Asthma Visits Research Articles

Utilization of electronic portal referrals to a community agency for children presenting with an asthma exacerbation to a pediatric emergency department

Purpose To evaluate referral rates and factors associated with referrals to a community agency for children evaluated for an asthma exacerbation at a pediatric emergency department (PED) and compare PED visits for asthma the following year between those referred and not referred. Methods We reviewed electronic health records of children 2–18 years evaluated in our PED from 01/01/2019 to 12/31/2019 with an ICD-10 diagnostic code for asthma (J45x) following the introduction of a portal where clinicians could refer children to a community agency focused on improving health outcomes for asthma. We abstracted data on demographics, PED visits, and hospitalizations and used multivariate logistic regression to evaluate factors associated with referrals. Results Of the 2262 charts analyzed, the majority of patients were male (61%), Black (76%), and held public insurance (71%). Only a minority of patients (n = 140, 6%) were referred. Age [6–12 years (AOR: 1.93, 95% CI: 1.21–3.08, p = .006), 13–18 years (AOR: 10.61, 95% CI: 6.53–17.24, p = .001)] and lifetime number of PED asthma visits [≥3 visits (AOR: 1.91, 95% CI, 1.01–3.62, p = .05)] were associated with referral. There was no significant difference in the mean number of PED visits in one year [referred: 0.59 (SD1.2) vs. not referred: 0.79 (SD1.3), t = 1.70, p = .09] between the two groups. Conclusion The referral rate to community agency from PED for asthma is low. There was no difference in short-term PED utilization for asthma between those referred and not referred.

Sociodemographic inequities in unscheduled asthma care visits among public assistance recipients in Japan: additional risk by household composition among workers

BackgroundPublic assistance programs aim to prevent financial poverty by guaranteeing a minimum income for basic needs, including medical care. However, time poverty also matters, especially in the medical care adherence of people with chronic diseases. This study aimed to examine the association between the dual burden of working and household responsibilities, with unscheduled asthma care visits among public assistance recipients in Japan.MethodsThis retrospective cohort study included public assistance recipients from two municipalities. We obtained participants’ sociodemographic data in January 2016 from the public assistance database and identified the incidence of asthma care visits. Participants’ unscheduled asthma visits and the frequency of asthma visits were used as the outcome variables. Unscheduled visits were defined as visits by recipients who did not receive asthma care during the first three months of the observation period. Participants’ age, sex, household composition, and work status were used as explanatory variables. Multiple Poisson regression analyses were performed to calculate the cumulative incidence ratio (IR) with a 95% confidence interval (CI) of unscheduled visits across the explanatory variables. The effect of modification on the work status by household composition was also examined.ResultsWe identified 2,386 recipients at risk of having unscheduled visits, among which 121 patients (5.1%) had unscheduled visits. The multivariable Poisson regression revealed that the working recipients had a higher incidence of unscheduled visits than the non-working recipients (IR 1.44, 95% CI 1.00–2.07). Among working recipients, the IRs of unscheduled visits were higher among recipients cohabiting with adults (IR 1.90 95% CI 1.00–3.59) and with children (IR 2.35, 95% CI 1.11–4.95) than for recipients living alone. Among non-working recipients, the IRs of unscheduled visits were lower for recipients living with family (IR 0.74, 95% CI 0.41–1.35) and those living with children (IR 0.50, 95% CI 0.20–1.23). A higher frequency in asthma visits was observed among working recipients living with family.ConclusionsWorking adults cohabiting with children are at the greatest risk of unscheduled visits among adults receiving public assistance. To support healthy lifestyles of public assistance recipients, medical care providers and policymakers should pay special attention to the potentially underserved populations.

Predictors of asthma control differ from predictors of asthma attacks in children: The Swiss Paediatric Airway Cohort.

It is unclear if predictors of asthma attacks are the same as those of asthma symptom control in children. We evaluated predictors for these two outcomes in a clinical cohort study. The Swiss Paediatric Airway Cohort (SPAC) is a multicentre prospective clinical cohort of children referred to paediatric pulmonologists. This analysis included 516 children (5-16 years old) diagnosed with asthma. At baseline, we collected sociodemographic information, symptoms, personal and family history and environmental exposures from a parental baseline questionnaire, and treatment and test results from hospital records. Outcomes were assessed 1 year later by parental questionnaire: asthma control in the last 4 weeks as defined by GINA guidelines, and asthma attacks defined as any unscheduled visit for asthma in the past year. We used logistic regression to identify and compare predictors for suboptimal asthma control and asthma attacks. At follow-up, 114/516 children (22%), reported suboptimal asthma control, and 114 (22%) an incident asthma attack. Only 37 (7%) reported both. Suboptimal asthma control was associated with poor symptom control at baseline (e.g. ≥1 night wheeze/week OR: 3.2; 95% CI: 1.7-6), wheeze triggered by allergens (2.2; 1.4-3.3), colds (2.3; 1.4-3.6) and exercise (3.2; 2-5), a more intense treatment at baseline (2.4; 1.3-4.4 for Step 3 vs. 1), history of preschool (2.6; 1.5-4.4) and persistent wheeze (2; 1.4-3.2), and exposure to tobacco smoke (1.7; 1-2.6). Incident asthma attacks were associated with previous episodes of severe wheeze (2; 1.2-3.3) and asthma attacks (2.8; 1.6-5 for emergency care visits), younger age (0.8; 0.8-0.9 per 1 year) and non-Swiss origin (0.3; 0.2-0.5 for Swiss origin). Lung function, exhaled nitric oxide (FeNO) and allergic sensitization at baseline were not associated with control or attacks. Children at risk of long-term suboptimal asthma control differ from those at risk of attacks. Prediction tools and preventive efforts should differentiate these two asthma outcomes.

Population-level trends in asthma and chronic obstructive pulmonary disease emergency department visits and hospitalizations before and during the coronavirus disease 2019 pandemic in the United States

BackgroundPrevious studies have identified reductions in exacerbations of chronic lung disease in many locales after onset of the coronavirus disease 2019 (COVID-19) pandemic. ObjectiveTo evaluate the population-level impacts of COVID-19 on asthma and chronic obstructive pulmonary disease (COPD) exacerbations—with a focus on disadvantaged communities—in the United States. MethodsWe analyzed 2016 to 2020 county-level data on asthma and COPD acute care use, with myocardial infarction hospitalizations as a comparator condition. We linked this with county-level lower respiratory disease mortality data. We calculated rates of emergency department (ED) visits, hospitalizations, and deaths and evaluated changes using linear regressions adjusted for year and county-fixed effects.For a supplementary analysis, we calculated ED visit rates nationwide for asthma, COPD, or any diagnosis using the 2016 to 2020 National Hospital Ambulatory Medical Care Survey. ResultsOur county-level data included 685 counties in 13 states. Rates of each outcome fell in 2020. In adjusted analyses, we found large reductions in asthma and COPD ED visit rates (eg, a 21.5 per 10,000-person reduction in COPD ED visits; 95% confidence interval, −23.8 to −19.1), with smaller reductions in hospitalizations and chronic lower respiratory mortality. Disadvantaged communities had mostly higher baseline rates of respiratory morbidity and larger absolute reductions in some outcomes.Among 90,808 ED visits in the National Hospital Ambulatory Medical Care Survey, asthma ED visits/y fell 33% during the pandemic and COPD visits by 51%; overall ED visits fell by only 7%. ConclusionOnset of the COVID-19 pandemic coincided with reductions in acute care utilization for asthma and COPD. Understanding the mechanism of this reduction might inform future efforts to prevent exacerbations.

Emergency department course of patients with asthma receiving initial emergency medical services care-Perspectives From the National Hospital Ambulatory Medical Care Survey.

Although 911 calls for acute shortness of breath are common, the role of emergency medical services (EMS) in acute asthma care is unclear. We sought to characterize the demographics, course, and outcomes of adult emergency department (ED) patients with asthma in the United States receiving initial EMS care. We analyzed data from the 2016-2019 National Hospital Ambulatory Medical Care Survey (NHAMCS). We included patients aged ≥18 years with an ED visit diagnosis of asthma, stratifying the cases according to initial EMS care. Accounting for the survey design of NHAMCS, we generated nationalized estimates of the number of EMS and non-EMS asthma visits. Using logistic regression, we determined the associations between initial EMS care and patient demographics (age, sex, race, and insurance type), ED course (initial vital signs, triage category, testing, medications), and outcomes (hospital admission, ED length of stay). Of 435million adult ED visits during 2016-2019, there were ≈5.3million related to asthma (1.3million annually, 1.2%; 95% confidence interval [CI], 1.1%-1.4%). A total of 602,569 (150,642 annually, 11.3%; 95% CI, 8.6%-14.8%) ED patients with asthma received initial EMS care. Compared with non-EMS asthma patients, EMS asthma patients were more likely to present with an "urgent" ED triage category (odds ratio [OR], 22.2; 95% CI, 6.6-74.9) and to undergo laboratory (OR, 2.78; 95% CI, 1.41-5.46) or imaging tests (OR, 2.42; 95% CI, 1.21-4.83). ED patients with asthma receiving initial EMS care were almost 3 times more likely to be admitted to the hospital (OR, 2.81; 95% CI, 1.27-6.25). There were no differences in demographics, ED use of β-agonists or corticosteroids, or ED length of stay between EMS and non-EMS asthma patients. Approximately 1 in 10 adult ED patients with asthma receive initial care by EMS. EMS asthma patients present to the ED with higher acuity, undergo more diagnostic testing in the ED, and are more likely to be admitted. Although limited in information regarding the prehospital course, these findings highlight the more severe illness of asthma patients transported by EMS and underscore the importance of EMS in emergency asthma care.

Impact of Hurricane Harvey on Inpatient Asthma Hospitalization Visits Within Southeast Texas, 2016-2019.

The aim of the study is to estimate inpatient asthma hospital visit rates among impacted Texans in Public Health Region 6/5S during the year of and after Hurricane Harvey. Asthma inpatient hospitalization discharges were collected from the Texas Health Care Information Collection database (2016-2019). Females (age-adjusted rates [AARs] = 4.8-5.0) and Black Texans (AARs = 5.0-8.1) experienced significantly higher AARs compared with males and White Texans during the year of and after Harvey. During the year of Hurricane Harvey, females were 1.49 times as likely to have an inpatient asthma visit compared with males, while Black Texans were 2.78 times as likely to have an inpatient asthma hospitalization compared with White Texans. Findings from this study may assist public health professionals and local officials to allocate future resources to the most impacted subgroups as well as establish effective processes to mitigate consequences.

Preference for and impact of telehealth vs in-person asthma visits among Black and Latinx adults

BackgroundBlack and Latinx adults experience disproportionate asthma-related morbidity and limited specialty care access. The severe acute respiratory syndrome coronavirus 2 pandemic expanded telehealth use. ObjectiveTo evaluate visit type (telehealth [TH] vs in-person [IP]) preferences and the impact of visit type on asthma outcomes among Black and Latinx adults with moderate-to-severe asthma. MethodsFor this PREPARE trial ancillary study, visit type preference was surveyed by e-mail or telephone post-trial. Emergency medical record data on visit types and asthma outcomes were available for a subset (March 2020 to April 2021). Characteristics associated with visit type preferences, and relationships between visit type and asthma outcomes (control [Asthma Control Test] and asthma-related quality of life [Asthma Symptom Utility Index]), were tested using multivariable regression. ResultsA total of 866 participants consented to be surveyed, with 847 respondents. Among the participants with asthma care experience with both visit types, 42.0% preferred TH for regular checkups, which associated with employment (odds ratio [OR] = 1.61; 95% confidence interval [CI], 1.09-2.39; P = .02), lower asthma medication adherence (OR = 1.06; 95% CI, 1.01-1.11; P = .03), and having more historical emergency department and urgent care asthma visits (OR = 1.10 for each additional visit; 95% CI, 1.02-1.18; P = .02), after adjustment. Emergency medical record data were available for 98 participants (62 TH, 36 IP). Those with TH visits were more likely Latinx, from the Southwest, employed, using inhaled corticosteroid–only controller therapy, with lower body mass index, and lower self-reported asthma medication adherence vs those with IP visits only. Both groups had comparable Asthma Control Test (18.4 vs 18.9, P = .52) and Asthma Symptom Utility Index (0.79 vs 0.84, P = .16) scores after adjustment. ConclusionTH may be similarly efficacious as and often preferred over IP among Black and Latinx adults with moderate-to-severe asthma, especially for regular checkups. Trial RegistrationClinicalTrials.gov Identifier: NCT02995733.

Association between asthma and headache: Findings from the NHANES 2001-2004.

With the adjustment of sociodemographic factors, our study aimed to explore the association between asthma control and headache using a representative sample in the United States. A total of participants aged >20 years from the National Health and Nutrition Examination Survey (NHANES) cycles 2001-2004 were included. The presence of asthma and headache was determined by questionnaires. Multivariate logistic regression was performed. Participants with asthma had higher odds of suffering headaches (odds ratio = 1.62, 95% confidence interval: 1.30-2.02, p < 0.001). Those who had an asthma attack in the past year had higher odds of experiencing headaches than those who did not (odds ratio = 1.94, 95% confidence interval: 1.11-3.39, p =0.022). No statistically significant association was found between participants who had emergency care visit for asthma in the past year and those who had not. Patients with asthma attack in the past year were more likely to have a headache than those who without.

Comparison of associations of household-level and neighbourhood-level poverty markers with paediatric asthma care utilisation by race/ethnicity in an open cohort of community health centre patients

ObjectiveThe objective of this research was to examine how different measurements of poverty (household-level and neighborhood-level) were associated with asthma care utilisation outcomes in a community health centre setting among...

The acute care burden of asthma in children was profoundly reduced during the COVID-19 pandemic: A multi-centre Canadian retrospective study.

Asthma is a chronic lung condition that can be exacerbated when triggered by viruses. Pandemic public health restrictions aimed to reduce COVID-19 transmission indirectly effected other circulating viruses. This study assessed the impact of the pandemic and associated public health measures on acute paediatric asthma across four tertiary sites in three Canadian provinces. We queried whether pandemic-related changes would impair preventive care and delay presentation to care, increasing asthma exacerbation severity. This retrospective study compared the frequency of acute care access and severity of presentation to emergency departments (ED) for acute asthma to four tertiary care children's hospitals during the COVID-19 pandemic (from March 17, 2020 to June 30, 2021) to a pre-lockdown control period (July 1, 2018 to March 16, 2020). Data was subjected to interrupted time series and Chi-square analysis. Our study included 26,316 acute asthma visits to ED. Sites experienced a 63% to 89% reduction in acute asthma visits during the pandemic, compared with pre-lockdown controls, and a 17% to 85% reduction in asthma, that is out of proportion as a fraction of all-cause ED visits. For asthma, there was no difference in severity measured by rate of ward admission or rate of Paediatric Intensive Care Unit (PICU) admission. Public health measures appear to have resulted in a specific protective association on acute asthma with reduced acute care utilization over and above the reduction in all-cause presentations, without an increase in severity upon presentation. Our study indicates an importance to antiviral public health and engineering strategies to reduce viral transmission and thereby asthma morbidity.

Recovery of Breakthrough Asthma Attacks Treated With Oral Steroids While on Monoclonal Antibody Therapy: Protocol for a Prospective Observational Study (BOOST).

Asthma attacks are a common and important problem. Someone experiences an asthma attack in the United Kingdom every 10 seconds. Asthma attacks cause coughing, wheezing, breathlessness, and chest tightness and are highly stressful for patients. They result in reduced quality of life, with days lost from work or school. Asthma attacks are treated with oral corticosteroids (OCSs), but these have many short- and long-term side effects. Asthma monoclonal antibodies (mAbs) have revolutionized the treatment of severe asthma by reducing asthma attacks and OCS burden by over 50%, but some people still experience attacks while on mAbs. The MEX study showed that residual asthma attacks are broadly eosinophilic (high fractional exhaled nitric oxide [FeNO]) or noneosinophilic (low FeNO), but it did not measure response to OCS treatment. There is an evidence gap in understanding the clinical and inflammatory responses that occur when using OCSs to treat residual asthma attacks in patients taking asthma mAbs. The primary objective is to compare the clinical recovery between high-FeNO and low-FeNO attacks after acute treatment with oral prednisolone among people established on long-term asthma mAb treatment. The exploratory objective is to compare the inflammatory response to acute treatment with oral prednisolone between high-FeNO and low-FeNO attacks. BOOST (Breakthrough Asthma Attacks Treated With Oral Steroids) is a single-center, prospective observational study of 60 adults established on long-term asthma mAb treatment who receive acute treatment with oral prednisolone (usual care) for an asthma attack. The primary outcome will be the proportion of treatment failure (the need to start oral prednisolone or antibiotics or an unscheduled health care visit for asthma, following an attack) at day 28. The secondary outcomes will be the change in forced expiratory volume in 1 second and the change in visual analogue scale symptom score between the stable state, attack, day 7, and day 28 visits. The exploratory outcomes include the changes in sputum, nasal, and blood inflammometry between the stable state, attack, day 7, and day 28 visits. The last asthma attack visit is anticipated to occur in December 2023. Data analysis and publication will take place in 2024. We will test the hypothesis that there is a difference in the rate of recovery of clinical and inflammatory measures between high-FeNO and low-FeNO asthma attacks that occur in patients on mAb therapy. The study data will help power a future randomized placebo-controlled trial of prednisolone treatment for nonsevere attacks in patients treated with asthma mAbs and will provide important information on whether corticosteroid treatment should be FeNO-directed. DERR1-10.2196/46741.

Pollen and asthma morbidity in Atlanta: A 26-year time-series study

BackgroundCompared to many environmental risk factors, the relationship between pollen and asthma is understudied, including how associations may differ by pollen type and between subgroups, and how associations may be changing over time. ObjectivesWe evaluated the association between ambient pollen concentrations and emergency department (ED) visits for asthma and wheeze in Atlanta, Georgia during 1993–2018. We estimated overall associations for 13 individual pollen taxa, as well as associations by decade, race, age (5–17, 18–64, 65+), and insurance status (Medicaid vs non-Medicaid). MethodsSpeciated pollen data were acquired from Atlanta Allergy & Asthma, a nationally certified pollen counting station. ED visit data were obtained from individual hospitals and from the Georgia Hospital Association. We performed time-series analyses using quasi-Poisson distributed lag models, with primary analyses assessing 3-day (lag 0–2 days) pollen levels. Models controlled for day of week, holidays, air temperature, month, year, and month-by-year interactions. ResultsFrom 1993 to 2018, there were 686,259 ED visits for asthma and wheeze in the dataset, and the number of ED visits increased over time. We observed positive associations of asthma and wheeze ED visits with nine of the 13 pollen taxa: trees (maple, birch, pine, oak, willow, sycamore, and mulberry), two weeds (nettle and pigweed), and grasses. Rate ratios indicated 1–8% increases in asthma and wheeze ED visits per standard deviation increases in pollen. In general, we observed stronger associations in the earliest period (1993–2000), in younger people, and in Black patients; however, results varied by pollen taxa. ConclusionsSome, but not all, types of pollen are associated with increased ED visits for asthma/wheeze. Associations are generally higher in Black and younger patients and appear to have decreased over time.

Economic impact of a more extensive use of FENO testing on the Italian population with asthma

BackgroundAsthma is a common chronic inflammatory airway affecting over 260 million people worldwide, and characterized, in the large majority of cases, by the so-called “type 2 inflammation”. Fractional exhaled nitric oxide (FENO) testing is noninvasive point-of-care tool to assess type 2 inflammation and therefore improve asthma management. It has been suggested to determine eligibility for a specific biologic therapy and predict likelihood to respond. The aim of this study was to estimate the overall economic impact of an extensive use of FENO testing on the Italian population with asthma, including extra costs of testing and savings generated by more appropriate prescriptions, increased adherence and lower frequency of exacerbations.MethodsA cost of illness analysis was firstly performed to estimate the yearly economic burden from the National Healthcare Service (NHS) perspective in Italy of the management of asthmatic patients with standard of care (SOC) according to the application of GINA (Global Initiative for Asthma) guidelines; then, we evaluated the changes in the economic burden in patient management by introducing FENO testing into clinical practice. The cost items considered were: visits/exams, exacerbations, drugs, management of adverse events caused by short-term oral corticosteroids use. Efficacy of FeNO test and SOC is based on literature evidence. Costs refer to published data or Diagnosis Related Group/outpatient tariffs.ResultsConsidering one asthma visit every 6 months, the total yearly cost for the management of patients with asthma in Italy is 1,599,217,876€ (409.07€ per patient), while for FENO testing strategy this figure is 1,395,029,747€ (356.84€ per patient). An increased utilization rate of FENO testing from 50 to 100% of patients may lead to savings for the NHS from about 102 to 204 million € compared to SOC.ConclusionsOur study showed that FeNO testing strategy may improve the management of asthmatic patients leading to significant savings for the NHS.

HPR110 Risk Factors Associated with Repeat Pediatric Asthma Visits to Emergency Departments

The purpose of this study was to identify factors associated with repeat pediatric ED visits due to asthma over time.

Air quality health index (AQHI) based on multiple air pollutants and mortality risks in Taiwan: Construction and validation

The currently used air quality index (AQI) is not able to capture the additive effects of air pollution on health risks and reflect non-threshold concentration-response relationships, which has been criticized. We proposed the air quality health index (AQHI) based on daily air pollution-mortality associations, and compared its validity in predicting daily mortality and morbidity risks with the existing AQI. We examined the excess risk (ER) of daily elderly (≥65-year-old) mortality associated with 6 air pollutants (PM2.5, PM10, SO2, CO, NO2, and O3) in 72 townships across Taiwan from 2006 to 2014 by performing a time-series analysis using a Poisson regression model. Random effect meta-analysis was used to pool the township-specified ER for each air pollutant in the overall and seasonal scenarios. The integrated ERs for mortality were calculated and used to construct the AQHI. The association of the AQHI with daily mortality and morbidity were compared by calculating the percentage change per interquartile range (IQR) increase in the indices. The magnitude of the ER on the concentration-response curve was used to evaluate the performance of the AQHI and AQI, regarding specific health outcomes. Sensitivity analysis was conducted using coefficients from the single- and two-pollutant models. The coefficients of PM2.5, NO2, SO2, and O3 associated with mortality were included to form the overall and season-specific AQHI. An IQR increase in the overall AQHI at lag 0 was associated with 1.90%, 2.96%, and 2.68% increases in mortality, asthma, and respiratory outpatient visits, respectively. The AQHI had higher ERs for mortality and morbidity on the validity examinations than the current AQI. The AQHI, which captures the combined effects of air pollution, can serve as a health risk communication tool to the public.

Outcomes before and after providing interdisciplinary hematology and pulmonary care for children with sickle cell disease.

People with sickle cell disease (pwSCD) are at risk of developing lung conditions that complicate their SCD but often face health care access barriers. An interdisciplinary clinic providing pulmonary care for pwSCD was created in 2014 at the Nationwide Children's Hospital (NCH) to address access barriers that may prevent optimized treatment. We hypothesize that pwSCD and pulmonary disease would have fewer hospitalizations for acute chest syndrome (ACS), asthma, and vaso-occlusive episodes in the 2 years after their initial SCD-pulmonary clinic visit compared with the 2 years before. From 2014 to 2020, 119 pwSCD were evaluated in the SCD-pulmonary clinic and followed up at the NCH for at least 2 years before and after this initial visit. Acute care outcomes, pulmonary function, polysomnography, echocardiogram, laboratory, and medication prescribing data were collected and analyzed using the Wilcoxon signed ranked and McNemar tests. The median number of acute care visits for ACS (P< .001) and asthma (P= .006) were significantly lower during the 2 years after pwSCD's initial SCD-pulmonary clinic evaluation compared with the 2 years before. Asthma and allergic rhinitis were more frequently diagnosed and prescriptions for hydroxyurea (P= .005) and inhaled corticosteroids (P= .005) were more common in the post-SCD-pulmonary clinic period. The median number of prescribed systemic corticosteroids was lower in the 2 years after SCD-pulmonary clinic evaluation (P<.0001). Lactate dehydrogenase and white blood cell counts also significantly decreased. Implementing a multidisciplinary SCD-pulmonary clinic is feasible and may allow improved management of pulmonary problems and lead to improvements in the usage of health and acute care.

Racial and Ethnic Minorities at the Highest Risk of Uncontrolled Moderate-to-Severe Asthma: A United States Electronic Health Record Analysis.

The identification of risk factors associated with uncontrolled moderate-to-severe asthma is important to improve asthma outcomes. Aim of this study was to identify risk factors for uncontrolled asthma in United States cohort using electronic health record (EHR)-derived data. In this retrospective real-world study, de-identified data of adolescent and adult patients (≥12 years old) with moderate-to-severe asthma, based on asthma medications within 12 months prior to asthma-related visit (index date), were extracted from the Optum® Humedica EHR. The baseline period was 12 months prior to the index date. Uncontrolled asthma was defined as ≥2 outpatient oral corticosteroid bursts for asthma or ≥2 emergency department visits or ≥1 inpatient visit for asthma. A Cox proportional hazard model was applied. There were 402,403 patients in the EHR between January 1, 2012, and December 31, 2018, who met the inclusion criteria and were analyzed. African American (AA) race (hazard ratio [HR]: 2.08), Medicaid insurance (HR: 1.71), Hispanic ethnicity (HR: 1.34), age of 12 to <18 years (HR 1.20), body mass index of ≥35 kg/m2 (HR: 1.20), and female sex (HR 1.19) were identified as risk factors associated with uncontrolled asthma (P < 0.001). Comorbidities characterized by type 2 inflammation, including a blood eosinophil count of ≥300 cells/μL (as compared with eosinophil <150 cells/μL; HR: 1.40, P < 0.001) and food allergy (HR: 1.31), were associated with a significantly higher risk of uncontrolled asthma; pneumonia was also a comorbidity associated with an increased risk (HR: 1.35) of uncontrolled asthma. Conversely, allergic rhinitis (HR: 0.84) was associated with a significantly lower risk of uncontrolled asthma. This large study demonstrates multiple risk factors for uncontrolled asthma. Of note, AA and Hispanic individuals with Medicaid insurance are at a significantly higher risk of uncontrolled asthma versus their White, non-Hispanic counterparts with commercial insurance.

Using a Statistical Model to Estimate the Effect of Wildland Fire Smoke on Ground Level PM2.5 and Asthma in California, USA

Forest fire activity has been increasing in California. Satellite imagery data along with ground level measurements of PM2.5 have been previously used to determine the presence and level of smoke. In this study, emergency room visits for asthma are explored for the impacts of wildland smoke over the entire state of California for the years 2008–2015. Smoke events included extreme high-intensity fire and smoke along with low and moderate smoke events. The presence of wildland fire smoke detected by remote sensing significantly increased fine particulate matter (PM2.5) and significantly increased the odds of exceeding expected concentrations of PM2.5 at ground level. Smoke observed above a monitoring site increases the chance of PM2.5 exceeding 35 µg m−3 (odds ratio 114 (87–150) when high levels of smoke are detected). The strength of association of an asthma emergency room visit is increased with higher PM2.5 concentrations. The odds ratios (OR) are highest for asthma hospital visits when daily mean PM2.5 concentrations experienced exceed 35 µg m−3 for multiple days (OR 1.38 (1.21–1.57) with 3 days). Nonetheless, on days with wildland fire smoke, the association of an emergency room visit for asthma due to PM2.5 is not observed. Further study is needed to confirm these findings and determine if this is a product of smoke avoidance and reduction of personal exposure during smoke episodes.

Acute Effects of Ambient Air Pollution on Asthma Emergency Department Visits in Ten U.S. States.

Previous studies of short-term ambient air pollution exposure and asthma morbidity in the United States have been limited to a small number of cities and/or pollutants and with limited consideration of effects across ages. To estimate acute age group-specific effects of fine and coarse particulate matter (PM), major PM components, and gaseous pollutants on emergency department (ED) visits for asthma during 2005-2014 across the United States. We acquired ED visit and air quality data in regions surrounding 53 speciation sites in 10 states. We used quasi-Poisson log-linear time-series models with unconstrained distributed exposure lags to estimate site-specific acute effects of air pollution on asthma ED visits overall and by age group (1-4, 5-17, 18-49, 50-64, and y), controlling for meteorology, time trends, and influenza activity. We then used a Bayesian hierarchical model to estimate pooled associations from site-specific associations. Our analysis included asthma ED visits. We observed positive associations for multiday cumulative exposure to all air pollutants examined [e.g., 8-d exposure to : rate ratio of 1.016 with 95% credible interval (CI) of (1.008, 1.025) per increase, : 1.014 (95% CI: 1.007, 1.020) per increase, organic carbon: 1.016 (95% CI: 1.009, 1.024) per increase, and ozone: 1.008 (95% CI: 0.995, 1.022) per increase]. and ozone showed stronger effects at shorter lags, whereas associations of traffic-related pollutants (e.g., elemental carbon and oxides of nitrogen) were generally stronger at longer lags. Most pollutants had more pronounced effects on children ( y old) than adults; had strong effects on both children and the elderly ( y old); and ozone had stronger effects on adults than children. We reported positive associations between short-term air pollution exposure and increased rates of asthma ED visits. We found that air pollution exposure posed a higher risk for children and older populations. https://doi.org/10.1289/EHP11661.

Low parental numeracy and severe asthma exacerbations in a prospective study of Puerto Rican youth

BackgroundNumeracy is the mathematical knowledge required to understand and act on instructions from health care providers. Whether persistently low parental numeracy is linked to childhood asthma exacerbations is unknown. ObjectiveTo evaluate whether low parental numeracy at 2 time points is associated with asthma exacerbations and worse lung function in Puerto Rican youth. MethodsProspective study of 225 youth with asthma in San Juan (PR) who participated in 2 visits approximately 5.3 years apart, with the first at ages 6 to 14 years and the second at ages 9 to 20 years. Parental numeracy was assessed with a modified version of the Asthma Numeracy Questionnaire (score range = 0-3 points), and persistently low parental numeracy was defined as a score less than or equal to 1 point at both visits. Asthma exacerbation outcomes included more than or equal to 1 emergency department (ED) visit, more than or equal to 1 hospitalization, and more than or equal to 1 severe exacerbation (≥1 ED visit or ≥1 hospitalization) for asthma in the year before the second visit. Spirometry was conducted using an EasyOne spirometer (NDD Medical Technologies, Andover, Massachusetts). ResultsIn an analysis adjusting for age, sex, parental education, use of inhaled corticosteroids, and the time between study visits, persistently low parental numeracy was associated with more than or equal to 1 ED visit for asthma (odds ratio [ORs], 2.17; 95% confidence interval [CI], 1.10-4.26), more than or equal to 1 hospitalization for asthma (OR, 3.92; 95% CI, 1.42-10.84), and more than or equal to 1 severe asthma exacerbation (OR, 1.99; 95% CI, 1.01-3.87) in the year before the follow-up visit. Persistently low parental numeracy was not significantly associated with change in lung function measures. ConclusionPersistently low parental numeracy is associated with asthma exacerbation outcomes in Puerto Rican youth.