Impact of Unmet Social Needs, Scarcity, and Future Discounting on Adherence to Treatment in Children With Asthma: Protocol for a Prospective Cohort Study

BACKGROUND

Asthma is one of the most prevalent chronic diseases of childhood and disproportionately affects children with lower socioeconomic status. Controller medications such as inhaled corticosteroids significantly reduce asthma exacerbations and improve symptoms. However, a large proportion of children still have poor asthma control, in part owing to suboptimal adherence. Financial barriers contribute to hindering adherence, as do behavioral factors related to low income. For example, unmet social needs for food, lodging, and childcare may create stress and worry in parents, negatively influencing medication adherence. These needs are also cognitively taxing and force families to focus on immediate needs, leading to scarcity and heightening future discounting; thus, there is the tendency to attribute greater value to the present than to the future in making decisions.

OBJECTIVE

In this project, we will investigate the relationship between unmet social needs, scarcity, and future discounting as well as their predictive power over time on medication adherence in children with asthma.

METHODS

This 12-month prospective observational cohort study will recruit 200 families of children aged 2 to 17 years at the Asthma Clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary care pediatric hospital in Montreal, Canada. The primary outcome will be adherence to controller medication, measured using the proportion of prescribed days covered during follow-up. Exploratory outcomes will include health care use. The main independent variables will be unmet social needs, scarcity, and future discounting, measured using validated instruments. These variables will be measured at recruitment as well as at 6- and 12-month follow-ups. Covariates will include sociodemographics, disease and treatment characteristics, and parental stress. Primary analysis will compare adherence to controller medication, measured using the proportion of prescribed days covered, between families with versus those without unmet social needs during the study period using multivariate linear regression.

RESULTS

The research activities of this study began in December 2021. Participant enrollment and data collection began in August 2022 and are expected to continue until September 2024.

CONCLUSIONS

This project will allow the documentation of the impact of unmet social needs, scarcity, and future discounting on adherence in children with asthma using robust metrics of adherence and validated measures of scarcity and future discounting. If the relationship between unmet social needs, behavioral factors, and adherence is supported by our findings, this will suggest the potential for novel targets for integrated social care interventions to improve adherence to controller medication and reduce risk across the life course for vulnerable children with asthma.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05278000; https://clinicaltrials.gov/ct2/show/NCT05278000.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37318.

A Framework for Cross-Sector Partnerships to Address Childhood Adversity and Improve Life Course Health

Childhood adversity and its structural causes drive lifelong and intergenerational inequities in health and well-being. Health care systems increasingly understand the influence of childhood adversity on health outcomes but cannot treat these deep and complex issues alone. Cross-sector partnerships, which integrate health care, food support, legal, housing, and financial services among others, are becoming increasingly recognized as effective approaches address health inequities. What principles should guide the design of cross-sector partnerships that address childhood adversity and promote Life Course Health Development (LCHD)? The complex effects of childhood adversity on health development are explained by LCHD concepts, which serve as the foundation for a cross-sector partnership that optimizes lifelong health. We review the evolution of cross-sector partnerships in health care to inform the development of an LCHD-informed partnership framework geared to address childhood adversity and LCHD. This framework outlines guiding principles to direct partnerships toward life course-oriented action: (1) proactive, developmental, and longitudinal investment; (2) integration and codesign of care networks; (3) collective, community and systemic impact; and (4) equity in praxis and outcomes. Additionally, the framework articulates foundational structures necessary for implementation: (1) a shared cross-sector theory of change; (2) relational structures enabling shared leadership, trust, and learning; (3) linked data and communication platforms; and (4) alternative funding models for shared savings and prospective investment. The LCHD-informed cross-sector partnership framework presented here can be a guide for the design and implementation of cross-sector partnerships that effectively address childhood adversity and advance health equity through individual-, family-, community-, and system-level intervention.

Paediatric ED utilisation in the early phase of the COVID-19 pandemic

BACKGROUND

Past epidemics, including influenza, have resulted in increased paediatric patient volume in EDs. During the early weeks of the COVID-19 pandemic, it was unclear how ED volume would be impacted in paediatric hospitals. The objective of this study was to examine differences in the international experience of paediatric ED utilisation and disposition at five different children's hospitals.

METHODS

We obtained data on ED volume, acuity level and disposition (hospitalisation and intensive care unit (ICU) admission) for the time period 1 December1-10 August for the years 2017-2020 from hospitals in five cities (Boston, Massachusetts, USA; Singapore; Melbourne, Australia; Seattle, Washington, USA; and Paris, France). Per cent change was analysed using paired t-tests or Wilcoxon signed rank test.

RESULTS

Overall ED volume dramatically decreased in all five hospitals during the early months of COVID-19 compared with prior years. There was a more varied response of decreases in ED volume by acuity level, hospitalisation and ICU admission among the five hospitals. The one exception was a 2% increase in ICU admissions in Paris. As of August 2020, all hospitals have demonstrated increases in ED volume; however, they are still below baseline.

CONCLUSION

Paediatric EDs in these five cities demonstrated differential decreases of ED volume by acuity and disposition during the early months of the COVID-19 pandemic.

Characteristics of Future Models of Integrated Outpatient Care

Replacement of fee-for-service with capitation arrangements, forces physicians and institutions to minimize health care costs, while maintaining high-quality care. In this report we described how patients and their families (or caregivers) can work with members of the medical care team to achieve these twin goals of maintaining-and perhaps improving-high-quality care and minimizing costs. We described how increased self-management enables patients and their families/caregivers to provide electronic patient-reported outcomes (i.e., symptoms, events) (ePROs), as frequently as the patient or the medical care team consider appropriate. These capabilities also allow ongoing assessments of physiological measurements/phenomena (mHealth). Remote surveillance of these communications allows longer intervals between (fewer) patient visits to the medical-care team, when this is appropriate, or earlier interventions, when it is appropriate. Systems are now available that alert medical care providers to situations when interventions might be needed.

Easiness of Legal Access to Concealed Firearm Permits and Homicide Rates in the United States

OBJECTIVES

To examine the relation of "shall-issue" laws, in which permits must be issued if requisite criteria are met; "may-issue" laws, which give law enforcement officials wide discretion over whether to issue concealed firearm carry permits or not; and homicide rates.

METHODS

We compared homicide rates in shall-issue and may-issue states and total, firearm, nonfirearm, handgun, and long-gun homicide rates in all 50 states during the 25-year period of 1991 to 2015. We included year and state fixed effects and numerous state-level factors in the analysis.

RESULTS

Shall-issue laws were significantly associated with 6.5% higher total homicide rates, 8.6% higher firearm homicide rates, and 10.6% higher handgun homicide rates, but were not significantly associated with long-gun or nonfirearm homicide.

CONCLUSIONS

Shall-issue laws are associated with significantly higher rates of total, firearm-related, and handgun-related homicide.

State Intimate Partner Violence-Related Firearm Laws and Intimate Partner Homicide Rates in the United States, 1991 to 2015

BACKGROUND

To prevent intimate partner homicide (IPH), some states have adopted laws restricting firearm possession by intimate partner violence (IPV) offenders. "Possession" laws prohibit the possession of firearms by these offenders. "Relinquishment" laws prohibit firearm possession and also explicitly require offenders to surrender their firearms. Few studies have assessed the effect of these policies.

OBJECTIVE

To study the association between state IPV-related firearm laws and IPH rates over a 25-year period (1991 to 2015).

DESIGN

Panel study.

SETTING

United States, 1991 to 2015.

PARTICIPANTS

Homicides committed by intimate partners, as identified in the Federal Bureau of Investigation's Uniform Crime Reports, Supplementary Homicide Reports.

MEASUREMENTS

IPV-related firearm laws (predictor) and annual, state-specific, total, and firearm-related IPH rates (outcome).

RESULTS

State laws that prohibit persons subject to IPV-related restraining orders from possessing firearms and also require them to relinquish firearms in their possession were associated with 9.7% lower total IPH rates (95% CI, 3.4% to 15.5% reduction) and 14.0% lower firearm-related IPH rates (CI, 5.1% to 22.0% reduction) than in states without these laws. Laws that did not explicitly require relinquishment of firearms were associated with a non-statistically significant 6.6% reduction in IPH rates.

LIMITATIONS

The model did not control for variation in implementation of the laws. Causal interpretation is limited by the observational and ecological nature of the analysis.

CONCLUSION

Our findings suggest that state laws restricting firearm possession by persons deemed to be at risk for perpetrating intimate partner abuse may save lives. Laws requiring at-risk persons to surrender firearms already in their possession were associated with lower IPH rates.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

Firearm-Related Laws in All 50 US States, 1991-2016

OBJECTIVES

To describe a new database containing detailed annual information on firearm-related laws in place in each of the 50 US states from 1991 to 2016 and to summarize key trends in firearm-related laws during this time period.

METHODS

Using Thomson Reuters Westlaw data to access historical state statutes and session laws, we developed a database indicating the presence or absence of each of 133 provisions of firearm laws in each state over the 26-year period. These provisions covered 14 aspects of state policies, including regulation of the process by which firearm transfers take place, ammunition, firearm possession, firearm storage, firearm trafficking, and liability of firearm manufacturers.

RESULTS

An examination of trends in state firearm laws via this database revealed that although the number of laws nearly doubled during the study period, there was substantial heterogeneity across states, leading to a widening disparity in the number of firearm laws.

CONCLUSIONS

This database can help advance firearm policy research by providing 26 years of comprehensive policy data that will allow longitudinal panel study designs that minimize the limitations present in many previous studies.

The impact of preterm birth <37 weeks on parents and families: a cross-sectional study in the 2 years after discharge from the neonatal intensive care unit

BACKGROUND

Little is known about the quality of life of parents and families of preterm infants after discharge from the neonatal intensive care unit (NICU). Our aims were (1) to describe the impact of preterm birth on parents and families and (2) and to identify potentially modifiable determinants of parent and family impact.

METHODS

We surveyed 196 parents of preterm infants <24 months corrected age in 3 specialty clinics (82% response rate). Primary outcomes were: (1) the Impact on Family Scale total score; and (2) the Infant Toddler Quality of Life parent emotion and (3) time limitations scores. Potentially modifiable factors were use of community-based services, financial burdens, and health-related social problems. We estimated associations of potentially modifiable factors with outcomes, adjusting for socio-demographic and infant characteristics using linear regression.

RESULTS

Median (inter-quartile range) infant gestational age was 28 (26-31) weeks. Higher Impact on Family scores (indicating worse effects on family functioning) were associated with taking ≥3 unpaid hours/week off from work, increased debt, financial worry, unsafe home environment and social isolation. Lower parent emotion scores (indicating greater impact on the parent) were also associated with social isolation and unpaid time off from work. Lower parent time limitations scores were associated with social isolation, unpaid time off from work, financial worry, and an unsafe home environment. In contrast, higher parent time limitations scores (indicating less impact) were associated with enrollment in early intervention and Medicaid.

CONCLUSIONS

Interventions to reduce social isolation, lessen financial burden, improve home safety, and increase enrollment in early intervention and Medicaid all have the potential to lessen the impact of preterm birth on parents and families.

Booster seat laws and fatalities in children 4 to 7 years of age

OBJECTIVE

To determine whether state booster seat laws were associated with decreased fatality rates in children 4 to 7 years of age in the United States.

METHODS

Retrospective, longitudinal analysis of all motor vehicle occupant crashes involving children 4 to 7 years of age identified in the Fatality Analysis Reporting System from January 1999 through December 2009. The main outcome measure was fatality rates of motor vehicle occupants aged 4 to 7 years. Because most booster laws exclude children 6 to 7 years of age, we performed separate analyses for children 4 to 5, 6, and 7 years of age.

RESULTS

When controlling for other motor vehicle legislation, temporal and economic factors, states with booster seat laws had a lower risk of fatalities in 4- to 5-year-olds than states without booster seat laws (adjusted incidence rate ratio 0.89; 95% confidence interval [CI] 0.81-0.99). States with booster seat laws that included 6-year-olds had an adjusted incidence rate ratio of 0.77 (95% CI 0.65-0.91) for motor vehicle collision fatalities of 6-year-olds and those that included 7-year-olds had an adjusted incidence rate ratio of 0.75 (95% CI, 0.62-0.91) for motor vehicle collision fatalities of 7-year-olds.

CONCLUSIONS

Booster seat laws are associated with decreased fatalities in children 4 to 7 years of age, with the strongest association seen in children 6 to 7 years of age. Future legislative efforts should extend current laws to children aged 6 to 7 years.

Children injured by violence in the United States: emergency department utilization, 2000-2008

OBJECTIVES

Children victimized by violence are often treated in the emergency department (ED). However, our understanding of the magnitude and financial costs of this patient population is inadequate. The authors examined the scope, risk factors for, and financial cost of ED visits for intentional injury in children in the United States over time.

METHODS

Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2000 through 2008, the records of children aged 0 to 17 years evaluated in an ED for intentional injuries were examined. Nationally representative rates of ED visits for intentional injuries, the proportion of ED visits accounted for by children with intentional injuries, and risk factors for intentional injury visits were calculated. The Web-based Injury Statistics Query and Reporting System (WISQARS) Cost of Injury Reports was used to generate the medical costs accrued by intentional injuries in children.

RESULTS

Almost 340,000 children were treated in U.S. EDs each year from 2000 through 2008 for intentional injuries, comprising 1.2% (95% confidence interval [CI] = 1.1% to 1.4%) of all U.S. pediatric ED visits. The rate of ED visits for violent injuries has not changed over time. In 2008, 49 children per 10,000 (95% CI = 36 to 61) were treated in the ED for a violent injury. In a multivariate model, increasing age, residing in a metropolitan area, African American race, and the lack of private insurance were independent predictors of intentional injury visits among children. In 2005, the aggregate medical cost of intentionally inflicted injuries in children in the United States was $765 million.

CONCLUSIONS

ED visits among children for violent injury still represent an important clinical, public health, and economic challenge. The ED could be considered as a potential venue for prevention and intervention efforts.