Gaps in health insurance coverage and emergency department use among children with asthma

SABA prescriptions and asthma management practices in Singapore: results from a cross-sectional, observational SABINA III study

OBJECTIVES

To evaluate asthma characteristics and treatment patterns, including short-acting β2-agonist (SABA) prescriptions, in primary and specialist care in the Singapore cohort of the SABA use IN Asthma (SABINA III) study.

DESIGN

Cross-sectional, observational study.

SETTING

Multicentre study conducted at five sites across Singapore.

METHODS

In patients with asthma (aged ≥12 years), data on demographics, disease characteristics and asthma treatment prescriptions were collected using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by 2017 Global Initiative for Asthma recommendations) and practice type (primary/specialist care).

RESULTS

Of the 205 patients analysed (mean (SD) age, 53.6 (16.8) years; female, 62%), 55.9% were enrolled by specialists and 44.1% by primary care physicians. Most study patients (80.5%) had moderate-to-severe asthma (86.0% in specialist care and 74.4% in primary care). In the 12 months before study enrolment, 18.0% of patients experienced ≥1 severe exacerbation. Asthma was well or partly controlled in 78.0% of patients. Overall, 17.1% of all patients were overprescribed SABA (≥3 SABA canisters/year) in the preceding 12 months, and overprescription was greater in specialist versus primary care (26.3% vs 5.6%). Only 2.9% of patients were prescribed SABA monotherapy, while 41.0% received SABA in addition to maintenance therapy. Among the latter, 40.5% were overprescribed SABA. Overall, a higher percentage of patients prescribed ≥3 SABA canisters (vs 0-2 SABA canisters) were assessed as having uncontrolled asthma during the study visit (42.9% vs 17.6%). Maintenance therapy in the form of inhaled corticosteroids (ICS) or ICS/long-acting β2 agonist fixed-dose combinations were prescribed to 14.1% and 84.9% of patients, respectively, in the 12 months before enrolment.

CONCLUSIONS

In this Singapore cohort, ~17% of all patients and more than 40% of patients prescribed SABA in addition to maintenance therapy were overprescribed SABA. These findings emphasise the need to align clinical practices with the latest evidence-based treatment recommendations.

TRIAL REGISTRATION

NCT03857178.

Pharmacoequity in Allergy-Immunology: Disparities in Access to Medications for Allergic Diseases and Proposed Solutions in the United States and Globally

Pharmacoequity is the principle that individuals should have access to high-quality medications regardless of race and ethnicity, socioeconomic status, or availability of resources. In this review, we summarize access to therapeutics for allergic diseases in the United States and other selected countries. We focus on domains of health care access (health insurance coverage, medication availability, and specialist access) as well as system-level factors and clinician- and patient-level factors such as interpersonal racism and cultural beliefs, and how they can affect timely access to appropriate therapy for allergic diseases. Finally, we propose how pharmacoequity in allergy-immunology can be achieved by highlighting solutions to factors limiting access to medications for allergic diseases, and identify potential future research directions.

Analyzing COVID-19 and Air Pollution Effects on Pediatric Asthma Emergency Room Visits in Taiwan

(1) Background: An asthma exacerbation that is not relieved with medication typically requires an emergency room visit (ERV). The coronavirus disease 2019 (COVID-19) pandemic began in Taiwan in January of 2020. The influence of the COVID-19 pandemic on pediatric ERVs in Taiwan was limited. Our aim was to survey pediatric asthma ERVs in the COVID-19 era; (2) Methods: Data were collected from the health quality database of the Taiwanese National Health Insurance Administration from 2019 to 2021. Air pollution and climatic factors in Taipei were used to evaluate these relationships. Changes in the rates of pediatric asthma ERVs were assessed using logistic regression analysis. Poisson regression was used to evaluate the impact of air pollution and climate change; (3) Results: The rate of pediatric asthma ERVs declined in different areas and at different hospital levels including medical centers, regional and local hospitals. Some air pollutants (particulate matter ≤ 2.5 µm, particulate matter ≤ 10 µm, nitrogen dioxide, and carbon monoxide) reduced during the COVID-19 lockdown. Ozone increased the relative risk (RR) of pediatric asthma ERVs during the COVID-19 period by 1.094 (95% CI: 1.095-1.12) per 1 ppb increase; (4) Conclusions: The rate of pediatric asthma ERVs declined during the COVID-19 pandemic and ozone has harmful effects. Based on these results, the government could reduce the number of pediatric asthma ERVs through healthcare programs, thereby promoting children's health.

Health Insurance Coverage Gaps Among Children With a History of Adversity

Health insurance stability among children with adverse childhood experiences (ACEs) is essential for accessing health care services. This cross-sectional study used an extensive, multi-year, nationally representative database of children aged 0 to 17 to examine the association between ACE scores and continuous or intermittent lack of health insurance over a 12-month period. Secondary outcomes were reported reasons for coverage gaps. Compared with children having 0 ACEs, those with 4+ ACEs had a higher likelihood of being part-year uninsured rather than year-round private insured (relative risk ratio [RRR]: 4.20; 95% CI: 3.25, 5.43), year-round public insured (RRR: 1.37; 95% CI: 1.06, 1.76), or year-round uninsured (RRR: 2.28; 95% confidence interval [CI]: 1.63, 3.21). Among children who experienced part-year or year-round uninsurance, a higher ACE score was associated with a greater likelihood of coverage gap due to difficulties with the application or renewal process. Policy changes to reduce administrative burdens may improve health insurance stability and access to health care among children who endure ACEs.

Epidemiology of Current Asthma in Children Under 18: A Two-Decade Overview Using National Center for Health Statistics (NCHS) Data

OBJECTIVE

 This study conducted a comprehensive two-decade analysis of current asthma among children under 18 in the United States using National Center for Health Statistics (NCHS) data. The primary objective was to assess the prevalence of current asthma, evaluate temporal trends, and identify disparities based on gender, age, insurance status, household poverty levels, and race/ethnicity.

METHODS

 Data spanning 2003-2019 from NCHS were analyzed, focusing on current asthma prevalence among children under 18. Age-adjusted prevalence rates were calculated and stratified by various factors, including gender, age groups, health insurance status, poverty levels, and race/ethnicity.

RESULTS

 The study revealed substantial disparities in current asthma prevalence. Over the two-decade period, the overall prevalence of current asthma fluctuated. It increased from 2003 (8.5%) to 2009 (9.6%) and then decreased by 2019 (7.0%). Gender disparities were evident, with males (9.9%) consistently reporting a higher prevalence than females (7.5%). Older children aged between 10-17 years (10.4%) consistently had a higher prevalence of asthma than younger children aged 0-4 (5.3%) and 5-9 years (9.5%). Children with Medicaid insurance (11.2%) had the highest prevalence, followed by insured (8.9%), privately insured (7.7%), and uninsured children (6.1%). Children living below the federal poverty level (FPL) consistently reported the highest prevalence (11.3%), while children above 400% of the FPL (7.1%) had the lowest prevalence. Racial disparities were observed, with Black children (14.3%) having higher asthma prevalence, followed by White (7.6%) and Asian children (5.4%).

CONCLUSION

The study highlights significant disparities in current asthma prevalence over the two-decade period analyzed. While the overall prevalence showed fluctuations, it generally increased from 2003 to 2009 and then decreased by 2019. Gender disparities were evident, with males consistently reporting a higher prevalence compared to females. Older children in the 10-17 age group consistently had a higher asthma prevalence than younger age groups. Moreover, disparities based on insurance status and income levels were also apparent, with children on Medicaid and those living below the FPL reporting higher asthma prevalence. Racial disparities were observed, with Black children having the highest prevalence, followed by White and Asian children. These findings emphasize the importance of addressing these disparities and tailoring interventions to improve asthma management and prevention across different demographic groups.

Incidence rates of childhood asthma with recurrent exacerbations in the US Environmental influences on Child Health Outcomes (ECHO) program

BACKGROUND

Descriptive epidemiological data on incidence rates (IRs) of asthma with recurrent exacerbations (ARE) are sparse.

OBJECTIVES

This study hypothesized that IRs for ARE would vary by time, geography, age, and race and ethnicity, irrespective of parental asthma history.

METHODS

The investigators leveraged data from 17,246 children born after 1990 enrolled in 59 US with 1 Puerto Rican cohort in the Environmental Influences on Child Health Outcomes (ECHO) consortium to estimate IRs for ARE.

RESULTS

The overall crude IR for ARE was 6.07 per 1000 person-years (95% CI: 5.63-6.51) and was highest for children aged 2-4 years, for Hispanic Black and non-Hispanic Black children, and for those with a parental history of asthma. ARE IRs were higher for 2- to 4-year-olds in each race and ethnicity category and for both sexes. Multivariable analysis confirmed higher adjusted ARE IRs (aIRRs) for children born 2000-2009 compared with those born 1990-1999 and 2010-2017, 2-4 versus 10-19 years old (aIRR = 15.36; 95% CI: 12.09-19.52), and for males versus females (aIRR = 1.34; 95% CI 1.16-1.55). Black children (non-Hispanic and Hispanic) had higher rates than non-Hispanic White children (aIRR = 2.51; 95% CI 2.10-2.99; and aIRR = 2.04; 95% CI: 1.22-3.39, respectively). Children born in the Midwest, Northeast and South had higher rates than those born in the West (P < .01 for each comparison). Children with a parental history of asthma had rates nearly 3 times higher than those without such history (aIRR = 2.90; 95% CI: 2.43-3.46).

CONCLUSIONS

Factors associated with time, geography, age, race and ethnicity, sex, and parental history appear to influence the inception of ARE among children and adolescents.

Short-Term Exposure Effect of Ambient Fine Particulate Matter, Ozone and Cold Temperature on Emergency Room Visits for Asthma Patients

(1) Background: The acute effects of ozone, cold temperature and particulate matter less than 2.5 μm (PM_2.5) in size related to asthma attacks are well known worldwide. The adverse effects of ozone and cold temperature on asthma morbidity in Taiwan are still inconclusive. (2) Methods: This retrospective study included patients who had asthma emergency room visits (ERVs) from 1 January 2016 to 31 December 2019 in a regional hospital in Taiwan. The short-term negative effects were estimated using Distributed Lag Non-Linear Models (DLNMs) for the relative risks (RRs) of asthma ERVs associated with PM_2.5, ozone and cold temperature exposures within 5 days. (3) Results: There was a significant association between a 10 ppm increase in PM_2.5 exposure and asthma ERVs at a 2-day lag (RR 1.166, 95% confidence interval (C.I.): 1.051-1.294). There was a significant association between ozone and asthma ERVs at a 1-day lag (RR 1.179, 95% C.I.: 1.034-1.345). The ambient temperature in cold weather compared with the temperature of minimum asthma ERV showed an RR of 1.214, 95% C.I.: 1.009-1.252 at a 1-day lag. (4) Conclusions: This study provides evidence that short-term exposure to fine suspended particulates, ozone and inverse temperature is associated with asthma exacerbation.

Global Considerations in Asthma Treatment: Management in Low Resource Settings

Low-resource settings have a disproportionately higher burden of asthma due to factors that include environmental triggers, access to healthcare, availability of medications, and uncoordinated health systems. The application of guideline-based management can vary, which further impacts the treatment delivered. This chapter aims to outline the global landscape of asthma management, including cultural and social factors, with suggestions for interventions.

Unmet needs for vision care among children with gaps in health insurance coverage

BACKGROUND

Access to vision care is essential for diagnosing and treating vision impairments. Gaps in health insurance coverage may prevent children from receiving vision care and lead to unmet needs for vision services.

METHODS

This study used deidentified data on children 3-17 years of age from the 2016-2019 National Survey of Children's Health. The primary outcome was caregiver-reported unmet needs for vision care in the previous 12 months.

RESULTS

Based on a sample of 106,876 children, 3.8% of US children had a recent gap in coverage, and 5.0% lacked insurance in the entire year leading up to the survey. The estimated population prevalence of caregiver-reported unmet needs for vision care was 0.7%. However, children with gaps in coverage had almost 19-fold higher odds of having caregiver-reported unmet vision care needs (OR = 18.7; 95% CI, 11.5-30.2; P < 0.001), and children with a complete lack of coverage also had a ninefold higher odds of caregiver-reported unmet vision care needs (OR = 9.5; 95% CI, 5.5-16.4; P < 0.001), compared to children with year-round private coverage. In the 2018-2019 data, results were similar when analyzing completion of routine vision testing within the past 12 months.

CONCLUSIONS

Children with gaps in coverage had the highest likelihood of caregiver-reported unmet vision care needs compared with children with year-round coverage or children with year-round lack of coverage.

Social Determinants of Emergency Department Visits in Mild Compared to Moderate and Severe Asthma

BACKGROUND

Social determinants of health (SDH) influence emergency department (ED) use among children with asthma. We aimed to examine if SDH were more strongly associated with ED use among children with moderate/severe compared to mild asthma.

METHODS

This study utilized the 2016-2019 data from the National Survey of Children's Health. Children with asthma ages 0-17 years (N = 9937) were included in the analysis. Asthma severity and all-cause ED use in the past year were reported by caregivers. The association between patient factors and ED visits was evaluated using ordinal logistic regression.

RESULTS

Based on the study sample, 29% of children with asthma had moderate/severe asthma. In the mild group, 30% visited the ED at least once in the past 12 months, compared to 49% in the moderate/severe group. SDH associated with ED visits included race/ethnicity, insurance coverage, and parental educational attainment, but the strength of these associations did not vary according to asthma severity.

CONCLUSIONS

In a nationally representative data set, SDH were equally predictive of ED use regardless of children's asthma severity. Interventions to reduce ED use among children with asthma should be considered for children with any severity of asthma, especially children in socially disadvantaged groups at higher risk of ED utilization.

Concordance of Data on Children's Unmet Health Care Needs Between 2 National Surveys

OBJECTIVE

We used public data from 2 national surveys to determine how survey mode and questionnaire wording potentially impact estimated prevalence and predictors of children's unmet health care needs.

METHODS

Data from 2016-2017 were obtained for the National Health Interview Survey (NHIS), where interviewers ask caregivers about each type of unmet health care need in person, and the National Survey of Children's Health (NSCH), a self-administered questionnaire asking a general question about any unmet health care needs, with subparts about specific types of unmet needs. Weighted proportions and multivariable logistic regression were used to analyze each data set.

RESULTS

The weighted proportion of any unmet health care needs was significantly higher in the NHIS (7.5%; 95% confidence interval [CI], 7.0-8.1; N = 17 723) than in the NSCH (3.3%; 95% CI, 2.9-3.7; N = 65 766). When analyzing specific unmet needs, unmet need for dental care was significantly higher according to the NHIS (4.2% vs 1.9% in the NSCH), as was unmet need for vision care (1.7% vs 0.8%). Conversely, estimates of unmet need for medical care were comparable between the surveys (1.4% and 1.0%). On multivariable analysis, predictors of unmet health care needs, such as being uninsured, had effect sizes of similar magnitude in both surveys.

CONCLUSION

The NHIS design, asking about each type of unmet need in person, may have been more conducive to identifying the full range of unmet health care needs among children. However, our results did not indicate that this was a source of bias in multivariable regression analysis.

Structural Inequities and Barriers to Accessing Kidney Healthcare Services in the United States: A Focus on Uninsured and Undocumented Children and Young Adults

The population of children living in poverty and lacking healthcare insurance has increased in the United States of America in the last decade. Several factors have been responsible for this trend including illegal immigration, socioeconomic deprivation, young age, racial segregation, environmental degradation, and discriminatory housing policies. These systemic barriers have contributed to the exclusion of families from essential healthcare services. They are also contributory to the development of chronic illnesses (such as dialysis-dependent kidney disease) that are debilitating and frequently require considerable therapeutic resources. This unfortunate scenario creates a never-ending vicious cycle of poverty and diseases in a segment of society. For pediatric nephrologists, the challenges of caring for uninsured children with chronic kidney disease are all too familiar. Federally funded healthcare programs do not cover this patient population, leaving them the option of seeking care in emergency healthcare settings. Presentation with a critical illness often necessitates urgent placement of vascular catheters and the choice of acute hemodialysis. Adverse social environment influences the need for protracted chronic hemodialysis and a delay in kidney transplantation. Consequently, there is greater comorbidity, recurrent hospitalization, and a higher mortality rate. New policies should address the deficit in health insurance coverage while promoting social programs that will remove structural barriers to health care resources for undocumented children and young adults.

Short- and Long-Term Health Consequences of Gaps in Health Insurance Coverage among Young Adults

In cross-sectional data, gaps in health insurance coverage are associated with worse health and lower utilization of preventive services. The authors investigated if these associations persisted 2-6 years after disruption of insurance coverage in a cohort of young adults. Data from the National Longitudinal Survey of Youth 1997, a longitudinal cohort study of participants who were ages 13-17 years in 1997, were analyzed. Annual interview data from 2007 through 2017 were included and analyzed in 2021. Health outcomes (general self-rated health, annual preventive care use, and work-related health limitations) in each year were regressed on insurance coverage status, classified as: continuous private coverage, continuous public coverage, gap in coverage, or year-round lack of coverage. In a series of models, insurance coverage status was lagged by 2, 4, or 6 years to capture long-term associations with health outcomes. The analytic sample included 8197 young adults contributing 49,580 observations. Contemporaneous gaps in coverage were associated with 17% lower odds of reporting better self-rated health (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.78, 0.88; P < 0.001), compared to year-round private insurance. This association remained similar when the insurance covariate was lagged 2, 4, or 6 years (eg, 6-year lagged OR: 0.82; 95% CI: 0.72, 0.93; P = 0.002). Results were similar for preventive care use and work-related health limitation. Among young adults, gaps in coverage are adversely associated with health status and health care utilization up to 6 years later. Policy efforts should target insurance continuity during this life course stage.

Socioeconomic disparities in asthma health care utilization, exacerbations, and mortality: A systematic review and meta-analysis

BACKGROUND

Prior studies investigating the effect of socioeconomic status (SES) on asthma health care outcomes have been heterogeneous in the populations studied and methodologies used.

OBJECTIVE

We sought to systematically synthesize evidence investigating the impact of SES on asthma health care utilization, exacerbations, and mortality.

METHODS

We searched Embase, Medline, and Web of Science for studies reporting differences in primary care attendance, exacerbations, emergency department attendance, hospitalization, ventilation/intubation, readmission, and asthma mortality by SES. Study quality was assessed using the Newcastle Ottawa Scale, and meta-analyses were conducted using random-effects models. We conducted several prespecified subgroup analyses, including by health care system (insurance based vs universal government funded) and time period (before vs after 2010).

RESULTS

A total of 61 studies, comprising 1,145,704 patients, were included. Lower SES was consistently associated with increased secondary health care utilization including emergency department attendance (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), hospitalization (OR, 1.63; 95% CI, 1.34-1.99), and readmission (OR, 1.31; 95% CI, 1.19-1.44). Substantial associations were also found between SES and ventilation/intubation (OR, 1.76; 95% CI, 1.13-2.73), although there was no association with primary care attendances (OR, 0.79; 95% CI, 0.51-1.24). We found evidence of borderline significance for increased exacerbations (OR, 1.18; 95% CI, 0.98-1.42) and mortality (OR, 1.12; 95% CI, 0.92-1.37) among more deprived groups. There was no convincing evidence that disparities were associated with country-level health care funding models or that disparities have narrowed over time.

CONCLUSIONS

Patients with a lower SES have substantially increased secondary care health care utilization. We found evidence suggestive of increased exacerbations and mortality risk, although CIs were wide. These disparities have been consistently reported worldwide, including within countries offering universally funded health care systems. Systematic review registration: CRD42020173544.

Continuous Eligibility for Medicaid Associated With Improved Child Health Outcomes

Fluctuating insurance coverage, or churning, is a recognized barrier to health care access. We assessed whether state policies that allow children to remain covered in Medicaid for a 12-month period, regardless of fluctuations in income, are associated with health and health care outcomes, after controlling for individual factors and other Medicaid policies. This cross-sectional study uses a large, nationally representative database of children ages 0 to 17. Continuous eligibility was associated with improved rates of insurance, reductions in gaps in insurance and gaps due to application problems, and lower probability of being in fair or poor health. For children with special health care needs, it was associated with increases in use of medical care and preventive and specialty care access. However, continuous eligibility was not associated with health care utilization outcomes for the full sample. Continuous eligibility may be an effective strategy to reduce gaps in coverage for children and reduce paperwork burden on Medicaid agencies.

Gender, socioeconomic status and emergency department visits among cancer survivors in the USA: a population-based study

Aim: To assess patterns of emergency department visits and subsequent hospitalization in relation to gender and socioeconomic status among a cohort of cancer survivors in the USA. Materials & methods: National Health Interview Survey datasets (2011-2017) were reviewed and participants with a history of cancer and complete information about emergency department visits in the past 12 months were included. Multivariable logistic regression analyses were used to assess factors associated with emergency department visits and subsequent hospitalization after the most recent emergency department visit. Results: A total of 22,240 cancer survivors were included in the current analysis; of which 16,133 participants (72.5%) who have not visited an emergency department in the past 12 months and 6107 participants (27.5%) who have visited an emergency department in the past 12 months. Multivariable logistic regression analysis suggested the following factors are associated with emergency department visits; younger age (odds ratio [OR] with increasing age: 0.98; 95% CI: 0.98-0.99), female gender (OR: 1.07; 95% CI: 1.00-1.15), African American race (OR: 1.26; 95% CI: 1.13-1.40), unmarried status (OR for married vs unmarried: 0.79; 95% CI: 0.74-0.84), lower yearly earnings (OR: 1.36; 95% CI: 1.20-1.54), poor health status (OR: 7.02; 95% CI: 6.02-8.18) and incomplete health insurance coverage (OR for complete coverage vs incomplete coverage: 0.66; 95% CI: 0.54-0.80). On the other hand, the following factors were associated with subsequent hospitalization: older age (OR: 1.004; 95% CI: 1.000-1.008), male gender (OR for female vs male: 0.86; 95% CI: 0.78-0.94), unmarried status (OR for married vs unmarried status: 0.80; 95% CI: 0.73-0.88), not working (OR: 1.44; 95% CI: 1.23-1.68), lower yearly earnings (OR: 1.31; 95% CI: 1.07-1.60), poor health status (OR: 8.43; 95% CI: 6.76-10.51) and lack of health insurance coverage (OR for complete coverage vs incomplete coverage: 0.71; 95% CI: 0.55-0.93). Conclusion: Female cancer survivors were more likely to visit the emergency department, whereas they were less likely to be subsequently hospitalized. Cancer survivors with lower socioeconomic status were more likely to visit emergency departments and to be subsequently hospitalized.

Insurance coverage and health care use among children with diabetes

BACKGROUND

Health insurance coverage may be associated with pediatric diabetes mellitus (DM) management. However, it is unknown how continuity of insurance coverage is associated with health care use outcomes in pediatric DM.

METHODS

We used the nationally representative 2016-2019 National Survey of Children's Health to examine how interruption of health insurance coverage may affect health care use among children with DM. Children ages 0-17 years with DM were included in the analysis. Outcomes included emergency department visits, specialist visits, and unmet health care needs in the last 12 months. Insurance coverage was classified as continuous private, continuous public, or discontinuous (including gaps in coverage and year-round lack of coverage).

RESULTS

Based on a sample of 548 children, 56% percent had continuous private insurance coverage, as compared to 32% with continuous public insurance, and 12% with discontinuous coverage. Thirty-five percent of children had visited the ED in the past 12 months, and only 47% had visited any specialist in the past 12 months, including but not limited to a pediatric endocrinologist. An estimated 19% of children had unmet health care needs over the past 12 months. On multivariable analysis, children with coverage gaps were significantly less likely than children with continuous private coverage to have a visited a specialist in the past 12 months (adjusted odds ratio: 0.27; 95% CI: 0.08, 0.88; p = 0.030).

CONCLUSIONS

This study points to a need to establish and maintain specialist follow-up for children with DM, especially those from socioeconomically disadvantaged backgrounds.

Demographic and Risk Factor Differences between Children with "One-Time" and "Repeat" Visits to the Emergency Department for Asthma

This retrospective study examines demographic and risk factor differences between children who visited the emergency department (ED) for asthma once (“one-time”) and more than once (“repeat”) over an 18-month period at an academic medical center. The purpose is to contribute to the literature on ED utilization for asthma and provide a foundation for future primary research on self-management effectiveness (SME) of childhood asthma. For the first round of analysis, an 18-month retrospective chart review was conducted on 252 children (0–17 years) who visited the ED for asthma in 2019–2020, to obtain data on demographics, risk factors, and ED visits for each child. Of these, 160 (63%) were “one-time” and 92 (37%) were “repeat” ED patients. Demographic and risk factor differences between “one-time” and “repeat” ED patients were assessed using contingency table and logistic regression analyses. A second round of analysis was conducted on patients in the age-group 8–17 years to match another retrospective asthma study recently completed in the outpatient clinics at the same (study) institution. The first-round analysis indicated that except age, none of the individual demographic or risk factors were statistically significant in predicting of “repeat” ED visits. More unequivocally, the second-round analysis revealed that none of the individual factors examined (including age, race, gender, insurance, and asthma severity, among others) were statistically significant in predicting “repeat” ED visits for childhood asthma. A key implication of the results therefore is that something other than the factors examined is driving “repeat” ED visits in children with asthma. In addition to contributing to the ED utilization literature, the results serve to corroborate findings from the recent outpatient study and bolster the impetus for future primary research on SME of childhood asthma.

Association of Affordable Care Act Implementation With Ambulance Utilization for Asthma Emergencies in New York City, 2008-2018

IMPORTANCE

Emergency medical services (EMS) are an essential component of the health care system, but the effect of insurance expansion on EMS call volume remains unclear.

OBJECTIVE

This study investigated the association between health insurance expansion and EMS dispatches for asthma, an ambulatory care-sensitive condition. We hypothesized that insurance expansion under the Patient Protection and Affordable Care Act (ACA) would be associated with decreased EMS dispatches for asthma emergencies.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined 14 865 267 ambulance calls dispatched within New York City from 2008 to 2018, including 217 303 calls for asthma-related emergencies, and used interrupted time series analysis to study the change in the annual incidence of EMS dispatches for asthma emergencies after implementation of the ACA. Multivariable linear regression examined the association between the uninsured rate and the incidence of asthma-related dispatches, controlling for population demographic characteristics and air quality index.

EXPOSURES

Implementation of ACA on January 1, 2014.

MAIN OUTCOMES AND MEASURES

Incidence of EMS dispatches for asthma emergencies per 100 000 population per year (ie, asthma EMS dispatch rate) as classified by the 911 call-taker.

RESULTS

In this study of 217 303 EMS dispatches for asthma-related emergencies, there was a decrease in the asthma EMS dispatch rate after implementation of the ACA, from a mean (SD) of 261 (24) dispatches per 100 000 population per year preintervention to 211 (47) postintervention (P = .047). This decrease in asthma EMS dispatch rate after ACA implementation was significant on interrupted time series analysis. Prior to 2014, the annual asthma EMS dispatch rate was increasing by 11.8 calls per 100 000 population per year (95% CI, 6.1 to 17.4). After ACA implementation, the asthma EMS dispatch rate decreased annually by 28.5 calls per 100 000 population per year (95% CI, -37.6 to -19.3), a significant change in slope from the preintervention period (P < .001). Multivariable linear regression, controlling for percentage of individuals younger than age 18 years, degree of racial/ethnic diversity, median household income, and air quality index, found that a 1% decrease in the citywide uninsured rate was associated with a decrease of 98.9 asthma dispatches per 100 000 population per year (95% CI, 5.72-192.10; P = .04).

CONCLUSIONS AND RELEVANCE

Insurance expansion within New York City under the ACA was associated with a significant reduction in the asthma EMS dispatch rate. Insurance expansion may be a viable method to reduce EMS utilization for ambulatory care-sensitive conditions such as asthma.

Change of address as a measure of housing insecurity predicting rural emergency department revisits after asthma exacerbation

OBJECTIVE

Housing insecurity is an important socioeconomic factor that may impact emergency department (ED) use for children with asthma, but housing insecurity screening has primarily relied on patient surveys or linkage to external data sources. Using patient addresses recorded in the electronic medical record (EMR), we sought to correlate recent changes in address (as a proxy for housing insecurity) with ED revisit risk.

METHODS

We retrospectively identified patients age 2-17 years seen in our rural ED for asthma exacerbation during 2016-2018. We used EMR data from the 12 months before the earliest ED visit to compare patients with and without a recent change of address (over previous 12 months) on 30- and 90-day all-cause and asthma-specific ED revisits.

RESULTS

The study included 632 children, of whom 85 (13%) had a recent address change before the index ED visit. Moving was not associated with asthma-specific 30-day or 90-day revisits. Ninety-day all-cause revisits were more common among patients who had recently moved (36% vs. 25%; p = 0.019), although this difference was not statistically significant after multivariable adjustment for Medicaid insurance coverage and number of recent health system encounters (odds ratio: 1.49; 95% confidence interval: 0.91, 2.46; p = 0.114).

CONCLUSIONS

A history of recent address change in the EMR was not independently associated with repeat ED visits for asthma exacerbation. Many children presenting to the ED did not have recent encounters with our health system where address could be ascertained. This EMR-based proxy for housing insecurity may be more applicable to patients under continuous follow-up.

Demographic and Risk-Factor Differences between Users and Non-Users of Unscheduled Healthcare among Pediatric Outpatients with Persistent Asthma

This study assesses differences between users and non-users of unscheduled healthcare for persistent childhood asthma, with regard to select demographic and risk factors. The objectives are to provide important healthcare utilization information and a foundation for future research on self-management effectiveness (SME), informed by a recently developed "holistic framework" for measuring SME in childhood asthma. An 18-month retrospective chart review was conducted on 59 pediatric outpatients with persistent asthma-mild, moderate, or severe, to obtain data on various demographic and risk factors, and healthcare use for each child. The study examined five types of "unscheduled" healthcare use. Users had non-zero encounters (at least one) in any of the five types; non-users had zero encounters (not even one) in all five types. Differences between users and non-users were assessed using contingency table and logistic regression analysis. There were 25 users and 34 non-users of unscheduled healthcare. Each severity category contained users and non-users. The only statistically significant finding was that the mild persistent category had fewer users than severe persistent (p < 0.05). There were no significant differences between users and non-users for any other demographic or risk factor examined. After adjusting for asthma severity, there were no other significant differences between users and non-users of unscheduled healthcare. This is a crucial finding which suggests that something else is driving unscheduled healthcare use in these children, given there were users and non-users in each asthma severity category. These results provide impetus for future research on the role of other aspects of the "holistic framework" in explaining differences in uses of unscheduled healthcare in persistent childhood asthma.

Social Determinants of Health and Emergency Department Use Among Children With Sickle Cell Disease

Sickle cell disease (SCD) is associated with disproportionate emergency department (ED) use. This study described the social determinants of health associated with ED visits and hospital admission from the ED among children with SCD using a nationally representative dataset. We analyzed data from 126 children 0 to 17 years of age with SCD included in the 2011 to 2017 rounds of the National Health Interview Survey (mean age, 8 y; 50% female individuals; 74% African American). Study variables were summarized using weighted means and proportions and compared according to ED use and admission by Wald tests. Fifty-two identified children had visited the ED within the last 12 months and 21 were admitted to the hospital after their most recent ED visit. Children living in a single-mother household were more likely to visit the ED (P=0.040), as were younger children (mean age, 6 vs. 9 y; P=0.034), with no evaluated social determinants of health significantly impacting hospital admission from the ED. The lack of association between ED use and either poverty or insurance type may be related to the overall high level of social disadvantage among children with SCD. Our findings demonstrate the need to better characterize specific social factors impacting acute care use among children with SCD.

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

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