Disparities in assessments of asthma control between children, parents, and physicians

Adverse Childhood Experiences and Related Events are Associated with Asthma Symptoms in Children

OBJECTIVE

To examine the association between adverse childhood experiences (ACEs) and related events and asthma symptom burden in children.

METHODS

This is a cross-sectional study of baseline data from 147 participants with asthma from a cohort of children enrolled in the Pediatric ACEs Screening and Resiliency Study. Participants completed the PEdiatric ACEs and Related Life Events Screener (PEARLS) tool, a 17-item questionnaire, capturing 3 domains of childhood adversity-child maltreatment, household challenges, and social context. Asthma symptom burden was assessed using the International Study of Asthma and Allergies in Childhood core questionnaire, which asks participants to identify the presence and frequency of severe wheezing that limits speech, wheezing with exercise, nocturnal wheezing, and nocturnal cough in the last 12 months. Using multivariable logistical regression models, we examined the relationship between reported PEARLS and asthma symptoms.

RESULTS

Of children with asthma, 86% reported at least 1 adversity, with 48% reporting 4 or more. The odds of severe wheeze limiting speech increased by 19% with each additional reported adversity captured by the PEARLS tool (95% confidence intervals (CI) 1.01-1.41). Increasing PEARLS scores were also associated with 16% increased odds of reporting wheeze with exercise (95% CI 1.03-1.31). Wheezing with exercise was associated with the household challenges domain (odds ratio (OR) 1.34; 95% CI 1.05-1.72), while severe wheeze limiting speech was associated with the social context domain (OR 1.75; 95%CI 1.02-3.02).

CONCLUSIONS

Childhood adversities are associated with increased asthma symptom burden, suggesting the tool may be helpful in identifying children at risk for poorly controlled asthma.

Altered Symptom Perception in Children With Asthma Is Associated With Poor Childhood Opportunity and Adverse Outcomes

BACKGROUND

Effective asthma self-management requires that children recognize their asthma symptoms when they occur. However, some children have altered symptom perception, which impairs their ability to respond to their asthma symptoms in a timely manner.

OBJECTIVE

To characterize the prevalence and features of altered symptom perception in children aged 5 to 18 years. We hypothesized that children with altered symptom perception would have more features of uncontrolled asthma, more health inequity, and poorer longitudinal asthma outcomes over 12 months.

METHODS

Children (N = 371) completed an outpatient research visit for clinical characterization. Altered symptom perception was defined by discordance between child responses on the 6-item Asthma Control Questionnaire and medical provider-elicited symptoms. Electronic medical records were reviewed for 12 months for the occurrence of an asthma exacerbation treated with systemic corticosteroids and an asthma exacerbation prompting an emergency department visit.

RESULTS

Approximately 15% of children had altered symptom perception and their asthma features were similar to those of children with uncontrolled asthma. Children with altered symptom perception were uniquely distinguished by non-White race and more severe prior exacerbations. These children also resided in ZIP codes with the poorest childhood opportunity (ie, poorest education, health and environmental features, and socioeconomic features). Outcomes of children with altered symptom perception were equally disparate with approximately 2-fold higher odds of a future exacerbation and approximately 3-fold higher odds of an emergency department visit for asthma.

CONCLUSIONS

Altered symptom perception is present in a small but significant number of children with asthma and is related to poorer childhood opportunity and other health inequities that require additional intervention.

Validity of the Childhood Asthma Control Test in diverse populations: A systematic review

PURPOSE

We examined the validity of the Childhood Asthma Control Test (C-ACT) and identified recommended thresholds for uncontrolled asthma in children from varying backgrounds.

METHODS

A systematic literature review was performed utilizing PubMed, Ovid Medline, SCOPUS, CINAHL, and conference proceedings. Studies were included if they enrolled children, had a primary outcome of asthma control, examined test validity or psychometrics, and utilized the C-ACT. Along with study design and demographic data, we extracted all outcomes and comparisons used to validate the C-ACT. We evaluated risk of bias using the COSMIN Risk of Bias tool. Our protocol was registered with PROSPERO (CRD42020211119).

RESULTS

Of 4924 records screened, 28 studies were included. Studies were conducted internationally and published between 2007 and 2018. Average number of enrolled participants was 193 (SD = 155, range = 22-671). Ten studies calculated Cronbach's α (mean [SD] = 0.78(0.05), range = 0.677-0.83). Thirteen studies recommended cut-offs for uncontrolled asthma (≤18-≤24). Nine studies found significant agreement or correlation between C-ACT and Global Initiative for Asthma guidelines/physician assessment of asthma control (correlation coefficients range = 0.219-0.65). Correlation coefficients between C-ACT and spirometry were <0.6 in five of six studies that included spirometry. Kappa values for C-ACT and various spirometry measurements ranged 0.00-0.34.

CONCLUSIONS

The C-ACT showed good internal consistency and mixed levels of agreement and correlation with various clinical asthma measures. Recommended cut-offs for asthma control varied and had no consistent relationship with nationality, race, ethnicity, or language. Few studies examined cross-cultural validity and multiple populations remain under-studied.

Asthma attacks in children are always preceded by poor asthma control: myth or maxim?

Some, but not all, asthma exacerbations in children are preceded by poor asthma control https://bit.ly/3muIy6h.

Association between family management and asthma control in children with asthma

PURPOSE

The purpose of this study is to investigate the association between family management and asthma control in children with asthma.

DESIGN AND METHODS

This cross-sectional descriptive study recruited 142 children with asthma and their parents. We used the Family Management Measure (FaMM), the Childhood Asthma Control Test (C-ACT), and fractional exhaled nitric oxide (FeNO) detectors to assess family management and asthma control. The McNemar's test was used to determine the proportional difference between C-ACT and FeNO in evaluating asthma control. Pearson correlation analysis and multiple linear regression analysis were used to assess the relationship between family management and asthma control in children with asthma.

RESULTS

There was no significant difference in the proportion of C-ACT and FeNO in evaluating asthma control (McNemar's test p = .593). Child's Daily Life, Condition Management Ability, and Parental Mutuality were positively correlated with C-ACT (r = 0.398 to 0.655; all p < .05) and negatively correlated with FeNO (r = -0.245 to -0.402; all p < .05); Condition Management Effort, Family Life Difficulty, and View of Condition Impact were negatively correlated with C-ACT (r = -0.416 to -0.672; all p < .05) and positively with FeNO (r = 0.248 to 0.427; all p < 0.05). Child's Daily Life, Condition Management Effort, and View of Condition Impact dimensions significantly predicted the C-ACT results, and the Condition Management Effort and View of Condition Impact dimensions significantly predicted the FeNO results (p < .05).

PRACTICAL IMPLICATIONS

Pediatric nurses could provide family management education for parents to improve asthma control in children. In addition, pediatric nurses might assess asthma control condition of asthmatic children in combination with C-ACT and FeNO levels.

Videogames in the Treatment of Obstructive Respiratory Diseases: A Systematic Review

Introduction: Millions of people suffer from obstructive respiratory conditions globally. Including videogames in rehabilitation programs can be an interesting alternative to traditional programs or a complementary activity. Objective: To explore the use of videogames in the treatment of patients with obstructive respiratory diseases. Methods: A systematic literature search was performed to identify randomized clinical trials evaluating the effects of videogames on health outcomes in patients with respiratory obstructive diseases. The following databases were searched: PubMed, Web of Science, ScienceDirect, and Scopus. The methodological quality of the studies included was assessed with the Downs and Black quality assessment method. Results: Nine articles were included, of which three used videogames as physical training methods and managed to improve exercise capacity, strength, quality of life, and symptoms. The remaining six articles used videogames to educate patients about the disease and showed slight improvements in knowledge of the disease and use of medication. Conclusion: The results of this review show that videogames are a very useful complementary therapy. They can contribute to enhance rehabilitation programs, as they improve exercise capacity, muscle strength, quality of life, severity, control, and knowledge of the disease. Videogames should be supervised by a professional so that programs can be tailored to patients, proposing different activities in the game and controlling the correct performance, and generating an increase in adherence to treatment. Registry: prospective register of systematic reviews (PROSPERO) CRD42018094094.

Asthma control in children: Body plethysmography in addition to spirometry

BACKGROUND

There is a lack of agreement among measures of asthma control in children. In Central Europe, body plethysmography is additionally used for asthma monitoring. However, its value is still unclear.

OBJECTIVES

We investigated the possible additional value of body plethysmographic measures (specific resistance, residual volume-total lung capacity ratio [RV/TLC]) compared with spirometric measures forced expiratory volume in 1 second (FEV ₁ ), forced vital capacity (FVC), FEV ₁ /FVC, forced expiratory flow at 25% to 75% of forced vital capacity (FEF _25-75 ), and fraction of exhaled nitric oxide (FeNO) for assessment of asthma control.

METHODS

One hundred and forty-five asthmatic children aged 5 to 17 were included. All children performed measurements of FeNO, spirometry, and body plethymography. Asthma control was assessed by the asthma control test (c-ACT/ACT) and a doctor's assessment of asthma control.

RESULTS

Investigating single lung function parameters, FEV₁ , FEV ₁ /FVC, FEF _25-75 and RV/TLC differed between controlled and partly controlled asthma. However, we found no differences between controlled and uncontrolled asthma with regard to single lung function parameters or for any parameter if investigated in a multivariable approach. This was also true if we combined obtained parameters from spirometry (comparing pathologic vs normal spirometry). Investigating the combination of body plethysmography and doctor's assessment of asthma control a significant association was found ( P = 0.02). Furthermore, combined spirometry and body plethysmography showed a significant association with both doctor's assessed asthma control ( P = 0.009) and the c-ACT/ACT ( P = 0.04). The addition of FeNO did not improve the results.

CONCLUSIONS

The combination of body plethysmography and spirometry shows best agreement with asthma control in children compared with spirometry or body plethysmography alone. Further studies are needed to find out whether additional measurements of body plethysmography improve the outcome of children in asthma monitoring.

Characteristics of inner-city children with life-threatening asthma

BACKGROUND

Intensive care unit (ICU) admission is a risk factor for fatal asthma. Little is known about risk factors for pediatric ICU admissions for asthma.

OBJECTIVE

To examine characteristics of underserved minority children with prior ICU admissions for asthma.

METHODS

Baseline survey data, salivary cotinine levels, and allergen specific IgE serologic test results were obtained from children with uncontrolled asthma enrolled in a randomized clinical trial of a behavioral education environmental control intervention. Characteristics of children with and without prior ICU admission were compared using χ² and t tests. Logistic regression assessed significance of higher odds of prior ICU admission comparing factor-level categories.

RESULTS

Patients included 222 primarily African American (93.7%), male (56%), Medicaid-insured (92.8%) children with a mean (SD) age of 6.4 (2.7) years with uncontrolled asthma. Most (57.9%) had detectable cotinine levels, 82.6% were sensitized to more than 1 environmental allergen, and 27.9% had prior ICU admissions. Prior ICU patients were more likely to be very poor (<$10,000 per year) and sensitized to more than 1 allergen tested (most importantly mouse) (P < .05). Allergen sensitization in the groups did not differ for cockroach, cat, dog, Alternaria, Aspergillus, dust mite, grass, or tree. Although more ICU patients received combination controller therapy, they also overused albuterol. Only 27.4% of ICU patients received specialty care in the previous 2 years, which was not significantly different from non-ICU patients.

CONCLUSION

Children with high mortality risk, including history of ICU admission, were twice as likely to live in extreme poverty, have atopy (particularly mouse allergen), use combination controller therapy, and overuse albuterol.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01981564.

Assessing Exercise-Induced Bronchoconstriction in Children; The Need for Testing

Objective: Exercise-induced bronchoconstriction (EIB) is a specific morbidity of childhood asthma and a sign of insufficient disease control. EIB is diagnosed and monitored based on lung function changes after a standardized exercise challenge test (ECT). In daily practice however, EIB is often evaluated with self-reported respiratory symptoms and spirometry. We aimed to study the capacity of pediatricians to predict EIB based on information routinely available during an outpatient clinic visit. Methods: A clinical assessment was performed in 20 asthmatic children (mean age 11.6 years) from the outpatient clinic of the MST hospital from May 2015 to July 2015. During this assessment, video images were made. EIB was measured with a standardized ECT performed in cold, dry air. Twenty pediatricians (mean years of experience 14.4 years) each evaluated five children, providing 100 evaluations, and predicted EIB severity based on their medical history, physical examination, and video images. EIB severity was predicted again after additionally providing baseline spirometry results. Results: Nine children showed no EIB, four showed mild EIB, two showed moderate, and five showed severe EIB. Based on clinical information and spirometry results, pediatricians detected EIB with a sensitivity of 84% (95% CI 72-91%) and a specificity of 24% (95% CI 14-39%).The agreement between predicted EIB severity classifications and the validated classifications after the ECT was slight [Kappa = 0.05 (95% CI 0.00-0.17)]. This agreement still remained slight when baseline spirometry results were provided [Kappa = 0.19 (95% CI 0.06-0.32)]. Conclusion: Pediatricians' prediction of EIB occurrence was sensitive, but poorly specific. The prediction of EIB severity was poor. Pediatricians should be aware of this in order to prevent misjudgement of EIB severity and disease control.

Implementation of the Asthma Control Test in Primary Care to Improve Patient Outcomes

BACKGROUND

Asthma is one of the major chronic diseases in the pediatric population, affecting 9.5% of children. The National Heart, Lung, and Blood Institute recommends the use of the Asthma Control Test (ACT) for periodic assessment of asthma control. The purpose of this evidence-based project was to implement the Asthma Control Test screening tool into the primary care practice to improve management of patients with asthma by more accurately addressing asthma control.

METHODS

The project was a pre- and post-implementation study comparing two different groups of patients with asthma seen at the clinic over 5-week periods.

RESULTS

After the implementation of the educational program and project, 82.6% of advanced practice registered nurses and 30.7% of pediatric resident physicians used an Asthma Control Test, resulting in identification of 9 (21%) patients who were considered not well-controlled. All (100%) of those children identified as not well-controlled through the Asthma Control Test received an adjustment in their medication therapy.

CONCLUSIONS

The Childhood ACT and ACT are simple, self-administered, validated questionnaires that can easily be incorporated into a primary care practice to assess the level of asthma control and to identify patients with asthma that is not well controlled.

Question 1: Why do children still die from asthma?

Asthma is one of the commonest chronic conditions in children and can occasionally be fatal. Little has changed regarding the risk factors for children dying from asthma in the last 30 years. The majority of deaths from asthma occur in children from socio-economically disadvantaged backgrounds. These should be preventable with better education of families, oversight of medication adherence and improved communication between health care professionals and families. More needs to be done to deliver basic messages more effectively about asthma management to the most vulnerable in communities around the world.

E-Healthcare for Celiac Disease-A Multicenter Randomized Controlled Trial

OBJECTIVE

To evaluate the (cost-)effectiveness of online consultations in follow-up of patients with celiac disease (CD).

STUDY DESIGN

Multicenter randomized, controlled trial involving 304 patients aged ≤25 years with CD for ≥1 year, randomized to an online (n = 156) or outpatient consultation (n = 148). An online consultation included questionnaires for symptom and growth measurement. Antitransglutaminase-type-2 antibodies were determined using a point-of-care (POC) test. Controls had a traditional consultation with antitransglutaminase-type-2 antibodies testing in laboratories. Both groups completed questionnaires concerning CD-specific health-related quality of life (HRQOL), gluten-free diet adherence, and patient satisfaction. Six months later, participants repeated HRQOL and patient satisfaction questionnaires and the POC test. The primary outcome was anti-transglutaminase-type-2 antibodies after 6 months, and the secondary outcomes were health problems, dietary adherence, HRQOL, patient satisfaction, and costs.

RESULTS

The performance of the POC test was inferior to laboratory testing (2/156 positive POC tests vs 13/148 positive laboratory tests; P = .003). Health problems were detected significantly more frequently using online consultation. The detection of growth problems and dietary transgressions was similar. HRQOL (from 1 [good] to 5 [poor]) improved after online consultation (from 3.25 to 3.16 [P = .013] vs controls from 3.10 to 3.23; P = .810). Patient satisfaction (from 1 [low] to 10 [high]) was 7.6 (online) vs 8.0 (controls; P = .001); 58% wished to continue online consultations. Mean costs per participant during the studied period were €202 less for the online group (P < .001).

CONCLUSIONS

The primary outcome could not be tested because the POC test was unreliable. Nevertheless, our results indicate that online consultations for children and young adults with CD are cost saving, increase CD-specific HRQOL, and are satisfactory for the majority.

TRIAL REGISTRATION

Trialregister.nl: NTR3688.

Illness Experience, Self-Determination, and Recreational Activities in Pediatric Asthma

Although asthma self-management depends on ongoing and accurate self-assessment by the patient, pediatric asthma patients have weak skills in the area of symptom perception. Before developing an asthma game targeted to improving asthma self-management and improved symptom awareness, we sought to identify gaps in existing games. To clarify the role of relatedness and autonomy in asthma health game design, we investigated symptom awareness, vocabulary, and self-determination through a series of semi-structured interviews with children suffering from asthma. Using self-determination theory as a framework, interviews were oriented to patients' illness experience and vocabulary related to symptomatology, as well as to recreational activities. Formative analysis of the interviews reveals attitudes, perceptions, and motivational factors arising in the context of childhood asthma, and it elucidates the images and vocabulary associated with both illness experience and recreational activities. Qualitative assessment of patient perspectives leads to specific recommendations for game design ideas that will support market entry of a spirometer-controlled game for children with asthma.

Development of a nomogram to estimate the quality of life in asthmatic children using the Childhood Asthma Control Test

BACKGROUND

Pediatric Asthma Quality of Life Questionnaire (PAQLQ) provides detailed information on QoL in asthmatic children, whereas Childhood Asthma Control Test (C-ACT) Questionnaire is the most validated instrument for asthma control. No study assessed the relationship between C-ACT and QoL in children by means of those instruments. The aim of this study was to determine whether a QoL estimation is possible using the C-ACT questionnaire in asthmatic children.

METHODS

Medical history, spirometry, C-ACT, and PAQLQ were assessed in 144 (60% male) outpatient asthmatic children from September 2011 to November 2014. A generalized linear model (GLM) for the prediction of PAQLQ was obtained through a stepwise procedure starting from a full model with all C-ACT items, and predictive nomograms were created.

RESULTS

Fifty-five (38%) well-controlled (WC) asthma, 37 (26%) partially controlled (PC) asthma, and 52 (36%) uncontrolled asthma (UA) patients were enrolled. Persistent asthmatics (PA) were significantly more uncontrolled (p < 0.0001). A significant reduction in FEV1 , FEV1 /FVC, and FEF25-75 (p = 0.005, p < 0.0001, and p < 0.001, respectively) was found in WC vs. UA. Through a stepwise process, a reduced model showed a positive relationship between the PAQLQ and the four items of C-ACT. The regression equations for predicted PAQLQ were ln(PAQLQ) = 1.17 + 0.05*C-ACT2 + 0.03*C-ACT3 + 0.04*C-ACT6 + 0.03*C-ACT7. Thus, a nomogram was constructed.

CONCLUSION

The designed nomogram provides a highly predictive assessment of QoL in individual patients, facilitating a more comprehensive assessment of asthmatic children in usual clinical care.

Asthma deaths in children in New South Wales 2004-2013: Could we have done more?

AIMS

The aim of this study was to characterise the deaths of children from asthma in New South Wales (NSW) over the last 10 years and ascertain whether there were modifiable factors that could have prevented the deaths.

METHODS

The hospital medical records, coronial reports, immunisation records and all relevant correspondence from general practitioners, medical specialists and hospitals were reviewed for children who died with asthma in the 10 years (2004-2013).

RESULTS

In 10 years, there were 20 deaths (0-7 per year) with a male predominance (70%) occurring in children aged 4-17 years. Sixteen (80%) had persistent asthma and 4 (20%) had intermittent asthma. The majority (55%) had been hospitalised for asthma in the preceding 12 months, 25% in the preceding 6 weeks. The majority (55%) was aged 10-14 years. Ninety percent were atopic. Psychosocial issues were identified in the majority (55%) of families. Forty percent had a child protection history. Seventy-five percent had consulted a general practitioner in the year before their death, 45% had a current written asthma action plan and 50% had not seen a paediatrician ever in relation to their asthma. Of the 16 children at school, the schools were aware of the asthma in 14 (88%) cases, but only half had copies of written asthma plans.

CONCLUSIONS

Improved communication and oversight between health-care providers, education and community protection agencies could reduce mortality from asthma in children.

Prompting asthma intervention in Rochester-uniting parents and providers (PAIR-UP): a randomized trial

IMPORTANCE

A disproportionate number of impoverished and minority children have asthma and receive suboptimal preventive care.

OBJECTIVE

To evaluate whether the Prompting Asthma Intervention in Rochester-Uniting Parents and Providers (PAIR-UP) intervention, administered in primary care offices, improves the delivery of preventive care and reduces morbidity for urban children with asthma.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial in which 12 urban primary care practices were matched based on size and type and randomly allocated to the PAIR-UP intervention or usual care (UC). We enrolled 638 children aged 2 to 12 years with persistent or poorly controlled asthma in the waiting room prior to a visit with a clinician for any reason from October 2009 to January 2013. Blinded interviewers called caregivers within 2 weeks to inquire about preventive measures taken at the visit and called them 2 and 6 months later to assess symptoms.

INTERVENTIONS

Children enrolled at PAIR-UP practices received prompts for the caregiver and clinician at the time of the visit that outlined the child's asthma severity or control as well as specific guideline-based recommendations to enhance preventive care. These practices also received educational resources and periodic feedback on their asthma care performance. The UC practices received copies of the asthma guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was symptom-free days (SFDs) per 2 weeks at the 2-month follow-up.

RESULTS

We enrolled 638 children (participation rate of 80%; 36% were black, 36% were Hispanic, and 68% had Medicaid insurance). Groups were similar in demographic characteristics and asthma severity at baseline. At the index visit, more children in the PAIR-UP group received a preventive medication action (new medication, increased dose, recommendation to restart preventive medication) than in the UC group (58% vs 33%; odds ratio [OR] = 2.8; 95% CI, 1.9 to 3.9). More children in the PAIR-UP group than in the UC group received an asthma action plan (61% vs 23%; OR = 8.3; 95% CI, 3.7 to 18.7), discussions regarding asthma (93% vs 78%; OR = 4.5; 95% CI, 2.8 to 7.2), and secondhand smoke counseling (80% vs 63%; OR = 2.6; 95% CI, 1.2 to 5.5). At the 2-month follow-up, children in the PAIR-UP group had more SFDs per 2 weeks than those in the UC group (mean difference, 0.78 days; 95% CI, 0.29 to 1.27). At 6 months, the improvement in SFDs was no longer statistically significant (mean difference, 0.56; 95% CI, -0.14 to 1.25).

CONCLUSIONS AND RELEVANCE

The PAIR-UP intervention improved the delivery of preventive asthma care and reduced asthma morbidity for high-risk urban children with persistent asthma at 2 months, but the improvement in SFDs was no longer significant at 6 months.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01105754.