Effect of Access to a Medical
Home on Emergency Department
Use & Family Financial Burden in
Childhood Asthma in the US
Abdoulaye Diedhiou, MD, MS, PhD
Janice C. Probst, PhD
Amy B. Martin, Dr.PH
James W. Hardin, PhD
Sudha Xirasagar, MD, PhD
What’s the Problem?

Most common chronic illness in children
 9%
US children had current asthma (2007)
 Low-income,

Health care utilization (2004)
7
million pediatrician visits
 750,000+

minority, and inner-city children
Emergency Department (ED) visits
Asthma “paradox”
 Advances
in knowledge and treatment
 Disproportionate use of EDs
 Major economic and social impacts
Why Do We Care?

Preventable morbidity and mortality
 Key

issue: poor access to primary care
The medical home: improving access to care
7
components, 37 specific topics (AAP, 2002)
 Shared responsibility for doctors & parents
 Challenges in documenting presence & benefits



Addressed in Healthy People 2010
Title V Block Grant mandates
Understanding disparities in asthma outcomes
& patterns of health services utilization
Hypotheses


Children with asthma receiving care consistent
with that in a medical home experience fewer
emergency department visits than their peers
without a medical home.
Among children with asthma, families report
fewer financial problems due to care when they
are linked to a medical home.
Data Source & Study Population

2005-2006 National Survey of Children with
Special Health Care Needs (NS-CSHCN)

Nationally representative survey of children 0-17 yrs

Random digit dialing telephone survey using the
design of the NIS

Two distinct samples: national, referent

Parents/guardians of 40,723 CSHCN interviewed


78% of respondents were mothers
Study population: 14,916 children with asthma
Study Variables

Dependent variables
 ED
visits, past 12 months
 Family’s perceived financial burden

Independent variable: medical home composite
measure

Derived using “on every” scoring approach

4 criteria to meet or qualify as legitimate skip
“Floor” criteria: PDN, source for sick and well care
 Family-centered, compassionate, culturally effective
 Comprehensive with no problems obtaining referrals
 Effective care coordination

Theoretical Domains (Andersen)
Environment & Health Care
System
Study Variables
•
•
•
•
Predisposing
•
Population Characteristics
•
•
•
•
•
Enabling
•
•
•
•
•
Rural/Urban location
Geographic region
Medical home
Race
Age
Gender
Primary language spoken
Language of interview
Parental income
Parental educational attainment
Type of health insurance
Consistency in insurance coverage
Family structure
Presence of siblings
Siblings with SHCN
•
Diagnosis of current asthma
Perceived asthma severity
Co-morbidities
Utilization Behavior
•
ED visits
Functional/Satisfaction
•
Perceived financial burden
•
Need/Clinical
•
Data Analysis


Instrumental variable approach
Covariates: socio-demographics, insurance,
residence, co-morbidities, geographic region

Analysis with SAS Callable SUDAAN

Weighted %, means, & standard errors (SE)

Chi-square/Fisher’s and t tests

Multivariate: OR and 95% CI

Statistical significance set at p<0.05
Selected Descriptive Results
Variable
Perceived Financial Burden
No, Financial Impact
Yes, Financial Impact
ED visit, past 12 months
No ED visits
1 ED visit
2 ED visits
3-4 ED visits
5+ ED visits
Medical Home Status
Yes, Medical Home
No Medical Home
Unweighted
Observations
Weighted
Percent
SE
Weighted
Percent
12251
2509
83.0
17.0
0.5
0.5
8565
2787
1595
1142
827
55.4
18.4
11.7
8.2
6.3
0.7
0.5
0.5
0.4
0.4
7380
6938
49.9
50.1
0.7
0.7
Who has a medical home?
a
Selected Characteristics
Non-Hispanic White
Two-parent Family
English-speaking
Income ≥ 201%FPL
More Than High School
Private Insurance
Consistent Coverage
No/Minor Severity
a All
p<0.0001
% with
% without
Medical Home Medical Home
67.6
60.8
97.9
64.7
74.3
66.9
94.4
72.6
50.4
47.5
93.3
47.2
64.4
49.7
88.2
54.8
Selected Bivariate
Total, All Yes, Medical No, Medical
Children with
Home
Home
Asthma
Mean ED visits (SE)
a
% Reporting Financial
a
Burden (SE)
a p<0.0001
1.18
(0.03)
0.90
(0.04)
1.44
(0.05)
16.99
(0.53)
10.28
(0.60)
23.61
(0.87)
for all differences between
children with and without a medical home
Multivariate Results, Odds Ratiosa,b
Odds Ratio & 95% CI
1.5
1.2
Line of equal
odds
0.9
0.6
0.3
0.0
a Medical
ED Visits
Financial
Burden
Home Yes vs. No; All p < 0.0001
b Adjusted for socio-demographics, insurance,
co-morbidities, residence, geographic region
In Summary

Having a medical home
A

marker of many advantages
Benefits of a Medical home
 Consistent
 Mitigates

with hypotheses
effects of race and uninsurance
Study limitations and strengths
 Cross-sectional
data
 Parent-reported
information
 Data
from unique survey
Implications

Securing a medical home for children with asthma
 Advocacy
and Awareness campaigns
 Diffusion/facilitation
of medical home improvement
models
 Local

partnerships involving ED physicians
Need for policies/incentives addressing
 Payment
 Children

issues
in transition to adulthood
Effects of nominal/ordinal measures (medical
“homeness”)
~ Thank You ~
Contact:
Dr. Abdoulaye Diedhiou
SC Public Health Consortium
University of South Carolina
diedhiou@mailbox.sc.edu