1
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Hall K, Barry F, Thompson LR, Ravandi B, Hall JE, Chang TP, Halterman JS, Szilagyi PG, Okelo SO. Feasibility of text message follow-up for pediatric asthma care after an emergency department visit. J Asthma 2024; 61:140-147. [PMID: 37610221 DOI: 10.1080/02770903.2023.2248507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
Background: Many children seen in the Emergency Department (ED) for asthma do not follow-up with their primary care provider. Text messaging via short message service (SMS) is a ubiquitous, but untested means of providing post-ED asthma follow-up care.Objective: To evaluate responses to an asthma assessment survey via SMS following an ED visit and estimate the likelihood of response by sociodemographic and clinical characteristics. Methods: We recruited 173 parents of children 2-17 years-old presenting for ED asthma care to receive a follow-up text (participation rate: 85%). One month later, parents received via SMS a 22-item survey that assessed asthma morbidity. We assessed response rates overall and by various sociodemographic and clinical characteristics, including age, parental education, and indicators of asthma severity.Results: Overall, 55% of parents (n = 95) responded to the SMS survey. In multivariable logistic regression (MLR), parents who graduated high school had a four-fold higher response rate compared to parents with less than a high school degree (OR: 4.05 (1.62, 10.13)). More parents of children with oral steroid use in the prior 12 months responded to survey items (OR: 2.53 (1.2, 5.31)). Reported asthma characteristics included: 48% uncontrolled, 22% unimproved/worse, 21% with sleep disruption, and 10% who were hospitalized for asthma.Conclusions: Text messaging may be a viable strategy to improve post-ED asthma assessment and to identify children with persistent symptoms in need of enhanced care or modification of care plans.
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Affiliation(s)
- Kaitlin Hall
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Frances Barry
- Frances Barry Psychotherapy Practice, Santa Monica, CA, USA
| | - Lindsey R Thompson
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Bahareh Ravandi
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern CA, Los Angeles, CA, USA
| | - Jeanine E Hall
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern CA, Los Angeles, CA, USA
| | - Todd P Chang
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern CA, Los Angeles, CA, USA
| | - Jill S Halterman
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Peter G Szilagyi
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Sande O Okelo
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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2
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Okelo SO. Racial Inequities in Asthma Care. Semin Respir Crit Care Med 2022; 43:684-708. [DOI: 10.1055/s-0042-1756492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractRacial inequities in asthma care are evolving as a recognized factor in long-standing inequities in asthma outcomes (e.g., hospitalization and mortality). Little research has been conducted regarding the presence or absence of racial inequities among patients seen in asthma specialist settings, this is an important area of future research given that asthma specialist care is recommended for patients experiencing the poor asthma outcomes disproportionately experienced by Black and Hispanic patients. This study provides a systematic review of racial asthma care inequities in asthma epidemiology, clinical assessment, medication prescription, and asthma specialist referral practices.
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Affiliation(s)
- Sande O. Okelo
- Division of Pediatric Pulmonology and Sleep Medicine, The David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
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3
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Sagheb E, Wi CI, Yoon J, Seol HY, Shrestha P, Ryu E, Park M, Yawn B, Liu H, Homme J, Juhn Y, Sohn S. Artificial Intelligence Assesses Clinicians' Adherence to Asthma Guidelines Using Electronic Health Records. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1047-1056.e1. [PMID: 34800704 PMCID: PMC9007821 DOI: 10.1016/j.jaip.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 10/20/2021] [Accepted: 11/07/2021] [Indexed: 05/25/2023]
Abstract
BACKGROUND Clinicians' asthma guideline adherence in asthma care is suboptimal. The effort to improve adherence can be enhanced by assessing and monitoring clinicians' adherence to guidelines reflected in electronic health records (EHRs), which require costly manual chart review because many care elements cannot be identified by structured data. OBJECTIVE This study was designed to demonstrate the feasibility of an artificial intelligence tool using natural language processing (NLP) leveraging the free text EHRs of pediatric patients to extract key components of the 2007 National Asthma Education and Prevention Program guidelines. METHODS This is a retrospective cross-sectional study using a birth cohort with a diagnosis of asthma at Mayo Clinic between 2003 and 2016. We used 1,039 clinical notes with an asthma diagnosis from a random sample of 300 patients. Rule-based NLP algorithms were developed to identify asthma guideline-congruent elements by examining care description in EHR free text. RESULTS Natural language processing algorithms demonstrated a sensitivity (0.82-1.0), specificity (0.95-1.0), positive predictive value (0.86-1.0), and negative predictive value (0.92-1.0) against manual chart review for asthma guideline-congruent elements. Assessing medication compliance and inhaler technique assessment were the most challenging elements to assess because of the complexity and wide variety of descriptions. CONCLUSIONS Natural language processing technologies may enable the automated assessment of clinicians' documentation in EHRs regarding adherence to asthma guidelines and can be a useful population management and research tool to assess and monitor asthma care quality. Multisite studies with a larger sample size are needed to assess the generalizability of these NLP algorithms.
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Affiliation(s)
- Elham Sagheb
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minn
| | - Chung-Il Wi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Jungwon Yoon
- Department of Pediatrics, Myongji Hospital, Goyang, South Korea
| | - Hee Yun Seol
- Pusan National University, Yangsan Hospital, Yangsan, South Korea
| | - Pragya Shrestha
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Euijung Ryu
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Barbara Yawn
- Department of Family and Community Health, University of Minnesota, Minneapolis, Minn
| | - Hongfang Liu
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minn
| | - Jason Homme
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Young Juhn
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn.
| | - Sunghwan Sohn
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minn.
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4
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Afolabi T, Fairman KA. Association of Asthma Exacerbation Risk and Physician Time Expenditure With Provision of Asthma Action Plans and Education for Pediatric Patients. J Pediatr Pharmacol Ther 2022; 27:244-253. [PMID: 35350158 DOI: 10.5863/1551-6776-27.3.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/14/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To provide information about factors underlying provision of asthma action plans (AAPs) to a minority of pediatric patients with asthma, assess whether risk of exacerbation acts on provision of AAP and asthma education directly, suggesting targeting to highest-risk patients, or indirectly by influencing physician-patient interaction time. METHODS This study was a retrospective cross-sectional analysis of a nationally representative sample of physician office visits that consisted of patients aged 2 to 18 years with asthma. Exacerbation risk comprised proxy indicators of control and severity. Direct and time-mediated effects of exacerbation risk on provision of AAP and education were calculated from logistic regression models. RESULTS Asthma action plans were provided in 14.3% of visits, education in 23.9%. Total direct effects of exacerbation risk (ORs = 3.88-4.69) far exceeded indirect, time-mediated effects (both ORs = 1.03) on AAPs. Direct effects on education were similar but smaller. After adjusting for risk, physician time expenditure of ≥30 minutes was associated with nearly doubled odds of providing AAP or education (ORs = 1.90-1.99). Visits that included allied health professionals alongside physician care were significantly associated with all 4 outcomes in multivariate analyses (ORs = 3.06-5.28). CONCLUSIONS Exacerbation risk has a strong, direct association with AAP provision in pediatric asthma, even controlling for physician time expenditure. Provision of AAP and education to pediatric patients with asthma may be facilitated by increasing available time for office visits and involving allied health professionals.
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Affiliation(s)
- Titilola Afolabi
- Midwestern University College of Pharmacy-Glendale (TA, KAF), Glendale, AZ.,Phoenix Children's Hospital (TA), Phoenix, AZ
| | - Kathleen A Fairman
- Midwestern University College of Pharmacy-Glendale (TA, KAF), Glendale, AZ
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5
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Agnikula Kshatriya BS, Sagheb E, Wi CI, Yoon J, Seol HY, Juhn Y, Sohn S. Identification of asthma control factor in clinical notes using a hybrid deep learning model. BMC Med Inform Decis Mak 2021; 21:272. [PMID: 34753481 PMCID: PMC8579684 DOI: 10.1186/s12911-021-01633-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There are significant variabilities in guideline-concordant documentation in asthma care. However, assessing clinician's documentation is not feasible using only structured data but requires labor-intensive chart review of electronic health records (EHRs). A certain guideline element in asthma control factors, such as review inhaler techniques, requires context understanding to correctly capture from EHR free text. METHODS The study data consist of two sets: (1) manual chart reviewed data-1039 clinical notes of 300 patients with asthma diagnosis, and (2) weakly labeled data (distant supervision)-27,363 clinical notes from 800 patients with asthma diagnosis. A context-aware language model, Bidirectional Encoder Representations from Transformers (BERT) was developed to identify inhaler techniques in EHR free text. Both original BERT and clinical BioBERT (cBERT) were applied with a cost-sensitivity to deal with imbalanced data. The distant supervision using weak labels by rules was also incorporated to augment the training set and alleviate a costly manual labeling process in the development of a deep learning algorithm. A hybrid approach using post-hoc rules was also explored to fix BERT model errors. The performance of BERT with/without distant supervision, hybrid, and rule-based models were compared in precision, recall, F-score, and accuracy. RESULTS The BERT models on the original data performed similar to a rule-based model in F1-score (0.837, 0.845, and 0.838 for rules, BERT, and cBERT, respectively). The BERT models with distant supervision produced higher performance (0.853 and 0.880 for BERT and cBERT, respectively) than without distant supervision and a rule-based model. The hybrid models performed best in F1-score of 0.877 and 0.904 over the distant supervision on BERT and cBERT. CONCLUSIONS The proposed BERT models with distant supervision demonstrated its capability to identify inhaler techniques in EHR free text, and outperformed both the rule-based model and BERT models trained on the original data. With a distant supervision approach, we may alleviate costly manual chart review to generate the large training data required in most deep learning-based models. A hybrid model was able to fix BERT model errors and further improve the performance.
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Affiliation(s)
| | - Elham Sagheb
- Department of Artificial Intelligence and Informatics, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA
| | - Chung-Il Wi
- Precision Population Science Lab, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN USA
| | - Jungwon Yoon
- Department of Pediatrics, Myongji Hospital, Goyang, South Korea
| | - Hee Yun Seol
- Pusan National University, Yangsan Hospital, Yangsan, South Korea
| | - Young Juhn
- Precision Population Science Lab, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN USA
| | - Sunghwan Sohn
- Department of Artificial Intelligence and Informatics, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA
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6
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Klok T, Ottink MD, Brand PLP. Question 6: What is the use of allergy testing in children with asthma? Paediatr Respir Rev 2021; 37:57-63. [PMID: 32981859 DOI: 10.1016/j.prrv.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
Disagreement exists between asthma guidelines on the routine use of allergy testing in the diagnostic work-up of a child with persistent asthma, although the important role of inhalant allergy in the pathophysiology of asthma and allergic rhinitis is undisputed. The usefulness of screening for inhalant allergies in asthma is connected to the efficacy of allergen reduction measures and specific immunotherapy, both of which appear to be more effective in children than in adults. Allergen-specific exposure reduction recommendations are therefore an essential part of childhood asthma management. Such recommendations should be guided by appropriate diagnosis of inhalant allergy, based on a structured allergy history and results of sensitization tests. Specific IgE testing and skin prick testing show comparable results in identifying clinically important sensitizations. Although a therapeutic medication trial can be started pragmatically in children with asthma without diagnosing their inhalant allergy, we recommend making or excluding an accurate diagnosis of inhalant allergy.
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Affiliation(s)
- Ted Klok
- Deventer ziekenhuis, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands.
| | - Mark D Ottink
- Medisch Spectrum Twente, Koningsplein 1, PO Box 50000, 7500 KA Enschede, The Netherlands.
| | - Paul L P Brand
- Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands; LEARN Network, University Medical Centre and University of Groningen, Groningen, The Netherlands.
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7
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Kshatriya BSA, Sagheb E, Wi CI, Yoon J, Seol HY, Juhn Y, Sohn S. Deep Learning Identification of Asthma Inhaler Techniques in Clinical Notes. PROCEEDINGS. IEEE INTERNATIONAL CONFERENCE ON BIOINFORMATICS AND BIOMEDICINE 2021; 2020:10.1109/bibm49941.2020.9313224. [PMID: 34336372 PMCID: PMC8323494 DOI: 10.1109/bibm49941.2020.9313224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
There are significant variabilities in clinicians' guideline-concordant documentation in asthma care. However, assessing clinicians' documentation is not feasible using only structured data but requires labor intensive chart review of electronic health records. Although the national asthma guidelines are available it is still challenging to use them as a real-time tool for providing feedback on adhering documentation guidelines for asthma care improvement. A certain guideline element, such as teaching or reviewing inhaler techniques, is difficult to capture by handcrafted rules since it requires contextual understanding of clinical narratives. This study examined a deep learning based natural language model, Bidirectional Encoder Representations from Transformers (BERT) coupled with distant supervision to identify inhaler techniques from clinical narratives. The BERT model with distant supervision outperformed the rule-based approach and achieved performance gain compared with the BERT without distant supervision.
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Affiliation(s)
| | - Elham Sagheb
- Division of Digital Health Sciences, Mayo Clinic, Rochester MN, USA
| | - Chung-Il Wi
- Community Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester MN, USA
| | - Jungwon Yoon
- Department of Pediatrics, Myongji Hospital, South Korea
| | - Hee Yun Seol
- Pusan National University Yangsan Hospital South Korea
| | - Young Juhn
- Community Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester MN, USA
| | - Sunghwan Sohn
- Division of Digital Health Sciences, Mayo Clinic, Rochester MN, USA
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8
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Akinbami LJ, Salo PM, Cloutier MM, Wilkerson JC, Elward KS, Mazurek JM, Williams S, Zeldin DC. Primary care clinician adherence with asthma guidelines: the National Asthma Survey of Physicians. J Asthma 2019; 57:543-555. [PMID: 30821526 DOI: 10.1080/02770903.2019.1579831] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background and objectives: Although primary care clinicians provide >60% of U.S. asthma care, no nationally representative study has examined variation in adherence among primary care groups to four cornerstone domains of the Expert Panel Report-3 asthma guidelines: assessment/monitoring, patient education, environmental assessment, and medications. We used the 2012 National Asthma Survey of Physicians: National Ambulatory Medical Care Survey to compare adherence by family/general medicine practitioners (FM/GM), internists, pediatricians and Community Health Center mid-level clinicians (CHC). Methods: Adherence was self-reported (n = 1355 clinicians). Adjusted odds of almost always adhering to each recommendation (≥75% of the time) were estimated controlling for clinician/practice characteristics, and agreement and self-efficacy with guideline recommendations. Results: A higher percentage of pediatricians adhered to most assessment/monitoring recommendations compared to FM/GM and other groups (e.g. 71.6% [SE 4.0] almost always assessed daytime symptoms versus 50.6% [SE 5.1]-51.1% [SE 5.8], t-test p < 0.05) but low percentages from all groups almost always performed spirometry (6.8% [SE 2.0]-16.8% [SE 4.7]). Pediatricians were more likely to provide asthma action/treatment plans than FM/GM and internists. Internists were more likely to assess school/work triggers than pediatricians and CHC (environmental assessment). All groups prescribed inhaled corticosteroids for daily control (84.0% [SE 3.7]-90.7% [SE 2.5]) (medications). In adjusted analyses, pediatric specialty, high self-efficacy and frequent specialist referral were associated with high adherence. Conclusions: Pediatricians were more likely to report high adherence than other clinicians. Self- efficacy and frequent referral were also associated with adherence. Adherence was higher for history-taking recommendations and lower for recommendations involving patient education, equipment and expertise.
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Affiliation(s)
- Lara J Akinbami
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD, USA.,United States Public Health Service, Rockville, MD, USA
| | - Paivi M Salo
- Division of Intramural Research, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, USA
| | - Michelle M Cloutier
- Department of Pediatrics, UCONN Health Farmington, CT and Connecticut Children's Medical Center, Hartford, CT, USA
| | | | - Kurtis S Elward
- Department of Family Medicine and Population Health, the Virginia Commonwealth University, Richmond, VA, USA
| | - Jacek M Mazurek
- National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, USA
| | - Sonja Williams
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD, USA
| | - Darryl C Zeldin
- Division of Intramural Research, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, USA
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9
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Guilbert T, Zeiger RS, Haselkorn T, Iqbal A, Alvarez C, Mink DR, Chipps BE, Szefler SJ. Racial Disparities in Asthma-Related Health Outcomes in Children with Severe/Difficult-to-Treat Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:568-577. [PMID: 30172020 DOI: 10.1016/j.jaip.2018.07.050] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/22/2018] [Accepted: 07/29/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND There are limited data that examine differences in asthma etiology between black and white children with severe or difficult-to-treat asthma. OBJECTIVE To describe demographic, clinical, and asthma-related outcomes in black and white children and examine whether differences in outcomes are explained by confounding factors in sequential multivariable models. METHODS Black (n = 86) and white (n = 262) children aged 6-11 years from The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens 3-year observational study were analyzed. Baseline demographics and clinical characteristics were described for both cohorts, and outcomes at month 12 were analyzed using statistical models, sequentially adjusting for potential confounders. RESULTS Black children were more likely to be male (79.1% vs 66.4%; P < .05), obese (12.8% vs 1.5%; P < .001), and from a lower income stratum (USD43,400 vs 55,770; P < .001) than white children. Black children had higher geometric mean IgE levels (434.8 vs 136.8 IU/mL; P < .001), were more likely to have very poorly controlled asthma (72.1% vs 53.4%), use long-term systemic corticosteroids (30.2% vs 9.2%; P < .001), have poorer quality of life (5.5 vs 6.1; P < .001), and have an emergency department visit (27.4% vs 7.7%, P < .001) in the 3 months before month 12. Differences in asthma control and the severity of exacerbations persisted even after accounting for all confounding factors. CONCLUSIONS Among children with severe or difficult-to-treat asthma, asthma burden is greater in black than white children particularly related to several clinical and patient-reported outcome measures that are not explained by differences in background or clinical characteristics.
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Affiliation(s)
- Theresa Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Cincinnati, Ohio.
| | - Robert S Zeiger
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Pasadena, Calif
| | | | - Ahmar Iqbal
- US Medical Affairs, Genentech, Inc., South San Francisco, Calif
| | | | | | | | - Stanley J Szefler
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
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10
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Holder-Niles F, Haynes L, D'Couto H, Hehn RS, Graham DA, Wu AC, Cox JE. Coordinated Asthma Program Improves Asthma Outcomes in High-Risk Children. Clin Pediatr (Phila) 2017; 56:934-941. [PMID: 28436286 DOI: 10.1177/0009922817705186] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Innovative approaches within primary care are needed to reduce fragmented care, increase continuity of care, and improve asthma outcomes in children with asthma. Our objective was to assess the impact of coordinated team-based asthma care on unplanned asthma-related health care utilization. A multidisciplinary asthma team was developed to provide coordinated care to high-risk asthma patients. Patients received an in-depth diagnostic and family needs assessment, asthma education, and coordinated referral to social and community services. Over a 2-year period, 141 patients were followed. At both 1 and 2 years postintervention, there was a significant decrease from preintervention rates in urgent care visits (40%, P = .002; 50%, P < .0001), emergency department visits (63%, P < .0001; 70%, P < .0001), and inpatient hospitalization (69%, P = .002; 54%, P = .04). Our coordinated asthma care program was associated with a reduction in urgent care visits, emergency department visits, and inpatient hospitalizations among high-risk children with asthma.
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Affiliation(s)
- Faye Holder-Niles
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | | | - Helen D'Couto
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | | | - Dionne A Graham
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Ann Chen Wu
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA.,3 Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Joanne E Cox
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
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11
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Butz A, Morphew T, Lewis-Land C, Kub J, Bellin M, Ogborn J, Mudd SS, Bollinger ME, Tsoukleris M. Factors associated with poor controller medication use in children with high asthma emergency department use. Ann Allergy Asthma Immunol 2017; 118:419-426. [PMID: 28254203 PMCID: PMC5385291 DOI: 10.1016/j.anai.2017.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/03/2017] [Accepted: 01/09/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Understanding health and social factors associated with controller medication use in children with high-risk asthma may inform disease management in the home and community. OBJECTIVE To examine health and social factors associated with the Asthma Medication Ratio (AMR), a measure of guideline-based care and controller medication use, in children with persistent asthma and frequent emergency department (ED) use. METHODS Study questionnaires, serum allergen sensitization, salivary cotinine, and pharmacy record data were collected for 222 children enrolled from August 2013 to February 2016 in a randomized clinical trial that tested the efficacy of an ED- and home-based intervention. Logistic regression was used to examine factors associated with an AMR greater than 0.50, reflecting appropriate controller medication use. RESULTS Most children were male (64%), African American (93%), Medicaid insured (93%), and classified as having uncontrolled asthma (44%). Almost half (48%) received non-guideline-based care or low controller medication use based on an AMR less than 0.50. The final regression model predicting an AMR greater than 0.50 indicated that children receiving specialty care (odds ratio [OR], 4.87; 95% confidence interval [CI], 2.06-11.50), caregivers reporting minimal worry about medication adverse effects (OR, 0.50; 95% CI, 0.25-1.00), positive sensitization to ragweed allergen (OR, 3.82; 95% CI, 1.63-8.96), and negative specific IgE for dust mite (OR, 0.33; 95% CI, 0.15-0.76) were significantly associated with achieving an AMR greater than 0.50. CONCLUSION Clinical decision making for high-risk children with asthma may be enhanced by identification of sensitization to environmental allergens, ascertaining caregiver's concerns about controller medication adverse effects and increased referral to specialty care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01981564.
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Affiliation(s)
- Arlene Butz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; School of Nursing, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Cassia Lewis-Land
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joan Kub
- School of Nursing, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa Bellin
- School of Social Work, University of Maryland, Baltimore, Maryland
| | - Jean Ogborn
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawna S Mudd
- School of Nursing, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Elizabeth Bollinger
- Department of Pediatric Pulmonary and Allergy, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Mona Tsoukleris
- School of Pharmacy, University of Maryland, Baltimore, Maryland
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12
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Yawn BP, Rank MA, Cabana MD, Wollan PC, Juhn YJ. Adherence to Asthma Guidelines in Children, Tweens, and Adults in Primary Care Settings: A Practice-Based Network Assessment. Mayo Clin Proc 2016; 91:411-21. [PMID: 26944837 PMCID: PMC6334649 DOI: 10.1016/j.mayocp.2016.01.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 12/18/2015] [Accepted: 01/05/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess primary care adherence to 2007 US asthma guidelines. PATIENTS AND METHODS Patients with persistent asthma aged 5 to 65 years from 22 primary care participating practices provided the data for this analysis of baseline information from the pragmatic randomized clinical trial the Asthma Tools Study. Using a combination of abstracted medical record data and patient-reported demographic information, we assessed the medical record documentation for elements of the 2007 US asthma guidelines. Elements assessed included documentation of (1) assessment of control, (2) factors that affect control (medication adherence evaluation, inhaler technique education, and evaluation for triggers), (3) self-management support (action plan), and (4) asthma medications prescribed (short-acting β-agonists and daily maintenance therapy). The baseline data was collected from March 16, 2009, to May 1, 2014. RESULTS In 1176 patients (285 children, 211 tweens, and 680 adults) from 16 family medicine and 6 pediatric practices across the United States, documented guideline adherence was highest for prescription of medications (88.0% for short-acting β-agonists and 70.4% for maintenance medications) and lowest for an asthma action plan (3.1%). Documentation of control (15.0%) and factors that affect control (inhaler technique education, 7.6%; medication adherence assessment, 32.5%; and allergy evaluation, 32.5%) was not common and even less common for adults compared with children. A total of 22.2% of the enrolled patients had no asthma-related visit in the year before enrollment. Adherence to the nonmedication elements were higher in practices located in cities of more than 250,000 people and cities that used electronic medical records. Older patient age was negatively associated with guideline adherence. CONCLUSION AND RELEVANCE Adherence to asthma guidelines is poor in primary care practices, leaving many opportunities for improvement.
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Affiliation(s)
- Barbara P Yawn
- Department of Research, Olmsted Medical Center, Rochester, MN.
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, AZ
| | - Michael D Cabana
- Departments of Pediatrics, Epidemiology, and Biostatistics, Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Peter C Wollan
- Department of Research, Olmsted Medical Center, Rochester, MN
| | - Young J Juhn
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
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Garbutt JM, Yan Y, Strunk RC. Practice Variation in Management of Childhood Asthma Is Associated with Outcome Differences. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:474-80. [PMID: 26868727 DOI: 10.1016/j.jaip.2015.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 12/18/2015] [Accepted: 12/23/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although specialist asthma care improves children's asthma outcomes, the impact of primary care management is unknown. OBJECTIVE To determine whether variation in preventive and acute care for asthma in pediatric practices affects patients' outcomes. METHODS For 22 practices, we aggregated 12-month patient data obtained by chart review and parent telephone interviews for 948 children, 3 to 12 years old, diagnosed with asthma to obtain practice-level measures of preventive (≥1 asthma maintenance visit/year) and acute (≥1 acute asthma visit/year) asthma care. Relationships between practice-level measures and individual asthma outcomes (symptom-free days, parental quality of life, emergency department [ED] visits, and hospitalizations) were explored using generalized estimating equations, adjusting for seasonality, specialist care, Medicaid insurance, single-family status, and race. RESULTS For every 10% increase in the proportion of children in the practice receiving preventive care, symptom-free days per child increased by 7.6 days (P = .02) and ED visits per child decreased by 16.5% (P = .002), with no difference in parental quality of life or hospitalizations. Only the association between more preventive care and fewer ED visits persisted in adjusted analysis (12.2% reduction; P = .03). For every 10% increase in acute care provision, ED visits per child and hospitalizations per child decreased by 18.1% (P = .02) and 16.5% (P < .001), respectively, persisting in adjusted analyses (ED visits 8.6% reduction, P = .02; hospitalizations 13.9%, P = .03). CONCLUSIONS Children cared for in practices providing more preventive and acute asthma care had improved outcomes, both impairment and risk. Persistence of improved risk outcomes in the adjusted analyses suggests that practice-level interventions to increase asthma care may reduce childhood asthma disparities.
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Affiliation(s)
- Jane M Garbutt
- Departments of Medicine and Pediatrics, Washington University in St Louis, St Louis, Mo.
| | - Yan Yan
- Department of Surgery, Washington University in St Louis, St Louis, Mo
| | - Robert C Strunk
- Donald Strominger Professor of Pediatrics, Pediatric Allergy, Immunology, and Pulmonary Medicine, Washington University in St Louis, St Louis, Mo
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14
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Lee MG, Cross KJ, Yang WY, Sutton BS, Jiroutek MR. Frequency of asthma education in primary care in the years 2007-2010. J Asthma 2015; 53:220-6. [PMID: 26313596 DOI: 10.3109/02770903.2015.1087024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Recent research suggests that health disparities persist among asthmatic patients and receipt of asthma education, though recent guidelines have highlighted the importance of receiving asthma education. The purpose of this study was to identify trends in the receipt of asthma education as well as to identify disparities in asthma education using the most recently available data in National Ambulatory Medical Care Survey, 2007-2010. METHODS Weighted chi-square tests were conducted to identify associations between asthma education and variables of interest. A weighted multivariate logistic regression model was subsequently constructed to jointly assess the association of factors of interest on receipt of asthma education. Submission to the Campbell University Institutional Review Board resulted in expedited approval. RESULTS The percentage of patients who receive asthma education remains quite low. After adjusting for all variables of interest: no statistically significant difference in receipt of asthma education between year groups (2007-2008, 2009-2010) was found (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.52-1.34); patients seen by pediatricians (vs. internal medicine physicians) and Hispanic or Latino patients (vs. non-Hispanic or Latino patients) were more likely to receive asthma education (OR 2.72, 95% CI 1.11-6.66 and OR 2.33, 95% CI 1.18-4.60, respectively); and patients not prescribed a controller medication were less likely to receive asthma education than those who were (OR 0.56, 95% CI 0.37-0.82). CONCLUSIONS Combined with previously published results, it appears the provision of asthma education continues to be low, despite proven benefits. Additionally, some patient and physician characteristics may be associated with the delivery of asthma education.
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Affiliation(s)
- Marquise G Lee
- a Department of Clinical Research , Campbell University College of Pharmacy & Health Sciences , Buies Creek , NC , USA
| | - Kevin J Cross
- a Department of Clinical Research , Campbell University College of Pharmacy & Health Sciences , Buies Creek , NC , USA
| | - Wan Yu Yang
- a Department of Clinical Research , Campbell University College of Pharmacy & Health Sciences , Buies Creek , NC , USA
| | - Beth S Sutton
- a Department of Clinical Research , Campbell University College of Pharmacy & Health Sciences , Buies Creek , NC , USA
| | - Michael R Jiroutek
- a Department of Clinical Research , Campbell University College of Pharmacy & Health Sciences , Buies Creek , NC , USA
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15
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Frey SM, Fagnano M, Halterman JS. Caregiver education to promote appropriate use of preventive asthma medications: what is happening in primary care? J Asthma 2015; 53:213-9. [PMID: 26288255 DOI: 10.3109/02770903.2015.1075549] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe actions taken by providers at primary care visits to promote daily use of preventive asthma medication, and determine whether patient or encounter variables are associated with the receipt of asthma medication education. METHODS As part of a larger study in Rochester, NY, caregivers of children (2-12 years old) with asthma were approached before an office visit for well-child, asthma-specific or other illness care from October 2009 to January 2013. Eligibility required persistent symptoms and a prescription for an inhaled asthma controller medication. Caregivers were interviewed within two weeks to discuss the health care encounter. RESULTS We identified 185 eligible children from six urban primary care offices (27% Black, 38% Hispanic, 65% Medicaid). Overall, 42% of caregivers reported a discussion of appropriate preventive medication use, fewer than 25% received an asthma action plan, and 17% reported "ideal" medication education (both discussing proper medication use and completing an asthma action plan); no differences were seen upon comparing well-child and asthma-specific visits with other visits. Well-child and asthma-specific visits together were more likely, compared with other visits, to include a recommendation for a follow-up visit (43% versus 23%, p = 0.007). No patient factors were associated with report of preventive medication education. CONCLUSIONS Guideline-recommended education for caregivers about preventive-asthma medication is not occurring in the majority of primary care visits for urban children with symptomatic persistent asthma. Novel methods to deliver asthma education may be needed to promote appropriate preventive medication use and reduce asthma morbidity.
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Affiliation(s)
- Sean M Frey
- a Department of Pediatrics , University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Maria Fagnano
- a Department of Pediatrics , University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Jill S Halterman
- a Department of Pediatrics , University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
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16
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Halterman JS, Fagnano M, Tremblay PJ, Fisher SG, Wang H, Rand C, Szilagyi P, Butz A. Prompting asthma intervention in Rochester-uniting parents and providers (PAIR-UP): a randomized trial. JAMA Pediatr 2014; 168:e141983. [PMID: 25288141 PMCID: PMC4232370 DOI: 10.1001/jamapediatrics.2014.1983] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Jill S. Halterman
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Maria Fagnano
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Paul J. Tremblay
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Susan G. Fisher
- Department of Clinical Sciences, Temple University, Philadelphia, PA
| | - Hongyue Wang
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY
| | - Cynthia Rand
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Peter Szilagyi
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Arlene Butz
- Pediatrics, Johns Hopkins University, Baltimore, MD
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Welkom JS, Hilliard ME, Rand CS, Eakin MN, Riekert KA. Caregiver depression and perceptions of primary care predict clinic attendance in head start children with asthma. J Asthma 2014; 52:176-82. [PMID: 25144553 DOI: 10.3109/02770903.2014.956891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate the mediating role of perceptions of primary care (PC) on the association between depression and PC clinic attendance among caregivers of children with asthma. In adults, depression is associated with lower PC clinic attendance and ∼25% of mothers presenting to a pediatric PC clinic will screen positive for depression. Adults' perceptions about their medical care mediate the depression-clinic attendance relation, but this has not been tested in children or in an asthma population. METHODS This is a secondary prospective data analysis of 141 caregivers of Head Start children diagnosed with asthma, offered an intervention to reduce barriers to PC. Caregivers rated their depressive symptoms and perceptions of PC (access, provider contextual knowledge, and continuity of care) at baseline. PC clinic attendance was tracked prospectively for 6-months. RESULTS At baseline, 26% of caregivers screened positive for depression. Within 6-months, 66% of children attended a PC appointment. A positive depression screen was not associated with PC attendance (p = 0.07) or continuity of care (p = 0.98) but was inversely associated with perceptions of both access (p = 0.03) and provider contextual knowledge (p = 0.02). Though the total indirect effect was not significant, the specific indirect effect of depression on PC attendance through access was significant (95% CI: 0.01, 0.68). CONCLUSIONS Providing tangible resources to reduce barriers to PC without addressing perceptions of access may not sufficiently improve PC clinic attendance in pediatric asthma. Screening caregivers for depression may identify families requiring targeted interventions to improve their perceptions of access.
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Affiliation(s)
- Josie S Welkom
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine , Baltimore, MD , USA , and
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18
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Lewis P, Fagnano M, Koehler A, Halterman JS. Racial disparities at the point of care for urban children with persistent asthma. J Community Health 2014; 39:706-11. [PMID: 24435717 PMCID: PMC4074435 DOI: 10.1007/s10900-013-9815-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Little is known about disparities in preventive asthma care delivery at the time of an office visit. Our objective was to better understand what treatments are delivered at the point of care for urban children with asthma, and whether there are racial disparities. We enrolled 100 Black and 77 White children (2-12 years) with persistent asthma from 6 primary care practices. We evaluated how frequently providers delivered guideline-based asthma actions at the index visit. We also assessed asthma morbidity prior to the index visit and again at 2 month follow-up. Black children had greater symptom severity and were less likely to report having a preventive medication at baseline, but were no more likely to report a preventive medication action at the time of an office visit. Symptoms persisted for Black children at follow-up, suggesting additional preventive actions were needed. Further efforts to promote consistent guideline-based preventive asthma care are critical.
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Affiliation(s)
- Porschea Lewis
- Department of Pediatrics, Strong Memorial Hospital, University of Rochester School of Medicine and Dentistry, Box 777, 601 Elmwood Avenue, Rochester, NY, 14642, USA
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19
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Nelson KA, Garbutt JM, Wallendorf MJ, Trinkaus KM, Strunk RC. Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children. J Asthma 2014; 51:907-12. [PMID: 24894745 DOI: 10.3109/02770903.2014.927483] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children. METHODS We prospectively enrolled 2-10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP "Acute Asthma" visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP. RESULTS One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5 ± 2.3 (standard deviation), range 0-10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2 ± 2.8; range 1-18. The mean number of PCP Acute Asthma visits/child was 0.7 ± 1.6; range 0-11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI -0.018, 0.06). CONCLUSIONS Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.
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Affiliation(s)
- Kyle A Nelson
- Department of Emergency Medicine, Boston Children's Hospital , Boston , USA
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20
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Butz AM, Halterman J, Bellin M, Kub J, Tsoukleris M, Frick KD, Thompson RE, Land C, Bollinger ME. Improving preventive care in high risk children with asthma: lessons learned. J Asthma 2014; 51:498-507. [PMID: 24517110 PMCID: PMC4428172 DOI: 10.3109/02770903.2014.892608] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Rates of preventive asthma care after an asthma emergency department (ED) visit are low among inner-city children. The objective of this study was to test the efficacy of a clinician and caregiver feedback intervention (INT) on improving preventive asthma care following an asthma ED visit compared to an attention control group (CON). METHODS Children with persistent asthma and recent asthma ED visits (N = 300) were enrolled and randomized into a feedback intervention or an attention control group and followed for 12 months. All children received nurse visits. Data were obtained from interviews, child salivary cotinine levels and pharmacy records. Standard t-test, chi-square and multiple logistic regression tests were used to test for differences between the groups for reporting greater than or equal to two primary care provider (PCP) preventive care visits for asthma over 12 months. RESULTS Children were primarily male, young (3-5 years), African American and Medicaid insured. Mean ED visits over 12 months was high (2.29 visits). No difference by group was noted for attending two or more PCP visits/12 months or having an asthma action plan (AAP). Children having an AAP at baseline were almost twice as likely to attend two or more PCP visits over 12 months while controlling for asthma control, group status, child age and number of asthma ED visits. CONCLUSIONS A clinician and caregiver feedback intervention was unsuccessful in increasing asthma preventive care compared to an attention control group. Further research is needed to develop interventions to effectively prevent morbidity in high risk inner-city children with frequent ED utilization.
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Affiliation(s)
- Arlene M. Butz
- Department of Pediatrics, School of Medicine, Baltimore, MD, USA
- School of Nursing, The Johns Hopkins University, Baltimore, MD, USA
| | - Jill Halterman
- Department of Pediatrics, School of Medicine and Dentistry, The University of Rochester, Rochester, NY, USA
| | - Melissa Bellin
- School of Social Work, The University of Maryland, Baltimore, MD, USA
| | - Joan Kub
- School of Nursing, The Johns Hopkins University, Baltimore, MD, USA
| | - Mona Tsoukleris
- School of Pharmacy, The University of Maryland, Baltimore, MD, USA
| | - Kevin D. Frick
- Department of Health Policy and Management and Carey Business School, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Richard E. Thompson
- Department of Biostatistics, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Cassia Land
- Department of Pediatrics, School of Medicine, Baltimore, MD, USA
| | - Mary E. Bollinger
- Department Pediatrics, School of Medicine, The University of Maryland, Baltimore, MD, USA
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21
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Okelo SO, Siberry GK, Solomon BS, Bilderback AL, Yamazaki M, Hetzler T, Ferrell CL, Dhepyasuwan N, Serwint JR. Asthma treatment decisions by pediatric residents do not consistently conform to guidelines or improve with level of training. Acad Pediatr 2014; 14:287-93. [PMID: 24629404 PMCID: PMC8923062 DOI: 10.1016/j.acap.2013.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 12/14/2013] [Accepted: 12/17/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare asthma treatment decisions by pediatric residents to current asthma guidelines and to learn whether treatment decisions vary by postgraduate year in training. METHODS We conducted a Web-based survey of residents from 10 training programs through the Continuity Research Network of the Academic Pediatric Association (CORNET). Surveys included 6 vignettes of patients receiving low-dose inhaled steroids with guideline- and non-guideline-based indicators of asthma status and 1 stable patient on high-intensity medication. RESULTS There were 369 resident respondents (65% response rate), 26% postgraduate year (PGY) 1, 38% PGY2, and 36% PGY3+. Seventy-five percent of each resident group reported seeing fewer than 1 asthma patient per continuity clinic session. A majority of residents made appropriate treatment recommendations in 2 of 4 vignettes of guideline-based indicators of asthma status: first, 97% overall stepping up treatment for mild persistent asthma; and second, 52% overall stepping down treatment for a patient with well-controlled asthma on high-intensity medications. Inconsistent with guideline recommendations, 82% of residents overall did not step down treatment for a patient with well-controlled asthma receiving low-intensity therapy; 75% of residents did not step up treatment for a patient with a recent hospitalization for asthma. Of the 3 vignettes evaluating non-guideline-based indicators of asthma status, a majority of residents (60%) stepped up treatment for parental reports of worse asthma, while a minority did so for a parental report of being bothered by their child's asthma (27%) or when wheezing was reported at physical examination (43%). There were no statistically significant differences for any of the comparisons by year in training. CONCLUSIONS Pediatric residents' management of asthma is consistent with national guidelines in some cases but not in others. There were no differences in the outpatient asthma management decisions between residents by years in training. Educational efforts should be focused on strategies to facilitate pediatric resident adherence to national asthma guideline recommendations for outpatient asthma management.
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Affiliation(s)
- Sande O. Okelo
- Division of Pediatric Pulmonology, The David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - George K Siberry
- Pediatric, Adolescent, and Maternal AIDS (PAMA) Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Barry S. Solomon
- Division of General Pediatrics & Adolescent Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew L. Bilderback
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michiyo Yamazaki
- Department of Family, Population and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Theresa Hetzler
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Cynthia L. Ferrell
- Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | | | - Janet R. Serwint
- Division of General Pediatrics & Adolescent Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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