Keeping Children With Asthma Out of Hospitals: Parents' and Physicians' Perspectives on How Pediatric Asthma Hospitalizations Can Be Prevent
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《小儿科》
Center for the Advancement of Underserved Children
Section of General Pediatrics, Department of Pediatrics, and Department of Epidemiology
Health Policy Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
Boston University School of Public Health, Boston, Massachusetts
ABSTRACT
Background. A total of 196000 hospitalizations occur each year among the 9 million US children who have been diagnosed with asthma. Not enough is known about how to prevent pediatric asthma hospitalizations.
Objectives. To identify the proportion of preventable pediatric asthma hospitalizations and how such hospitalizations might be prevented, according to parents and physicians of hospitalized children with asthma.
Methods. A cross-sectional survey was conducted of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of all children who were admitted for asthma to an urban hospital in a 14-month period.
Results. The 230 hospitalized children had a median age of 5 years; most were poor (median annual family income: $13356), were nonwhite (93%), and had public (74%) or no (14%) health insurance. Compared with children who were hospitalized for other ambulatory care–sensitive conditions, hospitalized children with asthma were significantly more likely to be African American (70% vs 57%), to be older, and not to have made a physician visit or telephone contact before admission (52% vs 41%). Only 26% of parents said that their child's admission was preventable, compared with 38% of PCPs and 43% of IAPs. The proportion of asthma hospitalizations that were assessed as preventable varied according to the source or combination of sources, from 15% for agreement among all 3 sources to 54% as identified by any 1 of the 3 sources. PCPs (83%) and IAPs (67%) significantly more often than parents (44%) cited parent/patient-related reasons for how hospitalizations could have been prevented, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (27%) and IAPs (26%) significantly more often than PCPs (11%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child's condition, and better quality of care. Multivariate analyses revealed that an age 11 years and no physician contact before the hospitalization were associated with 2 times the odds of a preventable asthma hospitalization.
Conclusions. The proportion of asthma hospitalizations assessed as preventable varies from 15% to 54%, depending on the source. Adolescents and families who fail to contact physicians before hospitalization are at greatest risk for preventable hospitalizations. Many pediatric asthma hospitalizations might be prevented if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers.
Key Words: asthma minority groups hospitalization children pediatrics patient admission health services research
Abbreviations: ACSC, ambulatory care–sensitive condition PCP, primary care physician IAP, inpatient attending physician NAEPP, National Asthma Education and Prevention Program
Approximately 9 million US children who are younger than 18 years (12%) have ever been diagnosed with asthma.1 In 2002, 196000 children were hospitalized for asthma,2 which is the second most common reason for hospitalization in US children and the leading cause of hospitalizations among children who are 3 to 12 years old.3 In 2000, pediatric asthma hospitalizations in the United States were responsible for >$835 million in charges,3 equivalent to an average charge of $5493 per hospitalization.
The prevention of pediatric asthma hospitalizations is an important health care and public health goal, given the prevalence of asthma, coupled with the large number of hospitalizations and substantial associated expense. Indeed, a Healthy People 2010 objective is to reduce the pediatric asthma hospitalization rate in the United States by 25% between 1996 and 2010.4 Not enough is known, however, about the risk factors for preventable pediatric asthma hospitalizations and the specific measures by parents and health care providers that can prevent hospitalizations of children with asthma.
Asthma is classified as a preventable hospitalization condition (also known as an avoidable hospitalization condition) or ambulatory care–sensitive condition (ACSC), defined as a diagnosis for which a hospitalization can be avoided with timely, effective outpatient care.5, 6 In a recent study of 554 consecutive hospitalizations for ACSCs,7 we found that asthma was by far the most common diagnosis and that an asthma diagnosis was associated with 2 to 3 times the adjusted odds of a hospitalization being preventable according to the child's parents, primary care physician (PCP), and inpatient attending physician (IAP). An additional noteworthy finding was that not all hospitalizations for ACSCs are actually preventable. In that study, data were pooled and collectively analyzed on all 20 pediatrics preventable hospitalizations; no additional analyses were performed to provide insights on the specific subset of preventable asthma hospitalizations. The aim of the current study, therefore, was to examine the subset of all 230 asthma hospitalizations to determine (1) the proportion of asthma hospitalizations that are actually preventable; (2) the reasons for how asthma hospitalizations can be prevented, according to the children's parents and physicians; and (3) factors associated with an increased risk for preventable asthma hospitalizations.
METHODS
A detailed description of the study methods was previously provided elsewhere.7 A summary of selected relevant methods and a comprehensive description of the data analyses are presented herein.
Definitions
Consistent with our previous study,7 when referring to a specific hospitalization, the term "preventable" is used to denote any hospital admission that was considered to be preventable according to 1 or more of the sources interviewed (parents, PCPs, and IAPs).
Study Participants
We enrolled a consecutive series of all children (18 years old) with asthma as the primary diagnosis and who were admitted to the inpatient ward of an inner-city hospital (Boston Medical Center) over a 14-month period (May 1997 to December 1998). Exclusion criteria were (1) direct admission to the PICU; (2) children whose parents could not be interviewed at any point during the hospital stay, such as in cases that were being investigated for suspected neglect or abuse; and (3) children who were hospitalized for several conditions whose listed primary diagnosis was not asthma. Children admitted for asthma were identified by review of the daily inpatient ward census logs, with cross-referencing and confirmation via inspection of medical records.
Data Collected and Questionnaire
We abstracted baseline sociodemographic data on each patient from the medical record. We recorded the child's age, the admission diagnosis, the name of the child's regular pediatrician (if the child had one), the name of the IAP, the type of insurance coverage, the child's race/ethnicity (verified by the parent/legal guardian), the parent/legal guardian's highest level of education attained, and the combined monthly family income.
The parent/legal guardian (herein referred to as "parent") of each admitted child completed a questionnaire in English or Spanish that was orally administered by a trained, bilingual Latina research assistant. For parents who had limited English proficiency and spoke a language other than English or Spanish, the research assistant administered the questionnaire with the assistance of a medical interpreter from the hospital's interpreter services. Before study initiation, we conducted a 4-month pilot study to test and refine further the questionnaire. In the final questionnaire, parents were asked why their child was admitted to the hospital and whether they believed that anything could have been done to prevent the hospitalization (and if yes, what). When the parents reported that their child had a regular doctor, we asked whether the child had visited the physician or the parents had spoken to the physician before the hospitalization and assessed the parents' general satisfaction with the physician's care. When the parents reported that the child had no regular health care provider, they were asked where they took their child for check-ups, vaccinations, and acute care. All parents also were asked to assess whether their child had easy access to health care, whether health care costs or health insurance problems ever caused them not to bring their child in for needed care, and whether they encountered difficulties in getting medications for their child because of excessive costs or because health insurance did not cover the medications.
Efforts were made to conduct a brief in-person or telephone interview with the IAP and PCP (for children with a regular physician) of every hospitalized child. Each physician was asked to assess whether the child's hospitalization was preventable or not and to provide detailed reasons for the assessment. When we were unsuccessful in reaching a physician on the first contact, we telephoned the physician at least 10 additional times for at least 1 month before scoring the physician as unavailable for a given patient. In the rare case that the PCP also was the IAP on the inpatient ward, assessment of preventability was recorded only for the PCP.
Two of the authors (G.F. and S.T.-K.) independently coded whether each source assessed a given hospitalization as preventable and independently categorized all reasons given for the preventability of the hospitalization. The independent coding and categorizations of the 2 authors then were compared, and any disagreements were discussed and reclassified by consensus. There were no cases in which consensus could not be reached.
Data Analysis
Bivariate comparisons were done using the 2 test or Fisher's exact test (for comparisons with low expected cell counts) for categorical variables and Wilcoxon's 2-sample test for continuous variables; a 2-tailed P < .05 was considered statistically significant. Sociodemographic and health services use characteristics and the preventability of hospitalizations of patients with asthma were compared with the characteristics and hospitalizations of 330 children who were admitted with other ACSCs at the same hospital during the same time interval, as described in our earlier work.7 "Don't know" responses to the question regarding the preventability of a hospitalization were recoded as missing. To assess interobserver agreement on the preventability of the asthma hospitalizations, we calculated simple coefficients by using SAS (SAS Institute, Inc, Cary, NC), and coefficients were interpreted using the scale of Landis and Koch.8 Multivariable analyses were performed using stepwise logistic regression. The dependent variable was the preventability of the asthma hospitalization (dichotomized as yes/no) according to 1 or more sources. The independent variables that were chosen for analysis were those used in our previous study of preventable pediatric hospitalizations. In cases in which an independent variable was defined in >1 way, separate models were run for each definition. Multivariable models were generated using stepwise logistic regression with an -to-enter of .05. All variables that were found to be significant for the stepwise regression were included in a final model that adjusted further for children's insurance status, poverty status, and parental educational attainment. All statistical analyses were performed by using SAS 8.2 software.9
Informed Consent and Institutional Review Board Approval
Written informed consent was obtained from the parent of each participating child. The study was approved by the Boston Medical Center Institutional Review Board.
RESULTS
Study Sample
A total of 234 asthma hospitalizations fulfilled initial study enrollment criteria. Four parents refused to participate in the study; there were no significant differences in age or race/ethnicity between study refusals and the final 230 subjects.
Children admitted for asthma were significantly older than those admitted for other ACSCs, with a median age of 5.0 versus 2.5 years (Table 1). There were no differences between the 2 groups in health insurance coverage, with approximately three quarters of each group covered by public insurance, and no insurance coverage for 14% of children hospitalized for asthma and 17% of those hospitalized for other ACSCs. Compared with children hospitalized for other ACSCs, a greater proportion of those hospitalized for asthma were African American. The parents of children with asthma significantly less often contacted their child's physician before the hospitalization by an office visit or telephone call compared with parents of children with other ACSCs (48% vs 59%; P = .02). There were no significant intergroup differences in parental educational attainment, annual combined family income, the child's having a regular physician, satisfaction with the child's medical care, access to medical care, deferring medical care because of cost or health insurance problems, or difficulty obtaining the child's medications (Table 1). Approximately 70% of families in each group lived in poverty, and 40% of parents had not graduated high school. The vast majority of families in both groups had a regular physician for their child, high satisfaction with care, easy access to care, no previous difficulty obtaining the child's medications, and no previous deferral of the child's medical care because of expense or insurance problems.
Preventability of Asthma Hospitalizations
Only 26% of parents reported that their child's asthma hospitalization was preventable, compared with 38% of PCPs and 43% of IAPs (P < .001; Table 2). The proportion of asthma hospitalizations that were preventable varied according to the source or combination of sources making the preventability assessment, ranging from 15% for agreement among all 3 sources (parents and the 2 physicians groups) to 54% for any of the sources who assessed the hospitalization as preventable (Table 2). There was fair agreement between the parents and each of the physician groups on the preventability of the children's asthma hospitalizations and moderate agreement between to the 2 physician groups (Table 2). Illustrative cases of agreement and disagreement among a child's parents and physicians about the preventability of asthma hospitalizations are provided in Fig 1.
The proportion of hospitalizations that were assessed as preventable by parents did not significantly differ between asthma and other ACSC hospitalizations (Table 2). For the remaining 9 sources who assessed preventability, however, significantly higher proportions of asthma hospitalizations were assessed as preventable. For example, the proportion of hospitalizations that were assessed as preventable by any physician source was 49% for asthma hospitalizations compared with only 29% for other ACSC hospitalizations (P < .001).
Reason for Preventability of Hospitalizations
Parent/Patient-Related Reasons
The most common reasons for the preventability of asthma hospitalizations cited by all 3 assessing sources (parents and the 2 physician groups) were parent and patient related (Table 3). PCPs and IAPs were substantially more likely to cite parent/patient-related reasons than the parents (83% vs 67% vs 44%, respectively). Among the parent/patient-related reasons, medication-related issues were identified most often by all 3 sources; these included adherence problems, medications not being given soon enough, families running out of medications, and refills not being called in to pharmacies. Inadequate preventive measures was another reason in this category that was frequently identified by all 3 sources; this consisted of failure to avoid known triggers of the child's asthma exacerbations, including exposure to cigarette smoke (the most often cited in this subcategory), household dust, other children with upper respiratory infections, and pet dander, such as allowing a child who is allergic to dogs to play with a puppy (Fig 1).
The second most commonly identified parent/patient-related reason identified by both physician groups was delaying or failure to obtain needed follow-up medical care, reported by 32% of PCPs and 22% of IAPs. In contrast, no parent identified delayed or failure to obtain needed follow-up care as a reason. Similarly, 10% of each physician group cited parents' not adequately educating themselves about the child's asthma as a reason, but none of the parents cited this reason. Other less commonly cited reasons included not telephoning the PCP early enough during an asthma exacerbation, not monitoring the child's peak flow, and an adolescent's not taking enough responsibility for his or her own asthma care.
Physician-Related Reasons
Parents and IAPs identified physician-related reasons for preventability significantly more often than PCPs (27%, 26%, and 11%, respectively; P = .04; Table 3). The specific reason in this category most often cited by all 3 groups was an inadequate or no intervention administered to the child. Parents specifically identified ineffective and inappropriate medications, not being prescribed a second medication from a different medication class, not being given a nebulizer for home use, and not being given any treatment during an office visit. PCPs cited outpatient treatment that was not aggressive enough, the need for better outpatient control, and failure to use inhaled corticosteroids as part of the outpatient treatment regimen. IAPs identified outpatient treatment that was not aggressive or effective enough, failure to prescribe medication for home use, the family's not being given a nebulizer for home use, and failure to prescribe or adequately dose outpatient corticosteroids for an exacerbation.
Lack of adequate education of the parent and the child by the physician also was a frequently cited physician-related reason (Table 3). Parents cited a desire for more information, PCPs identified both their own inadequate outpatient education of families and insufficient discharge education of families during their hospitalization, and IAPs reported all reasons identified by parents and PCPs. Poor quality of care was cited by 9% of parents and 8% of IAPs but only 2% of PCPs, although these differences were not statistically significant. Other less frequently cited reasons included no follow-up arranged by the primary care practice, the child was discharged too early from the hospital, lack of referral to a specialist, and an inappropriate admission.
Other Reasons
All remaining reasons individually occurred infrequently (Table 3). All but 1 of the equipment/medication failures consisted of a broken home nebulizer machine, with the remaining instance the loss of a nebulizer that used to be in the household. Housing conditions identified included mold contamination, cockroach and rodent infestations, inadequate home heating, and excessive dust and moisture. Health care system issues included the lack of a PCP, the need for more nurse outreach, and refusal by the pharmacy to provide medication. Other identified reasons included financial issues (inability to afford a home nebulizer machine), social issues (including homelessness, child neglect, and lack of social support), employment exposure (in an adolescent), no reason given, and a "don't know" response. In addition, a few parents cited weather-related reasons (weather changes and cold temperatures), and an IAP cited a hospitalization that lasted only for a few hours.
Bivariate Analyses: Risk Factors for Preventable Asthma Hospitalizations
The child's age was consistently and significantly associated with the likelihood of an asthma hospitalization's being preventable (Table 4). For example, 25% to 90% of hospitalizations were preventable among 15- to 18-year-olds, compared with only 4% to 34% of hospitalizations for children who were younger than 24 months. Uninsured children also frequently were found to have a higher risk for preventable hospitalizations; 45% of hospitalizations for uninsured children but only 18% of those for privately insured children were assessed as preventable (P < .05) when parents were the assessing source. Certain associations with preventable hospitalizations were noted less consistently, including no physician contact by telephone or office visit before hospitalization, having no regular physician, and a history of not bringing the child in for a physician visit because of expense or insurance problems. No significant association with preventable hospitalizations was noted for the following: satisfaction with care, previous difficulty getting medications, access to care, the child's race/ethnicity, parental educational attainment, poverty status, or the quartile of the annual combined family income (Table 4).
Multivariable Analyses
Two risk factors were significantly associated with preventable asthma hospitalizations: having made no telephone call or office visit to the physician before the hospitalization and an age 11 years (Table 5). No telephone call or office visit to the physician before the child's hospitalization was associated with twice the adjusted odds of a preventable hospitalization as per 4 of 10 assessing sources, and an age 11 years was associated with twice the adjusted odds of a preventable hospitalization as per 3 of 10 assessing sources.
DISCUSSION
The study findings indicate that the proportion of asthma hospitalizations assessed as preventable can vary from 15% to 54%, depending on the source (parent, PCP, or IAP) or combinations of sources making the assessment. These data suggest that a fairly substantial proportion of asthma hospitalizations might be prevented with timely, effective outpatient care. Although our study was limited to 1 urban hospital in the Northeast, extrapolating the findings to national data2, 3 suggests that from 29400 to 105840 of the 196000 annual pediatric asthma hospitalizations in the United States might be prevented, along with an estimated $161 to $581 million in charges. Caution must be exercised in making these projections, however, as additional studies are needed of other populations and regions to determine whether the proportion of preventable hospitalizations and cost savings hold true in other settings.
These results also confirm our earlier work on ACSCs in general,7 which revealed that many ACSC hospitalizations seem to be unavoidable. Thus, administrative database analyses of pediatric asthma hospitalizations may be of limited utility, because many of these hospitalizations (46–85%) may not be preventable, even with timely, effective ambulatory care. As has been argued elsewhere,10 it may be time for a new paradigm for preventable asthma hospitalizations in which preventability is determined using data from the parent, PCP, and IAP of each hospitalized child.
Asthma Triggers
The National Asthma Education and Prevention Program (NAEPP) identified controlling asthma triggers as an essential component of asthma management and ensuring the delivery of quality health care.11 Our study findings reveal that failure to control asthma triggers also is an important cause of preventable pediatric asthma hospitalizations. Parents, PCPs, and IAPs reported that 9% to 13% of preventable pediatric asthma hospitalizations could have been prevented by avoiding known asthma triggers. Household exposure to cigarette smoke was the most common trigger cited, followed by dust in the home, pet dander, and preventable exposures to other children with upper respiratory infections. These data further underscore the importance of parental tobacco cessation counseling and reducing or eliminating exposure to allergens and irritants in the home, school, and adolescent workplace. Recent research revealed that most parents are aware of asthma triggers and 82% have attempted an environmental control measure, but more than half of environmental actions by parents do not meet current guidelines and are unlikely to control triggers effectively.12 Trigger reduction is a particularly high priority for preventing hospitalizations in poor inner-city children with asthma: studies have found that among low-income urban households with a child with asthma, 47% to 50% have smokers in the home, 34% have furry pets, and 47% to 58% have high levels of cockroach allergen.13, 14
Adherence
The most common reason for the preventability of asthma hospitalizations was medication related, including adherence problems, running out of medications, and refills not being called in. These issues account for approximately one third to one half of all preventable asthma hospitalizations, depending on the assessing source. These striking findings underscore that educating families about adherence and ensuring adequate medication supply may have a potentially significant impact on preventing asthma hospitalizations. Our results are consistent with recent research indicating that poor adherence is associated with various adverse childhood asthma outcomes, including increased days of wheezing, impaired functional status, more missed school, and a higher risk for hospitalization.15 Poor adherence continues to be a major issue in the treatment of pediatric asthma, with adherence rates of 46% to 60% for preventive asthma medications (as assessed by electronic monitoring devices).16–19 Additional studies are needed of the most effective means of improving adherence for children with asthma.
Follow-up Care
Delayed or no follow-up care was the second most common cause of preventable hospitalizations according to physicians, accounting for 22% and 32% of preventable hospitalizations as per IAPs and PCPs, respectively. Parents, however, never cited delayed or no follow-up as a cause of preventable pediatric hospitalizations. This physician-parent gap can be viewed as instructive in 2 ways. First, it seems that parents are not receiving the message that follow-up is essential to high-quality childhood asthma care, so clinicians need to consider more effective mechanisms for educating parents about the importance of follow-up visits. Second, this finding suggests that it is crucial to identify and remove any barriers that families face in scheduling and keeping follow-up appointments. Mechanisms of reducing or eliminating delayed or no follow-up care might include efficient and family-friendly scheduling systems and personnel at the front desk in outpatient, emergency, and inpatients settings and postal or telephone reminders to families shortly before scheduled follow-up visits. The NAEPP recommendations11 identify scheduling routine follow-up care as a key clinical activity, because it provides opportunities to address variations in patients' symptoms and severity, exposure to allergens, adherence, the management plan, and patient self-management.
Education
Several study findings highlight the importance and need for better and more comprehensive asthma education of children and parents. Parents were significantly less likely than physicians to believe that their children's asthma hospitalizations are preventable. This gap suggests that parents need better information about the preventability of pediatric asthma hospitalizations and about steps that can be taken to keep their children out of the hospital. Indeed, the study parents themselves reported a desire for more asthma information from their children's physicians. Parents and both physician groups reported that better education of parents by physicians can prevent pediatric asthma hospitalizations. Both physician groups identified specific educational issues that can be viewed as instructive in improving the quality of pediatric asthma care. The physicians admitted that better outpatient asthma education of families could have prevented several asthma hospitalizations. In addition, insufficient hospital discharge education was identified as a measure that could have prevented subsequent asthma hospitalizations.
Physicians not infrequently reported that pediatric asthma hospitalizations could have been prevented had parents better educated themselves about their child's asthma, with 14% and 10% of PCPs and IAPs, respectively, citing this reason. No parent, however, cited this reason, suggesting that there is a greater need for health care providers and parents to discuss the importance of parents' learning more about pediatric asthma as a means of preventing children's hospitalizations. These findings also suggest that additional means of educating families and patients about childhood asthma, such as the use of asthma educators, asthma nurse specialists in pediatric practices, and community health workers, have the potential to prevent hospitalizations. The NAEPP11 identified providing routine education of parents and patients on patient self-management as a key clinical activity for quality asthma care.
Quality-of-Care Issues
The study findings indicate several quality-of-care issues that, if properly addressed, could potentially lead to a reduction in preventable asthma hospitalizations. Both physician groups in this study cited a failure to prescribe outpatient corticosteroids as a reason for preventable asthma hospitalizations. These findings are noteworthy in light of studies indicating that corticosteroids continue to be underutilized,20–23 even though they have been shown to be highly effective in the management of pediatric asthma.24–27 Both physician groups in our study noted that pediatric asthma hospitalizations could have been avoided with more aggressive outpatient treatment and better outpatient control. These data highlight the importance of recent research indicating that some children continue to be undertreated in relation to treatment guidelines for NAEPP asthma severity classification categories.22
Limitations
Certain limitations of this study should be noted. The study population consisted of urban children who were predominantly poor, racial/ethnic minorities who were hospitalized in the northeastern United States. Additional studies are needed to determine whether these findings would be confirmed in suburban and rural settings, other regions of the Unites States, nonpoor populations, and those with a different racial/ethnic background. Physician survey responses were collected without personal identifiers (to ensure confidentiality and detailed answers), so it was not possible to examine whether preventable asthma hospitalizations occurred more often with certain PCPs or less often with PCPs who had received recent asthma-specific continuing medical education.
Housing and Health Care System Issues
Although cited less frequently than other reasons, housing issues were identified by both parents and physicians as reasons for preventable hospitalizations. Mold contamination, cockroach and rodent infestations, inadequate home heating, and excessive dust and moisture were specifically identified by parents and physicians. These findings suggest that greater attention to housing issues by health care providers, social workers, public health workers, home care nurses, and low-income housing programs could result in a reduction in preventable pediatric asthma hospitalizations. The study results also indicate that addressing certain health care system issues could lead to fewer pediatric asthma admissions, including ensuring that every child with asthma has a PCP, providing more nurse outreach, and examining why certain pharmacies may sometimes refuse to provide prescribed medications.
Groups at Risk for Preventable Asthma Hospitalizations
Parental failure to telephone or visit a child's physician before an admission was found to be associated with double the adjusted odds of a preventable asthma hospitalization. This finding highlights the importance of health care providers' educating families and providing ongoing reinforcement about consistently contacting the physician's office at the earliest indication of a child's having an asthma exacerbation. Adolescents also were found to have double the adjusted odds of a preventable asthma hospitalization. This may relate (at least in part) to the higher risk for nonadherence among adolescents with asthma.18, 19 Targeting adolescents for additional education, particularly regarding asthma self-management skills, may prove useful in reducing preventable asthma hospitalizations.
CONCLUSIONS
The proportion of asthma hospitalizations that are assessed as preventable by parents and physicians varies from 15% to 54%, depending on the source. Adolescents and families who fail to contact physicians before hospitalization are at greatest risk for preventable hospitalizations. Many pediatric asthma hospitalizations might be prevented if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers.
ACKNOWLEDGMENTS
This study was supported by a grant to Dr Flores from the Minority Medical Faculty Development Program and Generalist Physician Faculty Scholars Program of the Robert Wood Johnson Foundation and an Independent Scientist (K02) Award from the Agency for Healthcare Research and Quality.
We are grateful to Barbara Bolstorff for assistance with data collection, and special thanks are owed to all of the families and physicians whose participation made this study possible.
FOOTNOTES
Accepted May 25, 2005.
Presented in part as a platform presentation at the annual meetings of the Pediatric Academic Societies; May 3, 2004; San Francisco, CA; and the American Public Health Association; November 10, 2004; Washington, DC; and as a poster at the annual research meeting of AcademyHealth; June 6, 2004; San Diego, CA.
No conflict of interest declared.
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Section of General Pediatrics, Department of Pediatrics, and Department of Epidemiology
Health Policy Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
Boston University School of Public Health, Boston, Massachusetts
ABSTRACT
Background. A total of 196000 hospitalizations occur each year among the 9 million US children who have been diagnosed with asthma. Not enough is known about how to prevent pediatric asthma hospitalizations.
Objectives. To identify the proportion of preventable pediatric asthma hospitalizations and how such hospitalizations might be prevented, according to parents and physicians of hospitalized children with asthma.
Methods. A cross-sectional survey was conducted of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of all children who were admitted for asthma to an urban hospital in a 14-month period.
Results. The 230 hospitalized children had a median age of 5 years; most were poor (median annual family income: $13356), were nonwhite (93%), and had public (74%) or no (14%) health insurance. Compared with children who were hospitalized for other ambulatory care–sensitive conditions, hospitalized children with asthma were significantly more likely to be African American (70% vs 57%), to be older, and not to have made a physician visit or telephone contact before admission (52% vs 41%). Only 26% of parents said that their child's admission was preventable, compared with 38% of PCPs and 43% of IAPs. The proportion of asthma hospitalizations that were assessed as preventable varied according to the source or combination of sources, from 15% for agreement among all 3 sources to 54% as identified by any 1 of the 3 sources. PCPs (83%) and IAPs (67%) significantly more often than parents (44%) cited parent/patient-related reasons for how hospitalizations could have been prevented, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (27%) and IAPs (26%) significantly more often than PCPs (11%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child's condition, and better quality of care. Multivariate analyses revealed that an age 11 years and no physician contact before the hospitalization were associated with 2 times the odds of a preventable asthma hospitalization.
Conclusions. The proportion of asthma hospitalizations assessed as preventable varies from 15% to 54%, depending on the source. Adolescents and families who fail to contact physicians before hospitalization are at greatest risk for preventable hospitalizations. Many pediatric asthma hospitalizations might be prevented if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers.
Key Words: asthma minority groups hospitalization children pediatrics patient admission health services research
Abbreviations: ACSC, ambulatory care–sensitive condition PCP, primary care physician IAP, inpatient attending physician NAEPP, National Asthma Education and Prevention Program
Approximately 9 million US children who are younger than 18 years (12%) have ever been diagnosed with asthma.1 In 2002, 196000 children were hospitalized for asthma,2 which is the second most common reason for hospitalization in US children and the leading cause of hospitalizations among children who are 3 to 12 years old.3 In 2000, pediatric asthma hospitalizations in the United States were responsible for >$835 million in charges,3 equivalent to an average charge of $5493 per hospitalization.
The prevention of pediatric asthma hospitalizations is an important health care and public health goal, given the prevalence of asthma, coupled with the large number of hospitalizations and substantial associated expense. Indeed, a Healthy People 2010 objective is to reduce the pediatric asthma hospitalization rate in the United States by 25% between 1996 and 2010.4 Not enough is known, however, about the risk factors for preventable pediatric asthma hospitalizations and the specific measures by parents and health care providers that can prevent hospitalizations of children with asthma.
Asthma is classified as a preventable hospitalization condition (also known as an avoidable hospitalization condition) or ambulatory care–sensitive condition (ACSC), defined as a diagnosis for which a hospitalization can be avoided with timely, effective outpatient care.5, 6 In a recent study of 554 consecutive hospitalizations for ACSCs,7 we found that asthma was by far the most common diagnosis and that an asthma diagnosis was associated with 2 to 3 times the adjusted odds of a hospitalization being preventable according to the child's parents, primary care physician (PCP), and inpatient attending physician (IAP). An additional noteworthy finding was that not all hospitalizations for ACSCs are actually preventable. In that study, data were pooled and collectively analyzed on all 20 pediatrics preventable hospitalizations; no additional analyses were performed to provide insights on the specific subset of preventable asthma hospitalizations. The aim of the current study, therefore, was to examine the subset of all 230 asthma hospitalizations to determine (1) the proportion of asthma hospitalizations that are actually preventable; (2) the reasons for how asthma hospitalizations can be prevented, according to the children's parents and physicians; and (3) factors associated with an increased risk for preventable asthma hospitalizations.
METHODS
A detailed description of the study methods was previously provided elsewhere.7 A summary of selected relevant methods and a comprehensive description of the data analyses are presented herein.
Definitions
Consistent with our previous study,7 when referring to a specific hospitalization, the term "preventable" is used to denote any hospital admission that was considered to be preventable according to 1 or more of the sources interviewed (parents, PCPs, and IAPs).
Study Participants
We enrolled a consecutive series of all children (18 years old) with asthma as the primary diagnosis and who were admitted to the inpatient ward of an inner-city hospital (Boston Medical Center) over a 14-month period (May 1997 to December 1998). Exclusion criteria were (1) direct admission to the PICU; (2) children whose parents could not be interviewed at any point during the hospital stay, such as in cases that were being investigated for suspected neglect or abuse; and (3) children who were hospitalized for several conditions whose listed primary diagnosis was not asthma. Children admitted for asthma were identified by review of the daily inpatient ward census logs, with cross-referencing and confirmation via inspection of medical records.
Data Collected and Questionnaire
We abstracted baseline sociodemographic data on each patient from the medical record. We recorded the child's age, the admission diagnosis, the name of the child's regular pediatrician (if the child had one), the name of the IAP, the type of insurance coverage, the child's race/ethnicity (verified by the parent/legal guardian), the parent/legal guardian's highest level of education attained, and the combined monthly family income.
The parent/legal guardian (herein referred to as "parent") of each admitted child completed a questionnaire in English or Spanish that was orally administered by a trained, bilingual Latina research assistant. For parents who had limited English proficiency and spoke a language other than English or Spanish, the research assistant administered the questionnaire with the assistance of a medical interpreter from the hospital's interpreter services. Before study initiation, we conducted a 4-month pilot study to test and refine further the questionnaire. In the final questionnaire, parents were asked why their child was admitted to the hospital and whether they believed that anything could have been done to prevent the hospitalization (and if yes, what). When the parents reported that their child had a regular doctor, we asked whether the child had visited the physician or the parents had spoken to the physician before the hospitalization and assessed the parents' general satisfaction with the physician's care. When the parents reported that the child had no regular health care provider, they were asked where they took their child for check-ups, vaccinations, and acute care. All parents also were asked to assess whether their child had easy access to health care, whether health care costs or health insurance problems ever caused them not to bring their child in for needed care, and whether they encountered difficulties in getting medications for their child because of excessive costs or because health insurance did not cover the medications.
Efforts were made to conduct a brief in-person or telephone interview with the IAP and PCP (for children with a regular physician) of every hospitalized child. Each physician was asked to assess whether the child's hospitalization was preventable or not and to provide detailed reasons for the assessment. When we were unsuccessful in reaching a physician on the first contact, we telephoned the physician at least 10 additional times for at least 1 month before scoring the physician as unavailable for a given patient. In the rare case that the PCP also was the IAP on the inpatient ward, assessment of preventability was recorded only for the PCP.
Two of the authors (G.F. and S.T.-K.) independently coded whether each source assessed a given hospitalization as preventable and independently categorized all reasons given for the preventability of the hospitalization. The independent coding and categorizations of the 2 authors then were compared, and any disagreements were discussed and reclassified by consensus. There were no cases in which consensus could not be reached.
Data Analysis
Bivariate comparisons were done using the 2 test or Fisher's exact test (for comparisons with low expected cell counts) for categorical variables and Wilcoxon's 2-sample test for continuous variables; a 2-tailed P < .05 was considered statistically significant. Sociodemographic and health services use characteristics and the preventability of hospitalizations of patients with asthma were compared with the characteristics and hospitalizations of 330 children who were admitted with other ACSCs at the same hospital during the same time interval, as described in our earlier work.7 "Don't know" responses to the question regarding the preventability of a hospitalization were recoded as missing. To assess interobserver agreement on the preventability of the asthma hospitalizations, we calculated simple coefficients by using SAS (SAS Institute, Inc, Cary, NC), and coefficients were interpreted using the scale of Landis and Koch.8 Multivariable analyses were performed using stepwise logistic regression. The dependent variable was the preventability of the asthma hospitalization (dichotomized as yes/no) according to 1 or more sources. The independent variables that were chosen for analysis were those used in our previous study of preventable pediatric hospitalizations. In cases in which an independent variable was defined in >1 way, separate models were run for each definition. Multivariable models were generated using stepwise logistic regression with an -to-enter of .05. All variables that were found to be significant for the stepwise regression were included in a final model that adjusted further for children's insurance status, poverty status, and parental educational attainment. All statistical analyses were performed by using SAS 8.2 software.9
Informed Consent and Institutional Review Board Approval
Written informed consent was obtained from the parent of each participating child. The study was approved by the Boston Medical Center Institutional Review Board.
RESULTS
Study Sample
A total of 234 asthma hospitalizations fulfilled initial study enrollment criteria. Four parents refused to participate in the study; there were no significant differences in age or race/ethnicity between study refusals and the final 230 subjects.
Children admitted for asthma were significantly older than those admitted for other ACSCs, with a median age of 5.0 versus 2.5 years (Table 1). There were no differences between the 2 groups in health insurance coverage, with approximately three quarters of each group covered by public insurance, and no insurance coverage for 14% of children hospitalized for asthma and 17% of those hospitalized for other ACSCs. Compared with children hospitalized for other ACSCs, a greater proportion of those hospitalized for asthma were African American. The parents of children with asthma significantly less often contacted their child's physician before the hospitalization by an office visit or telephone call compared with parents of children with other ACSCs (48% vs 59%; P = .02). There were no significant intergroup differences in parental educational attainment, annual combined family income, the child's having a regular physician, satisfaction with the child's medical care, access to medical care, deferring medical care because of cost or health insurance problems, or difficulty obtaining the child's medications (Table 1). Approximately 70% of families in each group lived in poverty, and 40% of parents had not graduated high school. The vast majority of families in both groups had a regular physician for their child, high satisfaction with care, easy access to care, no previous difficulty obtaining the child's medications, and no previous deferral of the child's medical care because of expense or insurance problems.
Preventability of Asthma Hospitalizations
Only 26% of parents reported that their child's asthma hospitalization was preventable, compared with 38% of PCPs and 43% of IAPs (P < .001; Table 2). The proportion of asthma hospitalizations that were preventable varied according to the source or combination of sources making the preventability assessment, ranging from 15% for agreement among all 3 sources (parents and the 2 physicians groups) to 54% for any of the sources who assessed the hospitalization as preventable (Table 2). There was fair agreement between the parents and each of the physician groups on the preventability of the children's asthma hospitalizations and moderate agreement between to the 2 physician groups (Table 2). Illustrative cases of agreement and disagreement among a child's parents and physicians about the preventability of asthma hospitalizations are provided in Fig 1.
The proportion of hospitalizations that were assessed as preventable by parents did not significantly differ between asthma and other ACSC hospitalizations (Table 2). For the remaining 9 sources who assessed preventability, however, significantly higher proportions of asthma hospitalizations were assessed as preventable. For example, the proportion of hospitalizations that were assessed as preventable by any physician source was 49% for asthma hospitalizations compared with only 29% for other ACSC hospitalizations (P < .001).
Reason for Preventability of Hospitalizations
Parent/Patient-Related Reasons
The most common reasons for the preventability of asthma hospitalizations cited by all 3 assessing sources (parents and the 2 physician groups) were parent and patient related (Table 3). PCPs and IAPs were substantially more likely to cite parent/patient-related reasons than the parents (83% vs 67% vs 44%, respectively). Among the parent/patient-related reasons, medication-related issues were identified most often by all 3 sources; these included adherence problems, medications not being given soon enough, families running out of medications, and refills not being called in to pharmacies. Inadequate preventive measures was another reason in this category that was frequently identified by all 3 sources; this consisted of failure to avoid known triggers of the child's asthma exacerbations, including exposure to cigarette smoke (the most often cited in this subcategory), household dust, other children with upper respiratory infections, and pet dander, such as allowing a child who is allergic to dogs to play with a puppy (Fig 1).
The second most commonly identified parent/patient-related reason identified by both physician groups was delaying or failure to obtain needed follow-up medical care, reported by 32% of PCPs and 22% of IAPs. In contrast, no parent identified delayed or failure to obtain needed follow-up care as a reason. Similarly, 10% of each physician group cited parents' not adequately educating themselves about the child's asthma as a reason, but none of the parents cited this reason. Other less commonly cited reasons included not telephoning the PCP early enough during an asthma exacerbation, not monitoring the child's peak flow, and an adolescent's not taking enough responsibility for his or her own asthma care.
Physician-Related Reasons
Parents and IAPs identified physician-related reasons for preventability significantly more often than PCPs (27%, 26%, and 11%, respectively; P = .04; Table 3). The specific reason in this category most often cited by all 3 groups was an inadequate or no intervention administered to the child. Parents specifically identified ineffective and inappropriate medications, not being prescribed a second medication from a different medication class, not being given a nebulizer for home use, and not being given any treatment during an office visit. PCPs cited outpatient treatment that was not aggressive enough, the need for better outpatient control, and failure to use inhaled corticosteroids as part of the outpatient treatment regimen. IAPs identified outpatient treatment that was not aggressive or effective enough, failure to prescribe medication for home use, the family's not being given a nebulizer for home use, and failure to prescribe or adequately dose outpatient corticosteroids for an exacerbation.
Lack of adequate education of the parent and the child by the physician also was a frequently cited physician-related reason (Table 3). Parents cited a desire for more information, PCPs identified both their own inadequate outpatient education of families and insufficient discharge education of families during their hospitalization, and IAPs reported all reasons identified by parents and PCPs. Poor quality of care was cited by 9% of parents and 8% of IAPs but only 2% of PCPs, although these differences were not statistically significant. Other less frequently cited reasons included no follow-up arranged by the primary care practice, the child was discharged too early from the hospital, lack of referral to a specialist, and an inappropriate admission.
Other Reasons
All remaining reasons individually occurred infrequently (Table 3). All but 1 of the equipment/medication failures consisted of a broken home nebulizer machine, with the remaining instance the loss of a nebulizer that used to be in the household. Housing conditions identified included mold contamination, cockroach and rodent infestations, inadequate home heating, and excessive dust and moisture. Health care system issues included the lack of a PCP, the need for more nurse outreach, and refusal by the pharmacy to provide medication. Other identified reasons included financial issues (inability to afford a home nebulizer machine), social issues (including homelessness, child neglect, and lack of social support), employment exposure (in an adolescent), no reason given, and a "don't know" response. In addition, a few parents cited weather-related reasons (weather changes and cold temperatures), and an IAP cited a hospitalization that lasted only for a few hours.
Bivariate Analyses: Risk Factors for Preventable Asthma Hospitalizations
The child's age was consistently and significantly associated with the likelihood of an asthma hospitalization's being preventable (Table 4). For example, 25% to 90% of hospitalizations were preventable among 15- to 18-year-olds, compared with only 4% to 34% of hospitalizations for children who were younger than 24 months. Uninsured children also frequently were found to have a higher risk for preventable hospitalizations; 45% of hospitalizations for uninsured children but only 18% of those for privately insured children were assessed as preventable (P < .05) when parents were the assessing source. Certain associations with preventable hospitalizations were noted less consistently, including no physician contact by telephone or office visit before hospitalization, having no regular physician, and a history of not bringing the child in for a physician visit because of expense or insurance problems. No significant association with preventable hospitalizations was noted for the following: satisfaction with care, previous difficulty getting medications, access to care, the child's race/ethnicity, parental educational attainment, poverty status, or the quartile of the annual combined family income (Table 4).
Multivariable Analyses
Two risk factors were significantly associated with preventable asthma hospitalizations: having made no telephone call or office visit to the physician before the hospitalization and an age 11 years (Table 5). No telephone call or office visit to the physician before the child's hospitalization was associated with twice the adjusted odds of a preventable hospitalization as per 4 of 10 assessing sources, and an age 11 years was associated with twice the adjusted odds of a preventable hospitalization as per 3 of 10 assessing sources.
DISCUSSION
The study findings indicate that the proportion of asthma hospitalizations assessed as preventable can vary from 15% to 54%, depending on the source (parent, PCP, or IAP) or combinations of sources making the assessment. These data suggest that a fairly substantial proportion of asthma hospitalizations might be prevented with timely, effective outpatient care. Although our study was limited to 1 urban hospital in the Northeast, extrapolating the findings to national data2, 3 suggests that from 29400 to 105840 of the 196000 annual pediatric asthma hospitalizations in the United States might be prevented, along with an estimated $161 to $581 million in charges. Caution must be exercised in making these projections, however, as additional studies are needed of other populations and regions to determine whether the proportion of preventable hospitalizations and cost savings hold true in other settings.
These results also confirm our earlier work on ACSCs in general,7 which revealed that many ACSC hospitalizations seem to be unavoidable. Thus, administrative database analyses of pediatric asthma hospitalizations may be of limited utility, because many of these hospitalizations (46–85%) may not be preventable, even with timely, effective ambulatory care. As has been argued elsewhere,10 it may be time for a new paradigm for preventable asthma hospitalizations in which preventability is determined using data from the parent, PCP, and IAP of each hospitalized child.
Asthma Triggers
The National Asthma Education and Prevention Program (NAEPP) identified controlling asthma triggers as an essential component of asthma management and ensuring the delivery of quality health care.11 Our study findings reveal that failure to control asthma triggers also is an important cause of preventable pediatric asthma hospitalizations. Parents, PCPs, and IAPs reported that 9% to 13% of preventable pediatric asthma hospitalizations could have been prevented by avoiding known asthma triggers. Household exposure to cigarette smoke was the most common trigger cited, followed by dust in the home, pet dander, and preventable exposures to other children with upper respiratory infections. These data further underscore the importance of parental tobacco cessation counseling and reducing or eliminating exposure to allergens and irritants in the home, school, and adolescent workplace. Recent research revealed that most parents are aware of asthma triggers and 82% have attempted an environmental control measure, but more than half of environmental actions by parents do not meet current guidelines and are unlikely to control triggers effectively.12 Trigger reduction is a particularly high priority for preventing hospitalizations in poor inner-city children with asthma: studies have found that among low-income urban households with a child with asthma, 47% to 50% have smokers in the home, 34% have furry pets, and 47% to 58% have high levels of cockroach allergen.13, 14
Adherence
The most common reason for the preventability of asthma hospitalizations was medication related, including adherence problems, running out of medications, and refills not being called in. These issues account for approximately one third to one half of all preventable asthma hospitalizations, depending on the assessing source. These striking findings underscore that educating families about adherence and ensuring adequate medication supply may have a potentially significant impact on preventing asthma hospitalizations. Our results are consistent with recent research indicating that poor adherence is associated with various adverse childhood asthma outcomes, including increased days of wheezing, impaired functional status, more missed school, and a higher risk for hospitalization.15 Poor adherence continues to be a major issue in the treatment of pediatric asthma, with adherence rates of 46% to 60% for preventive asthma medications (as assessed by electronic monitoring devices).16–19 Additional studies are needed of the most effective means of improving adherence for children with asthma.
Follow-up Care
Delayed or no follow-up care was the second most common cause of preventable hospitalizations according to physicians, accounting for 22% and 32% of preventable hospitalizations as per IAPs and PCPs, respectively. Parents, however, never cited delayed or no follow-up as a cause of preventable pediatric hospitalizations. This physician-parent gap can be viewed as instructive in 2 ways. First, it seems that parents are not receiving the message that follow-up is essential to high-quality childhood asthma care, so clinicians need to consider more effective mechanisms for educating parents about the importance of follow-up visits. Second, this finding suggests that it is crucial to identify and remove any barriers that families face in scheduling and keeping follow-up appointments. Mechanisms of reducing or eliminating delayed or no follow-up care might include efficient and family-friendly scheduling systems and personnel at the front desk in outpatient, emergency, and inpatients settings and postal or telephone reminders to families shortly before scheduled follow-up visits. The NAEPP recommendations11 identify scheduling routine follow-up care as a key clinical activity, because it provides opportunities to address variations in patients' symptoms and severity, exposure to allergens, adherence, the management plan, and patient self-management.
Education
Several study findings highlight the importance and need for better and more comprehensive asthma education of children and parents. Parents were significantly less likely than physicians to believe that their children's asthma hospitalizations are preventable. This gap suggests that parents need better information about the preventability of pediatric asthma hospitalizations and about steps that can be taken to keep their children out of the hospital. Indeed, the study parents themselves reported a desire for more asthma information from their children's physicians. Parents and both physician groups reported that better education of parents by physicians can prevent pediatric asthma hospitalizations. Both physician groups identified specific educational issues that can be viewed as instructive in improving the quality of pediatric asthma care. The physicians admitted that better outpatient asthma education of families could have prevented several asthma hospitalizations. In addition, insufficient hospital discharge education was identified as a measure that could have prevented subsequent asthma hospitalizations.
Physicians not infrequently reported that pediatric asthma hospitalizations could have been prevented had parents better educated themselves about their child's asthma, with 14% and 10% of PCPs and IAPs, respectively, citing this reason. No parent, however, cited this reason, suggesting that there is a greater need for health care providers and parents to discuss the importance of parents' learning more about pediatric asthma as a means of preventing children's hospitalizations. These findings also suggest that additional means of educating families and patients about childhood asthma, such as the use of asthma educators, asthma nurse specialists in pediatric practices, and community health workers, have the potential to prevent hospitalizations. The NAEPP11 identified providing routine education of parents and patients on patient self-management as a key clinical activity for quality asthma care.
Quality-of-Care Issues
The study findings indicate several quality-of-care issues that, if properly addressed, could potentially lead to a reduction in preventable asthma hospitalizations. Both physician groups in this study cited a failure to prescribe outpatient corticosteroids as a reason for preventable asthma hospitalizations. These findings are noteworthy in light of studies indicating that corticosteroids continue to be underutilized,20–23 even though they have been shown to be highly effective in the management of pediatric asthma.24–27 Both physician groups in our study noted that pediatric asthma hospitalizations could have been avoided with more aggressive outpatient treatment and better outpatient control. These data highlight the importance of recent research indicating that some children continue to be undertreated in relation to treatment guidelines for NAEPP asthma severity classification categories.22
Limitations
Certain limitations of this study should be noted. The study population consisted of urban children who were predominantly poor, racial/ethnic minorities who were hospitalized in the northeastern United States. Additional studies are needed to determine whether these findings would be confirmed in suburban and rural settings, other regions of the Unites States, nonpoor populations, and those with a different racial/ethnic background. Physician survey responses were collected without personal identifiers (to ensure confidentiality and detailed answers), so it was not possible to examine whether preventable asthma hospitalizations occurred more often with certain PCPs or less often with PCPs who had received recent asthma-specific continuing medical education.
Housing and Health Care System Issues
Although cited less frequently than other reasons, housing issues were identified by both parents and physicians as reasons for preventable hospitalizations. Mold contamination, cockroach and rodent infestations, inadequate home heating, and excessive dust and moisture were specifically identified by parents and physicians. These findings suggest that greater attention to housing issues by health care providers, social workers, public health workers, home care nurses, and low-income housing programs could result in a reduction in preventable pediatric asthma hospitalizations. The study results also indicate that addressing certain health care system issues could lead to fewer pediatric asthma admissions, including ensuring that every child with asthma has a PCP, providing more nurse outreach, and examining why certain pharmacies may sometimes refuse to provide prescribed medications.
Groups at Risk for Preventable Asthma Hospitalizations
Parental failure to telephone or visit a child's physician before an admission was found to be associated with double the adjusted odds of a preventable asthma hospitalization. This finding highlights the importance of health care providers' educating families and providing ongoing reinforcement about consistently contacting the physician's office at the earliest indication of a child's having an asthma exacerbation. Adolescents also were found to have double the adjusted odds of a preventable asthma hospitalization. This may relate (at least in part) to the higher risk for nonadherence among adolescents with asthma.18, 19 Targeting adolescents for additional education, particularly regarding asthma self-management skills, may prove useful in reducing preventable asthma hospitalizations.
CONCLUSIONS
The proportion of asthma hospitalizations that are assessed as preventable by parents and physicians varies from 15% to 54%, depending on the source. Adolescents and families who fail to contact physicians before hospitalization are at greatest risk for preventable hospitalizations. Many pediatric asthma hospitalizations might be prevented if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers.
ACKNOWLEDGMENTS
This study was supported by a grant to Dr Flores from the Minority Medical Faculty Development Program and Generalist Physician Faculty Scholars Program of the Robert Wood Johnson Foundation and an Independent Scientist (K02) Award from the Agency for Healthcare Research and Quality.
We are grateful to Barbara Bolstorff for assistance with data collection, and special thanks are owed to all of the families and physicians whose participation made this study possible.
FOOTNOTES
Accepted May 25, 2005.
Presented in part as a platform presentation at the annual meetings of the Pediatric Academic Societies; May 3, 2004; San Francisco, CA; and the American Public Health Association; November 10, 2004; Washington, DC; and as a poster at the annual research meeting of AcademyHealth; June 6, 2004; San Diego, CA.
No conflict of interest declared.
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