Dataset Information

Association of an Asthma Improvement Collaborative With Health Care Utilization in Medicaid-Insured Pediatric Patients in an Urban Community.

ABSTRACT:

Importance

Asthma is the most common chronic condition of childhood. Hospitalizations and emergency department (ED) visits for asthma are more frequently experienced by minority children and adolescents and those with low socioeconomic status.

Objective

To reduce asthma-related hospitalizations and ED visits for Medicaid-insured pediatric patients residing in Hamilton County, Ohio.

Design, setting, and participants

From January 1, 2010, through December 31, 2015, a multidisciplinary team used quality-improvement methods and the chronic care model to conduct interventions in inpatient, outpatient, and community settings in a large, urban academic pediatric hospital in Hamilton County, Ohio. Children and adolescents aged 2 to 17 years who resided in Hamilton County, had a diagnosis of asthma, and were Medicaid insured were studied.

Interventions

Interventions were implemented in 3 phases: hospital-based inpatient care redesign, outpatient-based care enhancements, and community-based supports. Plan-do-study-act cycles allowed for small-scale implementation of change concepts and rapid evaluation of how such tests affected processes and outcomes of interest.

Main outcomes and measures

The study measured asthma-related hospitalizations and ED visits per 10 000 Medicaid-insured pediatric patients. Data were measured monthly on a rolling 12-month mean basis. Data from multiple previous years were used to establish a baseline. Data were tracked with annotated control charts and with interrupted time-series analysis.

Results

Of the estimated 36 000 children and adolescents with asthma in Hamilton County (approximately 13 000 of whom are Medicaid insured and 6000 of whom are cared for in Cincinnati Children's Hospital primary care practices), asthma-related hospitalizations decreased from 8.1 (95% CI, 7.7-8.5) to 4.7 (95% CI, 4.3-5.1) per 10 000 Medicaid patients per month by June 30, 2014, a 41.8% (95% CI, 41.7%-42.0%) relative reduction. Emergency department visits decreased from 21.5 (95% CI, 20.6-22.3) to 12.4 (95% CI, 11.5-13.2) per 10 000 Medicaid patients per month by June 30, 2014, a 42.4% (95% CI, 42.2%-42.6%) relative reduction. Improvements were sustained for the subsequent 12 months. The proportion of patients who were rehospitalized or had a return ED visit for asthma within 30 days of an index hospitalization was reduced from 12% to 7%. The proportion of patients with documented well-controlled asthma in this study's primary care population increased from 48% to 54%.

Conclusions and relevance

An integrated, multilevel approach focused on enhancing availability and accessibility of treatments, removing barriers to adherence, mitigating multidomain risks, augmenting self-management, and creating a collaborative relationship between the family and the health care system was associated with improved asthma outcomes for a population of Medicaid-insured pediatric patients. Similar models used in accountable care organizations or across patient panels and with other chronic conditions could be feasible and warrant evaluation.

SUBMITTER: Kercsmar CM

PROVIDER: S-EPMC5710369 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:Opioids are vital to pain management and sedation after trauma-related hospitalization. However, there are many confounding clinical, social, and environmental factors that exacerbate pain, post-injury care needs, and receipt of opioid prescriptions following orthopaedic trauma. This retrospective study sought to characterize differences in opioid prescribing and dosing in a national Medicaid eligible sample from 2010-2018. The study population included adults, discharged after orthopaedic trauma hospitalization, and receiving an opioid prescription within 30 days of discharge. Patients were identified using the International Classification of Diseases (ICD-9; ICD-10) codes for inpatient diagnosis and procedure. Filled opioid prescriptions were identified from National Drug Codes and converted to morphine milligram equivalents (MME). Opioid receipt and dosage (e.g., morphine milligram equivalents [MME]) were examined as the main outcomes using regressions and analyzed by year, sex, race/ethnicity, residence rurality-urbanicity, and geographic region. The study population consisted of 86,091 injured Medicaid-enrolled adults; 35.3% received an opioid prescription within 30 days of discharge. Male patients (OR = 1.12, 95% CI: 1.07-1.18) and those between 31-50 years of age (OR = 1.15, 95% CI: 1.08-1.22) were found to have increased odds ratio of receiving an opioid within 30 days of discharge, compared to female and younger patients, respectively. Patients with disabilities (OR = 0.75, 95% CI: 0.71-0.80), prolonged hospitalizations, and both Black (OR = 0.87, 95% CI: 0.83-0.92) and Hispanic patients (OR = 0.72, 95% CI: 0.66-0.77), relative to white patients, had lower odds ratio of receiving an opioid prescription following trauma. Additionally, Black and Hispanic patients received lower prescription doses compared to white patients. Individuals hospitalized in the Southeastern United States and those between the ages of 51-65 age group were found to be prescribed lower average daily MME. There were significant variations in opioid prescribing practices by race, sex, and region. National guidelines for use of opioids and other pain management interventions in adults after trauma hospitalization may help limit practice variation and reduce implicit bias and potential harms in outpatient opioid usage.

Project description:ImportanceAn intervention model (the Parent-focused Redesign for Encounters, Newborns to Toddlers; the PARENT intervention) for well-child care that integrates a community health worker into preventive care services may enhance early childhood well-child care.ObjectiveTo examine the effectiveness of the PARENT intervention vs usual care for parents with children younger than 2 years of age.Design, setting, and participantsA cluster randomized clinical trial was conducted between March 2019 and July 2022. Of the 1283 parents with a child younger than 2 years of age presenting for a well-child visit at 1 of the 10 clinic sites (2 federally qualified health centers in California and Washington) approached for trial participation, 937 were enrolled.InterventionFive clinics implemented the PARENT intervention, which is a team-based approach to care that uses a community health worker in the role of a coach (ie, health educator) as part of the well-child care team to provide comprehensive preventive services, and 5 clinics provided usual care.Main outcomes and measuresThere were 2 primary outcomes: score for parent-reported receipt of recommended anticipatory guidance during well-child visits (score range, 0-100) and emergency department (ED) use (proportion with ≥2 ED visits). The secondary outcomes included psychosocial screening, developmental screening, health care use, and parent-reported experiences of care.ResultsOf the 937 parents who were enrolled, 914 remained eligible to participate (n = 438 in the intervention group and n = 476 in the usual care group; 95% were mothers, 73% reported Latino ethnicity, and 63% reported an annual income <$30 000). The majority (855/914; 94%) of the children (mean age, 4.4 months at parental enrollment) were insured by Medicaid. Of the 914 parents who remained eligible and enrolled, 785 (86%) completed the 12-month follow-up interview. Parents of children treated at the intervention clinics (n = 375) reported receiving more anticipatory guidance than the parents of children treated at the usual care clinics (n = 407) (mean score, 73.9 [SD, 23.4] vs 63.3 [SD, 27.8], respectively; adjusted absolute difference, 11.01 [95% CI, 6.44 to 15.59]). There was no difference in ED use (proportion with ≥2 ED visits) between the intervention group (n = 376) and the usual care group (n = 407) (37.2% vs 36.1%, respectively; adjusted absolute difference, 1.2% [95% CI, -5.5% to 8.0%]). The effects of the intervention on the secondary outcomes included a higher amount of psychosocial assessments performed, a greater number of parents who had developmental or behavioral concerns elicited and addressed, increased attendance at well-child visits, and greater parental experiences with the care received (helpfulness of care).Conclusions and relevanceThe intervention resulted in improvements in the receipt of preventive care services vs usual care for children insured by Medicaid by incorporating community health workers in a team-based approach to early childhood well-child care.Trial registrationClinicalTrials.gov Identifier: NCT03797898.