Racial and Ethnic Disparities in Acute Care Use for Pediatric Asthma

Jorge Kaufmann; Miguel Marino; Jennifer Lucas; Steffani R. Bailey; Sophia Giebultowicz; Jon Puro; David Ezekiel-Herrera; Shakira F. Suglia; John Heintzman

doi:10.1370/afm.2771

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Table 1.

Characteristics of Children Aged 3 to 17 Years With Asthma in the ADVANCE Clinical Research Network, 2012-2018

		Racial, Ethnic, and Language Group
Characteristic	All (N = 41,276)	Non-Hispanic White (n = 10,164)	Non-Hispanic Black (n = 10,041)	Latine, Prefer English (n = 9,239)	Latine, Prefer Spanish (n = 11,832)
Female, No. (%)	17,709 (42.9)	4,429 (43.6)	4,257 (42.4)	4,011 (43.4)	5,012 (42.4)
Age at first visit, mean (SD), y	7.6 (3.7)	8.2 (3.8)	7.6 (3.7)	7.6 (3.7)	6.9 (3.4)
BMI category, No. (%)^{^a}
Never overweight	16,726 (40.5)	4,663 (45.9)	4,565 (45.5)	3,592 (38.9)	3,906 (33.0)
Sometimes overweight	10,083 (24.4)	2,222 (21.9)	2,233 (22.2)	2,261 (24.5)	3,367 (28.5)
Always overweight	14,467 (35.0)	3,279 (32.3)	3,243 (32.3)	3,386 (36.6)	4,559 (38.5)
Payor type, No. (%)
Never insured	1,122 (2.7)	275 (2.7)	188 (1.9)	264 (2.9)	395 (3.3)
Some private	2,423 (5.9)	1,140 (11.2)	409 (4.1)	618 (6.7)	256 (2.2)
Some private and public	3,324 (8.1)	984 (9.7)	659 (6.6)	1,003 (10.9)	678 (5.7)
Some public	34,407 (83.4)	7,765 (76.4)	8,785 (87.5)	7,354 (79.6)	10,503 (88.8)
Federal poverty level, No. (%)
Always >138%	2,916 (7.1)	1,029 (10.1)	805 (8.0)	620 (6.7)	462 (3.9)
Above and below 138%	5,151 (12.5)	1,350 (13.3)	946 (9.4)	930 (10.1)	1,925 (16.3)
Always ≤138%	28,103 (68.1)	5,973 (58.8)	7,072 (70.4)	6,437 (69.7)	8,621 (72.9)
Not documented	5,106 (12.4)	1,812 (17.8)	1,218 (12.1)	1,252 (13.6)	824 (7.0)
Urbanicity, No. (%)^{^b}
Metropolitan	35,401 (85.8)	7,507 (73.9)	9,619 (95.8)	7,174 (77.6)	11,101 (93.8)
Micropolitan	4,493 (10.9)	1,998 (19.7)	183 (1.8)	1,705 (18.5)	607 (5.1)
Rural	1,382 (3.3)	659 (6.5)	239 (2.4)	360 (3.9)	124 (1.0)
US region, No. (%)
Northeast	4,129 (10.0)	228 (2.2)	1,449 (14.4)	1,163 (12.6)	1,289 (10.9)
South	17,515 (42.4)	3,819 (37.6)	5,293 (52.7)	3,677 (39.8)	4,726 (39.9)
Midwest	3,819 (9.3)	708 (7.0)	2,457 (24.5)	356 (3.9)	298 (2.5)
West	15,813 (38.3)	5,409 (53.2)	842 (8.4)	4,043 (43.8)	5,519 (46.6)
Visits per year, No. (%)
≤1	17,900 (43.4)	5,005 (49.2)	5,420 (54.0)	3,914 (42.4)	3,561 (30.1)
2 or 3	8,015 (19.4)	1,825 (18.0)	1,933 (19.3)	1,790 (19.4)	2,467 (20.9)
≥4	15,361 (37.2)	3,334 (32.8)	2,688 (26.8)	3,535 (38.3)	5,804 (49.1)
Maximum asthma severity, No. (%)^{^c}
Intermittent	11,348 (27.5)	2,537 (25.0)	3,324 (33.1)	2,169 (23.5)	3,318 (28.0)
Mild persistent	6,541 (15.8)	1,193 (11.7)	1,780 (17.7)	1,691 (18.3)	1,877 (15.9)
Moderate to severe persistent	3,583 (8.7)	787 (7.7)	1,062 (10.6)	757 (8.2)	977 (8.3)
Not documented	19,804 (48.0)	5,647 (55.6)	3,875 (38.6)	4,622 (50.0)	5,660 (47.8)
Influenza vaccination rate, No. (%)
<50% annually	28,851 (69.9)	8,019 (78.9)	7,332 (73.0)	6,743 (73.0)	6,757 (57.1)
50% to 80% annually	8,685 (21.0)	1,542 (15.2)	1,968 (19.6)	1,771 (19.2)	3,404 (28.8)
≥80% annually	3,740 (9.1)	603 (5.9)	741 (7.4)	725 (7.8)	1,671 (14.1)
Pneumococcal vaccination ever, No. (%)	26,560 (64.3)	5,585 (54.9)	6,705 (66.8)	5,677 (61.4)	8,593 (72.6)
Smoker, No. (%)
Never	26,905 (65.2)	6,136 (60.4)	6,048 (60.2)	6,010 (65.1)	8,711 (73.6)
Ever	969 (2.3)	424 (4.2)	262 (2.6)	163 (1.8)	120 (1.0)
Passive only	3,018 (7.3)	1,566 (15.4)	665 (6.6)	408 (4.4)	379 (3.2)
Not documented	10,384 (25.2)	2,038 (20.1)	3,066 (30.5)	2,658 (28.8)	2,622 (22.2)
Albuterol prescriptions per year, mean (SD)	0.6 (0.6)	0.5 (0.6)	0.7 (0.7)	0.6 (0.6)	0.7 (0.7)
Inhaled corticosteroid prescription ever, No. (%)	12,267 (29.7)	2,860 (28.1)	2,944 (29.3)	2,411 (26.1)	4,052 (34.2)

ADVANCE = Accelerating Data Value Across a National Community Health Center; BMI = body mass index; RUCA = rural-urban commuting area; US = United States.
Notes: All children had at least 1 year of observation. Data are representative of 345 clinics spanning 18 US states and 4 regions: Northeast (Massachusetts, Rhode Island), South (Florida, Georgia, Maryland, North Carolina), Midwest (Indiana, Kansas, Missouri, Ohio, Wisconsin), and West (Alaska, California, Hawaii, Nevada, New Mexico, Oregon, Washington).
↵a Overweight if BMI >85th percentile. Category reflects all available measures during study period. Biologically implausible values were flagged as more than 8 SDs above or 4 SDs below mean BMI.
↵b RUCA classification code based on 2010 census tract information and patients’ primary clinic zip code.
↵c Maximum asthma severity diagnosed in an ambulatory visit encounter or documented in the patient problem list.

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Table 2.

Clinic Visits for Asthma Exacerbation Among Children With Asthma Aged 3 to 17 Years (N = 41,276)

	Clinic Visit Outcomes for Asthma Exacerbation
Outcome and Group	Unadjusted		Adjusted^{^a}
Visits	Predicted probability, %^{^b}	OR (95% CI)	Predicted probability, %^{^b}	OR (95% CI)
Non-Hispanic White	22.4	Ref	34.3	Ref
Non-Hispanic Black	24.9	1.15 (1.02-1.30)	34.1	0.99 (0.89-1.09)
Latine, prefer English	24.1	1.10 (1.01-1.20)	34.1	0.99 (0.92-1.06)
Latine, prefer Spanish	27.4	1.31 (1.20-1.43)	36.1	1.10 (1.02-1.18)

Visit rate	Predicted annual rate^{^c}	RR (95% CI)	Predicted annual rate^{^c}	RR (95% CI)
Non-Hispanic White	15.1	Ref	19.3	Ref
Non-Hispanic Black	15.3	1.01 (0.84-1.23)	20.0	1.03 (0.87-1.23)
Latine, prefer English	24.8	1.65 (0.95-2.86)	22.9	1.18 (0.93-1.51)
Latine, prefer Spanish	18.7	1.24 (1.03-1.50)	17.9	0.92 (0.80-1.06)

OR = odds ratio; RR = rate ratio; Ref = reference.
Notes: Visits to community health center ambulatory clinics only. Values in bold denote statistically significant results (P <.05).
↵a Adjusted for age, sex, body mass index, insurance type, federal poverty level, urbanicity, US region, documented asthma severity, number of yearly visits, albuterol and inhaled corticosteroid prescriptions, influenza and pneumococcal vaccinations, and tobacco smoke exposure.
↵b Predicted probability of ever having a visit with a clinic-coded asthma exacerbation; adjusted results are averaged over covariates.
↵c Predicted annual rate of visits with clinic-coded asthma exacerbation per 100 person-years; adjusted results are averaged over covariates.

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Table 3.

Asthma-Related ED Visits Among Children With Asthma Aged 3 to 17 Years Receiving Oregon-Medicaid (N = 6,555)

	Asthma-Related ED Visit Outcomes
Outcome and Group	Unadjusted		Adjusted^{^a}
Visits	Predicted probability, %^{^b}	OR (95% CI)	Predicted probability, %^{^b}	OR (95% CI)
Non-Hispanic White	9.5	Ref	9.9	Ref
Non-Hispanic Black	13.3	1.47 (1.06-2.04)	13.3	1.40 (1.04-1.89)
Latine, prefer English	10.0	1.07 (0.84-1.36)	10.8	1.10 (0.85-1.43)
Latine, prefer Spanish	9.4	0.99 (0.78-1.27)	9.9	0.99 (0.77-1.28)

Visit rate	Predicted annual rate^{^c}	RR (95% CI)	Predicted annual rate^{^c}	RR (95% CI)
Non-Hispanic White	5.4	Ref	5.9	Ref
Non-Hispanic Black	9.9	1.84 (1.39-2.44)	8.8	1.49 (1.09-2.04)
Latine, prefer English	5.5	1.02 (0.75-1.39)	5.3	0.90 (0.67-1.21)
Latine, prefer Spanish	5.4	1.00 (0.77-1.31)	5.4	0.92 (0.68-1.24)

ED = emergency department; OR = odds ratio; RR = rate ratio; Ref = reference.
Note: Values in bold denote statistically significant results (P < .05).
↵a Adjusted for age, sex, body mass index, federal poverty level, urbanicity, documented asthma severity, number of yearly visits, albuterol and inhaled corticosteroid prescriptions, influenza and pneumococcal vaccinations, and tobacco smoke exposure.
↵b Predicted probability of ever having had an asthma-related ED visit; adjusted results are averaged over covariates.
↵c Predicted annual rate of asthma-related ED visits per 100 person-years; adjusted results are averaged over covariates.

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SUPPLEMENTAL MATERIALS IN PDF FILE BELOW

KaufmannSupp.pdf -
Supplemental Table 1. Characteristics of Oregon-Medicaid-recipient children age 3-17 years with asthma having had a minimum of one year observation time in the ADVANCE Clinical Research Network, 2012-2018.

Supplemental Table 2. Asthma exacerbation outcomes among Oregon-Medicaid recipient children (age 3-17) with asthma, at community health center ambulatory visits (AV), for children having had at least 1 AV in the ADVANCE Clinical Research Network, 2012-2018.

Supplemental Table 3. Asthma-related hospital inpatient admission outcomes for Oregon-Medicaid recipient children with asthma age 3-17, having had at least 1 community health center visit in the ADVANCE Clinical Research Network, 2012-2018 (N = 6,555).
VISUAL ABSTRACT IN PNG FILE BELOW

Kauffman_visual_abstract.png -
How do patterns of health visits vary by demographics and facility type for children with asthma?

A new study analyzes the likelihood of use of community health centers, emergency departments, and inpatient admissions by race/ethnicity, compared to White children.