Prevalence of asthma and health service utilization of asthmatic children in an inner city

Health Disparities in Environmental and Occupational Lung Disease

Pulmonary health disparities disproportionately impact disadvantaged and vulnerable populations. This article focuses on disparities in disease prevalence, morbidity, and mortality for asthma, chronic obstructive pulmonary disease, pneumoconiosis, and lung cancer. Disparities are categorized by race, age, sex, socioeconomic status, and geographic region. Each category highlights differences in risk factors for the development and severity of lung disease. Risk factors include social, behavioral, economic, and biologic determinants of health (occupational/environmental exposures, psychosocial stressors, smoking, health literacy, health care provider bias, and health care access). Many of these risk factors are complex and inter-related; strategies proposed to decrease disparities require multilevel approaches.

Update in Pediatric Asthma: Selected Issues

Asthma is a complex condition that affects 14% of the world's children and the approach to management includes both pharmacologic as well as non-pharmacologic strategies including attention to complex socioeconomic status phenomena. After an historical consideration of asthma, allergic and immunologic aspects of asthma in children and adolescents are presented. Concepts of socioeconomic aspects of asthma are considered along with environmental features and complications of asthma disparities. Also reviewed are links of asthma with mental health disorders, sleep disturbances and other comorbidities. A stepwise approach to asthma management is discussed that includes pharmacologic and non-pharmacologic strategies in the pediatric population. The role of immunotherapy and use of various immunomodulators are considered as well.

Trends in Asthma Control, Treatment, Health Care Utilization, and Expenditures Among Children in the United States by Place of Residence: 2003-2014

BACKGROUND

Examining national trends in asthma treatment and control is essential to inform treatment and public health initiatives.

OBJECTIVE

Explore national trends in asthma control and treatment over time among children and those residing in poor-urban areas.

METHODS

This was an analysis of trends from 2003 to 2014 among children (aged 1-17 years) in the Medical Expenditure Panel Survey. Indicators of poor control included use of more than 3 canisters of short-acting β-agonists (SABAs) in 3 months, asthma attack, emergency department/inpatient hospitalization, and systemic corticosteroids. Treatment included inhaled corticosteroids, controller medications, SABAs, and greater than or equal to 0.7 ratio of controller-to-total prescriptions. Other measures included the number of asthma medications, outpatient visits, asthma-specific drug, and total expenditures per-patient-per-year.

RESULTS

There were 8.4 million children with asthma in the United States in 2014; 11.1% lived in poor-urban areas. There was a statistically significant decrease in the percentage of children using inhaled corticosteroids, controller medications, daily preventive medications, systemic corticosteroids, SABAs, more than 3 canisters of SABAs (in 3 months), overall asthma prescriptions, and outpatient visits. There was a significant increase in the percentage of children reporting having an asthma attack. Trends for children residing in poor-urban areas were compared with all others; however, limited data and variability in annual estimates prevent clear conclusions.

CONCLUSIONS

Results suggest lack of improvement in treatment and control since 2003 among children with asthma in the United States. There is significant room for improvement in asthma control and disease management among children.

Modern life makes children allergic. A cross-sectional study: associations of home environment and lifestyles with asthma and allergy among children in Tianjin region, China

PURPOSE

In the past 60 years, the prevalences of asthma and allergy among children have increased around the world. Neither genetic nor outdoor environmental factors can explain this increase.

METHODS

We performed a cross-sectional study of 7366 children in Tianjin, China, on associations of home environment and lifestyles with asthma and allergy.

RESULTS

The prevalences of diagnosed asthma, rhinitis and eczema among 0- to 8-year-old children in the Tianjin area were 4%, 9% and 39%. Home environment and lifestyle, together with infections, were strong risk factors. For asthma and allergy, the population attributable fraction (PAF) due to modern floors and wall coverings (i.e., laminated wooden floors and painted walls compared to tile floors and lime-coated walls) was 22%. Window condensation in winter and air conditioner use in summer, both of which are proxies for less ventilation, accounted for 7-17% of rhinitis and eczema. Cesarean delivery accounted for 10% of eczema symptoms. We developed a modern life index from appropriate home characteristics and lifestyle and food consumption habits and found it to have a clear dose-response relationship with asthma and allergy in Tianjin children.

CONCLUSIONS

The results indicate that a "modern" home environment together with a modern lifestyle is associated with increased prevalences of asthma and allergies among children. Appropriate indoor environmental interventions and education of children's caregivers are important in the management of childhood asthma and allergy.

Health Disparities Among Children with Asthma in the United States by Place of Residence

BACKGROUND

Children residing in poor-urban areas may have greater asthma morbidity. It is unclear whether this is due to individual characteristics such as race and ethnicity or place of residence.

OBJECTIVE

Assess indicators of control and treatment by residence.

METHODS

This was a cross-sectional analysis of children (aged 1-17 years) in the 2000-2014 Medical Expenditure Panel Survey (MEPS). Indicators of poor control included use of more than 3 canisters of short-acting beta agonist (SABA) in 3 months, asthma attack, and emergency department (ED) or inpatient (IP) visit during the year. Treatment measures included use of controller medications and a ratio of controller-to-total prescriptions of 0.7 or more.

RESULTS

There were 15,052 children with asthma in the MEPS 2000-2014 data, reflecting 8.4 million children in 2014. After controlling for covariates, children with asthma residing in poor-urban areas had lower odds of using controller medications (odds ratio [OR] = 0.77), having a controller-to-total ratio of 0.7 or more (OR = 0.75), and reporting an asthma attack (OR = 0.75) and higher odds of having an ED/IP visit (OR = 1.3) compared with those living elsewhere. Black race and Hispanic ethnicity were associated with greater odds of excessive SABA use (OR = 2.11) and ED/IP visits (OR = 2.03) and lower odds of controller-to-total ratio of 0.07 or more (OR = 0.50).

CONCLUSIONS

Poor-urban residence may be independently associated with asthma control and treatment even after controlling for individual characteristics such as race and ethnicity. Future research is needed to understand the sources of these geographic health disparities to more successfully target public health interventions.

Increased healthcare utilisation among atopic children in a general practice database: a nested index-control study

Background

Atopic eczema, asthma, and allergic rhinitis (AR) create a serious burden on general practice resources.

Aim

To investigate the use of general practice resources (that is, consultation visits, telephone contacts, and home visits) in children with physician-diagnosed atopic disorders (ADs).

Design & setting

In a nested index-control study design, all children (here defined as individuals aged 2–18 years) listed in a representative general practice database were selected in 2014.

Method

Children diagnosed with ADs were matched on age and sex with non-atopic controls within the same practice. For all the different groups, the number and frequency of children contacting the GP were calculated.

Results

Of the children with atopic eczema (n = 15 202), 80% consulted the GP in 2014 (controls = 67%). Of the children with asthma (n = 7754), 80% consulted the GP (controls = 65%), and for children with AR (n = 6710), this was 82% (controls = 66%). Of the children with all three ADs, 91% consulted the GP (controls = 68%). On average, a child with atopic eczema contacted the GP 2.8 times/year (controls = 1.9); for children with asthma, the contact frequency was 3.0 (controls = 1.9); and for AR, 3.2 (controls = 1.9). For children with all three ADs, the contact frequency was 4.3 (controls = 2.0). Consultations related to the ADs investigated only explain a smaller part of the increased healthcare utilisation in atopic children.

Conclusion

Atopic children use more general practice resources compared to non-atopic children, yet frequently for morbidity or other health-related questions not related to one of the ADs.

Health service use among children with and without eczema, asthma, and hay fever

BACKGROUND

Atopic diseases, for example, eczema, asthma, and hay fever, are among the most common chronic diseases of childhood. Knowledge on health service use among children with atopic disease is limited. This study aimed to investigate the total use and costs of health services for children with and without eczema, asthma, and hay fever in a Danish general population.

METHODS

We conducted a health survey with four complete birth cohorts from the City of Copenhagen. Individual questionnaire data on eczema, asthma, and hay fever for children aged 3, 6, 11, and 15 years were linked to register information on use and costs of health services and prescribed medication and parental education. In total 9,720 children participated (50.5%).

RESULTS

We found increased health service use (number of additional consultations per year [95% confidence interval]) among children with current eczema symptoms (1.77 [1.29-2.26]), current asthma symptoms (2.53 [2.08-2.98]), and current hay fever symptoms (1.21 [0.74-1.67]), compared with children without these symptoms. We also found increased use of prescribed medication and most subtypes of health services. Current asthma symptoms and current eczema symptoms, but not current hay fever symptoms, increased the health service costs with at least €300 per year per child.

CONCLUSION

Children with eczema, asthma, and hay fever used health services and prescribed medication more than children without these diseases.

Childhood Asthma Prevalence among Puerto Ricans and Mexican Americans: Implications for Behavioral Intervention Research

Parental management is the least understood, but often a vital, element of treatment effectiveness in childhood asthma. This study identifies individual, household, and community-level variables relevant to home treatment effectiveness among two Hispanic groups: Mexican Americans and Puerto Ricans. The relationship between these variables and lifetime prevalence of childhood asthma (LTP) are examined with data in the Hispanic Health and Nutrition Examination Survey, 1982-84 (HHANES), a mixed cross-sectional retrospective national survey. Unadjusted estimates indicate that Puerto Rican ethnicity, poverty, urban residence, and single parenthood are positively associated with LTP. Children born outside the mainland United States, children of low weight for age, and males show an increased risk of LTP In a multiple logistic regression model, Puerto Rican ethnicity, low weight for age, and male gender remain positively associated, and poverty becomes negatively associated, with LTP Implications are discussed for programs designed to assist children of Hispanic origin with asthma.

Inner-city asthma: special considerations for management

PURPOSE OF REVIEW

Asthma is prevalent in inner-city populations, exhibiting significant morbidity and mortality. This review focuses on the consequential findings of recent literature, providing insight into onset of asthma, complicating factors, prediction of exacerbations, and novel treatment strategies.

RECENT FINDINGS

Analyses of environmental influence on inner-city children demonstrated novel interactions, implicating potentially protective benefits from early life exposures to pests and pets and isolating detrimental effects of air pollution on asthma morbidity. Through detailed characterization of inner-city asthmatics, predictors of seasonal exacerbations surfaced. Focused, season-specific treatment of inner-city asthmatics with omalizumab identified those most likely to benefit from season-tailored therapy. Comparative studies of urban and rural populations revealed that race and household income, rather than location of residence, impose the greatest risk for increased asthma prevalence and morbidity.

SUMMARY

Challenging previously conceived exposure-disease relationships, recent literature has elucidated new avenues in the complex interplay between immunologically active exposures and their effects on inner-city asthma. These findings, and improved understanding of other relevant exposures, could steer the direction of primary (and secondary) disease prevention research. Moreover, careful identification of asthma characteristics has effectively established predictors of exacerbations, highlighting individuals for which additional therapies are warranted and for whom such treatments are most likely to be effective.

Neighborhood poverty, urban residence, race/ethnicity, and asthma: Rethinking the inner-city asthma epidemic

BACKGROUND

Although it is thought that inner-city areas have a high burden of asthma, the prevalence of asthma in inner cities across the United States is not known.

OBJECTIVE

We sought to estimate the prevalence of current asthma in US children living in inner-city and non-inner-city areas and to examine whether urban residence, poverty, or race/ethnicity are the main drivers of asthma disparities.

METHODS

The National Health Interview Survey 2009-2011 was linked by census tract to data from the US Census and the National Center for Health Statistics. Multivariate logistic regression models adjusted for sex; age; race/ethnicity; residence in an urban, suburban, medium metro, or small metro/rural area; poverty; and birth outside the United States, with current asthma and asthma morbidity as outcome variables. Inner-city areas were defined as urban areas with 20% or more of households at below the poverty line.

RESULTS

We included 23,065 children living in 5,853 census tracts. The prevalence of current asthma was 12.9% in inner-city and 10.6% in non-inner-city areas, but this difference was not significant after adjusting for race/ethnicity, region, age, and sex. In fully adjusted models black race, Puerto Rican ethnicity, and lower household income but not residence in poor or urban areas were independent risk factors for current asthma. Household poverty increased the risk of asthma among non-Hispanics and Puerto Ricans but not among other Hispanics. Associations with asthma morbidity were very similar to those with prevalent asthma.

CONCLUSIONS

Although the prevalence of asthma is high in some inner-city areas, this is largely explained by demographic factors and not by living in an urban neighborhood.

Operational definitions of asthma in recent epidemiological studies are inconsistent

OBJECTIVE

The best combination of questions to define asthma in epidemiological asthma studies is not known. We summarized the operational definitions of asthma used in prevalence studies and empirically assess how asthma prevalence estimates vary depending on the definition used.

METHODS

We searched the Thomson Reuters ISI Web of knowledge and included (1) cross-sectional studies (2) on asthma prevalence (3) conducted in the general population and (4) containing an explicit definition of asthma. The search was limited to the 100 most-cited papers or published since January 2010. For each paper, we recorded the asthma definition used and other variables. Then we applied the definitions to the data of the Portuguese National Asthma survey (INAsma) and of the 2005-2006 National Health and Nutrition Examination Survey (NHANES) computing asthma prevalence estimates for the different definitions.

RESULTS

Of 1738 papers retrieved, 117 were included for analysis. Lifetime asthma, diagnosed asthma and current asthma were defined in 8, 12 and 29 different ways, respectively. By applying definitions of current asthma on INAsma and NHANES data, the prevalence ranged between 5.3%-24.4% and 1.1%-17.2%, respectively.

CONCLUSIONS

There is considerable heterogeneity in the definitions of asthma used in epidemiological studies leading to highly variable estimates of asthma prevalence. Studies to inform a standardized operational definition are needed. Meanwhile, we propose a set of questions to be reported when defining asthma in epidemiological studies.

Factors Influencing Treatment of Asthma in Children in the Prehospital Setting

Study Objective:

The purpose of this study is to describe treatment of asthma in children by paramedics.

Design:

Retrospective review of an advanced life support (ALS) run reports over a one-year period.

Setting:

Review of paramedic response to pediatric respiratory emergencies in an urban, primarily inner-city, prioritized, dual-response emergency medical services (EMS) system.

Participants:

Patients < 19 years of age complaining of shortness of breath, paramedics, pediatric residents, and attending physicians.

Measurements and Main Results:

The medical records of 383 patients were reviewed for demographic and medical information. The population was separated into an ALS treatment group (received ALS) and a NO-ALS group (evaluation and/or oxygen only). Sixty percent of the patients (n = 231) were classified into the ALS group; 89% received epinephrine. Sixty-six percent (n = 101) of the NO-ALS patients received evaluation only, and the remaining 34% (n = 51) were evaluated and received oxygen. The ALS patients were older and had significantly higher respiratory rates and accessory muscle use than did the NO-ALS patients. Relief was reported in 66 % of ALS patients. No adverse reactions were reported in the ALS group. Determining factors influencing ALS treatment included age, the use of medications at home, wheezing, accessory muscle use, respiratory rate, and presence or absence of upper respiratory infection (URI) symptoms.

Conclusions:

This study demonstrates that asthma constitutes the majority of pediatric emergencies in the prehospital setting in this inner-city EMS system. The ALS treatment of pediatric asthma improves patient status. Factors which may influence paramedic judgment in treating asthma in children may be inappropriate. There is a critical need for further research in the prehospital treatment of pediatric asthma and in developing education interventions directed at the entire spectrum of prehospital care of pediatric emergencies.

Life style and home environment are associated with racial disparities of asthma and allergy in Northeast Texas children

A high prevalence and racial disparities in asthma and allergy have been observed in American children. This study aimed to identify risk factors for asthma and allergy among children, and their contribution to racial disparities in allergy prevalence. A population-based cross-sectional study was carried out among children aged 1-8 years in Northeast Texas 2008-2009. The health conditions, life style and home environment of 3766 children were surveyed by parental questionnaires through e.g. daycares, elementary school, and medical clinics. Among participants who indicated their ethnicity, 255 were Mexican-Americans, 178 Afro-Americans and 969 Caucasians. Afro-American children had a significantly higher prevalence of asthma and eczema. Caucasian had the highest prevalence of rhinitis. Compared to Mexican-American children, Afro-American and Caucasian children were breast fed shorter time, more often went to day care center, had pets and environmental tobacco smoke exposure at home more often. For all children, being at a day care center, being exposed to dampness and environmental tobacco smoke at home were strong risk factors for asthma and allergy. Central air conditioning system was associated with an increased prevalence of wheeze among Mexican-American children, while pets were associated with an increased risk of rhinitis among Afro-American and Caucasian children. Caucasian children were generally not healthier than relatively poor Mexican-American children. Differences in the prevalence of asthma and allergy between races cannot be explained by socioeconomic status only. Life style and home environmental exposures are important risk factors for asthma and allergy in Northeast Texas children.

Pattern of asthma medication use among children from a large urban center in Brazil

PURPOSE

Despite the advances in asthma therapeutics, there are few data on the use and determinants of anti-asthmatic drugs in the general population of children. This study describes the use of asthma medications among children in the general population and in children with current asthma, living in a large urban center in Brazil.

METHODS

A population-based cross-sectional survey, aimed at analyzing asthma determinants, was conducted with 1,382 children aged 4-11 years, between February and May 2006, in Salvador, Brazil. At baseline, an extensive questionnaire was applied, including questions about the use of asthma medications in the last 12 months.

RESULTS

In all studied children (n = 1,382) aged 4-11 years, oral beta2-agonists were the drugs most frequently used (9.8%), followed by short-acting inhaled beta2-agonists (4.3%) and systemic corticosteroids (1.6%). Anti-asthmatic drug use was higher among males than females, and it significantly decreased with age in both genders. A total of 312 children (22.6%) reported current asthma, and 62% of them were not being treated with any anti-asthmatic drugs. Of all those who reported following a certain type of treatment, 20% used oral beta2-agonists alone; 6.1%, short-acting inhaled beta2-agonists alone; and 4.8%, a combination of both drugs. Anti-asthmatic drug use did not differ according to socioeconomic status, except for the use of inhaled beta2-agonists and systemic corticosteroids.

CONCLUSIONS

An overwhelming majority of asthmatic children were not using long-term medications for asthma, in particular inhaled corticosteroids, regardless of the severity of their disease. This result points to the deficiencies of the Brazilian public health system in recognizing this important pharmacological need for child care and thereby limiting the access of these children to a group of efficacious, available, and low risk therapeutic medications.

Managing outpatient asthma exacerbations

Asthma is a chronic inflammatory disease that renders individuals vulnerable to acute exacerbations. A wide variety of allergic and nonallergic triggers can incite an asthma exacerbation. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, avoidance of relapses, and prevention of future episodes. A written asthma home management plan is essential to minimize the severity of exacerbations. Short-acting beta-agonists, oxygen, and corticosteroids remain fundamental to early intervention in acute asthma exacerbations. Anticholinergics and magnesium sulfate can help nonresponders. Combination inhalers of the long-acting beta-agonist formoterol and inhaled steroid budesonide have been effective in flexible dosing in treating early acute exacerbations and as a daily controller medication outside the United States. Initiation or intensification of long-term controller therapy, treatment of comorbid conditions, trigger avoidance, and prompt follow-up can help prevent relapses. Listening to patient preferences and concerns enhances adherence, and regular follow-up care can help prevent future episodes.

Factors associated with preventive asthma care in inner-city children

The goal of this cross-sectional study was to determine if the caregiver's quality of life was associated with the child receiving appropriate preventive asthma care (2 or more preventive asthma care visits per year) in a sample of inner-city children with moderate to severe persistent asthma. Our findings confirm that children with moderate to severe persistent asthma are not receiving adequate preventive asthma care despite experiencing frequent asthma symptoms. Having a recent emergency department (ED) visit and increased number of school absences due to asthma were the strongest factors associated with these children receiving guideline-based preventive asthma care. However, for a subgroup of children without recent ED care, we found that low caregiver education level, increased school absences, and decreased caregiver's quality of life, albeit a trend, were associated with the child's receiving adequate preventive asthma care. This suggests that in a subgroup of children receiving adequate preventive care, other issues beyond basic asthma management may need to be addressed.

Physician asthma education program improves outcomes for children of low-income families

STUDY OBJECTIVES

To determine whether an interactive physician seminar that has been shown to improve patient/parent satisfaction and to decrease emergency department visits for children with asthma was also effective for those children from low-income families.

DESIGN

Seventy-four pediatricians and 637 of their patients were randomized to receive two asthma seminars or no educational programs and were observed for 2 years.

SETTING

Physicians in the New York, NY, and Ann Arbor, MI, areas were enrolled, and, on average, 10 patients with asthma per provider were surveyed and observed for 2 years.

PATIENTS OR PARTICIPANTS

A total of 637 subjects were enrolled, and 369 subjects remained in the study after 2 years. Of these, 279 had complete medical and survey information.

INTERVENTIONS

Physicians were randomized, and then a random sample of their patients was enrolled and surveyed regarding the physician's communication style, the child's asthma symptoms, medical needs, and asthma care. Low income was defined as annual income of < 20,000 dollars.

MEASUREMENTS AND RESULTS

The families of 36 children (13%) had an income of < 20,000 dollars, and they were treated by 23 physicians. Low-income children in the treatment group tended to have higher levels of use of controller medications, to receive a written asthma action plan, and to miss fewer days of school, although these differences were not statistically significant compared to low-income children in the control group. However, low-income treatment group children were significantly less likely to be admitted to an emergency department (annual rate, 0.208 vs 1.441, respectively) or to a hospital (annual rate, 0 vs 0.029, respectively) for asthma care compared to children in the control group.

CONCLUSIONS

The educational program for physicians improved asthma outcomes for their low-income patients. Provider interventions targeted to these high-risk patients may diminish hospital and emergency department asthma care.

Variations in asthma care by race/ethnicity among children enrolled in a state Medicaid program

OBJECTIVE

To examine differences in the process of care for Medicaid-enrolled white, Hispanic, and black children with asthma.

DESIGN

Retrospective cohort study using Medicaid claims data to analyze the process of asthma care in 1994, including all white (non-Hispanic), black (non-Hispanic), and Hispanic children (aged 2-18 years) with asthma in the non-health maintenance organization portion of the Massachusetts Medicaid program (N = 5773). Main outcome measures included performance on 6 claims-based process-of-care measures that reflect national guidelines. Measures addressed primary and specialty care for asthma, appropriate asthma pharmacotherapy, and timely follow-up care after asthma emergency department (ED) visits and hospitalizations.

RESULTS

Controlling for case mix, provider type, disability status, age, and gender, Hispanic children with asthma were 39% less likely than white children to have a specialist visit for asthma (odds ratio [OR]: 0.61; confidence interval [CI]: 0.46-0.81) and 41% less likely to receive a follow-up visit within 5 days of being seen in the ED for asthma (OR: 0.59; CI: 0.36-0.95). However, Hispanic children received better care in 2 respects. They were 16% more likely than white children to receive a minimum of 2 asthma visits per year (CI: 1.01-1.34) and 27% less likely to be overprescribed beta-agonist medications (OR: 0.73; CI: 0.54-0.99). Black children were 64% less likely than white children to receive timely follow-up care after being seen in the ED for asthma (OR: 0.36; CI: 0.18-0.73). There were no racial/ethnic differences in the prescribing of antiinflammatory medications or timely follow-up care after an asthma hospitalization.

CONCLUSIONS

This study demonstrates important differences in the process of care experienced by racial/ethnic subpopulations within a Medicaid population, which may help explain differential outcomes. Efforts to improve asthma outcomes should target specific areas in which black and Hispanic children may be receiving suboptimal care.

Management of the acute exacerbation of asthma

All patients with asthma are at risk of having asthma exacerbations characterized by worsening symptoms, airflow obstruction, and an increased requirement for rescue bronchodilators. The goals of managing an asthma exacerbation are prompt recognition and rapid reversal of airflow obstruction to avert relapses and future episodes. Short-acting beta-agonists, oxygen, and corticosteroids form the basis of management of acute asthma exacerbation, but a role is emerging for anticholinergics and newer agents such as levalbuterol and formoterol. Initiation or intensification of long-term controller therapy, treatment of comorbid conditions, avoidance of likely triggers, and timely follow-up care prevent setbacks. Acceptance of current treatment guidelines by physicians and adherence to the recommended clinical regimens by patients are essential for effective management of asthma. The physician should strive to establish a constructive relationship with the patient by addressing the patient's concerns, reaching agreement on the goals of therapy, and developing a written action plan for patient self-management.

Serum IgE level in malnutrition

Infections and malnutrition remain the main causes of infant mortality in developing countries. In protein-calorie malnutrition, immunologic responses are affected, which often facilitates infections. However, the presence of asthma and allergic rhinitis are not commonly recognized in malnourished individuals. The aim of this study was to evaluate serum IgE values in children with primary moderate protein-calorie malnutrition.

METHODS

The level of IgE in peripheral blood of 18 children between 2 and 4 old with moderate protein-calorie malnutrition and without associated parasitic infestation was compared with that of 15 well nourished children of similar age. IgE serum levels were measured by an immunoenzymatic method.

RESULTS

The median level of serum IgE in malnourished children was 69.30 ng/ml while the control group showed a mean level of 95.97 ng/ml. This difference was significant (p < 0.01).

CONCLUSION

Malnourished children show decreased serum IgE levels. This might be one of the adaptive mechanisms of malnutrition employed in an attempt to use energy and protein reserves for growth and other functions. Our results are coherent with the decrease in IgE mediated reactions in malnourished patients.

Managing outpatient asthma exacerbations

Asthma is a chronic inflammatory disease that renders individuals prone to acute exacerbations. Several allergic and nonallergic triggers can incite an asthma exacerbation. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, prevention of relapses, and forestalling future episodes. A written asthma home-management plan is essential to minimize the severity of exacerbations. Short-acting b-agonists, oxygen, and corticosteroids are fundamental to early intervention in acute asthma exacerbation. Anticholinergics and magnesium sulfate can help nonresponders. Newer agents such as levalbuterol and long-acting b-agonists might be future additions to our armamentarium of drugs to treat acute exacerbations. Initiation or intensification of long-term controller therapy, treatment of co-morbid conditions, and avoidance of possible triggers along with prompt follow-up can help prevent relapses. Listening to patient preferences and concerns to enhance adherence and regular follow-up care can help prevent future episodes.

Racial and income disparities in childhood asthma in the United States

OBJECTIVE

To examine racial and income disparities in asthma prevalence in US children, and disparities in morbidity and ambulatory health care use among children with asthma.

METHODS

Using 1993-1996 National Health Interview Survey data, we measured asthma prevalence and morbidity in children aged 3 to 17 years (N = 14 211) stratifying by race and poverty status. Measures of morbidity included asthma-related activity limitation and number of bed days. We used the ratio of asthma-related doctor contacts to number of bed days in the past 2 weeks to measure health care use adjusted for severity of illness.

RESULTS

An annual average of 7.4% of children aged 3 to 17 years had asthma. There were no significant differences in asthma prevalence between race and poverty groups. In contrast, asthma-related morbidity was higher among black and poor children. Black poor children were most likely to have activity limitations due to asthma: 49% were limited compared with about 20% of black nonpoor, white poor, and white nonpoor children. Among children with activity limitations, black children and white poor children were more likely to have severe limitations, and white nonpoor children were least likely. Finally, white nonpoor children had the highest level of ambulatory care use for asthma after accounting for disease severity, and black poor children had the lowest level.

CONCLUSIONS

We found no significant racial or income disparities in asthma prevalence among children in the United States. However, black children and poor children are at higher risk for activity limitation, more severe activity limitation, and relative underuse of ambulatory health care. Black children living in poverty are at highest risk. Targeted interventions to reduce the burden of asthma morbidity in this population are likely to reduce disparities in asthma morbidity as well as reduce overall childhood asthma morbidity.

Acute severe asthma: Outcome and Medicaid insurance

OBJECTIVE: Economically disadvantaged children receive less preventive asthma care and more inpatient care. Studies have not evaluated the association of insurance status on children with severe exacerbations. We evaluated differences in severity of illness, resource use, and outcome associated with Medicaid insurance among children receiving intensive care for asthma. DESIGN: Retrospective cohort study. SETTING: Fourteen American pediatric intensive care units participating in the Pediatric Intensive Care Evaluations database. Methods: Patients with a primary diagnosis of asthma treated from May 1995 to February 2000 were identified. Demographic information and clinical data were evaluated to determine whether there was an association between Medicaid insurance, severity of illness, and length of stay. RESULTS: Twenty-six percent of the children had Medicaid insurance; 22% of children with Medicaid insurance received mechanical ventilation compared with 15% of those with commercial insurance and 16% in a health maintenance organization. After adjustment for severity of illness (Pediatric Risk of Mortality III and use of invasive therapies), Medicaid insurance was significantly associated with increased length of stay in the intensive care unit and hospital. Among children who received mechanical ventilation, patients with Medicaid also received ventilator support significantly longer. CONCLUSIONS: Asthmatic children receiving Medicaid had longer pediatric intensive care unit and hospital stays and an increased risk of mechanical ventilation compared with asthmatic children with commercial or health maintenance organization insurance. Further studies are needed to evaluate differences in outcome and resource utilization for economically disadvantaged asthmatic children.

Socioeconomic differences in children's health: how and why do these relationships change with age?

The effects of socioeconomic status (SES) on health are well documented in adulthood, but far less is known about its effects in childhood. The authors reviewed the literature and found support for a childhood SES effect, whereby each decrease in SES was associated with an increased health risk. The authors explored how this relationship changed as children underwent normal developmental changes and proposed 3 models to describe the temporal patterns. The authors found that a model's capacity to explain SES-health relationships varied across health outcomes. Childhood injury showed stronger relationships with SES at younger ages, whereas smoking showed stronger relationships with SES in adolescence. Finally, the authors proposed a developmental approach to exploring mechanisms that link SES and child health.

A multi-stage asthma screening procedure for elementary school children

This paper describes an asthma screening procedure developed to identify children with asthma for an intervention study. Students were classified into three categories based on questionnaire responses (previous asthma, suspected asthma, and no evidence of asthma). Those classified as suspected asthma by questionnaire underwent further testing, including spirometry and exercise challenge. Using the questionnaire alone, the measured asthma prevalence was 32%; the addition of spirometry and step testing reduced this estimate to 9.89%. The diagnosis of asthma was confirmed in 96% of children who saw the study physician. This screening procedure can identify school children with suspected undiagnosed asthma.

Social factors associated with prolonged hospitalization among diabetic children

OBJECTIVE

To determine social factors associated with increased risk of hospital admission from diabetic ketoacidosis (DKA) or diabetic coma as well as risk of prolonged hospital stay.

METHODS

A cohort of all children (</=21 years) with type 1 diabetes mellitus (DM) in the National Inpatient Sample admitted for DKA or diabetic coma during 1996 or 1997 was conducted. Patients' age, race, gender, and insurance coverage were identified. Length of stay and charges were examined; prolonged length of stay was defined as >/=7 days.

RESULTS

A total of 8443 children with a primary hospital diagnosis of DKA and 123 children with type 1 DM and coma were identified; 55% of the children were girls, 32% were nonwhite, 29% received Medicaid insurance, and 33% resided in areas of poverty. Children with prolonged hospital stay were significantly more likely to be of nonwhite race (odds ratio [OR]: 2.0; 95% confidence interval [CI]: 1.6-2.5), to receive Medicaid insurance (OR: 1.4; 95% CI: 1.1-1.7), to live in areas of poverty (OR: 1.3; 95% CI: 1.1-1.7), and to be of younger age.

CONCLUSIONS

When compared with state census data, nonwhite and poor children were more likely to be admitted with complications of DM and to have significantly prolonged and expensive hospital stays. These children should be targeted for intensive diabetes education and outpatient medical support both to improve their health and potentially to decrease total health care costs.

Children with asthma and nebulizer use: parental asthma self-care practices and beliefs

We examined demographic characteristics, patterns of medication use, asthma morbidity, and asthma self-management practices and beliefs among inner-city children currently using a nebulizer. We also describe the relationship between asthma self-management practices and beliefs and anti-inflammatory (AI) therapy. We observed a high rate of morbidity, including frequent emergency room visits, hospitalizations, symptom days and nights, and school absences in this group of school-aged children with asthma. More than three-quarters (81%) reported asthma symptoms consistent with mild persistent or greater severity of asthma, and therefore these subjects should be taking AI medications. Another 16% (36 of 231) of these children reported symptoms consistent with mild intermittent asthma. Only 1 out of 7 children in this study reported taking AI medications. We found that parents of children taking daily AI medications were more likely to agree with the belief that children should use asthma medications daily even when the child is not reporting any symptoms.

The use of parent report to assess the quality of care in primary care visits among children with asthma

OBJECTIVE

To determine the accuracy of parent report and the accuracy of the medical record in documenting physician performance of elements of pediatric asthma care in the primary care setting.

METHODS

A convenience sample of 79 English-speaking parents of 4--12-year old children with asthma presenting to medical center--affiliated inner-city primary care pediatric clinics in the Bronx, Dallas, and Chicago was enrolled, and the office visit was audiotaped. Parents were interviewed 1--16 days after the visit by telephone.

OUTCOME MEASURES

Accuracy of parent report was the primary outcome. The "reference standard" was an independent evaluation of the audiotaped record of the primary care visit. The National Asthma Education and Prevention Program was used as a guide to select data elements to assess quality of pediatric asthma care during primary care visits.

RESULTS

Sufficient documentation was significantly (P <.001) less likely to be present in the medical record than in the follow-up interview for each element of care. When these elements were combined into a cumulative score, 71% of parent interviews but only 37% of medical records scored > or = 5 (out of a possible 6), with 29% of medical records scoring < 3. Parents were able to accurately report (concordance of parent data with audiotape reference standard) whether or not the visit had included performance of 5 of the 6 elements of care.

CONCLUSIONS

Our study suggests that parent telephone interview within 2 weeks after the visit is more accurate than the medical record for documentation of the quality of asthma care in pediatric primary care visits. The medical record was not sufficient to assess the quality of primary care related to asthma, primarily because of missing data. Therefore, our data suggest that assessing quality of care using the medical record will not only bias the findings in the direction of more deficient care but will also make improvement in care more difficult. Further validation of our strategy for using parent report to assess the quality of care in primary care visits will require its application in a variety of other primary care settings.

Short-term outcomes after acute treatment of pediatric asthma

CONTEXT

The short-term course of pediatric patients after emergency department (ED) treatment for acute asthma has not been comprehensively documented; most previous studies have limited outcomes to ED length-of-stay, hospital admission, and relapse.

OBJECTIVE

To describe symptom persistence, medication use, functional disability, follow-up, and relapse in these children in the 2 weeks after acute treatment and ED discharge.

DESIGN

Randomly selected, prospective cohort from September 1996 to August 1997; follow-up telephone interviews at 1 and 2 weeks. Setting. A large, inner-city children's hospital emergency department. Patients. Random sample of pediatric asthma visits requiring ED treatment but not admission; 457 were eligible, 388 with complete follow-up (85%); final sample included 367 patients after multiple visits deleted.

MAIN OUTCOME MEASURES

Details of symptom persistence, functional disability, medication use, relapse, and routine follow-up.

RESULTS

Results included significant morbidity: 23% (95% confidence interval [CI]: 19, 27) with cough and 12% (95% CI: 9, 15) with wheeze persistent at 2 weeks; 20% (95% CI: 16, 24) with decreased activity at 1 week; 45% (95% CI: 39, 51) missed >2 and 24% (95% CI: 19, 29) >/=5 days of school or day care; 17% (95% CI: 13, 21) spent >/=3 days in bed; 54% (95% CI: 47, 60) of caretakers missed at least 1 and 18% (95% CI: 13, 24) missed >2 days of school or work; and 32% (95% CI: 28, 38) of patients were still using greater than baseline medication at 2 weeks. Reported relapse rates were averaged at 13% (95% CI: 10, 17) with 3% (95% CI: 1, 5) admitted. Routine office follow-up was poor: 29% (95% CI: 25, 34) had had a visit; 48% (95% CI: 43, 54) reported no visit/none planned.

CONCLUSIONS

A considerable proportion of inner-city pediatric patients discharged from the hospital from the ED after standard treatment for acute asthma had poor short-term outcomes. Conventional markers of successful ED treatment, such as avoiding hospital admission or relapse, do not adequately describe outcomes of acute care. The patient-oriented measures described here may provide more useful indicators of outcome in the evaluation of acute asthma care.

Prevalence of asthma and other allergic diseases in an adolescent population: association with gender and race

OBJECTIVES

To estimate the prevalence and severity of asthma in an adolescent population by sex and race.

METHODS

Cross-sectional, population-based survey of school children.

SETTING

Midwestern city experiencing damage from the 1993 Mississippi River flood.

PARTICIPANTS

2,693 children attending grades 7 to 12.

MEASUREMENTS

Questions from the International Study of Asthma and Allergies in Childhood (ISAAC).

RESULTS

Two thousand six hundred ninety-three children were surveyed, for a response rate of 90%. In this population, 16.4% reported having ever been diagnosed with asthma; 25% reported wheezing in the last 12 months; 32% reported symptoms of rhinitis in the last 12 months; and 22% reported ever having hay fever. The prevalence rate for current asthma was 12.6%. Female students had significantly greater prevalence rates for current asthma (16.4% vs 9.0%, OR = 1.85); ever-diagnosed asthma (18.5% vs 14.3%, OR = 1.36); wheezing > or = 4 times in the last 12 months (12.0% vs 5.6%, OR = 1.95); current rhinitis (38.7% vs 25.4%, OR = 1.73); and hay fever (26.4% vs 18.4%, OR = 1.57). All associations with sex remained significant, except ever-diagnosed asthma, after controlling for other known risk factors in logistic regression. African-Americans had higher prevalence rates than other races with differences reaching statistical significance for ever-diagnosed asthma and current asthma; however, these relationships did not remain significant after controlling for other known risk factors in logistic regression.

CONCLUSIONS

Our prevalence rates were similar to those reported by other studies that used the ISAAC questionnaire. Female students reported significantly more asthma, wheezing, rhinitis, and hay fever than male students. Female students also reported more severe symptoms and a greater number of emergency room and hospital admissions.

Barriers to asthma care in urban children: parent perspectives

BACKGROUND

Despite improved treatment regimens for asthma, the prevalence and morbidity from asthma are increasing, especially among underserved, minority children.

OBJECTIVE

The purpose of this study was to identify barriers to the treatment of asthma among urban, minority children as perceived by parents.

METHODS

Parents were recruited from 4 schools located in low-income, urban areas with high rates of asthma hospitalizations. Focus groups involving parents of children 5 to 12 years old with asthma were conducted using a standardized questionnaire. Parents' comments were analyzed to identify barriers, and 3 independent raters coded parents' comments to assess reliability of interpretation.

RESULTS

Forty parents who represented 47 children participated in the focus groups. All parents described their racial background as black. Parents' average age was 36.8 years, 92% were females, 70% were nonmarried, and 38% had less than a high school education. Forty-five percent of children had intermittent or mild asthma and 55% had moderate to severe asthma. The most frequent types of barriers identified by parents were patient or family characteristics (43%), followed by environmental (28%), health care provider (18%), and health care system (11%). Parents were specifically concerned about the use, safety and long-term complications of medications, the impact of limitation of exercise on their child's quality of life, and their own quality of life.

CONCLUSIONS

In contrast with the widespread beliefs that access to medical care, health insurance, and continuity of care are the major barriers to quality asthma care, the barriers most frequently reported by parents were related to patient and family characteristics, health beliefs, or to their social and physical environment. To improve asthma management and health outcomes for urban, minority children with asthma, it is critical to tailor education about asthma and its treatment, and address quality of life issues for both children and parents.

Watch, Discover, Think, and Act: a model for patient education program development

In this report we describe the development of the Watch, Discover, Think and Act asthma self-management computer program for inner-city children with asthma. The intervention focused on teaching two categories of behaviors--asthma specific behaviors such as taking preventive medication and self-regulatory processes such as monitoring symptoms and solving asthma problems. These asthma self-management behaviors were then linked with empirical and theoretical determinants such as skills and self-efficacy. We then further used behavioral science theory to develop methods such as role modeling and skill training linked to the determinants. We matched these theoretical methods to practical strategies within the computer simulation and created a culturally competent program for inner-city minority youth. Finally, we planned a program evaluation that linked program impact and outcomes to the theoretical assumptions on which the intervention was based.

Emergency department visits by urban African American children with asthma

BACKGROUND

Asthma morbidity among African American children has been identified as a significant national health concern. High emergency department use is one index of this morbidity and may reflect disease severity, disease management, and social factors.

OBJECTIVE

This study examined the prevalence and correlates of emergency department use and other indices of asthma morbidity among a sample of urban, low-income, African American children.

METHODS

Parents of 392 elementary school children with asthma who had consented to participate in an asthma education program were interviewed by phone according to a standardized protocol.

RESULTS

Children had a mean of 6.2 days of restricted activity (SD 8.1) and 7.9 symptomatic nights (SD 8.1). The mean number of school days missed because of asthma was 9.7 (SD 13.5). Among children with asthma symptoms in the past 12 months, 73.2% could identify a specific physician or nurse who provided asthma care. For those families without an identified asthma primary care provider, 39.3% received their usual asthma care from the emergency department. A total of 43.6% of the children had been to the emergency department for asthma care without hospitalization in the previous 6 months. Close to 80% of children reported using one or more prescribed asthma medication, and of these only 12% reported using inhaled anti-inflammatory medications. Families of children who had used the emergency department in the prior 6 months reported more asthma symptoms, lower social support, problems paying for health care, and the absence of a hypoallergenic mattress cover and that they had seen a physician for regular asthma care in the past 6 months.

CONCLUSIONS

We conclude that asthma management for children in the inner city relies on episodic care and emergency care, that asthma medication management does not conform to current guidelines, and that asthma symptoms resulting in school absences and workdays lost are prevalent.

Asthma knowledge, roles, functions, and educational needs of school nurses

In October 1997, 790 school nurses in Maryland and the District of Columbia were surveyed to determine their attitudes, knowledge, and beliefs about asthma. Results for 550 (70%) nurses indicated school nurses possess a generally appropriate level of knowledge concerning asthma, and most asthma myths have been replaced with knowledge. However, school nurses also have varied responsibilities that affect their ability to provide health education and support services to children with asthma at school. Little time is available for a proactive role. Concerns about the criteria and follow-up for delegating medication administration within the school setting were reported. A lack of communication existed with parents about the child's asthma. Open communication between school nurses and the family is recommended to establish a partnership and improve asthma management outcomes. In addition, school policies and procedures should be updated to meet the demands of children with asthma.

Prevalence and burden of illness for asthma and related symptoms among kindergartners in Chicago public schools

BACKGROUND

Asthma mortality rates in poor communities of Chicago are among the highest in the country. Possible explanations include increased asthma prevalence, increased severity, and suboptimal health care.

OBJECTIVE

To estimate the prevalence of asthma and asthma-related symptoms among inner-city kindergarten children, and to characterize their burden of illness, asthma-related health care access, and pharmacologic treatment.

METHODS

Cross-sectional survey of parents of kindergartners was conducted in 11 randomly selected Chicago elementary schools. A self-administered 16-item questionnaire was given to parents of kindergartners. Parents who reported doctor-diagnosed asthma or at least one of several key asthma-related symptoms were then interviewed with a supplemental questionnaire examining asthma-related health care and medication use.

RESULTS

Based on data from 638 children [mean age 5.7 (SD = 0.6) years], the prevalence of diagnosed asthma was 10.8%. Sixteen percent of the respondents reported that their child had wheezed in the past year. The prevalence of asthma-related symptoms unassociated with a diagnosis of asthma was 30.1%. The children with diagnosed asthma had evidence of a high burden of illness: over 40% were reported to have had sleep disturbance due to wheezing > or =1 to 2 nights/week and 86.6% reported acute care visits for respiratory symptoms in the past year. Self-reported access to medical care was high. Over 40% of the children with doctor diagnosed asthma were reported to have used a beta2-agonist in the preceding 2 weeks, and 12.2% used an inhaled anti-inflammatory.

CONCLUSIONS

These data suggest that asthma prevalence in school-aged children in inner-city communities may be higher than US estimates. The burden of illness experienced by these children is substantial. Also, a large proportion of children were reported to have respiratory symptoms consistent with asthma, and no asthma diagnosis, suggesting possible undiagnosed asthma. While measures of health care access appear to indicate that the majority of children with asthma experience no identified barriers to health care, there is evidence to suggest undertreatment.

Characteristics of children having multiple Medicaid-paid asthma hospitalizations

OBJECTIVES

We undertook this population-based study to describe the characteristics of poor children with multiple asthma hospitalizations and to discern if poor minority children have a greater risk for these events than poor white children.

METHODS

We conducted a retrospective analysis of 1994 California hospital discharge data for asthma hospitalizations among 1 to 12-year-old Medicaid patients (N = 6844 discharges). Risk factors for multiple Medicaid asthma hospitalizations were calculated by using logistic regression procedures.

RESULTS

In 1994, asthma hospitalizations accounted for 11.6% of Medicaid-funded hospitalizations for 1 to 12-year-olds in California. These hospitalizations had a mean length of 2.7 days and a mean hospital charge of $6532. After we controlled for source of admission and length of stay, African American children (OR, 1.93; 95% CI 1.49-2.49) and Latino children (OR, 1.34; 95% CI 1.04-1.72) had a higher risk of multiple Medicaid-paid hospitalizations for asthma than did white children. Adjusted odds ratios for multiple asthma hospitalizations were 1.35 (CI, 1.05-1.74) for children with emergency room admissions, and 1.16 (CI, 0.97-1.39) for children having hospital stays of at least 5 days duration.

CONCLUSIONS

Among children with Medicaid-paid hospitalizations for asthma, the risk for multiple asthma hospitalizations within a year was greater among African Americans and Latinos than among whites. Programs attempting to decrease repeat hospitalizations for asthma may benefit by focusing on these populations.

Exercise-induced bronchospasm in high school athletes via a free running test: incidence and epidemiology

BACKGROUND

Exercise-induced bronchospasm (EIB) affects up to 35% of athletes and up to 90% of asthmatics. Asthma morbidity and mortality have increased over the past several decades among residents of Philadelphia, PA. It is possible that a simple free running test for EIB may serve as a tool to study the factors contributing to recent trends in asthma, and to screen for asthma in athletes in the urban setting.

OBJECTIVES

The purposes of this study were to (1) assess a free running test to screen for EIB, and (2) examine prevalence of and epidemiologic factors associated with EIB in high school athletes.

DESIGN

Cross-sectional observational study on the incidence and risk factors for EIB. To validate our method and criteria for the diagnosis of EIB, a repeat test was performed on a portion of the athletes. In a randomized single-blinded fashion, 15 athletes who had demonstrated EIB initially received albuterol or placebo prior to a repeat exercise test.

SETTING

Community high school athletic facilities.

PARTICIPANTS

We studied 238 male high school varsity football players.

INTERVENTION

All athletes underwent an acquaintance session with a questionnaire, followed by a 1-mile outdoor run (6 to 8 mins).

MEASUREMENTS

Peak expiratory flow (PEF) measurements were determined prior to and 5, 15, and 30 min after exercise. Heart rates (HRs) and dyspnea scores were measured. EIB was defined as a decrease of 15% in PEF at any time point after exercise. Associations of EIB with demographic factors were assessed by univariate and multivariate analyses.

RESULTS

Two hundred thirty-eight athletes participated: 92 European-Americans (EA), 140 African-Americans (AA), 5 Hispanics, and 1 Native American. Mean age was 16+/-1 years. Average HR postexercise was 156+/-24 beats/min. Twenty-four (10%) reported a history of treated asthma. The prevalence of EIB among the remaining 214 athletes was 19 of 214 (9%). The rate of EIB among AA athletes was higher than among EA athletes: (17/126 [13%] AA vs 2/82 [2%] EA, p = 0.01). During the validation portion of the study, the placebo-treated group (n = 7) demonstrated a consistent drop in PEF after exercise on repeat testing, with a 16+/-5% fall in PEF on initial testing and a 14+/-13 drop with placebo. In contrast, the fall in airflow in the albuterol-treated athletes (n = 8) following exercise reversed with albuterol treatment, from a 15+/-6% fall in PEF at initial testing to an increase in PEF of 6+/-9% from baseline following albuterol administration. A history of wheezing (p < 0.001), residence in a poverty area (p < 0.0001), race (p = 0.01), remote history of asthma (p < 0.001), and absolute water content of the air on the day tested (p = 0.04) were significantly associated with EIB. By stepwise regression, EIB was most closely associated with a history of wheezing (p = 0.001) and poverty area residence (p = 0.003).

CONCLUSIONS

Our findings indicate a substantial rate of unrecognized EIB exists among urban varsity athletes, and suggest that active screening for EIB, especially for students residing in poverty areas, may be indicated to identify individuals at risk for EIB and asthma.

Patient-provider communication during the emergency department care of children with asthma. The National Cooperative Inner-City Asthma Study, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD

OBJECTIVES

Poor children's reliance on emergency facilities is one factor implicated in the rise of morbidity attributed to asthma. Although studies have examined doctor-patient communication during routine pediatric visits, little data are available about communication during emergency care. This study sought to describe communication during emergency treatment of childhood asthma to learn if a "patient-centered" provider style was associated with increased parent satisfaction and increased parent and child participation.

METHODS

This cross-sectional, observational study examined 104 children aged 4 to 9 years and their guardian(s) attending emergency departments in seven cities. Quantitative analysis of provider-family dialogue was performed. Questionnaires measured satisfaction with care, provider informativeness, and partnership.

RESULTS

Providers' talk to children was largely supportive and directive; parents received most counseling and information. Children spoke little to providers (mean: 20 statements per visit versus 156 by parents). Providers made few statements about psychosocial aspects of asthma care (mean: three per visit). Providers' patient-centered style with parents was associated with more talk from parents and higher ratings for informativeness and partnership. Patient-centered style with children was associated with five times the amount of talk from children and with higher parent ratings for "good care," but not for informativeness or partnership.

CONCLUSIONS

Communication during emergency asthma care was overwhelmingly biomedical. Children took little part in discussions. A patient-centered style correlated with increased parent and child participation, but required directing conversation toward both parents and children.

Is the asthma quality of life questionnaire a useful measure for low-income asthmatics?

The purpose of this study was to evaluate the reliability and validity of the Asthma Quality of Life Questionnaire (AQLQ) in a population-based sample of low-income adults with asthma. A total of 112 subjects (46 African American, 66 Caucasian; mean age = 33 +/- 9 yr; 26% male) were recruited from the Baltimore County, Maryland and Atlanta, Georgia metropolitan areas. Internal consistency reliability (Cronbach's alpha) was high for the overall scale (0. 96); 2-wk reproducibility (intraclass correlation, ICC) was 0.82 (n = 38). Overall score was significantly correlated with FEV1 percentage of predicted (r = 0.20), and the Asthma Disease Severity Scale (r = -0.38). Correlations between overall score and the SF-36 Physical Component Summary (r = 0.49), SF-36 Mental Component Summary (r = 0.37), Cantril's Ladder (r = 0.23), and the Health Utilities Index (r = 0.22) supported the validity of the AQLQ in this sample. Comparison of reliability and validity estimates across racial groups found few substantive differences. Internal consistency, reproducibility, and validity estimates found in this sample were consistent with those of a reliable and valid measure and were comparable to those found in other populations. These results suggest the AQLQ is a useful indicator of health- related quality of life in low-income asthmatics.

Relationships of race and socioeconomic status with prevalence, severity, and symptoms of asthma in Chicago school children

BACKGROUND

Asthma mortality rates in Chicago are among the highest in the United States, with substantially greater rates in poor and minority populations. How much of the differential can be attributed to differences in prevalence versus severity or access to care has not been determined.

OBJECTIVE

To examine rates of asthma prevalence, severity, and symptoms and to explore the relationships of these rates to race and socioeconomic status in a random sample of Chicago school children.

METHODS

Self-administered survey.

RESULTS

Overall, rates of asthma were higher than previously reported, with 16% of students in the stratified cluster random sample of 3,670 children in the 7th and 8th grades having had asthma. Prevalence rates were significantly higher in schools with >98% African Americans than in other schools, with the highest prevalence rates seen in African American schools in low income neighborhoods. Rates were associated with the percent of African American children in the school and with median income of the school's census tract. Relationships were most consistent with indices of more severe disease.

CONCLUSIONS

Asthma prevalence is higher than previously noted, with rates greatest in minority and low income populations. Differences are more striking for measures of severity than for symptoms of wheezing, but are far less than previously reported differences in mortality, suggesting that additional factors, such as differential access to continuous health care, may be affecting high death rates from asthma in Chicago.

Asthma, rhinitis and eczema in Maltese 13-15 year-old schoolchildren -- prevalence, severity and associated factors [ISAAC]. International Study of Asthma and Allergies in Childhood

BACKGROUND

Allergic conditions, especially asthma, seem to be increasingly common the world over. The International Study of Asthma and Allergies in Childhood [ISAAC] was the first worldwide study carried out with standardized questionnaires in order to create a reliable global map of childhood allergy.

OBJECTIVES

The Maltese Islands were one of the centres participating in this study and in this paper the data obtained from 4184 13-15 year olds from 22 state and three private schools [88.7% response rate], and also data obtained from some added 'local' questions addressed to the same children, are included. in order to evaluate the problem of allergic conditions in Maltese schoolchildren.

RESULTS

27.9% of the participants were wheezers 'ever' while 16% were current wheezers. Of the latter children 15.1% were experiencing nocturnal wheezing at least once a week and 22% had a wheezing episode severe enough to limit speech. Nasal problems were present in 52.7% of these teenagers and 47.4% of all respondents persisted with these symptoms up to the year of answering the questionnaire. Hayfever had been diagnosed in 32.3% of all the children. 12.8% of respondents had a recurring itchy rash suggestive of eczema for at least 6 months of their lives and 10% had it currently. This was slightly lower than the global mean, unlike the case of wheezing, which in Malta was more common than the world average, and rhinitis, for which we had the second highest cumulative prevalence rate in the world. Multiple variables such as gender, smoking, family history of atopy, pets, soft furnishings and living in busy roads affected the prevalence and severity of the allergic conditions studied.

CONCLUSIONS

Allergic conditions are very common in Maltese schoolchildren and are causing a lot of hardship to these same youngsters. The results of this study should serve as a stimulus to try and decrease this suffering through better management of these conditions, measures to control possible detrimental factors and further research on asthma, allergic rhinitis and eczema.

Health service use by African Americans and Caucasians with asthma in a managed care setting

Managed care plan members provide a population for analysis that minimizes the financial barriers to routine medical care that have been linked to high rates of asthma-related hospitalization, emergency care, and mortality among urban African Americans. We examined patterns of asthma care among 464 African American (AA) and 1,609 Caucasian (C) asthma patients, age 15 to 45 yr, in a southeast Michigan managed care system during 1993. Compared with C, AA had fewer visits to asthma specialists (0.32 versus 0.50 visits/yr, p = 0.002), and filled fewer prescriptions for inhaled steroids (1.44 versus 1.74 Rx/yr, p = 0.038), while being more likely to visit the emergency department with asthma (0.71 versus 0.28 visits/yr, p < 0. 001), to be hospitalized with asthma (0.08 versus 0.03 admissions/yr, p = 0.002), or to have filled prescriptions for oral steroids (0.91 versus 0.59 Rx/yr, p < 0.001). AA were equally likely to have visited a primary care physician for asthma (0.95 versus 0.93 visits/yr, p = 0.81). Similar physician visit profiles and discrepancies in the use of oral steroids persisted when analyzing exclusively low socioeconomic status subgroups. These results suggest that ethnic differences in patterns of asthma-related health care persist within managed care settings and are only partially due to financial barriers.

Prevalence of bronchial asthma in schoolchildren in Delhi

There is a paucity of information on the prevalence of asthma in children in India. Some evidence suggests that asthma is less common in developing than in the developed countries. The present study was carried out to estimate its current magnitude in children in Delhi. The questionnaire-based study was carried out in two randomly selected schools in Delhi. All the children were eligible. The age range was 4-17 years. The questionnaires were distributed to all the children present (n = 2867) to be answered by either parent. The key questions were related to complaints of recurrent wheezing in the past, in the last 1 year, and also wheezing exclusively induced by exercise or colds. In all, 2609 questionnaires were completed and returned (response rate 91%). There was a slight excess of males (54%). The prevalence of current asthma was 11.6% and past asthma was reported by 4.1% of children, giving a cumulative prevalence of 15.7%. Exclusive exercise-induced asthma was 2.8% and that associated with colds, 2.3%. The current prevalence of all wheezing was thus 16.7% and cumulative prevalence was 20.8%. While there was no sex-related difference in prevalence, wheezers were the highest in the 9-13 year age group. A significant association was found between the prevalence of wheezing and a family history of asthma (odds ratio 3.65) and presence of smokers in the family (odds ratio 1.62). When both the above factors combined, the odds ratio for risk of asthma was 4.58. There was no significant association with any economic class. Only 11% of asthmatics had been labeled so by their physicians. The prevalence of bronchial asthma and wheezing in children in Delhi is quite high and comparable to that reported from several developed countries. A positive family history of asthma and presence of smokers in the family emerged as significant risk factors.

Asthma in non-inner city Head Start children

OBJECTIVE

Asthma is a significant cause of morbidity and mortality in children. The objective of this study was to determine whether the federal program Head Start in Dane County, Wisconsin, could be used as a mechanism to identify preschool-aged children with asthma.

DESIGN

Five-year, cross-sectional survey of parents with children enrolled in Head Start.

METHODS

Investigator-administered asthma screening questionnaire to parents of enrolling Head Start children in Dane County, Wisconsin.

MEASUREMENTS

Asthma prevalence and asthma-related health care use, including emergency department visits, hospitalizations, and medication usage, were measured using an asthma screening questionnaire developed by investigators.

RESULTS

Information was gathered on 2215 children. The prevalence of physician-diagnosed asthma in the screened children was 15.8%. Parental reports of physician-diagnosed asthma were validated in a subset of 133 children, with a 98.5% confirmation rate. Independent risk factors for asthma included male gender (relative risk, 1.4) and African-American ethnicity (relative risk, 1.4). Asthma-related morbidity was substantial with 26.7% of identified children hospitalized for asthma and 54.5% with an emergency department visit during their lifetime. The majority of children (46.4%) were treated with intermittent, quick relief medications (beta-agonists) alone, whereas only 6.1% were on daily, long-term controller medications.

CONCLUSIONS

Asthma screening through a Head Start program provides an effective means of targeting preschool-aged children from socioeconomic groups at high risk for asthma. Identification of children early in the disease course and those at high risk for asthma provides an ideal opportunity for the implementation of preventive and therapeutic interventions.