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Krebs LD, Hill N, Villa-Roel C, McLane P, Rowe BH, Gupta S. “Not just the asthma”: Understanding the acute asthma experiences of adult women with asthma presenting to the emergency department through photovoice. CANADIAN JOURNAL OF RESPIRATORY, CRITICAL CARE, AND SLEEP MEDICINE 2022. [DOI: 10.1080/24745332.2022.2133756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lynette D. Krebs
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nicole Hill
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
- Department of Sociology, University of Alberta, Edmonton, Alberta, Canada
| | - Cristina Villa-Roel
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick McLane
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
- Strategic Clinical Networks, Alberta Health Services, Edmonton, Alberta, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Samir Gupta
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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2
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Macias‐Konstantopoulos W, Ciccolo G, Muzikansky A, Samuels‐Kalow M. A pilot mixed‐methods randomized controlled trial of verbal versus electronic screening for adverse social determinants of health. J Am Coll Emerg Physicians Open 2022; 3:e12678. [PMID: 35224551 PMCID: PMC8847702 DOI: 10.1002/emp2.12678] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Wendy Macias‐Konstantopoulos
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
- Center for Social Justice and Health Equity Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Gia Ciccolo
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
| | - Alona Muzikansky
- Biostatistics Center, Division of Clinical Research, Mass General Research Institute Massachusetts General Hospital Boston Massachusetts USA
| | - Margaret Samuels‐Kalow
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
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3
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Shulhan-Kilroy J, Elliott SA, Scott SD, Hartling L. Parents' self-reported experiences and information needs related to acute pediatric asthma exacerbations: A mixed studies systematic review. PEC INNOVATION 2021; 1:100006. [PMCID: PMC10194336 DOI: 10.1016/j.pecinn.2021.100006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 05/30/2023]
Abstract
Objective To systematically review the scientific literature examining parents' experiences and information needs for the management of their child's asthma exacerbations. Methods We searched five databases for quantitative and qualitative studies in Canada and the United States from 2002 onwards. A convergent integrated approach and the Mixed Method Appraisal Tool were used to analyze and appraise the evidence, respectively. Results We included 84 studies (27 quantitative, 54 qualitative, 3 mixed methods). Some parents lacked confidence in recognizing or managing exacerbations. A few parents were uncertain when and where to seek medical help. The main barrier to accessing care was cost. Impacts on parents included poor sleep, distress, and lifestyle disruptions. Parents felt they lacked information and wanted education on treatments and how to recognize and manage exacerbations via education sessions, written materials, community outreach and online resources. Conclusion Improved education for parents may help reduce parents' stress, asthma-related morbidities for children and use of urgent health services. Innovation The development of tailored interventions and knowledge translation strategies with input from target audiences (e.g. parents, health care providers) is necessary to meet their information needs and support adherence to clinical recommendations. 84 studies reviewed and analyzed using the convergent integrated approach Parents lacked confidence in recognizing, treating or seeking care for exacerbations Cost was a barrier to care; parents affected by psychosocial impacts Parent's desired education on treatments and how to recognize and manage exacerbations Interventions and knowledge translation strategies must be developed with parents
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Affiliation(s)
- Jocelyn Shulhan-Kilroy
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Sarah A. Elliott
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Shannon D. Scott
- Evidence in Child Health to Enhance Outcomes (ECHO), Faculty of Nursing, University of Alberta, Edmonton, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence (ARCHE), Department of Pediatrics, University of Alberta, Edmonton, Canada
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4
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Giannouchos TV, Washburn DJ, Gary JC, Foster MJ. Frequent emergency department use in the paediatric population: A systematic literature review. J Eval Clin Pract 2021; 27:193-203. [PMID: 32141125 DOI: 10.1111/jep.13382] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We systematically reviewed the literature on paediatric frequent emergency department (ED) users to identify and to synthesize characteristics and factors associated with frequent ED utilization among this population in the United States. METHODS We searched Medline (Ovid), CINAHL (Ebsco), and Embase (Ovid) to identify all relevant studies after 1990. We focused on US studies analysing paediatric frequent ED (PFED) users excluding those focused on specific subgroups. Two reviewers independently selected articles and extracted data on predisposing, enabling, behavioural, need and reinforcing factors. RESULTS Fifteen studies met the inclusion criteria. PFED users comprised 3% to 14% of all paediatric ED users and accounted for 9% to 42% of all paediatric ED visits in 11 studies that defined frequent use as four to six ED visits per year. Most PFED users were less than 5 years old who had public insurance coverage and a regular provider. Public insurance compared to private residency in disadvantaged areas, having at least one chronic or complex condition and a history of hospitalization, were associated with frequent use. Children who had a regular primary care provider were less likely to exhibit frequent ED use. CONCLUSIONS Minimizing unnecessary ED visits by frequent utilizers is a quality improvement and cost-saving priority for health systems. Our findings indicate that many PFED users have greater healthcare needs and face barriers accessing care in a timely manner, even though some have regular providers. To better address the needs of this vulnerable group, health systems should focus on educating caregivers and expanding access to providers in other settings.
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Affiliation(s)
- Theodoros V Giannouchos
- School of Public Health, Department of Health Policy and Management, Texas A&M University, College Station, Texas, USA.,Population Informatics Lab, Texas A&M University, College Station, Texas, USA
| | - David J Washburn
- School of Public Health, Department of Health Policy and Management, Texas A&M University, College Station, Texas, USA
| | - Jodie C Gary
- Health Science Center College of Nursing, Texas A&M University, Bryan, Texas, USA
| | - Margaret J Foster
- Medical Sciences Library, Texas A&M University, College Station, Texas, USA
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5
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Dawson RM, Heiney SP, Messias DH, Ownby D. A Patient-Centered Asthma Management Communication Intervention for Rural Latino Children: Protocol for a Waiting-List Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e18977. [PMID: 33258784 PMCID: PMC7738259 DOI: 10.2196/18977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/16/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
Background Rural Latino children with asthma suffer high rates of uncontrolled asthma symptoms, emergency department visits, and repeat hospitalizations. This vulnerable population must negotiate micro- and macrolevel challenges that impact asthma management, including language barriers, primary care access, parental time off from work, insurance coverage, distance from specialty sites, and documentation status. There are few proven interventions that address asthma management embedded within this unique context. Objective Using a bio-ecological approach, we will determine the feasibility of a patient-centered collaborative program between rural Latino children with asthma and their families, school-based nursing programs, and primary care providers, facilitated by the use of a smartphone-based mobile app with a Spanish-language interface. We hypothesize that improving communication through a collaborative, patient-centered intervention will improve asthma management, empower the patient and family, decrease outcome disparities, and decrease direct and indirect costs. Methods The specific aims of this study include the following: (1) Aim 1: produce and validate a Spanish translation of an existing asthma management app and evaluate its usability with Latino parents of children with asthma, (2) Aim 2: develop and evaluate a triadic, patient-centered asthma intervention preliminary protocol, facilitated by the bilingual mobile app validated in Aim 1, and (3) Aim 3: investigate the feasibility of the patient-centered asthma intervention from Aim 2 using a waiting-list randomized controlled trial (RCT) to investigate the effects of the intervention on school days missed and medication adherence. Results Mobile app translation, initial usability testing, and app software refinement were completed in 2019. Analysis is in progress. Preliminary protocol testing is underway; we anticipate that the waiting-list RCT, using the refined protocol developed in Aim 2, will commence in fall 2020. Conclusions Tailored, technology-based solutions have the potential to successfully address issues affecting asthma management, including communication barriers, accessibility issues, medication adherence, and suboptimal technological interventions. Trial Registration ClinicalTrials.gov NCT04633018; https://www.clinicaltrials.gov/ct2/show/NCT04633018 International Registered Report Identifier (IRRID) DERR1-10.2196/18977
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Affiliation(s)
- Robin M Dawson
- College of Nursing, University of South Carolina, Columbia, SC, United States
| | - Sue P Heiney
- College of Nursing, University of South Carolina, Columbia, SC, United States
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6
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Nicholson E, McDonnell T, De Brún A, Barrett M, Bury G, Collins C, Hensey C, McAuliffe E. Factors that influence family and parental preferences and decision making for unscheduled paediatric healthcare - systematic review. BMC Health Serv Res 2020; 20:663. [PMID: 32680518 PMCID: PMC7366445 DOI: 10.1186/s12913-020-05527-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 07/09/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Health systems offer access to unscheduled care through numerous routes; however, it is typically provided by general practitioners (GPs), by emergency medicine doctors in in emergency departments (EDs) and by GPs in out-of-hours GP services such as practitioner cooperatives. Unscheduled healthcare constitutes a substantial portion of healthcare delivery. A systematic review was conducted to establish the factors that influence parents' decision making when seeking unscheduled healthcare for their children. The systematic review question was "What are the factors that influence the decision making of parents and families seeking unscheduled paediatric healthcare?" METHOD Five databases (CINAHL, PubMed, SCOPUS, PsycInfo, EconLit) and four grey literature databases (Proquest, Lenus, OpenGrey, Google Scholar) were searched. The titles and abstracts of 3746 articles were screened and full-text screening was performed on 177 of these articles. Fifty-six papers were selected for inclusion in the review. Data relating to different types of unscheduled health services (namely primary care, the emergency department and out-of-hours services) were extracted from these articles. A narrative approach was used to synthesise the extracted data. RESULTS Several factors were identified as influencing parental preferences and decision making when seeking unscheduled healthcare for their children. A number of the included studies identified pre-disposing factors such as race, ethnicity and socioeconomic status (SES) as impacting the healthcare-seeking behaviour of parents. Unscheduled healthcare use was often initiated by the parent's perception that the child's condition was urgent and their need for reassurance. The choice of unscheduled service was influenced by a myriad of factors such as: waiting times, availability of GP appointments, location of the ED, and the relationship that the parent or caregiver had with their GP. CONCLUSION Policy and planning initiatives do not always reflect how patients negotiate the health system as a single entity with numerous entry points. Altering patients' behaviour through public health initiatives that seek to improve, for instance, health literacy or reducing emergency hospital admissions through preventative primary care requires an understanding of the relative importance of factors that influence behaviour and decision making, and the interactions between these factors.
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Affiliation(s)
- E. Nicholson
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS) UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - T. McDonnell
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS) UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - A. De Brún
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS) UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
| | - M. Barrett
- Department of Emergency Medicine/National Children’s Research Centre, Children’s Health Ireland at Crumlin, Dublin, Ireland
- UCD School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - G. Bury
- UCD School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
| | - C. Collins
- Irish College of General Practitioners, 4/5 Lincoln Place, Dublin 2, Ireland
| | - C. Hensey
- Children’s Health Ireland at Temple St, Temple St, Rotunda, Dublin 1, Ireland
| | - E. McAuliffe
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems (IRIS) UCD School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin 4, Ireland
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Shi Q, Castillo F, Viswanathan K, Kupferman F, MacDermid JC. Low Income and Nonadherence to Health Supervision Visits Predispose Children to More Emergency Room Utilization. Glob Pediatr Health 2020; 7:2333794X20938938. [PMID: 35187205 PMCID: PMC8851101 DOI: 10.1177/2333794x20938938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 11/17/2022] Open
Abstract
Social inequity can have broad health impacts. The purpose of this study was to examine the effects of low income and nonadherence to health supervision visits on emergency room (ER) utilization in Eastern Brooklyn, New York. This study surveyed parents/guardians of children who received routine medical care at Brookdale ambulatory clinics from June 2017 to February 2018. Participants were asked to fill out a questionnaire on social demographics, food insecurity, and relocation. Electronic medical records (EMRs) were reviewed to retrieve numbers of missing health supervision and ER visit in past 12 months. Comorbidity was identified through EMR by International Classification of Diseases. Logistic regression analyses were used to examine the effects of nonadherence to health supervision visits on ER utilization when controlling for demographics, food insecurity, recent moving, and comorbidity. Among 268 participants, 56.0% reported their household income was less than $20,000 annually, 39.6% missed at least 1 health supervision visit, and 31.7% had at least 1 ER visit within the past 12 months. Younger age (adjusted odds ratio [aOR] = 0.92, 95% confidence interval [CI] = 0.86-0.97, P < .01), household income less than $20,000 (aOR = 1.86, 95% CI = 1.02-3.39), preexisting comorbidity (aOR = 2.36, 95% CI = 1.26-4.42), and nonadherence to health supervision visits (aOR = 5.83, 95% CI = 3.21-10.56) were associated with increased ER utilization. Nonadherence to health supervision visits is an independent risk factor and potentially modifiable. Evaluation and remediation should be pursued as a means of improving health outcomes of children in vulnerable circumstances.
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Affiliation(s)
- Qiyun Shi
- McMaster University, Hamilton, Ontario, Canada
- Brookdale University Hospital and Medical Center, New York, NY, USA
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8
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Butz AM, Bollinger ME, Ogborn J, Morphew T, Mudd SS, Kub JE, Bellin MH, Lewis-Land C, DePriest K, Tsoukleris M. Children with poorly controlled asthma: Randomized controlled trial of a home-based environmental control intervention. Pediatr Pulmonol 2019; 54:245-256. [PMID: 30614222 PMCID: PMC6408727 DOI: 10.1002/ppul.24239] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/08/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Few trials have tested targeted environmental control (EC) interventions based on biomarkers of second hand smoke (SHS) exposure and allergen sensitization in reducing asthma emergency department (ED) visits in children with poorly controlled asthma. METHODS Overall, 222 children with poorly controlled asthma were randomized into a home-based EC intervention (INT) or control (CON) group and followed for ED visits over 12 months. All children received allergen-specific IgE serologic testing and SHS exposure biomarker testing to inform the EC intervention. Pharmacy data was examined for asthma medication fills. Cox proportional hazards and multivariate regression models were performed to examine factors associated with repeat ED visits. RESULTS There was no difference in increased risk of >1 ED visit at 12 months between INT and CON groups. Most children (75%) had moderate/severe persistent asthma. Over half (56%) had SHS exposure and 83% tested positive for >1 allergen sensitization. Among children without SHS exposure, the median time to first recurrent ED visit differed by group (CON: 195; INT: >365 days) after adjusting for child age, allergic sensitization, medication fills prior to baseline, controller medication use, and the interaction between group status and SHS exposure. Children who had positive allergic sensitizations, younger, had increased controller medication use and randomized to the CON group and had no SHS exposure had increased risk for a repeat ED visit over 12 months. CONCLUSIONS In this study, a home-based EC intervention was not successful in reducing asthma ED revisits in children with poorly controlled asthma with SHS exposure. Allergic sensitization, young age, and increased controller medication use were important predictors of asthma ED visits.
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Affiliation(s)
- Arlene Manns Butz
- Division of General Pediatrics and Adolescent Medicine, Baltimore, Maryland.,The Johns Hopkins University School of Nursing, University of Maryland, Baltimore, Maryland
| | - Mary E Bollinger
- School of Medicine, Department of Pediatrics, Baltimore, Maryland
| | - Jean Ogborn
- Department of Pediatric Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Shawna S Mudd
- The Johns Hopkins University School of Nursing, University of Maryland, Baltimore, Maryland
| | - Joan E Kub
- Department of Nursing, USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California.,University of Maryland, Baltimore, Maryland
| | - Melissa H Bellin
- School of Social Work, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cassia Lewis-Land
- Division of General Pediatrics and Adolescent Medicine, Baltimore, Maryland
| | - Kelli DePriest
- The Johns Hopkins University School of Nursing, University of Maryland, Baltimore, Maryland
| | - Mona Tsoukleris
- The School of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, Maryland
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9
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Pade KH, Agnihotri NT, Vangala S, Thompson LR, Wang VJ, Okelo SO. Asthma specialist care preferences among parents of children receiving emergency department care for asthma. J Asthma 2019; 57:188-195. [PMID: 30663904 DOI: 10.1080/02770903.2019.1565768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To learn factors associated with desire for asthma specialist care among parents of children seeking emergency department (ED) care for asthma, and if referral was indicated based on national asthma guidelines. Methods: We surveyed parents of children ages 0-18 years seeking pediatric ED asthma care, then comparisons were made according to parental level of interest in asthma specialist care, with regard to socio-demographics, asthma morbidity and care, by chi-squared and logistic regression. Results: Of 149 children, 20% reported specialist care, but 75% met guideline criteria for referral. About 80% of parents not seeing an asthma specialist expressed a desire to see one. Higher rates of prior urgent care visits (48% vs. 22%, p = 0.03), ED visits (82% vs. 35%, p < 0.001) and oral steroid use (53% vs. 22%, p = 0.009) were reported by parents who desired an asthma specialist compared with parents who did not. 87% of parents not seeing a specialist attributed this to a perceived lack of necessity by their primary care provider. An ED visit within the prior 12 months was the most significant predictor in parental desire for specialist care (odds ratio 9.75; 95% CI 3.42-27.76) in adjusted logistic regression models. Conclusion: High rates of parental preference for asthma specialist care suggest that directly querying parents may be an efficient method to identify children appropriate for specialist care in the ED.
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Affiliation(s)
- Kathryn H Pade
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
| | - Neha T Agnihotri
- Division of Internal Medicine & Pediatrics, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sitaram Vangala
- Division of General Internal Medicine and Health Services Research, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lindsey R Thompson
- Department of Pediatrics, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Vincent Joseph Wang
- Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Sande O Okelo
- Department of Pediatrics, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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10
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Cabey WV, Shea JA, Kangovi S, Kennedy D, Onwuzulike C, Fein J. Understanding Pediatric Caretakers' Views on Obtaining Medical Care for Low-acuity Illness. Acad Emerg Med 2018; 25:1004-1013. [PMID: 29741232 DOI: 10.1111/acem.13436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 04/07/2018] [Accepted: 04/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND A significant proportion of low-acuity emergency department (ED) visits are by patients under 18 years of age. Results from prior interventions designed to reduce low-acuity pediatric ED use have been mixed or poorly sustained, perhaps because they were not informed by patient and caretakers' perspectives. The objective of this study was to explore caretaker decision-making processes, values, and priorities when deciding to seek care. METHODS We conducted semistructured interviews of caretakers in both emergency and primary care settings, incorporating stimulated recall methodology. We also explored receptiveness to two care delivery innovations: use of community health workers (CHWs) and video teleconferencing. RESULTS Interviews of 57 caretakers identified multiple barriers to accessing primary care for their children's acute illness, including transportation, work constraints, and childcare. Frequent ED users lacked reliable social supports to overcome barriers. Fear of unforeseen health outcomes and a lack of trust in unfamiliar providers also influenced decision-making, rather than lack of general knowledge about minor illness. Receptiveness to CHWs was mixed, reflecting concerns for privacy and level of expertise. The option of video teleconferencing for low-acuity care was well received by caretakers. CONCLUSIONS Caretakers who used the ED frequently had limited social support and reported difficulty accessing care when compared to other caretakers. Fear also motivated care seeking and a desire for immediate medical care. Teleconferencing for low-acuity visits may be a useful health care delivery tool to reduce access barriers and provide rapid reassurance without engaging the ED.
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Affiliation(s)
| | - Judy A. Shea
- Department of Medicine Division of General Internal Medicine Philadelphia PA
| | - Shreya Kangovi
- Department of Medicine Division of General Internal Medicine Philadelphia PA
| | | | | | - Joel Fein
- Department of Pediatrics Perelman School of Medicine The Children's Hospital of Philadelphia Philadelphia PA
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11
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Ostermeyer B, Baweja NUA, Schanzer B, Han J, Shah AA. Frequent Utilizers of Emergency Departments: Characteristics and Intervention Opportunities. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20171206-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Das LT, Abramson EL, Stone AE, Kondrich JE, Kern LM, Grinspan ZM. Predicting frequent emergency department visits among children with asthma using EHR data. Pediatr Pulmonol 2017; 52:880-890. [PMID: 28557381 DOI: 10.1002/ppul.23735] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/24/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE For children with asthma, emergency department (ED) visits are common, expensive, and often avoidable. Though several factors are associated with ED use (demographics, comorbidities, insurance, medications), its predictability using electronic health record (EHR) data is understudied. METHODS We used a retrospective cohort study design and EHR data from one center to examine the relationship of patient factors in 1 year (2013) and the likelihood of frequent ED use (≥2 visits) in the following year (2014), using bivariate and multivariable statistics. We applied and compared several machine-learning algorithms to predict frequent ED use, then selected a model based on accuracy, parsimony, and interpretability. RESULTS We identified 2691 children. In bivariate analyses, future frequent ED use was associated with demographics, co-morbidities, insurance status, medication history, and use of healthcare resources. Machine learning algorithms had very good AUC (area under the curve) values [0.66-0.87], though fair PPV (positive predictive value) [48-70%] and poor sensitivity [16-27%]. Our final multivariable logistic regression model contained two variables: insurance status and prior ED use. For publicly insured patients, the odds of frequent ED use were 3.1 [2.2-4.5] times that of privately insured patients. Publicly insured patients with 4+ ED visits and privately insured patients with 6+ ED visits in a year had ≥50% probability of frequent ED use the following year. The model had an AUC of 0.86, PPV of 56%, and sensitivity of 23%. CONCLUSION Among children with asthma, prior frequent ED use and insurance status strongly predict future ED use.
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Affiliation(s)
- Lala T Das
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York
| | - Erika L Abramson
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York.,Department of Pediatrics, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York
| | - Anne E Stone
- Department of Pediatrics, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York
| | - Janienne E Kondrich
- Department of Pediatrics, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York
| | - Lisa M Kern
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York.,Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Zachary M Grinspan
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York.,Department of Pediatrics, Weill Cornell Medicine, New York, New York.,New York Presbyterian Hospital, New York, New York
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13
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Mudd SS, Ogborn CJ, Bollinger ME, Morphew T, Kub J, Lewis-Land C, Bellin MH, Butz A. Parental decision making associated with pediatric emergency department use for asthma. Ann Allergy Asthma Immunol 2016; 117:490-494. [PMID: 27788877 PMCID: PMC5117360 DOI: 10.1016/j.anai.2016.08.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/16/2016] [Accepted: 08/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Disadvantaged minority children are disproportionately affected by asthma. This group is also known to frequently use the emergency department (ED) for asthma care. Understanding decisions for use of the ED is important to prevent high cost. OBJECTIVE To examine caregiver factors associated with the decision to use the ED for asthma care in inner-city children with asthma. METHODS One hundred fifty participants in a randomized clinical trial testing the effectiveness of a home-based asthma intervention were enrolled, and questionnaires were administered to caregivers during the child's ED asthma visit. Sociodemographics, health characteristic data, and caregiver interview data were examined to ascertain factors that affected caregiver decision making to use the ED for asthma care. A cluster analysis was performed to correlate caregiver reasons for the decision to use the ED for asthma care. RESULTS Three clusters emerged for decision making: urgency, preference for the use of the ED, and access to care issues. The perception of urgency was the most common reason reported by caregivers (91%) followed by reporting a preference for the ED for care (37%) and reporting access to care issues (31%). Access to care was primarily attributable to the inability to get a same-day appointment with their primary care practitioner (24%). CONCLUSION The caregiver factors involved in the decision to use the ED can provide a basis for further intervention and investigation. Such factors include caregiver asthma home management, improvement in relationships with primary care practitioners, and access to care-related issues.
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Affiliation(s)
- Shawna S Mudd
- Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, Maryland.
| | - C Jean Ogborn
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Joan Kub
- Department of Community and Public Health, Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Cassie Lewis-Land
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa H Bellin
- University of Maryland School of Social Work, Baltimore, Maryland
| | - Arlene Butz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Makhinova T, Barner JC, Richards KM, Rascati KL. Asthma Controller Medication Adherence, Risk of Exacerbation, and Use of Rescue Agents Among Texas Medicaid Patients with Persistent Asthma. J Manag Care Spec Pharm 2016; 21:1124-32. [PMID: 26679962 PMCID: PMC10401995 DOI: 10.18553/jmcp.2015.21.12.1124] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adherence to asthma long-term controller medications is one of the key drivers to improve asthma management among patients with persistent asthma. While suboptimal use of controller medications has been found to be associated with more frequent use of oral corticosteroids (OCS), few studies exist regarding the relationship between adherence to controller therapy and the use of short-acting beta2-agonists (SABAs). A better understanding of the association between adherence to asthma controller agents and use of reliever medications will help health care providers and decision makers enhance asthma management. OBJECTIVE To determine if there is a relationship between asthma controller adherence, risk of exacerbation requiring OCS, and use of asthma rescue agents. METHODS Texas Medicaid claims data from January 1, 2008, to August 31, 2011, were retrospectively analyzed. Continuously enrolled patients aged 5-63 years with a primary diagnosis of asthma (ICD-9-CM code 493) and with 4 or more prescription claims for any asthma medication in 1 year (persistent asthma) were included. The index date was the date of the first asthma controller prescription, and patients were followed for 1 year. The primary outcome variables were SABA (dichotomous: less than 6 vs. ≥ 6) and OCS (continuous) use. The primary independent variable was adherence (proportion of days covered [PDC]) to asthma long-term controller medications. Covariates included demographics and nonstudy medication utilization. Multivariate logistic and linear regression analyses were employed to address the study objective. RESULTS The study sample (n = 32,172) was aged 15.0 ± 14.5 years, and adherence to controller therapy was 32.2% ± 19.7%. The mean number of SABA claims was 3.7 ± 3.1, with most patients having 1-5 claims (73.2%), whereas 19.4% had ≥ 6 SABA claims. The mean number of OCS claims was 1.0 ± 1.4. Adherent (PDC ≥ 50%) patients were 96.7% (OR = 1.967; 95% CI = 1.826-2.120) more likely to have ≥ 6 SABA claims when compared with nonadherent (PDC less than 50%) patients (P less than 0.001). As for OCS use, adherent patients had 0.11 fewer claims compared with nonadherent patients (P less than 0.001). Importantly, patients with ≥ 6 SABA claims had 0.7 more OCS claims compared with patients with less than 6 claims for SABA (P less than 0.001). The odds of having ≥ 6 SABA claims were higher for concurrent dual therapy users, older age, males, African Americans and higher number of nonstudy medications (P less than 0.001). Dual therapy users, younger age, Hispanic ethnicity, and higher number of nonstudy medications were associated with an increase in OCS use (P less than 0.005). CONCLUSIONS Adherence to long-term controller medications was suboptimal among patients with asthma. Adherent patients had fewer OCS claims, indicating that adherence to controller therapy is critical in preventing asthma exacerbations requiring OCS use. Although there was a positive relationship between adherence to long-term controller medication and SABA use, increased SABA use served as a predictor of increased OCS use, which indicates poor asthma control. Health care providers should be aware of OCS and SABA use among patients who are both adherent and nonadherent to asthma controller medications.
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Affiliation(s)
- Tatiana Makhinova
- The University of Texas at Austin, 2409 University Ave., STOP A1930, Austin, TX 78712-1120.
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Baltrus P, Xu J, Immergluck L, Gaglioti A, Adesokan A, Rust G. Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach. J Asthma 2016; 54:53-61. [PMID: 27285734 DOI: 10.1080/02770903.2016.1196367] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. RESULTS The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. CONCLUSIONS At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.
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Affiliation(s)
- Peter Baltrus
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,b Department of Community Health & Preventive Medicine , Morehouse School of Medicine , Atlanta , GA , USA
| | - Junjun Xu
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA
| | - Lilly Immergluck
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,c Departments of Microbiology , Biochemistry, & Immunology and Pediatrics, Morehouse School of Medicine , Atlanta , GA , USA
| | - Anne Gaglioti
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,d Department of Family Medicine , Morehouse School of Medicine , Atlanta , GA , USA
| | - Adeola Adesokan
- e Master of Science in Clinical Research Program, Morehouse School of Medicine , Atlanta , GA , USA
| | - George Rust
- a National Center for Primary Care, Morehouse School of Medicine , Atlanta , GA , USA.,d Department of Family Medicine , Morehouse School of Medicine , Atlanta , GA , USA
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Hasegawa K, Stoll SJ, Ahn J, Kysia RF, Sullivan AF, Camargo CA. Association of Insurance Status with Severity and Management in ED Patients with Asthma Exacerbation. West J Emerg Med 2016; 17:22-7. [PMID: 26823926 PMCID: PMC4729414 DOI: 10.5811/westjem.2015.11.28715] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 11/02/2015] [Accepted: 11/17/2015] [Indexed: 02/07/2023] Open
Abstract
Introduction Previous studies have demonstrated an association of low socioeconomic status with frequent asthma exacerbations. However, there have been no recent multicenter efforts to examine the relationship of insurance status – a proxy for socioeconomic status – with asthma severity and management in adults. The objective is to investigate chronic and acute asthma management disparities by insurance status among adults requiring emergency department (ED) treatment in the United States. Methods We conducted a multicenter chart review study (48 EDs in 23 U.S. states) on ED patients, aged 18–54 years, with acute asthma between 2011 and 2012. Each site underwent training (lecture, practice charts, certification) before reviewing randomly selected charts. We categorized patients into three groups based on their primary health insurance: private, public, and no insurance. Outcome measures were chronic asthma severity (as measured by ≥2 ED visits in one-year period) and management prior to the index ED visit, acute asthma management in the ED, and prescription at ED discharge. Results The analytic cohort comprised 1,928 ED patients with acute asthma. Among these, 33% had private insurance, 40% had public insurance, and 27% had no insurance. Compared to patients with private insurance, those with public insurance or no insurance were more likely to have ≥2 ED visits during the preceding year (35%, 49%, and 45%, respectively; p<0.001). Despite the higher chronic severity, those with no insurance were less likely to have guideline-recommended chronic asthma care – i.e., lower use of inhaled corticosteroids (ICS [41%, 41%, and 29%; p<0.001]) and asthma specialist care (9%, 10%, and 4%; p<0.001). By contrast, there were no significant differences in acute asthma management in the ED – e.g., use of systemic corticosteroids (75%, 79%, and 78%; p=0.08) or initiation of ICS at ED discharge (12%, 12%, and 14%; p=0.57) – by insurance status. Conclusion In this multicenter observational study of ED patients with acute asthma, we found significant discrepancies in chronic asthma severity and management by insurance status. By contrast, there were no differences in acute asthma management among the insurance groups.
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Affiliation(s)
- Kohei Hasegawa
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Samantha J Stoll
- North Shore Medical Center, Department of Emergency Medicine, Salem, Massachusetts
| | - Jason Ahn
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Rashid F Kysia
- John H. Stroger Jr. Hospital of Cook County, Department of Emergency Medicine, Chicago, Illinois
| | - Ashley F Sullivan
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A Camargo
- Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
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18
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Hamburger R, Berhane Z, Gatto M, Yunghans S, Davis RK, Turchi RM. Evaluation of a statewide medical home program on children and young adults with asthma. J Asthma 2015; 52:940-8. [PMID: 25539026 DOI: 10.3109/02770903.2014.999282] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Asthma, the most common chronic condition among children, accounts for significant healthcare utilization and impact on quality of life. Care coordination in a medical home is considered standard practice, but has not been rigorously evaluated. METHODS We initiated this pilot study of children/young adults with asthma (n = 967), ages: birth to 24 years, receiving care from a subset of pediatric practices (n = 20) participating in the Pennsylvania Medical Home Initiative, Educating Practices in Community-Integrated Care (92 practices statewide). We hypothesized children and youth with asthma receiving care coordination in the context of a formal medical home program would experience favorable associations with healthcare utilization and quality of life measures. RESULTS A total of 9240 care coordination encounters for this cohort of children/youth occurred over 100 days. The average length of care coordination encounter was 20.7 minutes. The most common care coordination activity was referral management (21%) and the care coordinator in the practice most often contacted parent/family and specialists (75%). Children with more severe asthma had more hospitalizations and emergency department (ED) visits than children with less severe asthma. There was a significant decrease in school absences, ED visits and acute care visits for children/youth with asthma with increasing length of time in a medical home program (p < 0.05). CONCLUSION Care coordination for children/youth with asthma is feasible and may yield improvements in healthcare utilization, expenditures and quality of life. Larger-scale implementation of care coordination and medical home models for children/youth with asthma and other diagnoses are warranted.
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Affiliation(s)
- Robert Hamburger
- a Nova Southeastern University College of Osteopathic Medicine , Fort Lauderdale , FL , USA .,b Department of Epidemiology and Biostatistics , School of Public Health, Drexel University , Philadelphia , PA , USA
| | - Zekarias Berhane
- b Department of Epidemiology and Biostatistics , School of Public Health, Drexel University , Philadelphia , PA , USA
| | - Molly Gatto
- c Make-A-Wish Foundation of Philadelphia and Susquehanna Valley , Blue Bell , PA , USA
| | - Suzanne Yunghans
- d Pennsylvania Chapter, American Academy of Pediatrics , Media , PA , USA
| | - Renee K Davis
- e Department of Community Health and Prevention , Maternal and Child Health Working Group, School of Public Health, Drexel University , Philadelphia , PA , USA
| | - Renee M Turchi
- e Department of Community Health and Prevention , Maternal and Child Health Working Group, School of Public Health, Drexel University , Philadelphia , PA , USA .,f Department of Pediatrics , St. Christopher's Hospital for Children , Philadelphia , PA , USA , and.,g Department of Community Health and Prevention , School of Public Health, Drexel University , Philadelphia , PA , USA
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Hurley SL, Colling C, Bender L, Harris PS, Harrold JK, Teno JM, Ache KA, Casarett D. Increasing inpatient hospice use versus patient preferences in the USA: are patients able to die in the setting of their choice? BMJ Support Palliat Care 2014; 7:46-52. [PMID: 25394918 DOI: 10.1136/bmjspcare-2013-000599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 09/24/2014] [Accepted: 10/27/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND Growth in hospice utilisation has been accompanied by an increase in the proportion of hospice patients who die in an inpatient hospice setting rather than at home. OBJECTIVE To determine whether this increase in inpatient utilisation is consistent with patient preferences. DESIGN Retrospective cohort study. SETTING Seven hospices in the Coalition of Hospices Organised to Investigate Comparative Effectiveness (CHOICE) network. PATIENTS 70 488 patients admitted between 1 July 2008 and 31 May 2012. MEASUREMENTS We measured changes in patients' stated preferences at the time of admission regarding site of death, including weights to adjust for non-response bias. We also assessed patients' actual site of death and concordance with patients' preferences. RESULTS More patients died receiving inpatient care in 2012 as compared to 2008 (1920 (32.7%), 2537 (18.5%); OR 1.21; 95% CI 1.19 to 1.22; p<0.001). However, patients also expressed an increasing preference for dying in inpatient settings (weighted preferences 27.5% in 2012 vs 7.9% in 2008; p<0.001). The overall proportion of patients who died in the setting of their choice (weighted preferences) increased from 74% in 2008 to 78% in 2012 (p<0.001). LIMITATIONS This study included only seven hospices, and results may not be representative of the larger hospice population. CONCLUSIONS Although more patients are dying while receiving inpatient care, these changes in site of death seem to reflect changing patient preferences. The net effect is that patients in this sample were more likely to die in the setting of their choice in 2012 than they were in 2008.
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Affiliation(s)
| | - Caitlin Colling
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura Bender
- Penn Home Care & Hospice Services, Penn Medicine, Bala Cynwyd, Pennsylvania, USA
| | - Pamela S Harris
- Kansas City Hospice and Palliative Care, Kansas City, Missouri, USA
| | | | - Joan M Teno
- Brown University School of Public Health, Providence, Rhode Island, USA
| | | | - David Casarett
- Division of Geriatric Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Magzamen S, Brandt SJ, Tager IB. Examining household asthma management behavior through a microeconomic framework. HEALTH EDUCATION & BEHAVIOR 2014; 41:651-62. [PMID: 24799127 DOI: 10.1177/1090198114532288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
National guidelines on the effective management of pediatric asthma have been promoted for over 20 years, yet asthma-related morbidity among low-income children remains disproportionately high. To date, household and clinical interventions designed to remediate these differences have been informed largely by a health behavior framework. However, these programs have not resulted in consistent sustained improvements in targeted populations. The continued funding and implementation of programs based on the health behavior framework leads us to question if traditional behavioral models are sufficient to understand and promote adaptation of positive health management behaviors. We introduce the application of the microeconomic framework to investigate potential mechanisms that can lead to positive management behaviors to improve asthma-related morbidity. We provide examples from the literature on health production, preferences, trade-offs and time horizons to illustrate how economic constructs can potentially add to understanding of disease management. The economic framework, which can be empirically observed, tested, and quantified, can explicate the engagement in household-level activities that would affect health and well-being. The inclusion of a microeconomic perspective in intervention research may lead to identification of mechanisms that lead to household decisions with regard to asthma management strategies and behavior. The inclusion of the microeconomic framework to understand the production of health may provide a novel theoretical framework to investigate the underlying causal behavioral mechanisms related to asthma management and control. Adaptation of an economic perspective may provide new insight into the design and implementation of interventions to improve asthma-related morbidity in susceptible populations.
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Affiliation(s)
- Sheryl Magzamen
- University of California, Berkeley, Berkeley, CA, USA University of Wisconsin-Madison, Madison, USA
| | | | - Ira B Tager
- University of California, Berkeley, Berkeley, CA, USA
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Wang L, Tchopev N, Kuntz-Melcavage K, Hawkins M, Richardson R. Patient-Reported Reasons for Emergency Department Visits in the Urban Medicaid Population. Am J Med Qual 2014; 30:156-60. [DOI: 10.1177/1062860614525225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Lin Wang
- Johns Hopkins Medical Institutions, Baltimore, MD
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Hudson SM, Newman SD, Hester WH, Magwood GS, Mueller M, Laken MA. Factors influencing hospital admissions and emergency department visits among children with complex chronic conditions: a qualitative study of parents' and providers' perspectives. ACTA ACUST UNITED AC 2014; 37:61-80. [PMID: 24423943 DOI: 10.3109/01460862.2013.855844] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Children with complex chronic conditions (CCC) have greater health care needs and use rates than children in general. Elevated health care use includes more frequent hospital admissions, longer hospital stays, and greater health care expenses. Prior studies have examined population characteristics associated with increased hospital admissions, emergency department (ED) use, and general healthcare use, yet few studies have investigated these events from the parents' or health care providers' point of view. The purpose of this study was to explore parents/caregivers' and health care providers' perceptions of the factors placing infants and young children with CCC at risk for or protecting them against hospital admissions and ED visits. Parents or primary caregivers participated in interviews, and health care providers in pediatric acute care, pediatric primary care, and emergency care participated in focus groups. Interview and focus group data were analyzed using directed content analysis and an ecological risk and protective factors model. The analysis revealed that parents/caregivers and health care providers described risk factors and protective factors on multiple ecological levels surrounding the child with CCC. This article presents these findings, which add to current knowledge of factors influencing hospital admissions and ED visits and may be used to inform interventions addressing high health care utilization in this population. This article concludes with the implications of the findings for future research and nursing practice.
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Affiliation(s)
- Shannon M Hudson
- College of Nursing Faculty, Medical University of South Carolina College of Nursing , Charleston, SC , USA and
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23
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Olaguibel JM, Quirce S, Juliá B, Fernández C, Fortuna AM, Molina J, Plaza V. Measurement of asthma control according to Global Initiative for Asthma guidelines: a comparison with the Asthma Control Questionnaire. Respir Res 2012; 13:50. [PMID: 22726416 PMCID: PMC3462124 DOI: 10.1186/1465-9921-13-50] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 06/01/2012] [Indexed: 11/23/2022] Open
Abstract
Introduction Asthma Control Questionnaire (ACQ) is a validated tool to measure asthma control. Cut-off points that best discriminate “well-controlled” or “not well-controlled” asthma have been suggested from the analysis of a large randomized clinical trial but they may not be adequate for daily clinical practice. Aims To establish cut-off points of the ACQ that best discriminate the level of control according to Global Initiative for Asthma (GINA) 2006 guidelines in patients with asthma managed at Allergology and Pulmonology Departments as well as Primary Care Centers in Spain. Patients and methods An epidemiological descriptive study, with prospective data collection. Asthma control following GINA-2006 classification and 7-item ACQ was assessed. The study population was split in two parts: 2/3 for finding the cut-off points (development population) and 1/3 for validating the results (validation population). Results A total of 1,363 stable asthmatic patients were included (mean age 38 ± 14 years, 60.3% women; 69.1% non-smokers). Patient classification according to GINA-defined asthma control was: controlled 13.6%, partially controlled 34.2%, and uncontrolled 52.3%. The ACQ cut-off points that better agreed with GINA-defined asthma control categories were calculated using receiver operating curves (ROC). The analysis showed that ACQ < 0.5 was the optimal cut-off point for “controlled asthma” (sensitivity 74.1%, specificity 77.5%) and 1.00 for “uncontrolled asthma” (sensitivity 73%, specificity 88.2%). Kappa index between GINA categories and ACQ was 0.62 (p < 0.001). Conclusion The ACQ cut-off points associated with GINA-defined asthma control in a real-life setting were <0.5 for controlled asthma and ≥1 for uncontrolled asthma.
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Affiliation(s)
- José María Olaguibel
- Department of Allergy, Complejo Hospitalario de Navarra, Fundación Miguel Servet, Pamplona, Spain
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Canino G, Garro A, Alvarez MM, Colón-Semidey A, Esteban C, Fritz G, Koinis-Mitchell D, Kopel SJ, Ortega AN, Seifer R, McQuaid EL. Factors associated with disparities in emergency department use among Latino children with asthma. Ann Allergy Asthma Immunol 2012; 108:266-70. [PMID: 22469447 PMCID: PMC3324101 DOI: 10.1016/j.anai.2012.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 01/18/2012] [Accepted: 02/01/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND Significant disparities in emergency department (ED) rates exist for Latinos; however, few studies have investigated the factors that may account for these disparities. OBJECTIVES To examine individual/family and health system factors among Latino and non-Latino white (NLW) children with asthma to explain disparities in ED rates. METHODS The study was carried out in Puerto Rico (PR) and Rhode Island (RI) with the same design: a cross-sectional, observational approach with repeated measurements of selected variables. RESULTS The sample was composed of 804 children ages 7 to 15 years, with 405 from PR and 399 from RI. Latino children from both sites had significantly higher rates of ED use as compared with NLWs from RI. Regression analyses showed site, asthma control, parental reported severity of asthma and public insurance to be significantly associated with ED use. CONCLUSION Latino ethnicity and public insurance were among the most important factors related to frequent ED use. Revisions of the policies driving public insurance to assure better access to specialists, preventive education, and evidence-based treatment are needed. The results also suggest the need for the development of interventions in the ED that are geared toward educating families on how best to use emergency services.
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Affiliation(s)
- Glorisa Canino
- University of Puerto Rico, Medical Sciences Campus, Behavioral Sciences Research Institute, San Juan, Puerto Rico.
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Tai T, Bame SI. Cost-benefit analysis of childhood asthma management through school-based clinic programs. J Community Health 2011; 36:253-60. [PMID: 20803167 DOI: 10.1007/s10900-010-9305-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Asthma is a leading chronic illness among American children. School-based health clinics (SBHCs) reduced expensive ER visits and hospitalizations through better healthcare access and monitoring in select case studies. The purpose of this study was to examine the cost-benefit of SBHC programs in managing childhood asthma nationwide for reduction in medical costs of ER, hospital and outpatient physician care and savings in opportunity social costs of lowing absenteeism and work loss and of future earnings due to premature deaths. Eight public data sources were used to compare costs of delivering primary and preventive care for childhood asthma in the US via SBHC programs, including direct medical and indirect opportunity costs for children and their parents. The costs of nurse staffing for a nationwide SBHC program were estimated at $4.55 billion compared to the estimated medical savings of $1.69 billion, including ER, hospital, and outpatient care. In contrast, estimated total savings for opportunity costs of work loss and premature death were $23.13 billion. Medical savings alone would not offset the expense of implementing a SBHC program for prevention and monitoring childhood asthma. However, even modest estimates of reducing opportunity costs of parents' work loss would be far greater than the expense of this program. Although SBHC programs would not be expected to affect the increasing prevalence of childhood asthma, these programs would be designed to reduce the severity of asthma condition with ongoing monitoring, disease prevention and patient compliance.
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Affiliation(s)
- Teresa Tai
- Department of Management, Quinnipiac University, 275 Mount Carmel Avenue, Hamden, CT 06518, USA.
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Grant R, Ramgoolam A, Betz R, Ruttner L, Green JJ. Challenges to Accessing Pediatric Health Care in the Mississippi Delta. J Prim Care Community Health 2010; 1:152-7. [DOI: 10.1177/2150131910380727] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Increases in hospital emergency department use have been driven by insured patients with problems accessing primary care services. Access problems are especially pronounced in rural communities with health professional shortages. This qualitative study explored reasons for nonurgent pediatric emergency department use in the Mississippi Delta. Method: Using a community-based participatory research framework, a semistructured survey was administered face-to-face in a hospital emergency department waiting room with parents/caregivers who brought their children. Interviews were done over 144 hours in 2-hour blocks covering regular “business hours” and “after hours” (evenings/weekends). Open-ended items allowed qualitative data to be gathered describing reasons for emergency department use and perceptions of urgency of the visit in the parents’/caregivers’ own words. Results: There were 112 children, with a response rate of 87%. The mean child age was 5.7 years; 52% were male; 95% were African American and 5% white; 80.6% had Medicaid/SCHIP, 7.8% commercial, and 3.9% other insurance; 7.8% were uninsured. Most (88%) had a usual source of pediatric care. Only 24.3% tried to obtain care before emergency department visit; 23.2% said their children required “urgent” care. Mean distance from home to usual source of care was 10 miles. Ten percent cited transportation as a barrier to keeping health care appointments; 5.5% cited insurance or cost. Families who used the emergency department during evening/weekends were significantly more likely to have cited clinic hours of operation as a reason care was not sought previously than were “business hours” users, who emphasized convenience. Conclusion: Nonurgent pediatric emergency department use could be reduced by extending clinic hours, adding a walk-in service, and making transportation more available.
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Affiliation(s)
- Roy Grant
- Children’s Health Fund, New York, NY, USA
| | | | - Ryan Betz
- Delta State University, Cleveland, MS, USA
| | - Laura Ruttner
- Columbia University, Mailman School of Public Health, New York, NY, USA
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Piper CN, Elder K, Glover S, Baek JD, Murph K. Disparities between asthma management and insurance type among children. J Natl Med Assoc 2010; 102:556-61. [PMID: 20690318 DOI: 10.1016/s0027-9684(15)30633-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Asthma is a chronic illness among children. Minority children may be vulnerable to asthma complications since more than half are from households that are poor or near poor, and some have no health insurance. Asthma management plans are important for the long-term treatment of asthma and beneficial for self-management. This study analyzed insurance type and the relationship between having an asthma management plan among children across all races with asthma. This study utilized the 2002 and 2003 National Health Interview Survey. Findings showed that whites were significantly more likely than Non-Hispanic blacks and Hispanics to have an asthma management plan (OR, 1.66; p = .0031). In this study, children who reported Children's Health insurance Program (CHIP) coverage were twice as likely to have an asthma management plan (OR, 2.67; p = .0004). Mandating all insurers to provide an asthma management plan to children with asthma may reduce the race-based inequities and differences in asthma management plan status.
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Affiliation(s)
- Crystal N Piper
- College of Health and Human Services-Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina 28223, USA.
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Roby DH, Pourat N, Pirritano MJ, Vrungos SM, Dajee H, Castillo D, Kominski GF. Impact of patient-centered medical home assignment on emergency room visits among uninsured patients in a county health system. Med Care Res Rev 2010; 67:412-30. [PMID: 20519430 DOI: 10.1177/1077558710368682] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Medical Services Initiative program--a safety net-based system of care--in Orange County included assignment of uninsured, low-income residents to a patient-centered medical home. The medical home provided case management, a team-based approach for treating disease, and increased access to primary and specialty care among other elements of a patient-centered medical home. Providers were paid an enhanced fee and pay-for-performance incentives to ensure delivery of comprehensive treatment. Medical Services Initiative enrollees who were assigned to a medical home for longer time periods were less likely to have any emergency room (ER) visits or multiple ER visits. Switching medical homes three or more times was associated with enrollees being more likely to have any ER visits or multiple ER visits. The findings provide evidence that successful implementation of the patient-centered medical home model in a county-based safety net system is possible and can reduce unnecessary ER use.
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Affiliation(s)
- Dylan H Roby
- University of California-Los Angeles, UCLA School of Public Health, Department of Health Services & Center for Health Policy Research, 10960 Wilshire Blvd, Suite 1550, Los Angeles, CA 90024, USA.
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Kaiser KL, Barry TL, Mason A. Maternal health and child asthma health services use. Clin Nurs Res 2009; 18:26-43. [PMID: 19208819 DOI: 10.1177/1054773808330095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The primary purpose of this pilot study was to examine the influence of maternal health status on health services use in children with the diagnosis of asthma. A secondary purpose was to assess both preventive and illness-related child health services use patterns. Fifty-two asthmatic children and 43 mothers met the inclusion criteria. The majority of mothers (72%, n = 31/43) rated their own overall health as good to excellent. Eighty-six percent (n = 38/44) of the children had a medical home, 20% had peak flow meters, 26% had been to see a specialist, and 4% were currently under the care of a specialist. This pilot study raises important questions about the influence of maternal health on child health services use patterns for asthmatic children from low-income families. Understanding the influence of maternal health on health-seeking patterns for children with asthma is important for nursing intervention.
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Rand CS, Apter AJ. Mind the widening gap: have improvements in asthma care increased asthma disparities? J Allergy Clin Immunol 2008; 122:319-21. [PMID: 18678342 PMCID: PMC4446570 DOI: 10.1016/j.jaci.2008.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 07/03/2008] [Accepted: 07/03/2008] [Indexed: 11/30/2022]
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Peters AT, Klemens JC, Haselkorn T, Weiss ST, Grammer LC, Lee JH, Chen H. Insurance status and asthma-related health care utilization in patients with severe asthma. Ann Allergy Asthma Immunol 2008; 100:301-7. [PMID: 18450113 DOI: 10.1016/s1081-1206(10)60590-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Medicaid insurance has been associated with worse asthma outcomes, but the degree to which demographic factors contribute to this relationship has not been well explored. OBJECTIVE To evaluate whether insurance status is independently associated with health care utilization (HCU) and asthma control when demographic differences are taken into account. METHODS We used baseline data from adults with severe asthma in the Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study. HCU was defined as hospitalization or emergency department visit for asthma in the past 3 months. Asthma control was evaluated using the Asthma Therapy Assessment Questionnaire. Multiple logistic regression was used to compare HCU and asthma control in patients with Medicaid vs those with private health insurance. RESULTS Of 1315 patients analyzed, 130 (9.9%) had Medicaid insurance and 1,185 (90.1%) had private insurance. Medicaid insurance was associated with younger age, female sex, race other than white, obesity, active smoking, lower education level, and unemployment. In unadjusted analyses, Medicaid patients had significantly higher HCU (odds ratio [OR], 3.08; 95% confidence interval [CI], 2.11-4.50) and poorer asthma control (OR, 2.56; 95% CI, 1.84-3.57) compared with patients with private insurance. After adjusting for demographic differences, insurance status was no longer associated with HCU (OR, 1.43; 95% CI, 0.92-2.23), and the strength of its association with asthma control was reduced (OR, 1.67; 95% CI, 1.17-2.40). CONCLUSIONS Medicaid insurance is not associated with increased HCU in patients with severe asthma once demographic factors have been taken into account but remains modestly associated with poorer asthma control.
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Affiliation(s)
- Anju T Peters
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Camargo CA, Ramachandran S, Ryskina KL, Lewis BE, Legorreta AP. Association between common asthma therapies and recurrent asthma exacerbations in children enrolled in a state Medicaid plan. Am J Health Syst Pharm 2007; 64:1054-61. [PMID: 17494905 DOI: 10.2146/ajhp060256] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To evaluate the effectiveness of budesonide inhalation suspension relative to other common asthma therapies in a high-risk population, a study was conducted to compare the risk of having a repeat asthma-related hospitalization or emergency department (ED) visit in a Medicaid population of children; the relationship between asthma medication adherence level and repeat asthma hospitalizations or ED visits was also evaluated. METHODS Children eight years of age or younger, with a hospitalization or ED visit for asthma between January 1999 and June 2001 (index event), were identified in a Florida Medicaid database. Claims data for each child were examined 12 months before and after the index event. Cox proportional hazards regression was used to model the risk of subsequent asthma exacerbation according to the asthma medication received during the first 30 days after the index event. Logistic regression was used to model the relationship between medication adherence as measured by the medication possession ratio (MPR) and the likelihood of a subsequent asthma exacerbation. RESULTS There were 10,976 children in the study. Patients who had a claim for budesonide inhalation suspension had a lower risk of a subsequent hospitalization or ED visit (hazard ratio, 0.55; 95% confidence interval, 0.41-0.76; p < 0.001) than patients who did not have budesonide inhalation suspension claims. Other controller medications were not associated with a reduction in the risk of subsequent asthma exacerbations. Adherence to medication was poor (a median MPR of 0.08 for budesonide inhalation suspension and a median MPR of 0.16 for any asthma controller medication). The odds of a repeat hospitalization or ED visit were significantly lower for children who were adherent to their asthma controller medication. CONCLUSION Children with asthma and insured by Medicaid were at a high risk of repeat exacerbations leading to increased hospitalizations and ED visits. Treatment with budesonide inhalation suspension in the first 30 days after a hospitalization or ED visit for asthma was associated with a significant reduction in the risk of repeat asthma-related hospitalizations or ED visits during the following year. Children who were adherent to their asthma controller medication had significantly lower odds of having a subsequent asthma exacerbation.
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Affiliation(s)
- Carlos A Camargo
- EMNet Coordinating Center, Massachusetts General Hospital, Boston, MA 02114, USA.
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Koné P. AJ, Rivard M, Laurier C. Impact of Follow-Up by The Primary Care Or Specialist Physician on Pediatric Asthma Outcomes after An Emergency Department Visit: The Case of Montreal, Canada. ACTA ACUST UNITED AC 2007. [DOI: 10.1089/pai.2006.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Abstract
Increasingly, geographic information systems employing spatial data are being used to identify communities with poorer health care status. Since health care indicators are strongly linked to income, could these data, usually based on adult indicators, be used for pediatric health care need? We hypothesized that individual-level indicators such as quality of life scales (QOL) would be better than community-level indicators at identifying families with poorer health care practices. Surveys and medical record reviews were used for a sample of 174 caregivers of young children. Lower level of income was associated with poorer scores on several QOL domains, and on the primary health practices (i.e., non-urgent emergency room use and lack of age-appropriate immunization status). One community-level indicator, the medically underserved area (MUA), was almost as good as the best individual-level indicators at predicting primary health care practices. The community-level indicator of MUA appears to meet its initial intent, providing information on the location of very low-income individuals with high health care need even among a sample of Medicaid-insured children with an identified health care provider.
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Affiliation(s)
- Cheryl Zlotnick
- Center for the Vulnerable Child, Children's Hospital & Research Center at Oakland, Oakland, CA 94609-1809, USA.
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Valença LM, Restivo PCN, Nunes MS. Variação sazonal nos atendimentos de emergência por asma em Gama, Distrito Federal. J Bras Pneumol 2006. [DOI: 10.1590/s1806-37132006000400005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: Quantificar o atendimento por asma em um serviço de emergência público e estudar a flutuação sazonal, considerando as condições climáticas locais, caracterizadas por duas estações, uma chuvosa e úmida e outra seca. MÉTODOS: Levantamento retrospectivo conduzido em um hospital geral comunitário. Um total de 37.642 consultas emergenciais por asma, bronquite, pneumonia, infecções de vias aéreas superiores e outras condições foram identificadas durante um período de dois anos. As informações constantes em cada guia de atendimento foram levantadas para posterior análise. RESULTADOS: Asma foi o segundo diagnóstico mais freqüente dentre as condições respiratórias (24%). A maioria das consultas por asma foi feita em crianças de zero a catorze anos (56,6%). A análise de regressão mostrou uma variação sazonal dos atendimentos, com concentração significativamente maior de casos de asma no mês de março (p = 0,0109) e concentração menor nos meses de agosto e setembro (p = 0,0485 e p = 0,0169, respectivamente). A correlação entre asma e clima foi mais significativa em relação à flutuação da umidade defasada de um e dois meses (p = 0,0026 e p = 0,0002, respectivamente). CONCLUSÃO: As visitas por asma ao pronto-socorro foram mais freqüentes durante a estação úmida. O aumento do número de casos cresceu um a dois meses após o aumento da umidade e diminuiu no período seco. Essa correlação positiva levanta a possibilidade de uma relação causal com a proliferação de ácaros domésticos e fungos ambientais.
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Valerio M, Cabana MD, White DF, Heidmann DM, Brown RW, Bratton SL. Understanding of asthma management: Medicaid parents' perspectives. Chest 2006; 129:594-601. [PMID: 16537856 DOI: 10.1378/chest.129.3.594] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE This article explores parental caregiver perspectives on barriers to asthma care in the Medicaid system. METHODS Focus groups were held for parents of children with persistent asthma to identify barriers to asthma care for children insured by Medicaid in the Ypsilanti, MI area. Semistructured questions regarding health goals, asthma care, and access were used. Themes were defined as distinct categories or concepts regarding aspects of asthma care and coded. RESULTS Thirty-six adults participated in four focus groups, 89% were the biological mother, and 64% were African American. Major themes identified included caregiver emotions, caregiver/patient knowledge, environmental issues, school/daycare support, Medicaid health-care system issues, the role of medical providers, and emerging adolescence. Parents demonstrated asthma awareness but were not confident in their role as the child's disease manager. A specific gap was seen in the caregiver's level of self-efficacy to control exposure to asthma triggers, monitor the child's symptoms, and modify medications based on asthma symptoms. CONCLUSION Medicaid-insured families face unique barriers related to income and insurance limitations as well as issues common to others with asthma. Caregivers demonstrated a high level of asthma knowledge, but like other caregivers gaps between knowledge and behavior existed. Barriers to asthma care that may be specific to Medicaid-insured patients included difficulty maintaining continuity of care due to physician participation in Medicaid programs, and concerns about possible differences in asthma care from health-care providers due to their Medicaid insurance status.
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Affiliation(s)
- Melissa Valerio
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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Jones CA, Clement LT, Hanley-Lopez J, Morphew T, Kwong KYC, Lifson F, Opas L, Guterman JJ. The Breathmobile Program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program. ACTA ACUST UNITED AC 2006; 8:205-22. [PMID: 16117716 DOI: 10.1089/dis.2005.8.205] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Despite more than a decade of education and research-oriented intervention programs, inner city children with asthma continue to engage in episodic "rescue" patterns of healthcare and experience a disproportionate level of morbidity. The aim of this study was to establish and evaluate a sustainable community-wide pediatric asthma disease management program designed to shift inner city children in Los Angeles from acute episodic care to regular preventive care in accordance with national standards. In 1995 the Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA), the Los Angeles County Department of Health Services (LAC DHS), and the Los Angeles Unified School District (LAUSD) established an agreement to initiate and sustain the Breathmobile Program. This program includes automated case identification, mobile school-based clinics, and highly structured clinical encounters supported by an advanced information technology solution. Interdisciplinary teams of asthma care specialists provide regular and ongoing care to children at school and county clinic sites over a wide geographic area of urban Los Angeles. Each team operates in a specially equipped mobile clinic (Breathmobile), efficiently moving a structured healthcare process to school and county clinic sites with large numbers of children. Demographic, clinical, and participation data is tracked carefully in an electronic medical record system. Program operations, clinical oversight, and patient tracking are centralized at a care coordination center. Clinical operations and methods have been replicated in fixed specialty clinic sites at the Los Angeles County + University of Southern California Medical Center. Clinical and process measures are regularly evaluated to assure quality, plan iterative improvement, and support evidence-based care. Four Breathmobiles deliver ongoing care at more than 90 school sites. The program has engaged over five thousand patients and their families in a continuity care model that has demonstrated efficacy over usual episodic care. More than 90% of patients in all asthma severity categories achieved clinical control of asthma with significant reductions in inpatient (IP) and emergency department (ED) use. On February 14, 2002, the program became the first program in the United States to receive the award of disease-specific care certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Proper design and resource allocation can sustain a school-based community-wide pediatric asthma disease management program and shift a population of inner city children from acute episodic care to routine preventive care in accordance with national standards. An evidence-based approach to evaluating and maintaining quality, coupled with stratified care delivery, can assure the efficient use of safety net healthcare resources.
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Affiliation(s)
- Craig A Jones
- Division of Allergy and Immunology, Department of Pediatrics at the Los Angeles County and University of Southern California Medical Center, USA.
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Abstract
OBJECTIVES To examine current trends of asthma prevalence, diagnosis, and utilization of care in rural areas, increase awareness about asthma disease burden, and provide general recommendations for improving care in this setting. DATA SOURCES MEDLINE searches were conducted for articles published from 1966 onward, with human subjects and the English language as descriptors. Other terms used included undiagnosed frequent wheezing, hygiene hypothesis, atopic sensitization, endotoxin, telemedicine, and asthma prevalence and care in rural or urban areas. STUDY SELECTION Review and original research studies that reported on asthma care in rural areas were selected for evaluation. RESULTS Contrary to common belief, evidence suggests that asthma prevalence of rural and urban youth is comparable in the United States and may indeed be higher in rural areas. Data are not available to determine prevalence rates for rural adults in the United States. This review presents data suggesting that the utilization of asthma care among rural and urban residents may not be comparable. Rural residents are confronted with certain barriers to care that are not as common in the urban setting. These include lack of health care insurance, geographic obstacles to obtaining care, inability of getting suitable appointments, scarcity of health care professionals, and poor access to information about asthma. CONCLUSIONS Current literature suggests that asthma in rural areas may be underdiagnosed and deserves additional study. Improving formal and continuing education of health care professionals, compensating for health care shortages by using existing resources, and facilitating patient support and education are some of the ways to address the special needs faced by rural residents.
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Affiliation(s)
- Dennis R Ownby
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia 30912, USA.
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Redlener I, Grant R, Krol DM. Beyond primary care: Ensuring access to subspecialists, special services, and health care systems for medically underserved children. Adv Pediatr 2005; 52:9-22. [PMID: 16124334 DOI: 10.1016/j.yapd.2005.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Irwin Redlener
- Mailman School of Public Health, Columbia University, New York, New York, USA
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