Original articleAsthma, lower airway diseasesFactors associated with disparities in emergency department use among Latino children with asthma
Introduction
Emergency Department (ED) use represents an important indicator of asthma morbidity because it is associated with frequent asthma exacerbations. The frequency of ED visits may reflect inadequate disease management skills by the family or long-term asthma management that deviates from guideline-based care.1 National epidemiological data indicate significant disparities in ED use for asthma, with Latinos and Blacks in the northeastern United States demonstrating particularly high rates of ED use, even when key sociodemographic indicators, such as poverty and insurance status, are controlled.[2], [3] However, few studies have investigated the factors that may account for these disparities. A number of general factors have been associated with higher rates of overall ED use among children with asthma, including poverty,[4], [5] young age,6 asthma severity,[2], [5] low inhaled corticosteroid (ICS) use,[5], [7] and poor environmental control.8 Frequent ED use has also been associated with health system factors such as lack of a usual source of care,5 lack of access to a specialist, poor continuity with a primary care provider,9 and having public insurance.10 Many of these factors traditionally associated with lower socioeconomic and minority status may explain the disparities in ED use observed among Latino and black children with asthma.
In previously reported data from the Rhode Island Puerto Rico Asthma Center, we showed that island Puerto Ricans had significantly higher rates of ED use than non-Latino whites (NLWs) and Latinos (Puerto Ricans and Dominicans) living in Rhode Island (RI). This difference was striking, because island Puerto Ricans had similar asthma control to NLWs and milder severity than RI, Dominicans, Puerto Ricans, and NLWs, whereas no differences in severity between these three groups were observed in RI.11 We speculated that these findings could be attributable in part to differences across sites in the health care system, but did not present empirical evidence to evaluate this hypothesis. However, in that study, we did not focus on ED use or health care context factors, such as insurance status and source of care.
In this paper, we build on our previous results11 to empirically examine the extent to which differences in individual/family factors (ie, asthma control, parental perception of asthma severity, medication concerns) and health system factors (public vs private insurance, usual source of care) among Latinos and NLWs are related to frequent ED use for asthma in our Rhode Island Puerto Rico Asthma Center sample. Our main hypothesis is that health care system variables will account for disparities in ED use for asthma between Puerto Rico and Rhode Island, whereas individual/family variables may account for disparities in ED use between Latinos and NLW families in both sites.
Section snippets
Study design and sampling
The methods of our study have been described in detail elsewhere.12 The study design was the same in both sites: a cross-sectional, observational approach with repeated measurements of selected variables. The Latino subsample from RI included Dominican children in addition to mainland Puerto Rican children (but no other Latino groups). Dominicans represent an understudied group who also show high rates of parent-reported asthma and ED use.[5], [13] Similar to Puerto Rican children; Dominican
Results
The sample was composed of 804 children (ages 7–15 years), with 405 from PR and 399 from RI. Among the RI children, 151 were NLW, 112 were of Puerto Rican descent, and 136 were of Dominican descent. To evaluate whether it was acceptable to combine the Puerto Ricans and Dominicans into one RI Latino sample, we compared key demographic indicators between these groups. No significant differences existed regarding asthma indicators (severity, control, frequency of ED visits for asthma,
Discussion
In our previous work,11 we had hypothesized that the apparent paradox (higher rates of ED use with milder asthma among island Puerto Ricans) could be related to public insurance policies on the island. Our current findings provide support for this hypothesis, because public insurance was 1 of the important variables in predicting ED utilization. Public insurance status was also associated with increased ED use in NLWs. Public insurance has been found to be a predictor of frequent
Conclusions and Recommendations
The high rates of ED utilization particularly among island Puerto Ricans are troubling because ED treatment is associated with lack of continuity of care, and little or no preventive care, factors that are necessary for achieving good control of asthma.10 Our results suggest the need for the development of interventions that are geared toward educating families on how best to use the ED, enhance continuity with providers, and motivate families to attend follow-up visits. Revisions of public
Acknowledgments
We thank Vilmary Cruz, MA, and Sonia Delgado for their invaluable help as field supervisors of this study, and Drs. José Rodríguez-Santana, Robert Klein, and Federico Montealegre for their clinical input.
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Disclosures: Authors have nothing to disclose.
Funding Sources: This study was supported by Grants # U01-Hl072438-01 and HL 072519-05 (G. Fritz and G. Canino, P.I.s) from the National Heart Lung and Blood Institute and from NIH Grant # 5P60 MD002261-02 funded by the National Center for Minority Health and Health Disparities (NCMHD-NH). In addition it was supported for technical assistance by the UPR School of Medicine Endowed Health Services Research Center, Grants 5S21MD000242 and 5S21MD000138, from NCMHD-NIH.