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* From the Harlem Lung Center, Harlem Lung Center and the Joseph L. Mailman School of Public Health at Columbia University, New York, NY.
Correspondence to: Jean G. Ford, MD, FCCP, Harlem Hospital Center, Harlem Lung Center, 506 Lenox Ave, MLK 12–106, New York, NY 10037; e-mail: jf24{at}columbia.edu
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Abstract |
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Design: A cross-sectional survey.
Setting: Harlem Hospital Center ED and outpatient chest clinic.
Participants: Three hundred seventy-five adult residents of Harlem, a predominantly African-American community in New York City.
Measurements: Asthma severity was assessed by self-reported symptoms using National Asthma Education and Prevention Program guidelines, health-care utilization, and psychometric scales.
Results: Respondents with more severe asthma were more likely to have a primary asthma care provider, and to have had more scheduled office visits for asthma in the year prior to the interview (mean number of visits for patients with severe asthma, 3.6 visits; moderate asthma, 2.4 visits; and mild asthma, 1.7 visits). Despite having a regular source of care, 69% of respondents identified the ED as their preferred source of care; 82% visited the ED more than once in the year prior to interview (median, four visits). Persons with moderate or severe asthma were 3.8 times more likely to be frequent ED users compared to those with mild asthma (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.2 to 6.6). This was the strongest predictor of frequent ED use. Other predictors of ED use were number of comorbid disorders (OR, 1.5; 95% CI, 1.1 to 2.1) and self-reported global health in the year prior to the ED visit (OR, 1.8; 95% CI, 1.2 to 2.7). Psychological characteristics were not predictive of frequent ED use when controlling for disease severity.
Conclusions: Frequent ED users present with serious medical conditions. They do not substitute physician care with ED care; they augment it to address serious health needs.
Key Words: access • African American • asthma • emergency department • psychosocial • severity • urban • utilization
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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ED visits for asthma usually indicate a failure of available primary care, and most of these visits can be prevented.6 7 8 Through improvement of patient asthma management skills, provision of appropriate pharmacotherapy, and avoidance of known triggers of asthma exacerbations, there can be a reduction of symptoms and exacerbations and a return to normal or near-normal lung function.6 Frequent ED use for asthma also is associated with an elevated risk for near-fatal and fatal episodes.9 10 Nevertheless, ED visits remain the primary if not sole source of care for many low-income people with asthma in urban areas, and are a major source of asthma-related costs.11 12
Understanding correlates of asthma-related ED visits is essential before proper interventions can be designed to reduce ED use for asthma. Poverty and lack of access to quality health care may be risk factors for ED visits among both children and adults.13 14 15 16 17 18 However, in urban minority communities such as Harlem where poverty is a condition shared by many persons with asthma, it is not clearly understood what distinguishes the frequent users of the ED from those who use it little or not at all. A range of psychosocial factors may contribute to exacerbations ending in ED visits,6 19 20 21 22 23 but little is known about the role of these factors in determining ED use in the context of poverty and poor access to health care. This article presents a study of asthma-related ED use at Harlem Hospital Center, conducted by the Harlem Lung Center. The study was designed to assess criteria used to classify asthma severity and to test the hypotheses that frequent ED use is associated with: (1) poor access to care, (2) psychological risk factors, and (3) asthma severity.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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2 = 3.57; p = 0.06).
Measures Collected With the Comprehensive Asthma Questionnaire
Demographic Characteristics:
These were classified based on
self-report by respondents. Per capita income was calculated by
dividing reported household income by the reported number of household
members.
Asthma Severity:
This was determined using the National
Asthma Education and Prevention Program (NAEPP) 1997 guidelines. We
classified respondents either as mild intermittent/mild persistent or
moderate/severe based on self-reported frequencies of daytime symptoms,
exacerbation episodes, and sleep disturbances due to asthma symptoms
(referred to as "nighttime symptoms"). We also classified
respondents by combining all of these categories, classifying the
respondent in the most severe category for which he or she qualified.
We used classification by nighttime symptoms in analyses of the
associations of severity with other variables.
Health-Care Utilization:
This included the number of ED and
scheduled office visits in the previous year, any history of admission
to a hospital overnight for asthma and to an ICU, and any history of
endotracheal intubation. We defined frequent ED use as two or more
visits for asthma in the year prior to the interview.
Psychological Measures:
These were measured using standard
psychometric questions. Depressive symptoms were assessed using five
items from the Center for Epidemiologic Studies depression
scale.24
The health locus-of-control scale was used to
measure three orientations to control of one’s health: internal,
chance, or powerful others.20
Self-esteem was measured
using Rosenberg’s scale.25
Asthma Knowledge:
This was measured using an 11-item scale
developed as part of the REACH study26
; the score of the
scale indicates percentage of correct responses, ranging from 0 to
100%.
Measures Collected During the ED Visit by Medical Staff
Medical History:
This was recorded during the ED visit based
on self-report to the admitting nurse. It is a count of up to nine
prior conditions: hypertension, diabetes, alcohol abuse, drug abuse,
depression, heart disease, lung disease, pneumonia, and kidney
diseases.
Global Health:
This was recorded from an adopted version of
the global health question from the 36-item Short Form.27
Respondents were asked whether their health before getting sick had
been excellent, very good, fair, or poor.
Statistical Analysis
We used Pearson’s correlation to assess associations between
continuous variables, t tests to assess differences in
continuous variables between groups, and 2
tests to assess associations between categorical variables. We used
logistic regression to assess the simultaneous effect of the risk
factors on predicting ED use. All analyses were conducted using
software (SPSS version 6.1.3; SPSS; Chicago, IL).
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Results |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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12 years of education. Only 24%
of the respondents worked full-time or part-time, and 47% had an
annual household income of $9,000 or less. Forty-six percent were
current smokers, 15% were past smokers, and 39% never smoked.
Twenty-eight percent were classified with comorbid bronchitis, defined
as cough and phlegm most days for 3 months that has lasted at least
2 years.
Asthma Classification:
Venn diagrams depict the overlap among
NAEPP severity classifications for mild intermittent and mild
persistent asthma (Fig 1
) and moderate and severe persistent asthma (Fig 2
). For mild intermittent and mild persistent asthma, classification by
the three criteria (daytime symptoms, nighttime symptoms, and
exacerbations) converged for only 25% of the patients, and
classification by two of the three criteria converged for 36% of the
patients. For moderate and severe persistent asthma, agreement among
criteria was somewhat better: all three criteria converged for 38% and
two criteria converged for 32% of the patients.
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Correlates of Asthma Severity:
Table 1
shows correlates of asthma severity. Severity was unrelated to gender,
age, or employment status. Lower levels of education were related to
moderate and severe persistent asthma. Current smokers and respondents
with bronchitis were more likely to have moderate and severe persistent
asthma. Severity was unrelated to access to health insurance.
Regardless of severity, most respondents said they "relied
primarily" on the ED for their asthma care. Respondents with more
severe disease were more likely to have a health-care provider whom
they identified as a primary asthma care provider, and to have had more
scheduled office visits for asthma in the year prior to the interview
(mean number of visits among patients with severe asthma, 3.6 visits;
moderate asthma, 2.4 visits; and mild asthma, 1.7 visits). Respondents
with severe disease were also more likely to have been hospitalized for
asthma in the year prior to the interview.
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Patterns and Predictors of ED Use
In the 12 months prior to their interview, 304 patients (82%)
visited the ED for asthma two or more times and 68 patients (18%)
visited the ED once. People with more than one visit had a mean of 8.5
visits (SD, 14.7) and a median of 4.0 visits. There were no significant
differences between one-time and frequent ED users in age, gender,
ethnicity, education, employment status, or annual household income
(Table 2 ).
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Disease Severity:
Disease severity as measured by any of the
criteria was related to frequent ED use. Persons with moderate or
severe persistent asthma were 3.8 times more likely to be frequent ED
users compared to those with mild asthma (odds ratio [OR], 3.8; 95%
confidence interval [CI], 2.2 to 6.6). Frequent ED users were also
more likely to report more health problems in addition to asthma (OR,
1.5; 95% CI, 1.1 to 2.1), and to be in poorer general health in the
year prior to the ED visit (OR, 1.8; 95% CI, 1.2 to 2.7).
Utilization of Health Care:
One-time ED users were as
likely as frequent ED users to say that they rely on the ED for their
asthma care (70% vs 69%, not significant). They also did not differ
in access to health insurance; 31% of one-time users vs 23% of
frequent users had no insurance coverage (OR, 0.7; 95% CI, 0.4 to
1.2). However, a history of hospitalization for asthma, ICU use, or
intubation were all significantly associated with frequent ED use (OR,
2.5; 95% CI, 1.2 to 5.5; OR, 10.0; 95% CI, 1.3 to 72.7; and OR, 4.4;
95% CI, 1.3 to 14.6, respectively).
People who visited a doctor’s office for asthma and those who reported having an asthma care provider were significantly more likely than people who did not to be frequent ED users (OR, 2.2; 95% CI, 1.3 to 3.8; and OR, 1.8; 95% CI, 1.1 to 3.1, respectively). Because visiting a doctor’s office for asthma and having an asthma care provider may be indicators of severity, we repeated this using regression analysis controlling for asthma severity. In that analysis, having visited a doctor’s office for asthma remained a significant predictor of frequent ED use (OR, 1.8; 95% CI, 1.1 to 3.4), but having an asthma care provider did not (OR, 1.6; 95% CI, 0.9 to 2.9).
Psychological Characteristics:
There is some evidence of a
relationship between mental health status and frequent ED use. People
with a higher level of depressive symptoms and those who do not
perceive themselves to be in charge of their health (low internal locus
of control) were more likely to be frequent ED users (OR, 1.5; 95% CI,
1.0 to 2.2; and OR, 1.1; 95% CI, 1.0 to 1.1, respectively). But
neither external control orientation (powerful others or chance health
locus of control) nor the respondents’ level of self-esteem was
associated with frequency of ED use. None of these psychological
characteristics remained significant when the analyses were repeated
using regression analysis controlling for asthma severity. In addition,
there was no association between the respondent’s level of asthma
knowledge and ED use.
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Current guidelines6 recommend that patients contact their providers when home management of an evolving exacerbation is unsuccessful. If the patient has access to a medical care provider at a time of crisis and with the administration of appropriate therapy, most asthma exacerbations should not result in an ED visit. But approximately 70% of our respondents, regardless of disease severity, access to a primary asthma care provider, or health insurance status, relied on the ED as the main source of care. This raises a question whether provider assistance in crisis management is functionally inaccessible for most patients, or whether patients simply prefer to utilize the ED during an exacerbation. In our community, having visited a physician’s office for asthma and having an asthma care provider were related to increased frequency of ED use. A plausible explanation is that a visit to a physician’s office for asthma and having an asthma care provider may be themselves indicators of severity.27 When controlled for disease severity, however, the association between a visit to a physician for asthma (but not to specialty care) remained a significant predictor of frequent ED use. Only specialty care for asthma was protective against frequent ED visits. General medical care alone, even when available, did not prevent repeated ED visits.14
We also found that compared with the one-time users, frequent ED users were more likely to report general health problems in addition to asthma, as indicated by the number of disorders reported in the medical history obtained at the ED and self-reported global health in the year prior to the ED visit. That comorbid conditions are more common among frequent ED users indicates the need for an integrated approach to disease management in this population. Focusing on asthma management alone is insufficient for Harlem and similar communities.
As part of our analysis, we examined application of NAEPP guidelines for asthma classification. Our findings underscore the difficulty of attempting to classify asthma severity based only on a reported history of symptoms. We found that the classifications were not reliable, namely that the classifications resulting from only daytime or only nighttime symptoms usually did not agree. The classification problem is greatest for the persons with mild intermittent and mild persistent asthma, but even for those with moderate or severe asthma, the classifications agreed for only one of three respondents. This finding is consistent with the observations of the NAEPP and demonstrates that classification of asthma severity based on symptoms alone is varied and fluid.
Our study is restricted by the cross-sectional design, which limits our conclusions to correlational observations rather than identification of causal processes. Our study design has the advantage of allowing us to examine a geographically and socioeconomically homogeneous group, thus controlling for some effects of poverty that may mask other differences among frequent ED users. At the same time, because our sample is homogenous, we are limited in describing larger socioeconomic effects or in making generalizations. Our results are also limited in that close to half of those eligible to participate in the study did not participate. Although the interviewed respondents did not differ significantly in most demographic characteristics from those who were not interviewed, we do not know whether their disease was in fact more severe. This may bias our descriptive statistics, but would not affect our conclusions regarding differences between frequent and one-time ED users.
Nevertheless, from our results, a picture emerges of patients with serious medical conditions indicated by comorbid disease and more severe asthma, who do not substitute physician care with ED care, but for whom ED use supplements regular care.8 These results suggest that to be effective, interventions aimed at reducing ED use must address the emergency and urgent care issues facing patients with greater asthma morbidity and comorbid conditions.
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Footnotes |
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This research was supported by National Heart, Lung, and Blood Institute grant No. RO1 HL 51492.
Received for publication October 4, 2000. Accepted for publication April 19, 2001.
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