Group Title: BMC Public Health
Title: Lack of insurance coverage and urgent care use for asthma : a retrospective cohort study
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Title: Lack of insurance coverage and urgent care use for asthma : a retrospective cohort study
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Creator: Markovitz, Barry
Andresen, Elena
Publisher: BMC Public Health
Publication Date: 2006
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Abstract: BACKGROUND:Asthma is a common chronic disease with profound impacts upon individuals and the US health care system. Inadequate health care coverage has been associated with more frequent and severe exacerbations of the disease. We examined the relationship between adequacy of health care coverage and use of emergent care of adults with asthma.METHODS:The 2001 Behavioral Risk Factor Surveillance System was the source of data on adults with current asthma. Bivariate and multiple logistic regression analysis modeled identifiable factors in predicting urgent or emergent care.RESULTS:Key variables included demographics and information on self-reported gaps in health care coverage. The primary outcome was emergency room or urgent care visits for worsening of asthma symptoms. Of 16,234 subjects nationally with current asthma, 2,195 from eight states had valid responses to a supplemental module asking about emergency room use or urgent care visits because of asthma. Thirty four percent of these individuals required such care in the previous year. Having an interruption in health care coverage in the past year was associated with an increased risk of needed urgent or emergent care (crude Odds Ratio OR 1.48, 95% confidence intervals CI1.03, 2.1). The association was not statistically significant in the adjusted multivariate model including race/ethnicity, employment status, gender, age, education and the ability to identify a primary physician (adjusted OR 1.2, 95% CI 0.8, 1.8).CONCLUSION:This study provides population-level, generalizable evidence of increased risk of exacerbations of asthma in adults and (1) their demographic characteristics, and (2) continuous adequate health care coverage.
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Research article

Lack of insurance coverage and urgent care use for asthma: A
retrospective cohort study
Barry P Markovitz*I and Elena M Andresen2


Address: 1Washington University School of Medicine, St. Louis, MO, USA and 2Department of Veterans Affairs Medical Center/University of
Florida College of Public Health and Health Professions, Gainesville, FL, USA
Email: Barry P Markovitz* markovitz@wustl.edu; Elena M Andresen andresen@phhp.ufl.edu
* Corresponding author


Published: 24 January 2006
BMC Public Health 2006, 6:14 doi: 10.1 186/1471-2458-6-14


Received: 26 October 2004
Accepted: 24 January 2006


This article is available from: http://www.biomedcentral.com/1471-2458/6/14
2006 Markovitz and Andresen; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.



Abstract
Background: Asthma is a common chronic disease with profound impacts upon individuals and
the US health care system. Inadequate health care coverage has been associated with more
frequent and severe exacerbations of the disease. We examined the relationship between adequacy
of health care coverage and use of emergent care of adults with asthma.
Methods: The 2001 Behavioral Risk Factor Surveillance System was the source of data on adults
with current asthma. Bivariate and multiple logistic regression analysis modeled identifiable factors
in predicting urgent or emergent care.
Results: Key variables included demographics and information on self-reported gaps in health care
coverage. The primary outcome was emergency room or urgent care visits for worsening of
asthma symptoms. Of 16,234 subjects nationally with current asthma, 2,195 from eight states had
valid responses to a supplemental module asking about emergency room use or urgent care visits
because of asthma. Thirty four percent of these individuals required such care in the previous year.
Having an interruption in health care coverage in the past year was associated with an increased
risk of needed urgent or emergent care (crude Odds Ratio [OR] 1.48, 95% confidence intervals
[Cl] 1.03, 2.1). The association was not statistically significant in the adjusted multivariate model
including race/ethnicity, employment status, gender, age, education and the ability to identify a
primary physician (adjusted OR 1.2, 95% Cl 0.8, 1.8).
Conclusion: This study provides population-level, generalizable evidence of increased risk of
exacerbations of asthma in adults and (I) their demographic characteristics, and (2) continuous
adequate health care coverage.


Background
Asthma is a chronic illness affecting an estimated 7.2% of
adults in the U.S. with significant morbidity and mortality
[1]. An estimated 4,487 deaths, 1.8 million emergency
department visits, and 10.4 million physician office visits
were attributed to asthma in 2000. Asthma is one of a


number of chronic conditions that, improperly managed
by regular outpatient care, results in increased morbidity,
use of emergency services and inpatient hospitalization
[2]. Adequate insurance coverage in patients with asthma
correlates with reduced use of urgent or emergent care. For
example, Davidson found children on Medicaid far more


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likely to utilize emergency room care, compared to chil-
dren with adequate private insurance [3]. Impaired access
to health care strongly correlated with socioeconomic
status has been and continues to be a major impediment
to optimal care for many individuals with such chronic
diseases and consequently is likely to be related to the
increased use of emergency care [4]. In his paper, Andrulis
summarizes a large body of evidence to this effect and the
corollary that reducing health care access disparities
improves outcomes of those with chronic diseases such as
asthma.

The Behavioral Risk Factor Surveillance Survey (BRFSS) is
a state-based, telephone (random-digit-dialed) survey of
the noninstitutionalized U.S. population aged 18 years of
age and older, on data related to chronic diseases and
their risk factors [5,6]. This survey provides annual popu-
lation-based cross sectional data that can be used to track
self-reported risks and health conditions over time and
allow for testing of hypotheses regarding such risks and
disease outcomes. The BRFSS includes national universal
questions and modules, and, as in 2001, state-added
modules on special topics of interest to these states. We
used the BRFSS 2001 to assess the relationship between
access to health care and short-term asthma outcomes.
Specifically we asked whether any interruption in health
care coverage resulted in the use of more urgent or emer-
gency care for subjects with asthma.

Methods
The population studied included those respondents to the
BRFSS 2001 with affirmative answers to the two asthma
questions (asked in all 50 states, the District of Columbia
and U.S. Territories): "Have you ever been told by a doc-
tor, nurse, or other health professional that you have
asthma?" and "Do you still have asthma?" An additional
series of questions regarding asthma was asked of partici-
pants as a state-added module in eight states in 2001; to
be included in this analysis, a valid response to one or
both of the following questions was required: "During the
past 12 months, how many times did you visit an emer-
gency room (ER) or urgent care center because of your
asthma?" and "During the past 12 months, how many
times did you see a doctor, nurse, or other health profes-
sional for urgent treatment of worsening asthma symp-
toms?" Responses to these questions were combined and
the dichotomous variable created as a yes or no reply to
either or both of these original questions regarding urgent
or emergency care for asthma. The eight states who chose
to use the asthma care module represented a broad range
of the U.S. population (Indiana, Iowa, Michigan, Missis-
sippi, Missouri, Pennsylvania, South Dakota, Washing-
ton).


The primary predictor variable was the reply to the ques-
tion: "During the past 12 months, was there any time that
you did not have any health insurance or coverage?" The
additional potential confounding variables analyzed
included age (recorded as 18-24, then 5 year epochs, then
> 80 years of age; the 13 categories were then analyzed as
a continuous variable; age also was analyzed as 18-64 vs.
> 65 years), gender, race/ethnicity (white non-Hispanic,
black non-Hispanic, others non-Hispanic, Hispanic),
employment status (employed, homemaker/ student/
retired, unemployed/can't work), education (< high
school graduate, high school graduate, college graduate),
income (< $10,000/year, $10-50,000/year and >
$50,000/year), marital status (married vs. not married)
and response to the questions "Do you have one person
you think of as your personal doctor or health care pro-
vider?" and "Was there a time during the last 12 months
when you needed to see a doctor, but could not because
of the cost?"

Descriptive analyses compared characteristics of those
who had or did not have urgent care/ER use. Bivariate
analysis of categorical variables with outcome was tested
with chi-square and ranked ordinal variables by chi-
square for trend (p < 0.05 considered significant); unad-
justed odds ratios (OR) with 95% confidence intervals
(CI) are presented. Logistic regression was performed with
odds ratios and 95% confidence intervals reported. Logis-
tic regression used "coverage" as the primary exposure,
and included any additional variable if it had a meaning-
ful effect on the odds ratio of coverage (10% or more
change in the OR), or if the additional variable itself was
a significant predictor of urgent care/ER use. Effect modi-
fication by age dichotomizedd at 65) was also examined
using a liberal p-value for interaction of 0.10. All analyses
were performed with SPSS 11.0 for Macintosh for
unweighted data (SPSS, Inc., Chicago, IL, 2002). The
study was approved by the St. Louis University Institu-
tional Review Board.

Results
There were 24,067 affirmative replies (11.33% of total
respondents) to the first asthma question ("..ever been
told you have asthma") and 16,324 reported still having
asthma. Of these subjects, 2,195 individuals had valid
responses to the questions regarding urgent or emergency
room use in the past year; of this group, 34% of subjects
needed such care in the previous year. Comparison of the
subjects from the BRFSS focused sample of eight states
showed no differences health coverage, health behaviors,
and demographic factors except for a slightly higher per-
centage of respondents who were white/non-Hispanic in
the smaller group (83% in the eight-state sample versus
76% in the BRFSS national sample of persons with
asthma: chi square = 59.8, p < 0.001). Table 1 illustrates


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Table I: Use of urgent or emergency asthma care in the 2001 Behavioral Risk Factor Surveillance System (8 states; n = 2,195 with valid
replies)


Required urgent or emergency room
care for asthma in past 12 months


Yes (%)


No (%)


Health care coverage gap in past year? *


Gender *


One physician identified as primary?


Health plan in past year


Race/ethnicity *





Age group*


Too costly to see physician in past year*


Income *



Employment *



Education



Marital status


Smoke now?


Yes
No
Total s
Men
Women
Totals
Yes
No
Totals
Yes
No
Totals
White/non-Hispanic
Black/non-Hispanic
Other/non-Hispanic
Hispanic**
Totals
18 to 64
65 and older
Totals
Yes
No
Totals
<$ 10,000
$10-50,000
> $50,000
Totals
Employed
Homemaker/student/retired
Unemployed/can't work
Totals
< HS graduate
HS graduate
College graduate
Totals
Married
Not married
Totals
Yes
No
Totals


56(8)
611 (92)
667 (100)
172 (23)
580 (77)
752 (100)
606 (81)
146 (19)
752 (100)
667 (89)
83 (1 1)
750 (100)
576 (77)
92(12)
59(8)
23 (3)
750 (100)
658 (88)
92(12)
750 (100)
31 (19)
136 (81)
167 (100)
83 (12)
464 (67)
150 (22)
697 (100)
411 (55)
169 (23)
172 (23)
752 (100)
108 (14)
462 (61)
182(24)
752 (100)
345 (46)
406 (54)
751 (100)
233 (55)
194 (45)
427 (100)


75 (6)
1210 (94)
1285 (100)
482 (33)
961 (67)
1443 (100)
1120 (78)
320 (22)
1440 (100)
1288 (89)
152 (1 1)
1440 (100)
1235 (87)
88 (6)
70 (5)
34(2)
1427 (100)
1 147(80)
284 (20)
1431 (100)
43 (1 1)
337 (98)
380 (100)
I 18 (9)
801 (64)
331 (27)
1250 (100)
816 (57)
411 (29)
214(15)
1441 (100)
198 (14)
902 (63)
338 (24)
1438 (100)
700 (49)
739 (51)
1439 (100)
394 (50)
401 (50)
795 (100)


0.






0











I


0
0.


0.



0
0.

0


1.48 (1.03,2.1) 131
1821
1952
59 (0.48, 0.72) 654
1541
2195
1.20 (1.0,1.5) 1726
466
2192
.95 (0.71,1.26) 1955
235
2190
reference 181 I
2.24 (1.63,3.0) 180
1.81 (1.24,2.6) 129
1.45 (0.83,2.5) 57
2177
.77 (1.37,2.28) 1805
376
2181
.79 (1.08,2.95) 74
473
547
reference 201
.82 (0.60,1.13) 1265
64 (0.45, 0.92) 481
1947
reference 1227
81 (0.66, 1.01) 580
.56 (1.24,1.97) 386
2193
reference 306
.94 (0.72,1.22) 1364
01 (0.75, 1.36) 520
2190
.90 (0.75,1.07) 1045
1 145
2190
.22 (0.97,1.55) 627
595
1222


* p < 0.05 by chi-square analysis
** small sample size may limit interpretation of results for Hispanic subjects
HS = High school, OR = odds ratio, Cl = confidence interval


bivariate analysis of the relationship between individual
predictors and the use of urgent or emergency room care.
A positive reply to interruption in health care coverage
was associated with an increased risk of needing urgent or
emergency room care (OR 1.48, 95% CI 1.03, 2.1), as was
black/non-Hispanic race (OR 2.24, 95% CI 1.63, 3.0),
other non-Hispanic race (OR 1.81, 95% CI 1.24, 2.6), and


age (18-64, OR 1.77, 95% CI 1.37, 2.28), and a positive
response to the inability to see a physician in the past year
due to cost (1.19, 95% CI 1.08, 2.95). In addition, male
gender was associated with a reduced risk of needing
urgent or emergent care (OR 0.59, 95% CI 0.48, 0.72) and
being unemployed/can't work carried an increased risk
(OR 1.56, 95% CI 1.24, 1.97).


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crude OR (95%
Cl)


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Table 2: Logistic regression model of predictors of needing urgent or emergency room care in past year in subjects with asthma from
the 2001 Behavioral Risk Factor Surveillance System (8 states; n = 2,195)


Race/ethnicity



Health care coverage gap in past year?

Gender

Age
Education


Employment status


One physician identified?


White/non-Hispanic
Black/non-Hispanic
Other/non-Hispanic
Hispanic
No
Yes
Female
Male
(per 5 year increase)
College graduate
< High school graduate
High school graduate
Employed
Homemaker/student/retired
Unemployed/can't work
No
Yes


* Odds ratios adjusted for all other variables in the model
Cl = confidence interval


A series of logistic regression models were evaluated to
examine potentially confounding factors and the most
parsimonious model is presented in Table 2. Once race/
ethnicity was entered into the model, the odds ratio of the
primary predictor of interest was not statistically signifi-
cant at 1.2 (95% CI 0.8, 1.8) and varied little irrespective
of adding or subtracting additional variables.

Retaining a significant effect were black/non-Hispanic
race (OR 2.4, 95% CI 1.7, 3.4), other/non-Hispanic race
(OR 2.1, 95% CI 1.4, 3.1), male gender (OR 0.6, 95% CI
0.5,0.7), and unemployed/can't work status (OR 1.6, 95%
CI 1.2, 2.1). Although subjects above the age of 65
required more urgent or emergent care for asthma in the
bivariate analysis, age, whether entered as a ranked varia-
ble (in 5 year increments) or as dichotomous (older or
younger than age 65), was not a significant predictor of
urgent or emergent care use in multivariable analysis.

Discussion
In our descriptive analysis, a break in health care coverage
in the past year was associated with the use of urgent or
emergent care for asthma. In addition to the burden of
asthma on society, there is substantial impairment of the
quality of life in individuals with current disease, as
shown in work by Ford et al. using the BRFSS 2000 survey
[7]. They found that adults with asthma experienced twice
the number of impaired physical or mental health days
each month compared to those without asthma. More
than one third of the subjects in the sample in our report
required urgent or emergency room care at least once in
the past year for their disease.


Lack of or interruptions of health care coverage has been
demonstrated to be associated with increased use of emer-
gency care, as emergency rooms become the health care
provider of last resort for those without insurance, and
therefore without proper maintenance or preventative
care [4]. As Andrulis discusses, socioeconomic status and
race are also well-established markers of poorer health
care outcomes, but there is evidence that once access to
health care is leveled across class and race, these differ-
ences are markedly reduced. He cites several studies that
support this paradigm: having adequate insurance ensures
access to regular care which reduces the use of emergency
care, as a large portion of emergency room visits are for
non-urgent care by individuals without adequate insur-
ance. Since passage of the Emergency Medical Treatment
and Active Labor Act (EMTALA) in 1985, no one can be
denied emergency room care in the U.S. for lack of ability
to pay. Additional support is evident in survey of almost
500 nonelderly adults with asthma in California, where a
correlation was demonstrated between insurance status
(Medi-Cal), access to regular care, and the use of emer-
gency room visits for asthma symptoms [8].

However, not all the evidence is consistent as efforts are
made to extend health care coverage to more groups with
government programs. New York was an early developer
of the Child Health Insurance Program (CHIP) that pro-
vided coverage to children ineligible for existing Medicaid
and without other insurance. Szilagyi et al. found sub stan-
tial improvements in the health care of children with
asthma associated with this program [9]. Finkelstein com-
pared 1,928 Medicaid-covered with 11,007 privately-



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Adjusted OR*


reference
2.4
2.1
1.1
reference
1.2
reference
0.6
1.0
reference
0.9
0.9
reference
0.9
1.6
Reference
1.2


95% Cl


1.7,3.4
1.4,3.1
0.6,2.0

0.8,1.8

0.5,0.7
0.9,1.0

0.6,1.2
0.7,1.1

0.7,1.1
1.2,2.1


1.0,1.6


BMC Public Health 2006, 6:14







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insured children with asthma within the same HMO and
found Medicaid-insured children 1.4 times as likely to
receive emergency room care (95% CI 1.2, 1.5) and 1.3
times as likely to be hospitalized (95% CI 1.1, 1.5) as non-
Medicaid-insured within this HMO [10].

In our descriptive univariate analysis, a break in health
care coverage was a significant, albeit modest, predictor of
needing urgent or emergency room care in the previous
year. This relationship became non-significant once race/
ethnicity was considered in the regression model. In an ad
hoc analysis, we considered whether minority status
might operate as an effect modifier (interaction) of health
insurance gap. While the health gap effect in minorities
was greater than for whites, the difference was not signifi-
cant. This analysis could not confirm that the effect was
statistically significantly different by (modified by) race/
ethnicity. This potential should be examined in future
studies, since it is plausible that the effect of inconsistent
coverage has a larger effect for minority adults in the U.S.
In our analysis, Blacks and other minorities were more
likely to have a gap in insurance coverage (data not
shown) and were also more likely to require urgent or
emergent care; race/ethnicity is, therefore, a classic con-
founder in this analysis. Race/ethnicity is likely to be a
marker for a constellation of factors rather than a risk fac-
tor in and of itself. Race/ethnicity is also potentially asso-
ciated with more severe disease, although we could not
determine that from the BRFSS. Thus, it is an important
adjustment factor in order to observe the independent
effect of a gap in coverage. Interestingly, the role of having
a single physician identified as the primary health care
provider did not appear to play a role in this analysis. It
may be that using a single emergency room or urgent care
visit as the primary outcome measure is too insensitive a
measure to distinguish the role of a gap in health care cov-
erage. However, a separate model using just emergency
room care as the dependent variable showed little differ-
ences in the predictors' effects (results not shown).

One of the limitations of this study is the reduced power
with only 2,195 subjects with complete data for analysis,
and only 131 subjects had a gap in health insurance cov-
erage in the previous year. With a modest effect size of OR
= 1.2, this study had less than 10% power to detect a sig-
nificant effect. A larger study with over 5,000 respondents
(with a health insurance gap) would be required to con-
firm the relationship reported here. Further, because
BRFSS does not sample persons aged <18 years or persons
who are in institutions, who are in households without a
telephone, and potentially under samples those who are
hearing impaired, who have cognitive, speech, and other
communication impairments, or who have limited stam-
ina and cannot get to the telephone, findings in this report
cannot be generalized to the individual or aggregate state


populations without some limitation. In addition, only 8
states are included in this report. While the subset of peo-
ple with asthma described here vary minimally from the
national BRFSS, some caution should be used in general-
izing to other states. The considerable advantage of data
from the BRFSS is the random selection of community-
dwelling adults, which allow for population inferences
that are not present in analyses of health plan enrollees
and clinical databases. In addition, the BRFSS provides
self-reported data that are not limited to process, billing,
encounter, or utilization variables recorded in electronic
databases.

We did not have detailed information about the underly-
ing medical severity of asthma of the subjects. In addition,
the response rate to the BRFSS overall in 2001 was only
51%, and there may be systematic differences between
those who replied to the survey in these matters and those
who did not [1]. The BRFSS survey data are examined for
quality, and some biases are noted in demographics of
respondents [11]. For our analyses, if those who did not
respond were more likely to need urgent care and to have
inadequate heath care coverage, our estimate is biased
toward the null, or no effect. However, even a moderate
relative relationship would translate to substantial public
health impact because of the large number of people
affected.

Conclusion
In this study, 7% of respondents with asthma had a break
in coverage, and among these, over 43% required urgent
or emergency room care compared to 34% of all subjects
with asthma. With an estimated 14.7 million adults with
asthma in the U.S., cautious extrapolation suggests that
upwards of 80,000 individuals may experience at least
one additional urgent care visit associated with inade-
quate health care coverage. Finally, these results suggest
that racial/ethnic differences in the use of urgent care for
asthma are not related only to problems in health care
coverage. These disparities need to be examined in more
detail in future research where the effects of race/ethnic-
ity and severity of illness can be measured more precisely,
and their effects isolated better on access to care and
asthma care.

Competing interests
The authors) declare that they have no competing inter-
ests.

Authors' contributions
BPM and EMA both participated in the design, data anal-
ysis and manuscript preparation of this study.

Acknowledgements


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The authors would like to thank Vince Campbell, PhD, from the Centers
for Disease Control and Prevention, for advice and manuscript review.
Sarah Boslaugh, PhD, provided valuable statistical assistance.

Funding for Dr. Andresen was provided, in part, by the Centers for Disease
Control and Prevention (CDC) Prevention Research Center at Saint Louis
University (U48CCU710806).

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