key: cord-0740497-ier5tbhr authors: Ulrich, Lisa; Macias, Charlie; George, Ashish; Bai, Shasha; Allen, Elizabeth title: Unexpected decline in pediatric asthma morbidity during the coronavirus pandemic date: 2021-04-13 journal: Pediatr Pulmonol DOI: 10.1002/ppul.25406 sha: d6b7e61b13715d31e2fe369338227b9308f5039d doc_id: 740497 cord_uid: ier5tbhr The Coronavirus disease 2019 (COVID‐19) pandemic profoundly impacted health care utilization. We evaluated asthma‐related emergency department (ED) and inpatient health care utilization by a county‐specific Medicaid population, ages 2–18, during the COVID‐19 pandemic and compared it to utilization from a 3‐year average including 2017–2019. All‐cause ED utilization and asthma medication fill rates were evaluated during the same timeframes. Relative to the 2017–2019 3‐year average, cumulative asthma‐related ED visits from January through June decreased by 45.8% (p = .03) and inpatient admission rates decreased by 50.5% (p = .03). The decline in asthma‐related ED utilization was greater than the reduction of overall ED use during the same time period, suggesting that the decline involved factors specific to asthma and was not due solely to avoidance of health care facilities. Fill rates for asthma controller medications decreased during this time (p = .03) and quick relief medication fill rates had no significant change (p = .31). Multiple factors may have contributed to the decrease in acute asthma health care visits. Locally, decreased air pollution and viral exposures coincided with the “Stay‐at‐home” order in Ohio, and increased utilization of telehealth for assessment during exacerbations may have impacted outcomes. Identification of the cause of the decline in visit rates could spur new interventions to limit the need for ED and inpatient visits for asthma patients, leading to both economic and health‐associated benefits. Cases of novel coronavirus were first reported in Wuhan, Hubei province, China, in December 2019. 1 The Coronavirus disease (COVID- 19) was declared a worldwide pandemic on March 11, 2020 by the World Health Organization. 2 While adult hospitals worked to increase patient capacity to accommodate COVID-19 patients during this time, pediatric hospitals saw patient volumes decrease. 3 Initial reports from London, 4 Boston, 5 and Philadelphia 6, 7 suggest that acute asthma visits declined as well. This significant decline in pediatric asthma health care utilization has not been confirmed elsewhere in the United States. At Nationwide Children's Hospital in Columbus, Ohio, asthma contributes to a significant portion of emergency department (ED) and inpatient (inpatient) visits. As part of a larger quality improvement project the hospital routinely monitors ED and inpatient admission rates for children with asthma in a pediatric accountable care organization Partners for Kids (PFK). 8 In response to the spread of viral infection to the United States, the state of Ohio closed schools on March 14, 2020 and enacted a "Stay at Home" order limiting all nonessential travel from the home March 22, 2020-May 29, 2020. 9 We hypothesized that the rates of ED and inpatient visits for asthma would decrease during the COVID-19 pandemic. We aimed to compare baseline ED and admission rates for asthma in PFK patients at our institution to rates during the COVID-19 pandemic. We also investigated pharmacy fill rates of asthma-related controller and reliever medications (short acting β-agonists), looking for possible association with health care utilization rates. The Nationwide Children's Hospital (NCH) is a large, 527-bed freestanding tertiary referral center in an urban setting in Franklin County, Ohio with over 18,000 patients discharged annually. Both ED and inpatient data was based on annualized member-months, a product of total monthly enrollment of patients 2-18 years old in Franklin County covered by the Medicaid managed care plan and the number of months in the plan. 12 Baseline data was established from a 3-year average of ED and inpatient rates from 2017 to 2019 to avoid effects of single year variation. These were compared to 2020 rates January through June, including after the COVID-19 restrictions were put into place in Franklin County, Ohio from March to June 2020. The rate of ED visits with any discharge diagnosis (not limited to asthma) at NCH for all PFK patients between the ages of 2 and 18 years old in Franklin County was also evaluated during the same timeframes. Data was collected monthly from the EMR and was displayed in similar cumulative line graphs. Pharmacy billing information regarding asthma controller and reliever (short-acting β-agonist) medications filled for covered patients aged 2-18 living in Franklin County was obtained from PFK. Data was displayed in similar cumulative line graphs. Prescription counts were based on the number of days supply for the script, so that a script with days supply of less than 60 counts as one fill, and a script with days supply between 60 and 89 counts as two fills, and so on. Medication lists were updated to reflect new Healthcare Effectiveness Data and Information Set (HEDIS) recognized asthma therapies that became available during the years studied. This study did not meet the definition of human subject's research and IRB approval was waived. Statistical comparisons were conducted for ED visit rates for all diagnoses, asthma ED visit rates, cumulative year to date asthma inpatient visit rates, and medication fill rates for asthma controller and The rate of ED visits for PFK patients with any diagnosis (not limited to asthma) seen at NCH also declined but less so than was It also includes evidence of medication fill rates in the same population to address concerns with medication adherence. By providing historic health care utilization data illustrating the seasonality of acute asthma visits, as well as variability from year to year, our approach more graphically illustrates the degree to which 2020 has departed from normal illness patterns. These results are likely generalizable to other similar Medicaid populations, and potentially non-Medicaid populations, as they are similar to previous results including both populations. 6 Further evaluation is required at our institution to confirm generalizability to the non-Medicaid population. While COVID-19 data was not available as part of our PFKcentered asthma quality improvement database, previous pediatric studies have shown that children accounted for less than 5% of total COVID-19 infections and they tended to have less severe manifestations of COVID-19. 15, 16 When studied, asthma was not associated with an increased rate of hospitalization with COVID-19. 17 This could explain the lack of increase in patient volume in our pediatric institution during this period. There are several potential reasons for the decline in visit rates. Air pollution and poor air quality can contribute to increase in asthma symptoms and potentially trigger exacerbations. 18 Pollution related to road traffic has been linked to asthma exacerbations, along with other pollutants. 19 During the COVID-19 pandemic, air quality was improved in many major urban cities with "Stay At Home" orders limiting nonessential travel. 20 Franklin County, a mostly urban county with 800 miles of roads, 21 also saw an improvement in the Air Quality Index (AQI), in March-May 2020 when compared to March-May 2019 but further studies are needed to determine the definitive etiology of this improvement. [22] [23] [24] The AQI, established by the United States Environmental Protection Agency, is used to evaluate five major pollutants including ground-level ozone, particle pollution, carbon monoxide, sulfur dioxide, and nitrogen dioxide. 25 Viruses are another common cause of asthma exacerbation in children. 26 Asthma exacerbation prevalence tends to increase as schools reopen in September and children are exposed to more viral illnesses. 27 School closures and the Ohio "Stay at Home" order, prohibiting all large gatherings, likely resulting in decreased viral exposure for children. Children's Hospital of Philadelphia reported a decline in rhinovirus, a common viral pathogen trigger for asthma exacerbations, during the pandemic. 6 Nationwide Children's Hospital also saw a decline in non-COVID-19 respiratory viral pathogen testing and positivity during this time. 28 The decline in viral exposure likely contributed to decrease in asthma exacerbations and need for acute care. Despite relatively low pediatric infection rates, COVID-19 has caused uncertainty for many parents of children with chronic respiratory conditions. Increased anxiety levels related to COVID-19 were found in the mothers of both healthy patients and patients with cystic fibrosis. 29 Caregivers of patients with asthma may also have higher asthma-related anxiety levels due to COVID-19. Previous studies have shown that increased asthma-related anxiety in urban adolescents and their caregivers was associated with an increase in asthma preventative care. 30 A 15.3% improvement in adherence to controller (preventative) medication was reported in adult patients with asthma and chronic obstructive pulmonary disease in conjunction with the pandemic. 31 Asthma providers estimated, per survey, that their pediatric asthma patients had a 20% improvement in asthma medication adherence during the pandemic. 32 Controller medications are effective in preventing asthma exacerbations when taken properly, but adherence rates are typically low. 33 An increase in adherence due to asthma-related anxiety caused by COVID-19 could contribute to the decrease in asthma exacerbations seen. However, in our largely urban, Medicaid patient population between the ages of 2-18 improvements in asthma medication adherence (estimated by pharmacy fill rates) was not seen for controller medications. For our population, improved medication utilization did not appear to contribute to reduced asthma morbidity during the pandemic. Anxiety related to the pandemic and the potential for COVID-19 exposures in the ED may have caused parents to delay seeking care for their child's asthma exacerbation. A survey by the Kaiser Family Foundation, released May 2020, reported that 48% of Americans had a family member who delayed their medical care during the COVID-19 pandemic. 34 While the overall decline in Franklin County PFK population ED utilization suggests this was possibly a factor in Columbus, the greater decline in asthma-specific ED utilization suggests a change in underlying asthma morbidity as well. This is further supported by a lack of increase in acute asthma medication fill rates, which may have otherwise enabled families to avoid ED visits. Telemedicine became a more widely accepted health care option during the pandemic. Providers conducted medical visits by phone or video visits to allow for the recommended social distancing and limited travel necessary during the pandemic. In 2014, in Houston, TX, telemedicine was shown to reduce unnecessary ambulance transports to the ED when it was performed at the time of an acute medical event. 35 Telemedicine visits increased drastically at NCH during the pandemic. It is possible that these visits were used during acute asthma exacerbations to provide a rapid assessment and prevent the need to go to the ED. Limitations of this study include reliance on EMR discharge diagnosis codes for ED and inpatient for data collection and the possibility of incomplete data if these codes were not entered correctly. We were not able to identify visits to other medical centers for acute asthma care during this study. We were not able to evaluate the demographics of the PFK population more closely to determine if health care utilization differed based on age, asthma severity, or race. This will be an important focus of follow up studies in this population. A small portion of the asthma medication fills included in this report were utilized by patients with a diagnosis other than asthma (e.g., by those with cystic fibrosis). It is unlikely that this nonasthma patient population substantially impacted the trends seen in our data. At the time of this report, information regarding telemedicine visit use for this population was not accessible; we plan to evaluate this factor when this data become available. The drastic decline in ED and inpatient visit rates for asthma exacerbation was in excess of the decline seen in ED utilization for all diagnoses. We suspect a reduction in respiratory viral illnesses and potential improved air quality caused by the Stay at Home order during the pandemic contributed to this decline. We did not see evidence of improved asthma medication adherence, based on pharmacy fill rates, that could explain the reduced health care utilization. Identification of factors, such as efforts to reduce respiratory viral contagion, that contribute to the reduction in asthma morbidity may suggest new interventions to improve patient quality of life and reduce the financial health care burden of this common pediatric condition. Mark Engelhardt for his assistance in data gathering. The authors declare that there are no conflict of interests. Lisa Ulrich: conceptualization (lead); data curation (equal); supervision (lead); writing original draft (lead); writing review and editing (lead). Charlie Macias: conceptualization (equal); data curation (lead); formal analysis (equal); methodology (equal); writing original draft (supporting); writing review and editing (equal). Ashish George: conceptualization (supporting); data curation (supporting); investigation (supporting); resources (equal); writing original draft (supporting); writing review and editing (equal). Shasha Bai: conceptualization (supporting); formal analysis (lead); methodology (equal); writing review and editing (equal). Elizabeth Allen: conceptualization (equal); data curation (equal); formal analysis (supporting); methodology (equal); supervision (equal); writing original draft (equal); writing review and editing (equal). The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. http://orcid.org/0000-0002-7232-2442 Ashish George http://orcid.org/0000-0002-2952-1884 Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia Rolling updates on coronavirus disease (Covid-19) Covid-19: the effects on the practice of pediatric emergency medicine Covid-19: reduced asthma presentations in children Impact of the Covid-19 pandemic on pediatric emergency department utilization for asthma Pediatric asthma healthcare utilization, viral testing, and air pollution changes during the covid-19 pandemic Initial effects of the covid-19 pandemic on pediatric asthma emergency department utilization Quality improvementdriven reductionin countywide medicaid acute asthma health care utilization Partners for Kids: Pediatric accountable care Health carrier information definitions R: A language and environment for statistical computing The economic burden of asthma in the United States Epidemiology of covid-19 among children in China Systematic review of covid-19 in children shows milder cases and a better prognosis than adults Prevalence and characterization of asthma in hospitalized and non-hospitalized patients with covid-19 Effect of outdoor air pollution on asthma exacerbations in children and adults: systematic review and multilevel meta-analysis Chronic burden of nearroadway traffic pollution in 10 european cities Changes in U.S. Air pollution during the covid-19 pandemic Air quality summary-March 2020. Mid-Ohio Regional Planning Commission Air quality summary-April 2020. Mid-Ohio Regional Planning Commission Air quality summary-May 2020. Mid-Ohio Regional Planning Commission Role of viral infections in the development and exacerbation of asthma in children The september epidemic of asthma exacerbations in children: a search for etiology Respiratory pathogen report. 2020. Nationwide Children's Hospital Effect of the Covid-19 pandemic on anxiety among children with cystic fibrosis and their mothers Association of youth and caregiver anxiety and asthma care among urban young adolescents Changes in medication adherence among patients with asthma and COPD during the COVID-19 pandemic Impact of covid-19 on pediatric asthma: Practice adjustments and disease burden Medication adherence and the risk of severe asthma exacerbations: a systematic review Nearly half of americans delayed medical care due to the pandemic Telehealthenabled emergency medical services program reduces ambulance transport to urban emergency departments Unexpected decline in pediatric asthma morbidity during the coronavirus pandemic