Explaining Racial Disparities in Child Asthma Readmission Using a Causal Inference Approach

Abstract

IMPORTANCE Childhood asthma is characterized by disparities in the experience of morbidity, including the risk for readmission to the hospital after an initial hospitalization. African American children have been shown to have more than 2 times the hazard of readmission when compared with their white counterparts.OBJECTIVE To explain why African American children are at greater risk for asthma-related readmissions than white children. DESIGN, SETTING, AND PARTICIPANTSThis study was completed as part of the Greater Cincinnati Asthma Risks Study, a population-based, prospective, observational cohort. From August 2010 to October 2011, it enrolled 695 children, aged 1 to 16 years, admitted for asthma or wheezing who identified as African American (n = 441) or white (n = 254) in an inpatient setting of an urban, tertiary care children's hospital. MAIN OUTCOMES AND MEASURESThe main outcome was time to asthma-related readmission and race was the predictor. Biologic, environmental, disease management, access, and socioeconomic hardship variables were measured; their roles in understanding racial readmission disparities were conceptualized using a directed acyclic graphic. Inverse probability of treatment weighting balanced African American and white children with respect to key measured variables. Racial differences in readmission hazard were assessed using weighted Cox proportional hazards regression and Kaplan-Meier curves. RESULTSThe sample was 65% male (n = 450), and the median age was 5.4 years. African American children were 2.26 times more likely to be readmitted than white children (95% CI, 1.56-3.26). African American children significantly differed with respect to nearly every measured biologic, environmental, disease management, access, and socioeconomic hardship variable. Socioeconomic hardship variables explained 53% of the observed disparity (hazard ratio, 1.47; 95% CI, 1.05-2.05). The addition of biologic, environmental, disease management, and access variables resulted in 80% of the readmission disparity being explained. The difference between African American and white children with respect to readmission hazard no longer reached the level of significance (hazard ratio, 1.18; 95% CI, 0.87-1.60; Cox P = .30 and log-rank P = .39). CONCLUSIONS AND RELEVANCEA total of 80% of the observed readmission disparity between African American and white children could be explained after statistically balancing available biologic, environmental, disease management, access to care, and socioeconomic and hardship variables across racial groups. Such a comprehensive, well-framed approach to exposures that are associated with morbidity is critical as we attempt to better understand and lessen persistent child asthma disparities.

Characteristics of Pediatric Emergency Revisits After an Asthma-Related Hospitalization

“…This finding is consistent with our previous work assessing relationships between index hospitalization and asthma-related rehospitalization. 27,36 Moreover, bivariate analyses suggest that black children are more likely than white ones to return for asthma-related revisits multiple times. Although black children were more likely to have multiple asthma-related revisits than white children, this does not appear to be related to overuse or misuse of the emergency setting (ie, children presenting when not ill).…”

Características e fatores associados à hospitalização nos primeiros anos de vida: coorte de nascimentos de Pelotas de 2004, Rio Grande do Sul, Brasil

“…There is evidence in the literature of the association between maternal smoking during pregnancy and risk of hospitalization in childhood 35,36 . In this study, children of mothers that smoked showed higher hospitalization rates than children born to mothers that did not smoke during pregnancy.…”

The Child Opportunity Index and Disparities in Pediatric Asthma Hospitalizations Across One Ohio Metropolitan Area, 2011-2013

“…(1) Asthma-related morbidity disproportionately affects racial minorities and the socioeconomically disadvantaged. (1–3) Marked disparities exist across regions with considerable neighborhood-to-neighborhood variability. (4) At the population level, areas with high rates of poverty, substandard housing, and crime have high rates of asthma morbidity.…”

“…(5–9) At the patient level, influential factors may include socioeconomic status, culture, ethnicity, health beliefs, and gene-environment interactions. (3, 5, 10–12) Factors related to these social determinants of health (SDH) play an undeniable role at both levels. (5)…”