Effectiveness of Community Health Worker Intervention at Dayton Children’s Hospital at Decreasing Emergency Department Visits and Hospitalization Rates for Pediatric Asthma Patients

Abstract

Objective:

To determine whether asthma interventions completed by the community health workers (CHWs) at Dayton Children’s Hospital decrease the rate of Emergency Department (ED) visits and hospitalizations.

Methods:

The data was chosen from the CHW patient population that met the inclusion criteria of at least 1 hospitalization/ED visit or Primary Care Provider referral in the twelve months prior to intervention during 2019 to 2020. The visit rates from 12 months before and after intervention were analyzed with Markov Chain Monte Carlo where the likelihood was assumed to be Poisson.

Results:

The number of ED visits decreased by 2 to 4 visits (P < 1e-5) per year per patient on average. This was an 83% decrease in the number of ED visits a year for the total patient population. Hospitalization rates also saw a decrease of 0.1 to 1.5 admissions (P = .006) per year per patient. This showed an overall 77% reduction in hospitalizations for the total patient population.

Introduction/Literature Review

Interest in how social determinants of health affect pediatric asthma has been growing due to its negative effect on asthma exacerbations, hospitalization rate, and quality of life.^1-3 Recent studies regarding such social determinants, indicate hospitals and communities have tried to provide services to patients to help them achieve asthma control. One such service is the community health worker (CHW) who individually assesses patients and their families to find potential exacerbating factors that may exist in their daily lives. The CHW is able to make interventions such as finding cleaner living conditions as well as eliminating allergens in the home that predispose the patient to asthma exacerbation. Additionally, the CHW team is able to help families have access to resources in situations of food insecurity and lack of transportation.^1,4-8

Previous studies have shown that when CHW interventions are done in comorbid diseases such as in pediatric asthma and obesity, a yearlong intervention increased the patient’s asthma control from 61.9% before starting intervention to 85.7% upon conclusion of the intervention. ⁶ Other studies have focused on specific CHW interventions in minorities. There is a higher prevalence of asthma in the African American and Hispanic populations as compared to their Caucasian equivalents. ² In 1 study, CHW intervention focused on Hispanic pediatric patients with asthma. ¹ After the intervention, the experimental group as compared to the control showed a significant decrease in number of asthma exacerbations.

One area of research that requires further investigation is in that of effectiveness of the CHW intervention in pediatric asthma patients. The literature has established that the intervention itself is successful in decreasing rates of asthma exacerbations, hospitalization rates, and emergency department (ED) visits in other parts of the country. However, in Dayton, this has not been established, and given the diversity of the population in this city, further studies are warranted in the field of CHW intervention for pediatric patients to establish whether the intervention is truly effective to impact outcomes such as hospitalization rates and ED visits.

Specific Aim

Specific Aims: The aim is to determine whether pediatric patient CHW intervention is effective at decreasing rates of ED visits and hospitalization at Dayton Children’s Hospital. This will be valuable to further the understanding of the effectiveness of CHW interventions and how they can be improved if deemed ineffective.

Methods

Context/Protocol

The data was chosen and collected based on subjects through the CHW intervention program at Dayton Children’s Hospital from 2019 through 2020. Once a patient was in the ED or admitted for asthma exacerbation, they were referred to the CHW. The CHW then performed an intake screening to determine what interventions were needed. Finally, a retrospective chart review was performed on patients who met the inclusion criteria. The number of hospitalizations and ED visits 12 months before and after intervention were collected.

The inclusion criteria for this study included at least 1 ED visit/hospitalization or direct referral from PCP in the 12 months prior to the CHW intervention. The exclusion criteria included any other comorbid chronic illnesses which could impact the rate of hospitalizations and likelihood of returning to the ED. In total, 70 patients were included in this study.

Data Collection

The CHW gave each patient the Pediatric Asthma Quality of Life Questionnaire. Based on the answers to the survey, the CHW decided what intervention was appropriate and the amount of time required for this intervention to be completed. The independent variable for the study was time. The dependent variable was the frequency of ED visits/hospitalizations. Data was gathered and collected from the chosen patients that qualified for the CHW intervention from 2019 to 2020 and met the inclusion criteria. The patient’s hospitalization rates and ED visits from 12 months prior to intervention and 12 months post intervention were gathered retrospectively from the electronic health record.

Data Analysis

The data was analyzed with Markov Chain Monte Carlo where the likelihood was assumed to be Poisson distributed because ER visits and hospitalizations are frequency-based observations. Histogram plots were created from the analysis based on the probability of a particular visit or admission frequency representing the observed frequency. These distributions were then subtracted to create histograms of the difference of ED visits/hospitalizations before and after intervention at the population level as well as normalized for the individual patient level. Median, standard deviation, 95% confidence region, and P-values were calculated for all 4 histograms.

Results

The distribution of frequencies for the observed number of ED visits pre and post intervention is demonstrated in Figure 1. Overall, if those 2 distributions are subtracted, the reduction in ED visits was 38.7 with a standard deviation of 7.5, 95% confidence region of [24.7, 54.3], and P-value <.001 (Figure 1).

Figure 1.

Reduction in emergency department visits.

The distribution of frequencies for the observed number of admissions pre and post intervention is demonstrated in Figure 2. Overall, if they are subtracted, the reduction in admissions was 9.6 with a standard deviation of 4.3, 95% confidence region of [1.97, 18.9], and P-value of .006 (Figure 2).

Figure 2.

Reduction in hospital admissions.

The decreases in both ED visits and admissions were normalized by the number of patients. The reduction in ED visits was 2.98 with a standard deviation of 0.58, 95% confidence region of [1.9, 4.18], and P-value of <.001. The reduction in admissions was 0.74 with a standard deviation of 0.33, 95% confidence region of [0.15, 1.46], and P-value of .006 (Figure 3).

Figure 3.

Decreases in ED visits and hospitalizations.

Discussion

The number of ED visits and hospitalizations decreased after CHW intervention in a statistically significant way. The number of ED visits decreased by an average of 3 visits per year per patient on average. This was a reduction from 47 total ED visits before CHW intervention to 8 total post intervention representing an 83% decrease in the number of ED visits a year for the total patient population. Hospitalization rates also saw a decrease at the individual patient level of an average of 1 admission a year per patient. The total number of hospitalizations pre CHW intervention was 13 and decreased to 3 total post CHW intervention. This showed an overall 77% reduction in hospitalizations. According to Perry et al, ⁹ the US spends approximately $5.92 billion per year on pediatric asthma with $1.59 billion on hospitalizations alone. On average, pediatric asthma hospitalizations cost $12 006 per admission. ⁹ A single pediatric ED visit in the state of Ohio with the primary diagnosis of asthma is around $2164. ¹⁰ By having the CHW intervention, the average patient saved $1000 to $18 000 a year.

Future studies could evaluate ethnicity and socioeconomic status and what affect it has on the likelihood of intervention success; specifically focused on the Social Determinant of Health key area of neighborhood and built environment. There are specific populations that have a great susceptibility to asthma and subsequent exacerbations. We now know that the CHW intervention works in our patient population. It remains to be seen whether the groups that are most susceptible to asthma exacerbations are having the same success of intervention as depicted in this study. Further study is warranted to evaluate the intervention effectiveness in these groups and what could be done to increase the success in these groups if needed. Literature review does not demonstrate any notable study involving CHW intervention in the pediatric asthma population. Dayton is home to a diverse patient population (5% of population is Foreign Born and 25% of population is non-white) and thus it can be extrapolated that the CHW interventions applied to this patient population can be used in a wide variety of demographics. ¹¹

Conclusion

Overall, this study was beneficial in that the data showed the community health worker intervention is successful. There was an 86% overall decrease in ED visits with a 77% reduction in hospitalizations in the 12 months post intervention. This amounts to a decrease in 2 to 4 ED visits and 0.1 to 1.5 hospitalizations a year per child. By having the CHW intervention, the average patient saved $1000 to $18 000 a year in hospitalization bills. Future studies are necessary to further evaluate other factors that can affect intervention success such as ethnicity and socioeconomic status; or more specifically the Social Determinant of Health key area of neighborhood and built environment. It is imperative that the patients most susceptible to asthma exacerbations are fully receiving the benefits of the intervention. Additionally, based on these findings, it is highly recommended that CHWs become established as a standard aspect of a patient’s asthma management team.