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Study selection, data extraction, bias assessment, search results, description of study characteristics and outcomes, care coordination in communities, policy and environmental changes affecting communities, home-based interventions in communities, community-based health services, strength and limitations, conclusions, acknowledgments, community interventions for childhood asthma ed visits and hospitalizations: a systematic review.

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India Gill , Aashna Shah , Eun Kyung Lee , Rachael Sommer , Kristie Ross , Aparna Bole , Darcy Freedman; Community Interventions for Childhood Asthma ED Visits and Hospitalizations: A Systematic Review. Pediatrics October 2022; 150 (4): e2021054825. 10.1542/peds.2021-054825

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Video Abstract

A systematic review of interventions in community environments found significant reductions in childhood asthma exacerbations leading to emergency department visits and hospitalizations.

Structural and social determinants of childhood asthma inequities manifest within geographic communities that are often segregated. Childhood asthma disproportionately affects Black, Hispanic, and low-income populations. Community interventions have the potential to improve inequities in emergency healthcare. This systematic review was conducted to assess the effectiveness of childhood asthma community interventions and provide a conceptual model to inform implementation of future community interventions.

Publications from PubMed, ScienceDirect, CINAHL, Cochrane Library, Web of Science, and hand searched references were examined from 2010 to 2021. Community intervention studies among children with asthma were included. Main outcomes were emergency department visits and hospitalizations. Community interventions exclusively focusing on schools or hospitals were excluded. Two reviewers independently assessed eligibility for final inclusion. Emergency healthcare findings were extracted in addition to co-benefits (eg, fewer missed school days and caregiver workdays).

Out of 1856 records, 26 publications met the inclusion criteria. Community interventions were categorized by care coordination ( n = 8), policy and environmental changes (eg, smoke-free legislature, traffic reduction models, and green housing) ( n = 8), home-based ( n = 6), and community-based health services ( n = 4). Selected studies indicated that community interventions significantly reduced childhood asthma emergency department visits and hospitalizations through increased caregiver self-efficacy, home environmental trigger reduction, and increased access to healthcare. Because of heterogeneity among studies, we were unable to conduct a meta-analysis.

Findings show significant associations between community interventions and the reduction of emergency healthcare, suggesting a protective effect for severe cases of childhood asthma.

Asthma is among the most prevalent chronic conditions in children, affecting almost 6 million children in the United States. 1   In the most severe, uncontrolled cases, children with asthma experience disruptions to their everyday life, including missed school, unplanned emergency department (ED) visits, and hospitalizations. This results in increased healthcare costs and decreased quality of life and educational potential. 2   The annual clinical and academic burden of childhood asthma results in approximately 10.5 million missed school days, 640 000 ED visits, and 157 000 hospitalizations. 3  

Childhood asthma disproportionately affects children in low-income populations, inner-cities, 2 , 4 , 5   and underrepresented minority populations. 6 , 7   Black children (13.5%) are more likely to have current asthma than White (5.7%) children. 8   Among Hispanic populations, the current childhood asthma prevalence is 8.0% and is even higher for a subset of Puerto Rican children (17.0%). 9   Black children are 4 times more likely to have an asthma hospitalization and over 7 times increased risk to die of asthma when compared with White children. 10   Additionally, children from low-income populations are more likely to visit the ED than affluent children. 11   Black race, living in an urban residence, and poverty are attributable to 30% of the risk for asthma hospitalization. 12  

The communities where children live have a significant impact on the social patterning of asthma inequities. 13 , 14   Black and Hispanic children compared with White children disproportionately live in historically disinvested neighborhoods. 15 – 19   Major sources of air pollution, such as industrial facilities and major highways, which decrease the ambient air quality and exacerbate asthma symptoms, are found in low-income communities. 20 – 23   Inequities in air pollution exposure are more pronounced than inequities based on income when comparing underrepresented minorities to White populations. 24  

Neighborhoods can also exacerbate asthma symptoms by exposure to poor indoor air quality, allergens, and type of housing. 25 – 27   Substandard, deteriorated housing found in low-income communities is associated with mold, pest infestation, and water damage. 28   Safety concerns, such as community violence, may force children to stay indoors for longer periods of time, increasing potential for exposure to indoor sources of asthma triggers. 29   Lack of quality transportation, available social services, and access to healthcare resources in the community is a barrier and can further prevent caregivers from appropriately managing their children’s asthma. 29  

Community interventions may be a plausible solution to reduce childhood asthma exacerbations leading to ED visits and hospitalizations. Community interventions are strategies seeking to reduce adverse health outcomes in a population within a defined local context. It is important to understand the effectiveness of community interventions given spatial patterning of childhood asthma risk. 13 , 30 – 33   Children spend a vast majority of their time in their communities, including visiting family or friends, attending school, recreational centers, or other public places. Based on this premise and the community level inequities in exposure to in-home asthma triggers, there is a need to identify strategies affecting communities.

A seminal systematic review conducted by Chan and colleagues found significant associations between multicomponent community-based interventions (eg, interventions focusing on asthma self-management education, reduction of home environmental triggers, care coordination, school involvement, primary healthcare provider assessment, community support, and/or advocacy for policy changes) and reductions in childhood asthma severity. 34   Their review found that most studies included interventions related to asthma self-management education, home environmental assessment, and care coordination; many were held in clinical settings. 34   However, less is known about the impact of community interventions with multiple components compared with more expansive environmental changes affecting whole communities (eg, smoke-free legislature, traffic reduction models, and green housing) as it relates to the reduction of emergency healthcare utilization. Accordingly, this systematic review aimed to examine the broader scope of community interventions to evaluate evidence of their effectiveness for reducing childhood asthma exacerbations leading to ED visits and hospitalizations and provide a conceptual model to inform the implementation of future community interventions.

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines 35   to perform the systematic review. We developed a protocol and registered it with the International Prospective Register of Systematic Reviews (registration number: CRD42020196132), before conducting the review and writing the final report.

Five electronic databases (ScienceDirect, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PubMed, and the Cochrane Library) were used to search articles published from January 2010 to December 2021. We examined studies to see how effective community interventions are in reducing childhood asthma ED visits and hospitalizations. In each database we used search terms such as: (asthma AND [“community intervention” OR “community based” OR environment OR “evidence based” OR “patient education” OR “health education” OR “environmental justice” OR “collective action”] AND [hospitalization OR hospitalized OR inpatient OR emergency]). Our search strategy also comprised medical subject headings in addition to search terms related to childhood asthma ED visits and hospitalizations. To review our complete search strategy of database-specific search terms see the Supplemental Information. Additional studies were identified from hand searched reference sections.

Searches were limited to full-text articles published in the English language. Eligible studies included children with asthma who were exposed to community interventions. Community interventions comprised those that were place-based (eg, neighborhoods, zip codes, counties, etc), including those that were community-led (eg, community health workers [CHWs], local leaders, community partners, etc) and/or sociodemographic-based (eg, low-income, Black, Hispanic, etc). The main outcomes were childhood asthma ED visits and hospitalizations occurring after exposure to community interventions. Eligible study designs consisted of randomized controlled trials, longitudinal cohort, quasi-experimental design, natural experiment, or time series studies to examine the benefits and effectiveness of community interventions. There were no limitations for geographic location; all studies published worldwide were considered.

Searches excluded children with asthma exposed to no community interventions, community interventions in collaboration with drug therapies, and animal studies. Community interventions exclusively examining school or clinical settings were omitted as well as studies with only non-clinical outcomes. Though schools and clinics are important aspects of the community, recently published systematic reviews on school-based self-management, 36   asthma education for school staff, 37   school and community-based, 38   and inpatient quality improvement 39   interventions already exist. Though quality improvement studies did not clearly demonstrate effective reductions in asthma ED revisits or readmissions, 39   school-based self-management interventions improved hospitalizations and ED visits. 36   We made exceptions to our exclusion criteria for mobile community clinics that were located at schools as it is critical to identify methods of reducing barriers to care in underserved communities.

Titles and abstracts from each search engine were reviewed independently by 2 authors during the initial search. Eligible studies identified from the initial search were evaluated by 2 authors in the second phase for the full text review. Any disagreements between individual judgment were brought to the other co-authors for a discussion and resolved consensus for inclusion or exclusion. We abstracted data on study design, geographic location, study participants, sample size, type and description of community intervention, outcome measurements, and key results. A summary of findings is displayed in Table 1 .

Systematic Review Summary of Findings

Abbreviations: BMI, body mass index; CMH, Cochran-Mantel-Haenszel; IRR, incidence rate ratio; NO 2 , nitrogen dioxide; OR, odds ratio; PM10, particulate matter smaller than 10 µm; SD, standard deviation.

Two authors assessed the eligible studies for risk of bias to describe the quality of the body of evidence. For the randomized controlled trials, we used the Cochrane Risk of Bias tool for randomized trials version 2 and its associated version for cluster randomized trials. 40   The Cochrane Risk of Bias tool for randomized trials version 2 examines 5 domains of bias: (1a) bias arising from the randomization process, (1b) bias arising from the timing of identification or recruitment of participants, (2) bias caused by deviations from the intended interventions, (3) bias caused by missing outcome data, (4) bias in measurement of the outcome, and (5) bias in selection of the reported result. 40   Individual domains and an overall score were graded with low, some concerns, or high risk of bias. For the remaining non-randomized controlled trials, we used the Risk Of Bias In Non-Randomized Studies – of Interventions (ROBINS-I). 41   This tool included 7 domains of bias: (1) bias caused by confounding, (2) bias in selection of participants into the study, (3) bias in classification of interventions, (4) bias caused by deviations from intended interventions, (5) bias caused by missing data, (6) bias in measurement of outcomes, and (7) bias in selection of the reported result. 41   Domain and overall scores for the ROBINS-I yielded low, moderate, critical, serious, or missing or unclear risk of bias.

We identified 1816 records and an additional 40 records from hand searched reference sections. We reviewed 74 records for full text review and 48 were removed. We identified 26 records that met our inclusion criteria for the final report ( Fig 1 ). Because of the heterogeneous nature of the identified community interventions from eligible studies, a meta-analysis could not be performed.

Literature search results on community interventions for reducing childhood asthma ED visits and hospitalizations. Publications from PubMed, ScienceDirect, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Web of Science, and hand searched references from 2010 to 2021 were examined for childhood asthma community interventions. Out of 1816 records identified, 74 full text records were assessed for eligibility, and 26 publications met the inclusion criteria.

Community interventions were arranged into 4 categories: (1) care coordination in communities ( n = 8), 42 – 49   (2) policy and environmental changes affecting communities ( n = 8), 50 – 57   home-based interventions in communities ( n = 6), 58 – 63   and community-based health services ( n = 4). 64 – 67   However, there is some overlap in services as many studies included an aspect of interventions in the home as a core activity. Sources for the main outcomes include electronic health records ( n = 4), 50 , 51 , 57 , 66   medical claims ( n = 5), 42 , 43 , 52 , 53 , 56   and caregiver self-reports ( n = 14). 44 , 45 , 47 – 49 , 54 , 55 , 58 – 61 , 62 – 64   Three studies used both electronic health records and self-reports. 46 , 65 , 67   Community interventions were held in majority Black and Hispanic populations for 19 out of the 20 publications that reported racial demographics. 42 – 47 , 49 , 54 , 55 , 58 – 67   There was 1 study conducted in Canada 51   and 1 in Australia. 57   The remaining were across all 4 regions of the United States, including Puerto Rico.

Eight studies investigated the relationship between care coordination and reduction of emergency healthcare utilization. 42 – 49   Seven care coordination models significantly reduced both ED visits and hospitalizations. 42 – 44 , 46 – 49   Five care coordination studies were affiliated with the Merck Childhood Asthma Network (MCAN), 44 – 48   a coordination model incorporating culturally relevant asthma education, dissemination of asthma awareness in the community, and physician education. MCAN programs employed asthma care coordinators to connect families with health and social services and facilitate communication between families, physicians, and schools. Asthma care coordinators were nurses, CHWs or health educators. According to a cross site evaluation of MCAN programs, ED visits decreased by 36% to 63% and hospitalizations declined by 26% to 78% ( P = .01). 44   The remaining 3 care coordination studies were the Community Asthma Initiative (CAI), 49   Child Asthma Link Line, 43   and the Allies Against Asthma community coalitions. 42   Care coordination programs engaged community collaboration with healthcare, government, and academic partnerships. Stakeholders included representation from community members, families with asthma, community-based organizations, CHWs, healthcare agencies, clinical practices, Medicaid managed care organizations, academic leaders, and the government.

We found 8 studies related to policy and environmental changes. Three studies assessed the impact of policies focusing on home environmental trigger reduction in low-income communities and illustrated favorable reductions in emergency healthcare utilization. 53 – 55   The first study was the Green and Healthy Homes Initiative, an environmental justice project in partnership with the US Department of Energy and Environment. Green and Healthy Homes Initiative was designed to combat the shortage of affordable quality housing in low-income communities. Comprehensive environmental home assessments were performed to improve poor quality housing. Investigators found evidence of a 65.5% reduction in hospitalizations and a 27.7% reduction in ED visits for children with asthma ( P <.02). 55   The second study was the Controlling Asthma through Home Remediation (CAHR) program. CAHR had a unique relationship with community-based organizations. In addition to reducing emergency healthcare utilization, they successfully advocated for systemic changes in the regulation and enforcement of maintenance and repairs with the New York City Housing Authority. 54   Lastly, Lantz and colleagues predicted a Medicaid population of 7619 children with asthma in a United States Midwestern city would avert 1334 annual ED visits and 153 hospital admissions for a potential “Pay for Success” multicomponent environmental home-based demonstration project. 53   Potential significant savings for children with an ED visit in the last year are $1.4 million for the federal Medicaid and $634 000 for the state Medicaid programs. For children with a hospitalization in the last year, possible savings of $2.8 million to federal Medicaid and $1.3 million to state Medicaid are expected. 53  

Three studies investigated the influence of smoke-free laws including all public places (eg, workplaces, restaurants, and school grounds). 50 – 52   There were mixed results on the effect of smoke-free laws on emergency healthcare utilization. Croghan and colleagues discovered a reduction in ED visits (risk ratio [RR] = 0.751, 95% confidence interval [CI]: 0.595 to 0.947, P = .015) 50   and Landers found reductions in hospital discharges after the enactment of county smoke-free laws across 12 states (b = −1.32; P <.05). 52   Gaudreau and colleagues found no significant changes in hospital admissions after a smoking ban. 51   Only 3 studies that assessed the impact of county-level smoke-free laws (or an international equivalent that matched the average size of a US county) met our inclusion criteria. Although there is a wealth of evidence supporting the reductions of asthma hospital admissions, discharges, or ED visits in larger settings, we omitted studies with exclusive statewide or nationwide settings. 68 – 71  

There were mixed findings from 2 air pollution reduction strategies. 56 , 57   After the closure of a local steel industry, childhood asthma hospital admissions significantly decreased by 30.3% ( P = .004). 57   Peel and colleagues investigated a traffic reduction strategy and observed up to a 20% decrease in morning traffic counts. They found a 30% decrease in associated 8-hour maximum ozone concentrations and a 30% reduction in 1-hour maximum carbon monoxide concentrations. Although there were decreased traffic counts and air pollutants, there was no impact on childhood asthma ED visits. 56   However, Friedman and colleagues previously studied the same traffic reduction strategy and found 11.1% decrease in daily acute care visits for childhood asthma. 72   The differential findings may be attributed to the available data sources.

Six studies focused on the impact of home-based interventions in predominately Black and Hispanic, low-income communities. 58 – 63   These studies employed CHWs, environmental health professionals, community nurses, or other health educators for home visit programs to conduct healthy home assessments and identify asthma triggers. They also provided comprehensive asthma education, healthy home supplies, and arranged weatherization, remediation, mold abatement, and pest control. The objective was to reduce exposure to cockroaches, dust mites, mold, and tobacco smoke. Simultaneous implementation of care coordination and home-based interventions resulted in fewer missed daycare or school days 44 , 47 – 49   and missed caregiver workdays. 60 , 62 , 63   Though there is evidence in the literature to support the impact of home-based interventions, 73 , 74   only half of the home-based interventions resulted in significant decreases to both asthma ED visits and hospitalizations. 59 , 60 , 63   Most notably in the Healthy Homes University program, there was a 68% decrease for hospitalizations, 53% reduction for ED visits, and 48% decrease for unscheduled visits to a healthcare provider ( P <.0001). 60  

We found 4 community-based health services interventions. Researchers for 2 studies sought to improve access to healthcare. Both analyzed the impact of Breathmobiles, mobile asthma clinics that deliver asthma screening, evaluation, and treatment services to children and maintained continuity with healthcare providers. 64 , 66   Breathmobiles reduced barriers to healthcare and economic concerns but yielded mixed findings to reduce emergency healthcare utilization. For example, Eakin and colleagues found no significant decline in ED visits for children randomized to a Breathmobile plus home-based program in the inner-city of Baltimore. 64   However, Morphew and colleagues found Breathmobile participants in Orange County, California were 50% to 60% less likely to need an ED visit ( P <.001) and had 68% reduction in hospitalizations ( P <.001). The intervention improved health outcomes among children with asthma and comorbid conditions, including obesity. 66  

Two studies investigated the difference in the effectiveness of delivering interventions across various settings. 65 , 67   Martin and colleagues compared the difference between CHW-delivered asthma management, support, and education in the home setting to a certified asthma educator with the same content in a clinical setting. ED visits and hospitalizations were lower in the CHW group, but emergency care visit reductions were not significant. 65   Naar and colleagues evaluated cognitive behavioral therapy to address barriers for poor self-management of asthma at any location (eg, home, school, and community center). The effect of this intervention was compared with an in-home family therapy and support model. Participants that received the cognitive behavioral therapy at a setting of their choice had fewer hospitalizations, but they did not experience a significant decline in ED visits. 67  

The risk of bias for community interventions ranged from moderate to critical for non randomized studies. Out of 22 non-randomized studies, 16 had serious risk of bias. 42 , 43 , 47 , 49 , 50 , 52 – 58 , 63 , 66   Most of the serious risk is attributed to bias from measurement of outcomes, which is accredited to self-reported outcomes, and bias from confounding. Five studies had a critical risk of bias, 45 , 51 , 60 – 62   which is also attributed to confounding. Childhood asthma is exacerbated by risk factors difficult to control in statistical analyses (eg, exposure to outdoor air pollutants and seasonal trends). Most investigators did not support their findings by exploring potential confounding exposure to secondhand smoke, seasonality, or change in medication use. The risk of bias ranged from some concerns to high concerns for randomized studies. Three out of 4 randomized controlled trials had a high risk of bias, 59 , 64 , 65   which is mainly attributed to bias caused by deviations from the intended intervention. 64 , 65   For more details on the risk of bias assessment, see the Supplemental Information.

We identified 26 community intervention publications designed to reduce childhood asthma ED visits or hospitalizations. The majority were in the care coordination ( n = 8) 42 – 49   and policy and environmental changes domain ( n = 8). 50 – 57   Both domains have the most promising impact on emergency healthcare utilization. Seven care coordination studies, 42 – 44 , 46 – 49   and 5 policy and environmental change studies were significantly associated with a reduction in both ED visits and hospitalizations. 50 , 52 , 54 , 55 , 57   Our findings provide examples of strategies that may be effective to treat asthma on a community level. Poor environmental conditions, particularly in historically disinvested communities, increase the risk for asthma ED visits and hospitalizations. 75   It is well documented that underrepresented minorities, urban residence, and low income are associated with childhood asthma. As with many social and environmental determinants of health, the burden of air pollution and substandard housing falls disproportionately on racial and ethnic minorities. 6   Interventions that cover entire communities may be more efficient in reducing asthma ED visits and hospitalizations.

The framework in Fig 2 illustrates a conceptual model of the relationship between community interventions and reductions in childhood asthma ED visits and hospitalizations. The figure displays pathways from community intervention domains to intermediate outcomes affecting caregiver quality of life, home environmental triggers, access to healthcare, and asthma management. There are 3 types of pathways: studies with all significant findings, majority of studies with significant results (at least two-thirds of studies), and studies with mixed significant findings (less than two-thirds of studies) for both outcomes. The conceptual model indicates that care coordination interventions and policy and environmental changes have the most impact on emergency healthcare utilization reduction. All care coordination interventions that measured quality of life (QoL) improved caregiver QoL. There is strong evidence, despite minimal variability, that care coordination programs increased access to healthcare and reduced home environmental triggers. Policies and environmental changes affecting communities were also effective in decreasing outdoor air pollution and home environmental triggers. There is some ambiguity in the home-based interventions domain, although they did increase caregiver QoL. The community-based health services domain also displayed mixed findings and may be an opportunity for further research.

Conceptual model of community interventions for reducing childhood asthma ED visits and hospitalizations. Community interventions are separated into 4 domains: community-based health services, care coordination, home-based, and policy and environmental changes. Pathways with dashed arrows signify mixed results or majority significant findings and smooth arrows illustrate significant associations for both emergency department visits and hospitalization reductions. See Table 1 . for a full description of study characteristics with intervention components. CHW, community health worker; ED, emergency department; PCP, primary care physicians.

Despite the heterogeneity across community intervention domains, the underlying commonality was community engagement. There are many community risks and barriers that prevent caregivers from managing their children’s asthma. This knowledge is imperative for designing effective interventions for communities. It will allow for pathways to build community ownership and integration to dismantle the barriers. Community members in low-income neighborhoods are all too familiar with the exposure to air pollutants, community violence, and poor-quality housing. When they form partnerships to execute an intervention, it may elicit trust in caregivers of children with asthma. This may further increase adherence to community interventions. It is easier to accept assistance from CHWs in a shared community with strong ties. 76   Trust is enhanced when interventions are designed to fit the unique needs of the defined community, implemented by members who share residence in the community, 44   and speak the same language. Community collaboration to codesign, implement, and evaluate intervention design is a unique component for effective community interventions. Encouraging early involvement of community partners, as well as a unique partnership with CHWs is a key to success. 48   Comprehensive asthma education, evaluation, and treatment offered with culturally and linguistically appropriate communication further addressed barriers to adherence and generated better asthma management from caregivers. 49  

Most of the community interventions identified were conducted in predominately Black or Hispanic populations. Similar to findings from Postma and colleagues’ systematic review on CHW-led interventions 77   and Chan and colleagues’ systematic review on multicomponent community-based interventions, 32   the focus of our findings were in underrepresented minority communities. Our findings provide evidence for models that are reproducible in similar low-income communities with comparable racial composition in the United States. This could potentially reduce racial inequities. Community intervention strategies to decrease asthma morbidity from these studies may not be generalizable to other racial groups or affluent populations. This systematic review highlights the substantial role that community interventions play in Black and Hispanic populations as a window of actionable opportunity. The built environment, racial segregation, and housing inequities are a result of historical structural racism, which contribute to the asthma inequities. 75   However, studies assessing community interventions focusing on the historical context of structural racism remain scarce. Future studies require quantitative and qualitative approaches that provide more geographic context of neighborhoods to understand the varying lived experiences of underrepresented minority children from White children with asthma.

The strengths of this systematic review include a comprehensive search using 5 databases, hand searched reference sections, and an assortment of search terms for community interventions. We also targeted a variety of community interventions to promote change based on the needs of the community. Rather than limit our search to only CHW delivered interventions, 77 – 79   or multicomponent community-based interventions, 32   we expanded the scope to gather studies reporting on expansive environmental changes in communities. Although we primarily analyzed asthma hospitalizations and ED visits as the main outcomes of interest, there were other co-benefits. Select community interventions found additional reductions in missed daycare or school days ( n = 9), 44 , 47 – 49 , 55 , 60 , 62 , 63 , 66   and missed caregiver workdays ( n = 4). 49 , 55 , 62 , 63   To measure QoL the majority of studies that assessed QoL used the Pediatric Asthma Caregiver’s Quality of Life instrument. 80   Out of 8 studies that measured caregiver QoL or self-efficacy, 6 studies showed improvements. 44 , 47 , 48 , 58 , 59 , 62  

Our systematic review had several limitations. Our broad inclusion criteria for community interventions limited our ability to conduct a complete analysis. Because of the heterogeneity in community interventions, we could not synthesize our findings into a meta-analysis. Limitations in the risk of bias assessment exist as many of the intervention studies were single arm studies and had no comparison group. The majority of studies had a serious risk of bias ( n = 16). 42 – 44 , 47 , 49 , 50 , 52 – 58 , 63 , 66   This is indicative of some problems in the study designs but does not mean the studies are too problematic to yield useful results. 41   Though Cochrane is the gold standard for systematic reviews, their ROBINS-I is generally designed for comparative studies.

The target population of this systematic review consisted of children with asthma. Other studies that analyzed all ages but did not report separate results for children were omitted from the final report. 81 – 86   Though we did not restrict our inclusion criteria to any specific geographic location, most studies were conducted in the United States. Findings may not be reproducible in communities outside of the United States, particularly in countries with minimal racial and socioeconomic inequities and countries with universal healthcare. It is possible that our refined search for full text availability in peer-reviewed journals, publications from 2010 to 2021, and articles issued in the English language limited our findings and potentially omitted relevant studies. We are confident that the 26 publications included in our final report serve as a representative sample of the most recent community interventions for childhood asthma ED visits and hospitalizations.

This systematic review found significant associations between community interventions and the reduction of emergency healthcare utilization, suggesting a protective effect for the most uncontrolled and severe cases of childhood asthma. Though there are persistent racial inequities in childhood asthma exacerbations leading to ED visits and hospitalizations, our research adds evidence of successful community interventions in predominately underrepresented minority communities.

We thank Vivian McCallum, MLS (User Services Librarian, Cleveland Health Sciences Library, Case Western Reserve University), who assisted with the development of the search strategy; and the anonymous reviewers for providing constructive feedback that helped improve the quality of our manuscript.

Dr Gill coordinated data collection, developed the research question, search strategy, and study protocol, conducted the title, abstract, and full text review, performed the risk of bias assessment, and drafted the initial manuscript for the systematic review; Ms Shah conducted the title, abstract, and full text review, performed the risk of bias assessment, and reviewed and revised the manuscript; Dr Lee and Mrs Sommer developed the research question, search strategy, and study protocol, conducted the title and abstract review, and reviewed and revised the manuscript; Drs Ross and Bole critically assessed the content with expert analysis and reviewed and revised the manuscript; Dr Freedman developed the research question, search strategy, study protocol, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Research reported in this article was funded through a grant from the S. Livingston Mather Charitable Trust and the Mary Ann Swetland Center for Environmental Health Endowment. The funders had no role in the design and conduct of the systematic review.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest to disclose.

controlling asthma through home remediation

community health worker

confidence interval

emergency department

Merck Childhood Asthma Network

quality of life

risk of bias in non-randomized studies – of interventions

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Asthma Emergency Department Visits Data

Asthma emergency department visits include the number of patients seen in an emergency department for asthma. These data can be used to identify trends and patterns of emergency department visits over time and in different geographic areas. This data may be compared with other risk factors, such as air pollution, to identify at-risk populations and environmental relationships. Advanced options include age group, and gender.

Asthma Emergency Department Visits Data Visualization

View data visualization

Measure Description:

• The ED Visit Count is the number of emergency department visits with a primary diagnosis code for asthma.
• The Crude Rate (Per 10K) is the rate of emergency department visits with a primary diagnosis code for asthma per 10,000 Population.
• The Age Adjusted Rate (Per 10K) is the age adjusted rate of emergency department visits with a primary diagnosis code for asthma per 10,000 Population. Age adjustment to the 2000 Standard US Census is done to allow direct comparison of rates in counties and state with different population age distributions.
• The Average Daily ED Visits is the number of ED visits with a primary diagnosis of asthma in a given month divided by the number of days in the month.

Other Asthma Content

• Asthma 
• Asthma Hospitalizations 

About Asthma Emergency Department Visits Data

What do these data tell us.

The numbers and rates of asthma emergency department visits in Iowa by year, age group, and gender.

If an asthma measure is going up or down over time.

If a segment of a population is at higher risk for hospitalization or a visit to the emergency department due to asthma.

How can we use this data?

To inform the public about asthma emergency department visits.

For program planning and evaluation by state and local partners.

What can these data not tell us?

What causes asthma, or what leads to asthma emergency department visits.

The total burden of asthma in a population.

The number of people who visited the emergency department due to asthma. Because personal identifiers are removed from the hospital discharge data before analysis, individuals who have multiple hospitalizations or emergency department visits cannot be identified.

What is the source of the data?

Hospitalization and emergency department data are collected by the Iowa Hospital Association on behalf of HHS in accordance with Iowa Code section 135.166.

Bridged-race population estimates from the National Center for Health Statistics and US Census. Data from 2000 to 2009 are based on intercensal population estimates and 2010-most current year are based on the postcensal population estimates.

What time period of data is available?

The Iowa Public Health Tracking portal displays Emergency Department visit data from the year 2003 through the most recent year of data available.

How are asthma emergency department visits identified?

Emergency Department visits are defined as Iowa residents who are treated and released or subsequently admitted to a facility in Iowa.

Asthma emergency department visits have asthma as the first-listed diagnosis.

Asthma is defined as the International Classification of Disease 9th Revision, Clinical Modification (ICD-9-CM) codes that begin with 493.

Asthma is defined as the International Classification of Disease 10th Revision, Clinical Modification (ICD-10-CM) codes that begin with J44 or J45.

What are the limitations of the data?

Multiple emergency department visits by the same patient cannot be identified, and are not excluded.

These data are not appropriate for estimating the total burden of asthma.

Iowa residents discharged from hospitals in surrounding states are not included, so emergency department visit rates for counties in which residents are likely to receive care in a surrounding state may be underestimated. Rates for counties in which residents are likely to visit hospitals that do not submit data to the Iowa Hospital Association (e.g., Veteran's Administration, Indian Health Services hospitals, and institutionalized populations) may also be artificially low.

nyc.gov > Health > EH Data Portal

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Environment & Health Data Portal

Asthma is a common disease in which the lungs become swollen, making breathing difficult . Symptoms include wheezing, coughing, shortness of breath and tightness in the chest. The exact causes of asthma are not known. Asthma cannot be cured, but it can be controlled .

Asthma is a leading cause of emergency room visits, hospitalizations and missed school days in New York City’s poorest neighborhoods. In NYC, asthma is more common among low-income Black and Latino children .

Asthma and the Environment

Certain things in the environment can trigger an asthma attack or make symptoms worse. Common triggers include :

• Tobacco smoke
• Air pollution, such as particulates, ozone and diesel exhaust
• Dust mites, cockroaches and mold

Controlling Asthma

Asthma does not have to prevent you from leading an active and healthy life. You can take charge by having a plan to control asthma , including these strategies for avoiding asthma triggers:

• Check the weather report daily for air pollution level (“air quality index”) and pollen counts. Limit time outside when air pollution levels or pollen counts are high.
• If you smoke, quit . Don’t allow smoking in your home or car.
• Remove clutter and clean regularly to reduce dust levels in your home .
• Work with your landlord to fix leaks promptly to prevent mold . If your landlord fails to fix the problem, call 311.
• Do not allow furry pets on the furniture or in the bedroom.
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About Asthma

Asthma emergency department visits (adults), severe asthma attacks can result in a visit to the ed. things like smoke, air pollution, dust mites, cockroaches, mold, pollen and pet dander can trigger asthma., asthma emergency department visits (adults), by nta, asthma emergency department visits (age 4 and under), asthma emergency department visits (age 4 and under), by nta, asthma emergency department visits (age 5 to 17), asthma emergency department visits (age 5 to 17), by nta, asthma hospitalizations (adults), asthma hospitalizations are more severe asthma outcomes. they're often clustered in high-poverty neighborhoods, where disinvestment and poor housing conditions expose residents to triggers., asthma hospitalizations (adults), by nta, asthma hospitalizations (age 4 and under), asthma hospitalizations (age 4 and under), by nta, asthma hospitalizations (age 5 to 17), asthma hospitalizations (age 5 to 17), by nta, adults with asthma (past 12 months), asthma is a common disease characterized by breathing difficulty. poor air quality and housing issues increase risk of developing and triggering asthma., children ever diagnosed with asthma, children ages 1 to 13 that have ever received an asthma diagnosis., asthma in public school children (age 5 to 14), persistent asthma in public school children (age 5 to 14), persistent asthma is when symptom occur more than twice per week., youth asthma (past 12 months), public high school students who reported having an asthma attack in the past 12 months., adults with asthma, adults age 18 and older who have ever been diagnosed with asthma., children with an asthma attack (past 12 months), children ages 1 to 13 who have had an asthma attack in the past year. asthma attacks are a measureable adverse health outcome of asthma., data stories, neighborhood reports, data explorer.

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INTRODUCTION

The diagnosis of asthma and more detailed management issues are reviewed separately. The management of asthma exacerbations is also covered separately. These topics are divided by age, care setting, and disease severity.

Asthma diagnosis and evaluation:

● (See "Asthma in children younger than 12 years: Initial evaluation and diagnosis" .)

● (See "Asthma in adolescents and adults: Evaluation and diagnosis" .)

• Article Information

NYC indicates New York City; PM 2.5 , fine particulate matter.

Data Sharing Statement

• How Wildfire Smoke Harms Health JAMA Medical News & Perspectives October 10, 2023 This Medical News article discusses why wildfires are intensifying and how to stay safe from residual smoke. Melissa Suran, PhD, MSJ

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Chen K , Ma Y , Bell ML , Yang W. Canadian Wildfire Smoke and Asthma Syndrome Emergency Department Visits in New York City. JAMA. 2023;330(14):1385–1387. doi:10.1001/jama.2023.18768

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Canadian Wildfire Smoke and Asthma Syndrome Emergency Department Visits in New York City

• 1 Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
• 2 School of the Environment, Yale University, New Haven, Connecticut
• 3 Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
• Medical News & Perspectives How Wildfire Smoke Harms Health Melissa Suran, PhD, MSJ JAMA

The wildfires in Canada in 2023 1 deteriorated air quality locally and distantly. For example, the smoke of wildfires in Quebec drifted into New York City (NYC), hundreds of kilometers away, and caused increased ambient fine particulate matter (PM 2.5 ) on June 6 to 8, 2023. Wildfire PM 2.5 has been shown to affect respiratory health, cardiovascular health, birth outcomes, and mental health. 2 However, previous work has mostly focused on populations residing near and affected directly by wildfires. 3 , 4 We examined the association between the 2023 Canadian wildfires and asthma syndrome emergency department (ED) visits in NYC.

Deidentified asthma syndrome ED visits were obtained from the NYC syndromic surveillance system, 5 which records information on patients’ visits, age, and residential zip code each day from all 53 EDs in the city. Asthma syndrome includes ED chief complaint mention of asthma, wheezing, or chronic obstructive pulmonary disease and was identified by a text-processing algorithm. 5 Ambient PM 2.5 concentrations from 10 local monitoring stations were obtained from the US Environmental Protection Agency. This study used public surveillance data and was exempt from further ethical review by the Yale University institutional review board.

We defined the wildfire smoke wave as at least 2 consecutive days with daily mean PM 2.5 exceeding the maximum level (56.8 μg/m 3 ) during a baseline period of January 2021 to May 2023, which was June 6 to 8, 2023. To control for the day-of-the-week effect, we used 2 adjacent, nonsmoke periods with the same days of the week as the smoke wave as the reference period: May 30 to June 1 and June 13 to 15. To estimate the association between the smoke wave and asthma syndrome ED visits, we calculated the incidence rate ratio (IRR) and 95% CIs of visits between the smoke wave and reference period. We also conducted subgroup analyses by age groups and boroughs and sensitivity analyses using alternative reference periods (May 30-June 1 and June 13-15 separately, or May 23-25 and June 20-22) and excluding visits with missing zip code (3.8% [30/783] and 5.1% [55/1089] during smoke wave and reference period). The short study period helped mitigate potential population-level confounding. Analyses were conducted using the fmsb package in R version 4.2.3 (R Foundation for Statistical Computing) and statistical significance was defined as a 95% CI not crossing 1.

During the smoke wave, citywide daily mean PM 2.5 levels reached 100.9 μg/m 3 (reference, 9.0 μg/m 3 ) and asthma syndrome ED visits increased to 261 per day (reference, 181.5 per day), both peaking on June 7, 2023 ( Figure and Table ). In contrast, daily mean temperature was generally similar during the smoke wave and the reference period (22.6 vs 24.8 °C).

We estimated significant increases in asthma syndrome ED visits during the smoke wave compared with nonsmoke periods in NYC overall (IRR = 1.44; 95% CI, 1.31-1.58) and all of its 5 boroughs ( Table ). We also estimated significant increases in visits among groups aged 5 to 17 years (IRR = 1.32; 95% CI, 1.04-1.67) and 18 to 64 years (IRR = 1.52; 95% CI, 1.36-1.70). Similar IRRs were estimated using the alternative reference periods (May 30-June 1, 1.50 [95% CI, 1.34-1.67]; June 13-15, 1.38 [95% CI, 1.24-1.54]; and May 23-25 and June 20-22, 1.52 [95% CI, 1.39, 1.67]) or excluding visits with missing zip code (1.46; 95% CI, 1.33-1.60).

Despite being located hundreds of kilometers away, the Canadian wildfires were associated with increased asthma syndrome ED visits in NYC during the June 2023 smoke wave. This association was acute (highest in the second day of the smoke wave) and affected individuals aged 5 to 64 years and all boroughs. Study limitations include the ecologic study design, study area restricted to NYC, examination of only one acute outcome based on syndromic surveillance, and lack of accounting for changes in population activity patterns or movement. Given the findings and that wildfires have become more frequent and larger in recent years as a result of a warming climate, timely communication about limiting wildfire smoke exposure is needed to protect vulnerable populations.

Accepted for Publication: August 31, 2023.

Published Online: September 21, 2023. doi:10.1001/jama.2023.18768

Corresponding Author: Kai Chen, PhD, Department of Environmental Health Sciences, Yale School of Public Health, 60 College St, New Haven, CT 06520-8034 ( [email protected] ).

Author Contributions: Dr Chen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chen, Bell, Yang.

Acquisition, analysis, or interpretation of data: Chen, Ma, Yang.

Drafting of the manuscript: Chen, Yang.

Critical review of the manuscript for important intellectual content: Ma, Bell, Yang.

Statistical analysis: Chen, Ma.

Administrative, technical, or material support: Ma, Bell.

Conflict of Interest Disclosures: Dr Bell reported receiving grants from the National Institutes of Health (NIH), the Environmental Protection Agency, HEI, the Wellcome Trust, the Robert Wood Johnson Foundation, Yale Women Faculty Forum, and the High Tide Foundation; receiving honoraria from NIH, Clinique, the Government of Hong Kong Special Administrative Region–Food and Health Bureau, Colorado School of Public Health, PAC-12, IOP, and Fund for Scientific Research–FNRS outside the submitted work; receiving travel reimbursement from the Colorado School of Public Health; and being a member of EPA Clean Air Scientific Advisory Council (CASAC) and multiple National Academies committees. No other disclosures were reported.

Data Sharing Statement: See the Supplement .

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Ecological determinants of respiratory health: Examining associations between asthma emergency department visits, diesel particulate matter, and public parks and open space in Los Angeles, California

Affiliations.

• 1 Chapman University, Department of Health Sciences, Crean College of Health and Behavioral Sciences, Orange, CA, United States.
• 2 Tennessee State University, Department of Agricultural and Environmental Sciences, Nashville, TN, United States.
• 3 San José State University, Department of Urban and Regional Planning, San José, CA, United States.
• PMID: 31024787
• PMCID: PMC6475663
• DOI: 10.1016/j.pmedr.2019.100855

Los Angeles County (LAC) low-income communities of color experience uneven asthma rates, evidenced by asthma emergency department visits (AEDV). This has partly been attributed to inequitable exposure to diesel particulate matter (DPM). Promisingly, public parks and open space (PPOS) contribute to DPM mitigation. However, low-income communities of color with limited access to PPOS may be deprived of associated public health benefits. Therefore, this novel study investigates the AEDV, DPM, PPOS nexus to address this public health dilemma and inform public policy in at-risk communities. Optimized Hotspot Analysis was used to examine geographic clustering of AEDVs, DPM, and PPOS at the census tract unit of analysis in LAC. Ordinary Least Squares (OLS) regression analysis was used to examine the extent to which DPM and PPOS predict AEDVs. Finally, Geographic Weighted Regression (GWR) was employed to account for spatial dependence in the global OLS model. Optimized Hotspot Analysis confirmed significant clustering of elevated AEDVs and DPM in census tracts with reduced PPOS. After controlling for pertinent demographic characteristics (poverty, children, race/ethnicity), regression analysis confirmed that DPM was significantly positively associated with AEDVs, whereas PPOS was significantly negatively associated with AEDVs. Furthermore, GWR revealed that 71.5% of LACs census tracts would benefit from DPM reductions and 79.4% would benefit from PPOS increases toward redressing AEDVs. This is the first study to identify AEDV reductions in census tracts with higher concentrations of PPOS. Thus, reducing DPM and increasing PPOS may serve to improve asthma outcomes, particularly in low-income communities of color.

Keywords: Asthma; Communities of color; Diesel particulate matter; Ecological determinants; Greenspace; Health disparities; Open space; Public parks.

• Center on Health Equity and Access
• Health Care Cost
• Health Care Delivery
• Value-Based Care

Emergency Department Use: A Reflection of Poor Primary Care Access?

• Grace Wong, MBA, MPH
• John Trombley II, MPP

An original emergency department patient survey, insurance claims data, and administrative records are used to examine the characteristics of nonurgent users.

To determine whether the use of the emergency department (ED) for nonurgent care reflects poor access to community-based primary care providers (PCPs).

Study Design

Using a survey of ED patients, insurance claims data, and administrative records identifying demographic factors, we analyzed the use of the ED in an impoverished area of Brooklyn, New York.

We examined original survey data to investigate the extent to which residents of northern and central Brooklyn use EDs for nonemergencies and whether these patients have access to PCPs. We used data from health insurers operating in northern and central Brooklyn, and New York state hospital ED visit data to investigate the factors influencing ED visits for ambulatory care—sensitive conditions (ACSCs). Logistic regression was used to identify characteristics that predict ED visits not resulting in admission for ACSCs.

Of 11,546 patients that completed our survey, the presenting complaint was self-described as emergent by 57%, 30% had no PCP, and 19% reported no health insurance coverage. Using health insurance plan encounter data, only 15 % of patients had seen any provider within 1 week of the ED visit. Insurance type, age, gender, race/ethnicity, and socioeconomic status of area of residence influence the likelihood of these ED visits.

Conclusions

Correlating data from 3 sources, we suggest that the expansion of insurance under the Affordable Care Act may not be sufficient to reduce ED use for nonurgent conditions.

Am J Manag Care. 2015;21(2):e152-e160

We analyzed whether the nonurgent use of the emergency department (ED) in an impoverished area of Brooklyn, New York, is associated with poor access to primary care and other modifiable factors. We found:

• Insurance type, age, gender, race/ethnicity, and socioeconomic status of area of residence influence the likelihood of these ED visits.
• Medicaid clients, rather than the uninsured, account for the largest share of patients using EDs for nonurgent conditions.
• Nonurgent ED visits are rarely preceded by a visit to a primary care provider, and this circumstance was unrelated to the type of health insurance.

The implementation of the Patient Protection and Affordable Care Act, with its expansion of public and private health insurance, raises questions about future use of the emergency department (ED), especially in deprived areas. There is evidence that, despite healthcare reform and the expansion of insurance coverage, there will be inadequate access to primary care for the newly insured. This, combined with a reduction in financial barriers to those using the ED, could increase demand for ED services. 1-3

The ED is not an optimal site for nonurgent care. Nonemergent care delivered in the ED worsens overcrowding, reduces patient satisfaction, and is more costly than care offered in other settings. 4 Treatment is often delivered without the availability of the complete medical history and without the capacity to ensure follow-up, resulting in episodic, fragmented, low-value care.

Annual ED visit rates in the United States have increased more than would be expected from population growth. 5 An increasing number of uninsured and Medicaid patients contribute to rising ED visit rates. 6,7 Factors known to influence an individual’s decision to visit the ED for nonurgent care have been reviewed. 8 The recent healthcare reform debates and the pressure to redesign Medicaid to reduce state budget deficits have prompted implementation of measures designed to reduce ED use, despite evidence that diverting low-acuity cases away from the ED results in smaller savings than strategies to reduce inpatient admissions. 9

The areas of northern and central Brooklyn are deprived sections of New York City with a large percentage of minorities, high unemployment, poverty and crime rates, and a significant percentage of households on public assistance and receiving food stamps. There are known poor health outcomes, including high rates of inpatient stays for ambulatory care—sensitive conditions (ACSCs) and premature mortality. 10

In this paper we investigate the extent to which ED visits in northern and central Brooklyn occur for diagnoses that could have been treated in another setting, and we explore the reasons patients use EDs for the treatment of nonurgent conditions, including limitations in access to primary care. Preventable encounters with the healthcare system in the ED for ACSCs, a measure of limited access to quality primary care and poor care coordination, 11-13 should be responsive to system changes that direct patients to non-ED care settings.

Because there is no single database that allows us to explore these questions, we combine data from 3 different sources to help us develop and test hypotheses. To assess the extent to which patients are treated in EDs for nonurgent conditions, we employ the rates of ED visits for ACSCs not resulting in admission. Administrative data, from the New York Statewide Planning and Research Cooperative System (SPARCS), document the extent of this potentially preventable ED use, and we analyze associated factors including insurance status and demographic and neighborhood factors. To complement the administrative data, we report findings from an original survey describing Brooklyn patients’ use of the ED. The survey allows us to explore whether patients believe their visit to the ED is an emergency and to identify other factors that may influence the use of EDs for nonurgent conditions. We use insurance data from plans operating in Brooklyn to investigate whether patients who have visited the ED for ACSCs have received outpatient care in the weeks before or after the ED visit. This information, with survey data, can help us understand whether patients who present in the ED for nonurgent conditions are receiving primary care.

The Brooklyn Health Care Improvement Project (BHIP) (see [available at www.ajmc.com ] for additional information), 14 directed by researchers at the State University of New York—Downstate, includes a coalition of northern and central Brooklyn federally qualified health centers (FQHCs), hospitals, insurance plans, and community-based organizations. BHIP was funded by a 2009 New York State Health Care Efficiency and Affordability Law grant to develop a comprehensive health planning strategy for a designated area within northern and central Brooklyn covering more than 1 million lives. BHIP collected data to develop and evaluate strategies for reducing unnecessary ED visits.

We triangulated our analysis of ED healthcare-seeking behavior for primary care-treatable conditions (ie, ACSCs) by our study population. We examined original survey data from a large sample of ED patients to investigate the extent to which EDs are used for self-reported nonemergencies and whether these patients report having access to primary care providers. The survey, of a total of 11,546 patients or their representatives, was completed in 2 rounds (two 2-week spans, each week including its full 168 hours) and represents approximately one-third of individuals visiting the ED at any 1 of the 6 BHIP participating hospitals. The survey was completed during the last 2 weeks in January 2011 and the first two weeks of August 2011. (The survey instrument is available in the eAppendix.)

Encounter data from health insurers operating in northern and central Brooklyn is used to investigate the relation between ED visits and visits to other outpatient care sites by patients with Medicaid and commercial health coverage. We examined de-identified insurance claims data, institutional and professional files (which are the parts of the insurance claims data) from 2007 to 2009, from 8 insurers serving the study area. These data were pooled and classified as commercial (approximately 500,000 covered lives) or Medicaid (389,000 covered lives), and divided into children (aged <18 years of age and representing 47% of members with claims) and adults (aged 18 years and over) for analysis.

Finally, ED visits for ACSCs (Billings’ definition 11 ) that do not result in admission to the hospital are analyzed using SPARCS hospital ED visit data. This population-based administrative data set is used to conduct a logistic regression analysis (SPSS version 19, IBM, Amonk, New York). The ED visit data for years 2007 through 2009 included randomly generated personal identifiers and residence geo-coded to 2010 US Census Tract (CT) boundaries, to link the data to 2010 US CT-level variables. The dependent variable is an ED visit for an ACSC diagnosis that did not result in an inpatient stay. Individual-level independent variables include age, gender, race/ethnicity, and primary payer. The model controls for CT community-level variables (derived from US Census 2010, file SF-1) include median household income, education achieved, self-assessed English language competence, and area housing vacancy rates. As a proxy for primary care provider (PCP) availability, the model includes the CT age-adjusted rate of inpatient discharges for ACSCs, a better indicator of PCP availability than the number of physicians in the neighborhood. 15

Survey respondents were 57% female and 64% native-born, and 86% had lived in the same residence for more than 1 year ( ). Self-identified race and ethnicity reflect the population in the study area: 79% identified themselves as black, 3% as white, and 0.5% as Asian. Hispanics accounted for 20.5%. Of all respondents, 57% indicated that their visit was a medical emergency, 30% stated that they had no PCP, and 19% reported no health insurance coverage. Rates of coverage exceeded 90% in those younger than 18 years and older than 65 years, and averaged 76% for the 18- to 64-year-old age group. Medicare accounted for 10% of all payers, while 20% were covered by commercial insurance. Medicaid including Child Health Plus or Family Health Plus accounted for 51%.

Of those who stated that their visit was nonemergent, one-third used the ED for convenience or because it is their usual source of care; 29% could not schedule a PCP appointment, believed the wait for an appointment was too long, or were advised by their usual source of care to present to the ED. Lack of insurance or lower out-of-pocket cost accounted for 6% of visits. Of those survey respondents claiming to not have a PCP, 20% are covered by a Medicaid managed care plan.

Encounter data from the insurance plans reveal that most patients visiting an ED in northern and central Brooklyn for ACSCs do not make regular visits to community or institution based non-ED providers. Timing of visits made before and after an ED visit for ACSCs are presented in . Fifteen percent of the patients presenting to the ED with an ACSC had seen any covered provider within 1 week prior to their visit and 38% had seen a provider within 4 weeks. The percentage of patients seeing a provider prior to an ED visit for an ACSC varied little with type of coverage or age group. Follow-up visits with a non-ED provider after an ED visit for an ACSC diagnosis occurred in about 45% of patients for whom we have encounter data, despite the generic instructions to seek follow-up appointments with their PCP. These findings are consistent with self-reported information from the survey about access to primary care providers.

A summary of the characteristics of the patients residing in our study area visiting EDs as compared with the residents of all of Brooklyn is presented in . The odds of an ED visit for an ACSC diagnosis not resulting in admission is lower among younger people, women, and among those classified as Asian ( ). The odds of visits by Medicare beneficiaries and Medicaid clients are significantly higher than those for patients with commercial insurance. The odds of an uninsured patient visiting an ED for an ACSC are no different than the odds of a privately insured patient making such a visit. Residing in a census tract with the lowest quartile of household median income, with highest rates of those without at least a high school education, with the highest vacant housing rates, and with the highest rates of those who do not speak English well are all associated with statistically significant higher odds ratios of ED visits for ACSCs. There is almost no relationship between ED visits for ACSCs and access to local primary care as measured by area hospital discharge rates for ACSCs.

Patients who receive ambulatory care in safety net hospital EDs often have a high prevalence of chronic medical conditions and substance abuse and rarely attend a primary care clinic, preferring to return to the ED for subsequent care. 16,17 The analysis of ED visits for ACSCs not resulting in a hospital admission is helpful in understanding 1 use of EDs that could be avoided through availability and appropriate use of community-based primary care. 18 The Agency for Healthcare Research and Quality has verified reliability of ED visits for ACSCs in terms of precision, minimum bias, and construct validity. 12 Other factors outside the direct control of the healthcare system, such as poor environmental conditions or lack of patient compliance, can result in ED visits for ACSCs. However, our analysis, the first using 3 data sources, suggests that unsatisfactory access to health services in the community is an important factor. Rates of ED visits for ACSCs not resulting in admission can be used to provide a measure of unmet community healthcare needs, to monitor how well complications from a number of common conditions are being avoided, and to compare the performance of healthcare systems across communities.

EDs have long served as the safety net for medically underserved patients, particularly adults with Medicaid and patients without any health insurance. 5 Self-reported health status and rates of diagnosis of such chronic illnesses as hypertension or diabetes 19 suggest that our study population is sicker than the borough and citywide averages, but this does not fully explain the high rate of ED use in this community. In contrast to a previous report from another state, 20 the uninsured were not responsible for the majority of primary care-treatable ED visits. Rather, the Medicaid population makes the largest percentage of these visits (40.7%), despite estimates that Medicaid clients represent only 15.2% of the study area population. 19 Black patients are at higher risk for ED visits for ACSCs, but this is in proportion to racial demographics of the study area. Our findings of high ED utilization for chronic ACSCs by black persons and Medicaid patients does not differ significantly from data indicating that nationally, barriers to primary care contribute to higher ED and hospital utilization rates seen in these groups. 21

Only about 57% of the patients we surveyed maintained that they were in the ED for a “medical emergency,” and 30% claimed they had no primary care provider. Our findings from insurance claims data, showing that about 38% of patients presenting at the ED with ACSCs had been seen by a primary care provider during the preceding month, are consistent with the self-reported perceptions about lack of access to primary care captured by our survey. The fact that nearly two-thirds of the patients who required ambulatory care medical services appeared at the ED without seeking care from a primary care physician is striking, since many of these patients have Medicaid coverage and have been auto-assigned to a PCP even if they did not select one; this is true because of their mandatory participation in a Medicaid managed care organization.

These data suggest that plans operating in northern and central Brooklyn need to improve their primary care networks, work with the providers in their networks to improve their accessibility to patients, and/or do a better job of communicating with their clients about the primary care services to which they are entitled. We have no explanation for why admission rates for ACSCs measured at the census tract level do not have a significant influence on the odds of ACSC ED visits. Since the total number of PCPs generally appears to be adequate (based on a review of the lists of health providers provided by area insurers, hospitals, and clinics) and many of the patients using the ED for conditions that could be treated by a community-based PCP are covered by Medicaid, other factors must contribute to the gap in access. Inadequate PCP availability after usual working hours, the low rates of providers speaking languages other than English, a lack of cultural competence, and substandard customer service, on the one hand, combined with 24/7 ED availability, the perception of high quality of care in the ED, and the convenience of “one-stop shopping,” on the other, may all contribute to patients choosing the ED as a source of primary care. 22

Our survey findings, in which 29% reported having difficulty making an appointment with a PCP, are consistent with these explanations. Previous studies suggest that the use of an ED for primary care reflects the extent to which patients have a relationship with a PCP and the perception of the urgency of need. A program that provided an enhanced referral system to family medicine homes from the ED was associated with decreased subsequent ED utilization by uninsured patients. 23

Although the number of primary care providers may not be a problem in northern and central Brooklyn, patient perception of access to these providers is. Survey responses show that many patients in Brooklyn, including a large number who have Medicaid coverage, are using EDs for conditions that can be treated in a primary care setting. Claims data from health insurers demonstrate that patients have often not contacted the provider designated to serve as their usual source of care prior to an ED visit. In our interviews, patients cite difficulties in getting appointments and a lack of “convenience” as barriers to the use of community-based primary care. Medicaid managed care plans are designed to provide early interventions and preventive care and to facilitate access to primary care in the attempt to provide a less expensive alternative to emergency care. 24 In northern and central Brooklyn, the Medicaid plans are not accomplishing this aim.

A range of factors contribute to ED visit rates for ACSCs; our evidence, however, suggests that a key determinant is not simply the number of PCPs in the area but the real or perceived convenience, quality, and effectiveness of local primary care. Universal strategies for reduction of ED overutilization by increasing access to, and timeliness and quality of, primary care for all patients likely to experience ACSCs are important. 25 Outpatient safety-net providers can help to reduce ED visits for ACSCs in the Medicaid population by making care more expedient. 26 If primary care providers in these areas of Brooklyn make it easier for patients to schedule appointments, offer convenient hours of operation, and provide a broad range of services in a dignified atmosphere, patients will be more likely to use this system for ACSCs. Furthermore, if the system can place such resources in proximity to an ED, patients would have the peace of mind that an ED is close at hand if there is the need for true emergency care. To decrease the reliance of this Brooklyn population on the ED as source of primary care, it is important to provide information regarding the accessibility of appropriate sources of care.

A community-based primary care program for uninsured low-income adults at Virginia Commonwealth University Medical Center in Richmond resulted in a decline in ED visits and inpatient admissions, while primary care visits increased. 27 When researchers followed uninsured Baltimore patients with no regular healthcare provider, they learned that improving access to primary care services by referral to a community health center was not sufficient to reduce visits to the ED. 28 This demonstrated that the characteristics of the source of care are important.

CONCLUSIONS

Most Medicaid clients in New York state are enrolled in managed care and have been assigned a PCP. In Brooklyn, Medicaid clients account for the largest share of patients using EDs for conditions treatable by community-based PCPs. State data suggest that adequate numbers of primary care physicians and clinics serve northern and central Brooklyn, but nonetheless, many Medicaid patients use the ED as their usual source of care and do not establish a relationship with a PCP. Educational efforts could improve the use of community-based PCPs among this patient population, but our findings suggest that it is a mistake to assume that people use EDs for non-emergency conditions simply out of ignorance. The primary care system in Brooklyn needs to do a better job of meeting patients’ needs. Survey and insurance encounter data suggest that many Medicaid patients chose the ED because the healthcare system has failed to provide easily accessible, culturally competent, timely, quality primary care. Ideally, this would include urgent care appointments with PCPs during daytime hours, the availability of same-day appointments, access to after-hours care, a means for urgent communication with a PCP, and convenient access to laboratory and x-ray testing. The many cultures represented in our study area will require a variety of solutions to meet these demands.

New interventions should be data-driven in order to detect effective strategies and to understand where to dedicate scarce resources. By identifying the neighborhoods with the highest rates of ED visits not resulting in admission, we have identified several areas in Brooklyn where the evaluation of the success of pilot projects designed to encourage the use of sources of care other than the ED should be feasible. Author Affiliations: State University of New York Downstate Medical Center (DW, GW, JT), Brooklyn, NY; International Longevity Center, Mailman School of Public Health, Columbia University (DW), New York, NY; The Hastings Center (MKG), Garrison, NY.

Funding Source: 2009 New York State Health Care Efficiency and Affordability Law grant (HEAL-9).

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DW, MKG, GW, JT); acquisition of data (DW, GW, JT); analysis and interpretation of data (DW, MKG, GW, JT); drafting of the manuscript (DW and MKG); critical revision of the manuscript for important intellectual content (DW, MKG, GW, JT); statistical analysis (DW, GW); ; obtaining funding (GW); administrative, technical, or logistic support (GW, JT); and supervision (GW).

Address correspondence to: Daniel Weisz, MD, MPA, 722 W 168th St, Room 1403, Mailman School of Public Health, Columbia University, New York, NY 10032. E-mail: [email protected] . REFERENCES

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11. Billings J, Zeitel L, Lukomnik J, Carey TS, Blank AE, Newman L. Impact of socioeconomic status on hospital use in New York City. Health Aff (Millwood) . 1993;12(1):162-173.

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13. Weinick RM, Billings J, eds. Tools for monitoring the local safety net. Agency for Health Care Research and Quality website. Available at http://archive.ahrq.gov/data/safetynet . Published July 2003. Accessed January 26, 2015.

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15. Gusmano MK, Rodwin VG, Weisz D. Health Care in World Cities: New York, Paris, and London. Baltimore, MD: Johns Hopkins University Press, 2010.

16. Blackburn J, Becker DJ, Sen B, Morrisey MA, Caldwell C, Menachemi N. Characteristics of low-severity emergency department use among CHIP enrollees. Am J Manag Care . 2013;19(12):e391-e399.

17. Rask KJ, Williams MV, McNagny SE, Parker RM, Baker DW. Ambulatory health care use by patients in a public hospital emergency department. J Gen Intern Med . 1998;13(9):614-620.

18. Johnson PJ, Ghildayal N, Ward AC, Westgard BC, Boland LL, Hokanson JS. Disparities in potentially avoidable emergency department (ED) care: ED visits for ambulatory care sensitive conditions. Med Care . 2012;50(12):1020-1028.

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Download PDF: Emergency Department Use: A Reflection of Poor Primary Care Access?

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Asthma-related Healthcare Use

• Emergency Department Visits With Asthma
• Hospital Inpatient Stays With Asthma
• Office Visits With Asthma

Healthcare Cost and Utilization Project (HCUP) — ED visits and hospital inpatient stays with asthma

The Healthcare Cost and Utilization Project (HCUP) is a family of healthcare databases, software tools, supplemental files, reports, and other related products developed through a federal, state, and Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). It builds on the data collection efforts of state data organizations, hospital associations, and private data organizations and is the largest collection of all-payer, encounter-level hospital care data in the United States. AHRQ transforms administrative statewide healthcare data into research-ready uniform databases with a common set of data elements. The National (Nationwide) Emergency Department Sample (NEDS) and the National (Nationwide) Inpatient Sample (NIS) databases from the HCUP are used to estimate asthma-related emergency department visits and hospitalizations, respectively.

• The Nationwide Emergency Department Sample (NEDS) The Nationwide Emergency Department Sample (NEDS) is a large all-payer emergency department (ED) database in the United States, yielding national estimates of hospital-owned ED visits. The NEDS contains unweighted data from over 28 million ED visits each year and weighted estimates of approximately 123 million ED visits. The database tracks information about ED visits across the country, which includes geographic areas, hospital and patient characteristics, and nature of visits (e.g., common reasons for ED visits including acute conditions, chronic conditions, and injuries). For additional information regarding NEDS, go to https://www.hcup-us.ahrq.gov/db/nation/neds/nedsdbdocumentation.jsp .
• The National (Nationwide) Inpatient Sample (NIS) The National (Nationwide) Inpatient Sample (NIS) is a database focused on inpatient hospital stays. Data in this database are acquired from 48 partners (47 states and the District of Columbia) and represent more than 97 percent of the U.S. population. The NIS includes a sample of all discharges from U.S. community hospitals, excluding rehabilitation and long-term acute care hospitals. The NIS contains unweighted data on more than seven million hospital stays and is ideal for generating national and regional estimates, thus enabling analyses of rare conditions, and special populations. Beginning with the 2012 data, the National Inpatient Sample (NIS) was redesigned to optimize national estimates. Nationwide statistics for years prior to 2012 have been regenerated using new trend weights to permit longitudinal analysis. For additional information regarding NIS, go to https://www.hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp .

Web tables for both ED visits and hospital inpatient short stays with asthma as the primary diagnosis include the weighted counts and rates per 10,000 U.S. resident population by selected patient characteristics (e.g., age, sex, race, ethnicity, metropolitan statistical area [MSA] status of patient’s residence location, and U.S. Census regions of hospital location). Data on race and ethnicity are available for hospitalization in NIS database since 1988 ( NIS Database Documentation Archive (ahrq.gov) ) and it is available for ED visits in NEDS database from 2019 onwards ( NEDS Description of Data Elements (ahrq.gov) ). Not all HCUP Partner organizations provide information on race and ethnicity, thus the availability of data on race and ethnicity may differ by year and can vary by hospital.

An asthma ED visit was defined as an ED visit with asthma as the primary diagnosis (ICD-9-CM diagnosis code of 493 until the implementation of ICD-10-CM in October 2015 and the diagnosis code of J45). An asthma hospital inpatient stay was defined as a hospital inpatient stay with asthma as the primary diagnosis (ICD-9-CM diagnosis code of 493 until the implementation of ICD-10-CM in October 2015 and diagnosis code of J45). The relative standard error (RSE) of an estimate is used to assess the reliability of the estimates. The RSE of an estimate is calculated by dividing the standard error of the estimate by the estimate itself and is expressed as a percentage of the estimate. If an estimate has a relative standard error of 30 percent or less, the estimate is considered reliable.

Ambulatory Healthcare Data

Physician office visits and emergency department visits data are provided by National Center for Health Statistics (NCHS) annually.

The National Ambulatory Medical Care Survey (NAMCS) is based on a sample of visits to non-federally employed office-based physicians who are primarily engaged in direct patient care and, starting in 2006, a separate sample of visits to community health centers. NAMCS provides objective, reliable information about the provision and use of ambulatory medical care services in the United States. Prior to 2012, NAMCS relied on paper instruments; the survey switched to an automated laptop-assisted data collection method in 2012.

The National Hospital Ambulatory Medical Care Survey (NHAMCS) collects data on the utilization and provision of ambulatory care services in hospital emergency and outpatient departments, and hospital-based ambulatory surgery centers in non-federal, general or short-stay hospitals, exclusive of federal, military, and Veterans Administration hospitals, located in the 50 States and the District of Columbia. The NHAMCS survey of hospital emergency and outpatient departments has been ongoing since 1992. Data on ambulatory surgery performed in hospitals have been collected annually, since 2009. Prior to 2012, NHAMCS relied on paper instruments; the survey switched to an automated laptop-assisted data collection method in 2012.

For additional information regarding the design of the NAMCS/NHAMCS, go to https://www.cdc.gov/nchs/ahcd/index.htm .  For the survey description, questionnaires, and related documentation, go to https://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm .

NAMCS/NHAMCS web tables for physician office and ED visits with asthma as the primary diagnosis include the weighted count and rate of visits per 10,000 U.S. civilian population by selected patient characteristics. An asthma physician office or ED visit was defined as a visit with asthma as the primary diagnosis (ICD-9-CM diagnosis code of 493 until year 2016 and ICD-10-CM diagnosis code of J45 in 2016 and after). The National Center for Health Statistics considers an estimate to be reliable if it has a relative standard error of 30 percent or less (i.e., the standard error is no more than 30 percent of the estimate).

The sample size of the NHAMCS ED database has continued to decline in recent years, thus limiting the presentation of estimates stratified by select demographic characteristics in the asthma web tables. Therefore, the data source used to estimate asthma ED visit rates for the web tables changed to the HCUP NEDS database starting with 2020 web tables.

NHAMCS asthma ED visits web tables now in the downloadable pdf titled “2010–2019 ED Visits Web Tables—NHAMCS.” This file contains web tables for years 2010 through 2019 for ED visits with asthma as the primary diagnosis that include the weighted counts and rates of visits per 10,000 U.S. civilian non-institutionalized population by selected patient characteristics (e.g., age, sex, race, ethnicity, MSA status, and U.S. Census regions of hospital location).

ED Visits, Hospitalizations, and Office Visits

2010–2019 ED Visits Web Tables—NHAMCS [PDF – 467 KB]

Follow @CDCasthma on Twitter to learn more about helping people with asthma live healthier lives by gaining control over their asthma.

• Asthma Action Plan
• America Breathing Easier pdf [PDF – 1.1 MB]
• ASL Asthma Film
• Asthma Clinical Guidelines

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Registration Is Now Open for the Next Healthy People 2030 Webinar, Air Quality Matters: Improving Health and Lung Function with Healthy People 2030 Objectives

The Office of Disease Prevention and Health Promotion (ODPHP) is pleased to announce its next Healthy People 2030 webinar:   Air Quality Matters: Improving Health and Lung Function with Healthy People 2030 Objectives .  This webinar will take place on Wednesday, June 12 from 2:00 to 3:00 pm ET. To register, please visit the  Healthy People 2030 Webinar Series Registration page . Continuing Education Credits* (CEs) are available.

During this one-hour event, ODPHP will present on three Healthy People 2030 featured objectives related to indoor and outdoor air quality and health. The webinar will also feature a presentation by the Centers for Disease Control and Prevention’s National Center for Health Statistics to share the latest data on the three featured objectives and a presentation by Healthy People 2030 Champion, the American Lung Association, to share details on their efforts to inform the public about the impact of air quality on their health and ways to reduce harmful pollution. 

The three  Healthy People 2030  objectives to be featured during the webinar are:

EH-01:  Reduce the number of days people are exposed to unhealthy air (LHI) Exposure to air pollution is linked to many health problems, including cancer, respiratory diseases, and heart disease. Outdoor air pollution is also linked to early death. Taking action to prevent air pollution through laws like the Clean Air Act can lead to major reductions in pollution and help prevent many serious health problems.

OSH-04:  Reduce pneumoconiosis deaths Pneumoconiosis is a group of lung diseases caused by breathing in mineral dusts, like asbestos, coal mine dust, or silica. People who work in certain mining, construction, and manufacturing jobs are at higher risk for pneumoconiosis. Strategies to reduce exposure to mineral dust at work are critical for reducing deaths from pneumoconiosis.

RD-04:  Reduce asthma attacks Millions of people in the United States have asthma attacks every year. Asthma attacks can lead to emergency department visits and even death. Reducing environmental triggers and making sure people get the right medications can help reduce asthma attacks.

To register, please visit the  Healthy People 2030 Webinar Series Registration page .

About the Series: Throughout the decade, the Healthy People 2030 Webinar Series will feature the latest data on the Leading Health Indicators, Overall Health and Well-Being Measures, and Healthy People 2030 objectives.

* Following the webinar, participants will receive instructions on how to obtain CE credit and certificate.

Nursing Accreditation Statement This nursing continuing professional development activity was approved by the American Public Health Association’s Public Health Nursing Section Approver Unit, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Medicine (CME) Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American Public Health Association (APHA) and the Office of Disease Prevention and Health Promotion (ODPHP). The APHA is accredited by the ACCME to provide continuing medical education for physicians. Designation Statement: The APHA designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit (s)™ per webinar. Health Education (CHES) Statement Sponsored by the American Public Health Association (APHA), a designated approver of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is designated for Certified Health Education Specialists (CHES®) to receive up to 1.0 total Category I contact education contact hours per webinar.

Related Healthy People 2030 topics:

• Neighborhood and Built Environment

Related Healthy People 2030 objectives:

• Reduce the number of days people are exposed to unhealthy air — EH‑01
• Reduce pneumoconiosis deaths — OSH‑04
• Reduce asthma attacks — RD‑04

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Linking to a non-federal website does not constitute an endorsement by ODPHP or any of its employees of the sponsors or the information and products presented on the website.

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Biden-Harris Administration Finalizes Suite of Standards to Reduce Pollution from Fossil Fuel-Fired Power Plants

Four final rules deliver on the Biden-Harris Administration’s day-one commitment to lead on climate action and to protect all communities from pollution

April 25, 2024

WASHINGTON – Today, April 25, the U.S. Environmental Protection Agency announced a suite of final rules to reduce pollution from fossil fuel-fired power plants in order to protect all communities from pollution and improve public health without disrupting the delivery of reliable electricity. These rules, finalized under separate authorities including the Clean Air Act, Clean Water Act, and Resource Conservation and Recovery Act, will significantly reduce climate, air, water, and land pollution from the power sector, delivering on the Biden-Harris Administration’s commitment to protect public health, advance environmental justice, and confront the climate crisis.

By announcing these final rules at the same time, EPA is following through on the commitment that Administrator Michael S. Regan made to industry stakeholders at CERAWeek 2022 to provide regulatory certainty as the power sector makes long-term investments in the transition to a clean energy economy. The standards are designed to work with the power sector’s planning processes, providing compliance timelines that enable power companies to plan in advance to meet electricity demand while reducing dangerous pollution.

“Today, EPA is proud to make good on the Biden-Harris Administration’s vision to tackle climate change and to protect all communities from pollution in our air, water, and in our neighborhoods,” said EPA Administrator Michael S. Regan. “By developing these standards in a clear, transparent, inclusive manner, EPA is cutting pollution while ensuring that power companies can make smart investments and continue to deliver reliable electricity for all Americans.”

“This year, the United States is projected to build more new electric generation capacity than we have in two decades – and 96 percent of that will be clean,” said President Biden’s National Climate Advisor Ali Zaidi. “President Biden’s leadership has not only sparked an unprecedented expansion in clean electricity generation, his leadership has also launched an American manufacturing renaissance. America is now a magnet for private investment, with hundreds of billions of dollars committed and 270,000 new clean energy jobs created. This is how we win the future, by harnessing new technologies to grow our economy, deliver environmental justice, and save the planet for future generations.”

The suite of final rules includes:

• A final rule for existing coal-fired and new natural gas-fired power plants that would ensure that all coal-fired plants that plan to run in the long-term and all new baseload gas-fired plants control 90 percent of their carbon pollution.  
• A final rule strengthening and updating the Mercury and Air Toxics Standards (MATS) for coal-fired power plants, tightening the emissions standard for toxic metals by 67 percent and finalizing a 70 percent reduction in the emissions standard for mercury from existing lignite-fired sources. 
• A final rule to reduce pollutants discharged through wastewater from coal-fired power plants by more than 660 million pounds per year, ensuring cleaner water for affected communities, including communities with environmental justice concerns that are disproportionately impacted.
• A final rule that will require the safe management of coal ash that is placed in areas that were unregulated at the federal level until now, including at previously used disposal areas that may leak and contaminate groundwater.

Delivering Public Health Protections for Communities, Providing Regulatory Certainty for the Industry, and Ensuring the Power Sector Can Provide Reliable Electricity for Consumers

Finalizing these four rules delivers on the Administration’s commitment to providing health protections for all communities, including communities with environmental justice concerns, many of which are located near power plants. At the same time, EPA is providing a predictable regulatory outlook for power companies, including opportunities to reduce compliance complexity, and clear signals to create market and price stability. Administrator Regan outlined this approach in 2022 when he committed to transparency and open dialogue so that state and federal energy regulators, power companies, and grid operators have clear information on which to base decisions.

EPA conducted regulatory impact analyses for each rule, showing that this suite of standards will deliver hundreds of billions of dollars in net benefits. EPA also performed a sensitivity analysis exploring the combined effect on the power sector of the carbon pollution, air toxics, and water rules, as well as EPA’s recent rules for the transportation sector. The projections regarding changes in electricity supply and demand align with recent reports from the Department of Energy (DOE) and National Renewable Energy Laboratory and peer-reviewed research in showing that the sector can meet growing demand for electricity and provide reliable, affordable electricity at the same time as it reduces pollution in accordance with these rules to protect health and the planet.

With the announcement today, the power sector can make planning decisions with a full array of information. In fact, the agency’s analysis indicates that issuing these rules at the same time is likely to create more efficiency for facilities that are now able to evaluate compliance steps together rather than only for each rule in isolation. Therefore, adding the cost of the rules modeled independently would likely reflect an overestimate of total costs.

“The new rules to clean up air pollution from power plants are good news for everyone, especially if there is a power plant near where you work, live or study. The American Lung Association applauds Administrator Regan and the entire team of professionals at the EPA for their resolute commitment to public health and environmental justice,” said Harold Wimmer, President and CEO of the American Lung Association. “Burning fossil fuels in power plants harms people’s lungs, makes kids sick and accelerates the climate crisis. The stronger clean air and climate protections will save lives.”

“These rules call on utilities and states to be full partners in making this transition fair for energy workers and communities,” said BlueGreen Alliance Executive Director Jason Walsh. “It also complements the historic federal investments made by the Biden-Harris administration and the previous Congress, which provide a toolbox of critical investments targeted to the workers and communities experiencing the economic impacts of energy transition.”

Stronger Carbon Pollution Standards for New Gas and Existing Coal Power Plants

EPA’s final Clean Air Act standards for existing coal-fired and new natural gas-fired power plants limit the amount of carbon pollution covered sources can emit, based on proven and cost-effective control technologies that can be applied directly to power plants. The regulatory impact analysis projects reductions of 1.38 billion metric tons of carbon pollution overall through 2047, which is equivalent to preventing the annual emissions of 328 million gasoline cars, or to nearly an entire year of emissions from the entire U.S. electric power sector. It also projects up to $370 billion in climate and public health net benefits over the next two decades.

The rule addresses existing coal-fired power plants, which continue to be the largest source of greenhouse gas emissions from the power sector, and ensures that new natural gas combustion turbines, some of the largest new sources of greenhouse gases being built today, are designed using modern technologies to reduce climate pollution.

The climate and health benefits of this rule substantially outweigh the compliance costs. In 2035 alone, the regulatory impact analysis estimates substantial health co-benefits including:

• Up to 1,200 avoided premature deaths
• 870 avoided hospital and emergency room visits
• 1,900 avoided cases of asthma onset
• 360,000 avoided cases of asthma symptoms
• 48,000 avoided school absence days
• 57,000 lost workdays

The final emission standards and guidelines will achieve substantial reductions in carbon pollution at reasonable cost. The best system of emission reduction for the longest-running existing coal units and most heavily utilized new gas turbines is based on carbon capture and sequestration/storage (CCS) – an available and cost-reasonable emission control technology that can be applied directly to power plants and can reduce 90 percent of carbon dioxide emissions from the plants.

Lower costs and continued improvements in CCS technology, alongside tax incentives from President Biden’s Inflation Reduction Act that allow companies to largely offset the cost of CCS, represent recent developments in emissions controls that informed EPA’s determination of what is technically feasible and cost-reasonable. The Bipartisan Infrastructure Law also includes billions of dollars to advance and deploy CCS technology and infrastructure. EPA projects that the sector can comply with the standards with negligible impact on electricity prices, thanks to cost declines in CCS and other emissions-reducing technologies. EPA analysis also finds that power companies can comply with the standards while meeting grid reliability, even when considering increased load growth.

The final rule includes requirements to help ensure meaningful engagement with affected stakeholders, including communities with environmental justice concerns, overburdened by pollution and climate change impacts, as well as the energy communities and workers who have powered our nation for generations. The standard also requires states to provide transparent data on compliance pathways and timelines through the state planning process, ensuring that workers and communities have the best-available information to plan for changes in the sector. President Biden’s Interagency Working Group on Coal and Power Plant Communities and Economic Revitalization has identified historic resources for energy communities to invest in infrastructure, deploy new technologies that can help clean up the electric power sector, support energy workers, and spur long-term economic revitalization. The final rule also follows guidance from the Council on Environmental Quality to ensure that deployment of CCS technologies is done in a responsible manner that incorporates the input of communities and reflects the best available science.

In addition to finalizing these rules, EPA has opened a non-regulatory docket and issued framing questions to gather input about a comprehensive approach to reduce GHG emissions from the entire fleet of existing gas combustion turbines in the power sector. EPA is committed to expeditiously proposing GHG emission guidelines for these units, as part of a comprehensive approach to the regulation of climate, toxic and air pollution from combustion turbines. 

To view the fact sheet for this rulemaking visit EPA’s Greenhouse Gas Standards and Guidelines for Fossil Fuel-Fired Power Plants webpage.

Strengthening Mercury and Air Toxics Standards

EPA is strengthening and updating the Mercury and Air Toxics Standards (MATS) for coal-fired power plants, achieving important hazardous air pollutant (HAP) emissions reductions and ensuring that the standards reflect the latest advancement in pollution control technologies. This final rule under the Clean Air Act is the most significant update since MATS was first issued in February 2012, building on highly successful and cost-effective protections.

EPA projects the final rule will reduce emissions of mercury and non-mercury metal HAPs, such as nickel, arsenic, and lead. Controlling these emissions from power plants improves public health for all Americans by reducing the risk of fatal heart attacks, cancer, developmental delays in children, and also reduces adverse environmental impacts. The final rule will also result in substantial co-benefits, including reductions in emissions of fine particulate matter (“soot”), sulfur dioxide, nitrogen oxides, and carbon dioxide nationwide. These public health improvements are especially important for children and communities with environmental justice concerns and others who regularly consume fish that accumulate high levels of pollutants from power plants.  

The final rule reduces the mercury emissions limit by 70 percent for lignite-fired units and reduces the emissions limit that controls for toxic metals by 67 percent for all coal plants—while also requiring the use of continuous emission monitoring systems to provide real-time, accurate data to regulators, facility operators, and the public to ensure that plants are meeting these lower limits and that communities are protected year-round from pollution exposure.

EPA projects that the final MATS limits will result in the following emissions reductions in the year 2028: 

• 1,000 pounds of mercury
• At least 7 tons of non-mercury HAP metals
• 770 tons of fine particulate matter (PM2.5)
• 280 tons of nitrogen oxides (NOx)
• 65,000 tons of carbon dioxide (CO2)

EPA’s final rule projects $300 million in health benefits and $130 million in climate benefits over the 10-year period from 2028-2037. Reductions in non-mercury HAP metal emissions are expected to reduce exposure to carcinogens such as nickel, arsenic, and hexavalent chromium, for residents living in the vicinity of these facilities.

To view the fact sheet for this rulemaking visit EPA’s Mercury and Air Toxics Standards webpage.

Stronger Limits on Water Pollution from Power Plants

EPA is strengthening wastewater discharge standards that apply to coal-fired power plants, finalizing a rule that follows the latest science and applies EPA’s longstanding authority under the Clean Water Act to reduce discharges of toxic metals and other pollutants from these power plants into lakes, streams, and other waterbodies. When implemented, this action will annually prevent more than 660 million pounds of pollution per year from being discharged to our nation’s waters—protecting freshwater resources that provide sources of drinking water for communities, support economic development, enhance outdoor recreation, and sustain vibrant ecosystems.

Power plants that burn coal to create electricity use large volumes of water. When this water is returned to lakes, streams, and other waterbodies it can carry pollutants, including mercury, arsenic, selenium, nickel, bromide, chloride, and iodide, and nutrient pollution. Exposure to these pollutants can harm people and ecosystems by contaminating drinking water sources, recreational waters, and aquatic life.

EPA’s final rule establishes technology-based discharge standards—known as Effluent Limitation Guidelines (ELGs)—that will apply to four types of wastewater:

• Flue gas desulfurization wastewater
• Bottom ash transport water
• Combustion residual leachate
• “Legacy wastewater” that is stored in surface impoundments (for example, coal ash ponds)

The agency’s final rule includes implementation flexibilities for power plants. For example, the final rule creates a new compliance path for electricity generating units that permanently stop burning coal by 2034. These units will be able to continue meeting existing requirements instead of the requirements contained in this final regulation. In a separate action finalized last year, EPA updated but maintained an existing provision allowing units to comply with less stringent standards if they will permanently stop burning coal by 2028.

Following rigorous analysis, EPA has determined that this final rule will have minimal effects on electricity prices. EPA’s analysis shows that the final rule will provide billions of dollars in health and environmental benefits each year. These water quality, health, and environmental improvements will benefit environmental justice communities that are disproportionately affected by pollution from coal-fired power plants.

To view the fact sheet for this rulemaking visit EPA’s Steam Electric Power Generating Effluent Guidelines webpage.

Latest Action to Protect Communities from Coal Ash Contamination

Under the Resource Conservation and Recovery Act, EPA is finalizing a rule to protect communities and hold polluters accountable for controlling and cleaning up the contamination created by the disposal of coal combustion residuals (CCR or coal ash), which can cause serious public health risks. The agency is finalizing regulations that require the safe management of coal ash at inactive surface impoundments at inactive power plants and historical coal ash disposal areas.

Coal ash is a byproduct of burning coal in power plants that, without proper management, can pollute waterways, groundwater, drinking water, and the air. Coal ash contains contaminants like mercury, cadmium, chromium, and arsenic which are associated with cancer and various other serious health effects. EPA’s final rule expands protections for the communities and ecosystems near active and inactive coal burning power plants, ensuring that groundwater contamination, surface water contamination, fugitive dust, floods and impoundment overflows, and threats to wildlife are all addressed.

Inactive coal ash surface impoundments at inactive facilities, referred to as “legacy CCR surface impoundments,” are more likely to be unlined and unmonitored, making them more prone to leaks and structural problems than units at facilities that are currently in service. To address these concerns, EPA established safeguards for legacy coal ash surface impoundments that largely mirror those for inactive impoundments at active facilities, including requiring the proper closure of the impoundments and remediating coal ash contamination in groundwater. EPA analysis shows the final rule will reduce existing disproportionate and adverse effects on communities with environmental justice concerns.

In addition, through implementation of the 2015 CCR rule, EPA found “historic” disposal units that are leaking and contaminating groundwater at currently regulated power plants, but which were exempt under the original 2015 regulations. These are areas where coal ash was placed directly on the land, such as coal ash in surface impoundments and landfills that closed prior to the effective date of the 2015 CCR Rule and inactive CCR landfills. This final rule extends a subset of EPA’s existing CCR requirements to these historic disposal units that will ensure any contamination from these areas is remediated, and will prevent further contamination. These requirements will apply to all active CCR facilities and inactive facilities with legacy CCR surface impoundments.

EPA does not expect this rule to affect the current operations of power plants, and therefore anticipates no impacts to electricity generation or grid reliability. This rule reflects the Administration’s commitment to reduce pollution from the power sector while providing long-term regulatory certainty and operational flexibility.

To view the fact sheet for this rulemaking visit EPA’s Legacy Coal Combustion Residuals Surface Impoundments and CCR Management Units webpage.

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Homelessness found to be a major issue for many patients in the emergency department

by Vanderbilt University Medical Center

Housing insecurity is an issue for one in 20 patients who go to emergency departments at major medical centers in the Southeast, according to a Vanderbilt University Medical Center (VUMC) study published in JAMA Network Open .

These patients were more likely to present with a chief complaint of suicide, to be uninsured, and to have multiple visits during the study period from Jan. 5 to May 16, 2023.

"This points to the importance of prioritizing mental health care and homeless health teams in hospital settings," said lead author Madeleine Ball, a class of 2024 student in the Vanderbilt University School of Medicine and 2023-2024 Research Committee Lead for VUMC's Homeless Health Service.

"Directing resources toward patients who come to the emergency department regularly could have significant impact for patients. Our study emphasizes the utility of screening for homelessness in all acute care centers to best tailor and optimize care for this susceptible patient population."

Study authors examined a total of 23,795 emergency department visits, using the Veterans Health Administration's Homelessness Screening Clinical Reminder to screen for homelessness.

Information from the questionnaire was combined with demographics, method of arrival, diagnoses, acuity, timing of presentation, disposition, and insurance status.

A total of 5% (1,185) screened positive for housing insecurity .

Unstable housing and homelessness can exacerbate adverse health outcomes , leading to increased risk of chronic disease, injury, and disability, the authors said, but emergency departments currently do not have a universal method to identify those at risk of, or currently experiencing, homelessness.

"Now that our team has made screening for housing insecurity common practice in the VUMC ED, we have several research questions to explore," Ball said.

"We plan to present a qualitative analysis of the implementation of this new screening process with a goal of answering a wide variety of research questions to optimize care for this patient population."

Senior author Jennifer Hess, MD, assistant professor of Emergency Medicine in the Department of Emergency Medicine at VUMC, said she hopes the analysis provides a call for other institutions to introduce screening and create tailored care plans for patients experiencing housing insecurity.

"This project contributed a vital first step in advancing health equity by identifying who may benefit from resources and additional assistance," Hess said.

"We are grateful for the diverse, multidisciplinary team that allowed this project to happen and look forward to where it may lead. As homelessness and housing insecurity continue to rise throughout the country, we need to make it a priority to improve care for this susceptible and often overlooked patient population."

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Heat-Related E.R. Visits Rose in 2023, C.D.C. Study Finds

By Noah Weiland

Reporting from Washington

The rate of emergency room visits caused by heat illness increased significantly last year in large swaths of the country compared with the previous five years, according to a study published on Thursday by the Centers for Disease Control and Prevention.

The research, which analyzed visits during the warmer months of the year, offers new insight into the medical consequences of the record-breaking heat recorded across the country in 2023 as sweltering temperatures stretched late into the year.

What the Numbers Say: People in the South were especially affected by serious heat illness.

The researchers used data on emergency room visits from an electronic surveillance program used by states and the federal government to detect the spread of diseases. They compiled the number of heat-related emergency room visits in different regions of the country and compared them to data from the previous five years.

Nearly 120,000 heat-related emergency room visits were recorded in the surveillance program last year, with more than 90 percent of them occurring between May and September, the researchers found.

The highest rate of visits occurred in a region encompassing Arkansas, Louisiana, New Mexico, Oklahoma and Texas. Overall, the study also found that men and people between the ages of 18 and 64 had higher rates of visits.

How It Happens: Heat can be a silent killer, experts and health providers say.

Last year was the warmest on Earth in a century and a half, with the hottest summer on record . Climate scientists have attributed the trend in part to greenhouse gas emissions and their effects on global warming, and they have warned that the timing of a shift in tropical weather patterns last year could foreshadow an even hotter 2024.

Heat illness often occurs gradually over the course of hours, and it can cause major damage to the body’s organs . Early symptoms of heat illness can include fatigue, dehydration, nausea, headache, increased heart rate and muscle spasms.

People do not typically think of themselves as at high risk of succumbing to heat or at greater risk than they once were, causing them to underestimate how a heat wave could lead them to the emergency room, said Kristie L. Ebi, a professor at the University of Washington who is an expert on the health risks of extreme heat.

“The heat you were asked to manage 10 years ago is not the heat you’re being asked to manage today,” she said. One of the first symptoms of heat illness can be confusion, she added, making it harder for someone to respond without help from others.

What Happens Next: States and hospitals are gearing up for another summer of extreme heat.

Dr. Srikanth Paladugu, an epidemiologist at the New Mexico Department of Health, said the state had nearly 450 heat-related emergency room visits in July last year alone and over 900 between April and September, more than double the number recorded during that stretch in 2019.

In preparation for this year’s warmer months, state officials are working to coordinate cooling shelters and areas where people can be splashed by water, Dr. Paladugu said.

Dr. Aneesh Narang, an emergency medicine physician at Banner-University Medical Center in Phoenix, said he often saw roughly half a dozen heat stroke cases a day last summer, including patients with body temperatures of 106 or 107 degrees. Heat illness patients require enormous resources, he added, including ice packs, fans, misters and cooling blankets.

“There’s so much that has to happen in the first few minutes to give that patient a chance for survival,” he said.

Dr. Narang said hospital employees had already begun evaluating protocols and working to ensure that there are enough supplies to contend with the expected number of heat illness patients this year.

“Every year now we’re doing this earlier and earlier,” he said. “We know that the chances are it’s going to be the same or worse.”

Noah Weiland writes about health care for The Times. More about Noah Weiland

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