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© 2015 American Academy of Allergy, Asthma & Immunology. Background: Earlier studies reported that many patients were frequently hospitalized for asthma exacerbation. However, there have been no recent multicenter studies to characterize this patient population with high morbidity and health care utilization. Objective: To examine the proportion and characteristics of children and adults with frequent hospitalizations for asthma exacerbation. Methods: A multicenter chart review study of patients aged 2 to 54 years who were hospitalized for asthma exacerbation at 1 of 25 hospitals across 18 US states during the period 2012 to 2013 was carried out. The primary outcome was frequency of hospitalizations for asthma exacerbation in the past year (including the index hospitalization). Results: The cohort included 369 children (aged 2-17 years) and 555 adults (aged 18-54 years) hospitalized for asthma exacerbation. Over the 12-month period, 36% of the children and 42% of the adults had 2 or more (frequent) hospitalizations for asthma exacerbation. Among patients with frequent hospitalizations, guideline-recommended outpatient management was suboptimal. For example, among adults, 32% were not on inhaled corticosteroids at the time of index hospitalization and 75% had no evidence of a previous evaluation by an asthma specialist. At hospital discharge, among adults with frequent hospitalizations who had used no controller medications previously, 37% were not prescribed inhaled corticosteroids. Likewise, during a 3-month postdischarge period, 64% of the adults with frequent hospitalizations were not referred to an asthma specialist. Although the proportion of patients who did not receive these guideline-recommended outpatient care appeared higher in adults, these preventive measures were still underutilized in children; for example, 38% of the children with frequent hospitalizations were not referred to asthma specialist after the index hospitalization. Conclusions: This multicenter study of US patients hospitalized with asthma exacerbation demonstrated a disturbingly high proportion of patients with frequent hospitalizations and ongoing evidence of suboptimal longitudinal asthma care.

Background: Lack of initiation or escalation of blood pressure (BP) lowering medication when BP is uncontrolled, termed therapeutic inertia (TI), increases with age and may be influenced by comorbidities., Methods: We examined the association of age and comorbidities with TI in 22,665 visits with a systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg among 7,415 adults age ≥65 years receiving care in clinics that implemented a hypertension quality improvement program. Generalized linear mixed models were used to determine the association of comorbidity number with TI by age group (65-74 and ≥75 years) after covariate adjustment., Results: Baseline mean age was 75.0 years (SD 7.8); 41.4% were male. TI occurred in 79.0% and 83.7% of clinic visits in age groups 65-74 and ≥75 years, respectively. In age group 65-74 years, prevalence ratio of TI with 2, 3-4, and ≥5 comorbidities compared with zero comorbidities was 1.07 (95% confidence interval [CI]: 1.04, 1.12), 1.08 (95% CI: 1.05, 1.12), and 1.15 (95% CI: 1.10, 1.20), respectively. The number of comorbidities was not associated with TI prevalence in age group ≥75 years. After implementation of the improvement program, TI declined from 80.3% to 77.2% in age group 65-74 years and from 85.0% to 82.0% in age group ≥75 years (P < 0.001 for both groups)., Conclusions: TI was common among older adults but not associated with comorbidities after age ≥75 years. A hypertension improvement program had limited impact on TI in older patients., (© The Author(s) 2023. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The emergency department (ED) has long served as a safety net for the uninsured and those with limited access to routine healthcare. This study aimed to compare the characteristics and severity of ED visits in an Illinois academic medical center (AMC) and community hospital (CH) of a single health system before and after the implementation of the Affordable Care Act (ACA)., Methods: This was a retrospective record review of 357,764 ED visits from January 1, 2011-December 31, 2016, of which 74% were at the AMC and 26% at the CH. We assessed the severity of ED visits by applying the previously validated Ballard algorithm, which classifies ED visits as non-emergent, intermediate, or emergent. Descriptive analyses were conducted to compare the characteristics of ED visits before and after the implementation of the ACA. We conducted multilevel logistic regression analysis to examine the odds of non-emergent compared to intermediate/emergent ED visits by the ACA implementation status controlling for patient demographic characteristics, insurance status, and multiple visits per patient., Results: ED visits for patients with Medicaid or other governmental coverages increased in the post-ACA compared to pre-ACA period (Pre: 33.2 % vs Post: 38.3% at the AMC, and Pre: 29.7% vs Post: 35.1% at the CH). A statistically significant decrease in ED visits for uninsured patients was observed at the AMC and CH in the post-ACA period compared to the pre-ACA period (Pre: 12.1% vs Post: 6.4%, and Pre: 13.9% vs Post: 9.8%, respectively). Results from the regression analysis showed a significant decreased odds of non-emergent vs intermediate/emergent ED visits during the post-ACA period compared to the pre-ACA period at the AMC (odds ratio [OR] 0.68; confidence interval [CI], 0.66-0.70). However, an increased odds of non-emergent vs. intermediate/emergent ED visits was observed at the CH (OR 1.09; CI, 1.04-1.14)., Conclusion: Similar to other Medicaid expansion states, ED utilization for uninsured patients decreased at both the AMC and the CH in the post-ACA period. While Medicaid visits for children < 18 years declined in the post-ACA period, it increased for ages 21 to 65 years of age. Contrary to our hypothesis, the severity of emergent ED visits increased in the post-ACA period but not at the CH.

Background: In a previous multicenter study during 1999-2000, we found a high prevalence of smoking among patients hospitalized for asthma exacerbations (35%) and suboptimal smoking cessation efforts. There have been no recent multicenter efforts to examine the smoking status and implementation of smoking cessation efforts among patients hospitalized for asthma exacerbation., Objective: To investigate the prevalence of cigarette smoking and the proportion and characteristics of patients who received an inpatient smoking cessation intervention., Methods: We conducted a secondary analysis of a 25-center observational study, which included 597 U.S. adults hospitalized for asthma exacerbation during 2012-2013., Results: Among the analytic cohort, 215 (36%) were current smokers. In the multivariable model, compared with patients with private health insurance, those with public health insurance (odds ratio [OR] 1.71 [95% confidence interval {CI}, 1.06-2.77]) or no health insurance (OR 1.75 [95% CI, 1.02-2.99]) were more likely to be current smokers. By contrast, patients with a previous evaluation by an asthma specialist in the past 12 months (OR 0.49 [95% CI, 0.28-0.86]) and use of inhaled corticosteroids (OR 0.63 [95% CI, 0.43-0.93]) were less likely to be current smokers. Among current smokers, only 55% received smoking cessation interventions during their hospitalization. In the multivariable model, current smokers who had public health insurance (OR 0.25 [95% CI, 0.07-0.82]) or no health insurance (OR 0.26 [95% CI, 0.07-0.94]) were less likely to receive inpatient smoking cessation interventions compared with those with private health insurance., Conclusion: Our findings showed a persistently high prevalence of smokers among U.S. patients hospitalized for asthma exacerbations and an underutilized opportunity to provide this at-risk population with smoking cessation interventions.

Overall, the goal of the emergency physician is proper recognition of the gravid woman whose pregnancy is complicated by hypertensive disease, particularly preeclampsia-eclampsia. As the classic triad of hypertension, proteinuria, and edema does not always occur simultaneously, supporting signs and symptoms as well as laboratory data may be necessary to support the diagnosis. Once the diagnosis is established, drug therapy aimed at the prevention of seizures and emergent control of blood pressure should be instituted to stop progression of the disease. Although many agents are undergoing investigation, magnesium sulfate and hydralazine remain the drugs of choice for anticonvulsant and antihypertensive therapy, respectively. Early consultation with an obstetrician should facilitate timely termination of the pregnancy with the least possible trauma to the mother and infant.