Trust and Virtual Communication During the COVID pandemic for adults with asthma from low income neighborhoods: What Have We Learned?

2023

05/2023

1097-6825

BACKGROUND: Low-income and marginalized adults disproportionately bear the burden of poor asthma outcomes. One consequence of the structural racism which preserves these inequities is decreased trust in government and healthcare institutions.

OBJECTIVE: We examined whether such distrust extends to health care providers during the pandemic.

METHODS: We enrolled adults living in low-income neighborhoods who had had a hospitalization, ED visit, or prednisone course for asthma in the prior year. Trust was a dichotomized measure derived from a 5-item questionnaire with a 5-point Likert scale response The items were translated to a binary variable "strong" versus "weak" trust. Communication was measured using a 13-item questionnaire with a 5-point Likert scale. Logistic regression was used to examine the association between communication and trust, controlling for potential confounders.

RESULTS: We enrolled 102 patients, 18-78 years, 87% female, 90% Black, 60% some post-high school education, 57% receiving Medicaid. 58 patients were enrolled prior to the March 12, 2020 pandemic start date. 70 (68%) patients named doctors as their most trusted source of health information. Strong trust was associated with a negative response to: "It is hard to reach a person in my doctor's office by phone." There was no evidence of an association between the overall communication scores and trust. Satisfaction with virtual messaging was weaker among those with less trust.

CONCLUSIONS: These patients trust their physicians, value their advice, and need to have accessible means of communication.

10.1016/j.jaci.2023.04.016

J Allergy Clin Immunol

37178729

A Health System-Initiated Intervention to Remediate Homes of Children With Asthma.

2023

05/2023

1098-4275

10.1542/peds.2022-058351

Pediatrics

37042200

New considerations of health disparities within allergy and immunology.

2023

314-323

02/2023

1097-6825

The pandemic, political upheavals, and social justice efforts in our society have resulted in attention to persistent health disparities and the urgent need to address them. Using a scoping review, we describe published updates to address disparities and targets for interventions to improve gaps in care within allergy and immunology. These disparities-related studies provide a broad view of our current understanding of how social determinants of health threaten patient outcomes and our ability to advance health equity efforts in our field. We outline next steps to improve access to care and advance health equity for patients with allergic/immunologic diseases through actions taken at the individual, community, and policy levels, which could be applied outside of our field. Key among these are efforts to increase the diversity among our trainees, providers, and scientific teams and enhancing efforts to participate in advocacy work and public health interventions. Addressing health disparities requires advancing our understanding of the interplay between social and structural barriers to care and enacting the needed interventions in various key areas to effect change.

10.1016/j.jaci.2022.11.004

J Allergy Clin Immunol

36503854

The West Philadelphia asthma care implementation study (NHLBI# U01HL138687).

2021

100864

2021 Dec

2451-8654

<p>Asthma is the most common chronic condition among children, with low-income families living in urban areas experiencing significantly higher rates. Evidence based interventions for asthma are routinely implemented in either the home, school, or primary care setting. However, even when caregivers of poor children are engaged in asthma interventions in one setting, they often have to navigate challenges in another setting, such as an under-resourced home, non-supportive school, or disengaged health care provider. The West Philadelphia Asthma Care Implementation Plan aims to compare the effectiveness of a primary care-based intervention, school-based intervention, and combined primary care and school intervention to usual care for improving asthma control in school-age children to explore if the synergistic effect of Community Health Worker (CHW) support in the home, school, and health care environments will result in improved asthma control. Children ages 5-13 with uncontrolled asthma from four West Philadelphia recruitment sites will be eligible for enrollment. The families of school age children interested in participating will be randomized to receive a primary care CHW or usual care. Those identified as attending a participating school will have a CHW-led school intervention or usual care in school. If proven effective, this care coordination program will assist caregivers in assessing resources, improving self-management skills, and ultimately reducing asthma-related ED visits and hospitalizations as well as provide additional information for healthcare systems and policy makers to inform their decisions about how and where to focus additional resources and investments in childhood asthma care to improve health outcomes.</p>

10.1016/j.conctc.2021.100864

Contemp Clin Trials Commun

34926863

Housing and Asthma Disparities.

2021

2021 Sep 29

1097-6825

<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>

10.1016/j.jaci.2021.09.023

J Allergy Clin Immunol

34599980

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

2020

2020 Oct 01

1098-4275

<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>

10.1542/peds.2019-3108

33004429

Initial effects of the COVID-19 pandemic on pediatric asthma emergency department utilization.

2020

2020 Jun 06

2213-2201

<p>Compared with historical trends, we describe a dramatic decrease in pediatric asthma-related emergency department utilization for all levels of acuity coincident with coronavirus disease 2019&nbsp;emergence. These findings have implications for clinicians and researchers seeking to understand the drivers of asthma exacerbations.</p>

10.1016/j.jaip.2020.05.045

J Allergy Clin Immunol Pract

32522565

The Tailored Adherence Incentives for Childhood Asthma Medications Randomized Trial: A Research Protocol for Children with High-Risk Asthma.

2020

2020 Apr 07

1929-0748

<p><strong>BACKGROUND: </strong>Poor adherence to inhaled corticosteroid (ICS) medications for children with high-risk asthma is a well-documented and poorly understood problem with a disproportionate prevalence and impact on urban minority children. Financial incentives have been shown as a compelling method to engage a high-risk asthma population, but whether and how adherence can be maintained and lead to sustained high adherence trajectories is unknown.</p>

<p><strong>OBJECTIVE: </strong>To determine the marginal effects of a financial incentive-based ICS adherence intervention on adherence, healthcare system use, and costs in a prospective cohort of child-caregiver dyads.</p>

<p><strong>METHODS: </strong>Participants include 125 children aged 5-12 years who have had at least two hospitalizations or one hospitalization and one emergency room visit for asthma in the prior year and their caregivers. All participants have an electronic inhaler sensor that is linked to a smartphone app to track medication use for 7 months. After one month of observation, participants are randomized to one of three possible arms for a 3-month experiment. Participants in arm 1 receive daily text message reminders, feedback, and nominal gain-framed financial incentives; those in arm 2 receive daily text message reminders and feedback only and those in arm 3 receive no reminders, feedback, or incentives. All participants are then observed for an additional 3 months with no reminders, feedback, or incentives to assess for sustained effects.</p>

<p><strong>RESULTS: </strong>Study enrollment began in September 2019. Estimated primary completion date is June of 2022 and analyses will be completed by June of 2023.</p>

<p><strong>CONCLUSIONS: </strong>The present study will provide data on whether a financial incentive-based mobile-health intervention for promoting ICS use is efficacious in high-risk asthma patients over time.</p>

<p><strong>CLINICALTRIAL: </strong>Clinicaltrial.gov NCT03907410; https://clinicaltrials.gov/ct2/show/NCT03907410.</p&gt;

10.2196/16711

JMIR Res Protoc

32459653

Variability in Diagnosed Asthma in Young Children in a Large Pediatric Primary Care Network.

2020

2020 Feb 07

1876-2867

<p><strong>OBJECTIVES: </strong>Our objectives were to (1) quantify the frequency of wheezing episodes and asthma diagnosis in young children in a large pediatric primary care network and (2) assess the variability in practice-level asthma diagnosis, accounting for common asthma risk factors and comorbidities. We hypothesized that significant variability in practice-level asthma diagnosis rates would remain after adjusting for associated predictors.</p>

<p><strong>METHODS: </strong>We generated a retrospective longitudinal birth cohort of children who visited one of 31 pediatric primary care practices within the first 6 months of life from 1/2005-12/2016. Children were observed for up to 8 years or until the end of the observation window. We used multivariable discrete time survival models to evaluate predictors of asthma diagnosis by 3-month age intervals. We compared unadjusted and adjusted proportions of children diagnosed with asthma by practice.</p>

<p><strong>RESULTS: </strong>Of the 161,502 children in the cohort, 34,578 children (21%) received at least one asthma diagnosis. In multivariable modeling, male gender, minority race/ethnicity, gestational age &lt;34 weeks, allergic rhinitis, food allergy, and prior wheezing episodes were associated with asthma diagnosis. After adjusting for variation in these predictors across practices, the cumulative incidence of asthma diagnosis by practice by age 6 years ranged from 11-47% (interquartile range (IQR): 24-29%).</p>

<p><strong>CONCLUSIONS: </strong>Across pediatric primary care practices, adjusted incidence of asthma diagnosis by age 6 years ranged widely, though variation gauged by the IQR was more modest. Potential sources of practice-level variation, such as differing diagnosis thresholds and labeling of different wheezing phenotypes as "asthma", should be further investigated.</p>

10.1016/j.acap.2020.02.003

Acad Pediatr

32044466

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

2019

e1918306

2019 Dec 02

2574-3805

<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>

10.1001/jamanetworkopen.2019.18306

JAMA Netw Open

31880799