Gender differences in the association of overweight and asthma morbidity among urban adolescents with asthma

Asthma and obesity disproportionately affect US African-American youth. Among youth with asthma, obesity has been associated with poor control. The impact of gender on this association is unclear. We examined these relationships in a sample of urban, African-American adolescents with asthma. Questionnaires were used to identify high school students with asthma, and to examine the association of body mass index (BMI) to asthma morbidity, by gender. Of 5967 students completing questionnaires, 599 (10%) met criteria for asthma and 507 had data sufficient for inclusion in further analyses (46% male, mean age = 15.1 yr). Univariately, BMI > 85th percentile was significantly related only to reported emergency department visits (ED) and school days missed for any reason, Odds Ratio (95%Confidence Interval) = 1.7(1.1–2.7), p  =  0.01 and 1.8(1.1–3.0), p  =  0.01, respectively. A significant gender-BMI interaction (p   <   0.05) was observed in multivariate models for ED visits, hospitalizations and school days missed for asthma. In gender-specific models, adjusted Risk Ratios for BMI > 85th and ED visits, hospitalizations, and school days missed because of asthma were 1.7(0.9–3.2), 6.6(3.1–14.6) and 3.6(1.8–7.2) in males. These associations were not observed in females. Gender modifies the association between BMI and asthma-related morbidity among adolescents with asthma. Results have implications for clinical management as well as future research.     

An Examination of Factors Affecting Quality of Life for Children With Asthma and Their Caregivers in Southeastern Georgia

IntroductionDespite effective treatments and interventions, asthma continues to affect children's health-related quality of life (QOL). This study explored factors affecting QOL of children with asthma and their caregivers.MethodsA mixed-model design was used. Children (7–17 years) completed the Paediatric Asthma Quality of Life Questionnaire, and parents/caregivers completed the Paediatric Asthma Caregiver's Quality of Life Questionnaire. These surveys focused on activity limitations, emotional function, and child symptoms.ResultsThe sample included 104 children and 104 caregivers. Analysis showed emergency department (ED) visits as a significant predictor of QOL for children in the domains of Physical Activity, Emotional, and Symptoms. Increased ED visits and reliever medication use predicted lower emotional QOL and physical QOL for parents, whereas increased use of controller medications predicated improved physical QOL.DiscussionFactors contributing to QOL, along with characteristics of those with the lowest QOL indicators, have been determined. Identification of interventions to reduce ED visits warrants further investigation.     

Adolescents' Perception of Asthma Symptoms and Health Care Utilization

Introduction

Pediatric asthma is accountable for a substantial use of health care services. The purpose of this study was to systemically examine the extent to which inaccurate perception of asthma symptoms is associated with the use of health care services.

Methods

This exploratory study included 126 adolescents with asthma who were between 13 and 20 years of age. Subjects were classified as having inaccurate symptom perception (IG); well-controlled accurate symptom perception (WCA); and poorly controlled accurate symptom perception (PCA). These groups were compared with respect to health care utilization, including emergency department (ED) visits, hospitalization, and office visits and school absenteeism in the past 3 months.

Results

More adolescents in the IG group had at least one hospitalization compared with adolescents in the PCA or WCA groups (23.1% vs. 11.1% vs. 2.6%, respectively). A similar trend was seen for ED visits. Compared with the WCA group, adolescents in the IG group were nearly nine times more likely to have been hospitalized, 3.4 times more likely to have visited an ED, and four times more likely to have missed school days.

Discussion

Adolescents with inaccurate symptom perception are more likely to have hospitalizations, ED visits, and missed days from school compared with those who have accurate perceptions. The findings underscore the importance of screening for perceptual accuracy of asthma symptoms and call for interventions promoting accurate symptom assessment in adolescents with asthma to ensure appropriate care.     

The relationship of fall school opening and emergency department asthma visits in a large metropolitan area

BACKGROUND: Asthma morbidity is seasonal, with the fewest exacerbations occurring in summer and the most exacerbations in early fall. OBJECTIVE: To determine if the fall increase in pediatric asthma emergency department (ED) visits is related to the school year start. DESIGN: Time-series study of daily asthma ED visits taken from an administrative claims database for the years 1991 to 2002. SETTING: Eleven municipal hospitals in New York City, NY.Patients Emergency department visits with asthma as the primary diagnosis among children aged 2 to 4, 5 to 11, and 12 to 17 years and adults with asthma aged 22 to 45 years as comparative group.Main Outcome Measure Rate of asthma ED visits after the September school opening compared with before the opening, during a 60-day window of each year. The delayed effect of school opening was examined by the lagged school-opening indicator for lag 0 through 9 days. The model adjusted for factors that may influence morbidity. There were 86 731 ED visits within the study period. RESULTS: Asthma ED visits for children aged 5 to 11 years were significantly associated with school opening day, with the highest lagged rate ratio being 1.46 (95% confidence interval [CI], 1.29-1.65). For children aged 2 to 4 years, the highest rate ratio was 1.19 (95% CI, 1.06-1.35), and for children aged 12 to 17 years, the highest lagged rate ratio was 1.13 (95% CI, 0.98-1.31). The rise in adult ED visits following school opening was less substantial, with the highest lagged rate ratio being 1.07 (95% CI, 1.00-1.14). CONCLUSION: The start of the September school year was associated with increases in pediatric asthma ED visits, particularly among grade school children.     

Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children

OBJECTIVES: To determine whether an organized, citywide asthma management program delivered by primary care providers (PCPs) increases adherence to the National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines and whether adherence to the guidelines by PCPs decreases medical services utilization in low-income, minority children. STUDY DESIGN: Analysis of the utilization of medical services for a cohort of 3748 children with asthma who presented for care at one of six primary care urban clinics in Hartford, Connecticut, and who were enrolled in a disease management program (Easy Breathing) between June 1, 1998 and August 31, 2002. RESULTS: Of the 3748 children with physician-confirmed asthma, 48% had persistent disease. Paid claims for inhaled corticosteroids increased 25% ( P <.0001) after enrollment in Easy Breathing. Provider adherence to the NAEPP guidelines for anti-inflammatory therapy increased from 38% to 96%. Easy Breathing children with asthma experienced a 35% decrease in overall hospitalization rates ( P <.006), a 27% decrease in asthma emergency department (ED) visits ( P <.01), and a 19% decrease in outpatient visits ( P <.0001). CONCLUSIONS: An organized, disease management program increased adherence to the NAEPP guidelines for anti-inflammatory use by PCPs in urban clinics. Adherence to this element of the guidelines by PCPs reduced hospitalizations, ED visits, and outpatient visits for children with asthma.     

Educational intervention by computer in childhood asthma: a randomized clinical trial testing the use of a new teaching intervention in childhood asthma

To affect asthma-related knowledge, behavior, and morbidity, researchers tested a new educational intervention for children with asthma: an asthma-specific computer game called Asthma Command, which was specifically designed for this study. Sixty-five children with moderately severe asthma were randomly assigned to one of two groups, and 54 completed the study. Both groups were seen approximately six times during the 1 year of the study. Control subjects (n = 29) played routine computer games. Experimental subjects (n = 25) played Asthma Command. Compared with children in the control group, experimental subjects showed improvement in knowledge about asthma (P less than .001), behavior related to the management of asthma (P less than .008), and a trend toward the reduction of acute visits due to asthma (P less than .13). Children in the experimental group also scored higher on the assessment of behaviors related to the management of asthma that were specifically addressed by the intervention provided by Asthma Command (P less than .01). Differences between the control and experimental groups showed a greater improvement in the experimental group in 21 (84%) of the 25 outcome variables in the study (P = .004, Sign test). The study indicates that an asthma-specific computer game can significantly affect knowledge and behavior and may potentially affect morbidity in childhood asthma.     

Deprivation, smoking, and quality of life in asthma.

AIMS: To explore associations of deprivation and smoking, with prevalence of asthma, wheeze, and quality of life. METHODS: Survey, using International Study of Asthma and Allergies in Childhood (ISAAC) methodology, of children aged 13-14 years attending Scottish schools previously surveyed in 1995. RESULTS: 4665/5247 (89%) pupils completed questionnaires. 3656/4665 (78.4%) had missed school for any reason in the last 12 months, 587 (12.6%) because of asthma or wheeze. Compared to children with 1-3 wheeze attacks per year, those with >12 attacks in the last year were more likely to have missed school, twice as likely to have missed physical education in the last month, to report interference with home activities, or to have visited accident and emergency departments, and three times more likely to have been hospitalised. Deprivation was not independently associated with self-reported asthma or wheeze, but was associated with school absence, either for any reason or specifically for asthma or wheeze, but not with use of services such as accident and emergency visits, doctor visits, or hospital admissions. Active smoking was associated with wheezy symptoms, and active and passive smoking with use of medical services. These associations were independent of wheeze severity, treatment taken, and other associated atopic conditions. Smoking also had an impact on school absence and home and school activities. CONCLUSIONS: Deprivation does not affect the prevalence of asthma or wheeze. Exposure to cigarette smoke was associated with the increased use of services. Deprivation and smoking have independent adverse effects on the quality of life in subjects with asthma or wheeze.     

Deprivation, smoking, and quality of life in asthma

Aims: To explore associations of deprivation and smoking, with prevalence of asthma, wheeze, and quality of life. Methods: Survey, using International Study of Asthma and Allergies in Childhood (ISAAC) methodology, of children aged 13–14 years attending Scottish schools previously surveyed in 1995. Results: 4665/5247 (89%) pupils completed questionnaires. 3656/4665 (78.4%) had missed school for any reason in the last 12 months, 587 (12.6%) because of asthma or wheeze. Compared to children with 1–3 wheeze attacks per year, those with >12 attacks in the last year were more likely to have missed school, twice as likely to have missed physical education in the last month, to report interference with home activities, or to have visited accident and emergency departments, and three times more likely to have been hospitalised. Deprivation was not independently associated with self-reported asthma or wheeze, but was associated with school absence, either for any reason or specifically for asthma or wheeze, but not with use of services such as accident and emergency visits, doctor visits, or hospital admissions. Active smoking was associated with wheezy symptoms, and active and passive smoking with use of medical services. These associations were independent of wheeze severity, treatment taken, and other associated atopic conditions. Smoking also had an impact on school absence and home and school activities. Conclusions: Deprivation does not affect the prevalence of asthma or wheeze. Exposure to cigarette smoke was associated with the increased use of services. Deprivation and smoking have independent adverse effects on the quality of life in subjects with asthma or wheeze.     

Health-related quality of life in overweight and nonoverweight black and white adolescents

OBJECTIVES: To assess the impact of obesity on quality of life (QOL) in black and white adolescents. STUDY DESIGN: One hundred ten overweight (body mass index [BMI], 41.7 +/- 8.9 kg/m2) and 34 nonoverweight adolescents (BMI, 20.6 +/- 2.9 kg/m2) and their parents completed measures of QOL. RESULTS: Overweight was associated with poorer adolescent-reported QOL and parent reports of their children's QOL. Examining groups by weight status and race, overweight whites reported the greatest impairment on Social/Interpersonal, Self-Esteem, and Physical Appearance QOL (all P < .01), whereas parents of overweight blacks reported the poorest General Health Perceptions scores regarding their children. Interactions between BMI z-score and race were detected for Social/Interpersonal, Self-esteem, Daily Living, Self-Efficacy, Self-regard, and Physical Appearance QOL (all P < .05): Higher BMI in whites was associated with greater impairments in QOL than in blacks. Parents reported similar relations for their children. CONCLUSIONS: According to adolescent and parent reports, overweight is associated with poorer QOL in adolescence, regardless of race; however, compared with overweight white adolescents, blacks report less impairment in QOL. Future research is required to determine whether differences in QOL are predictive of treatment success.     

Stressful life events and asthma in adolescents

Recent studies suggest that psychosocial factors may contribute to asthma. We examined associations of stressful life events with asthma prevalence and morbidity among Chicago adolescents. Self-reported asthma, measures of asthma morbidity, and 15 life events were collected from 2026 seventh to ninth grade students from 34 Chicago Catholic schools as part of the International Study of Allergies and Asthma in Childhood in 1994–95. Life events were reported by 77% of adolescents and overall asthma prevalence was 15.5%. Stressful life events in adolescents were significantly related to both asthma and asthma morbidity. Odds of asthma was 1.44 (95% confidence interval [CI] = 1.07, 1.95) for those reporting two to three stressful events and 1.92 (95% CI = 1.41, 2.62) for subjects endorsing more than three stressful events. In adolescents with asthma, number of asthma symptoms (odds ratio [OR] for increase in one event = 1.16, 95% CI = 1.07, 1.27), asthma-related school absenteeism (OR = 1.17, 95% CI = 1.04, 1.32), physician visits for asthma (OR = 1.16, 95% CI = 1.04, 1.29), and hospitalization for asthma (OR = 1.20, 95% CI = 1.001, 1.44) were significantly associated with the number of stressful events, independent of home exposure to cigarette smoke and dampness, use of inhaled substances, and sociodemographic factors. While these results are not sufficient to assign causality in the relationship between stress and asthma, they are supported by a number of other studies and by plausible biologic mechanisms. Assessing and addressing the effects of stressful life events may be helpful in managing asthma in inner city adolescents.     

Predictors of health care utilization of children with asthma in the community

The aim of this study was to assess the pattern of use of health care services among children with asthma symptoms within the community, and assess groups at increased risk of emergency department (ED) visits or hospital admissions (HA). Using International Study of Asthma and Allergies in Childhood phase II protocol, information about asthma management and utilization of health care services was collected by parental questionnaire in a community-based random sample of 5–7- and 9–11-year-old children (n = 11,094) in Dresden and Munich. Only 11.2% of children with current wheeze did not utilize any health care facility or consultation for their asthma symptoms in the 12 months prior to survey, while 86.2%, 12.3%, and 3.6% had at least one asthma related physician's consultation, ED visits, or HA, respectively. Predictors of ED visits and HA among current wheezers were: younger age, male gender, speech-limiting wheeze, level of exposure to environmental tobacco smoke. In addition, children of low socioeconomic status were more likely to have ED visits because of their asthma. Childhood asthma is a major public health problem in Germany leading to substantial morbidity and utilization of health care services. Exposure to tobacco smoke comes out as the major modifiable risk factor related to asthma morbidity in children.     

Improving follow-up for children with asthma after an acute Emergency Department visit

OBJECTIVE: To improve follow-up with primary care providers after acute Emergency Department (ED) asthma visits for children from low-income urban families. STUDY DESIGN: A prospective, randomized, controlled trial evaluated combined telephone asthma coaching and monetary incentive. The primary outcome was asthma-planning visits with primary care providers within 15 days of index ED visits. The subjects were urban parents whose children were treated for asthma in the ED and had Medicaid or no insurance. RESULTS: We enrolled 527 parents (264 control and 263 intervention). There was a significant difference ( P < .0001) between the intervention (35.7%) and control (18.9%) groups in the proportion of children who had asthma-planning visits and decreased mean nights/days with asthma symptoms by 4.36 intervention and 3.31 control at 2 weeks. The proportions of children with asthma-planning visits and acute asthma care visits during the 16-day to 6-month period were similar for both groups. CONCLUSIONS: Telephone coaching and a monetary incentive significantly increased the proportion of low-income urban parents who brought their children for asthma-planning visits, and decreased asthma symptoms shortly after asthma ED visits. The intervention did not increase subsequent asthma-planning visits or decrease ED visits or hospitalizations.     

Issues affecting young people with asthma through the transition period to adult care

Asthma is among the most common medical conditions affecting children and young people, with adolescence a recognised period of increased risk, overrepresented in analyses examining recent increasing asthma mortality rates. Asthma may change significantly during this period and management also occurs in the context of patients seeking increased autonomy and self-governance whilst navigating increasing academic and social demands. A number of disease factors can destabilise asthma during adolescence including: increased rates of anaphylaxis, anxiety, depression, obesity, and, in females, an emerging resistance to corticosteroids and the pro-inflammatory effects of oestrogen. Patient factors such as smoking, vaping, poor symptom recognition, treatment non-adherence and variable engagement with health services contribute to difficult to treat asthma.Significant deficiencies in the current approach to transition have been identified by a recent EAACI task force, and subsequent asthma-specific recommendations, published in 2020 provide an important framework moving forward. As with other chronic conditions, effective transition programmes plan ahead, engage with adolescents and their families to identify the patients’ management priorities and the current challenges they are experiencing with treatment. Transition needs may vary significantly across asthma patients and for more complex asthma may include dedicated transition clinics involving multidisciplinary care requiring input including, amongst others, allergy and immunology, psychological medicine, respiratory physicians and scientists and nurse specialists. Across different global regions, barriers to treatment may vary but need to be elicited and an individualised approach taken to optimising asthma care which is sustainable within the local adult healthcare system.     

以健康测量量表评价癫及哮喘患儿生活质量的对照研究

摘要 目的 以健康测量量表（SF 36）评估癫痫及哮喘患儿的生活质量。方法 采用SF-36量表对2007年6至12月在复旦大学附属儿科医院神经专科、呼吸专科及儿童保健门诊就诊的癫痫患儿、哮喘患儿和健康儿童进行生活质量评定。结果 研究期间85例癫痫患儿（癫痫组）、81例哮喘患儿（哮喘组）和87名健康儿童（正常对照组）进入分析。3组儿童的年龄、性别和受教育程度相匹配。①疾病及治疗情况：癫痫组和哮喘组服用1种药物者分别为70/85例和59/81例,癫痫组63/85例和哮喘组56/81例患病后规则服药,两组在服药种类和依从性上差异无统计学意义（P均＞0.05）;癫痫组36/85例至本次调查前至少有1年癫痫未发作;哮喘组29/81例最大呼气峰流速监测持续保持个人最佳值的80％以上。②生活质量评价：癫痫组的生活质量总分和8个分项的终得分与正常对照组差异均有统计学意义（P<0.01）;哮喘组的生活质量总分及生理功能、身体疼痛、总体健康和活力4个分项的终得分与正常对照组差异均有统计学意义（P<0.01）;无论疾病控制与否,癫痫组生活质量均较哮喘组差;癫痫组情感功能及精神健康状况明显差于哮喘组,其心理障碍不随疾病控制而明显改善。结论 ①癫痫和哮喘患儿生活质量较健康儿童明显下降;②癫痫患儿较哮喘患儿生活质量损害更为明显;③SF-36量表可作为评价疾病控制程度的手段,辅助评价疾病治疗的疗效;④癫痫 患儿的心理障碍应引起临床高度关注。     

Comprehensive environmental management of asthma and pediatric preventive care

To cite this article: Roy A, Downes MJ, Wisnivesky JP. Comprehensive environmental management of asthma and pediatric preventive care. Pediatr Allergy Immunol 2011; 22 : 277–282. Indoor environmental triggers can increase asthma morbidity. National guidelines recommend comprehensive use of environmental control practices (ECPs) as a component of asthma management. The purpose of this study was to examine the association between preventive asthma care and comprehensive ECP use among children with asthma. We used data from the National Asthma Survey, including 1,921 children with asthma. Comprehensive use was defined as using at least five of eight ECPs: (i) air filter, (ii) dehumidifier, (iii) mattress cover, (iv) pillow cover, (v) pet avoidance, (vi) smoke avoidance, (vii) removing carpets, and (viii) washing sheets in hot water. Univariate and multiple regression analyses were conducted to examine the association between comprehensive use of ECPs and receipt of preventive asthma care, as measured by number of routine asthma visits in the prior year and physician advice to modify the environment. Overall, 17% (95% CI: 14–19%) of participants had comprehensive ECP use. The most commonly used practices were ‘smoke avoidance’ (85%), ‘pet avoidance’ (59%), and ‘washing sheets in hot water’ (46%). Comprehensive use of ECPs was associated with having received physician advice [odds ratio (OR) 3.1, 95% CI: 2.2–4.4] and increased asthma visits (1–2 visits: OR 1.5, 95% CI: 1.0–2.4; 3–4 visits: OR 2.2, 95% CI: 1.3–3.8; ≥5 visits: OR 2.7, 95% CI: 1.5–4.8). Only a minority of parents implement comprehensive ECPs, and receipt of preventive asthma care is associated with comprehensive use. Further research is needed to determine the factors mediating these associations in order to inform more effective asthma counseling.     

Association of food allergy with asthma severity and atopic diseases in Jewish and Arab adolescents

Aim: To investigate the prevalence of reported food allergy and its association with atopic diseases and asthma severity among Jewish and Arab adolescents. Subjects and methods: The self‐report questionnaire of the International Study of Asthma and Allergies in Childhood (ISAAC) was administered to adolescents aged 13–14 years from randomly selected junior high schools in Israel. Questions regarding food allergy were added. Results: A total of 11 171 questionnaires were available for analysis. Food allergy was reported by 3.6% of participants: 1.9% milk, 0.6% egg, 0.6% peanut and 0.4% sesame. On multivariate analysis, food allergy was strongly associated with current asthma (OR, 2.5; 95% CI, 1.8–3.3), atopic eczema (OR, 3.2; 95% CI, 2.4–4.3) and allergic rhinitis (OR, 2.4; 95% CI, 1.8–3.1). Arabs were significantly more allergic to peanut (OR, 2.5; 95% CI, 1.5–4.1), egg (OR, 3.5; 95% CI, 2.1–5.9) and sesame (OR, 2.3; 95% CI, 1.2–4.5) than Jews, and less allergic to milk (OR, 0.6; 95% CI, 0.4–0.9). Asthmatic subjects with food allergy had significantly more parameters of severe asthma than those without food allergy (p < 0.001). Conclusions: The prevalence of allergy to specific foods differs between Jews and Arabs. Asthmatic adolescents with food allergy report more severe asthma than those without food allergy.     

Health consequences for children with undiagnosed asthma-like symptoms

BACKGROUND: A growing body of evidence indicates that there are a substantial number of children who report asthma-like symptoms and are not diagnosed with asthma. However, there is little information on the health consequences of asthma-like symptoms for children with these symptoms and no asthma diagnosis. OBJECTIVE: To assess the prevalence and health consequences (school absences, sleep disturbances, activity limitations, physician visits, emergency department visits, and hospitalizations) of asthma-like symptoms among children with and without physician diagnosis. STUDY DESIGN: We surveyed 122 829 children aged 12 to 14 years in 499 North Carolina public middle schools. A standardized questionnaire (International Study of Asthma and Allergies in Childhood [ISAAC]) containing video scenes of adolescents experiencing asthma-like symptoms was adapted to include questions on health consequences. RESULTS: Seventeen percent (n = 21 184) reported current asthma-like symptoms with no diagnosis of asthma (during the last 12 months.) Eleven percent (n = 13 619) of the children reported physician-diagnosed asthma with current asthma-like symptoms. Of the children with asthma-like symptoms and no diagnosis of asthma, 20% missed a half day or more of school per month because of wheeze, 25% had limited activities because of wheeze once or more per month, and 32% had sleep disturbances because of wheeze in the last 4 weeks. Seven percent of children with current asthma-like symptoms but no diagnosis reported 1 or more emergency department visits for asthma-like symptoms, and 5% reported wheeze-related hospitalizations in the last year. Of children with physician-diagnosed asthma, almost half (47%) reported missing a half day or more of school in the last month. Thirty percent of physician-diagnosed children reported 1 or more emergency department visits in the last year for asthma-like symptoms. CONCLUSIONS: The health consequences of asthma-like symptoms in children with no diagnosis are substantial; these children are essentially untreated. Better detection of this disease group by the medical community has the potential to improve health consequences for these children.     

How do ethnicity and primary language spoken at home affect management practices and outcomes in children and adolescents with asthma?

BACKGROUND: Lower rates of preventive medication use and higher rates of hospitalization and emergency department use have been documented among Latino children and adolescents with asthma. However, little is known about how language barriers influence asthma management practices and outcomes. OBJECTIVE: To examine the effects of language on asthma management practices and asthma-related outcomes. DESIGN: Cross-sectional survey of asthma management practices, perceived efficacy, asthma knowledge, family functioning, and health-related quality of life in 405 white non-Latino, African American non-Latino, and Latino children and adolescents from English- and Spanish-speaking homes. RESULTS: Latino children and adolescents from Spanish-speaking homes had lower rates of goal setting and peak flow monitoring, poorer asthma knowledge, and greater negative family impact than white children and adolescents (P < .05 for all). Although Latino children and adolescents from English-speaking homes did worse than their non-Latino white peers, the decrements were modest and not statistically significant (P>.16 for all). Management practices and outcomes for non-Latino African American children and adolescents closely approximated those of white children and adolescents. CONCLUSIONS: Language barriers seem to contribute to poorer asthma management practices and knowledge among Latino children and adolescents. Efforts to increase knowledge in this group may enhance asthma self-care and limit the morbidity associated with asthma.     

Doctor shopping before and after a visit to a paediatric emergency department

BACKGROUND:

Use of multiple care providers is known to be associated with poor continuity of care.

OBJECTIVES:

To estimate the prevalence of and identify risk factors for doctor shopping by parents of children with common acute illnesses seen in the emergency department (ED) of a children’s hospital.

SETTING:

ED at the Montreal Children’s Hospital (MCH), Montreal, Quebec.

METHODS:

Doctor shopping was defined as visiting three or more different care sites (the MCH ED, other EDs, outpatient clinics or private offices) for a single illness episode, including all visits occurring within successive 72 h periods up to a maximum of 15 days before and after an ED visit from April 1995 to March 1996. Logistic regression was used to compare characteristics of illness episodes with doctor shopping versus those without.

RESULTS:

Of the total 40,150 visits during the study period, doctor shopping was observed in 18% of the visits. The risk of doctor shopping was positively associated with an initial visit at other EDs (odds ratio [OR] 9.08, 95% CI 7.16 to 11.52), outpatient clinics (OR 4.47, 95% CI 3.71 to 5.37) or private offices (OR 1.71, 95% CI 1.48 to 1.96) versus those who visited the MCH ED first. The risk did not differ according to whether a paediatrician versus a general practitioner saw the child during the initial visit (OR 0.99, 95% CI 0.86 to 1.15). Some diagnoses (the reference category was upper respiratory infection), including urinary tract infection (OR 3.31, 95% CI 2.58 to 4.23) and gastroenteritis (OR 1.59, 95% CI 1.35 to 1.88), were associated with an increased risk of doctor shopping, while asthma was associated with a reduced risk (OR 0.71, 95% CI 0.60 to 0.86).

CONCLUSION:

Doctor shopping is common among parents of children with acute illnesses. Parents of children who were seen in the MCH ED first were less likely to doctor shop, perhaps because the parents were more confident about the advice and treatment received. Further research should investigate the underlying reasons for doctor shopping, eg, services other than an ED were not available and parents’ perceptions of the quality of health services.     

Maternal depressive symptoms and emergency department use among inner-city children with asthma

CONTEXT: Inner-city minority children with asthma use emergency departments (ED) frequently. OBJECTIVE: To examine whether maternal depressive symptoms are associated with ED use. DESIGN, SETTING, AND PATIENTS: Baseline and 6-month surveys were administered to mothers of children with asthma in inner-city Baltimore, Md, and Washington, DC. MAIN OUTCOME MEASURES: Use of the ED at 6-month follow-up was examined. Independent variables included asthma morbidity, age, depressive symptoms, and other psychosocial data. RESULTS: Among mothers, nearly half reported significant levels of depressive symptoms. There were no demographic or asthma-related differences between the children of mothers with high and low depressive symptoms. However, in bivariate analyses, mothers with high depressive symptoms were 40% (prevalence ratio [PR], 1.4; 95% confidence interval [CI], 1.0-3.6; P =.04) more likely to report taking their child to the ED. Mothers aged 30 to 35 years were more than twice as likely (PR, 2.2; 95% CI, 1.9-9.3; P =.001) to report ED use, as were children with high morbidity (PR, 1.9; 95% CI, 1.4-7.1; P =.006). Child age and family income were not predictive of ED use. After controlling for asthma symptoms and mother's age, mothers with depressive symptoms were still 30% more likely to report ED use. CONCLUSIONS: Depression is common among inner-city mothers of children with asthma. Beyond asthma morbidity, maternal age and depressive symptoms are strong predictors of reports of ED visits. Identifying and addressing poor psychological adjustment in mothers may reduce unnecessary ED visits and optimize asthma management among inner-city children.