Background

Housing conditions are a key driver of asthma incidence and severity. Previous studies have shown increased emergency department visits for asthma among residents living in poor-quality housing. Interventions to improve housing conditions have been shown to reduce emergency department visits for asthma, but identification and remediation of poor housing conditions is often delayed or does not occur. This study evaluates whether emergency department visits for asthma can be used to identify poor-quality housing to support proactive and early intervention.

Methods

We conducted a retrospective cohort study of children and adults living in and around New Haven, CT, USA, who were seen for asthma in an urban, tertiary emergency department between March 1, 2013, and Aug 31, 2017. We geocoded and mapped patient addresses to city parcels, and calculated a composite estimate of the incidence of emergency department use for asthma for each parcel (N_v × N_p/log₂[P], where N_v is the estimated mean number of visits per patient, N_p is the number of patients, and P is the estimated population). To determine whether parcel-level emergency department use for asthma was associated with public housing inspection scores, we used regression analyses, adjusting for neighbourhood-level and individual-level factors contributing to emergency department use for asthma. Public housing complex inspection scores were obtained from standardised home inspections, which are conducted every 1–3 years for publicly funded housing. We used a sliding-window approach to estimate how far in advance of a failed inspection the model could identify elevated use of emergency departments for asthma, using the city-wide 90th percentile as a cutoff for elevated incidence.

Findings

11 429 asthma-related emergency department visits from 6366 unique patients were included in the analysis. Mean patient age was 32·4 years (SD 12·8); 3836 (60·3%) patients were female, 2530 (39·7%) were male, 3461 (57·2%) were Medicaid-insured, and 2651 (41·6%) were Black. Incidence of emergency department use for asthma was strongly correlated with lower housing inspection scores (Pearson's r=–0·55 [95% CI –0·70 to –0·35], p=3·5 × 10⁻⁶), and this correlation persisted after adjustment for patient-level and neighbourhood-level demographics using a linear regression model (r=–0·54 [–0·69 to –0·33], p=7·1 × 10⁻⁶) and non-linear regression model (r=–0·44 [–0·62 to –0·21], p=3·8 × 10⁻⁴). Elevated asthma incidence rates were typically detected around a year before a housing complex failed a housing inspection.

Interpretation

Emergency department visits for asthma are an early indicator of failed housing inspections. This approach represents a novel method for the early identification of poor housing conditions and could help to reduce asthma-related morbidity and mortality.

Funding

Harvard-National Institute of Environmental Health Sciences (NIEHS) Center for Environmental Health.

中文翻译：

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在美国康涅狄格州纽黑文绘制急诊室哮喘就诊以识别劣质住房：一项回顾性队列研究

背景

住房条件是哮喘发病率和严重程度的关键驱动因素。先前的研究表明，居住在劣质住房中的居民因哮喘而急诊就诊的人数有所增加。改善住房条件的干预措施已被证明可以减少哮喘急诊就诊，但对恶劣住房条件的识别和补救往往被延迟或没有发生。本研究评估是否可以使用哮喘急诊就诊来识别质量差的住房以支持主动和早期干预。

方法

我们对居住在美国康涅狄格州纽黑文及其周边地区的儿童和成人进行了一项回顾性队列研究，这些儿童和成人在 2013 年 3 月 1 日至 2017 年 8 月 31 日期间因哮喘在城市三级急诊科就诊。我们对患者进行了地理编码和映射地址到城市地块，并计算每个地块的急诊科因哮喘发生率的综合估计值 ( N _v  ×  N _p /log ₂ [ P ]，其中N _v是每个患者的估计平均就诊次数，N _p是患者人数，P是估计的人口）。为了确定地块级急诊室用于哮喘是否与公共住房检查分数相关，我们使用回归分析，调整社区级和个人级因素对哮喘急诊室使用的影响。公共住房综合体检查分数是从标准化房屋检查中获得的，这些检查每 1-3 年对公共资助的住房进行一次。我们使用滑动窗口方法来估计该模型可以在检查失败之前提前多长时间识别出哮喘急诊科的使用率增加，使用全市第 90 个百分位数作为发病率升高的截止值。

发现

来自 6366 名独特患者的 11429 次与哮喘相关的急诊就诊被纳入分析。平均患者年龄为 32·4 岁 (SD 12·8)；3836 名 (60·3%) 患者为女性，2530 名 (39·7%) 患者为男性，3461 名 (57·2%) 为医疗补助保险患者，2651 名 (41·6%) 为黑人。因哮喘而在急诊科就诊的发生率与较低的房屋检查分数密切相关（Pearson 的r =–0·55 [95% CI –0·70 至 –0·35]，p=3·5 × 10 ^-6），以及在使用线性回归模型 ( r =–0·54 [–0·69 至 –0·33], p=7·1 × 10 ^-6 ) 和非- 线性回归模型 ( r =–0·44 [–0·62 至 –0·21], p=3·8 × 10 ⁻⁴). 哮喘发病率升高通常是在住宅区未通过房屋检查前一年左右检测到的。

解释

哮喘急诊就诊是房屋检查失败的早期指标。这种方法代表了一种早期识别恶劣住房条件的新方法，有助于降低与哮喘相关的发病率和死亡率。

资金

哈佛国家环境健康科学研究所 (NIEHS) 环境健康中心。