The relationship between Direct to Consumer Advertising (DTCA) and asthma-related emergency department use among Medicaid-enrolled children

Objective: Asthma is a leading cause of emergency department (ED) visits. There has been much debate on the impact of direct to consumer advertising (DTCA) on healthcare. This study seeks to examine the association between DTCA expenditure and asthma-related ED use. Study design: In this study, we combined Medicaid administrative data and a national advertising data on asthma medications. The sample size consisted of 180?584 Medicaid-enrolled children between the ages of 5 and 18 years who had an asthma diagnosis. Twenty percent of the Medicaid-enrolled children in the sample had asthma-related ED visits. Results: We found that DTCA expenditure is associated with a decrease in asthma-related ED visits (OR?=?0.75; CI: 0.64–0.89). However, at higher levels of DTCA expenditure, the likelihood of asthma-related ED visits increases (OR?=?1.25; CI: 1.05–1.49), indicating a decreased relationship between DTCA and asthma-related ED visits. Conclusions: Our findings suggest that DTCA may be associated with improved health outcomes for Medicaid-enrolled children with asthma.     

Emergency department utilization by patients not meeting Health Plan and Employer Data and Information Set (HEDIS) criteria for persistent asthma.

Emergency hospital utilization rates for asthma remain high despite advances in asthma controller medications and the presence of widely accepted asthma treatment guidelines. To explore this phenomenon, we analyzed administrative data to determine characteristics of patients seen in the emergency department (ED) for asthma. Complete pharmacy and diagnostic coding records were obtained from consecutive adults (aged 19-56 years) treated for asthma in the ED of a closed-network health maintenance organization between April and July of 2002. Subjects were stratified into asthma severity categories (persistent or non-persistent) based on the National Committee for Quality Assurance 2006 Health Plan and Employer Data and Information Set (HEDIS) criteria for persistent asthma. Eighty-one unique patients made a total of 89 ED visits for asthma during the study period. Of the 89 total ED visits for asthma, 44 (49%) occurred in patients that did not meet HEDIS criteria for persistent asthma. Of the 81 unique patients making asthma-related ED visits, 41 (51%) did not meet HEDIS criteria for persistent asthma. Over one-half (51%) of this nonpersistent population were not given either asthma reliever or asthma controller medications during the 12-month period before their index ED visit. Over the 24-month period before their index ED visit, 37% of nonpersistent patients were dispensed neither asthma reliever nor controller medications. Patients that do not meet HEDIS criteria for persistent asthma account for a substantial percentage of asthma-related ED visits. These patients have a history of low use of asthma medications before their ED visit.     

Improving preventive care in high risk children with asthma: lessons learned

Objectives: Rates of preventive asthma care after an asthma emergency department (ED) visit are low among inner-city children. The objective of this study was to test the efficacy of a clinician and caregiver feedback intervention (INT) on improving preventive asthma care following an asthma ED visit compared to an attention control group (CON). Methods: Children with persistent asthma and recent asthma ED visits (N?=?300) were enrolled and randomized into a feedback intervention or an attention control group and followed for 12 months. All children received nurse visits. Data were obtained from interviews, child salivary cotinine levels and pharmacy records. Standard t-test, chi-square and multiple logistic regression tests were used to test for differences between the groups for reporting greater than or equal to two primary care provider (PCP) preventive care visits for asthma over 12 months. Results: Children were primarily male, young (3–5 years), African American and Medicaid insured. Mean ED visits over 12 months was high (2.29 visits). No difference by group was noted for attending two or more PCP visits/12 months or having an asthma action plan (AAP). Children having an AAP at baseline were almost twice as likely to attend two or more PCP visits over 12 months while controlling for asthma control, group status, child age and number of asthma ED visits. Conclusions: A clinician and caregiver feedback intervention was unsuccessful in increasing asthma preventive care compared to an attention control group. Further research is needed to develop interventions to effectively prevent morbidity in high risk inner-city children with frequent ED utilization.     

Race/ethnicity and asthma management among adults presenting to the emergency department

We investigated whether racial/ethnic disparities exist in asthma management among 1785 adults requiring emergency department (ED) treatment. In this multicentre study, non‐Hispanic blacks with increased chronic asthma severity were only as likely (P > 0.05) as non‐Hispanic whites or Hispanics to utilize controller medications or see asthma specialists before ED presentation and to be prescribed recommended inhaled corticosteroids at ED discharge. Improved ED education on evidence‐based chronic disease management is needed to address continuing race/ethnicity‐based asthma disparities.     

The Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) improves physician assessment of asthma morbidity in pediatric emergency department patients

Objectives: To determine whether the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED), a 12-item questionnaire, can help ED attendings accurately assess a patient’s asthma control and morbidity. Methods: This was a randomized-controlled trial performed at an urban pediatric ED of children aged 1–17 years presenting with an asthma exacerbation. Parents answered PACCI-ED questions about their children’s asthma. Attendings were randomized to view responses to the PACCI-ED (intervention group) or to be blinded to the completed PACCI-ED (control group). The two groups were compared on their empirical clinical assessment of: (1) chronic asthma control categories, (2) asthma trajectory (stable, worsening or improving), (3) patient adherence to controller medications, and (4) burden of disease for the patient’s family. The validated PACCI algorithm was used as the criterion standard for these four outcomes. Accuracy of clinical assessment was compared between intervention and control groups using chi-squared tests and an intention-to-treat approach. Results: Seventeen ED attendings were enrolled in the study and 77 children visits were included in the analysis. There were no significant differences between the intervention and the control groups for child’s gender, age, race, and asthma characteristics. Intervention group attendings were more accurate than control group attendings in assessing the category of chronic asthma control (43% versus 19%; p?=?0.03), disease trajectory (72% versus 45%; p?=?0.02), and the disease burden for families (74% versus 35%; p?=?0.001) over the past 12 months. There was a trend towards more accuracy of intervention versus control attendings for estimating patient adherence to controller medications (72% versus 48%; p?=?0.06). Conclusions: The PACCI-ED improves the assessment of asthma control, trajectory, and burden by ED attendings, and may help assessment of asthma medication adherence and prior asthma exacerbations. The PACCI-ED can be used to improve provider assessment of asthma morbidity during pediatric ED visits for asthma exacerbations, and to identify children who may benefit from interventions to reduce asthma morbidity.     

Asthma Prevention in Urbanites

Objectives. The purpose of this intervention was to evaluate the efficacy of low-literacy asthma education and the provision of free asthma controller medications to persons living in the urban inner-city. Methods. The intervention was conducted as a series of three studies. A health educator from the Johnson Health Center (JHC) performed chart reviews in the first two studies to identify urban asthma patients with frequent emergency department (ED) visits. The third study evaluated participants from the community-at-large who came to the ED for episodic asthma care. Free controller medications and education were provided to participants in all three studies. Results. Emergency department utilization, inpatient admissions, and consumer medical costs were greatly reduced in all three studies during the 5-year intervention period. Lung function improved, and participants reported an improved quality of life. Conclusion. The provision of free asthma controller medications resulted in greatly improved asthma management and reduced costs. There was no evidence that an asthma education component per se produced any of the changes.     

Ozone pollution and asthma emergency department visits in the Central Valley,California, USA,during June to September of 2015: a time-stratified case-crossover analysis

Objective: The San Joaquin Valley (SJV) exceeds the state and national standards for ozone (O₃). This study investigates whether short-term exposure to O₃ is associated with asthma emergency department (ED) visits. Methods: We identified 1,101 ED visits in June–September of 2015 in SJV, California, who lived within 15?km of active air monitors. Conditional logistic regression models were used to obtain the odds ratio (OR) and 95% confidence interval (CI) associated with an interquartile (IQR) increase in ozone. We explored the potential effect modification by sex (female and male), race (White, Black and Hispanic), age (2–5, 6–18, 19–40, 41–64 and >?= 65) and county (Merced, Madera, Kings, Fresno and Kern). Results: An IQR range (18.1?ppb) increase in O₃ exposure three days before an asthma attack (lag 3) was associated with a 6.6% [OR: 1.066 (95% CI: 1.032, 1.082)] increase in the odds of having an asthma ED visit. The overall ORs differed across age groups and races/ethnicities, with strongest for children aged 6–18?years [OR: 1.219 (95% CI: 1.159, 1.280)], adults 19–40?years [OR: 1.102 (95% CI: 1.053, 1.154)] and Blacks [OR: 1.159 (95% CI: 1.088, 1.236)], respectively. O₃ exposure was not positively associated with asthma ED visits for Whites, while it was for other underrepresented groups. Fresno had the highest number of asthma ED visits and positive association among all five counties. Conclusion: We found that O₃ exposure is associated with asthma ED visits in the SJV.     

Self-management behaviors in World Trade Center rescue and recovery workers with asthma

Background: Asthma is a major source of morbidity among World Trade Center (WTC) rescue and recovery workers. While physical and mental health comorbidities have been associated with poor asthma control, the potential role and determinants of adherence to self-management behaviors (SMB) among WTC rescue and recovery workers is unknown. Objectives: To identify modifiable determinants of adherence to asthma self-management behaviors in WTC rescue and recovery worker that could be potential targets for future interventions. Methods: We enrolled a cohort of 381 WTC rescue and recovery workers with asthma. Sociodemographic data and asthma history were collected during in-person interviews. Based on the framework of the Model of Self-regulation, we measured beliefs about asthma and controller medications. Outcomes included medication adherence, inhaler technique, use of action plans, and trigger avoidance. Results: Medication adherence, adequate inhaler technique, use of action plans, and trigger avoidance were reported by 44%, 78%, 83%, and 47% of participants, respectively. Adjusted analyses showed that WTC rescue and recovery workers who believe that they had asthma all the time (odds ratio [OR]: 2.37; 95% confidence interval [CI]: 1.38–4.08), that WTC-related asthma is more severe (OR: 1.73; 95% CI: 1.02–2.93), that medications are important (OR: 12.76; 95% CI: 5.51–29.53), and that present health depends on medications (OR: 2.39; 95% CI: 1.39–4.13) were more likely to be adherent to their asthma medications. Illness beliefs were also associated with higher adherence to other SMB. Conclusions: Low adherence to SMB likely contributes to uncontrolled asthma in WTC rescue and recovery workers. Specific modifiable beliefs about asthma chronicity, the importance of controller medications, and the severity of WTC-related asthma are independent predictors of SMB in this population. Cognitive behavioral interventions targeting these beliefs may improve asthma self-management and outcomes in WTC rescue and recovery workers.

Key message: This study identified modifiable beliefs associated with low adherence to self-management behaviors among World Trade Center rescue and recovery rescue and recovery workers with asthma which could be the target for future interventions.

Capsule summary: Improving World Trade Center-related asthma outcomes will require multifactorial approaches such as supporting adherence to controller medications and other self-management behaviors. This study identified several modifiable beliefs that may be the target of future efforts to support self-management in this patient population.     

Prospective multicenter study of relapse following treatment for acute asthma among adults presenting to the emergency department. MARC investigators. Multicenter Asthma Research Collaboration

STUDY OBJECTIVE: To identify factors associated with relapse following treatment for acute asthma among adults presenting to the emergency department (ED). DESIGN: Prospective inception cohort study performed during October 1996 to December 1996 and April 1997 to June 1997, as part of the Multicenter Asthma Research Collaboration. SETTING: Thirty-six EDs in 18 states. PATIENTS: ED patients, aged 18 to 54 years, with physician diagnosis of acute asthma. For the present analysis, we restricted the cohort to patients sent home from the ED (n = 971), then further excluded patients with comorbid respiratory conditions (n = 32). This left 939 eligible subjects to have follow-up data. Interventions: None. MEASUREMENTS AND RESULTS: Two weeks after being sent home from the ED, patients were contacted by telephone. A relapse was defined as an urgent or unscheduled visit to any physician for worsening asthma symptoms during the 14-day follow-up period. Complete follow-up data were available for 641 patients, of whom 17% reported relapse (95% confidence interval, 14 to 20). There was no significant difference in peak expiratory flow rate (PEFR) between patients who suffered relapse and those who did not. In a multivariate logistic regression analysis (controlling for age, gender, race, and primary care provider status), patients who suffered relapse were more likely to have a history of numerous ED (odds ratio [OD] 1.3 per 5 visits) and urgent clinic visits (OR 1.4 per 5 visits) for asthma in the past year, use a home nebulizer (OR 2.2), report multiple triggers of their asthma (OR 1.1 per trigger), and report a longer duration of symptoms (OR 2.5 for 1 to 7 days). CONCLUSION: Among patients sent home from the ED following acute asthma therapy, 17% will have a relapse and PEFR does not predict who will develop this outcome. By contrast, several historical features were associated with increased risk. Further research should focus on ways to decrease the relapse rate among these high-risk patients. The clinician may wish to consider these historical factors when making ED decisions.     

Predictors of prior asthma specialist care among pediatric patients seen in the emergency department for asthma

Background: Asthma guidelines recommend specialist care for patients experiencing poor asthma outcomes during emergency department (ED) visits. The prevalence and predictors of asthma specialist care among an ED population seeking pediatric asthma care are unknown. Objective: To examine, in an ED population, factors associated with prior asthma specialist use based on parental reports of prior asthma morbidity and asthma care. Methods: Parents of children ages 0 to 17?years seeking ED asthma care were surveyed regarding socio-demographics, asthma morbidity, asthma management and current asthma specialist care status. We compared prior asthma care and morbidity between those currently cared for by an asthma specialist versus not. Multivariable logistic regression models to predict factors associated with asthma specialist use were adjusted for parent education and insurance type. Results: Of 150 children (62% boys, mean age 4.7?years, 69% Hispanic), 22% reported asthma specialist care, 75% did not see a specialist and for 3% specialist status was unknown. Care was worse for those not seeing a specialist, including under-use of controller medications (24% vs. 64%, p?<?0.001) and asthma action plans (20% vs. 62%, p?<?0.001). Multivariable logistic regression revealed that lack of recommendation by the primary care physician reduced the odds of specialist care (OR 0.01, 95% CI <0.01, 0.05, p?<?0.001). Conclusions: Asthma specialist care was infrequent among this pediatric ED population, consistent with the sub-optimal chronic asthma care we observed. Prospective trials should further investigate if systematic referral to asthma specialists during/after an ED encounter would improve asthma outcomes.     

Spatiotemporal patterns of childhood asthma hospitalization and utilization in Memphis Metropolitan Area from 2005 to 2015

Objective: To identify the key risk factors and explain the spatiotemporal patterns of childhood asthma in the Memphis metropolitan area (MMA) over an 11-year period (2005–2015). We hypothesize that in the MMA region this burden is more prevalent among urban children living south, downtown, and north of Memphis than in other areas. Methods: We used a large-scale longitudinal electronic health record database from an integrated healthcare system, Geographic information systems (GIS), and statistical and space-time models to study the spatiotemporal distributions of childhood asthma at census tract level. Results: We found statistically significant spatiotemporal clusters of childhood asthma in the south, west, and north of Memphis city after adjusting for key covariates. The results further show a significant increase in temporal gradient in frequency of emergency department (ED) visits and inpatient hospitalizations from 2009 to 2013, and an upward trajectory from 4 per 1,000 children in 2005 to 16 per 1,000 children in 2015. The multivariate logistic regression identified age, race, insurance, admit source, encounter type, and frequency of visits as significant risk factors for childhood asthma (p < 0.05). We observed a greater asthma burden and healthcare utilization for African American (AA) patients living in a high-risk area than those living in a low-risk area in comparison to the white patients: AA vs. white [odds ratio (OR) = 3.03, 95% confidence interval (CI): 2.75–3.34]; and Hispanic vs. white (OR = 1.62, 95% CI: 1.21–2.17). Conclusions: These findings provide a strong basis for developing geographically tailored population health strategies at the neighborhood level for young children with chronic respiratory conditions.     

Health care access,concentrated poverty,and pediatric asthma hospital care use in California's San Joaquin Valley: A multilevel approach

Background: California's San Joaquin Valley is a region with a history of poverty, low health care access, and high rates of pediatric asthma. It is important to understand the potential barriers to care that challenge vulnerable populations. Objective: The objective was to describe pediatric asthma-related utilization patterns in the emergency department (ED) and hospital by insurance coverage as well as to identify contributing individual-level indicators (age, sex, race/ethnicity, and insurance coverage) and neighborhood-level indicators of health care access. Methods: This was a retrospective study based on secondary data from California hospital and ED records 2007–2012. Children who used services for asthma-related conditions, were aged 0–14 years, Hispanic or non-Hispanic white, and resided in the San Joaquin Valley were included in the analysis. Poisson multilevel modeling was used to control for individual- and neighborhood-level factors. Results: The effect of insurance coverage on asthma ED visits and hospitalizations was modified by the neighborhood-level percentage of concentrated poverty (RR = 1.01, 95% CI = 1.01–1.02; RR = 1.03, 95% CI = 1.02–1.04, respectively). The effect of insurance coverage on asthma hospitalizations was completely explained by the neighborhood-level percentage of concentrated poverty. Conclusions: Observed effects of insurance coverage on hospital care use were significantly modified by neighborhood-level measures of health care access and concentrated poverty. This suggests not only an overall greater risk for poor children on Medi-Cal, but also a greater vulnerability or response to neighborhood social factors such as socioeconomic status, community cohesiveness, crime, and racial/ethnic segregation.     

Frequency of health service use in the year prior to asthma death

Objective: High frequency health service use (HSU) is associated with poorly controlled asthma, and is a recognized risk factor for near-fatal or fatal asthma. The objective of this study was to describe the frequency of HSU in the year prior to asthma death. Methods: Individuals aged 0–99 years who died from asthma from April 1996 to December 2011 in Ontario, Canada were identified as cases. Cases were matched to 4–5 live asthma controls by age, sex, rural/urban residence, socioeconomic status, duration of asthma and a co-diagnosis of COPD. HSU records in the year prior to death [hospitalization, emergency department (ED) and outpatient visits] were assembled. The association of prior HSU and asthma death was measured by conditional logistic regression models. Results: From 1996 to 2011, 1503 individuals died from asthma. While the majority of cases did not have increased HSU as defined in the study, compared to matched live asthma controls, the cases were 8-fold more likely to have been hospitalized two or more times (OR?=?7.60; 95% CI: 4.90, 11.77), 13-fold more likely to have had three or more ED visits (OR?=?13.28; 95% CI: 7.55, 23.34) and 4-fold more likely to have had five or more physician visits for asthma (OR?=?4.41; 95% CI: 3.58, 5.42). Conclusions: Frequency of HSU in the year prior was substantially higher in those died from asthma. Specifically, more than one asthma hospital admission, three ED visits or five physician visits increased the asthma mortality risk substantially and exponentially.     

Association Between Outpatient Follow-Up and Pediatric Emergency Department Asthma Visits

Background.?The National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend that patients receive a follow-up outpatient asthma visit after being discharged from an emergency department (ED) for asthma. Objective.?To measure the frequency of follow-up outpatient asthma visits and its association with repeat ED asthma visit. Design.?We conducted a retrospective cohort study of children with asthma using claims data from a university-based managed care organization from 01 1998 to 10 2000. We performed a multivariate survival analysis using Cox proportional hazards model to determine the effect of follow-up outpatient asthma visits on the likelihood of a repeat ED asthma visit, after controlling for severity of illness, patient age, gender, insurance, and the specialty of the primary care provider. Results:?A total of 561 children had 780 ED asthma visits. Of these, 103 (17%) had a repeat ED asthma visit within 1 year. Almost two-thirds of children (66%) did not receive outpatient follow-up for asthma within 30 days of an ED asthma visit. Outpatient asthma visits within 30 days of an ED asthma visit are associated with an increased likelihood (relative risk = 1.80; 95% confidence interval 1.19, 2.72) for repeat ED asthma visits within 1 year. Conclusions.?Most patients do not have outpatient follow-up after an ED asthma visit. However, those patients that present for outpatient follow-up have an increased likelihood for repeat ED asthma visits. For the primary care provider, these outpatient follow-up visits signal an increased risk that a patient will return to the ED for asthma and are a key opportunity to prevent future ED asthma visits.     

Exposure to environmental tobacco smoke among children presenting to the emergency department with acute asthma: a multicenter study

Environmental tobacco smoke (ETS) exposure has been associated with increased use of the emergency department (ED) for acute asthma care. The purpose of this study was to determine the prevalence of ETS exposure among children presenting to the ED for acute asthma care and whether ETS exposure affects acute asthma severity or response to therapy. We conducted a multi-center study of children 2-11 years with physician-diagnosed acute asthma presenting to 44 EDs in 18 states. Chi-square test, Student's t-test, Wilcoxon rank sum test, and logistic regression were used for the analyses. The study population included 954 children. Thirty-six percent (95% CI, 33-39%) of caregivers reported that their child was exposed to ETS. Among exposed children, 35% were exposed 1-6 days/week, and 65% were exposed daily. Compared to unexposed children, ETS-exposed children were older at asthma diagnosis, older at ED presentation, and were less likely to be Hispanic. Indicators of chronic asthma severity were higher among unexposed children (i.e., total number of medications, use of controller medications, use of beta(2) agonists, number of urgent clinic visits, and lifetime hospitalizations). There was a weak association between ETS and acute asthma severity. Response to therapy (including ED disposition) did not differ between groups. On multivariate analysis, ETS-exposed children were more likely to be older, female, non-Hispanic, have lower household income, not use controller medications, and have a pet at home (all P < 0.05). Our study showed that the prevalence of ETS exposure among children presenting to the ED with acute asthma differs across demographic factors. There were no significant differences in acute asthma symptoms or response to ED therapy between ETS-exposed and unexposed children. Lower use of controller medications and less frequent urgent clinic visits among ETS-exposed children suggest inadequate asthma care or milder disease. The weak association between ETS exposure and acute asthma severity might reflect confounding by psychological factors and/or chronic asthma severity. The frequency of ETS exposure suggests that the ED may be an appropriate venue to engage caregivers of children with asthma in asthma education and smoking cessation efforts.     

Asthma Exacerbations in North American Adults: Who Are the “Frequent Fliers” in the Emergency Department?

OBJECTIVE: To characterize adult asthma patients according to frequency of emergency department (ED) visits in the past year. DESIGN: Adults presenting with acute asthma to 83 US EDs underwent structured interviews in the ED and by telephone 2 weeks later. RESULTS: The 3,151 enrolled patients were classified into four groups: those reporting no ED visits in the past year (27%), one to two visits (27%), three to five visits (25%), and six or more visits (21%). The number of ED visits (NEDV) was associated with older age, nonwhite race, lower socioeconomic status, and several markers of chronic asthma severity (all p < 0.001). NEDV was strongly associated with Medicaid insurance (17% among those with no visits, 22% with one to two visits, 30% with three to five visits, 39% with six or more visits; p < 0.001). NEDV was unrelated to gender or having a primary care provider (PCP). In a multivariate model, independent predictors of high ED use (six or more visits a year) were nonwhite race, Medicaid, other public, and no insurance, and markers of chronic asthma severity. Patients with six or more ED visits accounted for 67% of all prior ED visits in the past year. CONCLUSIONS: High NEDV is associated with characteristics that may help with identification of "frequent fliers" in the ED. A better understanding of these characteristics may advance ongoing efforts to decrease asthma health-care disparities, including differential access to primary asthma care. National guidelines recommend specific ED treatments then referral to a PCP. Although longitudinal care is surely important, attempts to reduce frequent ED asthma visits may be better directed toward more specific preventive and educational needs.     

Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children

Objectives: To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children. Methods: We prospectively enrolled 2–10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP “Acute Asthma” visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP. Results: One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5?±?2.3 (standard deviation), range 0–10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2?±?2.8; range 1–18. The mean number of PCP Acute Asthma visits/child was 0.7?±?1.6; range 0–11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI ?0.018, 0.06). Conclusions: Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.