Andrew F. Beck

Role of Financial and Social Hardships in Asthma Racial Disparities

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.

Medical home quality and readmission risk for children hospitalized with asthma exacerbations.

OBJECTIVE: The medical home likely has a positive effect on outpatient outcomes for children with asthma. However, no information is available regarding the impact of medical home quality on health care utilization after hospitalizations. We sought to explore the relationship between medical home quality and readmission risk in children hospitalized for asthma exacerbations. METHODS: We enrolled 601 children, aged 1 to 16 years, hospitalized for an acute asthma exacerbation at a single pediatric facility that captures >85% of all asthma admissions in an 8-county area. Caregivers completed the Parent’s Perception of Primary Care (P3C), a Likert-based, validated survey. The P3C yields a total score of medical home quality and 6 subscale scores assessing continuity, access, contextual knowledge, comprehensiveness, communication, and coordination. Asthma readmission events were prospectively collected via billing data. Hazards of readmission were calculated by using Cox proportional hazards adjusting for chronic asthma severity and key measures of socioeconomic status. RESULTS: Overall P3C score was not associated with readmission. Among the subscale comparisons, only children with lowest access had a statistically increased readmission risk compared with children with the best access. Subgroup analysis revealed that children with private insurance and good access had the lowest rates of readmission within a year compared with other combinations of insurance and access. CONCLUSIONS: Among measured aspects of medical home in a cohort of hospitalized children with asthma, having poor access to a medical home was the only measure associated with increased readmission. Improving physician access for children with asthma may lower hospital readmission.

Identifying and Treating a Substandard Housing Cluster Using a Medical-Legal Partnership

BACKGROUND AND OBJECTIVE: There is a documented connection between the home environment and health. Medical-legal partnerships (MLPs) can address social and environmental determinants of health. Our objective was to describe a cluster of substandard housing identified and treated by an MLP based in a pediatric primary care setting. METHODS: Potential cases of poor-quality housing were identified during outpatient primary care. A case was defined as any rented housing unit with a reported unaddressed housing risk within a defined building portfolio (owned by a single developer) in which ≥1 child lived. An on-site MLP offered affected families legal services including ordinance enforcement and connection to resources. They also initiated portfolio-wide advocacy. Legal advocates reported case outcomes. Medical history and household demographics were collected from the medical record and compared with clinic-wide data by using Fisher’s exact test or χ2 statistics. RESULTS: After identification of a single case, an additional 15 cases were identified. Pest infestation was the most common initial risk identified. Of 14 units with outcome data, repairs were completed in 10 (71%). Of the 19 building complexes with the same owner, 11 received significant systemic repairs. Of the 45 children living within the 16 identified case units, 36% had asthma, 33% had developmental delay or behavioral disorder, and 9% had an elevated lead level. Affected children were more likely to have one of these diagnoses than the general clinic population (all P < .01). CONCLUSIONS: An MLP identified and improved home environmental conditions for children living in a cluster of substandard housing.

Geomedicine: Area-Based Socioeconomic Measures for Assessing Risk of Hospital Reutilization Among Children Admitted for Asthma

OBJECTIVES We assessed whether geographic information available at the time of asthma admission predicts time to reutilization (readmission or emergency department revisit). METHODS For a prospective cohort of children hospitalized with asthma in 2008 and 2009 in Cincinnati, Ohio, we constructed a geographic social risk index from geocoded home addresses linked to census tract extreme poverty and high school graduation rates and median home values. We examined geographic risk associations with reutilization and caregiver report of hardship. RESULTS Thirty-nine percent of patients reutilized within 12 months. Compared with those in the lowest geographic risk stratum, those at medium and high risk had 1.3 (95% confidence interval [CI] = 0.9, 1.9) and 1.8 (95% CI = 1.4, 2.4) the risk of reutilization, respectively. Caregivers of children at highest geographic risk were 5 times as likely to report more than 2 financial hardships (P < .001) and 3 times as likely to report psychological distress (P = .001). CONCLUSIONS A geographic social risk index may help identify asthmatic children likely to return to the hospital. Targeting social risk assessments and interventions through geographic information may help to improve outcomes and reduce disparities.

Enhancing Accurate Identification of Food Insecurity Using Quality-Improvement Techniques

BACKGROUND AND OBJECTIVES: Infants who live in households experiencing food insecurity are at risk for negative health and developmental outcomes. Despite large numbers of households within our population experiencing food insecurity, identification of household food insecurity during standard clinical care is rare. The objective of this study was to use quality-improvement methods to increase identification of household food insecurity by the second-year pediatric residents working in the Pediatric Primary Care Center from 1.9% to 15.0% within 6 months. A secondary aim was to increase the proportion of second-year pediatric residents identifying food insecurity. METHODS: A team was formed to identify key drivers thought to be critical to the process of identifying food insecurity during well-child care. This project addressed 5 key drivers and tested interventions based on these drivers over a 6-month period at a hospital-based primary care site that serves ∼15 000 children from underserved neighborhoods. Tests included implementing an evidence-based electronic screen for food insecurity, educational interventions to improve understanding of food insecurity, empowerment exercises targeting clinicians and families, and gaining buy-in and support from ancillary personnel. RESULTS: Implementation of these changes led to an increase in the identification rate of household food insecurity from 1.9% to 11.2% over the 6 months (P < .01). The proportion of residents identifying food insecurity increased from 37.5% to 91.9% (P < .01). CONCLUSIONS: Application of quality-improvement methods in a primary care clinic increased ability to effectively screen and positively identify households with food insecurity in this population.

Redesigning Health Care Practices to Address Childhood Poverty

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Explaining Racial Disparities in Child Asthma Readmission Using a Causal Inference Approach

IMPORTANCE Childhood asthma is characterized by disparities in the experience of morbidity, including the risk for readmission to the hospital after an initial hospitalization. African American children have been shown to have more than 2 times the hazard of readmission when compared with their white counterparts. OBJECTIVE To explain why African American children are at greater risk for asthma-related readmissions than white children. DESIGN, SETTING, AND PARTICIPANTS This study was completed as part of the Greater Cincinnati Asthma Risks Study, a population-based, prospective, observational cohort. From August 2010 to October 2011, it enrolled 695 children, aged 1 to 16 years, admitted for asthma or wheezing who identified as African American (n = 441) or white (n = 254) in an inpatient setting of an urban, tertiary care childrens hospital. MAIN OUTCOMES AND MEASURES The main outcome was time to asthma-related readmission and race was the predictor. Biologic, environmental, disease management, access, and socioeconomic hardship variables were measured; their roles in understanding racial readmission disparities were conceptualized using a directed acyclic graphic. Inverse probability of treatment weighting balanced African American and white children with respect to key measured variables. Racial differences in readmission hazard were assessed using weighted Cox proportional hazards regression and Kaplan-Meier curves. RESULTS The sample was 65% male (n = 450), and the median age was 5.4 years. African American children were 2.26 times more likely to be readmitted than white children (95% CI, 1.56-3.26). African American children significantly differed with respect to nearly every measured biologic, environmental, disease management, access, and socioeconomic hardship variable. Socioeconomic hardship variables explained 53% of the observed disparity (hazard ratio, 1.47; 95% CI, 1.05-2.05). The addition of biologic, environmental, disease management, and access variables resulted in 80% of the readmission disparity being explained. The difference between African American and white children with respect to readmission hazard no longer reached the level of significance (hazard ratio, 1.18; 95% CI, 0.87-1.60; Cox P = .30 and log-rank P = .39). CONCLUSIONS AND RELEVANCE A total of 80% of the observed readmission disparity between African American and white children could be explained after statistically balancing available biologic, environmental, disease management, access to care, and socioeconomic and hardship variables across racial groups. Such a comprehensive, well-framed approach to exposures that are associated with morbidity is critical as we attempt to better understand and lessen persistent child asthma disparities.

A Road Map to Address the Social Determinants of Health Through Community Collaboration

Economic, environmental, and psychosocial needs are common and wide-ranging among families cared for in primary care settings. Still, pediatric care delivery models are not set up to systematically address these fundamental risks to health. We offer a roadmap to help structure primary care approaches to these needs through the development of comprehensive and effective collaborations between the primary care setting and community partners. We use Maslow’s Hierarchy of Needs as a well-recognized conceptual model to organize, prioritize, and determine appropriate interventions that can be adapted to both small and large practices. Specifically, collaborations with community organizations expert in addressing issues commonly encountered in primary care centers can be designed and executed in a phased manner: (1) build the case for action through a family-centered risk assessment, (2) organize and prioritize risks and interventions, (3) develop and sustain interventions, and (4) operationalize interventions in the clinical setting. This phased approach to collaboration also includes shared vision, codeveloped plans for implementation and evaluation, resource alignment, joint reflection and adaptation, and shared decisions regarding next steps. Training, electronic health record integration, refinement by using quality improvement methods, and innovative use of clinical space are important components that may be useful in a variety of clinical settings. Successful examples highlight how clinical-community partnerships can help to systematically address a hierarchy of needs for children and families. Pediatricians and community partners can collaborate to improve the well-being of at-risk children by leveraging their respective strengths and shared vision for healthy families.

Doctors and Lawyers Collaborating to HeLP Children—: Outcomes from a Successful Partnership between Professions

Background. Clear associations exist between socioeconomic risks and health, and these risks are often amenable to legal interventions. Methods. This is a case study of an implementation of a medical-legal partnership (MLP) in three pediatric primary care centers that serve a predominantly high-risk population. Referral circumstances and outcomes over the first three years are described. Results. During the three-year study period, 1,808 MLP referrals were made for 1,614 patients by all levels of provider. Those referred were more likely to have asthma (p<.0001) and developmental delay/behavioral disorder (p<.0001) than the general clinic population. Housing (37%) and income/health benefit (33%) problems were the most common reasons for referral. Referrals led to 1,742 (89%) positive legal outcomes affecting nearly 6,000 cohabitating children and adults and translating into nearly

Determinants of Health and Pediatric Primary Care Practices

200,000 in recovered back benefits. Conclusion. Successful MLP implementation enabled pediatric providers to address social determinants of health potentially improving health and reducing disparities.