Multiple factors mediate racial disparities in pediatric ED visits related to asthma
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Key takeaways:
- Children who identified as Black or African American were more likely to have Medicaid, live in socioeconomically deprived areas, have less greenspace availability and visit the ED more often than children who identified as white or European American.
- 55% of the effect that race has on ED visits could be attributed to medical insurance, neighborhood socioeconomic deprivation and exposure to particulate matter and outdoor mold.
- Race did not have a direct effect on the number of visits to the ED due to asthma, but social, economic and environmental factors did mediate racial disparities in the number of these visits.
Social, economic and environmental factors at individual and neighborhood levels mediated racial disparities in pediatric visits to the ED related to asthma, according to a study published in The Journal of Allergy and Clinical Immunology.
These factors may be targeted by interventions designed to improve outcomes and eliminate inequities, Esteban Correa, PhD, health data scientist in the division of asthma research at Cincinnati Children’s Hospital Medical Center (CCHMC), and colleagues wrote.
In this retrospective population-based cohort study, the researchers examined electronic health records from 31,114 patients aged younger than 18 years who had an asthma-related visit to the CCHMC ED between 2009 and 2018.
The cohort comprised 14,330 children who identified as Black or African American (AA) with 103,488 visits and 16,784 children who identified as white or European American (EA) with 83,291 visits.
Rates of visits per year included 2.23 for the AA children and 2.15 for the EA children (P < .001). Also, Medicaid insurance covered 82.6% of the visits by AA children and 43.3% of the visits by EA children (P < .001).
A greater proportion of AA vs. EA children lived in areas with higher deprivation based on census tract-level socioeconomic variables (0.47 vs. 0.3; P < .001). They also lived closer to the CCHMC base facility (9 km vs. 21.6 km; P < .001) and to main roads (0.67 km vs. 0.76 km; P < .001).
Based on the average normalized vegetation index, the EA children had higher proportions of greenspace where they lived compared with the AA children (0.45 vs. 0.42; P < .001), but they also were exposed to higher daily quantities of particulate matter measuring less than 2.5 µm (PM2.5; 10.63 µm vs. 10.35 µm; P < .001).
The AA children were exposed to slightly higher levels of pollen (110.27 gr/m3 vs. 106.39 gr/m3; P = .001) and outdoor mold (1,139.82 spores/m3 vs. 1,057.01 spores/m3; P < .001) than the EA children.
Further, the researchers found a spatial agreement between the number of visits to the ED and deprivation, greenspace and proximity to CCHMC.
Once the researchers adjusted for all other variables, race did not have a significant direct effect on the number of ED visits (standardized coefficients [sB], 0.006). But Medicaid insurance (sB, 0.048), neighborhood socioeconomic deprivation (sB, 0.084) and exposure to PM2.5 (sB, 0.002) and outdoor mold (sB, 0.006; P < .001 for all) did significantly mediate the effect of race on ED visits.
Proximity to CCHMC or main roads, greenspace and exposure to pollen did not mediate this effect. However, 55% of the effect of race on the number of ED visits could be attributed to medical insurance, neighborhood socioeconomic deprivation and exposure to PM2.5 and outdoor mold.
The researchers additionally found a nonlinear interaction effect between age and gender, with older age leading to a 10% increase in visit rates for boys and girls (P = .001). There was an association between Medicaid and a 7% increased visit rate as well (P < .001).
AA children in the most deprived areas had a 10% higher rate of visits compared with those in the least deprived areas (P = .033) .
In the most polluted areas, AA children had a 10% increased rate of visits, and EA children had a 20% increased rate of visits (both, P < .001). Higher pollen and outdoor mold exposure also led to increased visits for AA and EA children (all, P < .001).
But the researchers did not find any significant interactions between rate of ED visits and EA race and deprivation, proximity to CCHMC or greenspace or between AA race and proximity to major roads.
Based on their mediation analysis, the researchers concluded that race had no direct effect on the number of ED visits, but this effect was mediated by social, economic and environmental variables.
The researchers also said that their findings could be used to improve deleterious environmental factors through healthy homes programs and clean air policies, which may reduce asthma exacerbations and the number of ED visits.
Noting that AA and EA children with the same social, economic and environmental circumstances visit the ED at similar rates, the researchers said race should be recognized as a sociopolitical construct emblematic of sociopolitical and not genetic factors.
Policymakers, the researchers continued, could use these findings to develop avenues for intervention that will address racial gaps in how asthma and other complex diseases are experienced.
Perspective
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Andrea Pappalardo, MD, FAAAAI, FACAAI
These findings are significant as they demonstrate that several factors with multiple levels of influence in a child’s life impact their asthma experience. The fact that systemic racism has influenced a child’s exposures and morbidity from a treatable disease like asthma is unfortunately not surprising to me.
However, we should further our efforts to influence high-level policy that dismantles what years of racism have done to our children’s potential in our country. We need to make significant changes to policies that allow for clean air and equitable access to care and services, green space and neighborhood investment, among many other potential interventions.
In Chicago, a similar pattern is unfortunately seen. What I like about this article is that it clearly highlights that we have the power to make changes that can directly influence a child’s life. By focusing on interventions that address social determinants of health, we could achieve health equity. But we cannot compensate for these disparities. They must be extinguished. Physician advocacy will be essential in doing so.
Policymakers need to address health care reform and clean air policies that influence equitable access to health care and improve the quality of the air that we breathe. Investment in green space, healthy housing and proactive legislation to address illegal practices that contribute to these disparities, such as redlining, should also be prioritized.
Research should investigate multilevel interventions that address health inequities in asthma and allergic disease as well.
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I think that these findings are significant. In the past, with respect to racial disparities seen with asthma and other atopic diseases, there has been controversy as some studies would describe a persistence of disparities despite controlling for more well-known socioeconomic factors. This was often attributed to genetic factors even though there still could have been confounders related to social factors that were not measured or that were related to structural determinants of health.
The authors of this study looked at multiple levels — individual, household, neighborhood and administrative — that feed into disparities in asthma outcomes. This study highlights how children who identify as AA and EA who had the same social, economic and environmental influences had similar ED visit rates.
One of the more powerful statements comes in their discussion that this “suggests that we should recognize race for what it is, a sociopolitical construct emblematic of sociopolitical factors as opposed to genetic ones.”
So, what do doctors need to do to compensate for these disparities? Ask about social and environmental influences on your patients’ asthma and make appropriate referrals to help support your patients if those influences are present. Build a strong patient/family-provider relationship with your patients and know that medical mistrust may also be a factor that influences health outcomes (and it is hard to quantify earned medical mistrust).
Also, doctors can advocate for policies that can add to positive change. Support programs that can improve social and environmental factors that feed into these disparities. The authors mention some specifics such as healthy homes programs, clear air policies, improving access to primary care and pharmacies as well as engaging community health care workers.
Although there is much information and research on disparities, I would like to see more research on specific interventions to reduce these disparities such as multi-tiered interventions for multiple level issues — what works, what doesn’t work, what is feasible?
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