Traffic-related air pollution and asthma hospital readmission in children: a longitudinal cohort study.

OBJECTIVE: To examine the association between exposure to traffic-related air pollution (TRAP) and hospital readmission for asthma or bronchodilator-responsive wheezing. STUDY DESIGN: A population-based cohort of 758 children aged 1-16 years admitted for asthma or bronchodilator-responsive wheezing was assessed for asthma readmission within 12 months. TRAP exposure was estimated with a land use regression model using the home address at index admission, with TRAP dichotomized at the sample median (0.37 µg/m3). Covariates included allergen-specific IgE, tobacco smoke exposure, and social factors obtained at enrollment. Associations between TRAP exposure and readmission were assessed using logistic regression and Cox proportional hazards models. RESULTS: The study cohort was 58% African American and 32% white; 19% of the patients were readmitted within 12 months of the original admission. Higher TRAP exposure was associated with a higher readmission rate (21% vs. 16%; P = .05); this association was not significant after adjusting for covariates (aOR, 1.4; 95% CI, 0.9-2.2). Race modified the observed association; white children with high TRAP exposure had 3-fold higher odds of asthma readmission (OR, 3.0; 95% CI, 1.1-8.1), compared with white children with low TRAP exposure. In African American children, TRAP exposure was not associated with increased readmission (OR, 1.1; 95% CI, 0.6-1.8). In children with high TRAP exposure, TRAP exposure was associated with decreased time to readmission in white children (hazard ratio, 3.2; 95% CI, 1.5-6.7) compared with African American children (hazard ratio, 1.0; 95% CI, 0.7-1.4). African American children had a higher readmission rate overall. CONCLUSION: TRAP exposure is associated with increased odds of hospital readmission in white children, but not in African American children.

Inequalities in neighborhood child asthma admission rates and underlying community characteristics in one US county.

OBJECTIVES: To characterize variation and inequalities in neighborhood child asthma admission rates and to identify associated community factors within one US county. STUDY DESIGN: This population-based prospective, observational cohort study consisted of 862 sequential child asthma admissions among 167 653 eligible children ages 1-16 years in Hamilton County, Ohio. Admissions occurred at a tertiary-care pediatric hospital and accounted for nearly 95% of in-county asthma admissions. Neighborhood admission rates were assessed by geocoding addresses to city- and county-defined neighborhoods. The 2010 US Census provided denominator data. Neighborhood admission distribution inequality was assessed by the use of Gini and Robin Hood indices. Associations between neighborhood rates and socioeconomic and environmental factors were assessed using ANOVA and linear regression. RESULTS: The county admission rate was 5.1 per 1000 children. Neighborhood rates varied significantly by quintile: 17.6, 7.7, 4.9, 2.2, and 0.2 admissions per 1000 children (P < .0001). Fifteen neighborhoods containing 8% of the population had zero admissions. The Gini index of 0.52 and Robin Hood index of 0.38 indicated significant inequality. Neighborhood-level educational attainment, car access, and population density best explained variation in neighborhood admission rates (R(2) = 0.55). CONCLUSION: In a single year, asthma admission rates varied 88-fold across neighborhood quintiles in one county; a reduction of the county-wide admission rate to that of the bottom quintile would decrease annual admissions from 862 to 34. A rate of zero was present in 15 neighborhoods, which is evidence of what may be attainable.

The Family Perspective on Hospital to Home Transitions: A Qualitative Study.

BACKGROUND AND OBJECTIVE: Transitions from the hospital to home can be difficult for patients and families. Family-informed characterization of this vulnerable period may facilitate the identification of interventions to improve transitions home. Our objective was to develop a comprehensive understanding of hospital-to-home transitions from the family perspective. METHODS: Using qualitative methods, focus groups and individual interviews were held with caregivers of children discharged from the hospital in the preceding 30 days. Focus groups were stratified based upon socioeconomic status. The open-ended, semistructured question guide included questions about communication and understanding of care plans, transition home, and postdischarge events. Using inductive thematic analysis, investigators coded the transcripts, resolving differences through consensus. RESULTS: Sixty-one caregivers participated across 11 focus groups and 4 individual interviews. Participants were 87% female and 46% nonwhite; 38% were the only adult in their household, and 56% resided in census tracts with ≥15% of residents living in poverty. Responses from participants yielded a conceptual model depicting key elements of families' experiences with hospital-to-home transitions. Four main concepts resulted: (1) "In a fog" (barriers to processing and acting on information), (2) "What I wish I had" (desired information and suggestions for improvement), (3) "Am I ready to go home?" (discharge readiness), and (4) "I'm home, now what?" (confidence and postdischarge care). CONCLUSIONS: Transitions from hospital to home affect the lives of families in ways that may affect patient outcomes postdischarge. The caregiver is key to successful transitions, and the family perspective can inform interventions that support families and facilitate an easier re-entry to the home.

Increasing recruitment rates in an inpatient clinical research study using quality improvement methods.

OBJECTIVE: One important benefit of successful patient recruitment is increased generalizability of findings. We sought to optimize enrollment of children admitted with asthma as part of a population-based, prospective, observational cohort study with the goal of enrolling at least 60% of all eligible and staffed patients. METHODS: Quality improvement methods were used to improve cohort recruitment. Weekly meetings with study staff and study leadership were held to plan and discuss how to maximize recruitment rates. Significant initial variability in recruitment success prompted the team to use small-scale tests of change to increase recruitment numbers. A number of tests were trialed, focusing primarily on reducing patient refusals and improving recruitment process efficiency. Recruitment rates were calculated by dividing eligible by enrolled patients and displayed using annotated Shewhart control charts. Control charts were used to illustrate week-to-week variability while also enabling differentiation of common-cause and special-cause variation. RESULTS: The study enrolled 774 patients, representing 54% of all eligible and 59% of those eligible for whom staff were available to enroll. Our mean weekly recruitment rate increased from 55% during the first 3 months of the study to a statistically significant sustained rate of 61%. This was sustained given numerous obstacles, such as departing and hiring of staff and adding a second recruitment location. CONCLUSIONS: Implementing quality improvement methods within a larger research study led to an increase in the rate of recruitment as well as the stability in recruitment rates from week-to-week.

A case study of pediatric asthma alerts from the beacon community program in cincinnati: technology is just the first step.

INTRODUCTION: The Beacon Community in Cincinnati, Ohio was an innovative, community-wide initiative to use technology to transform care. One important feature was the development of regional alerts to notify practices when patients were hospitalized or seen in the emergency department. The purpose of this paper is to describe the way in which technology engages the improvement process, and to describe the early stages of learning how to use technology to enhance quality improvement. METHODS: We interviewed key Beacon leaders as well as providers and office staff in selected practices. We also collected preliminary data from practices that reflected handling of alerts, including the number of asthma related alerts received and followed up. RESULTS: Regional alerts, supplied by the community-wide health information exchange, were a significant addition to the quality improvement effort in that they enabled practices to identify and follow up with additional children at risk. An important finding was the substantial effort at the practice level to integrate technology into ongoing patient care. CONCLUSIONS: Developing the technology for community wide alerts represented a significant endeavor in the Cincinnati Beacon Community. However, the technology was just the first step. Despite extra effort and time required on the part of individual practices, they reported that the value of having alerts was high. Hospital and ED visits represent some of the most costly aspects of care, and an efficient process for intervening with children using these costly services was seen as of significant value.

Cotinine in children admitted for asthma and readmission.

OBJECTIVE: To explore the relationship between tobacco smoke exposure (reported versus biomarker) and rates of readmission for children hospitalized for asthma. METHODS: We enrolled a prospective cohort of 774 children aged 1 to 16 years admitted for asthma or bronchodilator-responsive wheezing. The primary outcome was at least 1 asthma- or wheeze-related readmission within 1 year. Caregivers reported any tobacco exposure at home, in a secondary residence, or in the car. We measured serum and saliva cotinine levels with mass spectrometry. We used logistic regression to evaluate associations between tobacco exposure and readmissions. RESULTS: A total of 619 children had complete tobacco exposure data; 57% were African American and 76% had Medicaid. Seventeen percent of children were readmitted within 1 year. Tobacco exposure rates were 35.1%, 56.1%, and 79.6% by report, serum, and saliva measures, respectively. Caregiver report of any tobacco exposure was not associated with readmission (adjusted odds ratio: 1.18; 95% confidence interval: 0.79-1.89), but having detectable serum or salivary cotinine was associated with increased odds of readmission (adjusted odds ratio [95% confidence interval]: 1.59 [1.02-2.48] and 2.35 [1.22-4.55], respectively). Among children whose caregivers reported no tobacco exposure, 39.1% had detectable serum cotinine and 69.9% had detectable salivary cotinine. Of the children with reported exposure, 87.6% had detectable serum cotinine and 97.7% had detectable salivary cotinine. CONCLUSIONS: Detectable serum and salivary cotinine levels were common among children admitted for asthma and were associated with readmission, whereas caregiver report of tobacco exposure was not.

Role of financial and social hardships in asthma racial disparities.

BACKGROUND AND OBJECTIVES: Health care reform offers a new opportunity to address child health disparities. This study sought to characterize racial differences in pediatric asthma readmissions with a focus on the potential explanatory role of hardships that might be addressed in future patient care models. METHODS: We enrolled 774 children, aged 1 to 16 years, admitted for asthma or bronchodilator-responsive wheezing in a population-based prospective observational cohort. The outcome was time to readmission. Child race, socioeconomic status (measured by lower income and caregiver educational attainment), and hardship (caregivers looking for work, having no one to borrow money from, not owning a car or home, and being single/never married) were recorded. Analyses used Cox proportional hazards. RESULTS: The cohort was 57% African American, 33% white, and 10% multiracial/other; 19% were readmitted within 12 months. After adjustment for asthma severity classification, African Americans were twice as likely to be readmitted as whites (hazard ratio: 1.98; 95% confidence interval: 1.42 to 2.77). Compared with whites, African American caregivers were significantly more likely to report lower income and educational attainment, difficulty finding work, having no one to borrow money from, not owning a car or home, and being single/never married (all P ≤ .01). Hardships explained 41% of the observed racial disparity in readmission; jointly, socioeconomic status and hardship explained 49%. CONCLUSIONS: African American children were twice as likely to be readmitted as white children; hardships explained >40% of this disparity. Additional factors (eg, pollution, tobacco exposure, housing quality) may explain residual disparities. Targeted interventions could help achieve greater child health equity.

Connecting at-risk inpatient asthmatics to a community-based program to reduce home environmental risks: care system redesign using quality improvement methods.

INTRODUCTION: Connecting patients admitted with asthma to community-based services could improve care and more efficiently allocate resources. We sought to develop and evaluate an intervention to mitigate in-home environmental hazards (eg, pests, mold) for such children. METHODS: This was a controlled, quality improvement study on the inpatient units of an urban, academic children's hospital. Clinicians and public health officials co-developed processes to identify children with in-home risks and refer them for assessment and remediation. Processes assessed were the rate at which those identified as eligible were offered referrals, those referred received inspections, and primary care physicians (PCPs) were notified of risks and referrals. Consecutively occurring and seasonally matched intervention (n = 30) and historical control (n = 38) subcohorts were compared with respect to postdischarge mitigating actions (eg, discussions with landlords, PCPs), remaining risks, and morbidity (symptom-free days in previous 2 weeks and Child Asthma Control Test scores). RESULTS: In the first year, the percentage of eligible children offered referrals increased to a sustained rate of ∼90%; ∼65% of referrals led to in-home inspections (n = 50); and hazards were abated in 30 homes. PCP notification increased from 50% to ∼80%. After discharge, referred parents were more likely to discuss concerns with landlords, the health department, attorneys, and PCPs than patients admitted preimplementation (all P < .05). Referred households were more likely to report reduced presence of ≥2 exposures (P < .05). No differences in asthma morbidity were observed. CONCLUSIONS: We integrated environmental hazard mitigation into inpatient care. Community-engaged care delivery that reduces risks for poor asthma outcomes can be initiated within the hospital.

Improved documentation and care planning with an asthma-specific history and physical.

OBJECTIVE: The objective was to determine the effect of an electronic asthma-specific inpatient history and physical (H&P) template on documented history and improvements in care plans. METHODS: This was a before-after comparison of history and care plan documentation following implementation of a new H&P template. The template was implemented in May 2011. A retrospective review of the electronic health record was completed for 304 consecutive patients (2-16 years of age) admitted for asthma June to September 2010 and 242 admitted June to September 2011. Elements reviewed included asthma severity classification, utilization history (previous oral steroids, emergency visits, hospitalizations, intensive care admissions, and intubations), and environmental history (exposure to cockroaches, rodents, and mold). Assessed changes in care plans included social work or asthma-related subspecialty consult and change in controller medications. Patients from 2011 were compared with those from 2010 by using ttest and chi2 statistics with adjustment for confounders by use of logistic regression. Interrupted time-series analyses assessed variability in documentation over time. RESULTS: In 2011, the new H&P template was used in 74% of encounters. Compared with patients seen preimplementation, documentation in those seen after implementation was more likely to include severity classification (71% vs 44%; P < .0001), complete utilization history (73% vs 12%; P < .0001), and environmental history (66% v. 2%; P < .0001). Documentation became more consistent over time. Changes in care planning were also more common after implementation (63% vs 49%; P = .0006). CONCLUSIONS: A structured H&P template for asthma led to more complete and less variable documentation of important history and likely led to enhancements in care plans.