Paediatric asthma hospital utilization varies by demographic factors and area socio-economic status

doi:10.1016/j.puhe.2012.04.011

Public Health

Volume 126, Issue 11, November 2012, Pages 928-936

https://doi.org/10.1016/j.puhe.2012.04.011 Get rights and content

Summary

Objectives

Associations of emergency department (ED) visits and hospital admissions for asthma in children with demographics and area socio-economic status (SES) were examined to evaluate long-term trends and identify vulnerable populations.

Study design

Retrospective population-based trend and cross-sectional analyses.

Methods

Asthma hospital admissions (2000–2007) and ED visits (2005–2007) for children aged 0–14 years living in Orange County, California were linked with zip-code-level SES data (2000 US Census). Annual population estimates were obtained to calculate age-specific admissions and ED visit rates. Average annual percentage changes (AAPC) were calculated with joinpoint analyses. The risks of ED visits and hospital admissions were estimated from SES indicators with negative binomial regression.

Results

Rates of asthma hospital admissions and ED visits were highest among children aged 0–4 years, males and African Americans, and lowest among Asian/Pacific Islanders. African Americans and Hispanics/Latinos were more likely to be uninsured. Asthma admissions decreased significantly for all age groups over the study period. The greatest declines per 100,000 were among children aged 0–4 years (AAPC: −15.3%, 95% confidence interval −17.0% to −13.4%). Rates of hospital admissions and ED visits were significantly higher in low-SES groups. Hospital admission rates were 30–60% higher and ED visits were 80–90% higher in zip codes in the lowest tertile of median household income compared with the highest tertile of median household income.

Conclusions

Paediatric asthma hospitalizations and ED visit rates are declining in Orange County. However, certain groups are disproportionately affected, including those living in areas with low SES. This information will help in targeting intervention strategies to children at highest risk for severe asthma episodes.

Introduction

Asthma was estimated to affect 6.5 million children in the USA in 2005¹ and to account for 12.8 million missed school days in 2003, according to a national survey.² Rates of emergency department (ED) visits and hospital admissions for asthma have been reported to be highest among children, with those aged 0–4 years having the highest rates overall.² In addition, disproportionately higher rates of asthma have been reported for children who are male, non-Hispanic, African American or poor.1, 3, 4 Compounding this burden of asthma is that for racial/ethnic minorities (including African Americans and Hispanics or Latinos) and poorer families, access to high-quality health care is limited in the USA due to lack of private insurance.3, 4, 5

Efforts to reduce severe asthma episodes requiring treatment in an ED or inpatient hospital setting include use of controller medications, and healthcare provider and patient education.⁶ These approaches may be out of reach for children of low-income families in the USA who do not have private health insurance.⁵ Stafford et al. reported that asthma-related office visits in the USA increased throughout the 1980s, then levelled off during the next decade, corresponding with an increase in controller-medication use including inhaled corticosteroids.⁷ A recent meta-analysis reported that paediatric asthma education reduced mean numbers of hospitalizations and ED visits.⁸ However, this requires adequate access to health care.

The present population-based study evaluated asthma hospital data for Orange County, California. Therefore, results cannot be generalized beyond this region but are likely to be similar for other US counties. Orange County (total population in 2000: 2,846,297, with 25% under 18 years of age) has a fairly diverse population, with 30.8% being of Hispanic or Latino ethnicity and 9.2% being below the poverty level, according to the 2000 US Census Bureau (http://factfinder.census.gov/home/saff/main.html%3f_lang%3den). The Asthma and Chronic Lung Disease (ACLD) Institute, supported by the Children and Families Commission of Orange County, launched a variety of clinical and educational initiatives in 2002 to reduce the burden of asthma in Orange County children aged 0–5 years, when most asthma symptom phenotypes first emerge. As part of this effort, data were collected on asthma ED visits and hospital admissions for children of all ages in Orange County to examine trends in recent years and to investigate whether area-level socio-economic status (SES) indicators may be associated with episodes of paediatric asthma that are treated in the hospital setting. The aim of this study was to evaluate annual trends in asthma hospital encounters, and to identify groups that may benefit from targeted prevention or intervention programmes.

Section snippets

Hospital admissions and emergency-department visits

Two separate population-based datasets were obtained from the California Office of Statewide Health Planning and Development (OSHPD), one for asthma hospital admissions and another for asthma ED visits for children who live in Orange County. The hospital admissions data were available for 2000–2007. ED data collection began on 1 January 2005 and were available for 2005–2007. Reporting on ED visits and hospital admissions is required of all non-federal hospitals (excluding veterans

Patient characteristics for hospital admissions and ED visits

Table 1 displays patient characteristics including sex, race/ethnicity and age group for asthma hospital admissions for 2000–2007 and ED visits for 2005–2007 in Orange County. The youngest age group (0–4 years) had the highest rates of asthma admissions and ED visits, and males had higher rates of asthma admissions and ED visits than females for all age groups. Of the racial/ethnic groups, African Americans had the highest rates of asthma admissions and ED visits, followed by non-Hispanic

Discussion

The highest admission rate per 100,000 people was found among African Americans, and the smallest admission rate per 100,000 people was found among Asians and Pacific Islanders, who were at least as well insured as non-Hispanic Whites. The higher rates among African Americans are consistent with US national data,10, 11, 12 and suggest that targeted interventions and risk factor identification are needed. An analysis of the National Health Interview Survey suggested that the higher risk among

Acknowledgements

Ethical approval

This study was approved by the University of California Irvine Institutional Review Board and the Committee for the Protection of Human Subjects, California Health and Human Services Agency.

Funding

The Asthma and Chronic Lung Disease Institute, for the Children and Families Commission of Orange County, Grant no. FCI-CU3-13.

Competing interests

None declared.

References (12)

A.E. Shields
Trends in private insurance, Medicaid/State children's health insurance program, and the health-care safety net: implications for asthma disparities
Chest
(2007)
R.S. Stafford et al.
National trends in asthma visits and asthma pharmacotherapy, 1978–2002
J Allergy Clin Immunol
(2003)
A.A. Ginde et al.
Improved overall trends but persistent racial disparities in emergency department visits for acute asthma, 1993–2005
J Allergy Clin Immunol
(2008)
B. Bloom et al.
Summary of health statistics for U.S. children. National health interview survey, 2005
(2006)
L. Akinbami
Asthma prevalence, health care use and mortality: United States, 2003–2005. NCHS Health and Stats
(2006)
D.R. Gold et al.
Population disparities in asthma
Annu Rev Public Health
(2005)

There are more references available in the full text version of this article.

Cited by (36)

Multimodal, open-source big data analysis in asthma: A novel approach to inform public health programming
2023, World Allergy Organization Journal
Asthma is a chronic respiratory disease affecting over 358 million people worldwide; for this reason analysing big data on asthma from different countries could give a more detailed picture of current disease burden. We aim to investigate the correlations between asthma and key socio-demographic parameters from different world databases. We found a direct correlation with the gross domestic product (GDP) per capita and its nominal counterpart, with wealthiest countries seen to have the highest prevalence of asthma, as also confirmed by a similar correlation with the human development index (HDI). A positive correlation was also seen between asthma prevalence and a number of socio-cultural data being representative of a good life quality index and prevalent in more developed and wealthier countries. Concerning medical data, an inverse relationship was seen between asthma prevalence and helminthiasis. Those data indicate a higher prevalence for asthma in more developed countries, where socio-economic status is higher and also the access to medical care is more ubiquitous. The approach used in our study highlighted the role of medical literacy and access to healthcare facilities in the correct diagnosis of asthma and vice versa. Our data appear to be suitable in terms of a health programming approach because of the high burden of disease worldwide.
Prevalence of overweight and obesity in Aragón and variations according to health determinants
2023, Anales de Pediatria
La obesidad infantil constituye un grave problema de salud global en continuo aumento en todo el mundo. Muchos estudios señalan que determinados factores socioeconómicos están relacionados con el desarrollo de obesidad. El objetivo de este estudio fue analizar la prevalencia de sobrepeso y obesidad en Aragón, calculadas según los estándares de la Organización Mundial de la Salud (OMS) y estudiar su relación con factores socioeconómicos.
Se recopiló información sobre la totalidad de la población infantil de Aragón entre dos y 14 años y cada individuo fue clasificado como normopeso, sobrepeso u obesidad según su índice de masa corporal (IMC). Se obtuvieron las prevalencias por provincias y zonas básicas de salud (ZBS). Utilizamos el índice de privación (IP) de Aragón como marcador de la situación socioeconómica.
La muestra final estuvo constituida por 161.335 niños (51%) y niñas (49%) de dos a 14 años. La prevalencia global de sobrecarga ponderal (SP) fue de 31,1% (17,7% sobrepeso y 13,3% obesidad), siendo significativamente mayor en niños. Detectamos un porcentaje elevado (65%) de infrarregistro en la historia clínica.
Se encontró una relación directa entre el IP y la prevalencia de obesidad y SP en todo Aragón, con una fuerte correlación significativa en zonas urbanas, en las que los factores socioeconómicos llegan a explicar hasta 66,4% de la obesidad y 48,9% de la SP total.
En Aragón, la prevalencia de obesidad y SP es elevada y está relacionada con una situación socioeconómica familiar desfavorable.
Childhood obesity is a serious global health problem that is continuously increasing worldwide. Many studies suggest that socioeconomic factors are related to the development of obesity. The objective of our study was to analyse the prevalence of overweight and obesity in Aragón, calculated applying the World Health Organization (WHO) growth standards, and to study its association with socioeconomic factors.
We collected data for the entire paediatric population of Aragón aged 2–14 years. We classified each child as normal weight, overweight or obese based on the body mass index. We calculated prevalences by province and basic health care zone. To analyse differences in relation to social inequalities, we used the Aragón deprivation index as an indicator of socioeconomic status.
The final sample consisted of 161 335 children aged 2–14 years, 51% male and 49% female. The overall prevalence of excess weight was 31.1% (17.7% overweight and 13.3% obesity) and was significantly higher in boys. We found a high frequency of under-recording in health records (65%).
There was a direct association between the deprivation index and the prevalence of obesity and overweight throughout Aragón, with a significant strong correlation in urban areas, where socioeconomic factors explained up to 66.4% of obesity and 48.9% of body weight excess.
In Aragón, the prevalence of obesity and excess weight is high and associated with low family socioeconomic status.
Social vulnerability, medical care access and asthma related emergency department visits and hospitalization: An observational study
2022, Heart and Lung
Citation Excerpt :
Also, the financial burden in the less fortunate families was associated with higher asthma-related EDV/hospitalizations, which was mainly driven by problems in the proper management, regardless of the disease severity.25 Moreover, regions with a lower educational level suffered from higher asthma-related EDV, driven mainly by the lack of disease comprehension and the proper treatment usage.19,26 Furthermore, the lower educational level may also be associated with reduced employment rates and more significant financial problems with subsequent access to healthcare services.26,27
The Social Vulnerability Index (SVI) is a publicly available dataset to identify communities in greatest need of resources.
To examine the utility of using the county-level SVI as predictors of asthma-related outcomes.
We used the American Community Survey-derived SVI and the National Environmental Public Health Tracking Network – Query Tool to retrieve data for all counties with available SVI data and at least one matched outcome of interest. Then, we tested SVI as a predictor for emergency department visits (EDV) and hospitalizations, with investigating disparities in primary care physician (PCP) density and emergency department physicians (EDP) density. Linear and logistic regression models were used.
Compared to counties of the lowest SVI quartile, counties of mid-low, mid-high, and highest SVI quartiles had 1%, 4%, and 5% higher odds of asthma-related EDV per 10,000 population, respectively, and 4%, 21%, and 24% higher odds of asthma-related hospitalization per 10,000 population, respectively. Moreover, the data showed an apparent resources mismatch between the EDP densities per 10,000 populations and the SVI quartiles, and the effect of the county level SVI on the asthma-related EDV and hospitalization is not strongly affected by PCP or EDP densities.
The counties with the highest SVI -and the most vulnerable to asthma hazards- have a lower coverage of PCP and EDP. Interventions directed to address persistent social vulnerability would offer the opportunity of primary prevention with less exhaustion for the medical resources.
Tree canopy, pediatric asthma, and social vulnerability: An ecological study in Connecticut
2022, Landscape and Urban Planning
Citation Excerpt :
The risk of asthma is unequally distributed across populations and neighborhoods. Individual and area-level socioeconomic status is a frequently reported predictor of asthma prevalence and asthma-related health outcomes; socially and economically disadvantaged children are especially disproportionately affected (Largent et al., 2012; Nkoy et al., 2018). Most epidemiologic research in childhood asthma has focused on individual level factors, but there have been sufficient studies suggesting that area-based socioeconomic factors may influence health outcomes among children with asthma.
Despite a variety of health benefits associated with trees, previous findings on links between tree canopy and asthma have been mixed. Little is known about the association of tree canopy with asthma emergency department (ED) visits and hospitalizations at the neighborhood level. This study examines associations between tree canopy and pediatric asthma ED visit/hospitalization rates among the Connecticut population at the census tract level and investigates the moderating effect of social vulnerability on these associations. Using data of the combined pediatric asthma ED visits and hospitalizations (from 2010 to 2014), tree canopy coverage, and area-based social vulnerability, we applied multivariate negative binomial regression models, controlling for confounders including ozone and road density. Results show that every 10-percentage point increase in tree canopy cover was expected to bring a 4% decrease in asthma ED visit/hospitalization rates. Further, every 10-percentage point increase in social vulnerability index was associated with an 18% increase in asthma ED visit/hospitalization rates. We also found a nonlinear association, indicating a U-shape effect of tree canopy on pediatric asthma ED visit/hospitalization rates. The levels of social vulnerability moderated the association between the nonlinear effect of tree canopy and asthma ED visit/hospitalization rates (β = -5.629, p =.004). Findings suggests that tree canopy may help reduce pediatric asthma ED visits and hospitalizations. Particularly, the benefits of tree canopy in decreasing pediatric asthma ED visits and hospitalizations would be more effective in more socially vulnerable areas.
Socioeconomic determinants of pediatric asthma emergency department visits under regional economic development in western New York
2019, Social Science and Medicine
Although the links between asthma in children and physical environmental factors have been well established, the role of community-level socioeconomic status remains inconclusive. Consequently, little attention has been paid to the dynamic changes in the associations between socioeconomic status and asthma outcomes due to structural changes in the community, such as an influx of financial resources. This study examined the relationship between community-level socioeconomic status indicators and asthma-related emergency department utilization for school-aged children in 2011 and 2015, assessing the early impact of a large-scale regional economic development project in western New York, United States. Our analyses controlled for other community-level health risk factors, such as environmental exposure, and spatial correlation of the emergency department usage data. Results indicated that both median household income and health insurance coverage were key socioeconomic predictors of the children's asthma-related emergency department utilization over the study period. We also found that the risk of emergency department utilization for asthma decreased significantly in the area in which regional economic development projects were completed during the initial stage of the project. Through a comparison study we demonstrated that the spatial correlation present in asthma-related ED utilization improved model fit and corrected biases in the estimates. Although our findings suggest that improving the socioeconomic status of communities contributes to a reduction in emergency department utilization for pediatric asthma, more empirical studies are warranted for evaluating the comprehensive effects of regional economic development on public health.
SNAP benefits and childhood asthma
2019, Social Science and Medicine
Citation Excerpt :
The annual health care costs for asthma in the United States exceeded $56 billion in 2017 (Gracy, 2018; Pearson et al., 2014), which makes effective disease management a significant concern to a wide audience. It is well understood that poverty is a risk factor for asthma (Largent et al., 2012; Mangini et al., 2015) and that the disease prevalence is more common among African-American youth, males, and those that live in an urban environment (Gracy, 2018; Mangini et al., 2015; Perrin et al., 2007). There is increasing evidence that nutrition is a factor for asthma (Perrin et al., 2007) and that food insecurity —a lack of consistent access to sufficient food —is associated with an increased risk of asthma (Kirkpatrick et al., 2010; Mangini et al., 2015).
Anecdotal and descriptive evidence has led to the claim that some low-income households may face a “eat or breathe” tradeoff, but quantitative evidence is scarce. We link Medicaid claims data to monthly Supplemental Nutritional Assistance Program (SNAP) participation data from the state of Missouri from 2010 to 2013 to explore monthly patterns in children's emergency room (ER) claims for asthma and to examine whether these patterns are sensitive to the timing and amount of SNAP benefits. This allows us to empirically test whether SNAP households with Medicaid insurance face trade-offs between food and medicine that increases the likelihood that a child in a SNAP and Medicaid household will go to the ER for asthma at the end of the month. While we do not find overwhelming evidence that the timing of SNAP benefits receipt are associated with the timing of asthma-related ER visits, we do find clear evidence that increased SNAP benefits are associated with a reduction in the overall probability of an asthma-related ER visit.

View all citing articles on Scopus

View full text

Original ResearchPaediatric asthma hospital utilization varies by demographic factors and area socio-economic status

Summary

Objectives

Study design

Methods

Results

Conclusions

Introduction

Section snippets

Hospital admissions and emergency-department visits

Patient characteristics for hospital admissions and ED visits

Discussion

Acknowledgements

Chest

J Allergy Clin Immunol

J Allergy Clin Immunol

Summary of health statistics for U.S. children. National health interview survey, 2005

Asthma prevalence, health care use and mortality: United States, 2003–2005. NCHS Health and Stats

Population disparities in asthma

Annu Rev Public Health

Original Research
Paediatric asthma hospital utilization varies by demographic factors and area socio-economic status