Association of Insurance Status with Severity and Management in ED Patients with Asthma Exacerbation.

INTRODUCTION: Previous studies have demonstrated an association of low socioeconomic status with frequent asthma exacerbations. However, there have been no recent multicenter efforts to examine the relationship of insurance status - a proxy for socioeconomic status - with asthma severity and management in adults. The objective is to investigate chronic and acute asthma management disparities by insurance status among adults requiring emergency department (ED) treatment in the United States. METHODS: We conducted a multicenter chart review study (48 EDs in 23 U.S. states) on ED patients, aged 18-54 years, with acute asthma between 2011 and 2012. Each site underwent training (lecture, practice charts, certification) before reviewing randomly selected charts. We categorized patients into three groups based on their primary health insurance: private, public, and no insurance. Outcome measures were chronic asthma severity (as measured by ≥2 ED visits in one-year period) and management prior to the index ED visit, acute asthma management in the ED, and prescription at ED discharge. RESULTS: The analytic cohort comprised 1,928 ED patients with acute asthma. Among these, 33% had private insurance, 40% had public insurance, and 27% had no insurance. Compared to patients with private insurance, those with public insurance or no insurance were more likely to have ≥2 ED visits during the preceding year (35%, 49%, and 45%, respectively; p<0.001). Despite the higher chronic severity, those with no insurance were less likely to have guideline-recommended chronic asthma care - i.e., lower use of inhaled corticosteroids (ICS [41%, 41%, and 29%; p<0.001]) and asthma specialist care (9%, 10%, and 4%; p<0.001). By contrast, there were no significant differences in acute asthma management in the ED - e.g., use of systemic corticosteroids (75%, 79%, and 78%; p=0.08) or initiation of ICS at ED discharge (12%, 12%, and 14%; p=0.57) - by insurance status. CONCLUSION: In this multicenter observational study of ED patients with acute asthma, we found significant discrepancies in chronic asthma severity and management by insurance status. By contrast, there were no differences in acute asthma management among the insurance groups.

Prevalence of eosinophilia in hospitalized patients with asthma exacerbation.

BACKGROUND: Recent studies have identified the "eosinophilic phenotype" of asthma that is characterized by persistent eosinophilic inflammation and frequent exacerbations. However, the prevalence of eosinophilia in patients hospitalized for asthma exacerbation is not known. METHODS: We performed a pilot study in two sites participating in a multicenter chart review project of children and adults hospitalized for asthma exacerbation during 2012-2013. The pilot study investigated the prevalence of blood eosinophilia in this patient population. Eosinophilia was defined as a count of ≥300 cells/microliter at some time during the hospitalization. RESULTS: Among 80 patients hospitalized for asthma exacerbation, 47 (59%) underwent CBC with differential and had data on blood eosinophil count. These 47 comprised the analytic cohort. The median patient age was 32 years (IQR, 24-44 years), and 51% were female. Overall, 40% (95% CI, 26%-56%) of patients had eosinophilia. Although statistical power was limited, there were no statistically significant differences in patient characteristics or hospital course between patients with eosinophilia and those without (all P > 0.05). CONCLUSION: Our pilot study showed that 40% of patients hospitalized for asthma exacerbation had eosinophilia. The clinical meaning of this biomarker in the emergency department/inpatient setting requires further study in much larger samples with long-term follow-up; such studies appear feasible.

Underuse of guideline-recommended long-term asthma management in children hospitalized to the intensive care unit: a multicenter observational study.

BACKGROUND: Despite the significant burden of childhood asthma, little is known about prevention-oriented management before and after hospitalizations for asthma exacerbation. OBJECTIVE: To investigate the proportion and characteristics of children admitted to the intensive care unit (ICU) for asthma exacerbation and the frequency of guideline-recommended outpatient management before and after the hospitalization. METHODS: A 14-center medical record review study of children aged 2 to 17 years hospitalized for asthma exacerbation during 2012-2013. Primary outcome was admission to the ICU; secondary outcomes were 2 preventive factors: inhaled corticosteroid (ICS) use and evaluation by asthma specialists in the pre- and posthospitalization periods. RESULTS: Among 385 children hospitalized for asthma, 130 (34%) were admitted to the ICU. Risk factors for ICU admission were female sex, having public insurance, a marker of chronic asthma severity (ICS use), and no prior evaluation by an asthma specialist. Among children with ICU admission, guideline-recommended outpatient management was suboptimal (eg, 65% were taking ICSs at the time of index hospitalization, and 19% had evidence of a prior evaluation by specialist). At hospital discharge, among children with ICU admission who had not previously used controller medications, 85% were prescribed ICSs. Furthermore, 62% of all children with ICU admission were referred to an asthma specialist during the 3-month posthospitalization period. CONCLUSION: In this multicenter study of US children hospitalized with asthma exacerbation, one-third of children were admitted to the ICU. In this high-risk group, we observed suboptimal pre- and posthospitalization asthma care. These findings underscore the importance of continued efforts to improve prevention-oriented asthma care at all clinical encounters.

The willingness of and barriers to Korean health care providers participating in a humanitarian assistance field hospital responding to an urgent global health crisis.

PURPOSE: As the number of disaster and humanitarian crisis increases, there is an emphasis on the prompt dispatching of humanitarian assistance field hospitals (HAFHs) in order to relieve a disaster-stricken society as soon as possible. The participants' individual motivation constitutes one of the most important factors in achieving successful HAFH activities. The aims of this study are to evaluate health care providers' willingness to participate in HAFHs when there is an urgent global health need and to examine their motives, perceived barriers, and concerns using a simulated global disaster scenario. RESULTS: Seventy health care providers completed a survey which asked about their willingness to join a HAFH that was being dispatched immediately. Forty-five of the 70 respondents (64.3%) answered that they were willing to join an HAFH, which departed within 24 hours of a hypothetical earthquake. The major perceived barriers to participation in an HAFH included "pre- scheduled work commitments in home institutions," "insufficient support from home institutions," and "insufficient field safety and security". CONCLUSION: Policy-makers need to proactively establish support from the institutions that employ disaster-related health care providers, in order to secure their participation in HAFHs and to ensure optimal preparedness for global disaster relief activities.

Trends in pediatric mortality from food choking in children with intellectual disability during 1991-2005.

Unintentional injury is one of the leading causes for mortality in childhood. Choking or the interruption of respiration by internal obstruction of the airway, usually by food or small toys, is such a case. The present study was conducted to examine choking-related deaths from 1991-2005 among children with intellectual disability younger than 18 years of age living in residential care centers in Israel. The data for this study were obtained from the Office of the Medical Director (OMD), Division for Mental Retardation (DMR), Ministry of Social Affairs and Social Services. Every case of death in residential centers is reported to the OMD, who since 1991 has registered place of residence, date of birth, age at death, gender, ethnic background, level of ID, cause of death, autopsy and review committee, if established in a data register. The data concerned with food choking were extracted from the mortality register for the period 1991-2004. Over the study period (15 years) 1,107 cases of death were reported, with 5 (0.245%) caused by food choking in children. The average rate was 8.98 per 100,000 study population for food choking in children. The solution is prevention. In recent years, the OMD together with other professionals have produced educational material and seminars on feeding and preventive measures. Not every case can be prevented, but it is important to identify risk factors, to educate the care givers and professionals, and to ensure that food products that are common choking hazards are kept away from children, who are at risk.