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Cole MC, Raphael JL, Katkin JP, Yenduri NJS, Gazzaneo MC, Revana A, Anagnostou A, Farber HJ. Asthma outcomes in pediatric patients with 30-day follow-up after an asthma hospitalization in a Medicaid-managed care program. J Asthma 2023:1-7. [PMID: 36893220 DOI: 10.1080/02770903.2023.2185155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND National asthma guidelines recommend an outpatient follow-up after hospitalization for asthma. Our aim is determine if a follow-up visit within 30 days after an asthma hospitalization impacts risk for re-hospitalization and emergency department visits for asthma within the following year. METHODS This was a retrospective cohort study of claims data of Texas Children's Health Plan (a Medicaid managed care program) members age 1 to <18 years and hospitalized for asthma between January 1, 2012, and December 31, 2018. Primary outcomes were days to re-hospitalization and emergency department visit between 30 days and 365 days following the index hospitalization. RESULTS We identified 1,485 children age 1 to <18 years hospitalized for asthma. Comparing those with a 30 day follow-up to those without, there was no difference in days to re-hospitalization (adjusted hazard ratio 1.23, 95% Confidence Interval (CI) 0.74-2.06) or emergency department visit for asthma (aHR 1.08, 95% CI 0.88-1.33). Inhaled corticosteroid and short acting beta agonist dispensing were greater in the group completing the 30 day follow-up (means of 2.8 and 4.8 respectively for those with follow-up, 1.6 and 3.5 respectively for those without, p < 0.0001). CONCLUSION Having a follow-up outpatient visit within 30 days of an asthma hospitalization is not associated with a decrease in asthma re-hospitalization or emergency department visit in the 30-365 day period following the index hospitalization. Non-adherence to regular use of inhaled corticosteroid medication was high in both groups. These findings suggest need for improvement in the quality and quantity of post hospital asthma follow-up.
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Affiliation(s)
- Melissa C Cole
- Pediatrics, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jean L Raphael
- Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Julie P Katkin
- Pediatrics, Division of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Naga Jaya Smitha Yenduri
- Pediatrics, Division of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Maria C Gazzaneo
- Pediatrics, Division of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Amee Revana
- Pediatrics, Division of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Aikaterini Anagnostou
- Pediatrics, Division of Allergy and Immunology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Harold J Farber
- Pediatrics, Division of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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Hammon L, Mondzelewski L, Robinson C, Milder E. Well-Child Care Disparities in U.S. Military Health System. Acad Pediatr 2023; 23:363-371. [PMID: 35918041 DOI: 10.1016/j.acap.2022.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe adherence rates for well-child visits among military children in the first 15 months of life and identify any disparities in adherence in a universally insured population. METHODS A retrospective cohort analysis was conducted using the Military Health System data repository which included children who were born between October 2013 and September 2016 and were eligible for TRICARE (the military health insurance program). Children were followed from zero to fifteen months of life to assess adherence with a national Health Effectiveness Data and Information Set (HEDIS) metric of 6 well visits during this period. Differences in adherence rates were evaluated across select demographic characteristics including sponsor rank, race, age, service branch, patient sex, geographic region, number of enrollment sites and provider type. Fitted logistic regression models were used to determine the probability of adherence with the HEDIS metric and identify disparities. RESULTS The final cohort included 168,830 infants. Across all variables, the mean number of well visits was 6.7 with an overall adherence rate of 86%. Child beneficiaries of junior enlisted, Black, and Air Force military members had lower adherence with the HEDIS metric. Enrollment at a single site and having a pediatrician for a primary care manager was associated with higher rates of adherence. CONCLUSIONS Sponsor rank, race, and service branch, along with provider type and number of enrollment sites were significantly associated with the probability of adherence. Further research should evaluate barriers to care that affect a universally insured population.
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Affiliation(s)
- Laura Hammon
- Department of Pediatrics (L Hammon), Naval Hospital Rota, Spain.
| | - Lisa Mondzelewski
- Department of Pediatrics (L Mondzelewski), Naval Medical Center San Diego, Calif
| | - Camille Robinson
- Division of Adolescent Medicine (C Robinson), Naval Medical Center San Diego, Calif
| | - Edmund Milder
- Division of Pediatric Infectious Diseases (E Milder), Naval Medical Center San Diego, Calif
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Simms-Williams N, Nagakumar P, Thayakaran R, Adderley N, Hotham R, Mansur A, Nirantharakumar K, Haroon S. Preventing unscheduled hospitalisations from asthma: a retrospective cohort study using routine primary and secondary care data in the UK (The PUSH-Asthma Study)-protocol paper. BMJ Open 2022; 12:e058356. [PMID: 35985783 PMCID: PMC9396147 DOI: 10.1136/bmjopen-2021-058356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Asthma is the most common chronic respiratory disease in children and adults. Asthma results in significant disease-related morbidity, healthcare costs and, in some cases, death. Despite efforts through implementation of national guidelines to improve asthma care, the UK has one of the highest asthma-related morbidity and mortality rates in the western world. New approaches are necessary to prevent asthma attacks in children and adults. The objectives of this study are to assess the association between demographic and clinical factors and asthma-related hospital admissions in children and adults, describe the epidemiology of asthma phenotypes among hospital attenders, and externally validate existing asthma risk prediction models. METHODS AND ANALYSIS This is a retrospective cohort study of children and adults with asthma. Data will be extracted from the Clinical Practice Research Datalink (CPRD) Aurum database, which holds anonymised primary care data for over 13 million actively registered patients and covers approximately 19% of the UK population. The primary outcome will be asthma-related hospital admissions. The secondary outcomes will be prescriptions of short courses of oral corticosteroids (as a surrogate measure for asthma exacerbations), a composite outcome measure including hospital admissions and prescriptions of short courses of oral corticosteroids and delivery of asthma care management following hospital discharge. The primary analysis will use a Poisson regression model to assess the association between demographic and clinical risk factors and the primary and secondary outcomes. Latent class analysis will be used to identify distinct subgroups, which will further our knowledge on potential phenotypes of asthma among patients at high risk of asthma-related hospital admissions. A Concordance statistic (C-statistic) and logistic regression model will also be used to externally validate existing risk prediction models for asthma-related hospitalisations to allow for the optimal model to be identified and evaluated provide evidence for potential use of the optimal performing risk prediction model in primary care. ETHICS AND DISSEMINATION This study was approved by the CPRD Independent Scientific Advisory Committee (reference number: 21_000512). Findings from this study will be published in a peer-reviewed journal and disseminated at national and international conferences.
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Affiliation(s)
| | - Prasad Nagakumar
- Respiratory medicine, Birmingham Women's and Children's Hospitals NHS Foundation Trust, Birmingham, UK
- Institute of inflammation and ageing, University of Birmingham, Birmingham, UK
| | - Rasiah Thayakaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicola Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Richard Hotham
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Adel Mansur
- Institute of inflammation and ageing, University of Birmingham, Birmingham, UK
- Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Shamil Haroon
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Morillo D, Mena-Bucheli S, Ochoa A, Chico ME, Rodas C, Maldonado A, Arteaga K, Alchundia J, Solorzano K, Rodriguez A, Figueiredo C, Ardura-Garcia C, Bachmann M, Perkin MR, Chis Ster I, Cruz A, Romero NC, Cooper P. Prospective study of factors associated with asthma attack recurrence (ATTACK) in children from three Ecuadorian cities during COVID-19: a study protocol. BMJ Open 2022; 12:e056295. [PMID: 35710244 PMCID: PMC9207574 DOI: 10.1136/bmjopen-2021-056295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Asthma is a growing health problem in children in marginalised urban settings in low-income and middle-income countries. Asthma attacks are an important cause of emergency care attendance and long-term morbidity. We designed a prospective study, the Asthma Attacks study, to identify factors associated with recurrence of asthma attacks (or exacerbations) among children and adolescents attending emergency care in three Ecuadorian cities. METHODS AND ANALYSIS Prospective cohort study designed to identify risk factors associated with recurrence of asthma attacks in 450 children and adolescents aged 5-17 years attending emergency care in public hospitals in three Ecuadorian cities (Quito, Cuenca and Portoviejo). The primary outcome will be rate of asthma attack recurrence during up to 12 months of follow-up. Data are being collected at baseline and during follow-up by questionnaire: sociodemographic data, asthma history and management (baseline only); recurrence of asthma symptoms and attacks (monthly); economic costs of asthma to family; Asthma Control Test; Pediatric Asthma Quality of life Questionnaire; and Newcastle Asthma Knowledge Questionnaire (baseline only). In addition, the following are being measured at baseline and during follow-up: lung function and reversibility by spirometry before and after salbutamol; fractional exhaled nitric oxide (FeNO); and presence of IgG antibodies to SARS-CoV-2 in blood. Recruitment started in 2019 but because of severe disruption to emergency services caused by the COVID-19 pandemic, eligibility criteria were modified to include asthmatic children with uncontrolled symptoms and registered with collaborating hospitals. Data will be analysed using logistic regression and survival analyses. ETHICS AND DISSEMINATION Ethical approval was obtained from the Hospital General Docente de Calderon (CEISH-HGDC 2019-001) and Ecuadorian Ministry of Public Health (MSP-CGDES-2021-0041-O N° 096-2021). The study results will be disseminated through presentations at conferences and to key stakeholder groups including policy-makers, postgraduate theses, peer-review publications and a study website. Participants gave informed consent to participate in the study before taking part.
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Affiliation(s)
- Diana Morillo
- Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador
| | | | - Angélica Ochoa
- Department of Biosciences, Universidad de Cuenca, Cuenca, Ecuador
| | - Martha E Chico
- Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador
| | - Claudia Rodas
- Facultad de Medicina, Universidad de Azuay, Cuenca, Ecuador
| | - Augusto Maldonado
- School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador
- Emergency Department, Hospital General Docente Calderón, Quito, Ecuador
| | - Karen Arteaga
- Emergency Department, Hospital Verdi Cevallos Balda, Portoviejo, Ecuador
| | - Jessica Alchundia
- Pediatric Pneumology, Hospital de Especialidades Portoviejo, Portoviejo, Ecuador
| | - Karla Solorzano
- Pediatric Pneumology, Hospital de Especialidades Portoviejo, Portoviejo, Ecuador
| | | | - Camila Figueiredo
- Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | | | - Max Bachmann
- Norwich Medical School, University of East Anglia, University of East Anglia, Norwich, UK
| | | | - Irina Chis Ster
- Institute of Infection and Immunity, St. George's University of London, London, UK
- Institute of Infection and Immunity, St. George's University of London, London, UK
| | - Alvaro Cruz
- Núcleo de Excelência em Asma, Universidade Federal da Bahia, Salvador, Brazil
| | - Natalia Cristina Romero
- School of Medicine, Universidad Internacional del Ecuador, Quito, Ecuador
- GRAAL, Grups de Recerca d'America i Africa Llatines, Cerdanyola del Valles, Barcelona, Spain
| | - Philip Cooper
- Escuela de Medicina, Universidad Internacional del Ecuador, Quito, Ecuador
- Institute of Infection and Immunity, St. George's University of London, London, UK
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McDaniel JT, McDermott RJ, Martinasek MP, White RM. Prevalence of childhood asthma in US military and non-military families: Comparisons by rural-urban residence and geographic region. Chronic Illn 2020; 16:296-306. [PMID: 30335511 DOI: 10.1177/1742395318807546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to determine variables associated with asthma among children from military and non-military families. METHODS We performed secondary data analysis on the 2016 Behavioral Risk Factor Surveillance System. Parents with and without military experience (n = 61,079) were asked whether a child ever had asthma and currently has asthma. We used two multiple logistic regression models to determine the influence of rurality and geographic region on "ever" and "current" asthma in children of military and non-military families, while controlling for socio-demographic and behavioral variables. RESULTS Overall childhood asthma prevalence for children in military families was lower than non-military families (ever, 9.7% vs. 12.9%; currently, 6.2% vs. 8.2%) in 2016. However, multiple logistic regression showed variation in "ever" and "current" asthma among children of military and non-military families by rurality and race. DISCUSSION Developers of public health asthma interventions should consider targeting African-American children of military families living in urban areas. This population is approximately twice as likely to have asthma as Caucasian children of non-military families.
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Affiliation(s)
- Justin T McDaniel
- Department of Public Health and Recreation Professions, Southern Illinois University, Carbondale, IL, USA
| | - Robert J McDermott
- Department of Public Health and Recreation Professions, Southern Illinois University, Carbondale, IL, USA
| | - Mary P Martinasek
- Department of Health Sciences and Human Performance, University of Tampa, Tampa, FL, USA
| | - Robin M White
- Department of Nursing, University of Tampa, Tampa, FL, USA
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Ardura-Garcia C, Arias E, Hurtado P, Bonnett LJ, Sandoval C, Maldonado A, Workman LJ, Platts-Mills TAE, Cooper PJ, Blakey JD. Predictors of severe asthma attack re-attendance in Ecuadorian children: a cohort study. Eur Respir J 2019; 54:1802419. [PMID: 31515399 PMCID: PMC6860994 DOI: 10.1183/13993003.02419-2018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 08/11/2019] [Indexed: 01/23/2023]
Abstract
Asthma is a common cause of emergency care attendance in low- and middle-income countries (LMICs). While few prospective studies of predictors for emergency care attendance have been undertaken in high-income countries, none have been performed in a LMIC.We followed a cohort of 5-15-year-old children treated for asthma attacks in emergency rooms of public health facilities in Esmeraldas City, Ecuador. We collected blood and nasal wash samples, and performed spirometry and exhaled nitric oxide fraction measurements. We explored potential predictors for recurrence of severe asthma attacks requiring emergency care over 6 months' follow-up.We recruited 283 children of whom 264 (93%) were followed-up for ≥6 months or until their next asthma attack. Almost half (46%) had a subsequent severe asthma attack requiring emergency care. Predictors of recurrence in adjusted analyses were (adjusted OR, 95% CI) younger age (0.87, 0.79-0.96 per year), previous asthma diagnosis (2.2, 1.2-3.9), number of parenteral corticosteroid courses in previous year (1.3, 1.1-1.5), food triggers (2.0, 1.1-3.6) and eczema diagnosis (4.2, 1.02-17.6). A parsimonious Cox regression model included the first three predictors plus urban residence as a protective factor (adjusted hazard ratio 0.69, 95% CI 0.50-0.95). Laboratory and lung function tests did not predict recurrence.Factors independently associated with recurrent emergency attendance for asthma attacks were identified in a low-resource LMIC setting. This study suggests that a simple risk-assessment tool could potentially be created for emergency rooms in similar settings to identify higher-risk children on whom limited resources might be better focused.
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Affiliation(s)
- Cristina Ardura-Garcia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Erick Arias
- Fundación Ecuatoriana Para Investigación en Salud, Quito, Ecuador
| | - Paola Hurtado
- Fundación Ecuatoriana Para Investigación en Salud, Quito, Ecuador
| | - Laura J Bonnett
- Dept of Biostatistics, University of Liverpool, Liverpool, UK
| | - Carlos Sandoval
- Fundación Ecuatoriana Para Investigación en Salud, Quito, Ecuador
| | - Augusto Maldonado
- Colegio de Ciencias de la Salud, Universidad San Francsico de Quito, Quito, Ecuador
| | - Lisa J Workman
- Asthma and Allergic Diseases Center, University of Virginia, Charlottesville, VA, USA
| | | | - Philip J Cooper
- Fundación Ecuatoriana Para Investigación en Salud, Quito, Ecuador
- Facultad de Ciencias Medicas, de la Salud y la Vida, Universidad Internacional del Ecuador, Quito, Ecuador
- Institute of Infection and Immunity, St George's University of London, London, UK
- Both authors contributed equally
| | - John D Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- Medical School, Curtin University, Perth, Australia
- Both authors contributed equally
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Emergency Department Recidivism and Asthma: Revisiting an Old Problem. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:1914-1915. [PMID: 30390904 DOI: 10.1016/j.jaip.2018.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 06/13/2018] [Indexed: 11/20/2022]
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Ardura-Garcia C, Stolbrink M, Zaidi S, Cooper PJ, Blakey JD. Predictors of repeated acute hospital attendance for asthma in children: A systematic review and meta-analysis. Pediatr Pulmonol 2018; 53:1179-1192. [PMID: 29870146 PMCID: PMC6175073 DOI: 10.1002/ppul.24068] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/15/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Asthma attacks are common and have significant physical, psychological, and financial consequences. Improving the assessment of a child's risk of subsequent asthma attacks could support front-line clinicians' decisions on augmenting chronic treatment or specialist referral. We aimed to identify predictors for emergency department (ED) or hospital readmission for asthma from the published literature. METHODS We searched MEDLINE, EMBASE, AMED, PsycINFO, and CINAHL with no language, location, or time restrictions. We retrieved observational studies and randomized controlled trials (RCT) assessing factors (personal and family history, and biomarkers) associated with the risk of ED re-attendance or hospital readmission for acute childhood asthma. RESULTS Three RCTs and 33 observational studies were included, 31 from Anglophone countries and none from Asia or Africa. There was an unclear or high risk of bias in 14 of the studies, including 2 of the RCTs. Previous history of emergency or hospital admissions for asthma, younger age, African-American ethnicity, and low socioeconomic status increased risk of subsequent ED and hospital readmissions for acute asthma. Female sex and concomitant allergic diseases also predicted hospital readmission. CONCLUSION Despite the global importance of this issue, there are relatively few high quality studies or studies from outside North America. Factors other than symptoms are associated with the risk of emergency re-attendance for acute asthma among children. Further research is required to better quantify the risk of future attacks and to assess the role of commonly used biomarkers.
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Affiliation(s)
| | | | - Seher Zaidi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Philip J Cooper
- Facultad de Ciencias Medicas, de la Salud y la Vida, Universidad Internacional del Ecuador, Quito, Ecuador.,Institute of Infection and Immunity, St George's University of London, London, UK
| | - John D Blakey
- Respiratory Medicine, Royal Liverpool Hospital, Liverpool, UK.,Health Services Research, Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
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Montgomery MP, Allen ED, Thomas O, Robinson BF, Clark D, Connelly A, Mott JA, Conrey E. Association between pediatric asthma care quality and morbidity and English language proficiency in Ohio. J Asthma 2018; 56:603-610. [PMID: 29738270 DOI: 10.1080/02770903.2018.1474364] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Limited English proficiency can be a barrier to asthma care and is associated with poor outcomes. This study examines whether pediatric patients in Ohio with limited English proficiency experience lower asthma care quality or higher morbidity. METHODS We used electronic health records for asthma patients aged 2-17 years from a regional, urban, children's hospital in Ohio during 2011-2015. Community-level demographics were included from U.S. Census data. By using chi-square and t-tests, patients with limited English proficiency and bilingual English-speaking patients were compared with English-only patients. Five asthma outcomes-two quality and three morbidity measures-were modeled using generalized estimating equations. RESULTS The study included 15 352 (84%) English-only patients, 1744 (10%) patients with limited English proficiency, and 1147 (6%) bilingual patients. Pulmonary function testing (quality measure) and multiple exacerbation visits (morbidity measure) did not differ by language group. Compared with English-only patients, bilingual patients had higher odds of ever having an exacerbation visit (morbidity measure) (adjusted odds ratio [aOR], 1.4; 95% confidence interval [CI], 1.2-1.6) but lower odds of admission to intensive care (morbidity measure) (aOR, 0.3; 95% CI, 0.2-0.7), while patients with limited English proficiency did not differ on either factor. Recommended follow-up after exacerbation (quality measure) was higher for limited English proficiency (aOR, 1.8; 95% CI, 1.4-2.3) and bilingual (aOR, 1.6; 95% CI, 1.3-2.1), compared with English-only patients. CONCLUSIONS In this urban, pediatric population with reliable interpreter services, limited English proficiency was not associated with worse asthma care quality or morbidity.
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Affiliation(s)
- Martha P Montgomery
- a Epidemic Intelligence Service, Division of Scientific Education and Professional Development , Centers for Disease Control and Prevention , Atlanta , Georgia.,b Ohio Department of Health , Columbus , Ohio
| | | | | | - Byron F Robinson
- a Epidemic Intelligence Service, Division of Scientific Education and Professional Development , Centers for Disease Control and Prevention , Atlanta , Georgia
| | - Donnie Clark
- c Nationwide Children's Hospital , Columbus , Ohio
| | | | - Joshua A Mott
- a Epidemic Intelligence Service, Division of Scientific Education and Professional Development , Centers for Disease Control and Prevention , Atlanta , Georgia
| | - Elizabeth Conrey
- b Ohio Department of Health , Columbus , Ohio.,d Maternal and Child Health Epidemiology Program, Division of Reproductive Health , Centers for Disease Control and Prevention , Atlanta , Georgia
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