Asthma-related Emergency Department Visits Research Articles

The Role of Neighborhood Air Pollution in Disparate Racial and Ethnic Asthma Acute Care Use.

The share of Black or Latinx residents in a census tract remains associated with asthma-related Emergency Department visit rates after controlling for socioeconomic factors. The extent to which evident disparities relate to within-city heterogeneity of long-term air pollution exposure remains unclear. To investigate the role of intraurban spatial variability of air pollution in asthma acute care use disparity. An administrative database was used to define census tract population-based incidence rates of asthma-related Emergency Department visits. We estimate the association between census tract incidence rates and (a) average fine and coarse particulate matter (PM2.5, PM10), nitrogen dioxide (NO2), and sulfur dioxide (SO2); and (b) racial/ethnic composition using generalized linear models controlling for socioeconomic and housing covariates. We additionally examine for attenuation of incidence risk ratios (IRR) associated with race/ethnicity when controlling for air pollution exposure. PM2.5, PM10, and SO2 are each associated with census tract-level incidence rates of asthma-related ED visits and multipollutant models show evidence of independent risk associated with PM10 and SO2. Association between census tract incidence rates and Black resident share (IRR [CI] = 1.51 [1.48-1.54]) is attenuated by 24% when accounting for air pollution (1.39 [1.35-1.42]), and the association with Latinx resident share (1.11 [1.09-1.13]) is attenuated by 32% (1.08 [1.06-1.10]). Neighborhood-level rates of asthma acute care use are associated with local air pollution. Controlling for air pollution attenuates associations with census tract racial/ethnic composition, suggesting that intracity variability in air pollution could contribute to neighborhood-to-neighborhood asthma morbidity disparities.

A randomized controlled trial of a family-based community health worker delivered intervention for urban adolescents with uncontrolled asthma

ABSTRACT Black adolescents with asthma are at elevated risk for health disparities. This study used mixed methods to test an evidence-based, family intervention adapted for home-based delivery by community health workers (CHWs). Fifty-nine families were randomly assigned to receive the adapted intervention, Reach for Control (RFC), or home-based case management. Paired t-tests showed adolescents in both groups had significant decreases in asthma-related emergency department visits. Families in RFC also had significant improvements in asthma management. Qualitative interviews suggested high satisfaction with CHW delivery, but treatment dose was low. Additional studies are needed to develop effective interventions for this population.

The impact of outdoor pollution and extreme temperatures on asthma-related outcomes: A systematic review for the EAACI guidelines on environmental science for allergic diseases and asthma.

Air pollution is one of the biggest environmental threats for asthma. Its impact is augmented by climate change. To inform the recommendations of the EAACI Guidelines on the environmental science for allergic diseases and asthma, a systematic review (SR) evaluated the impact on asthma-related outcomes of short-term exposure to outdoor air pollutants (PM2.5, PM10, NO2 , SO2 , O3 , and CO), heavy traffic, outdoor pesticides, and extreme temperatures. Additionally, the SR evaluated the impact of the efficacy of interventions reducing outdoor pollutants. The risk of bias was assessed using ROBINS-E tools and the certainty of the evidence by using GRADE. Short-term exposure to PM2.5, PM10, and NO2 probably increases the risk of asthma-related hospital admissions (HA) and emergency department (ED) visits (moderate certainty evidence). Exposure to heavy traffic may increase HA and deteriorate asthma control (low certainty evidence). Interventions reducing outdoor pollutants may reduce asthma exacerbations (low to very low certainty evidence). Exposure to fumigants may increase the risk of new-onset asthma in agricultural workers, while exposure to 1,3-dichloropropene may increase the risk of asthma-related ED visits (low certainty evidence). Heatwaves and cold spells may increase the risk of asthma-related ED visits and HA and asthma mortality (low certainty evidence).

The increasing burden of asthma acute care in Singapore: an update on 15-year population-level evidence

BackgroundIn Singapore, there is currently scarce population-based research informing the recent trends of asthma-related healthcare burdens. In this study, we investigated the past 25-year trends of asthma-related hospitalisations, emergency department (ED) visits and deaths in Singapore and projected the future burdens from 2023 to 2040.MethodsWe acquired annually-measured data from the Singapore Ministry of Health Clinical and National Disease Registry, containing 25-year asthma-related hospitalisation and death rates as well as 15-year ED visit rates. We conducted change-point analysis and generalised linear modelling to identify time intervals with stable trends and estimate asthma-related healthcare utilisation and mortality rates. To project future asthma-related burdens, we developed a probabilistic model which combined projections of future population size with the estimated rate outcomes from the last stable period.ResultsOur results show that the asthma hospitalisation rate in Singapore had remained at approximately 80 episodes per 100,000 from 2003 to 2019 and are likely to grow by 1.7% each year (95% CI: 0.7, 5.0%), leading to a total of 163,633 episodes from 2023 to 2040 which corresponds to an estimated $103,075,820 based on 2022 USD. Besides, Singapore’s asthma-related ED visit rate was 390 per 100,000 in 2019 and is expected to decline by 3.4% each year (95% CI: − 5.8, 0.0%), leading to a total of 208,145 episodes from 2023 to 2040 which corresponds to USD$15,053,795. In contrast, the 2019 asthma-related mortality rate in Singapore was approximately 0.57 per 100,000 and is likely to stay stably low (change per year: -1.3, 95% CI: − 11.0, 4.3%). Between 2023 and 2040, Singapore’s estimated total number of asthma-related deaths is 638 episodes.ConclusionsCurrently, the burden of asthma acute care in Singapore is high; Singapore’s asthma-related hospitalisation and ED visit rates are relatively higher than those of other developed economies, and its asthma admission rate is expected to increase significantly over time, possibly indicating excess resource use for asthma. The established national asthma programme in Singapore, together with recent efforts in reinforcing primary care at the national level, provides opportunities to reduce avoidable asthma admissions.

Seasonal pattern of emergency department visits by children with asthma.

It is important to understand the factors associated with seasonal asthma attacks among children so we can evaluate them appropriately. The study examined the seasonal variation of asthma-related emergency department visits by children in Istanbul. This descriptive study examined all paediatric patients with asthma who visited the paediatric emergency department of a tertiary hospital in Istanbul, Türkiye, between January 2017 and December 2022. Asthma diagnosis was based on physical examination and clinical history of the patients and asthma-related visits during winter, spring, summer, and autumn were considered repeated measurements. Data analysis was done using SPSS 25.0. Visits by asthmatic children to the emergency department constituted 4.9% of all visits. Some 56.9% of the asthmatic children were male and 43.1% were female. Asthma-related emergency department visits were 10.4% in 2017 and 3.6% in 2022. Visits to paediatric emergency departments due to asthma decreased from 19 685 in 2017 to 7485 in 2022. Between 2017 and 2022, children aged 0-5 years represented the highest proportion of visits (64-72.8%). Asthmatic children aged 0-5 years and 6-11 years were admitted to the hospital mostly in January (13.5%, 13.5%) and December (12.8%, 14.0%). In the age group 12-18 years, the visits occurred mostly in January (11.9%) and March (11.2%). The frequency and number of asthma-related visits to the paediatric emergency department decreased over the 6-year period of this study. There were increases in visits in October, November, December, and January, and decreases in June, July and August.

Impact of Guideline-Based Asthma Treatment on Health Services Use in Singapore Before and During COVID-19 Outbreak.

To date, the role of standard asthma care in reducing asthma-related health services use (HSU) during the COVID-19 pandemic remains unclear. This study examined the impact of guideline-based asthma treatment on the use of asthma-related emergency department (ED) visits, polyclinic visits (total visits and urgent visits characterized by nebuliser use) before and during the pandemic. Data from April 2017 to October 2020 was obtained from the National University Health System, one of the three healthcare clusters in Singapore. Using generalized linear models, we estimated the joint effects of the ratio of preventer to reliever dispensations (PRR) and COVID-19 on asthma-related ED visits per hospital per month, total asthma-related polyclinic visits and asthma-related urgent polyclinic visits per clinic per month. Findings show that before the onset of COVID-19, for every 0.5 unit increase in PRR, the number of asthma-related ED visits and urgent polyclinic visits decreased by 12.9% (95% CI: -13.0% to -12.9%) and 6.8% (95% CI: -6.9% to -6.7%), respectively, whereas total asthma-related polyclinic visits increased by 1.0% (95% CI: 0.9% to 1.0%). During the pandemic, a 0.5 unit increase of PRR decreased the number of asthma-related ED visits, urgent and total polyclinic visits by 16.9% (95% CI: -17.0% to - 16.9%), 9.3% (95% CI: -9.5% to -9.2%) and 0.7% (95% CI: -0.8% to -0.7%), respectively. These findings suggest that regardless of the COVID-19 pandemic, an increase in PRR consistently reduced the frequency of asthma-related urgent and emergent care, although it barely influenced routine asthma follow-up visits.

Asthma-related emergency admissions and associated healthcare resource use in Alberta, Canada

BackgroundThere is a lack of real-world research assessing asthma management following asthma-related emergency department (ED) discharges. The objective of this study was to characterise follow-up care, healthcare resource use (HCRU)...

Predicting pediatric severe asthma exacerbations: an administrative claims-based predictive model

Objective Previous machine learning approaches fail to consider race and ethnicity and social determinants of health (SDOH) to predict childhood asthma exacerbations. A predictive model for asthma exacerbations in children is developed to explore the importance of race and ethnicity, rural-urban commuting area (RUCA) codes, the Child Opportunity Index (COI), and other ICD-10 SDOH in predicting asthma outcomes. Methods Insurance and coverage claims data from the Arkansas All-Payer Claims Database were used to capture risk factors. We identified a cohort of 22,631 children with asthma aged 5–18 years with 2 years of continuous Medicaid enrollment and at least one asthma diagnosis in 2018. The goal was to predict asthma-related hospitalizations and asthma-related emergency department (ED) visits in 2019. The analytic sample was 59% age 5–11 years, 39% White, 33% Black, and 6% Hispanic. Conditional random forest models were used to train the model. Results The model yielded an area under the curve (AUC) of 72%, sensitivity of 55% and specificity of 78% in the OOB samples and AUC of 73%, sensitivity of 58% and specificity of 77% in the training samples. Consistent with previous literature, asthma-related hospitalization or ED visits in the previous year (2018) were the two most important variables in predicting hospital or ED use in the following year (2019), followed by the total number of reliever and controller medications. Conclusions Predictive models for asthma-related exacerbation achieved moderate accuracy, but race and ethnicity, ICD-10 SDOH, RUCA codes, and COI measures were not important in improving model accuracy.

Association of serotonin reuptake inhibitors with asthma control.

Background: Clinical trials demonstrated that selective serotonin reuptake inhibitors (SSRI) can improve asthma control in patients with comorbid major depressive disorder (MDD) and that this effect may be greater than the effect of SSRIs on depression. These findings suggest that SSRIs may improve asthma control in patients without MDD. Objective: The current retrospective study examined the effect of SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRI) on asthma control in adult patients. We hypothesized that patients would have fewer asthma exacerbations after treatment with an SSRI or SNRI. Methods: Electronic health record data of adult patients (N = 592) who were seen at a University of Texas Southwestern (UTSW) hospital or clinic and had (1) an SSRI or SNRI prescription, (2) a previous asthma diagnosis, and (3) no mood disorder diagnosis were extracted by using the UTSW Clinical Data Exchange Network. Wilcoxon signed rank tests were used to compare oral corticosteroid prescriptions and asthma-related emergency department (ED) visits and hospitalizations in the 12 months before and after the start of an SSRI/SNRI. Results: Therapy with SSRIs/SNRIs was associated with a significant decrease in oral corticosteroid use (p = 0.003), ED visits (p = 0.002), and hospitalizations (p < 0.001). Conclusion: Results from the current study add to the existing literature by demonstrating a reduced rate of severe exacerbations in patients with asthma by using an SSRI/SNRI without limiting the analytic sample to a high-illness-severity subgroup defined by symptoms of asthma or depression. Future work should include a prospective, placebo controlled study with individuals who have asthma and no comorbid mental health condition, verified by a mental health professional.

Impact of Initiating Biologics in Patients With Severe Asthma on Long-Term Oral Corticosteroids or Frequent Rescue Steroids (GLITTER): Data From the International Severe Asthma Registry.

Effectiveness of biologics has neither been established in patients with high oral corticosteroid exposure (HOCS) nor been compared with effectiveness of continuing with HOCS alone. To examine the effectiveness of initiating biologics in a large, real-world cohort of adult patients with severe asthma and HOCS. This was a propensity score-matched, prospective cohort study using data from the International Severe Asthma Registry. Between January 2015 and February 2021, patients with severe asthma and HOCS (long-term OCSs for ≥1 year or ≥4 courses of rescue OCSs within a 12-month period) were identified. Biologic initiators were identified and, using propensity scores, matched 1:1 with noninitiators. The impact of biologic initiation on asthma outcomes was assessed using generalized linear models. We identified 996 matched pairs of patients. Both groups improved over the 12-month follow-up period, but improvement was greater for biologic initiators. Biologic initiation was associated with a 72.9% reduction in the average number of exacerbations per year versus noninitiators (0.64 vs 2.06; rate ratio, 0.27 [95% CI, 0.10-0.71]). Biologic initiators were 2.2 times more likely than noninitiators to take a daily long-term OCS dose of less than 5 mg (risk probability, 49.6% vs 22.5%; P= .002) and had a lower risk of asthma-related emergency department visits (relative risk, 0.35 [95% CI, 0.21-0.58]; rate ratio, 0.26 [0.14-0.48]) and hospitalizations (relative risk, 0.31 [95% CI, 0.18-0.52]; rate ratio, 0.25 [0.13-0.48]). In a real-world setting, including patients with severe asthma and HOCS from 19 countries, and within an environment of clinical improvement, initiation of biologics was associated with further improvements across multiple asthma outcomes, including exacerbation rate, OCS exposure, and health care resource utilization.

Population-level SDOH and Pediatric Asthma Health Care Utilization: A Systematic Review.

Spatial analysis is a population health methodology that can determine geographic distributions of asthma outcomes and examine their relationship to place-based social determinants of health (SDOH). To systematically review US-based studies analyzing associations between SDOH and asthma health care utilization by geographic entities. Pubmed, Medline, Web of Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature. Empirical, observational US-based studies were included if (1) outcomes included asthma-related emergency department visits or revisits, and hospitalizations or rehospitalizations; (2) exposures were ≥1 SDOH described by the Healthy People (HP) SDOH framework; (3) analysis occurred at the population-level using a geographic entity (eg, census-tract); (4) results were reported separately for children ≤18 years. Two reviewers collected data on study information, demographics, geographic entities, SDOH exposures, and asthma outcomes. We used the HP SDOH framework's 5 domains to organize and synthesize study findings. The initial search identified 815 studies; 40 met inclusion criteria. Zip-code tabulation areas (n = 16) and census-tracts (n = 9) were frequently used geographic entities. Ten SDOH were evaluated across all HP domains. Most studies (n = 37) found significant associations between ≥1 SDOH and asthma health care utilization. Poverty and environmental conditions were the most often studied SDOH. Eight SDOH-poverty, higher education enrollment, health care access, primary care access, discrimination, environmental conditions, housing quality, and crime - had consistent significant associations with asthma health care utilization. Population-level SDOH are associated with asthma health care utilization when evaluated by geographic entities. Future work using similar methodology may improve this research's quality and utility.

Using Randomized Controlled Trials to Estimate the Effect of Community Interventions for Childhood Asthma.

The Centers for Disease Control and Prevention's Controlling Childhood Asthma and Reducing Emergencies initiative aims to prevent 500,000 emergency department (ED) visits and hospitalizations within 5 years among children with asthma through implementation of evidence-based interventions and policies. Methods are needed for calculating the anticipated effects of planned asthma programs and the estimated effects of existing asthma programs. We describe and illustrate a method of using results from randomized control trials (RCTs) to estimate changes in rates of adverse asthma events (AAEs) that result from expanding access to asthma interventions. We use counterfactual arguments to justify a formula for the expected number of AAEs prevented by a given intervention. This formula employs a current rate of AAEs, a measure of the increase in access to the intervention, and the rate ratio estimated in an RCT. We justified a formula for estimating the effect of expanding access to asthma interventions. For example, if 20% of patients with asthma in a community with 20,540 annual asthma-related ED visits were offered asthma self-management education, ED visits would decrease by an estimated 1,643; and annual hospitalizations would decrease from 2,639 to 617. Our method draws on the best available evidence from RCTs to estimate effects on rates of AAEs in the community of interest that result from expanding access to asthma interventions.

Associations between serum per- and polyfluoroalkyl substances and asthma morbidity in the National Health and Nutrition Examination Survey (2003-18).

Per- and polyfluoroalkyl substances (PFAS) are a class of chemicals widely used in manufacturing and are highly resistant to degradation, so they accumulate in the environment. Serum concentrations of these so-called forever chemicals have been associated with impairment of innate and adaptive immune responses. The relationship between serum PFAS levels and asthma morbidity has not been studied. We tested the association between serum PFAS concentration and asthma exacerbations. We performed secondary analysis of data from the National Health and Nutrition Examination Survey (NHANES, 2003-18). We fit multivariable logistic regression models to estimate odds ratios and 95% CIs for asthma exacerbation in the prior 12 months, given serum concentrations of PFAS. Models were adjusted for relevant covariates. Of 1101 participants with self-reported current asthma and available serum PFAS data, we observed that higher serum perfluorooctanoic and perfluorodecanoic acids were associated with greater odds of asthma attacks in the previous 12 months (respectively, adjusted odds ratio 1.16, 95% CI 1.01, 1.33; and adjusted odds ratio 1.21, 95% CI 1.03, 1.43). After stratification by age, the association between perfluorooctanoic acid and asthma attacks was significant in the 12-18-year-old group only (adjusted odds ratio 1.56, 95% CI 1.06, 2.31). No significant relationships were observed between PFAS and asthma-related emergency department visits. After correction for multiple comparison testing, none of the associations reached the threshold of significance. The role of these bioaccumulative forever chemicals in susceptibility to asthma attacks warrants further examination in longitudinal studies. (J Allergy Clin Immunol Global 2023;2:100078.).

The moderating role of housing quality on concentrated poverty and asthma-related emergency department visits among Hispanics/Latinos

Background Rates of asthma-related emergency department visits have been shown to vary significantly by place (i.e. neighborhood) and race/ethnicity. The moderating factors of asthmatic events among Hispanic/Latino-specific populations are known to a much lesser degree. Objective To assess the extent to which housing moderates the effect of poverty on Hispanic/Latino-specific asthma-related emergency department (ED) visits at an ecological level. Methods Using data from the Office of Statewide Health Planning and Development (OSHPD) and the 2016–2017 U.S. Census, a cross-sectional ecological analysis at the census tract-level was conducted. Crosswalk files from the U.S. Department of Housing and Urban Development were used to associate zip codes to census tracts. Negative binomial regression was used to estimate rate ratios. Results The effect of poverty on asthma-related ED visits was significantly moderated by the median year of housing structures built. The effect of mid-level poverty (RR = 1.57, 95% CI 1.27, 1.95) and high-level poverty (RR = 1.47, 95% CI 1.22, 1.78) in comparison to low-level poverty, was significantly greater among census tracts with housing built prior to 1965 in comparison to census tract with housing built between 1965 and 2020. Conclusion Communities with older housing structures tend to be associated with increased Hispanic/Latino ED visits apart from affluent communities.

California's early transition to electric vehicles: Observed health and air quality co-benefits

The transition to electric vehicles is projected to have considerable public health co-benefits, but most evidence regarding air quality and health impacts comes from projections rather than real-world data. We evaluated whether population-level respiratory health and air quality co-benefits were already detectable at the relatively low levels of zero-emissions vehicles (ZEVs: battery electric, plug-in hybrid, hydrogen fuel cell vehicle) adoption in California, and evaluated the ZEV adoption gap in underserved communities. We conducted a zip code-level ecologic study relating changes in annual number of ZEVs (nZEV) per 1000 population from 2013 to 2019 to: (i) annual average monitored nitrogen dioxide (NO2) concentrations and (ii) annual age-adjusted asthma-related emergency department (ED) visit rates, while considering educational attainment. The average nZEV increased from 1.4 per 1000 population in 2013 (standard deviation [SD]: 2.1) to 14.7 per 1000 in 2019 (SD: 14.7). ZEV adoption was considerably slower in zip codes with lower educational attainment (p < 0.0001). A within-zip code increase of 20 ZEVs per 1000 was associated with a − 0.41 ppb change in annual average NO2 (95 % confidence interval [CI]:-1.12, 0.29) in an adjusted model. A within-zip code increase of 20 ZEVs per 1000 population was associated with a 3.2 % decrease in annual age-adjusted rate of asthma-related ED visits (95 % CI:-5.4, −0.9). Findings were supported by a variety of sensitivity analyses. Observational data on the early phase ZEV transition in California provided a natural experiment, enabling us to document the first real-world associations between increasing nZEV and changes in air quality and health. Results suggest co-benefits of the early-phase transition to ZEVs but with an adoption gap among populations with lower socioeconomic status which threatens the equitable distribution of possible co-benefits.

Asthma-Related Emergency Department Visits in Texas: Associations with Viruses and Allergenic Pollen

Asthma exacerbations cause many emergency department visits but much remains unknown about the role of seasonal environmental triggers including viruses and allergenic pollen. A better understanding of these triggers and the role of regionally-important pollen types such as ‘mountain cedar’ (in the Cupressaceae family) in Texas could help prioritize public health interventions.

The effect of the COVID-19 pandemic on pediatric asthma-related emergency department visits and hospital admissions in Montréal, Quebec: a retrospective cohort study.

Asthma is a chronic respiratory condition that affects 10% of Canadian children and is often exacerbated by viral respiratory infections, prompting concerns about the severity of SARS-CoV-2 disease in children with asthma. We compared sociodemographic and clinical characteristics of children presenting to the emergency department and the incidence of these visits, before and during the pandemic. We included children aged 0 to 17 years presenting with asthma to 2 tertiary pediatric emergency departments in Montréal, Quebec, between the prepandemic (Jan. 1, 2017, to Mar. 31, 2020) and pandemic (Apr. 1, 2020, to June 30, 2021) periods. We compared the number of emergency department visits and hospital admissions with an interrupted time series analysis and compared the sociodemographic characteristics based on the Canadian Index of Multiple Deprivation (CIMD) and clinical characteristics (including triage level, intensive care admissions, etc.) with Mann-Whitney and χ2 tests. We examined 22 746 asthma-related emergency department visits. During the pandemic, a greater proportion of patients presented a triage level 1 or 2 (19.3% v. 14.7%) and were admitted to the intensive care unit (2.5% v. 1.3%). The patients' CIMD quintile distributions did not differ between the 2 periods. We found a 47% decrease (relative risk [RR] 0.53, 95% confidence interval [CI] 0.37 to 0.76) in emergency department visits and a 49% decrease (RR 0.51, 95% CI 0.34 to 0.76) in hospital admissions during the pandemic. The decrease in asthma-related emergency department visits was observed through the third wave of the pandemic, but children presented with a higher acuity and with no identified sociodemographic changes. Future studies are required to understand individual behaviours that may have led to the increased acuity at presentation observed in this study.

Utility of Hypoglycemic Agents to Treat Asthma with Comorbid Obesity.

Adults with obesity may develop asthma that is ineffectively controlled by inhaled corticosteroids and long-acting beta-adrenoceptor agonists. Mechanistic and translational studies suggest that metabolic dysregulation that occurs with obesity, particularly hyperglycemia and insulin resistance, contributes to altered immune cell function and low-grade systemic inflammation. Importantly, in these cases, the same proinflammatory cytokines believed to contribute to insulin resistance may also be responsible for airway remodeling and hyperresponsiveness. In the past decade, new research has emerged assessing whether hypoglycemic therapies impact comorbid asthma as reflected by the incidence of asthma, asthma-related emergency department visits, asthma-related hospitalizations, and asthma-related exacerbations. The purpose of this review article is to discuss the mechanism of action, preclinical data, and existing clinical studies regarding the efficacy and safety of hypoglycemic therapies for adults with obesity and comorbid asthma.

Increased serum cotinine and obesity negatively impact asthma exacerbations and hospitalizations: A cross-sectional analysis of NHANES.

Asthma is the most common non-communicable chronic airway disease worldwide. Obesity and cigarette use independently increase asthma morbidity and mortality. Current literature suggests that obesity and smoking synergistically increase asthma-related wheezing. To assess whether increased serum cotinine and obesity act synergistically to increase the likelihood of having an asthma exacerbation, emergency department (ED) visit, or hospitalization. A cross-sectional analysis of the 2011-2015 iterations of NHANES database was performed. Patients aged 18 years or greater with asthma were included. Serum cotinine was utilized as an accurate measurement of cigarette use. Logistic regression models were constructed to determine whether elevated serum cotinine and obesity were associated with self-reported asthma exacerbations, asthma-specific ED usage, and hospitalizations for any reason in the past year. Odds ratios were adjusted for age, gender, race, and ethnicity. Interactions were assessed by multiplying the adjusted effect sizes for elevated cotinine and obesity. We identified 2179 (N = 32,839,290) patients with asthma, of which 32.2% were active smokers and 42.7% were obese. Patients with an elevated cotinine and asthma were significantly more likely to have had an asthma-related ED visit in the past year (adjusted odds ratio [AOR] 1.82; 95% CI 1.19-2.79), have a physician-prescribed asthma medication (AOR 2.04; 95% CI 1.11-3.74), and have a hospitalization for any reason (AOR 3.65; 95% CI 1.88-7.07) compared to those with low cotinine. Patients with asthma and obesity were more likely to have an asthma-related ED visit (AOR 1.67; 95% CI 1.06-2.62) or hospitalization for any reason in the past year compared to non-obese patients (AOR 2.76; 95% CI 1.69-4.5). However, a statistically significant interaction between obesity and cotinine was only identified in patients who currently have asthma compared to a previous asthma diagnosis (AOR 1.76; 95% CI 1.10-2.82). There were no synergistic interactions among ED usage or asthma exacerbations. Nearly one-third of patients with asthma were current smokers, and almost half were obese. This study identified elevated serum cotinine, a metabolite of cigarette use, and obesity as key risk factors for asthma exacerbations, asthma-related ED visits, and hospitalizations for any reason. Elevated serum cotinine and obesity were not found to act synergistically in increasing asthma exacerbations or ED visits. However, the presence of both risk factors increased the risk of currently having asthma (compared to a previous diagnosis) by 76%. Serum cotinine may be useful in predicting asthma outcomes.

Do upper respiratory viruses contribute to racial and ethnic disparities in emergency department visits for asthma?

There are marked disparities in asthma-related emergency department (ED) visit rates among children by race and ethnicity. Following the implementation of coronavirus disease 2019 (COVID-19) prevention measures, asthma-related ED visits rates declined substantially. The decline has been attributed to the reduced circulation of upper respiratory viruses, a common trigger of asthma exacerbations in children. To better understand the contribution of respiratory viruses to racial and ethnic disparities in ED visit rates, we investigated whether the reduction in ED visit rates affected Black, Latinx, and White children with asthma equally. Asthma-related ED visits were extracted from electronic medical records at Dell Children's Medical Center in Travis County, Texas. ED visit rates among children with asthma were derived by race/ethnicity. Incidence rate ratios (IRRs) and 95% CIs were estimated by year (2019-2021) and season. In spring 2019, the ED visit IRRs comparing Black children with White children and Latinx children with White children were 6.67 (95% CI= 4.92-9.05) and 2.10 (95% CI= 1.57-2.80), respectively. In spring 2020, when infection prevention measures were implemented, the corresponding IRRs decreased to 1.73 (95% CI= 0.90-3.32) and 0.68 (95% CI= 0.38-1.23), respectively. The striking reduction of disparities in ED visits suggests that during nonpandemic periods, respiratory viruses contribute to the excess burden of asthma-related ED visits among Black and Latinx children with asthma. Although further investigation is needed to test this hypothesis, our findings raise the question of whether Black and Latinx children with asthma are more vulnerable to upper respiratory viral infections.