Connecting At-Risk Inpatient Asthmatics to a Community-Based Program to Reduce Home Environmental Risks: Care System Redesign Using Quality Improvement Methods

Beck, Andrew F.; Simmons, Jeffrey M.; Sauers, Hadley; Sharkey, Kenneth; Alam, Md. Mahbubul; Jones, Camille; Kahn, Robert S.

doi:10.1542/hpeds.2013-0047

Cited by 32 publications

(35 citation statements)

References 41 publications

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“…Studies have identified asthma phenotypes, or clusters, that are potentially amenable to more tailored medical care (39,40). Indeed, medication changes or optimization, such as targeted addition of antihistamines, allergen-specific immunotherapy (23, 24), or omalizumab; or referrals for in-home exposure assessment and remediation have the potential to reduce future exacerbations and improve asthma control (25)(26)(27). Initiation of in-home assessments may be particularly relevant given that reported exposures often differ from what is truly found in the home (21).…”

Section: Discussionmentioning

confidence: 99%

“…For example, in Lowell, Massachusetts, an in-home environmental assessment and subsequent intervention to decrease triggers led to health improvements and cost savings for a population of low-income children with asthma (45). Locally, we have found success through relationships with health department housing inspectors (27) and a medical-legal partnership (46,47). Such interventions could play a significant role in the promotion of chronic asthma control for high-risk children.…”

Section: Original Researchmentioning

confidence: 99%

“…Others have shown that 45% of inner-city children with moderate to severe asthma are exposed to mold and 50% to cockroaches (15,21). Routine allergy testing (22), medication changes or addition of allergen-specific immunotherapy (23,24), and public health interventions to assess in-home allergen exposure and reduce or remediate exposures that are found all have the potential to reduce asthma morbidity among high-risk patients (25)(26)(27).…”

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confidence: 99%

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Allergen Sensitization Profiles in a Population-Based Cohort of Children Hospitalized for Asthma

Beck¹,

Huang

Kercsmar

et al. 2015

Annals ATS

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Rationale: Allergen sensitization is associated with asthma morbidity. A better understanding of allergen sensitization patterns among children hospitalized for asthma could help clinicians tailor care more effectively. To our knowledge, however, sensitization profiles among children hospitalized for asthma are unknown.Objectives: We sought to describe allergen sensitization profiles and the distribution of self-reported in-home exposures among children hospitalized for asthma. We also sought to assess how sensitization profiles varied by sociodemographic and clinical factors.Methods: This population-based cohort study includes data for 478 children, aged 4-16 years, hospitalized for an asthma exacerbation. Predictors included child age, race, sex, insurance status, reported income, salivary cotinine, exposure to traffic-related air pollution, asthma and atopic history, and season of admission. Outcomes included serum IgE specific to Alternaria alternata/A. tenuis, Aspergillus fumigatus, American cockroach, mouse epithelium, dust mite (Dermatophagoides pteronyssinus and farinae), cat dander, and dog dander (deemed sensitive if IgE > 0.35). Self-reported adverse exposures included mold/mildew, water leaks, cockroaches, rodents, and cracks or holes in the walls or ceiling. Presence of carpeting and furry pets was also assessed.Measurements and Main Results: More than 50% of included patients were sensitized to each of Alternaria, Aspergillus, dust mite, cat dander, and dog dander; 28% were sensitized to cockroach and 18% to mouse. Roughly 68% were sensitized to three or more allergens with evidence of clustering. African American children, compared with white children, were more likely to be sensitized to Alternaria, Aspergillus, cockroach, and dust mite (all P , 0.01). White children were more likely to be sensitized to mouse, cat, and dog (all P , 0.01). Lower income was associated with cockroach sensitization whereas higher income was associated with dog and cat sensitization (all P , 0.01). Atopic history was associated with sensitization to three or more allergens (P , 0.01). Although 42% reported exposure to at least one adverse in-home exposure (and 72% to carpet, 51% to furry pets), only weak relationships were seen between reported exposures and sensitizations.Conclusions: Most children admitted to the hospital for asthma exacerbations are sensitized to multiple indoor allergens. Atopy on the inpatient unit serves as a potential target for improvement in chronic asthma management.

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Section: Discussionmentioning

confidence: 99%

Section: Original Researchmentioning

confidence: 99%

mentioning

confidence: 99%

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Allergen Sensitization Profiles in a Population-Based Cohort of Children Hospitalized for Asthma

Beck¹,

Huang

Kercsmar

et al. 2015

Annals ATS

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“…42 Recent work with social services, public health officials, and legal aid advocates highlights the impact that such interventions can have for individual patients and populations. 36,[46][47][48] Enhanced, scaled partnerships of this sort may be especially relevant as health care reform pushes clinicians to find cost-effective methods for reducing health service utilization. 30 Nationally, identifying where social service and public health expenditures can be augmented may also prove impactful.…”

Section: Figurementioning

confidence: 99%

Role of Financial and Social Hardships in Asthma Racial Disparities

Beck¹,

Huang

Simmons³

et al. 2014

Pediatrics

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

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“…This document was used previously in our institution to increase referrals to a community program. 6,7 By reminding the physicians on admission, it ensured that the process started early in the patient's stay. A reminder was also built into the EMR-based attending handoff tool.…”

Section: Figurementioning

confidence: 99%

Local Pharmacy Partnership to Prevent Pediatric Asthma Reutilization in a Satellite Hospital

Sauers‐Ford¹,

Moore

Guiot³

et al. 2016

Pediatrics

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The World Health Organization 2003 report on medication adherence 1 quoted Haynes that "increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments." An obvious, yet critical, component to medication adherence is access to medications; consequently the failure either to fill new prescriptions or to refill existing ones is a critical point of failure in the postdischarge care of patients. 1, 2 Previous work at our institution has demonstrated a sustained reduction in hospital and emergency department (ED) reutilization in part due to efforts abstract OBJECTIVES: In our previous work, providing medications in-hand at discharge was a key strategy to reduce asthma reutilization (readmissions and emergency revisits) among children in a large, urban county. We sought to spread this work to our satellite hospital in an adjacent county. A key initial barrier was the lack of an outpatient pharmacy on site, so we sought to determine if a partnership with community pharmacies could improve the percentage of patients with medications in-hand at discharge, thus decreasing reutilization. METHODS:A multidisciplinary team partnered with community pharmacies. Using rapid-cycle improvement methods, the team aimed to reduce asthma reutilization by providing medications in-hand at discharge. Run charts were used to display the proportion of patients with asthma discharged with medications in-hand and to track 90-day reutilization rates. RESULTS:During the intervention period, the median percentage of patients with asthma who received medications in-hand increased from 0% to 82%. A key intervention was the expansion of the medication in-hand program to all patients. Additional changes included expanding team to evening stakeholders, narrowing the number of community partners, and building electronic tools to support key processes. The mean percentage of patients with asthma discharged from the satellite who had a readmission or emergency department revisit within 90 days of their index admission decreased from 18% to 11%. CONCLUSIONS: Impacting population-level asthma outcomes requires partnerships between community resources and health providers. When hospital resources are limited, community pharmacies are a potential partner, and providing access to medications in-hand at hospital discharge can reduce asthma reutilization.

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Connecting At-Risk Inpatient Asthmatics to a Community-Based Program to Reduce Home Environmental Risks: Care System Redesign Using Quality Improvement Methods

Abstract: We integrated environmental hazard mitigation into inpatient care. Community-engaged care delivery that reduces risks for poor asthma outcomes can be initiated within the hospital.

Cited by 32 publications

References 41 publications

Allergen Sensitization Profiles in a Population-Based Cohort of Children Hospitalized for Asthma

Allergen Sensitization Profiles in a Population-Based Cohort of Children Hospitalized for Asthma

Role of Financial and Social Hardships in Asthma Racial Disparities

Local Pharmacy Partnership to Prevent Pediatric Asthma Reutilization in a Satellite Hospital

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