Virginia Commonwealth University Lack of Routine Preventive Care as a determinant for Pediatric Asthma ER Visits Cristin Palumbo, MPH Dr. Saba Masho, MD, DrPH Virginia Commonwealth University School of Medicine

Outline Objectives Background Data Source Study Population and Sample Size Outcome Assessment Results Conclusions

Outline Objectives Background Data Source Study Population and Sample Size Outcome Assessment Results Conclusions

Objectives determine if there is a higher prevalence of pediatric asthma exacerbations in populations that lack adequate preventive medical care examine the prevalence of childhood ER visits for asthma among recipients and non-recipients of asthma management programs determine the relationship between adequate preventive medical care and asthma ER visits in children < 18 years of age. I want to see if there was a higher prevalence of pediatric asthma in populations that lack adequate preventive medical care. The prevalence and incidence of asthma has been continually increasing with in the United States. High rates of hospitalization, emergency room visits (ER) and infrequent prescribing of controller medications indicates the lack or inadequacies of asthma management in the home as well as primary care programs. This study examines the impact of adequate asthma management and preventive care on asthma ER visits.

Outline Objectives Background Data Source Study Population and Sample Size Outcome Assessment Results Conclusions

Background Asthma Preventable chronic inflammatory condition of the lungs that results in the tightening or narrowing of the airways Exacerbations are usually attributed to an allergic reaction from one or more of a variety of “triggers” cigarette smoke, pollen, mold, animal dander, feathers, dust, air pollution, food, exercise or emotional stress More than 40% of children in the US are exposed to environmental tobacco smoke (ETS) at home – according to the NHLBI National Asthma and Prevention Program

Why is asthma in children an important public health issue? Potentially dangerous asthma exacerbations are almost completely preventable with proper care Leading cause of school absenteeism attributed to a chronic condition, with more than 10 million days of school missed annually due to asthma-related issues* also one of the leading causes for emergency care visits, morbidities, hospitalizations, and mortalities in children* Children and parents are not receiving asthma management information to prevent, control and monitor asthma exacerbations One of the things that we talk about in Public health it ability to intervene and with pediatric asthma there is room for intervention. More than 40% of children in the US are exposed to environmental tobacco smoke (ETS) at home Children and parents do not all receive the proper asthma management information to prevent, control and monitor asthma exacerbations *American Lung Association, Asthma and Children Fact Sheet 2004.

Outline Objectives Background Data Source Study Population and Sample Size Outcome Assessment Results Conclusions

2003 National Health Interview Survey (NHIS) Continuous, nation-wide cross sectional survey of the health status and behaviors in the United States Multistage probability sampling, obtained through extensive questionnaires and flash cards Face-to-face questionnaires administered in randomly selected households

2003 National Health Interview Survey (NHIS) Children’s Sample Questionnaire Additional family history data was taken from the Family questionnaire portion of the survey

Outline Objectives Background Data Source Study Population and Sample Size Outcome Assessment Results Conclusions

Study Population Children, <18 years of age Diagnosed as having asthma by a physician Had an asthma episode in the past 12 months Data from the 2003 National Health Interview Survey (NHIS) was utilized. Children (N=653) under the age of 18 years and who have had asthma episode in the past year were included for this analysis. A composite variable was created to determine adequacy of care at home and in the primary care setting using standards from the Global Initiative for Asthma (GINA) supported by the National Heart, Lung and Blood Institute.

Sampling for children with active asthma diagnosis NHIS 2003 Study Population N=138,925 Household, Family/Person Sample Adult, Immunization ≥ 18 years N = 126,676 Sample Child < 18 years N = 12,249 No Asthma N = 10,713 Asthma N = 1,536 No asthma episode in the past 12 months N = 883 Has had an asthma episode in the past 12 months N = 653 Components of Adequate Preventive Care as guided by the Global Initiative for Asthma (GINA) ≥ 1 ER Visit In the past 12 months N = 237 No ER Visits In the past 12 months N = 416

Outline Objectives Background Study Design Data Source Outcome Assessment Results Conclusions

Outcome Assessment Outcome Variable Main Independent Variable ER visit in the past 12 months Main Independent Variable Composite variable created from 12 variables Use of proper medication and prescription inhalers, asthma management education, given asthma management plan, recognition of early signs and symptoms and proper response and monitoring and environment education Composite variable was dichotomized to create adequacy of care Score of < 6 = inadequate Score of > 6 = adequate Covariates Socio-demographic variables for both parents and children Access and utilization of care

Data Analysis Descriptive Crude analysis Adjusted analysis proportions, means Crude analysis binary logistic regressions ER visit in the past 12 months as the dependent variable Adjusted analysis multiple logistic regression

Outline Objectives Background Study Design Data Source Outcome Assessment Results Conclusions

Results NHIS asthma prevalence resembles the national average of 13% 12.5% As you can see the numbers I found in the NHIS data resembles nationally reported numbers of asthma prevalence

Results - Descriptive < $20,000/Year Family Income Variable Gender Male Female 58.6% 41.4% Age (years) <6 6 – 10 11 – 17 25.7% 28.5% 45.8% Race White African American All Other 70.7% 25.0% 4.3% Ethnicity Hispanic Non-Hispanic 22.3% 77.7% Family Income < $20,000/Year Family Income > $20,000/Year Family Income 25.4% 74.6% Just some general demographic information to give you an idea of what the population looks like. More than half were males, with the majority in the 11 to 17 age range.

Results Prevalence of ≥ 1 ER visit in the previous 12 months 22.7% of children with asthma 55.7% of children < 6 years 48.1% of African American children 49% of children whose mother, and 43.7% whose father did not graduate from high school 50.3% of children with < $20,000/year family income 90.6% who have stayed overnight in the hospital due to asthma

Variable Total ER Visit   Crude Adjusted N POR 95% CI Child's Age Under 6 years 167 93 2.752 1.780 4.254 3.409 2.042 5.691 6 to 10 Years 185 58 0.892 0.599 1.330 0.966 0.609 1.531 11 to 17 Years 297 86 1.000 Child's Race White 459 146 African American 162 78 0.538 0.250 1.160 0.525 0.222 1.240 All other races 28 13 1.071 0.479 2.394 0.739 0.291 1.873

Variable Total ER Visit   Crude Adjusted N POR 95% CI Mother's Education Level Less than High School 100 49 1.332 0.792 2.238 0.817 0.439 1.519 High School Diploma 169 63 0.824 0.519 1.307 0.748 0.445 1.257 Some College, No Degree 136 57 0.469 0.291 0.756 0.456 0.271 0.767 A.S/A, B.S/A, M.S/A, Pro 182 46 1.000 Family Income Less than $20,000/year 157 79 2.200 1.520 3.184 1.771 1.097 2.858 $20,000/year or more 460 145

Variable Total ER Visit   Crude Adjusted N POR 95% CI Place Most often Visit Other Office, Hospital, HMO 614 220 1.000 Hospital Emergency Room 14 10 0.233 0.069 0.721 0.421 0.120 1.477 Standard of Care Inadequate <6 383 148 1.638 1.106 2.426 2.055 1.257 3.361 Adequate >6 261 87

Results – Adjusted OR Significant Adjusted Results: ** 2.055 (1.257, 3.361) children with inadequate care visited the ER at least one time in the past 12 months ** 3.409 (2.042, 5.691) children under 6 years 1.771 (1.097, 2.858) children with family/income < $20,000/year 0.456 (0.271, 0.767) children whose mother has at least some college, but no degree

Conclusions Lack adequate asthma management and prevention are important determinants for asthma related ER visits in children Practices that support early interventions for asthma management and preventive care were associated with reduced risk of ER visits Initiatives to support mandatory asthma management education and programming at primary care practices and as well as the home setting are essential in the management of pediatric asthma. The finding are consistent with the literature pertaining to similar care issues in the ER not before reaching the ER. An organized, disease management program increased adherence to the National Asthma Education and Prevention Program asthma guidelines for PCPs, which reduced hospitalizations, ED visits, and outpatient visits for children with asthma. The findings were biologically plausible, as prevention of exacerbations lead to overall improved health outcomes. By preventing this harmful strain on a child’s respiratory system, their overall health and condition will benefit. Practices that support early interventions for asthma exacerbations by parents at home still may be associated with reduced risk of ER visits. Initiatives to support mandatory asthma management education and programming at primary care practices and as well as the home setting are essential in the management of pediatric asthma Policy makers need to involve health care professionals and parents/care takers in developing a reasonable approach to mandatory asthma management regiments for primary care providers

Study Limitations Questionnaire-based Recall bias Overestimating their child’s illness Dishonesty - preventive care measures preceding the ER visit Questions associated with child health care parents embarrassed or ashamed may lead to refusals or dishonesty Interviewer bias 200 different interviewers administering the questionnaire In this questionnaire, parents are asked to recall the activities of the past 12 months, which could lead to recall bias and both overestimating their child’s illness, as well as being dishonest about preventive care measures preceding the ER visit. Questions about the child health care, may make parents embarrassed or ashamed when they know their own habits and environments were detrimental to their child’s health. This may lead to refusals or dishonesty when answering questions. Possibility of interviewer bias, as there were over 200 different interviewers administering the questionnaire