Barriers to care may account for only small differences in asthma ED visits
Despite potential eligibility for no-cost medical treatment, patients with low socioeconomic status enrolled in the World Trade Center Health Registry experienced more ED visits due to asthma, according to a study published in JAMA Network Open.
“It is not known whether barriers to care, such as delays in World Trade Center Health Program participation, long waiting times for appointments and lack of coverage for comorbid conditions, differentially affect those with fewer resources. It is also unclear whether experiencing these barriers could, in turn, lead patients to resort to obtaining acute care through EDs,” the researchers wrote. “In other words, although treatment for asthma is available to all qualifying rescue and recovery workers and community members, those of lower socioeconomic status may not be able to access or use it as effectively as those who have higher socioeconomic status.”
To learn more, the researchers evaluated data from the World Trade Center Health Registry, which includes rescue and recovery workers and community members who worked, lived, studied or were present in downtown Manhattan, New York, during or immediately after Sept. 11, 2001. They then matched this information to a database of ED visits and performed analyses to determine whether health care barriers mediated the link between the frequency of ED visits and socioeconomic status.
Information on potential barriers to care, including education, income and race/ethnicity, were collected from 2003 to 2004, and data on asthma-related ED visits occurring after 2006-2007 but before 2016 were included in the analysis.
Effect of barriers to care
Overall, the study included 30,452 participants in the registry. Of these, more than half were men with a median age of 42 years. Two-thirds of the population were white, 13% were African American and 13% were Hispanic or Latino. Approximately half had a bachelor’s degree and 15% had an annual income less than $35,000, according to the data.
During the study period, 448 participants had at least one ED visit. Results demonstrated an association between having one or more barriers to care and having at least one ED visit due to asthma. Additionally, more participants with at least one ED visit had one or more barriers to care compared with those who had no hospitalizations (28% vs. 19%; P < .001).
In bivariate analyses, race, sex, income and educational attainment were all linked to having at least one ED visit, with white and Asian participants, those with higher education levels and those with higher incomes having lower rates of asthma-related ED visits than participants from other racial/ethnic groups and those with lower socioeconomic status. Notably, barriers to care were more common among nonwhite participants and those with the lowest income and education levels.
Analyses also showed that the number of barriers to care mediated the association between these factors and asthma-related ED visits, but the effect size was modest.
Certain barriers, however, had stronger effects on this relationship. Specifically, lack of money, lack of insurance and lack of transportation explained 11.8%, 11.9% and 9% of the difference in number of ED visits, respectively, between white and nonwhite participants. Similarly, lack of money, lack of insurance and lack of transportation explained 9.1%, 9% and 5.5% of the difference in the number of ED visits, respectively, between participants with incomes less than $35,000 vs. $200,000 or more. The same was true for the difference between the least and most educated participants, with lack of money, lack of insurance and lack of transportation again explaining 11.8%, 12.5% and 4.3% of the difference in ED visits, respectively.
Other barriers, such as lack of child care, not knowing where to go for care and inability to find a health care professional had a small or no effect on the association.
“This study produced two substantive findings. First, these data demonstrate that health disparities exist in ED visit rates in the 9/11-exposed population. Second, although this association is partially mediated by barriers to care, the barriers studied here accounted for only a relatively small percentage of the total effect sizes,” the researchers wrote.
They also noted that these findings indicate further research is needed.
“Health equity requires that public health officials identify vulnerable post-disaster subpopulations and provide additional resources to those who most need them.” – by Melissa Foster
Disclosures: Brite reports receiving funding from the CDC. Please see the study for all other authors’ relevant financial disclosures.