Community Health Benefits Through a Student-Run Nonprofit Pediatric Wellness Clinic

Purpose Community screening programs have been in effect since they were utilized in the 19th century at county fairs. A free pediatric health screening program was created by an osteopathic medical school in South Carolina in collaboration with a pediatric dental outreach organization to engage the local underserved community and train community-minded medical professionals. This study sought to demonstrate the efficacy and need for a student-run monthly pediatric health screening program in an underserved pediatric demographic. Methods A retrospective study of preexisting de-identified data obtained from a student-run health screening program was analyzed to determine the efficacy of the screening program in detecting chronic health risk factors in children in an underserved population. Patients were recruited through a partnership with a free dental clinic for underserved and uninsured children. Patients who attended the clinic were offered the opportunity to have a free, comprehensive health assessment following their dental visit. The function of this program was unique in that uninsured, underserved patients were provided free dental care and a free health assessment. Pediatric patients were screened for basic health information such as weight, height, BMI, vision, cardiovascular health, hypertension, asthma (reported via questionnaire by either the parent or child when applicable), nutrition, and lead poisoning (via questionnaire). The program also offered families additional support by connecting them to local resources and answering any questions they had about their children's health. Data from 14 health screening events was collected for quality improvement and efficacy monitoring. Descriptive analyses were performed. Results and analysis The health screening program assessed 124 children between October 2021 and March 2023 over 14 health screening events. The patients ranged from one year old to 26 years old, with a mean age of 9.65 years. Patients were predominantly Hispanic (79.67%). About one-third (27.64%) of children who were screened had positive findings associated with increased risk for chronic disease. Nearly half (43.90%) of families that were screened requested further information on ways to obtain health insurance and regular primary care services (utilized Access Health). Of the one-third of children with positive risk factors, 12.20% reported positive findings associated with asthma. Of the patients with positive risk factors, 8.94% had vision abnormalities, most of whom had not been seen by an ophthalmologist. This preliminary analysis will be followed by a secondary analysis that further investigates patient demographics (primarily Hispanic) as well as age distribution across various risk factors. Conclusion This pediatric health screening program has demonstrated a basic level of efficacy by successfully identifying increased risk for chronic disease in the underserved pediatric population. The need for these screening events was highlighted by the identification of untreated positive findings.

Changing high-risk asthma in Memphis through partnership: Results from the CHAMP program

BACKGROUND

Children in metro Shelby County, Tennessee, have disproportionally high asthma-related health care resource use (HRU) compared with those in other regions in Tennessee.

OBJECTIVE

To describe the goals, logistics, and outcomes of the Changing High-Risk Asthma in Memphis through Partnership (CHAMP) program implemented to improve pediatric asthma care in Shelby County.

METHODS

CHAMP established a multidisciplinary team with dedicated medical staff and community health workers, implemented a 24/7 call line to improve access to care, established a patient data registry to address fragmented care, assigned community health educators to improve asthma education and social needs, and partnered with services to address environmental triggers and social determinants of health. Patients eligible for CHAMP are Shelby County residents aged 2 to 18 years with high-risk asthma enrolled in Tennessee's Medicaid managed care program. Health care resource use outcomes 1-year pre- and post-CHAMP enrollment were analyzed for patients who had completed 1 year of CHAMP between January 2013 and December 2022. The 24/7 call line data between November 2013 and December 2022 were analyzed.

RESULTS

CHAMP has enrolled 1348 children; 945 have completed 1 year (63% male; 90% identified as Black). At 1-year post-CHAMP enrollment, patients had 58%, 68%, 42%, and 53% reductions in emergency department visits, inpatient and observation visits, urgent care visits, and total asthma exacerbations, respectively. The number of asthma exacerbations per patient significantly decreased from 2.97 to 1.40 at 1-year post-CHAMP enrollment. Of the calls made to the 24/7 call line, 58% occurred after hours and 52% led to issue resolution without a medical facility visit.

CONCLUSION

CHAMP successfully decreased asthma HRU in children with high-risk asthma in Shelby County by implementing initiatives that targeted barriers to asthma care.

Racial Disparities in Glaucoma Vision Outcomes and Eye Care Utilization: An IRIS Registry Analysis

PURPOSE

To evaluate racial disparities in vision outcomes and eye care utilization among glaucoma patients.

DESIGN

Retrospective cohort study.

METHODS

In this population-based IRIS Registry (Intelligent Research in Sight) study, we included patients with minimum one diagnosis code for glaucoma at least 6 months prior to January 1, 2015 and at least one eye exam, visual field (VF), optical coherence tomography (OCT), or eye-related inpatient or emergency department (ED) code in 2015. Multivariable logistic and negative binomial regression models were used to assess vision and utilization outcomes, respectively, across race and ethnicity from January 1, 2015 to January 1, 2020. Vision outcomes included cup-to-disc ratio (CDR) progression > 0.80, poor vision (visual acuity 20/200 or worse), low vision codes, and need for glaucoma filtering surgery. Utilization outcomes included outpatient eye exams, OCTs, VFs, inpatient/ED encounters, and lasers/surgeries.

RESULTS

Among 996,297 patients, 73% were non-Hispanic White, 15% non-Hispanic Black, 9% Hispanic, 3% Asian/Pacific Islander, and 0.3% Native American/Alaska Native. Compared to White eyes, Black and Hispanic eyes had higher adjusted odds of CDR progression (odds ratio [OR] = 1.12, 95% confidence interval [CI] = 1.08-1.17; OR = 1.28, 95% CI = 1.22-1.34), poor vision (OR = 1.26, 95% CI = 1.22-1.29; OR = 1.26, 95% CI = 1.22-1.31), glaucoma filtering surgery (rate ratio (RR) = 1.47, 95% CI = 1.42-1.51; RR = 1.13, 95% CI = 1.09-1.18). Hispanic eyes also had increased odds of low vision diagnoses (Hispanic OR = 1.18, 95% CI = 1.07-1.30). Black and Hispanic patients were less likely to have eye exams (RR = 0.94, 95% CI = 0.94-0.95; RR = 0.99, 95% CI = 0.99-0.99) and OCTs (RR = 0.86, 95% CI = 0.85-0.86; RR = 0.97, 95% CI = 0.96-0.98), yet Black patients had higher odds of inpatient/ED encounters (RR = 1.64, 95% CI = 1.37-1.96) compared to White patients. Native American patients were more likely to have poor vision (OR = 1.17, 95% CI = 1.01-1.36) and less likely to have outpatient visits (RR = 0.89, 95% CI = 0.86-0.91), OCTs (RR = 0.85, 95% CI = 0.82-0.89), visual fields (RR = 0.91, 95% CI = 0.88-0.94) or lasers/surgeries (RR = 0.87, 95% CI = 0.79-0.96) compared to White patients.

CONCLUSIONS

We found that significant disparities in US eye care exist with Black, Hispanic, and Native American patients having worse vision outcomes and less disease monitoring. Glaucoma may be undertreated in these racial and ethnic minority groups, increasing risk for glaucoma-related vision loss.

Collaborative Integration of Community Health Workers in Hospitals and Health Centers to Reduce Pediatric Asthma Disparities: A Quality Improvement Program Evaluation

To address pediatric asthma disparities on the South Side of Chicago, a community health worker (CHW) home visiting intervention was implemented collaboratively by academic institutions and community based health centers. This evaluation assessed the effectiveness of this longitudinal quality improvement CHW intervention in reducing asthma morbidity and healthcare utilization. All patients aged 2-18 who met the high-risk clinical criteria in outpatient settings or those who visited the ED due to asthma were offered the program. A within-subject study design analyzed asthma morbidity and healthcare utilization at baseline and follow-up. Multivariable mixed-effects regression models, adjusted for baseline demographic and asthma characteristics, were used to assess changes over time. Among 123 patients, the average age was 8.8 (4.4) years, and 89.3% were non-Hispanic black. Significant reductions were observed in the average daytime symptoms days (baseline 4.1 days and follow-up 1.6 days), night-time symptoms days (3.0 days and 1.2 days), and days requiring rescue medication (4.1 days and 1.6 days) in the past two weeks (all p < 0.001). The average number of emergency department visits decreased from 0.92 one year before to 0.44 one year after program participation, a 52% reduction (p < 0.001). No significant difference was found in hospital admissions. These results support the use of a collaborative approach to implement the CHW home visiting program as part of standard care for pediatric asthma patients in urban settings. This approach has the potential to reduce asthma disparities and underscores the valuable role of CHWs within the clinical care team.

Primary care provider perceptions of an asthma home visiting program

INTRODUCTION

Pediatric asthma home visiting programs have improved clinical outcomes, but little is known about how providers perceive these programs. The purpose of this study was to understand how primary care providers and their colleagues in a medical home perceive an asthma home visiting program that is available at no cost to their patients.

METHODS

After several years of running an asthma home visiting program using community health workers (CHW) in 10 pediatric primary care offices in the South Coast of Massachusetts, we surveyed the providers of patients who had enrolled in the program. An anonymous online survey was developed by the program leaders, the program analytics team, and the CHWs for quality improvement purposes. Survey domains included the perceived utility of various aspects of the program, impact on patients, and interaction with CHWs, as well as demographic information about the providers.

RESULTS

Of the 24 providers asked to complete the survey from eight primary care practices, 21 completed the survey (88%). Respondents perceived that the most beneficial aspects were environmental assessment (95%), asthma education (91%), and addressing environmental issues (86%). In addition to numerous positive free-text responses, suggestions for improvement were in the areas of referral completion, post-visit communication, and patient identification in the medical record. All respondents would continue to refer to the program.

CONCLUSIONS

Primary care providers and medical home staff perceived an asthma home visiting program to have high utility, particularly the environmental assessment, asthma education, and mitigation of environmental issues. Additional opportunities for improvement were identified.

Global, regional, and national burden of allergic disorders and their risk factors in 204 countries and territories, from 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Asthma and atopic dermatitis (AD) are chronic allergic conditions, along with allergic rhinitis and food allergy and cause high morbidity and mortality both in children and adults. This study aims to evaluate the global, regional, national, and temporal trends of the burden of asthma and AD from 1990 to 2019 and analyze their associations with geographic, demographic, social, and clinical factors.

METHODS

Using data from the Global Burden of Diseases (GBD), Injuries, and Risk Factors Study 2019, we assessed the age-standardized prevalence, incidence, mortality, and disability-adjusted life years (DALYs) of both asthma and AD from 1990 to 2019, stratified by geographic region, age, sex, and socio-demographic index (SDI). DALYs were calculated as the sum of years lived with disability and years of life lost to premature mortality. Additionally, the disease burden of asthma attributable to high body mass index, occupational asthmagens, and smoking was described.

RESULTS

In 2019, there were a total of 262 million [95% uncertainty interval (UI): 224-309 million] cases of asthma and 171 million [95% UI: 165-178 million] total cases of AD globally; age-standardized prevalence rates were 3416 [95% UI: 2899-4066] and 2277 [95% UI: 2192-2369] per 100,000 population for asthma and AD, respectively, a 24.1% [95% UI: -27.2 to -20.8] decrease for asthma and a 4.3% [95% UI: 3.8-4.8] decrease for AD compared to baseline in 1990. Both asthma and AD had similar trends according to age, with age-specific prevalence rates peaking at age 5-9 years and rising again in adulthood. The prevalence and incidence of asthma and AD were both higher for individuals with higher SDI; however, mortality and DALYs rates of individuals with asthma had a reverse trend, with higher mortality and DALYs rates in those in the lower SDI quintiles. Of the three risk factors, high body mass index contributed to the highest DALYs and deaths due to asthma, accounting for a total of 3.65 million [95% UI: 2.14-5.60 million] asthma DALYs and 75,377 [95% UI: 40,615-122,841] asthma deaths.

CONCLUSIONS

Asthma and AD continue to cause significant morbidity worldwide, having increased in total prevalence and incidence cases worldwide, but having decreased in age-standardized prevalence rates from 1990 to 2019. Although both are more frequent at younger ages and more prevalent in high-SDI countries, each condition has distinct temporal and regional characteristics. Understanding the temporospatial trends in the disease burden of asthma and AD could guide future policies and interventions to better manage these diseases worldwide and achieve equity in prevention, diagnosis, and treatment.

Partnering with Families and Communities to Improve Child Health and Health Equity

Pediatricians and other pediatric health providers collaborate with families and communities, including schools, health departments, and other partners to advance pediatric health challenges and health equity. This article will discuss best practices and guiding principles to support engagement and effective partnership with families and communities. Models for engaging families and communities while promoting health equity will also be discussed. Case studies and examples will be shared, as well as how they may be applied by pediatric health providers to promote child health.

Improving childhood asthma outcomes in East Harlem: the East Harlem Asthma Center of Excellence's Asthma Counselor Program

OBJECTIVES

To evaluate the effectiveness of the Asthma Counselor Program, a program of the New York City Department of Health and Mental Hygiene, designed to improve asthma outcomes among children.

METHODS

We used a pre-post study design among children who enrolled in the program. We included self-reported outcome measures by comparing the previous 12 months (captured at intake) to the 12 months following program enrollment. To calculate the 12 months after enrollment, we added the number of outcome events reported at each follow-up session, which are conducted approximately three months apart, to compute 12-month (or "year-end") post-enrollment outcomes.

RESULTS

We enrolled 136 children during the study period (2018); 85 children remained in the program for 12 months and 51 became lost-to-follow-up. Among those who remained in the program, at the "year-end" session, there were statistically significant reductions in the mean number of asthma-related unscheduled healthcare appointments or urgent-care visits (73%), uses of prednisone (65%), asthma-related school absences (60%), asthma-related ED visits (57%), and asthma-related hospitalizations (50%).

CONCLUSIONS

Twelve months after children enrolled in the program, they had significantly improved asthma outcomes. Our findings, along with results from similar studies, support multicomponent interventions, especially those led by masters-level social workers.

Impact of COVID-19 on pediatric asthma-related healthcare utilization in New York City: a community-based study

BACKGROUND

COVID-19 disproportionately affects families of low socioeconomic status and may worsen health disparities that existed prior to the pandemic. Asthma is a common chronic disease in children exacerbated by environmental exposures.

METHODS

A cross-sectional survey was conducted to understand the impact of the initial stage of the pandemic on environmental and social conditions, along with access to care for children with asthma in New York City (NYC). Participants were recruited from a community-based organization in East Harlem and a nearby academic Pediatric Pulmonary clinic and categorized as having either public or private insurance (n = 51).

RESULTS

Factors significantly associated with public compared to private insurance respectively were: increased reports of indoor asthma triggers (cockroach 76% vs 23%; mold 40% vs 12%), reduced income (72% vs 27%), and housing insecurity (32% vs 0%). Participants with public insurance were more likely to experience conditions less conducive to social distancing compared to respondents with private insurance, such as remaining in NYC (92% vs 38%) and using public transportation (44% vs 4%); families with private insurance also had greater access to remote work (81% vs 8%). Families with public insurance were significantly more likely to test positive for SARS-CoV-2 (48% vs 15%) but less likely to have gotten tested (76% vs 100%). Families with public insurance also reported greater challenges accessing office medical care and less access to telehealth, although not statistically significant (44% vs 19%; 68% vs 85%, respectively).

CONCLUSIONS

Findings highlight disproportionate burdens of the pandemic, and how these disparities affect children with asthma in urban environments.

Perceptions of Environmental Influence and Environmental Information-Seeking Behavior Among People With Asthma and COPD

Environmental exposures and socioeconomic status (SES) are associated with asthma and chronic obstructive pulmonary disease (COPD) morbidity and mortality. Despite efforts to reduce the impact of environmental exposures through regulation and education, knowledge gaps remain. We sought to understand how adults with asthma and COPD perceive and seek information about environmental factors, and how these responses varied by disease or socioeconomic characteristics. Participants with self-reported asthma or COPD enrolled in a digital platform for respiratory disease self-management, consisting of sensors to track medication use and a companion smartphone app, completed an electronic survey exploring perceptions of environmental factors. Using mixed-method analyses, we evaluated differences in responses by disease (asthma vs. COPD), education (≤ vs. &gt; some college), annual household income (&lt; vs. ≥ $50,000), and mean annual residential air pollutant exposure (&gt; vs. ≤80th percentile). Survey responses from 698 participants [500 asthma (72%) and 198 COPD (28%)] were analyzed. A high percentage of participants perceived that environmental factors could influence their symptoms, including: pollen (93% for asthma vs. 86% for COPD), mold (89 vs. 85%), second-hand smoke (89 vs. 83%), and air pollution (84% for both). Participants reported seeking environmental information daily from an average of three sources, preferring mobile apps and television (TV) programs. Significant differences were identified by disease.

Conclusion

Participants with asthma and COPD perceive a relationship between their respiratory symptoms and their environment and regularly seek out environmental information. This information can help inform digital health development for respiratory education and self-management.

Social Risk Interventions and Health Care Utilization for Pediatric Asthma: A Systematic Review and Meta-analysis

IMPORTANCE

Social determinants of health (SDOH) correlate with pediatric asthma morbidity, yet whether interventions addressing social risks are associated with asthma outcomes among children is unclear.

OBJECTIVE

To catalog asthma interventions by the social risks they address and synthesize their associations with asthma-related emergency department (ED) visits and hospitalizations among children.

DATA SOURCES

PubMed, Scopus, PsycINFO, SocINDEX, CINAHL, and references of included full-text articles were searched from January 1, 2008, to June 16, 2021.

STUDY SELECTION

Included articles were US-based studies evaluating the associations of interventions addressing 1 or more social risks with asthma-related ED visits and hospitalizations among children. The systematic review included 38 of the original 641 identified articles (6%), and the meta-analysis included 19 articles (3%).

DATA EXTRACTION AND SYNTHESIS

Data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. The SDOH intervention clusters were identified by grouping studies according to the social risks they addressed, using the Healthy People 2020 SDOH framework. Random-effects models created pooled risk ratios (RRs) as the effect estimates.

MAIN OUTCOMES AND MEASURES

Patients with ED visits or hospitalizations were the primary outcomes. Subgroup analyses were conducted by an SDOH intervention cluster. Sensitivity analyses were conducted for each, removing outlier studies and studies failing to meet the minimum quality threshold.

RESULTS

In total, 38 studies were included in the systematic review, with 19 of these studies providing data for the meta-analysis (5441 participants). All interventions addressed 1 or more of the health, environment, and community domains; no interventions focused on the economy or education domains. In the primary analysis, social risk interventions were associated with decreased ED visits (RR, 0.68; 95% CI, 0.57-0.81; I2 = 70%) and hospitalizations (RR, 0.50; 95% CI, 0.37-0.68; I2 = 69%). In subgroup analyses, the health, environment, and community intervention cluster produced the lowest RR for ED visits (RR, 0.53; 95% CI, 0.44-0.64; I2 = 50%) and for hospitalizations (RR, 0.33; 95% CI, 0.20-0.55; I2 = 71%) compared with other intervention clusters. Sensitivity analyses did not alter primary or subgroup effect estimates.

CONCLUSIONS AND RELEVANCE

The results of this systematic review and meta-analysis indicate that social risk interventions are associated with decreased asthma-related ED visits and hospitalizations among children. These findings suggest that addressing social risks may be a crucial component of pediatric asthma care to improve health outcomes.

Are primary care and continuity of care associated with asthma-related acute outcomes amongst children? A retrospective population-based study

BACKGROUND

Having a primary care provider and a continuous relationship may be important for asthma outcomes. In this study, we sought to determine the association between 1) having a usual provider of primary care (UPC) and asthma-related emergency department (ED) visits and hospitalization in Québec children with asthma and 2) UPC continuity of care and asthma outcomes.

METHODS

Population-based retrospective cohort study using Québec provincial health administrative data, including children 2-16 years old with asthma (N = 39, 341). Exposures and outcomes were measured from 2010-2011 and 2012-2013, respectively. Primary exposure was UPC stratified by the main primary care models in Quebec (team-based Family Medicine Groups, family physicians not in Family Medicine Groups, pediatricians, or no assigned UPC). For those with an assigned UPC the secondary exposure was continuity of care, measured by the UPC Index (high, medium, low). Four multivariate logistic regression models examined associations between exposures and outcomes (ED visits and hospitalizations).

RESULTS

Overall, 17.4% of children had no assigned UPC. Compared to no assigned UPC, having a UPC was associated with decreased asthma-related ED visits (pediatrician Odds Ratio (OR): 0.80, 95% Confidence Interval (CI) [0.73, 0.88]; Family Medicine Groups OR: 0.84, 95% CI [0.75,0.93]; non-Family Medicine Groups OR: 0.92, 95% CI [0.83, 1.02]) and hospital admissions (pediatrician OR: 0.66, 95% CI [0.58, 0.75]; Family Medicine Groups OR: 0.82, 95% CI [0.72, 0.93]; non-Family Medicine Groups OR: 0.76, 95% CI [0.67, 0.87]). Children followed by a pediatrician were more likely to have high continuity of care. Continuity of care was not significantly associated with asthma-related ED visits. Compared to low continuity, medium and high continuity of care decreased asthma-related hospital admissions, but none of these associations were significant.

CONCLUSION

Having a UPC was associated with reduced asthma-related ED visits and hospital admissions. However, continuity of care was not significantly associated with outcomes. The current study provides ongoing evidence for the importance of primary care in children with asthma.

Improved 10-year cost savings for patients served by the Boston Children's Hospital Community Asthma Initiative

OBJECTIVE

To provide a 10-year follow-up of asthma cost-savings for patients served by the Community Asthma Initiative (CAI) group compared to a coarsely cost-matched comparison group from similar neighborhoods (comparison group).

METHODS

CAI provided home visits and case management services for patients identified through emergency department (ED) visits and hospitalizations. Asthma costs for the two groups were extracted from the hospital administrative database for ED visits and hospitalizations for one year before and 10 years of follow-up. To eliminate cost differences at intake, a coarse cost-matching was implemented by randomly selecting comparison patients with similar costs to CAI patients (N = 208 pairs). The difference in cost-reduction between CAI and comparison patients was used to compute the adjusted Return on Investment (aROI).

RESULTS

There were no significant differences between CAI and comparison groups, including baseline age (5.9 years [SD 2.9] v. 4.4 [SD 3.1]); Hispanic (46.2% v. 35.1%) and Black (43.9% v. 53.0%) race/ethnicity; and public insurance (71.2% v. 68.8%). The cost reduction difference for CAI was significant at one year (P = 0.0001) and two years (P = 0.03), but did not reach the level of significance for years 3-10. The CAI group had a greater cumulative cost reduction of $5,321 (P = 0.08, not significant). Average program cost per patient was $2,636. CAI broke-even after 3 years (aROI = 1.04) and yielded an adjusted ROI of 1.99 at 10 years.

CONCLUSIONS

The greater reduction in cumulative cost for CAI patients suggested a shift in trajectory at 10 years of follow-up, resulting in a positive aROI after three years.

Community Health Worker Intervention to Address Social Determinants of Health for Children Hospitalized With Asthma

BACKGROUND

Social determinants of health (SDOH) contribute to racial disparities in asthma outcomes. Community health worker (CHW) programs represent a promising way to screen for SDOH and connect patients to resources, but the impact of CHW programs in the inpatient pediatric setting has been examined in few studies. In this study, we aimed to evaluate a CHW program for children hospitalized with asthma in a predominantly Hispanic community by examining rates of SDOH and social resource navigation.

METHODS

This pilot study involved a CHW intervention to improve pediatric asthma care. Patients were included if they were hospitalized with asthma over an 18-month period and enrolled in the CHW program during their hospitalization. In an intake interview, CHWs screened caregivers for SDOH and provided tailored social resource navigation. Descriptive statistics were used to assess rates of social risk factors and social resource navigation.

RESULTS

Eighty patients underwent SDOH screening. The majority of patients were Hispanic (81.3%, n = 65). Half of caregivers reported food or housing insecurity over the past 12 months (50.0%, n = 40), and most reported inadequate housing conditions (63.8%, n = 51). CHWs coordinated social resources for the majority of families (98.8%, n = 79), with the most common being food resources (42.5%, n = 34), housing resources (82.5%, n = 66), and appointment navigation (41.3%, n = 33).

CONCLUSIONS

CHWs identified a high burden of unmet social needs and provided associated social resource navigation in a largely Hispanic pediatric population hospitalized for asthma. CHW programs have potential to improve asthma outcomes by linking high-risk patients with social resources.

The Demographics of Patients Presenting for Laryngological Care at an Academic Medical Center

OBJECTIVES/HYPOTHESIS

Few studies address the demographics/epidemiology/socioeconomic status of patients presenting to a laryngologist at a tertiary care center for treatment. To identify any possible disparities in voice, airway, and swallowing care, we sought to analyze the aforementioned data for new patients presenting to the voice center at an academic medical center.

METHODS

This is a retrospective cohort study of prospectively collected data from an institutional database of 4,623 new adult patients presenting for laryngological care at a tertiary care, academic medical center from 2015 to 2020. Demographic data were analyzed.

RESULTS

Of 4,623 patients, 62.8% were female and 37.2% were male with ages ranging from 19 to 99 years (Avg 59.51, standard deviation 15.83). Patients were 81.8% white, 13% black, and 5.2% other, compared with 56.3% white, 34.8% black, 20% other in the local municipality from US Census Data. Payer mix included 46.98% Medicare, 42.59% commercial insurance, 3.22% Medicaid, 5.19% other, and 2.01% uninsured/self-insured. Patient demographics based on primary diagnosis codes were also examined. A majority of patients presented with voice-related complaints.

CONCLUSIONS

Understanding the demographics of those with laryngological disorders will help to develop targeted interventions and effective outreach programs for underrepresented patient populations. Future multicenter studies could provide further insight into the distribution of healthcare disparities in laryngology.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Prevention and Outpatient Treatment of Asthma Exacerbations in Children

Acute exacerbations cause significant morbidity and mortality in children with asthma worldwide. Although exacerbations can be minor and transient, in some children they are recurrent and significantly adversely impact quality of life. Children with frequent exacerbations account for a disproportionate amount of unscheduled care in nonprimary health facilities. Frequent exacerbators are often prescribed controller medications, but poor adherence is common. Major predictors for asthma exacerbations include genetic, social, comorbid, biological, and environmental factors. Although virus infections are a key trigger for exacerbations, other environmental factors also significantly increase risk. A previous exacerbation is a major risk factor for future exacerbations and thus identifies children to target for prevention of future episodes. In this review, we discuss both modifiable and fixed factors associated with asthma exacerbations, how to assess children for risk, and which pharmacological and nonpharmacological interventions may be of benefit. Finally, we review the current evidence around treatment within the outpatient setting for an emerging exacerbation.

Racial Disparities in Incidence of Legionnaires' Disease and Social Determinants of Health: A Narrative Review

OBJECTIVES

Racial and socioeconomic disparities in the incidence of Legionnaires' disease have been documented for the past 2 decades; however, the social determinants of health (SDH) that contribute to these disparities are not well studied. The objective of this narrative review was to characterize SDH to inform efforts to reduce disparities in the incidence of Legionnaires' disease.

METHODS

We conducted a narrative review of articles published from January 1979 through October 2019 that focused on disparities in the incidence of Legionnaires' disease and pneumonia (inclusive of bacterial pneumonia and/or community-acquired pneumonia) among adults and children (excluding articles that were limited to people aged <18 years). We identified 220 articles, of which 19 met our criteria: original research, published in English, and examined Legionnaires' disease or pneumonia, health disparities, and SDH. We organized findings using the Healthy People 2030 SDH domains: economic stability, education access and quality, social and community context, health care access and quality, and neighborhood and built environment.

RESULTS

Of the 19 articles reviewed, multiple articles examined disparities in incidence of Legionnaires' disease and pneumonia related to economic stability/income (n = 13) and comorbidities (n = 10), and fewer articles incorporated SDH variables related to education (n = 3), social support (none), health care access (n = 1), and neighborhood and built environment (n = 6) in their analyses.

CONCLUSIONS

Neighborhood and built-environment factors such as housing, drinking water infrastructure, and pollutant exposures represent critical partnership and research opportunities. More research that incorporates SDH and multilevel, cross-sector interventions is needed to address disparities in Legionnaires' disease incidence.

Aligning Partners in Pediatric Health: Using Geographical Information Systems to Plan Community Coalitions

Introduction: Compared with adults, children have higher emergency department (ED) utilization for asthma exacerbation. While community coalitions have been shown to prevent ED visits for asthma, there is little guidance on where to best implement these efforts. Geographical information systems (GIS) technology can help in the selection and coordination of potential coalition partners. This report proposes a model to be used by clinicians and child health equity advocates to strategize high-impact community health interventions. The aims were to identify the clusters of ED utilization for pediatric asthma, evaluate sociodemographic features of the population within the clusters, and identify potential primary care and school community partners. Methods: This model uses ED visit data from 450 nonmilitary California hospitals in 2012. We obtained ZIP code–level counts and rates for patients younger than 18 years discharged with a diagnosis code of 493 for asthma conditions from the California Office of Statewide Health Planning and Development’s Open Portal. We applied GIS spatial analysis techniques to identify statistically significant cluster for pediatric asthma ED utilization. We then locate the candidate community partners within these clusters. Results: There were 181 720 ED visits for asthma for all age groups in 2012 with 70 127 visits for children younger than 18 years. The top 3 geographic clusters for ED utilization rates were located in Fresno, Inglewood, and Richmond City, respectively. Spatial analysis maps illustrate the schools located within 0.5– and 1-mile radii of primary care clinics and provide a visual and statistical description of the population within the clusters. Conclusion: This study demonstrates a model to help clinicians understand how GIS can aid in the selection and creation of coalition building. This is a potentially powerful tool in the addressing child health disparities.

Community Health Workers in Home Visits and Asthma Outcomes

BACKGROUND

The Community Asthma Initiative (CAI) was included in the New England Asthma Innovations Collaborative, which received a Centers for Medicare and Medicaid Services (CMS) Innovation grant. Under this grant, CAI transitioned from a mixed community health worker and nurse model to a nurse-supervised community health worker model. CMS limited enrollment to patients with Medicaid and encouraged 3 home visits per family.

METHODS

A total of 389 patients enrolled under the CMS grant at Boston Children's Hospital from 2013 to 2015 (CMS group) were compared with 733 CAI patients with Medicaid enrolled from 2005 to 2012 (comparison group). Changes in 5 asthma-related measures (emergency department visits, hospitalizations, physical activity limitations, missed school days, and parent and/or guardian missed workdays) were compared between baseline and 6 and 12 months postenrollment. Measures were analyzed as dichotomous variables using logistic regression. Numbers of occurrences were analyzed as continuous variables. Changes in quality of life (QoL) among the CMS group were examined through a 13-question survey with activity and emotional health subscales.

RESULTS

Although patients in both groups exhibited improvement in all measures, the CMS group had greater odds of decreased hospitalizations (odds ratio 3.13 [95% confidence interval 1.49-6.59]), missed school days (1.91 [1.09-3.36]), and parent and/or guardian missed workdays (2.72 [1.15-6.41]) compared to the comparison group. Twelve months postenrollment, the CMS group experienced improvement in all QoL questions and subscales (all P values <.01).

CONCLUSIONS

The CMS group showed improved outcomes for hospitalizations and missed school and workdays compared to the comparison group. The CMS group also exhibited significant improvement in QoL.

Community health workers providing asthma education

Objectives: Children living in urban areas experience disproportionate rates of asthma. Substandard housing conditions in some urban areas contribute to greater exposure to household asthma triggers. This article examines the geographic connection between pediatric asthma and substandard housing in one mid-sized city in Pennsylvania and the effectiveness of a home-based Community Health Worker (CHW) intervention targeted at this high-risk area to improve families' abilities to manage their children's asthma.Methods: The CHWs provided education and resources to families of children diagnosed with mild, moderate or severe persistent asthma. A pre and post-test design was implemented to evaluate if the CHW intervention improved the family's ability to successfully manage their child's asthma. Eighty-one patients completed the program over a six-month period.Results: Results showed significant improvements in the areas of asthma knowledge, fewer missed days of school, fewer days with asthma symptoms, reduction in wheezing and fewer sleep disturbances. There was also a significant decrease in the number of Emergency Department visits and hospital days.Conclusions: By teaching asthma management skills and by addressing in-home triggers, home-based CHW led interventions can be an affordable and effective way for caregivers and children with asthma to improve asthma management.

Healthcare Disparities in Laryngology: A Scoping Review

OBJECTIVES/HYPOTHESIS

This scoping review aims to map out existing disparities research within the subspecialty of laryngology in order to highlight gaps in knowledge and guide future research.

STUDY DESIGN

Scoping Review.

METHODS

We completed a scoping review of PubMed, Ovid Embase, and the Cochrane Library for primary research focused on evaluating the existence and impact of disparities in race/ethnicity, sex/gender, insurance status, education level, income, geography, and LGBTQ identity in the context of various laryngological conditions. Publications of any design and date, performed in the United States, and focusing on the adult population exclusively were included.

RESULTS

Of the 4,999 unique abstracts identified, 51 articles were ultimately included. The most frequently examined condition in relation to disparities was laryngeal cancer (27 of 51), followed by voice disorders (15 of 51), deglutitive disorders (eight of 51), and airway disorders (one of 51). Sources of inequity evaluated from most common to least common were race/ethnicity (43 of 51), sex/gender (39 of 51), insurance status (23 of 51), geography (23 of 51), income (21 of 51), and education level (16 of 51). No study examined the association of LGBTQ identity with inequity.

CONCLUSIONS

This scoping review highlights the limited extent of disparities research in laryngology and establishes the need for further scholarship on the impact of disparities in laryngology care. The pathologies studied were, in decreasing order of frequency: laryngeal cancer, voice disorders, deglutitive disorders, and airway disorders. Race/ethnicity and sex/gender were the most common disparities examined, with no evaluation of LGBTQ-related care inequity.

LEVEL OF EVIDENCE

NA Laryngoscope, 2020.

Chronic pediatric health conditions among youth living in public housing and receiving care in a large hospital system in Bronx, NY

This study compared the prevalence of chronic pediatric health conditions for youth in public housing with youth not in public housing using clinical electronic health record (EHR) and housing data. Youth (ages 2-17 years) in a large urban health system were identified and categorized into two housing types—public housing (n = 10 770) and not in public housing (n = 84 883) by age (young childhood, middle childhood, young adolescence). The prevalence of some pediatric conditions was higher in public housing but varied by age. Disparities in health conditions among youth in public housing were more common in early adolescence: asthma (26.4 vs 18.6; P < .001); obesity (28.5 vs 24.6; P < .001); depression/anxiety (19.2 vs 17.3; P = .008); behavioral disorders (8.1 vs 5.3; P < .001). These results show that chronic pediatric conditions like asthma and obesity that lead to significant morbidity into adulthood are more common among youth living in public housing. However, this pattern is not consistent across all chronic conditions.

Applying a biopsychosocial model to inner city asthma: Recent approaches to address pediatric asthma health disparities

Pediatric asthma in inner cities is often severe and children living in these urban locations with socioeconomic disadvantage experience greater asthma morbidity. There are many interconnected risk factors that individually, and in combination, enhance asthma morbidity. These include biologic factors innate to the child, such as genetics and allergen susceptibility, as well as factors related to the family and neighborhood context. The biopsychosocial model can be used to frame these risk factors and develop interventions specific to the inner city. Successful inner city asthma interventions exist and key characteristics include multi-tiered components that operate within the community to coordinate disease management resources between patients, families and health care systems.

Does participation in the community outreach for asthma care and healthy lifestyles (COACH) program alter subsequent use of hospital services for children discharged with asthma?

Introduction: Transition from hospital to home is a challenging time for children with asthma and their caregivers because of the high risk for reutilization of acute hospital services. Detecting effective quality improvement initiatives to reduce utilization of urgent services in children discharged with asthma is an important clinical and public health question. This study was designed to identify the role of a multimodal, nurse-driven, inpatient initiated Community Outreach for Asthma Care and Healthy lifestyles (COACH) program on subsequent use of hospital services for pediatric patients with asthma.Methods: We utilized comparative effectiveness design to identify the difference in recurrent emergency department (ED) visits and/or admissions within 12-months after discharge between patients with asthma who engaged in the COACH program (Intervention group) and those who did not (Comparison group). We used administrative databases of hospitals included in the Meridian Health system to identify the number of and time to asthma-related readmissions and ED re-attendances.Results: We found no difference in the rate or number of recurrent hospital-based services used within 12 months, but found a reduction in ED re-visitation and/or readmission within 30 days for COACH program participants prior to and after adjustment for age, race/ethnicity, insurance status, and clinical presentation (Odd Ratio 0.44, 95% Confidence Interval 0.20, 0.93).Conclusion: Participation in the COACH program decreases the likelihood for subsequent use of hospital services within a month of discharge for children with asthma. Enhanced post-discharge interactions with families may reduce long-term reuse of hospital-based services for COACH program participants.

Oral corticosteroid use, obesity, and ethnicity in children with asthma

Objective: Comorbid asthma and obesity leads to poorer asthma outcomes, partially due to decreased response to controller medication. Increased oral steroid prescription, a marker of uncontrolled asthma, may follow. Little is known about this phenomenon among Latino children. Our objective was to determine whether obesity is associated with increased oral steroid prescription for children with asthma, and to assess potential disparities in these associations between Latino and non-Hispanic white children.Methods: We examined electronic health record data from the ADVANCE national network of community health centers. The sample included 16,763 children aged 5-17 years with an asthma diagnosis and ≥1 ambulatory visit in ADVANCE clinics across 22 states between 2012 and 2017. Poisson regression analysis was used to examine the rate of oral steroid prescription overall and by ethnicity controlling for potential confounders.Results: Among Latino children, those who were always overweight/obese at study visits had a 15% higher rate of receiving an oral steroid prescription than those who were never overweight/obese [rate ratio (RR) = 1.15, 95% CI 1.05-1.26]. A similar effect size was observed for non-Hispanic white children, though the relationship was not statistically significant (RR = 1.10, 95% CI: 0.92-1.33). The interactions between body mass index and ethnicity were not significant (sometimes overweight/obese p = 0.95, always overweight/obese p = 0.58), suggesting a lack of disparities in the association between obesity and oral steroid prescription by ethnicity.Conclusions: Children with obesity received more oral steroid prescriptions than those at a healthy weight, which may be indicative of worse asthma control. We did not observe significant ethnic disparities.

Beyond efficacy: a qualitative organizational perspective on key implementation science constructs important to physical activity intervention translation to rural community cancer care sites

PURPOSE

To identify constructs relevant to implementation of evidence-based physical activity (PA) behavior change interventions for rural women cancer survivors from an organizational perspective.

METHODS

During the development of a PA intervention implementation toolkit, 11 potential interventionists and 19 community and organizational stakeholders completed focus groups stratified by role. Narratives were audio recorded, transcribed, and coded for Consolidated Framework for Implementation Research (CFIR) constructs.

RESULTS

Multiple CFIR constructs were identified: Implementation Process (i.e., Engaging, Reflecting and Evaluating), Intervention Characteristics (i.e., Design Quality and Packaging, Cost, Evidence Strength and Quality, Adaptability, Complexity), Inner Setting (i.e., Implementation Readiness, Implementation Climate, Structural Characteristics), Outer Setting (i.e., Patient Needs and Resources, Cosmopolitanism), and Characteristics of Individuals (i.e., Knowledge and Beliefs, Stage of Change). Narratives identified rural implementation barriers (e.g., transportation) and facilitators (e.g., community-oriented). Unique needs of the cancer survivor (e.g., coping during cancer treatment and long-term effects on physical abilities) were emphasized as important barriers potentially addressed through Adaptability and Readiness implementation strategies. Narratives identified multi-level (i.e., individual-, organizational-, and community-level) strategies for targeting the identified constructs.

CONCLUSIONS

Fourteen CFIR constructs emerged as potentially important for organizations to consider when implementing PA interventions. Constructs were integrated into our implementation toolkit and research testing their potential mechanisms of action when implementing PA interventions in rural settings is warranted.

IMPLICATIONS

Strategies that target the identified constructs may enhance the implementation of PA programs for rural cancer survivors. Cancer survivors can facilitate these efforts by partnering with their health care providers and community organizations.

IMPLICATIONS FOR CANCER SURVIVORS

Organizations promoting physical activity programs for cancer survivors must overcome implementation barriers including but not limited to cost, necessary expertise, and lack of awareness. Cancer survivors can facilitate these efforts by partnering with their health care providers, cancer center, and local community organizations to raise awareness and champion these efforts. It will "take a village", with cancer survivors being their own best advocate, to bring physical activity promotion to a broad range of cancer survivors.

A Practical Approach to Severe Asthma in Children

Severe asthma accounts for only a small proportion of the children with asthma but a disproportionately high amount of resource utilization and morbidity. It is a heterogeneous entity and requires a step-wise, evidence-based approach to evaluation and management by pediatric subspecialists. The first step is to confirm the diagnosis by eliciting confirmatory history and objective evidence of asthma and excluding possible masquerading diagnoses. The next step is to differentiate difficult-to-treat asthma, asthma that can be controlled with appropriate management, from asthma that requires the highest level of therapy to maintain control or remains uncontrolled despite management optimization. Evaluation of difficult-to-treat asthma includes an assessment of medication delivery, the home environment, and, if possible, the school and other frequented locations, the psychosocial situation, and comorbid conditions. Once identified, aggressive management of issues related to poor adherence and drug delivery, remediation of environmental triggers, and treatment of comorbid conditions is necessary to characterize the degree of control that can be achieved with standard therapies. For the small proportion of patients whose disease remains poorly controlled with these interventions, the clinician may assess steroid responsiveness and determine the inflammatory pattern and eligibility for biologic therapies. Management of severe asthma refractory to traditional therapies involves considering the various biologic and other newly approved treatments as well as emerging therapies based on the individual patient characteristics.

Pervasive Income-Based Disparities In Inpatient Bed-Day Rates Across Conditions And Subspecialties

Building a culture of health in hospitals means more than participating in community partnerships. It also requires an enhanced capacity to recognize and respond to disparities in utilization patterns across populations. We identified all pediatric hospitalizations at Cincinnati Children's Hospital Medical Center, in the period 2011-16. Each hospitalized child's address was geocoded, allowing us to calculate inpatient bed-day rates for each census tract in Hamilton County, Ohio, across all causes and for specific conditions and pediatric subspecialties. We then divided the census tracts into quintiles based on their underlying rates of child poverty and calculated bed-day rates per quintile. Poorer communities disproportionately bore the burden of pediatric hospital days. If children from all of the county's census tracts spent the same amount of time in the hospital each year as those from the most affluent tracts, approximately twenty-two child-years of hospitalization time would be prevented. Of particular note were "hot spots" in high-poverty census tracts neighboring the hospital, where bed-day rates were more than double the county average. Hospitals that address disparities would benefit from a more comprehensive understanding of the culture of health-a culture that is more cohesive inside the hospital and builds bridges into the community.

Community Asthma Initiative: Cost Analyses using Claims Data from a Medicaid Managed Care Organization

Objective: Use claims data to examine the cost benefit of the Community Asthma Initiative (CAI), a Boston area nurse-supervised community health worker (CHW) asthma home-visiting program. Methods: The reduction in asthma treatment costs was assessed using Massachusetts claims data from one Medicaid Managed Care Organization (MCO) in the north east that included all costs between January 1, 2011 and December 31, 2016. The data was used to determine asthma-related utilization cost reductions between 1 year pre- and 1, 2 and 3 years post-intervention. The cost reductions for 45 CAI patients and 45 cost-matched comparison patients were measured. Return on investment (ROI) was computed as the difference in cost reduction for CAI patients and a cost-matched comparison population divided by CAI program cost. Results: The excess reduction in per patient asthma-related utilization costs among CAI patients compared to the comparison population was $806 (p = 0.047), $1,253 (p = 0.01) and $1,549 (p = 0.005) between 1 year pre- and 1, 2 and 3 years post-intervention. These yielded adjusted ROI's of 0.31, 0.78 and 1.37 after 1, 2 and 3 years post-CAI intervention. Conclusions: The reduction in asthma utilization costs of a home visit program by nurse-supervised CHWs exceeds program costs. The findings support the business case for the provision of secondary prevention of home-based asthma services through reimbursement from payers or integration into Accountable Care Organizations (ACOs).

Can interactive parental education impact health care utilization in pediatric asthma: A study in rural Texas

Objective It is well known that parent/patient education helps to reduce the burden of asthma in urban areas, but data are scarce for rural areas. This study explored the impact of asthma education in Ector County, a rural part of Health Services Region 9 in Texas, which has one of the highest prevalence rates of asthma in the state. Methods This prospective study investigated an interactive asthma education intervention in pediatric patients aged 2-18 years and their caregivers. Change in parental/caregiver knowledge about their child's asthma along with frequency of missed school days, emergency department (ED) visits and hospital admissions was obtained via telephone surveys before and after the educational intervention was delivered. Results The study enrolled 102 pediatric patients and their parents/caregivers. Asthma education was associated with significantly fewer school absences, ED visits and hospitalizations. Parents/caregivers reported feeling better educated, knowing what triggers an asthma exacerbation, identifying the signs of a severe asthma attack in their child, feeling confident about managing asthma and feeling that the asthma was under control. Conclusion Asthma education of caregivers and children was associated with better symptom management and fewer acute exacerbations, pointing to the relevance and importance of asthma education among pediatric patients in rural areas.

Caring for Young Children with Asthma: Perspectives from Urban Community Health Centers

Asthma disproportionately affects low-income, minority youth, with notable disparities among children <5 years of age. Understanding the perceptions of urban community health centers (CHCs) regarding treating young children with asthma could improve care for these patients. This study uses data from semi-structured focus groups with staff from eight urban CHCs. Themes emerged in three domains. Within the parent/family domain, providers noted low rates of follow-up visits, low health literacy, and-for young children specifically-misunderstanding about the diagnosis. At the CHC level, providers needed more staff, space, and comfort with applying the guidelines to infants and young children. CHCs reported asthma registries, population health oversight, and an asthma champion improved care. At the system level, providers wanted improved communication with emergency departments and community outreach programs. Reducing these multi-level barriers may improve care.

Evaluation of the Environmental Scoring System in Multiple Child Asthma Intervention Programs in Boston, Massachusetts

OBJECTIVES

To test the applicability of the Environmental Scoring System, a quick and simple approach for quantitatively measuring environmental triggers collected during home visits, and to evaluate its contribution to improving asthma outcomes among various child asthma programs.

METHODS

We pooled and analyzed data from multiple child asthma programs in the Greater Boston Area, Massachusetts, collected in 2011 to 2016, to examine the association of environmental scores (ES) with measures of asthma outcomes and compare the results across programs.

RESULTS

Our analysis showed that demographics were important contributors to variability in asthma outcomes and total ES, and largely explained the differences among programs at baseline. Among all programs in general, we found that asthma outcomes were significantly improved and total ES significantly reduced over visits, with the total Asthma Control Test score negatively associated with total ES.

CONCLUSIONS

Our study demonstrated that the Environmental Scoring System is a useful tool for measuring home asthma triggers and can be applied regardless of program and survey designs, and that demographics of the target population may influence the improvement in asthma outcomes.

Developing a framework for integrating health equity into the learning health system

While there have been gains in the overall quality of health care, racial and ethnic disparities in health outcomes continue to persist in the United States. The Learning Health System (LHS) has the potential to significantly improve health care quality using patient-centered design, data analytics, and continuous improvement. To ensure that health disparities are also being addressed, targeted approaches must be used. This document sets forth a practical framework to incorporate health equity into a developing LHS. Using a case study approach, the framework is applied to 2 projects focused on the reduction of health disparities to highlight its application.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions

BACKGROUND

Asthma is the most common chronic disease of childhood and a leading cause of hospitalization in children. A primary goal of asthma control is prevention of hospitalizations. A hospital admission is the single strongest predictor of future hospital admissions for asthma. The 30-day asthma readmission rate at our institution was significantly higher than that of other hospitals in the Children's Hospital Association. As a result, a multifaceted quality improvement project was undertaken with the goal of reducing the 30-day inpatient asthma readmission rate by 50% within two years.

METHODS

Analysis of our institution's readmission patterns, value stream mapping of asthma admission, discharge, and follow-up processes, literature review, and examination of comparable successful programs around the United States were all utilized to identify potential targets for intervention. Interventions were implemented in a stepwise manner, and included increasing inhaler availability after discharge, modifying asthma education strategies, and providing in-home post-discharge follow-up. The primary outcome was a running 12-month average 30-day inpatient readmission rate. Secondary outcomes included process measures for individual interventions.

RESULTS

From a peak of 7.98% in January 2013, a steady decline to 1.65% was observed by July 2014, which represented a 79.3% reduction in 30-day readmissions.

CONCLUSION

A significant decrease in hospital readmissions for pediatric asthma is possible, through comprehensive, multidisciplinary quality improvement that spans the continuum of care.

Economic Evidence for US Asthma Self-Management Education and Home-Based Interventions

The health and economic burden of asthma in the United States is substantial. Asthma self-management education (AS-ME) and home-based interventions for asthma can improve asthma control and prevent asthma exacerbations, and interest in health care-public health collaboration regarding asthma is increasing. However, outpatient AS-ME and home-based asthma intervention programs are not widely available; economic sustainability is a common concern. Thus, we conducted a narrative review of existing literature regarding economic outcomes of outpatient AS-ME and home-based intervention programs for asthma in the United States. We identified 9 outpatient AS-ME programs and 17 home-based intervention programs with return on investment (ROI) data. Most programs were associated with a positive ROI; a few programs observed positive ROIs only among selected populations (eg, higher health care utilization). Interpretation of existing data is limited by heterogeneous ROI calculations. Nevertheless, the literature suggests promise for sustainable opportunities to expand access to outpatient AS-ME and home-based asthma intervention programs in the United States. More definitive knowledge about how to maximize program benefit and sustainability could be gained through more controlled studies of specific populations and increased uniformity in economic assessments.

Boston children's hospital community asthma initiative: Five-year cost analyses of a home visiting program

OBJECTIVE

To evaluate the costs and benefits of the Boston Children's Hospital Community Asthma Initiative (CAI) through reduction of Emergency Department (ED) visits and hospitalizations for the full pilot-phase program participants.

METHODS

A cost-benefit analyses was conducted using hospital administrative data to determine an adjusted Return on Investment (ROI): on all 268 patients enrolled in the CAI program during the 33-month pilot program phase of CAI intervention between October 1, 2005 and June 30, 2008 using a comparison group of 818 patients from a similar cohort in neighboring ZIP codes without CAI intervention. Cost data through June 30, 2013 were used to examine cost changes and calculate an adjusted ROI over a 5-year post-intervention period.

RESULTS

CAI patients had a cost reduction greater than the comparison group of $1,216 in Year 1 (P = 0.001), $1,320 in Year 2 (P < 0.001), $1,132 (P = 0.002) in Year 3, $1,123 (P = 0.004) in Year 4, and $997 (P = 0.022) in Year 5. Adjusting for the cost savings for the comparison group, the cost savings from the intervention resulted in an adjusted ROI of 1.91 over 5 years.

CONCLUSIONS

Community-based, multidisciplinary, coordinated disease management programs can decrease the incidence of costly hospitalizations and ED visits from asthma. An ROI of greater than one, as found in this cost analysis, supports the business case for the provision of community-based asthma services as part of patient-centered medical homes and Accountable Care Organizations.

Background and Rationale

In 2011, CDC published the first CDC Health Disparities and Inequalities Report (CHDIR). This report examined health disparities in the United States associated with various characteristics, including race/ethnicity, sex, income, education, disability status, and geography. Health disparities were defined as "differences in health outcomes and their determinants between segments of the population, as defined by social, demographic, environmental, and geographic attributes". Among other recommendations, the 2011 CHDIR emphasized the need to address health disparities with a dual intervention strategy focused on populations at greatest need and on improving the health of the U.S. population by making interventions available to everyone. The 2013 CHDIR updated the 2011 CHDIR and included additional reports on social and environmental determinants of health; the supplement emphasized the importance of multisectoral collaboration, highlighting the need for a comprehensive, community-driven approach to reducing health disparities in the United States. A follow-up report described five interventions that were shown to be effective or demonstrated promise for reducing health disparities. These publications have focused attention on the need to address health disparities in the United States, as well as on programs and interventions that address them. This supplement describes additional interventions that address particular disparities observed by race and ethnicity, socioeconomic status, geographic location, disability, and/or sexual orientation across a range of conditions, including asthma, infection with HIV and hepatitis A, use of colorectal cancer screening, youth violence, food security, and health-related quality of life.

Epilogue

In 1985, the Report of the Secretary's Task Force on Black and Minority Health was published after the federal government convened the first group of health experts to analyze racial/ethnic health disparities among minorities. This analysis, also known as the Heckler report, revealed higher illness and death rates among minorities. The year 2015 marks the 30th anniversary of the Heckler Report and presents an opportunity to evaluate and continue to improve minority health at the national, state, tribal, territorial, and local levels.