Health care access, concentrated poverty, and pediatric asthma hospital care use in California's San Joaquin Valley: A multilevel approach

BACKGROUND: California's San Joaquin Valley is a region with a history of poverty, low health care access, and high rates of pediatric asthma. It is important to understand the potential barriers to care that challenge vulnerable populations. OBJECTIVE: The objective was to describe pediatric asthma-related utilization patterns in the emergency department (ED) and hospital by insurance coverage as well as to identify contributing individual-level indicators (age, sex, race/ethnicity, and insurance coverage) and neighborhood-level indicators of health care access. METHODS: This was a retrospective study based on secondary data from California hospital and ED records 2007-2012. Children who used services for asthma-related conditions, were aged 0-14 years, Hispanic or non-Hispanic white, and resided in the San Joaquin Valley were included in the analysis. Poisson multilevel modeling was used to control for individual- and neighborhood-level factors. RESULTS: The effect of insurance coverage on asthma ED visits and hospitalizations was modified by the neighborhood-level percentage of concentrated poverty (RR = 1.01, 95% CI = 1.01-1.02; RR = 1.03, 95% CI = 1.02-1.04, respectively). The effect of insurance coverage on asthma hospitalizations was completely explained by the neighborhood-level percentage of concentrated poverty. CONCLUSIONS: Observed effects of insurance coverage on hospital care use were significantly modified by neighborhood-level measures of health care access and concentrated poverty. This suggests not only an overall greater risk for poor children on Medi-Cal, but also a greater vulnerability or response to neighborhood social factors such as socioeconomic status, community cohesiveness, crime, and racial/ethnic segregation.