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Byline: Saul J. Weiner, MD (Department of Medicine University of Illinois at Chicago, Department of Pediatrics University of Illinois at Chicago, Veterans Affairs Center for Management of Complex Chronic Care, [...]

OBJECTIVES. TO better understand and improve the care of asthma patients who require emergency department (ED) care, the Illinois Emergency Department Asthma Collaborative (IEDAC) was created to develop, test, and disseminate an ED-based surveillance system. This report describes the development and testing of the pediatric IEDAC surveillance instruments and demonstrates how these instruments can be used to describe the health status, healthcare delivery, and outcome of children using ED services. METHODS. A convenience sample of 128 children presenting to 5 EDs in Illinois for asthma care was the study base. Data were collected on monthly samples of children aged 2 through 17 years who presented to these EDs from May to November 2003. Three instruments were used to collect data regarding the children's pre-ED, ED, and post-ED experience. RESULTS. At the ED visit, 73.4% of children met national guideline criteria for persistent-level asthma symptoms. Among this group, 53.2% were using inhaled corticosteroid (ICS) medications. At 1 month follow-up, 66.6% of the children met the criteria for persistent-level asthma symptoms, which was statistically unchanged from the ED visit. Among the latter group, 64.2% were using ICS medications, again statistically unchanged compared with the ED visit. At follow-up, 24.5% of children were reported to have returned to an ED or were subsequently hospitalized. The majority of children were noted at follow-up to have limitation of at least some activity. CONCLUSIONS. Children who presented to IEDAC EDs were found to have a high level of asthma burden that continued at follow-up despite treatment. Moreover, a substantial proportion of children had returned to an ED or were subsequently hospitalized. Encouraging trends in medication use were observed, although suboptimal medication use was also observed. Key Words asthma surveillance, emergency department, children Abbreviations ED--emergency department EPR-2--National Asthma Education and Prevention Program Expert Panel Report 2 IEDAC--Illinois Emergency Department Asthma Collaborative ICS--inhaled corticosteroid IQR--interquartile range MDI--metered-dose inhaler, EACH year emergency departments (EDs) in the United States receive numerous visits from children for asthma care. (1-3) In 2002, nearly 9 million children in the United States were told […]

Objective. To examine differences in the process of care for Medicaid-enrolled white, Hispanic, and black children with asthma. Design. Retrospective cohort study using Medicaid claims data to analyze the process of asthma care in 1994, including all white (non-Hispanic), black (non-Hispanic), and Hispanic children (aged 2-18 years) with asthma in the non-health maintenance organization portion of the Massachusetts Medicaid program (N = 5773). Main outcome measures included performance on 6 claims-based process-of-care measures that reflect national guidelines. Measures addressed primary and specialty care for asthma, appropriate asthma pharmacotherapy, and timely follow-up care after asthma emergency department (ED) visits and hospitalizations. Results. Controlling for case mix, provider type, disability status, age, and gender, Hispanic children with asthma were 39% less likely than white children to have a specialist visit for asthma (odds ratio [OR]: 0.61; confidence interval [CI]: 0.46-0.81) and 41% less likely to receive a follow-up visit within 5 days of being seen in the ED for asthma (OR: 0.59; CI: 0.36-0.95). However, Hispanic children received better care in 2 respects. They were 16% more likely than white children to receive a minimum of 2 asthma visits per year (CI: 1.01-1.34) and 27% less likely to be overprescribed [beta]-agonist medications (OR: 0.73; CI: 0.54-0.99). Black children were 64% less likely than white children to receive timely follow-up care after being seen in the ED for asthma (OR: 0.36; CI: 0.18-0.73). There were no racial/ethnic differences in the prescribing of antiinflammatory medications or timely follow-up care after an asthma hospitalization. Conclusions. This study demonstrates important differences in the process of care experienced by racial/ ethnic subpopulations within a Medicaid population, which may help explain differential outcomes. Efforts to improve asthma outcomes should target specific areas in which black and Hispanic children may be receiving suboptimal care. Pediatrics 2004;113:496-504; racial disparities; process of care; quality of care; Medicaid; pediatric asthma; guidelines. ABBREVIATIONS. ED, emergency department; PCCM, primary care case manager; ADG, ambulatory diagnostic group; NCQA, National Committee for Quality Assurance; NAEPP, National, Numerous studies have documented significant racial/ethnic differences in asthma hospitalization rates (1-4) and asthma emergency department (ED) visits, (2,4) after controlling for income, insurance status, and other socioeconomic factors. Asthma [...]

Background/Objective. Asthma is increasingly being recognized as an important public health concern for children in the United States. Effective management of childhood asthma may require not only improving guideline-based therapeutic interventions, but also addressing social and physical environmental risk factors. The objective of this project was to create a blueprint for improvement of national policy in this area. Design/Methods. A nominal group process with nationally recognized experts and leaders (referred to as "the committee") in childhood asthma. Results. The committee identified 11 policy recommendations (numbered in order below) in 2 broad categories: Improving Health Care Delivery and Financing, and Strengthening the Public Health Infrastructure. Recommendations regarding Improving Health Care Delivery and Financing include the development and implementation of quality-of-care standards in 1) primary care, 2) self-management education, and 3) case-management interventions, and the expansion of insurance coverage and benefit design by 4) extending continuous health insurance coverage for all children, 5) developing model insurance benefits packages for essential childhood asthma services, and 6) educating health care purchasers in how to use them. Recommendations for Strengthening the Public Health Infrastructure include public funding of asthma services that fall outside the insurance system through establishing 7) public health grants to foster asthma-friendly communities and 8) school-based asthma initiatives. 9) Launching a national asthma public education campaign, 10) developing a national asthma surveillance system, and 11) establishing a national agenda for asthma prevention research, with an emphasis on epidemiologic and behavioral sciences, are also recommended. Conclusions. Implementing these recommendations will require coordination of activities at the national, state, and local community level, and within and outside the health care delivery system. With a further commitment of national and local resources, implementation of these recommendations will likely lead to improved child and family asthma outcomes in the United States. Pediatrics 2002;109:919-930; childhood asthma, health care policy, health care services., CURRENT STATUS OF CHILDHOOD ASTHMA IN THE UNITED STATES Childhood asthma is an epidemic with major public health and financial consequences. The number of asthma cases in children under 5 [...]

Objective. Although the efficacy of inhaled antiinflammatory therapy in improving symptoms and lung function in childhood asthma has been shown in clinical trials, the effectiveness of these medications in real-world practice settings in reducing acute health care use has not been well-evaluated. This study examined the effect of inhaled antiinflammatory therapy on hospitalizations and emergency department (ED) visits by children for asthma. Design. Defined population cohort study over 1 year. Setting. Three managed care organizations (MCOs) in Seattle, Boston, and Chicago participating in the Pediatric Asthma Care-Patient Outcome Research and Treatment II trial. Participants. All 11 195 children, between 3 to 15 years old, with a diagnosis of asthma who were enrolled in the 3 MCOs between July 1996 and June 1997. Outcome Measures. We identified children with 1 or more asthma diagnoses using automated encounter data. Medication dispensings were identified from automated pharmacy data. Multivariate logistic regression analysis was used to calculate effects of inhaled antiinflammatory therapy on the adjusted relative risk (RR) for hospitalization and ED visits for asthma. Results. Over 12 months, 217 (1.9%) of children had an asthma hospitalization, and 757 (6.8%) had an ED visit. After adjustment for age, gender, MCO, and reliever dispensing, compared with children who did not receive controllers, the adjusted RRs for an ED visit were: children with any ([greater than or equal to] 1) dispensing of cromolyn, 0.4 (95% confidence interval ICI]: 0.3, 0.5); any inhaled corticosteroid (ICS), 0.5 (95% CI: 0.4, 0.6); any cromolyn or ICS combined (any controller), 0.4 (95% CI: 0.3, 0.5). For hospitalization, the adjusted RR for cromolyn was 0.6 (95% CI: 0.4, 0.9), for ICS 0.4 (95% CI: 0.3, 0.7), and for any controller 0.4 (95% CI: 0.3, 0.6). A significant protective effect for both events was seen among children with 1 to 5 and with >5 antiinflammatory dispensings. When the analysis was stratified by frequency of reliever dispensing, there was a significant protective effect for controllers on ED visits for children with 1 to 5 and with >5 reliever dispensings and on the risk of hospitalization for children with >5 reliever dispensings. Conclusions. Inhaled antiinflammatory therapy is associated with a significant protective effect on the risk for hospitalization and ED visits in children with asthma. Cromolyn and ICSs were associated with similar effects on risks. Pediatrics 2001;107:706-711; asthma drug therapy, inhaled antiinflammatory agents, health maintenance organizations, hospitalization, emergency department., ABBREVIATIONS. ED, emergency department; ICS, inhaled corticosteroid; MCO, managed care organization; PAC-PORT II, Pediatric Asthma Care-Patient Outcome Research and Treatment trial; NAEPP, National Asthma Education and Prevention Program; OR, odds [...]

Public hospitals and the irreplaceable services they provide may be endangered by health care reforms that fail to consider the consequences to them. The growth of for-profit managed care in general and of programs to bring low-income persons into managed care in the name of cost-cutting causes problems for public hospitals. Managed care programs may not accept those in greatest need such as the homeless or the mentally ill or those with pre-existing illness. Managed care may not address social problems such as substance abuse, access to convenient care, or the need for translators. Established care-seeking patterns may be disrupted among patients enrolled without their consent or knowledge and given no instruction on how to obtain care. Public hospitals may be excluded from the managed care network. Overburdened and underfunded and constrained by bureaucratic governance, public hospitals are disadvantaged if they must compete for patients and act flexibly in a competitive market environment.