The role of income in reducing racial and ethnic disparities in emergency room and urgent care center visits for asthma-United States, 2001-2009

Disparities in adult asthma outcomes among disaggregated data among Asian Americans in the National Health Interview Survey

Background

Asthma is a chronic lung disease affecting 8% of US adults, with significant disparities among racial and ethnic groups. The Asian American population is diverse, yet asthma research often aggregates data, potentially obscuring group-specific differences. Disaggregated data reveal that although Asian Americans overall appear to have lower asthma prevalence than non-Hispanic Whites, certain subgroups, like Filipino adults, have higher rates. Asthma outcomes are influenced by genetics, environmental exposures, and social determinants, although the specific impact of these factors remains unclear.

Objective

The objective was to better describe asthma outcomes among disaggregated Asian American groups.

Methods

We analyzed 2006-18 National Health Interview Survey data on asthma prevalence among non-Hispanic White and disaggregated Asian American adults. Logistic regression was used to calculate adjusted odds ratios (ORs) for Asian American asthma outcomes compared to non-Hispanic Whites, accounting for demographic, health, and socioeconomic factors.

Results

Asthma prevalence varied among adults: non-Hispanic White (n = 33,764), Chinese (n = 310, OR = 0.54), Filipino (n = 603, OR = 1.03), Asian Indian (n = 236, OR = 0.43), and other Asians (n = 601, OR = 0.61). Over half had poor asthma control: 62% non-Hispanic White, 53.5% Chinese (OR = 0.72), 50.2% Filipino (OR = 0.64), 54.8% Asian Indian (OR = 0.75), and 59.2% other Asian (OR = 0.82). Filipino adults showed higher asthma prevalence (OR = 1.37) but better control (OR = 0.74). Chinese (OR = 0.39) and Asian Indian (OR = 0.48) adults had fewer emergency department visits. Sociodemographic and health factors significantly affected symptoms, attacks, and emergency department visits.

Conclusion

Asthma prevalence and control varied widely among Asian American populations. Sociodemographic and health factors influenced poor asthma control more than racial group.

Preference for and impact of telehealth vs in-person asthma visits among Black and Latinx adults

BACKGROUND

Black and Latinx adults experience disproportionate asthma-related morbidity and limited specialty care access. The severe acute respiratory syndrome coronavirus 2 pandemic expanded telehealth use.

OBJECTIVE

To evaluate visit type (telehealth [TH] vs in-person [IP]) preferences and the impact of visit type on asthma outcomes among Black and Latinx adults with moderate-to-severe asthma.

METHODS

For this PREPARE trial ancillary study, visit type preference was surveyed by e-mail or telephone post-trial. Emergency medical record data on visit types and asthma outcomes were available for a subset (March 2020 to April 2021). Characteristics associated with visit type preferences, and relationships between visit type and asthma outcomes (control [Asthma Control Test] and asthma-related quality of life [Asthma Symptom Utility Index]), were tested using multivariable regression.

RESULTS

A total of 866 participants consented to be surveyed, with 847 respondents. Among the participants with asthma care experience with both visit types, 42.0% preferred TH for regular checkups, which associated with employment (odds ratio [OR] = 1.61; 95% confidence interval [CI], 1.09-2.39; P = .02), lower asthma medication adherence (OR = 1.06; 95% CI, 1.01-1.11; P = .03), and having more historical emergency department and urgent care asthma visits (OR = 1.10 for each additional visit; 95% CI, 1.02-1.18; P = .02), after adjustment. Emergency medical record data were available for 98 participants (62 TH, 36 IP). Those with TH visits were more likely Latinx, from the Southwest, employed, using inhaled corticosteroid-only controller therapy, with lower body mass index, and lower self-reported asthma medication adherence vs those with IP visits only. Both groups had comparable Asthma Control Test (18.4 vs 18.9, P = .52) and Asthma Symptom Utility Index (0.79 vs 0.84, P = .16) scores after adjustment.

CONCLUSION

TH may be similarly efficacious as and often preferred over IP among Black and Latinx adults with moderate-to-severe asthma, especially for regular checkups.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02995733.

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future

OBJECTIVES

The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas.

METHODS

A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult).

RESULTS

A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout.

CONCLUSIONS

Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

Caribbean Latinx with moderate-severe asthma bear greater asthma morbidity than other Latinx

BACKGROUND

Hispanic/Latinx (HL) ethnicity encompasses racially and culturally diverse subgroups. Studies suggest that Puerto Ricans (PR) may bear greater asthma-related morbidity than Mexicans, but these were conducted in children or had limited clinical characterization.

OBJECTIVES

This study sought to determine whether disparities in asthma morbidity exist among HL adult subgroups.

METHODS

Adults with moderate-severe asthma were recruited from US clinics, including from Puerto Rico, for the Person Empowered Asthma Relief (PREPARE) trial. Considering the shared heritage between PR and other Caribbean HL (Cubans and Dominicans [C&D]), the investigators compared baseline self-reported clinical characteristics between Caribbean HL (CHL) (PR and C&D: n = 457) and other HLs (OHL) (Mexicans, Spaniards, Central/South Americans; n = 141), and between CHL subgroups (C&D [n = 56] and PR [n = 401]). This study compared asthma morbidity measures (self-reported exacerbations requiring systemic corticosteroids, emergency department/urgent care (ED/UC) visits, hospitalizations, health care utilization) through negative binomial regression.

RESULTS

CHL compared to OHL were similar in age, body mass index, poverty status, blood eosinophils, and fractional exhaled nitric oxide but were prescribed more asthma controller therapies. Relative to OHL, CHL had significantly increased odds of asthma exacerbations (odds ratio [OR]: 1.84; 95% CI: 1.4-2.4), ED/UC visits (OR: 1.88; 95% CI: 1.4-2.5), hospitalization (OR: 1.98; 95% CI: 1.06-3.7), and health care utilization (OR: 1.91; 95% CI: 1.44-2.53). Of the CHL subgroups, PR had significantly increased odds of asthma exacerbations, ED/UC visits, hospitalizations, and health care utilization compared to OHL, whereas C&D only had increased odds of exacerbations compared to OHL. PR compared to C&D had greater odds of ED/UC and health care utilization.

CONCLUSIONS

CHL adults, compared with OHL, adults reported nearly twice the asthma morbidity; these differences are primarily driven by PR. Novel interventions are needed to reduce morbidity in this highly impacted population.

Socioeconomic status associates with worse asthma morbidity among Black and Latinx adults

BACKGROUND

Asthma disproportionately affects African American/Black (AA/B) and Hispanic/Latinx (H/L) patients and individuals with low socioeconomic status (SES), but the relationship between SES and asthma morbidity within these racial/ethnic groups is inadequately understood.

OBJECTIVE

To determine the relationship between SES and asthma morbidity among AA/B and H/L adults with moderate to severe asthma using multidomain SES frameworks and mediation analyses.

METHODS

We analyzed enrollment data from the PeRson EmPowered Asthma RElief randomized trial, evaluating inhaled corticosteroid supplementation to rescue therapy. We tested for direct and indirect relationships between SES and asthma morbidity using structural equation models. For SES, we used a latent variable defined by poverty, education, and unemployment. For asthma morbidity, we used self-reported asthma exacerbations in the year before enrollment (corticosteroid bursts, emergency room/urgent care visits, or hospitalizations), and Asthma Control Test scores. We tested for mediation via health literacy, perceived stress, and self-reported discrimination. All models adjusted for age, sex, body mass index, ethnicity, and comorbidities.

RESULTS

Among 990 AA/B and H/L adults, low SES (latent variable) was directly associated with hospitalizations (β = 0.24) and worse Asthma Control Test scores (β = 0.20). Stress partially mediated the relationship between SES and increased emergency room/urgent care visits and worse asthma control (β = 0.03 and = 0.05, respectively). Individual SES domains were directly associated with asthma morbidity. Stress mediated indirect associations between low educational attainment and unemployment with worse asthma control (β = 0.05 and = 0.06, respectively).

CONCLUSIONS

Lower SES is directly, and indirectly through stress, associated with asthma morbidity among AA/B and H/L adults. Identification of stressors and relevant management strategies may lessen asthma-related morbidity among these populations.

Reliever-Triggered Inhaled Glucocorticoid in Black and Latinx Adults with Asthma

BACKGROUND

Black and Latinx patients bear a disproportionate burden of asthma. Efforts to reduce the disproportionate morbidity have been mostly unsuccessful, and guideline recommendations have not been based on studies in these populations.

METHODS

In this pragmatic, open-label trial, we randomly assigned Black and Latinx adults with moderate-to-severe asthma to use a patient-activated, reliever-triggered inhaled glucocorticoid strategy (beclomethasone dipropionate, 80 μg) plus usual care (intervention) or to continue usual care. Participants had one instructional visit followed by 15 monthly questionnaires. The primary end point was the annualized rate of severe asthma exacerbations. Secondary end points included monthly asthma control as measured with the Asthma Control Test (ACT; range, 5 [poor] to 25 [complete control]), quality of life as measured with the Asthma Symptom Utility Index (ASUI; range, 0 to 1, with lower scores indicating greater impairment), and participant-reported missed days of work, school, or usual activities. Safety was also assessed.

RESULTS

Of 1201 adults (603 Black and 598 Latinx), 600 were assigned to the intervention group and 601 to the usual-care group. The annualized rate of severe asthma exacerbations was 0.69 (95% confidence interval [CI], 0.61 to 0.78) in the intervention group and 0.82 (95% CI, 0.73 to 0.92) in the usual-care group (hazard ratio, 0.85; 95% CI, 0.72 to 0.999; P = 0.048). ACT scores increased by 3.4 points (95% CI, 3.1 to 3.6) in the intervention group and by 2.5 points (95% CI, 2.3 to 2.8) in the usual-care group (difference, 0.9; 95% CI, 0.5 to 1.2); ASUI scores increased by 0.12 points (95% CI, 0.11 to 0.13) and 0.08 points (95% CI, 0.07 to 0.09), respectively (difference, 0.04; 95% CI, 0.02 to 0.05). The annualized rate of missed days was 13.4 in the intervention group and 16.8 in the usual-care group (rate ratio, 0.80; 95% CI, 0.67 to 0.95). Serious adverse events occurred in 12.2% of the participants, with an even distribution between the groups.

CONCLUSIONS

Among Black and Latinx adults with moderate-to-severe asthma, provision of an inhaled glucocorticoid and one-time instruction on its use, added to usual care, led to a lower rate of severe asthma exacerbations. (Funded by the Patient-Centered Outcomes Research Institute and others; PREPARE ClinicalTrials.gov number, NCT02995733.).

Factors Associated With Avoidable Emergency Department Visits in Broward County, Florida

Background

Improper utilization of emergency departments (EDs) in the United States is an issue that places a large burden on the healthcare system. Previous studies have shown that differences in race, gender, and income level have been associated with avoidable ED visits. Broward County, Florida, is diverse with people from many different socioeconomic backgrounds. The objective of this study is to determine the impact that race/ethnicity, gender, and payment methods have on the rates of avoidable ED visits at hospitals in Broward County, Florida.

Methods

This study utilized a dataset from the Broward Regional Health Planning Council that included ED visits in Broward County in 2019. Secondary data analysis was conducted utilizing a one-way analysis of variance (ANOVA) with post-hoc analysis to compare the proportions of non-emergent, emergent primary care-treatable, and emergent preventable ED visits amongst different race/ethnicities, genders, and payment/insurance methods.

Results

Compared to non-Hispanic white patients, non-Hispanic black and Hispanic patients had higher mean rates of non-emergent ED visits. Women had greater mean rates compared to men for non-emergent ED visits; males had higher mean rates than females for emergent primary care-treatable and emergent preventable. Patients covered by Medicaid had greater mean rates of non-emergent and emergent primary care-treatable visits compared to patients using other payment or insurance methods.

Conclusions

This study identified demographics within Broward County associated with avoidable ED visits. To reduce the burden of ED overutilization on the healthcare system, healthcare providers must better educate the at-risk populations about proper ED use. In addition, a comprehensive assessment of social determinants of health in patients overutilizing the ED will allow for better alignment of resources and policy changes to improve healthcare access and community health.

A randomized, open-label, pragmatic study to assess reliever-triggered inhaled corticosteroid in African American/Black and Hispanic/Latinx adults with asthma: Design and methods of the PREPARE trial

BACKGROUND

Asthma prevalence, morbidity, and mortality disproportionately impact African American/Black (AA/B) and Hispanic/Latinx (H/L) communities. Adherence to daily inhaled corticosteroid (ICS), recommended by asthma guidelines in all but the mildest cases of asthma, is generally poor. As-needed ICS has shown promise as a patient-empowering asthma management strategy, but it has not been rigorously studied in AA/B or H/L patients or in a real-world setting. Design and Aim The PeRson EmPowered Asthma RElief (PREPARE) Study is a randomized, open-label, pragmatic study which aims to assess whether a patient-guided, reliever-triggered ICS strategy called PARTICS (Patient-Activated Reliever-Triggered Inhaled CorticoSteroid) can improve asthma outcomes in AA/B and H/L adult patient populations. In designing and implementing the study, the PREPARE research team has relied heavily on advice from AA/B and H/L Patient Partners and other stakeholders. Methods PREPARE is enrolling 1200 adult participants (600 AA/Bs, 600H/Ls) with asthma. Participants are randomized to PARTICS + Usual Care (intervention) versus Usual Care (control). Following a single in-person enrollment visit, participants complete monthly questionnaires for 15 months. The primary endpoint is annualized asthma exacerbation rate. Secondary endpoints include asthma control; preference-based quality of life; and days lost from work, school, or usual activities. Discussion The PREPARE study features a pragmatic design allowing for the real-world assessment of a patient-centered, reliever-triggered ICS strategy in AA/B and H/L patients. Outcomes of this study have the potential to offer powerful evidence supporting PARTICS as an effective asthma management strategy in patient populations that suffer disproportionately from asthma morbidity and mortality.

Characteristics of telehealth users in NYC for COVID-related care during the coronavirus pandemic

OBJECTIVE

To explore whether racial/ethnic differences in telehealth use existed during the peak pandemic period among NYC patients seeking care for COVID-19 related symptoms.

MATERIALS AND METHODS

This study used data from a large health system in NYC - the epicenter of the US crisis - to describe characteristics of patients seeking COVID-related care via telehealth, ER, or office encounters during the peak pandemic period. Using multinomial logistic regression, we estimated the magnitude of the relationship between patient characteristics and the odds of having a first encounter via telehealth versus ER or office visit, and then used regression parameter estimates to predict patients' probabilities of using different encounter types given their characteristics.

RESULTS

Demographic factors, including race/ethnicity and age, were significantly predictive of telehealth use. As compared to Whites, Blacks had higher adjusted odds of using both the ER versus telehealth (OR: 4.3, 95% CI: 4.0-4.6) and office visits versus telehealth (OR: 1.4, 95% CI: 1.3-1.5). For Hispanics versus Whites, the analogous ORs were 2.5 (95% CI: 2.3-2.7) and 1.2 (95% CI: 1.1-1.3). Compared to any age groups, patients 65+ had significantly higher odds of using either ER or office visits versus telehealth.

CONCLUSIONS

The response to COVID-19 has involved an unprecedented expansion in telehealth. While older Americans and minority populations among others are known to be disadvantaged by the digital divide, few studies have examined disparities in telehealth specifically, and none during COVID-19. Additional research into sociodemographic heterogeneity in telehealth use is needed to prevent potentially further exacerbating health disparities overall.

CC16 Levels into Adult Life Are Associated with Nitrogen Dioxide Exposure at Birth

Rationale: Lung function and growth are adversely associated with nitrogen dioxide (NO2) exposure. Lower levels of circulating club cell secretory protein (CC16) in childhood are also associated with subsequent decreased lung function. NO2 exposure may induce epithelial damage in lungs and alter club cell proliferation and morphology.Objectives: To determine if increased ambient NO2 levels at participants' home addresses in early life were associated with decreased levels of CC16 from age 6 to 32 years.Methods: Participants were enrolled at birth in the Tucson Children's Respiratory Study and had circulating CC16 measured at least once between age 6 and 32. Linear mixed models were used to determine the association between estimated ambient NO2 exposure at participants' home address at birth or age 6 with CC16 levels from age 6 to 32.Measurements and Main Results: NO2 exposures at birth or age 6 were available for 777 children with one or more CC16 measurement. We found a negative association between NO2 exposure and CC16 levels, with a 4.7% (95% confidence interval, -8.6 to -0.7) decrease in CC16 levels from age 6 to 32 per interquartile range increase in NO2 exposure (6.0 ppb) at the participants' birth address. We observed modification by race (p interaction = 0.04), with stronger associations among participants with at least one black parent (-29.6% [95% confidence interval, -42.9% to -13.2%] per interquartile range). NO2 at participant's age 6 address was not significantly associated with CC16 levels (-1.9%; 95% confidence interval, -6.3 to 2.6).Conclusions: Higher exposure to NO2 at birth is associated with persistently low levels of CC16 from 6 to 32 years.

The impact of racial and ethnic disparities in inhaled corticosteroid adherence on healthcare expenditures in adults with asthma

Purpose: The purpose of this study is to determine racial and ethnic disparities with the adherence to inhaled corticosteroids (ICSs) in adults with persistent asthma, and their association with healthcare expenditures. Methods: A retrospective, cross-sectional study using the Medical Expenditure Panel Survey (MEPS) 2013-2014 data included patients ≥18 years with persistent asthma. Median medication possession ratio (MPR) was used to dichotomize adherence levels. Multivariate regression analysis was conducted to ascertain the association between adherence and race/ethnicity. Total expenditures and association with adherence were analyzed using a generalized linear model with a log link function and gamma distribution. Unadjusted expenditures were compared after bootstrapping. Results: The average MPR of ICSs for the sample of 277 patients was 0.34. The average MPR level was 0.33 among whites, 0.37 among African-Americans and 0.35 among other minorities. The average MPR was 0.30 among Hispanics, and 0.35 among non-Hispanics. African-Americans were less likely to be adherent than whites (OR 0.95). Hispanics were less likely to be adherent (OR 0.4; CI 0.206-0.777). Higher adherence was associated with significantly higher total health expenditure than lower adherence ($19,223 vs. $12,840 respectively, p < .0001). African-Americans had slightly higher total expenditure compared to whites; however, other minorities had significantly lower health expenditures compared to whites (p = .01). Non-Hispanics spent significantly less on healthcare compared to Hispanics (p = .04). Conclusions: Valuable insight into the economic cost of the disparities as they relate to persistent asthma provides further evidence of possible ethnic inequities that warrant addressing.

Racial/Ethnic Variation in Emergency Department Care for Children With Asthma

OBJECTIVE

To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients.

METHODS

This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED.

RESULTS

The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01).

CONCLUSIONS

In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.

Ozone pollution and asthma emergency department visits in the Central Valley, California, USA, during June to September of 2015: a time-stratified case-crossover analysis

Objective: The San Joaquin Valley (SJV) exceeds the state and national standards for ozone (O₃). This study investigates whether short-term exposure to O₃ is associated with asthma emergency department (ED) visits. Methods: We identified 1,101 ED visits in June-September of 2015 in SJV, California, who lived within 15 km of active air monitors. Conditional logistic regression models were used to obtain the odds ratio (OR) and 95% confidence interval (CI) associated with an interquartile (IQR) increase in ozone. We explored the potential effect modification by sex (female and male), race (White, Black and Hispanic), age (2-5, 6-18, 19-40, 41-64 and > = 65) and county (Merced, Madera, Kings, Fresno and Kern). Results: An IQR range (18.1 ppb) increase in O₃ exposure three days before an asthma attack (lag 3) was associated with a 6.6% [OR: 1.066 (95% CI: 1.032, 1.082)] increase in the odds of having an asthma ED visit. The overall ORs differed across age groups and races/ethnicities, with strongest for children aged 6-18 years [OR: 1.219 (95% CI: 1.159, 1.280)], adults 19-40 years [OR: 1.102 (95% CI: 1.053, 1.154)] and Blacks [OR: 1.159 (95% CI: 1.088, 1.236)], respectively. O₃ exposure was not positively associated with asthma ED visits for Whites, while it was for other underrepresented groups. Fresno had the highest number of asthma ED visits and positive association among all five counties. Conclusion: We found that O₃ exposure is associated with asthma ED visits in the SJV.

Asthma exacerbations and socio-economic status in French adults with persistent asthma: A prospective cohort study

INTRODUCTION

Adults disadvantaged by poor socio-economic status (SES) are more severely affected by asthma compared to those with better SES. We aimed to determine whether the frequency of asthma exacerbations (AEx), as well as aspects related to AEx management, differed based on SES in patients treated with daily treatments.

METHODS

This study, part of the prospective observational cohort ASTRO-LAB, included French adult patients with persistent asthma. Patients were considered as low SES if they benefited from publicly funded special health insurance and/or were perceived as low SES by their general practitioner. AEx was defined as at least one of the following: asthma-related oral corticosteroid course, medical contact, hospitalization, and death. We examined associations between SES and AEx frequency, perceived triggering factors and type of medical contact after AEx.

RESULTS

In our sample of 255 patients, 11.40% were considered as low SES. Patients with low SES did not report significantly more AEx than medium/high SES patients during one-year follow-up (0.79 versus 0.55, p = 0.38). The type of medical contact during AEx differed significantly between the two groups (p = 0.03): patients with medium/high SES consulted their general practitioner more frequently (OR = 2.23, 95% CI = 0.91-5.50, p = 0.08) and were less likely to visit an emergency department or be hospitalized (OR = 0.27, 95% CI = 0.09-0.84, p = 0.02).

CONCLUSIONS

AEx frequency did not differ significantly between low and medium/high SES patients, but differences were found in the management of AEx. Studies are needed to better understand the relation between precariousness and management of asthma.

Evaluation of individual and area-level factors as modifiers of the association between warm-season temperature and pediatric asthma morbidity in Atlanta, GA

INTRODUCTION

Previous studies have found associations between respiratory morbidity and high temperatures; however, few studies have explored associations in potentially sensitive sub-populations.

METHODS

We evaluated individual and area-level factors as modifiers of the association between warm-season (May-Sept.) temperature and pediatric respiratory morbidity in Atlanta. Emergency department (ED) visit data were obtained for children, 5-18 years old, with primary diagnoses of asthma or respiratory disease (diagnoses of upper respiratory infections, bronchiolitis, pneumonia, chronic obstructive pulmonary disease, asthma, or wheeze) in 20-county Atlanta during 1993-2012. Daily maximum temperature (Tmax) was acquired from the automated surface observing station at Atlanta Hartsfield International Airport. Poisson generalized linear models were used to estimate rate ratios (RR) between daily Tmax and asthma or respiratory disease ED visits, controlling for time and meteorology. Tmax effects were estimated for single-day lags of 0-6 days, for 3-, 5-, and 7-day moving averages and modeled with cubic terms to allow for non-linear relationships. Effect modification by individual factors (sex, race, insurance status) and area-level socioeconomic status (SES; ZIP code levels of poverty, education, and the neighborhood deprivation index) was examined via stratification.

RESULTS

Estimated RRs for Tmax and pediatric asthma ED visits were positive and significant for lag days 1-5, with the strongest single day association observed on lag day 2 (RR=1.06, 95% CI: 1.03, 1.09) for a change in Tmax from 27°C to 32°C (25th to 75th percentile). For the moving average exposure periods, associations increased as moving average periods increased. We observed stronger RRs between Tmax and asthma among males compared to females, non-white children compared to white children, children with private insurance compared to children with Medicaid, and among children living in high compared to low SES areas. Associations between Tmax and respiratory disease ED visits were weak and non-significant (p-value>0.05).

CONCLUSIONS

Results suggest socio-demographic factors (race/ethnicity, insurance status, and area-level SES) may confer vulnerability to temperature-related pediatric asthma morbidity. Our findings of weaker associations among children with Medicaid compared to other health insurance types and among children living in low compared to high SES areas run counter to our belief that children from disadvantaged households or ZIP codes would be more vulnerable to the respiratory effects of temperature. The potential reasons for these unexpected results are explored in the discussion.

Disparities in emergency department visits in American children with asthma: 2006-2010

OBJECTIVE

This article was to examine the trends in emergency department (ED) visits for asthma among American children in 2006-2010 across sociodemographic factors, parental smoking status, and children's body weight status.

METHODS

We analyzed 5,535 children aged 2-17 years with current asthma in the Asthma Call-Back Survey in 2006-2010. Multivariate log binomial regression was used to examine the disparities of ED visits by demographics, socioeconomic status, parental smoking status, children's body weight status, and the level of asthma control. We controlled for average state-level air pollutants. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were reported.

RESULTS

Minority children with current asthma had higher risks of ED visits compared with white children in 2009 and 2010, e.g., the PR (95% CI) for black children in 2009 was 3.64 (1.79, 7.41). Children who had current asthma and more highly educated parents experienced a higher risk of ED visits in 2007 (PRs [95% CI] = 2.15 [1.02, 4.53] and 2.97 [1.29, 6.83] for children with some college or college-graduated parents), but not significant in other years. Children with uncontrolled asthma were significantly more likely to visit the ED in 2008 (PRs [95% CI] = 2.79 [1.44, 5.41] and 6.96 [3.55, 13.64] for not-well-controlled and very poorly controlled children with asthma).

CONCLUSIONS

Minority children with current asthma or children with uncontrolled asthma were more likely to visit EDs for asthma treatment. However, the disparities in ED visits across sociodemographics, health status, or asthma control vary in scale and significance across time. More research is needed to explain these differences.

Ambient air pollution and emergency department visits for asthma: a multi-city assessment of effect modification by age

Previous studies have found strong associations between asthma morbidity and major ambient air pollutants. Relatively little research has been conducted to assess whether age is a factor conferring susceptibility to air pollution-related asthma morbidity. We investigated the short-term relationships between asthma emergency department (ED) visits and ambient ozone (O3), carbon monoxide (CO), nitrogen dioxide (NO2), sulfur dioxide (SO2), and fine particulate matter (PM2.5) in Atlanta (1993-2009), Dallas (2006-2009), and St. Louis (2001-2007). City-specific daily time-series analyses were conducted to estimate associations by age group (0-4, 5-18, 19-39, 40-64, and 65+ years). Sub-analyses were performed stratified by race and sex. City-specific rate ratios (RRs) were combined by inverse-variance weighting to provide an overall association for each strata. The overall RRs differed across age groups, with associations for all pollutants consistently strongest for children aged 5-18 years. The patterns of association across age groups remained generally consistent when models were stratified by sex and race, although the strong observed associations among 5-18 year olds appeared to be partially driven by non-white and male patients. Our findings suggest that age is a susceptibility factor for asthma exacerbations in response to air pollution, with school-age children having the highest susceptibility.

Health Disparities in Pediatric Asthma: Comprehensive Tertiary Care Center Experience

LOCATION

Study conducted at Nemours /Alfred I. duPont Hospital for Children, Wilmington, DE 19803 BACKGROUND: Although the treatment and management of asthma hasimproved over time, incidence and prevalence among children continues to rise in the United States. Asthma prevalence, health services utilization, and mortality rate demonstrate remarkable disparities. The underlying causes of these disparities are not fully understood. We aimed to examine racial/ethnic variances in pediatric asthma prevalence/admission.

PATIENTS AND METHODS

We retrospectively reviewed data on 1070 patients and applied a cross-sectional design to assess asthma admission between 2010 and 2011. Information was available on race/ethnicity, sex, insurance status, severity of illness (SOI), and length of stay/hospitalization (LOS).Chi-square statistic was used for the association between race and other variables in an attempt to explain the racial/ethnic variance.

RESULTS

The proportionate morbidity of asthma was highest amongCaucasians (40.92%) and African Americans (40.54%), intermediate among others (16.57%), and lowest among Asian (0.56%), American Indian/Alaska Native (0.28%), and Hawaiian Native/Pacific Islander (0.28%). Overall there were disparities by sex, with more boys (61.80%) diagnosed with asthma than girls (38.20%), χ2(7)=20.1, p=0.005. Insurance status, and SOI varied by race/ethnicity, but not LOS. Caucasian children were more likely to have private insurance, while African Americans and Hispanics were more likely to have public insurance (p<0.005). Asthma was more severe among non-Hispanic children, χ2(14)=154.6, p<0.001. While the overall readmission proportion was 2.8%, readmission significantly varied by race/ethnicity.

CONCLUSION

Racial/ethnic disparities in asthma admission exist among children in the Delaware Valley. There were racial/ethnic disparities in insurance status, asthma severity, and sex differed by race/ethnicity, but not in length of hospitalization.

Can the use of urgent care clinics improve access to care without undermining continuity in primary care?

PURPOSE

There is a niche for urgent care clinics as an alternate source of health care in the United States. This systematic review examines whether the use of urgent care clinics can improve access to care or if these facilities undermine continuity of primary care.

DATA SOURCES

Databases used were Cumulative Index for Nursing and Allied Health (CINAHL) and Medical Literature Analysis and Retrieval System Online (MEDLINE). Articles from 2004 to 2014 were searched using keywords-access, barriers, continuity of care, nurse practitioner (NP), urgent care, retail clinic, emergency, and primary care.

CONCLUSIONS

Urgent care clinics can improve access to care, but may also negatively impact continuity of care, preventative services, and ongoing management of chronic conditions. Barriers to primary care and benefits of urgent care are inversely related. Insufficient knowledge regarding navigation of the healthcare system, perceived urgency of medical need, and deflection of care contribute to use of urgent care over primary care.

IMPLICATIONS FOR PRACTICE

NPs are frontline healthcare providers essential to developing and maintaining successful communication and collaboration among providers across healthcare settings. In both primary care and urgent care facilities, NPs can ensure continuity of care, decreased healthcare costs, and optimized health outcomes for patients.

The impact of asthma exacerbations and preventive strategies

OBJECTIVE

To review the pathophysiologic mechanisms underlying asthma exacerbations, the impact of exacerbations, and both current and future treatment strategies to establish asthma control and reduce the risk of future exacerbations.

RESEARCH DESIGN AND METHODS

Relevant adult data were identified via PubMed, with additional references obtained by reviewing bibliographies from selected articles.

RESULTS

Asthma exacerbations or 'attacks' are acute episodes of progressive worsening of symptoms which occur in patients with all degrees of asthma severity and are an important cause of morbidity and mortality. For patients, these asthma attacks constitute a considerable part of the disease burden in terms of both personal suffering and economic impact. Exacerbations are characterized in part by decreases in expiratory flow or lung function. The pathophysiologic mechanism underlying these changes is likely to be different depending on the specific asthma phenotype. Asthma exacerbations are commonly initiated by upper respiratory tract infections and/or environmental allergens, although there are other known factors which increase the risk of a patient developing exacerbations, such as cigarette smoking. Establishing asthma control and reducing the risk of future exacerbations is the main goal of asthma treatment. Inhaled corticosteroids alone or in combination with long-acting β2-agonists, in addition to other step-up strategies such as leukotriene receptor antagonists and theophylline, are recommended. The anti-immunoglobulin E monoclonal antibody omalizumab should also be considered in difficult-to-treat allergic asthma.

CONCLUSIONS

Despite the currently available treatments, many patients with asthma remain symptomatic and experience exacerbations regardless of disease severity. New therapies, including long-acting anticholinergics, anti-cytokines, and chemoattractant receptor-homologous molecules, are under investigation with some promising results. In addition to increased education and use of self-management plans, these novel therapies are essential to help improve asthma control and reduce exacerbation risk.

The association between individual income and aggressive end-of-life treatment in older cancer decedents in Taiwan

OBJECTIVES

To examine the association of individual income and end of life (EOL) care in older cancer decedents in Taiwan.

DESIGN

Retrospective cohort study.

SETTING

National Health Insurance Research Database (NHIRD) in Taiwan.

PARTICIPANTS

28,978 decedents >65 years were diagnosed with cancer and died during 2009-2011 in Taiwan. Of these decedents, 10941, 16535, and 1502 were categorized by individual income as having low, moderate, and high SES, respectively.

MAIN OUTCOME MEASURES

Indicators of aggressiveness of EOL care: chemotherapy use before EOL, more than one emergency department (ER) visit, more than one hospital admission, hospital length of stay >14 days, intensive care unit (ICU) admission, and dying in a hospital.

RESULTS

Low individual income was associated with more aggressive EOL treatment (estimate -0.30 for moderate income, -0.27 for high income, both p<0.01). The major source of aggressiveness was the tendency for older decedents with low income to die in the acute care hospital. The indicators had an increasing trend from 2009 to 2011, except for hospital stay >14 days.

CONCLUSIONS

Low individual income is associated with more aggressive EOL treatment in older cancer decedents. Public health providers should make available appropriate education and hospice resources to these decedents and their families, to reduce the amount of aggressive terminal care such decedents receive.

Time Trends in Racial and Ethnic Disparities in Asthma Prevalence in the United States From the Behavioral Risk Factor Surveillance System (BRFSS) Study (1999-2011)

OBJECTIVES

We examined whether racial/ethnic disparities in the United States increased over time.

METHODS

We analyzed data from 3 868 956 adults across the United States from the Behavioral Risk Factor Surveillance System from 1999 to 2011. We used random intercepts models (individuals nested in states) to examine racial/ethnic disparities and time trends in asthma lifetime and its current prevalence, adjusted for covariates. We also investigated the heterogeneity in asthma prevalence by ethnicity of the major zone of residence.

RESULTS

Lifetime and current asthma prevalence were higher among non-Hispanic Black populations, with time trends highlighting increasing differences over time (b = 0.0078; 95% confidence interval [CI] = 0.0043, 0.0106). Lower odds ratios (ORs) of asthma were noted for Hispanic populations (OR = 0.74; 95% CI = 0.73, 0.76). Hispanics in states with more Puerto Rican residents reported greater risks of asthma (OR = 1.55; 95% CI = 1.24, 1.93) compared with Hispanics in states with larger numbers of Mexican or other ethnicities.

CONCLUSIONS

Disparities in asthma prevalence by racial/ethnic groups increased in the last decade, with non-Hispanic Blacks and Puerto Rican Hispanics at greater risk. Interventions targeting asthma treatments need to recognize racial, ethnic, and geographic disparities.

Asthma characteristics among older adults: using the California health interview survey to examine asthma incidence, morbidity and ethnic differences

OBJECTIVE

The purpose of this study was to examine the incidence, characteristics of asthma morbidity and care, and ethnic differences that exist in older adults with asthma in California.

METHODS

Data were from the 2009 California Health Interview Survey (CHIS). Characteristics of older adults (≥65 years) with and without asthma were compared using population-weighted estimates. Asthma-specific variables were compared among different ethnic groups. Multivariate analyses were preformed to determine factors associated with asthma status, asthma episodes/attacks, asthma symptom frequency and emergency department (ED) visits due to asthma.

RESULTS

Asthma was present in 8.1% of older adults, among which, 67.3% reported taking medication daily for asthma. Asthma symptoms were experienced every day by almost 20%, with over 34% of seniors with asthma having symptoms at least once per week. Despite having a lower frequency of asthma symptoms, Hispanics were 5.31 times more likely to visit the ED due to asthma than were Caucasians.

CONCLUSIONS

The findings from the study showed that older adults with asthma had difficulty with asthma control. We recommend a focus on asthma education so that when symptoms do occur, options are available to avoid costly ED visits. Further research should focus on specific asthma management skills and adherence to asthma treatment regimen among ethnic groups.

Reaching beyond disparity: safely improving asthma control in the at-risk African-American population

In the United States, substantial racial disparities exist in asthma prevalence, etiology, morbidity and mortality, particularly between African Americans and white Americans. African-American patients with asthma have inadequate access to appropriate healthcare, insufficient asthma management guidance from their physicians and poor adherence to asthma medications-all factors that may contribute to disproportionate morbidity. Historically, African Americans have been under-represented in clinical asthma studies, and a paucity of data exists surrounding asthma treatment response. One controversial study from 2006 suggests an increased safety risk with the use of long-acting beta2-adrenergic agonists (LABAs) in African Americans. More recently, several studies have evaluated the use of LABAs in combination with an ICS in African-American populations. This article reviews the existing data on asthma treatment outcomes, with particular emphasis on the recently published short- and long-term studies of ICS/LABA products conducted in African-American populations with moderate-to-severe asthma. Overall, evidence suggests that if African-American patients with asthma are provided with access to well-trained physicians, appropriate asthma management and effective medications, existing disparities in asthma control between African-American and white populations may be overcome.

Recent advances in the epidemiologic investigation of risk factors for asthma: a review of the 2011 literature

The present review aims to identify and summarize epidemiologic investigations published during 2011 on the environmental risk factors for asthma. Potentially eligible papers were identified by a MEDLINE search. In total, 1,130 items were retrieved. Based on a broad definition of environment, the following topics were included: obesity, diet, vitamin D, air pollution, farming environment, and social factors. Some of the more relevant contributions included evidence that 1) obesity precedes asthma, 2) fruit consumption is longitudinally associated with a lower risk of asthma and atopy, 3) a comprehensive statewide smoking ban was followed by a reduction in hospital admissions for asthma, 4) asthma is one of the diseases showing the largest burdens due to environmental tobacco smoke, 5) traffic-related urban air pollution is associated with bronchial inflammation as measured by fractional exhaled nitric oxide and uncontrolled asthma, 6) aeroallergens and desert dust may contribute to the short-term effects of air pollution and asthma, and 7) maternal exposure to air pollution before and during pregnancy may alter the immune competence in offspring.