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3. NIH news release. Global plan launched to cut childhood
nhlbi.nih.gov/new/press/asthma1.htm).
4. NHLBI. Morbidity & Mortality: 1998 Chartbook on Cardi-
nhlbi.nih.gov/resources/docs/cht-book.htm).
5. Lozano P, Sullivan SD, Smith DH, Weiss KB. The economic
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asthma care such as an office-based general pedia-
trician or subspecialist or care delivered in a non-
emergent walk-in clinic. Therefore, these data may
not apply to these other populations of patients. Ad-
ditionally, to participate in this study, the caregivers
of identified patients had to have a working tele-
phone, biasing against the most economically indi-
gent or transient populations. The results of the ED
use by both populations need to be considered in
light of the sampling methodology. Although we
matched on severity of illness (which correlates with
frequency of ED use), the patients in our ED cohort
likely use the ED more frequently than the AC co-
hort because of choice, access issues, or other issues
not related to the severity of their asthma.
6. Freid VM, Makuc DM, Rooks RN. Ambulatory health care
visits by children: principal diagnosis and place of visit. Vital
Health Stat 13. 1998; 137:1–23.
7. National Asthma Education Program. Expert Panel Report
II. Guidelines for the Diagnosis and Management of Asthma.
Bethesda, MD: U.S. Department of Health and Human Ser-
vices, 1997. NIH Publication No. 97-4051.
8. New York City Department of Health. Asthma Facts 1999.
Another important limitation to consider, and New York, 1999.
9. Miller JE. The effects of race/ethnicity and income on early
inherent in our observational study design, is our
inability to control for many of the environmental
childhood asthma prevalence and health care use. Am J Public
Health. 2000; 90:428–30.
and nonenvironmental risk factors that contribute 10. Wasilewski Y, Clark NM, Evans D, Levison MJ, Levin B,
Mellins RB. Factors associated with emergency department
to asthma exacerbation. Such unmeasured con-
founding could potentially contribute to the differ-
visits by children with asthma: implications for health educa-
tion. Am J Public Health. 1996; 86:1410–5.
ences observed in this study and reduce the ap-
parent effectiveness of AC interventions. Finally,
this study recruited patients from the New York
metropolitan region, an epicenter to pediatric
asthma in terms of overall prevalence and severity
of illness. As such, these data may not be widely
generalizable to other regions throughout the
United States.
Future prospective studies will be necessary to
address some of these limitations as well as to
study the effectiveness of an ED-based interven-
tion that identifies high-risk pediatric asthma pa-
tients and facilitates referral to a dedicated AC for
ongoing outpatient care.
11. Wever-Hess J, Kouwenberg JM, Duiverman EJ, Hermans
J, Wever AM. Risk factors for exacerbations and hospital ad-
missions in asthma of early childhood. Pediatr Pulmonol. 2000;
29:250–6.
12. Fielder HM, Lyons RA, Heaven M, Morgan H, Govier P,
Hooper M. Effect of environmental tobacco smoke on peak flow
variability [see comments]. Arch Dis Child. 1999; 80:253–6.
13. Nicolai T, Illi S, von Mutius E. Effect of dampness at home
in childhood on bronchial hyperreactivity in adolescence. Tho-
rax. 1998; 53:1035–40.
14. Eggleston PA, Rosenstreich D, Lynn H, et al. Relationship
of indoor allergen exposure to skin test sensitivity in inner-city
children with asthma. J Allergy Clin Immunol. 1998; 102(4 pt
1):563–70.
15. Bielory L, Deener A. Seasonal variation in the effects of
major indoor and outdoor environmental variables on asthma.
J Asthma. 1998; 35:7–48.
16. Huss K, Rand CS, Butz AM, et al. Home environmental
risk factors in urban minority asthmatic children. Ann Allergy.
1994; 72:173–7.
17. Rand CS, Butz AM, Kolodner K, Huss K, Eggleston P, Mal-
veaux F. Emergency department visits by urban African Amer-
ican children with asthma. J Allergy Clin Immunol. 2000;
105(1 pt 1):83–90.
CONCLUSIONS
We found that a comprehensive asthma care center
has a significant impact on measures of quality of 18. Crain EF, Kercsmar C, Weiss KB, Mitchell H, Lynn H.
care, access to care, resource utilization, and func-
tional status for pediatric asthma patients and
Reported difficulties in access to quality care for children with
asthma in the inner city. Arch Pediatr Adolesc Med. 1998; 152:
333–9.
their families. Similar impacts on care may occur
when provided by general pediatricians and family
physicians in settings where appropriate care and
follow-up are available, although we did not ex-
amine children cared for in these settings in this
study. Emergency physicians, as patient advocates,
have a unique opportunity to improve the effec-
tiveness of pediatric asthma care by identifying
moderate- to high-risk patients and referring them
to settings where comprehensive care and follow-
up may be delivered.
19. Weigers ME, Weinick RM, Cohen JW. MEPS Chartbook.
Rockville, MD: Agency for Health Care Policy and Research,
1996.
20. Donahue JG, Weiss ST, Livingston JM, Goetsch MA,
Greineder DK, Platt R. Inhaled steroids and the risk of hos-
pitalization for asthma. JAMA. 1997; 277:887–91.
21. Halterman JS, Aligne CA, Auinger P, McBride JT, Szilagyi
PG. Inadequate therapy for asthma among children in the
United States. Pediatrics. 2000; 105(1 pt 3):272–6.
22. Homer CJ, Szilagyi P, Rodewald L, et al. Does quality of
care affect rates of hospitalization for childhood asthma? Pe-
diatrics. 1996; 98:18–23.
23. James JM, Robbins JM, Gillaspy SR, Kellogg KW, Fawcett
DD. Patient referrals to a multispecialty asthma clinic. Asthma
Care Center Clinical Consortium. J Asthma. 1997; 34:387–94.
24. Farber HJ, Johnson C, Beckerman RC. Young inner-city
children visiting the emergency room (ER) for asthma: risk fac-
tors and chronic care behaviors. J Asthma. 1998; 35:547–52.
25. Warman KL, Silver EJ, McCourt MP, Stein RE. How does
home management of asthma exacerbations by parents of in-
ner-city children differ from NHLBI guideline recommenda-
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