PROPOSAL FOR IMPROVED CARE AND REDUCED HEALTH CARE COST IN PEDIATRIC ASTHMA 公开

Salerno, Angela Kim (2012)

Permanent URL: https://etd.library.emory.edu/concern/etds/qb98mf538?locale=zh
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Abstract

This paper describes pediatric asthma and its medical and financial burden in the
United States. Asthma is the third leading cause for hospitalizations in pediatrics,
costing $8 billion in 2006. Asthma is not preventable, but solutions exist to
decrease exacerbations, Emergency Department visits, and hospitalizations.
Significant racial, ethnic, and socioeconomic disparities exist in disease burden,
treatment, and provider-patient perceptions regarding care. Lower socio-
economic status is also associated with more environmental asthma triggers.
Public insurance programs shoulder a disproportionate burden of healthcare
costs. Additional societal burdens include missed school days, days of decreased
activity, and missed parent workdays.
The National Asthma Education and Prevention Program under the auspices of
the National Institutes for Health has four recommendations to decrease asthma
morbidity: use of asthma action plans, use of controller medications, reduction of
environmental allergens, and regular assessment and monitoring. Many children
are not receiving recommended care.
Current studies indicate the best success is through comprehensive care that
encompasses all four recommendations. Several urban-based programs have
made great strides in decreasing asthma morbidity among their pediatric
population. Only one has completed a thorough cost-analysis. Boston's
Community Asthma Initiative's return on investment was $1.46 for every dollar
invested. Medical home models used both in urban and rural areas also show
promise by decreasing emergency department visits and hospitalizations, but
have not been studied for pediatric asthma specifically.
Arguments for policy changes are strongly backed by current research; the
potential of additional effective policy changes can be discerned with two
additional cost-analyses and impact studies, as recommended below:
1) Environmental remediation with chemical-free allergen and pest removal
should be part of standard medical care for high-risk asthma patients. By
bundling with the other medical interventions, it has proven to be cost-
effective.
2) Emergency Department-based comprehensive care including
environmental assessments and remediation, similar to Boston's program,
should be implemented in high asthma burden areas throughout the U.S.
3) Further research is needed in pediatric medical home and primary care
models to discover their effects on childhood asthma morbidity.
4) Cost-analyses and impact studies for environmental remediation in non-
urban areas should be conducted.

Table of Contents

TABLE OF CONTENTS
Table of Figures ................................................................................. ii
List of Terms..................................................................................... iii
Introduction .......................................................................................1
Background ........................................................................................1

Pediatric Asthma Burden in the U.S.................................................1
Health Service Utilization ............................................................... 4

Disparities ..........................................................................................7
Health Care......................................................................................7
Environmental Factors ..................................................................10
Social Determinants ...................................................................... 11
Perceptions....................................................................................13

Medicaid, CHIP, and Children .......................................................... 17
Current Programs............................................................................ 24

Overview....................................................................................... 25
Boston's Community Asthma Initiative......................................... 28
Community Care of North Carolina .............................................. 35
Federally Qualified Health Centers ............................................... 38

Cost and Implementation .................................................................41
Recommendations ........................................................................... 43
References ........................................................................................47
Appendix A: Policy Recommendation .............................................. 52






ii
TABLE OF FIGURES:

Figure 1: The proportional impact of asthma prevalence, health care use and
mortality among children 0-17 years of age, by race and ethnicity, United States
2003-2005 ............................................................................................................... 4
Figure 2: Reasons for Preventability of Hospitalizations, According to Parents,
PCPs, and IAPs of Children Who Were Hospitalized With a Primary Diagnosis of
Asthma (n=230)...................................................................................................... 17
Figure 3: Children's Eligibility for Medicaid/CHIP by Income, January 2012...19
Figure 4: Children's Medicaid/CHIP Participation Rates, 2009 ........................21
Figure 5: Health Insurance Coverage of Children by Income and Race, 2009.. 23
Figure 6: CAI's Health Outcomes at Baseline, 6, and 12 Month Follow-Up
(n=544) .................................................................................................................. 32
Figure 7: Cost of ED Visits and Hospitalizations for CAI Patients and
Comparison Group 1 Year Back and 2 Years Forward.......................................... 33
Figure 8: Key Components of Community Care of North Carolina ....................37


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