Underutilization of Preventive Asthma Visits Among Urban Children With Persistent Asthma

Abstract

National guidelines recommend that children with persistent asthma have at least 2 preventive asthma visits (PAVs) per year. We sought to determine the percent of urban children with persistent asthma who had a PAV in the past year, and to identify differences in demographics, health-related variables, and management associated with PAVs. Using data from 530 children (3-10 years) participating in a school-based asthma trial, we found that only 25% of children had at least I PAV, with only 5% receiving ≥2 visits. Having a PAV was not associated with demographics or health-related variables. Importantly, having a PAV was associated with having a preventive medication, taking that medication daily, and having a medication adjustment. Although PAVs were associated with actions to improve asthma control and management, these visits were underutilized in this sample. This highlights the need for novel methods to ensure access and deliver care to this vulnerable pediatric population.

Introduction

Asthma is a leading chronic pediatric illness, affecting more than 6.7 million children in the United States.¹ Children with uncontrolled persistent asthma experience frequent symptoms, school absenteeism, activity limitation, emergency room visits, and hospitalizations.²

Minority and poor children in the United States suffer disproportionately from asthma.³ Being black and living in a lower income household are independent risk factors for pediatric asthma,⁴ and the prevalence of asthma is 30% higher among non-Hispanic black children than non-Hispanic white children.³ Additionally, minority and poor children experience greater asthma-related morbidity. Black children with asthma are more likely to have poorer lung function,⁵ more frequent rescue medication use,⁶ and more emergency department visits for asthma exacerbations.⁷ Black and poor children are also at higher risk for severe activity limitation due to asthma.⁸

In 2007, in order to minimize asthma-related morbidity and mortality, the National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and Prevention Program (NAEPP) updated specific guidelines for asthma therapy.⁹ The goal of asthma therapy is to achieve long-term asthma control with the least amount of medication. Long-term asthma control refers to reduced impairment through the prevention of symptoms and the maintenance of normal pulmonary function and activity levels, along with reduced risk of exacerbations, emergency visits, and hospitalizations.⁹

To achieve optimal asthma control, NHLBI guidelines recommend the use of daily preventive anti-inflammatory medications for every child with persistent asthma.⁹ When used consistently, preventive asthma medications reduce asthma symptoms and prevent exacerbations that can lead to hospitalizations.¹⁰ The national guidelines also recommend at least 2 preventive asthma visits (PAVs) per year.⁹ These visits provide opportunities for clinicians to recognize indicators of suboptimal asthma management (ie, increased use of rescue medications, urgent care visits, or hospitalizations) and make changes to a child’s therapy as appropriate.

Although minority and poor children are at an increased risk of greater asthma severity,^5,6 these at-risk populations are less likely to receive the standards of care put forth in the NHLBI guidelines.⁶ Black children are less likely than white children to report using preventive medications.^2,11 Furthermore, children from minority and low-income backgrounds are less likely to utilize preventive asthma services¹² and are more likely to have emergency visits⁷ or hospitalizations⁸ due to asthma. A better understanding of how often high-risk children with asthma access preventive asthma services and the variables associated with preventive service utilization within this population is needed, so that clinicians can more effectively address gaps in asthma care.

The objectives of this study are to (1) assess the prevalence of PAVs among a population of urban children with persistent asthma in Rochester, New York; (2) describe child, caregiver, and health care characteristics associated with the utilization of PAVs in this population; and (3) identify differences in asthma control and management related to the use of PAVs.

Methods

Study Information/Recruitment

This project was a secondary analysis of caregiver-reported baseline data from the School-Based Asthma Therapy (SBAT) program, a randomized control trial conducted in Rochester, New York from 2006 to 2009.¹³ During this 3-year period, 530 children aged 3 to 10 years with persistent asthma were enrolled. All subjects in this study had a physician diagnosis of asthma, a caregiver report of persistent-level symptoms (as defined by NHLBI guidelines), and attended school in the Rochester City School District. Exclusion criteria included other medical conditions that could interfere with the assessment of asthma-related outcomes (ie, cystic fibrosis, congenital heart disease, other lung disease), if the primary caregiver was unable to speak and understand English, if they were planning to leave the school district within 6 months, or if they did not have access to a telephone for follow-up surveys. The University of Rochester Institutional Review Board approved the study protocol.

Baseline Assessment

We conducted baseline assessments during home visits at the time of enrollment. According to NHLBI criteria, asthma severity was assessed by asking caregivers to report the frequency of their child experiencing any cough, wheeze, breathlessness, or chest tightness during the day; the frequency of similar nighttime symptoms; activity limitation; and the use of rescue medication for symptom relief within the past 2 weeks. Caregivers also reported the number of symptom-free days in the past 2 weeks, defined as having no signs of asthma for a full 24 hours. Baseline assessments included caregiver-reported information on child and caregiver demographics, health care–related variables, asthma symptoms, and asthma control variables.

Child and Caregiver Demographics

We asked about child age, gender, race, and ethnicity. Caregiver demographics included caregiver age, highest education level, marital status, mental health, health literacy, and car ownership. We measured caregiver mental health using the Kessler 10 Psychological Distress Scale,¹⁴ a series of 10 questions scored on a 5-point Likert-type scale. Higher scores reflect higher levels of caregiver anxiety and depression symptoms. Caregivers with a total score ≥20 were categorized as having psychological distress. Parental health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine.¹⁵ Parents who scored below 61 were considered to have low health literacy, and parents who scored above 60 were considered to have adequate health literacy (range 0-66).

Health Care-Related Variables

Caregivers reported on the child’s insurance status (Medicaid or other), whether or not the child had been uninsured at any point during the past year, and whether or not they had been delayed in seeking care in the past year for any reason. Parents were also asked to report the number of asthma-related visits to the primary care office and emergency department in the past year. PAVs were defined as an asthma check-up or follow-up in the past year.

Asthma Symptom and Control Variables

In addition to asthma severity, parent-reported symptom variables included the number of nights of sleep lost and the number of days that their child missed school due to asthma within the prior 2-week period. Asthma control variables included information on preventive medication use, preventive medication actions (defined as a new prescription or a change of dose), and perceived asthma control. Parent perceptions about a child’s medications were assessed using the Beliefs about Medicines Questionnaire.¹⁶

Analysis

We used Pearson’s chi-square and t tests to evaluate associations between variables of interest and PAVs in the past year. All analyses were conducted using SPSS (version 22.0), and a 2-sided α < .05 was considered statistically significant. Binary logistic regression controlling for asthma severity was performed to further explore the associations between PAVs in the past year and asthma control variables.

Results

Of the 530 children enrolled in this study (participation rate 74%), 135 (25%) reported at least 1 PAV in the past year. Only 5% of children had the recommended 2 or more PAVs.

Child and Caregiver Demographics

The demographic characteristics of the study sample are reported in Table 1. Overall, 58% of the sample was male, and the mean age of enrolled children was 7.1 years. The sample was 63% Black and 17% Hispanic. The majority of caregivers (78%) were unmarried, and 39% of caregivers self-reported their highest education level as lower than high school. Nearly 40% of caregivers were classified as having symptoms of psychological distress. More than half (65%) of caregivers achieved adequate health literacy scores, and 71% reported owning a car. PAVs were not associated with any child or caregiver demographic variables.

Table 1.

Child and Caregiver Demographics.

Variable	Overall (N = 530); n (%)	Yes PAV (N = 135); n (%)	No PAV (N = 395); n (%)	P
Child
Age, years
3-5	104 (20)	25 (19)	79 (20)	.71
6-10	426 (80)	110 (81)	316 (80)
Gender
Male	308 (58)	85 (63)	223 (56)	.19
Female	222 (42)	50 (37)	172 (44)
Race/Ethnicity
White	48 (9)	10 (7)	38 (10)	.08
Black	335 (63)	76 (56)	259 (65)
Mixed/Other	56 (11)	18 (13)	38 (10)
Hispanic/Spanish	91 (17)	31 (23)	60 (15)
Caregiver
Age, years
<30	178 (34)	48 (36)	130 (33)	.60
≥30	350 (66)	87 (64)	263 (67)
Highest education
Less than high school	205 (39)	55 (41)	150 (38)	.57
High school and higher	325 (61)	80 (59)	245 (62)
Marital status
Married	118 (22)	25 (19)	93 (24)	.23
Not married	412 (78)	110 (81)	302 (76)
Psychological distress
Well	319 (60)	81 (60)	238 (60)	.97
Distressed	210 (40)	53 (40)	157 (40)
Health literacy (N = 518)
Adequate	337 (65)	78 (60)	259 (67)	.13
Low	181 (35)	53 (40)	128 (33)
Car ownership
Yes	375 (71)	95 (70)	280 (71)	.88
No	154 (29)	40 (30)	114 (29)

Abbreviation: PAV, preventive asthma visit.

Health Care-Related Variables

While most of the children enrolled in this study (73%) had public health insurance, 20% of the sample reported being uninsured at some point in the past year (Table 2). Some caregivers (11%) reported needing to delay health care for their child at least once in the previous 12 months, and 151 children (28%) had 1 or more emergency visits due to asthma. Having at least 1 PAV was significantly associated with having an asthma-related emergency visit in the past year (P = .001), yet only 55 (36%) of these 151 children requiring emergency care for asthma reported having a PAV in the previous 12 months.

Table 2.

Health Care–Related Variables.

Variable	Overall (N = 530); n (%)	Yes PAV (N = 135); n (%)	No PAV (N = 395); n (%)	P
Insurance status
Medicaid	389 (73)	98 (73)	291 (74)	.81
Other	141 (27)	37 (27)	104 (26)
Uninsured in past year
Yes	104 (20)	27 (20)	77 (19)	.90
No	426 (80)	108 (80)	318 (81)
Delayed health care in past year	(N = 529)
Yes	60 (11)	15 (11)	45 (11)	.95
No	469 (89)	119 (89)	350 (89)
Any emergency department visit in past year
Yes	151 (28)	55 (41)	96 (24)	<.001*
No	379 (72)	80 (59)	299 (76)

Abbreviation: PAV, preventive asthma visit.

^*Statistically significant at P < .05.

Asthma Symptoms

Caregiver-reported symptoms are shown in Table 3. All the children enrolled in this study experienced persistent asthma symptoms in accordance with NHLBI guidelines when screened. On average, children experienced 8 symptom-free days and 4 nights with symptoms in a 2-week period. In addition, caregivers reported an average of 3 days of activity limitation and 4 days with rescue medication use in the previous 2 weeks. There was no difference in asthma severity or symptoms among children with and without a PAV in the past year.

Table 3.

Asthma Symptoms.

Variable	Overall (N = 530); Mean (SD)	Yes PAV (N = 135); Mean (SD)	No PAV (N = 395); Mean (SD)	P
Symptom-free days/2 wk	8.0 (4.8)	7.6 (5.0)	8.1 (4.8)	.29
Symptom days/2 wk	4.0 (4.3)	4.4 (4.7)	3.8 (4.2)	.17
Symptom nights/2 wk	4.1 (4.5)	4.4 (4.7)	4.0 (4.4)	.37
Days with activity limitation/2 wk	3.0 (3.8)	3.4 (4.5)	2.8 (3.5)	.13
Days with rescue medication use/2 wk	4.0 (4.6)	4.2 (4.9)	3.9 (4.5)	.55
Nights parent lost sleep/2 wk	2.1 (3.5)	2.2 (3.6)	2.1 (3.5)	.61
Days absent due to asthma/2 wk	0.4 (1.0)	0.4 (1.0)	0.4 (1.1)	.84

Asthma Control Variables

Caregiver report of at least 1 PAV in the prior year was significantly associated with having a current preventive medication (80% vs 65%; P = .001), taking that medication daily (78% vs 66%; P = .03), and having a preventive medication action in the same time period (58% vs 41 %; P = .049) (Figure 1). Having a PAV in the past year was not associated with parent beliefs about controller medications or caregiver smoker status. Although all children in the study had persistent asthma and many experienced frequent asthma symptoms, 80% of caregivers perceived their child’s asthma to be under good control.

Figure 1.

Asthma control variables.

*p-value < 0.05; p-values adjusted for asthma severity

In a binary logistic regression analysis controlling for asthma severity, reporting ≥1 PAV in the prior year was significantly associated with having a current preventive. asthma medication (adjusted odds ratio [aOR] 2.2; 95% CI = 1.3-3.4), taking that preventive medication daily (aOR 1.8; 95% CI = 1.1-3.0), and having a medication action in the prior year (aOR 3.5; 95% CI = 1.0-11.6).

Discussion

National guidelines recommend at least 2 PAVs per year and a daily preventive anti-inflammatory medication for all children with persistent asthma.⁹ PAVs are an important step to achieving the goals of guideline-based therapy: They ensure opportunities to evaluate asthma control, make recommended stepwise adjustments in medications, and provide ongoing education on self-management, environmental triggers, and smoking cessation.⁹

We found that PAVs are significantly underutilized in this population of urban children with persistent asthma. Only 5% of high-risk children with persistent asthma in this study had the recommended 2 or more visits in the prior year, and only 25% of all enrolled children reported a single PAV in the prior 12-month period. Alarmingly, the majority of children (75%) had no PAV. Among the 151 children who had an asthma-related visit to the emergency department in the past year, the prevalence of at least 1 PAV was still only 36%. The low rate of PAVs observed in this study sample is consistent with prior literature demonstrating preventive service underutilization among minority and poor populations.¹²

Factors that limit access to preventive primary care may help to explain this trend. Caregiver demographics such as education, health literacy, and mental health have been shown to influence service accessibility. Children whose mothers have higher levels of education tend to have more check-ups and fewer emergency visits,¹⁷ whereas parents with low health literacy are more likely to report barriers to care and weak provider-to-parent relationships.¹⁸ Children with a depressed parent have more hospitalizations and emergency visits than children without a depressed parent.¹⁹ Additionally, variables related to health care access such as the expense of health care services,²⁰ discontinuous health insurance,²¹ and limited transportation²² directly interfere with a family’s ability to regularly seek care. Interestingly, we did not identify significant associations between caregiver demographic or health care-related variables and PAV utilization within this study population. It is possible that our focus on high-risk children with persistent asthma made any potential contribution of social risk factors harder to detect.

Parents of children with persistent symptoms often underestimate the severity of their child’s asthma.²³ Caregiver misconceptions about their child’s asthma severity and control may also help to explain the low rates of PAVs that we observed. While caregivers clearly reported that their children are experiencing frequent symptoms due to asthma, 80% still perceived that their child’s asthma is under good control. If caregivers believe that their child is well, they may not think that a preventive visit is necessary.²⁴ This may be especially true for low-income families with limited time and resources.

In this study, caregivers were asked to report the number of PAVs that their child attended in the past year. Visits that were scheduled and subsequently cancelled or missed were not included in our data. Frequent cancellations or “no-shows” for scheduled appointments may also be contributing to underutilization of PAVs in this population. Patient-reported barriers to attending appointments include long waiting times,²⁵ logistical barriers such as transportation or time off work,²⁶ and forgetting appointments.²⁶

Importantly, while the rate of PAVs is low in this study sample, those children who did have at least 1 PAV in the past year were significantly more likely to be utilizing other important preventive measures to control their asthma. Children who had at least 1 PAV in the past year were not only more likely to be currently prescribed a preventive asthma medication, but they were also more likely to be taking that medication daily. Additionally, children who had a PAV in the past year were more likely to report that they had an adjustment in their medication during that time period.

These findings support the need to explore novel ways to improve the delivery of guideline-based care for pediatric asthma, especially within high-risk populations. For example, new systems of care that include care coordinators in a patient-centered medical home can help proactively identify children in need of preventive care visits, provide necessary outreach for patient reminders, and help remove barriers to accessing care.²⁷ Partnerships with community-based organizations and schools, and the use of technology such as telemedicine,²⁸ can help provide access to children without requiring travel to a primary care office. Further efforts to promote accessible care for families may require redefining the way care is delivered to meet patient needs and ultimately improve outcomes.

Study Limitations and Strengths

This is a secondary analysis, so we cannot infer causality in the observed associations between demographic, health care–related, symptom, and asthma control variables and PAVs. All data for this study were collected by caregiver report. As a result, reported medication usage, health care utilization, and perceptions of both medications and asthma control may have been influenced by social desirability bias.²⁹ However, a study evaluating the accuracy of recall among parents of children with asthma found that 91% of caregivers reported in “good agreement” with pediatric records.³⁰ In our study, 10% of baseline assessments were confirmed by medical record review, and we found that the majority (83%) of visits indicated in the medical record were consistent with caregiver report.¹³ All children in this sample were from urban Rochester, New York, thus findings can only be generalized to similar populations and areas.

This study also has several strengths, most notably the inclusion of a large, community-based sample of urban children with asthma. We included only children with persistent asthma symptoms, who are in greatest need for PAVs. Furthermore, we conducted a detailed in-person assessment with caregivers using structured surveys to provide a comprehensive measure of the families’ psychosocial situation and access to care.

Conclusions

The low rate of PAVs among this vulnerable population represents a failure at the health system level in providing guideline-based asthma management for the highest risk pediatric asthma patients. These findings align with a concerning trend of preventive service underutilization among minority and poor populations, and cannot be explained solely by sociodemographic and access variables that are usually cited as barriers to receiving adequate care. This study reaffirms that guideline-based care is important in helping patients receive effective preventive asthma care. As such, having PAVs should be a priority in the management of childhood asthma. New care delivery and outreach methods may be necessary to ensure that all children with persistent asthma receive appropriate guideline-based care.