: Children with asthma have ongoing health care needs and health insurance is a vital part of their health care access. Health care coverage may be associated with various cost barriers to asthma care. We examined cost barriers to receiving asthma care by health insurance type and coverage continuity among children with asthma using the 2012-2014 Child Asthma Call-back Survey (ACBS).Methods: The study sample included 3788 children under age 18 years with current asthma who had responses to the ACBS by adult proxy. Associations between cost barriers to asthma care and treatment were analyzed by demographic, health insurance coverage, and urban residence variables using multivariable logistic regression models.Results: Among insured children, more blacks reported a cost barrier to seeing a doctor (10.6% [5.9, 18.3]) compared with whites (2.9% [2.1, 4.0]) (p = 0.03). Adjusting for demographic factors (sex, age, and race), uninsured and having partial year coverage were associated with cost barrier to seeing a doctor (adjusted prevalence ratio aPR = 8.07 [4.78, 13.61] and aPR = 6.58 [3.78, 11.45], respectively) and affording medication (aPR = 8.35 [5.23, 13.34] and aPR = 4.93 [2.96, 8.19], respectively), compared with children who had full year coverage. Public insurance was associated with cost barrier to seeing a doctor (aPR = 4.43 [2.57, 7.62]), compared with private insurance.Conclusions: Having no health insurance, partial year coverage, and public insurance were associated with cost barriers to asthma care. Improving health insurance coverage may help strengthen access to and reduce cost barriers to asthma care.