1. 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

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

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

4. 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.

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

6. 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

7. 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.

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

9. 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

10. 2003 National Health Interview Survey (NHIS)
Children’s Sample Questionnaire
Additional family history data was taken from the Family questionnaire portion of the survey

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

12. 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.

13. 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

14. Outline Objectives Background Study Design Data Source
Outcome Assessment
Results
Conclusions

15. 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

16. 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

17. Outline Objectives Background Study Design Data Source
Outcome Assessment
Results
Conclusions

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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

24. Results – Adjusted OR Significant Adjusted Results:
** (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

25. 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

26. 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