First name
Douglas
Last name
Strane

Title

Housing and Asthma Disparities.

Year of Publication

2021

Date Published

2021 Sep 29

ISSN Number

1097-6825

Abstract

<p>The burden of asthma disproportionately affects minority and low-income communities, resulting in racial and socioeconomic disparities in asthma prevalence, exacerbations, and asthma-related death. Social determinants of health are increasingly implicated as root causes of disparities and healthy housing is perhaps the most critical social determinant in asthma health disparities. In many minority communities, poor housing conditions and value are a legacy of historical policies and practices imbued with structural racism, including redlining, displacement, and exclusionary zoning. As a result, poor quality, substandard housing is a characteristic feature of many underrepresented minority communities. Consequently, structurally deficient housing stock cultivates home environments rife with indoor asthma triggers. In this review we consider the historical context of urban housing policies and practices and how this contributed to the substandard housing conditions for many minority children in the present day. We describe the impact of poor housing quality on asthma and interventions that have attempted to mitigate its influence on asthma symptoms and healthcare utilization. We discuss the need to promote asthma health equity by reinvesting in these neighborhoods and communities to provide healthy housing.</p>

DOI

10.1016/j.jaci.2021.09.023

Alternate Title

J Allergy Clin Immunol

PMID

34599980

Title

An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations.

Year of Publication

2020

Date Published

2020 Oct 01

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVES: </strong>A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization.</p>

<p><strong>METHODS: </strong>Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group.</p>

<p><strong>RESULTS: </strong>From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; = .02).</p>

<p><strong>CONCLUSIONS: </strong>A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.</p>

DOI

10.1542/peds.2019-3108

PMID

33004429

Title

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children.

Year of Publication

2019

Number of Pages

e1918306

Date Published

2019 Dec 02

ISSN Number

2574-3805

Abstract

<p><strong>Importance: </strong>As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources.</p>

<p><strong>Objective: </strong>To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days.</p>

<p><strong>Design, Setting, and Participants: </strong>This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019.</p>

<p><strong>Exposures: </strong>Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers.</p>

<p><strong>Main Outcomes and Measures: </strong>Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017).</p>

<p><strong>Results: </strong>Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid.</p>

<p><strong>Conclusions and Relevance: </strong>In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.</p>

DOI

10.1001/jamanetworkopen.2019.18306

Alternate Title

JAMA Netw Open

PMID

31880799

Title

Families With TRICARE Report Lower Health Care Quality And Access Compared To Other Insured And Uninsured Families.

Year of Publication

2019

Number of Pages

1377-1385

Date Published

2019 Aug

ISSN Number

1544-5208

Abstract

<p>Children in military families, who receive health insurance through the TRICARE program, face barriers to care such as frequent relocations, unique behavioral health needs, increased complex health care needs, and lack of accessible specialty care. How TRICARE-insured families perceive health care access and quality for their children compared to their civilian peers' perceptions remains unknown. Using data from the Medical Expenditure Panel Survey, we found that TRICARE-insured families were less likely to report accessible or responsive care compared to civilian peers, whether commercially or publicly insured or uninsured. Military families whose children had complex health or behavioral health care needs reported worse health care access and quality than similar nonmilitary families. Addressing these gaps may require military leaders to examine barriers to achieving acceptable health care access across military treatment facilities and off-base nonmilitary specialty providers, particularly for children with complex health or behavioral health needs.</p>

DOI

10.1377/hlthaff.2019.00274

Alternate Title

Health Aff (Millwood)

PMID

31381389

Title

Growth Of Public Coverage Among Working Families In The Private Sector.

Year of Publication

2019

Number of Pages

1132-1139

Date Published

2019 Jul

ISSN Number

1544-5208

Abstract

<p>Working families have increasingly enrolled their children in Medicaid or the Children's Health Insurance Program in recent years. Parents' place of employment affects the availability and cost of family health insurance, making it a determinant of pediatric public insurance enrollment. We examined that enrollment in the period 2008-16 in families working full time and earning more than 100&nbsp;percent of the federal poverty level at three types of employers. Among low-income families (100-199&nbsp;percent of poverty), children's public health insurance coverage was highest for those with parents employed at small private firms, increasing from 53&nbsp;percent to 79&nbsp;percent, while the public insurance coverage rate also increased among children with parents working for large private firms (from 45&nbsp;percent to 69&nbsp;percent). Among moderate-income families (200-299&nbsp;percent of poverty) working at small private firms, public coverage increased from 21&nbsp;percent to 64&nbsp;percent. Increases in the number of working families with pediatric public insurance were driven by employees of large private firms. Maintaining high pediatric insurance coverage rates will require policies that recognize the changing role of public insurance for working families as the cost of employer-based coverage grows.</p>

DOI

10.1377/hlthaff.2018.05286

Alternate Title

Health Aff (Millwood)

PMID

31260364

Title

Determining Food-Insecure Families' Resource Access with Health System and Public Data.

Year of Publication

2019

Number of Pages

265-279

Date Published

2019

ISSN Number

1548-6869

Abstract

<p>Families' access to local food-insecurity (FI) resources differs. This study examines how health system and public data may be combined to identify limitations in community resources designed to address FI. We conducted a retrospective cohort study using electronic health record (EHR) data from nine practices that screened families for FI. Electronic health record data included demographic and clinical characteristics. Publicly available data included local socioeconomic and food resource information. We calculated the distance from each household to the nearest food pantry and determined the percentage of families who might have difficulty accessing resources. We demonstrate how health systems could merge these data sources to map where food-insecure families live, describe families' access to local resources, and identify regions where gaps in services exist. Health systems could use this approach to support households with FI and advocate for additional services in areas lacking resources in order to target population health efforts.</p>

DOI

10.1353/hpu.2019.0020

Alternate Title

J Health Care Poor Underserved

PMID

30827982

Title

Family Characteristics Associated With Child Maltreatment Across the Deployment Cycle of U.S. Army Soldiers.

Year of Publication

2017

Number of Pages

e1879-e1887

Date Published

2017 Sep

ISSN Number

1930-613X

Abstract

<p><strong>OBJECTIVE: </strong>Soldier deployment can create a stressful environment for U.S. Army families with young children. Prior research has identified elevated rates of child maltreatment in the 6 months immediately following a soldier's return home from deployment. In this study, we longitudinally examine how other child- and family-level characteristics influence the relationship of deployment to risk for maltreatment of dependent children of U.S. Army soldiers.</p>

<p><strong>METHODS: </strong>We conducted a person-time analysis of substantiated reports and medical diagnoses of maltreatment among the 73,404 children of 56,087 U.S. Army soldiers with a single deployment between 2001 and 2007. Cox proportional hazard models estimated hazard rates of maltreatment across deployment periods and simultaneously considered main effects for other child- and family-level characteristics across periods.</p>

<p><strong>RESULTS: </strong>In adjusted models, maltreatment hazard was highest in the 6 months following deployment (hazard ratio [HR] = 1.63, p &lt; 0.001). Children born prematurely or with early special needs independently had an increased risk for maltreatment across all periods (HR = 2.02, p &lt; 0.001), as well as those children whose soldier-parent had been previously diagnosed with a mental illness (HR = 1.68, p &lt; 0.001). In models testing for effect modification, during the 6 months before deployment, children of female soldiers (HR = 2.22, p = 0.006) as well as children of soldiers with a mental health diagnosis (HR = 2.78, p = 0.001) were more likely to experience maltreatment, exceeding the risk at all other periods.</p>

<p><strong>CONCLUSIONS: </strong>Infants and children are at increased risk for maltreatment in the 6 months following a parent's deployment, even after accounting for other known family- and child-level risk factors. However, the risk does not appear to be the same for all soldiers and their families in relation to deployment, particularly for female soldiers and those who had previously diagnosed mental health issues, for whom the risk appears most elevated before deployment. Accounting for the unique needs of high-risk families at different stages of a soldier's deployment cycle may allow the U.S. Army to better direct resources that prevent and address child maltreatment.</p>

DOI

10.7205/MILMED-D-17-00031

Alternate Title

Mil Med

PMID

28885950

Title

Under-ascertainment from healthcare settings of child abuse events among children of soldiers by the U.S. Army Family Advocacy Program.

Year of Publication

2016

Date Published

2016 Dec 09

ISSN Number

1873-7757

Abstract

<p>In cases of maltreatment involving children of U.S. Army service members, the U.S. Army Family Advocacy Program (FAP) is responsible for providing services to families and ensuring child safety. The percentage of cases of maltreatment that are known to FAP, however, is uncertain. Thus, the objective of this retrospective study was to estimate the percentage of U.S. Army dependent children with child maltreatment as diagnosed by a military or civilian medical provider who had a substantiated report with FAP from 2004 to 2007. Medical claims data were used to identify 0-17year old child dependents of soldiers who received a medical diagnosis of child maltreatment. Linkage rates of maltreatment medical diagnoses with corresponding substantiated FAP reports were calculated. Bivariate and multivariable analyses examined the association of child, maltreatment episode, and soldier characteristics with linkage to substantiated FAP reports. Across 5945 medically diagnosed maltreatment episodes, 20.3% had a substantiated FAP report. Adjusting for covariates, the predicted probability of linkage to a substantiated FAP report was higher for physical abuse than for sexual abuse, 25.8%, 95% CI (23.4, 28.3) versus 14.5%, 95% CI (11.2, 17.9). Episodes in which early care was provided at civilian treatment facilities were less likely to have a FAP report than those treated at military facilities, 9.8%, 95% CI (7.3, 12.2) versus 23.6%, 95% CI (20.8, 26.4). The observed low rates of linkage of medically diagnosed child maltreatment to substantiated FAP reports may signal the need for further regulation of FAP reporting requirements, particularly for children treated at civilian facilities.</p>

DOI

10.1016/j.chiabu.2016.11.007

Alternate Title

Child Abuse Negl

PMID

27955871

Title

Low-Income Working Families With Employer-Sponsored Insurance Turn To Public Insurance For Their Children.

Year of Publication

2016

Number of Pages

2302-2309

Date Published

2016 Dec 01

ISSN Number

1544-5208

Abstract

<p>Many families rely on employer-sponsored health insurance for their children. However, the rise in the cost of such insurance has outpaced growth in family income, potentially making public insurance (Medicaid or the Children's Health Insurance Plan) an attractive alternative for affordable dependent coverage. Using data for 2008-13 from the Medical Expenditure Panel Survey, we quantified the coverage rates for children from low- or moderate-income households in which a parent was offered employer-sponsored insurance. Among families in which parents were covered by such insurance, the proportion of children without employer-sponsored coverage increased from 22.5&nbsp;percent in 2008 to 25.0&nbsp;percent in 2013. The percentage of children with public insurance when a parent was covered by employer-sponsored insurance increased from 12.1&nbsp;percent in 2008 to 15.2&nbsp;percent in 2013. This trend was most pronounced for families with incomes of 100-199&nbsp;percent of the federal poverty level, for whom the share of children with public insurance increased from 22.8&nbsp;percent to 29.9&nbsp;percent. Among families with incomes of 200-299&nbsp;percent of poverty, uninsurance rates for children increased from 6.0&nbsp;percent to 9.2&nbsp;percent. These findings suggest a movement away from employer-sponsored insurance and toward public insurance for children in low-income families, and growth in uninsurance among children in moderate-income families.</p>

DOI

10.1377/hlthaff.2016.0381

Alternate Title

Health Aff (Millwood)

PMID

27920320

Title

Differential Child Maltreatment Risk Across Deployment Periods of US Army Soldiers.

Year of Publication

2016

Number of Pages

153-8

Date Published

2016 Jan

ISSN Number

1541-0048

Abstract

<p><strong>OBJECTIVES: </strong>We described the risk for maltreatment among toddlers of US Army soldiers over different deployment cycles to develop a systematic response within the US Army to provide families appropriate supports.</p>

<p><strong>METHODS: </strong>We conducted a person-time analysis of substantiated maltreatment reports and medical diagnoses among children of 112,325 deployed US Army soldiers between 2001 and 2007.</p>

<p><strong>RESULTS: </strong>Risk of maltreatment was elevated after deployment for children of soldiers deployed once but not for children of soldiers deployed twice. During the 6 months after deployment, children of soldiers deployed once had 4.43 substantiated maltreatment reports and 4.96 medical diagnoses per 10,000 child-months. The highest maltreatment rate among children of soldiers deployed twice occurred during the second deployment for substantiated maltreatment (4.83 episodes per 10,000 child-months) and before the first deployment for medical diagnoses of maltreatment (3.78 episodes per 10,000 child-months).</p>

<p><strong>CONCLUSIONS: </strong>We confirmed an elevated risk for child maltreatment during deployment but also found a previously unidentified high-risk period during the 6 months following deployment, indicating elevated stress within families of deployed and returning soldiers. These findings can inform efforts by the military to initiate and standardize support and preparation to families during periods of elevated risk.</p>

DOI

10.2105/AJPH.2015.302874

Alternate Title

Am J Public Health

PMID

26562128

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