key: cord-0989862-a6dmbjki
authors: Koinis-Mitchell, Daphne; D'Angelo, Christina; Dunsiger, Shira; McQuaid, Elizabeth; Rogers, Michelle L.
title: Effects of COVID-19 Pandemic on Children, Adolescents and Young Adults with Asthma in Rhode Island: Patterns in Emergency Department Utilization with Geospatial Mapping
date: 2022-02-25
journal: Ann Allergy Asthma Immunol
DOI: 10.1016/j.anai.2022.02.007
sha: 6fc57ab877df09bbdd0b6bdc508e27fb2a773542
doc_id: 989862
cord_uid: a6dmbjki

In Rhode Island, asthma-related emergency department utilization significantly decreased during the first ten months of the COVID-19 pandemic (1/1/20-10/31/20) compared to previous years. ED utilization rates remained highest in high-risk, urban communities also most affected by COVID-19, highlighting the need for future research and intervention aimed at supporting high-risk, urban youth and young adults with asthma.

Conflict of Interest: None. All authors declare that they have no relevant or material financial interests that relate to the research described in this paper. Despite early concerns for increased asthma exacerbations due to the respiratory involvement of COVID-19, trends indicate decreases in the frequency of ED visits and asthma-related hospitalizations for children, adolescents and young adults with asthma during spring 2020 when the first COVID-19 cases emerged and were rising in the US. 1, 2 Less is known as to whether these patterns were maintained throughout summer and fall months of 2020 as COVID-19 rates continued to increase. To our knowledge, there are no published reports on asthma-related ED utilization by geographical area to identify high-risk communities prior to and during the COVID-19-era. This would help to identify highrisk communities to target for continued intervention to enhance education on COVID-related safe practices as well as optimal asthma management strategies.

Lifespan is Rhode Island's (RI) largest health system with several hospitals/partners spanning the state, including Rhode Island Hospital (RIH). The pediatric division of RIH, Hasbro Children's Hospital (HCH), located in urban Providence, RI, is home to the vast majority of inpatient pediatric care in the state. The ED at HCH serves over 50,000 pediatric patients/year 3 representing a wide diversity of racial, ethnic, and socioeconomic groups. Pre-COVID, the HCH ED served approximately 3,327 patients with asthma-related difficulties annually; an average of 324 pediatric patients were hospitalized for asthma-related difficulties at HCH annually pre-COVID.

We aimed to examine current trends in ED utilization and hospitalizations for youth and young adults (ages 0-21) with asthma in RI during the early COVID-era (1/1/20-10/31/20) compared to pre-COVID. Further, we utilized geospatial mapping to identify ED utilization and specific community "hot spots" prior to and during the early COVID-era; findings will help to better understand changes in ED utilization over time within specific high-risk neighborhoods in order to target interventions where they are needed geographically. Lastly, we provide maps of RI indicating geographic distribution of COVID-19 rates to provide additional context and further inform how the spread of the virus in specific communities may have concurrently influenced ED utilization.

Data were collected from electronic health records from the Lifespan health system which includes five hospitals with EDs across RI including HCH. ED visits and hospital encounters with asthma-related ICD-10 codes (e.g., J45.2: Mild intermittent asthma, J45.3: Mild persistent asthma) for children, adolescents and young adults (ages 0-21) were compiled. Data were collected from the same 10-month period (January-October) to compare frequencies pre-COVID (2018, 2019) and during the early COVID-era (2020). Longitudinal time series plots (X statistical process control charts) were used to depict trends in ED visits and hospitalizations during the pre-COVID and COVID-era period. Paired t-tests were utilized to compare 1) average frequency of asthma-related ED visits and 2) the number of ED visits that resulted in a hospitalization, both during pre-COVID vs. COVID-era periods. Geospatial mapping was also utilized to compare utilization rates across the same time periods by geographical area using patient ZIP codes. Data from the RI Department of Health (DOH) were utilized to map the median COVID-19 cases/month from March to October 2020 by ZIP code to supplement the ED utilization maps and provide additional context. Geospatial maps (Figure 1 ) for pre-COVID and COVID-era periods indicate utilization rates by ZIP code and demonstrate higher ED utilization among our most high-risk communities.

For additional context, geospatial maps for median monthly COVID-19 cases by ZIP, highlighting areas with highest proportion of population in poverty, are available upon request; additional information regarding COVID-19 rates by ZIP is available via RI DOH Website. 4 Data demonstrate a decrease in asthma-related ED visits and hospitalizations in RI from 2018 to 2019 (possibly due to preexisting and increased community-based intervention efforts in high-risk communities by our team and the RI DOH) as well as during the COVID-era compared to typical pre-COVID periods, providing important insight into factors that may contribute or minimize asthma exacerbations among youth and young adults Findings are consistent with other published data reports from urban hospitals in the Northeast (e.g., Philadelphia, 1 Boston 2 ) though extend existing knowledge by identifying the prolonged decrease, beyond the first several months of the COVID-19 pandemic. Though the current study was observational and does not directly assess the underlying mechanisms, several contributing factors may be driving decreases in utilization patterns during this period. The closing of schools and implementation of COVID-safe practices (e.g., social distancing, masking) played an important role in decreasing infectious triggers (e.g., rhinovirus) and exposure to allergens and irritants (e.g., pollution) that can exacerbate asthma symptoms. 5 Further, high proportion of fear related to asthma has been found among urban minority caregivers which may contribute to additional worry regarding taking youth to an emergency setting. 6 Future research should shed light on the extent to which individuals actually experienced symptoms in the home setting during this period and how youth and caregivers responded to these symptoms to inform contributors to management behaviors and healthcare utilization patterns.

COVID-19 also accelerated the use of telemedicine and virtual approaches to disease management across health conditions, likely introducing more cost-effective and convenient models of service delivery for patients with asthma. Future studies should aim to understand how telemedicine was utilized during the COVID-era among urban, minority youth with asthma.

RI's singular DOH also instituted a COVID response plan 7 to increase testing/vaccination in the most affected, high-risk communities. It is not surprising that the utilization patterns observed pre-COVID and during the COVID-era were consistent with the proportion of COVID rates that were seen across the high-risk communities. Even with these mitigation efforts demonstrated by the DOH and additional community initiatives to address COVID rates, other multilevel contributors to health disparities in general (e.g., SES, structural racism, neighborhood disadvantage) need to be considered.

Initial effects of the COVID-19 pandemic on pediatric asthma emergency department utilization

Pandemic on Pediatric Emergency Department Use for Asthma

Hasbro Hospital Emergency Department, Hasbro Children's Hospital. Medical Home Portal

COVID-19 Response Data: Rhode Island Department of Health COVID-19 Data Tracker

Pediatric Asthma Health Care Utilization, Viral Testing, and Air Pollution Changes During the COVID-19 Pandemic

Perceptions of Asthma and Exercise, and Associations with Weight Status and Asthma Morbidity in Urban Children

Rhode Island's Hard-Hit Community Vaccination Strategy. Rhode Island Department of Health

Figure 1. Daily Asthma ED visits (top left) and ED Visits to Hospitalizations (top right) with Geospatial Maps (bottom) for Period