Black children are twice as likely as white children to be readmitted to the hospital for asthma – a disparity due in large part to a greater burden of financial and social hardships, according to a study posted online Feb. 3, 2014, in Pediatrics.

The study shows that 23 percent of black children who received inpatient treatment for asthma at Cincinnati Children’s were readmitted within a year. Meanwhile, 11 percent of other children in the study, most of whom were white, were readmitted in that timeframe.

Financial and social hardships, such as lack of employment and not owning a car, accounted for about 40 percent of the increased likelihood of asthma readmissions among black children, the study finds.

Understanding and addressing the factors driving disparities in asthma readmissions is increasingly important as hospitals face changes in how they are compensated.

“Readmission rates are a central focus of healthcare reform,” says Andrew Beck, MD, MPH, a pediatrician at Cincinnati Children’s and lead author of the study.  “Our findings suggest a more intense patient- and population-level focus on the financial and social hardships that underlie racial disparities may provide one path for achieving better outcomes.”

The study involved 774 patients, aged 1 to 16, who were admitted between Aug. 2010 and Oct. 2011.  More than half of the children, 57 percent, were black.

Caregivers of black children were significantly more likely than caregivers of white children to report financial and social hardships, which together with traditional measures of low socioeconomic status explained about half of the disparity in readmissions.

“There is tremendous potential for changes in clinical practice,” says Robert Kahn, MD, MPH, Associate Director of General and Community Pediatrics at Cincinnati Children’s and senior author of the study. “Transportation barriers might be addressed with home delivery of medications, job barriers with a connection to job training, and both helped by a community health worker. The goal would be upstream, community-based prevention, rather than paying for readmissions.” 

Secondhand Smoke Also Affects Readmissions

Exposures to secondhand smoke -- at home or in the car -- can double the odds of children with asthma being readmitted to the hospital.

The study, posted online Jan. 20, 2014, in Pediatrics, was based on a testing method that could become a more reliable tool for measuring tobacco exposure in clinical practice.

Instead of relying on often-inaccurate caregiver reports, this study involved testing blood and saliva for levels of cotinine, a substance produced when the body breaks down nicotine. More than 600 children were tested at Cincinnati Children’s and the Penn State Milton S. Hershey Children’s Hospital. Laboratory analysis was done at Boston Children’s Hospital.  

The study found no correlation between caregiver reports of tobacco exposure and asthma-related readmissions. But analysis of cotinine levels demonstrated a readmission risk that was twice as high for children exposed to secondhand smoke compared to unexposed children.

 “The ability to measure serum and salivary cotinine levels presents the possibility of an objective measure that can be obtained when a child is seen in the emergency department or in the hospital and may be used to predict future hospitalizations,” says Robert Kahn, MD, MPH, senior author of the study.

“Such a measure for exposure to tobacco smoke could be used to target specific interventions at caregivers of those children before discharge from the hospital. Several interventions, including parental counseling and contact with the primary care physician, could be adopted in clinical practice.”

Interventions do not have to be limited to clinical settings, researchers note.

“Of the 619 children in the study, 76 percent were covered by Medicaid,” says Judie Howrylak, MD, PhD, a physician at Hershey Children’s and lead author of the study. “Certainly there could be a financial incentive for insurance companies to help caregivers quit smoking, rather than pay the downstream costs of a future asthma readmission.”

Both studies appearing in Pediatrics involved data gathered through the NIH-funded Greater Cincinnati Asthma Risks Study (GCARS), which seeks to understand the causes of hospital readmission, particularly for low income and minority children. As part of this project, Kahn also is studying the association between traffic-related air pollution and asthma readmissions. He hopes to publish more findings within the coming year.