Addressing social risks related to health, environment and community was associated with reductions in asthma-related emergency department visits and hospitalizations in a systematic review and meta-analysis.
Asthma health education and environmental remediation proved to be the most beneficial components of effective social risk-based asthma interventions in the study, which is among the first systemic analyses to examine the impact of social interventions on asthma outcomes based on interventions detailed in the U.S. Health and Human Services Healthy People Social Determinants of Health (SDOH) 2020 framework.
Based on their review, researcher Jordan Tyris, MD, of Children’s National Hospital, Washington DC, and colleagues reported that existing interventions addressed social risk in just 3 of the 5 Healthy People SDOH 2020 domains; health, community and environment.
No interventions identified in the studies addressed the two other domains in Healthy People SDOH 2020; economy and education.
Findings from the systematic review and meta-analysis were published online December 6 in JAMA Pediatrics.
“(Our study) suggests that the added benefit of community, through the implementation of peer support with community health workers or health coaches, may have a greater association with reduced ED visits compared with hospitalizations,” they wrote. “The health and community intervention cluster that did not incorporate environment was associated with the least reductions in both ED visits and hospitalizations.”
The researchers searched for studies examining the impact of one or more social risks on asthma-related pediatric ED visits and hospitalizations, identifying 641 articles, with 38 meeting the criteria for inclusion in the systematic review and 19 included in the meta-analysis (n=5,441 participants).
In the primary analysis, social risk interventions were associated with decreased ED visits (RR, 0.68; 95% CI, 0.57-0.81; I2 = 70%) and hospitalizations (RR, 0.50; 95% CI, 0.37-0.68; I2 = 69%).
In the subgroup analyses, 6 studies provided outcome data for ED visits and hospitalizations for the health intervention cluster. For the environment intervention cluster subgroup analysis, only 1 study provided outcome data and 2 studies in the health and environment intervention cluster provided outcome data for ED visits, and 3 studies included data for hospitalizations.
“These interventions incorporated asthma education and home environment remediation,” the researchers wrote. “This subgroup analysis tied with the health and environment and community intervention cluster in producing the lowest relative risk for hospitalization (RR, 0.33; 95% CI, 0.21-0.50; I2 = 0%).
Four studies in the health and community intervention cluster provided outcomes for ED visits and 5 studies provided outcomes for hospitalization.
Health, environment and community were the only 3-domain intervention cluster, with interventions incorporating asthma education, home environment assessment or remediation and community health workers. Four studies provided outcome data for ED visits and hospitalizations for this cluster.
“This subgroup analysis produced the lowest relative risk for ED visits (0.53; 95% CI, 0.44-0.64 ; I2 = 50%) and tied with the health and environment intervention cluster for lowest relative risk for hospitalizations (0.33; 95% CI, 0.20-0.55; I2 = 71%),” the researchers wrote.
In the sensitivity analyses, when outlier studies for ED visits and hospitalization were removed, “the significance of the overall and subgroup effect estimates did not change, but heterogeneity was substantially reduced,” the researchers wrote.
“This meta-analysis, to the best of our knowledge, is the first to leverage the Healthy People 2020 SDOH framework to synthesize existing literature and quantify the association of social risk-based interventions with asthma-related health care utilization among children,” they noted.
“Our results support the core vision of an overarching Healthy People goal, which is rooted in improving a child’s living conditions to facilitate improved health….The present study takes an important step by highlighting the value of addressing individual level social risks, while, in parallel, the pediatric community advocates for policies to address population-level SDOH.”
In commentary published with the study, pediatrician Kelly Kelleher, MD, and Mattina Davenport, PhD, of Nationwide Children’s Hospital, Columbus, Ohio, identified several study limitations, including a lack of information about the impact of the interventions on specific at-risk groups, and the relatively small number of studies included in the systematic review and meta-analysis.
“Similarly, the authors knowingly did not focus on targeted policies that improve specific environmental factors that decrease asthma, such as tobacco smoking taxes and diesel regulations,” Kelleher and Davenport wrote.
“Still, there is likely little disagreement with the overall conclusions, which were similar to previous reviews. Those types of interventions do likely change asthma care utilization for children. The remaining questions are more difficult. Are such findings true for other environmentally influenced conditions, such as infant mortality and learning problems? Who should be accountable for or pay for social interventions? What is the role of the clinician in supervision of public health interventions?”
The commentary writers’ noted that the National Academies of Sciences, Engineering, and Medicine (NASEM) have proposed a classification system to “describe the integration of social care into health care service delivery,” identifying 5 key system-level activities: awareness, adjustment, assistance, alignment and advocacy.
“For equity to be advanced, differences in asthma outcomes at the intersection of race and ethnicity, gender, and sexual identities must be examined as a consequence of upstream determinants (eg, discrimination) and related mid-stream determinants (eg, access to health care, quality of housing, and incarceration),” they wrote. “Similarly, health care organizations will need to use the NASEM framework to extend their work on other aspects of integrating social care into health care organizations.”
“The complex role of severe poverty and discrimination in maintaining asthma disparities requires additional community-driven research and comprehensive programming and policy changes to address structural determinants rooted in the intersections of racism and classism (e.g. food insecurity, neighborhood segregation and environmental injustice.”
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Addressing social risks related to health, environment and community was associated with reductions in asthma-related emergency department visits and hospitalizations in a systematic review and meta-analysis.
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Asthma health education and environmental remediation proved to be the most beneficial components of effective social risk-based asthma interventions in the study.
Salynn Boyles, Contributing Writer, BreakingMED™
Researcher Kavita Parikh reported receiving grants from the Agency for Healthcare Research and Quality unrelated to this study. No other disclosures were reported.
Cat ID: 637
Topic ID: 85,637,254,730,100,637,192,63,925
