Quality of Care for Preschool Children With Asthma: The Role of Social Factors and Practice Setting
1 Division of General Pediatrics, Children's Hospital Boston, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
2 Department of Pediatrics, Division of Pulmonology, University of Michigan School of Medicine, Ann Arbor, Michigan
3 Division of Allergy and Immunology, Children's Hospital, Boston, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
4 Channing Laboratory, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts
5 Division of General Pediatrics, Children's Hospital, Boston, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
6 Department of Quality Improvement and Hospital Epidemiology, Children's Hospital, Boston, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
Objective. To determine whether patient race or source of payment is associated with differences in the quality of inpatient and outpatient treatment for young children with asthma.
Design. Structured medical record review.
Setting. Tertiary care pediatric hospital.
Patients. We studied 354 patients aged 1 to 6 years discharged with asthma between October 1, 1989 and September 30, 1990.
Measures. We developed indicators of the quality of asthma care provided before and during hospitalization and planned after discharge. Outpatient indicators were the use of inhaled beta-agonists and the use of preventive anti-inflammatory medications (inhaled steroids or cromolyn sodium) before admission. In-hospital indicators were the intensity of inhaled beta-agonist therapy in the emergency department and length of stay. Planning for post-hospital care was assessed by the prescription of a nebulizer for home use. We examined associations between these indicators and patient race and source of payment, and explored the influence of primary-care practice type on these associations.
Results. After adjustment for potential confounders, we found that Hispanic patients were less likely than white patients to have taken inhaled beta-agonists before admission. Both black and Hispanic patients were less likely than white patients to have taken anti-inflammatory medications. When we adjusted for the patients' primary-care practice type, the effect of patient race did not persist for these indicators of outpatient care. We found no differences by patient race in emergency department care or length of hospital stay. However, black and Hispanic patients were much less likely to be prescribed a nebulizer for home use upon discharge. After adjustment for confounders, there were no differences in the quality of asthma care by source of payment.
Conclusions. We found that young children of racial minorities admitted for an asthma exacerbation were less likely to have received maximally effective preventive therapy. We also identified marked differences in the quality of care planned after hospital discharge for black and Hispanic patients, compared with white patients. Particularly in an era of health reform, attention should focus on barriers to high-quality care for underserved children, who are already at high risk for asthma-related morbidity.
Submitted on February 22, 1994Accepted on June 27, 1994
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