Excessive Absenteeism Due to Asthma in California Elementary Schoolchildren

Neighborhood Socioeconomic Context Predicts Pediatric Asthma Exacerbation

Causes of asthma exacerbation in children have been studied extensively at the individual level, but contributions of neighborhood-level factors are less explored. We test which distinctive residential characteristics produce variation in uncontrolled asthma among pediatric patients. We extracted electronic medical record data from pediatric patients living in Southern California and used multilevel modeling techniques to isolate which neighborhood characteristics drive inequitable asthma control. Above and beyond the individual-level factors known to predict inadequate disease control, neighborhoods with greater concentration of non-Hispanic black residents (odds ratios [OR] = 1.02; 95% confidence interval [CI]: 0.99-1.03; P < .05), higher proportions of female-headed households (OR = 1.01; 95% CI: 0.99-1.01; P < .05), and higher levels of ambient air pollution (OR = 1.05; 95% CI: 1.01-1.10; P < .001) associate with greater odds of asthma exacerbation. The interplay between community characteristics and asthma management during childhood is complex, and place-based initiatives are needed to narrow the gap in asthma exacerbation.

Evaluation of the effect of an education program using cartoons and comics on disease management in children with asthma: a randomized controlled study

OBJECTIVE

The aim of this study was to determine the effect of an education program, the Health Promotion Program for Children with Asthma (HPPCA), on disease control and quality of life in children aged between 7 and 11 and diagnosed with asthma. The program was developed using cartoons and color-in materials and was based on the health promotion model developed by Nola J. Pender and brain-based learning theories.

MATERIALS AND METHODS

The sample of the study consisted of 74 children between the ages of 7 and 11 who presented to the respiratory diseases' unit of a university hospital in Istanbul. All participants were given basic asthma education by their physicians, and were then randomly assigned to a group that received the HPPCA program or a control group that received no further education. After the HPPCA education was applied to the experimental group alone, both groups were administered two post-tests as a follow-up and retest at the end of the first and fourth month after the intervention. The standardized Sociodemographic Question Form, the Childhood Asthma Control Test (C-ACT) and the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) were used for the follow-up.

RESULTS

The asthma control and quality of life scores of the children included in the experimental group were found to be significantly higher compared to the control group at the first- and fourth-month follow-ups (p<.001). The rate of school absenteeism decreased significantly in children who received HPPCA education at the first follow-up compared to the children who did not receive the education (p<.05).

PRACTICE IMPLICATIONS

The present study found that the HPPCA education, whose design was based on the health promotion model, and which was supported by cartoons in order to attract the attention of the children, was effective. The HPPCA was proven to create a sense of control over asthma and to improve the quality of life in the children. It is recommended that there be an asthma nurse in pediatric allergy and immunology outpatient clinics who can specifically provide an HPPCA. Further studies should be conducted to demonstrate the effectiveness of this program, which was examined in the present study for the first time with a randomized controlled method.HighlightsAsthma control is extremely important for the quality of life in children with asthma.Asthma education provided to school-age children yields the best results when new teaching techniques and multimedia content are used.Asthma education for children must be based on a good theoretical methodology.Children can best manage asthma when they learn about it directly.Asthma education conducted according to the guidelines is of great importance during the COVID-19 pandemic.

Chronic pediatric diseases and risk for reading difficulties: a narrative review with recommendations

Literacy is a major social determinant of health, rooted in skills that develop during early childhood. Children arriving at kindergarten unprepared to learn to read are more likely to have low reading proficiency thereafter. General and health literacy are highly correlated, affecting understanding of health conditions, treatment adherence, and transition to self-care and adult healthcare services. The American Academy of Pediatrics (AAP) recommends literacy and school readiness promotion during well-visits and neurodevelopmental surveillance is emphasized across primary and subspecialty care. While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and chronic medical conditions are less appreciated and under-researched. This review applies an eco-bio-developmental framework to explore literacy across five complex chronic conditions affecting millions of children worldwide: asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease. In each, integration of an efficient reading brain network may be impacted by direct factors, such as ischemia, anesthesia, and/or medications, and also indirect factors, such as altered parent-child routines, hospital stays, and missed school. By integrating literacy into care management plans for affected children, pediatric primary care and specialty providers are poised to identify risks early, target guidance and interventions, and improve academic and health outcomes. IMPACT: While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and/or chronic medical conditions such as asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease are substantial, less appreciated, and under-researched. General and health literacy are highly correlated, with implications for the understanding one's health condition, treatment adherence, and transitioning to self-care, which is especially important for children with complex and/or chronic illness. Pediatric primary care and specialty providers are poised to integrate reading and literacy into care management plans for children with complex and/or chronic illness, including early screening, guidance, support, and interventions.

Facilitators and barriers to the implementation of the Primary Care Asthma Paediatric Pathway: a qualitative analysis

OBJECTIVE

The aim of this qualitative study was to use a theory-based approach to understand the facilitators and barriers that impacted the implementation of the Primary Care Asthma Paediatric Pathway.

DESIGN

Qualitative semistructured focus groups following a randomised cluster-controlled design.

SETTING

22 primary care practices in Alberta, Canada.

PARTICIPANTS

37 healthcare providers participated in four focus groups to discuss the barriers and facilitators of pathway implementation.

INTERVENTION

An electronic medical record (EMR) based paediatric asthma pathway, online learning modules, in-person training for allied health teams in asthma education, and a clinical dashboard for patient management.

MAIN OUTCOME MEASURES

Our qualitative findings are organised into three themes using the core constructs of the normalisation process theory: (1) Facilitators of implementation, (2) Barriers to implementation, and (3) Proposed mitigation strategies.

RESULTS

Participants were positive about the pathway, and felt it served as a reminder of paediatric guideline-based asthma management, and an EMR-based targeted collection of tools and resources. Barriers included a low priority of paediatric asthma due to few children with asthma in their practices. The pathway was not integrated into clinic flow and there was not a specific process to ensure the pathway was used. Sites without project champions also struggled more with implementation. Despite these barriers, clinicians identified mitigation strategies to improve uptake including developing a reminder system within the EMR and creating a workflow that incorporated the pathway.

CONCLUSION

This study demonstrated the barriers and facilitators shaping the asthma pathway implementation. Our findings highlighted that if team support of enrolment (establishing buy-in), legitimisation (ensuring teams see their role in the pathway) and activation (an ongoing plan for sustainability) there may have been greater uptake of the pathway.

TRIAL REGISTRATION NUMBER

This study was registered at clinicaltrials.gov on 25 June 2015; the registration number is: NCT02481037, https://clinicaltrials.gov/ct2/show/NCT02481037?term=andrew+cave&cond=Asthma+in+Children&cntry=CA&city=Edmonton&draw=2&rank=1.

Artificial Intelligence Assesses Clinicians' Adherence to Asthma Guidelines Using Electronic Health Records

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.

Lung Function Tests, Quality of Life and Telemedicine: Three Windows on the Multifaceted World of Asthma in Adolescents

Asthma is a heterogeneous disease usually characterized by chronic airway inflammation and recognized as the most prevalent chronic illness among children. Despite this, the knowledge as to how asthma affects adolescents is still scarce. One of the main management problems of asthmatic adolescents is the poor adherence to pharmacological and non-pharmacological treatments. The assessment of respiratory function and the impact on quality of life are still two crucial challenges in the management of asthmatic adolescents. Additionally, the COVID-19 pandemic has prompted physicians to explore complementary management strategies including telemedicine technologies. This review aims to provide an update on the contribution of respiratory functional tests, how asthma affects quality of life of adolescents and, finally, how telemedicine contributes to the management of adolescent asthmatics during the COVID-19 pandemic.

Telemedicine use for pediatric asthma care: a mixed methods study

OBJECTIVES

To identify factors associated with telemedicine use for asthma care among children and young adults, and to describe the parent and patient experience of asthma care over telemedicine.

METHODS

Our mixed methods study consisted of an electronic health record analysis and a qualitative focus group analysis. We analyzed records for all patients aged 2-24 seen at UC Davis Health between March 19, 2020 and September 30, 2020 for a primary diagnosis of asthma. We performed multivariable logistic regression to quantify the relationships between patient characteristics and telemedicine use. We also conducted focus groups with parents and patients who received asthma care during the study period and used qualitative content analysis to identify themes from the transcripts.

RESULTS

502 patients met the inclusion criteria. Telemedicine use was significantly lower among patients with a primary language other than English (OR = 0.12, 95% CI: 0.025-0.54, p = 0.006), school-aged children (OR = 0.43, 95% CI: 0.24-0.77, p = 0.005), and patients who received asthma care from a primary care provider instead of a specialist (OR = 0.55, 95% CI: 0.34-0.91, p = 0.020). Six thematic categories emerged from focus groups: engaging with the patient, improving access to care, experience of visit, measurements, scheduling, and the future of telemedicine in asthma care.

CONCLUSIONS

Alternating telemedicine with in-person visits for asthma care may result in improved access to care and reduced burdens on patients and families. Providers and researchers should work to understand the specific reasons for low telemedicine use among non-English speaking patients so that these patients receive equitable access to care.

Chronic Absenteeism: Risks and Protective Factors Among Low-Income, Minority Children and Adolescents

BACKGROUND

Low-income and racial/ethnic minority students often face distinct challenges in attending school eading to lower academic performance, low graduation rates, and overall, an indicator of diminished long-term social and financial stability. Chronic absenteeism is a national problem and to address this, a better understanding of risks and points of intervention for the students most at risk is needed. This cross-sectional study sought to assess risks and protective factors associated with chronic absenteeism in a predominantly low-income minority school district in Southern.

METHODS

Conducted in southern California, students (N = 24,439) ages 9 to 21 years were recruited. A logistic regression was used to assess the role poor physical and mental health, safety, bullying, and family risk factors attributed to chronic absenteeism.

RESULTS

Results revealed that asthma (odds ratio [OR] = 1.35, p < .001), being overweight/obese (OR = 1.38, p < .01), presence of family risk factors (OR = 1.49, p < .001), bullying (OR = 0.84, p < .05) and perceptions of safety at school (OR = 1.24, p < .05) increased the odds of chronic absenteeism, while protective factors such as support (OR = 1.30, p < .001), increased sleep (OR = 0.96, p < .001) and positive growth mindset (OR = 0.96, p < .001), mitigated it.

CONCLUSION

This study not only identifies risk but protective factors worth adhering to, to promote school attendance. Future research should further examine the role of mental health in chronic absenteeism.

Continuous Eligibility for Medicaid Associated With Improved Child Health Outcomes

Fluctuating insurance coverage, or churning, is a recognized barrier to health care access. We assessed whether state policies that allow children to remain covered in Medicaid for a 12-month period, regardless of fluctuations in income, are associated with health and health care outcomes, after controlling for individual factors and other Medicaid policies. This cross-sectional study uses a large, nationally representative database of children ages 0 to 17. Continuous eligibility was associated with improved rates of insurance, reductions in gaps in insurance and gaps due to application problems, and lower probability of being in fair or poor health. For children with special health care needs, it was associated with increases in use of medical care and preventive and specialty care access. However, continuous eligibility was not associated with health care utilization outcomes for the full sample. Continuous eligibility may be an effective strategy to reduce gaps in coverage for children and reduce paperwork burden on Medicaid agencies.

Pediatric Asthma Is Associated With Poorer 3-Year Academic Achievement in Urban Elementary and Middle-School Students

OBJECTIVE

Asthma has been associated with worse academic performance in a single school year, yet this association may be magnified over time as students with asthma continue to fall behind. This study examined the relationship between asthma and standardized test performance aggregated across 3 school years, including whether performance varied by likelihood of having significant asthma.

METHODS

Data were from students in grades K-8 at 2 urban public schools in the Northeastern United States (2015-2018). Asthma was based on parent- and self-report and school health center records. Standardized test performance was assessed using Measures of Academic Progress (MAP) and Partnership for Assessment of Readiness for College and Careers (PARCC). Mixed effects linear and logistic regression models were used to evaluate the relationship between asthma and performance during 3 school years.

RESULTS

Any asthma was associated with worse MAP performance across the 3 academic years. Students with the most significant asthma demonstrated worse performance on MAP and PARCC. Aggregating across 3 school years, students scored 3.17 points worse on MAP reading (95% confidence interval [CI]: 0.7-5.63; P = .012) and 3.56 points worse on MAP mathematics (95% CI: 0.52-6.6; P = .022); they had 48.8% (95% CI: 1.9%-73.2%; P = .044) and 58.0% (95% CI: 21%-78%; P = .007) lower odds of proficiency on PARCC English/Language Arts and Mathematics, respectively compared to those without asthma.

CONCLUSIONS

The relationship between asthma and poorer academic achievement in 1 school year may be magnified over multiple years, particularly among those with more significant asthma. School-based asthma interventions may support academic growth and more equitable health outcomes.

The Asthma Toolkit Bootcamp to Improve Rural Primary Care for Pediatric Asthma

BACKGROUND

Children with asthma living in rural areas receive most of their care from primary care providers who have variable knowledge of evidence-based guideline management.

OBJECTIVE

To test the capacity of the Asthma Toolkit Bootcamp program to improve primary care provider guidelines adherence and reduce health care utilization in rural children with asthma.

METHODS

The Asthma Toolkit Bootcamp program provided intensive training in National Heart, Lung, and Blood Institute guidelines-based asthma care, evaluated within a RE-AIM implementation science framework. All primary care practices serving pediatric patients in rural La Plata County, Colorado, received (1) online instruction, (2) full-day training, and (3) follow-up, in-practice training 1 month later. Training focused on spirometry use, severity and control assessment, medication management, asthma action plan utilization, and adoption of a standardized visit protocol.

RESULTS

RE-AIM evaluation determined successful enrollment of practices in La Plata County (Reach) and provider uptake of evidence-based practices including spirometry (Adoption). Pediatric asthma patients receiving spirometry increased from 22% pretraining to 86% posttraining; severity assessment from 47% to 88%; and action plans from 40% to 86%. Significant improvements in health care utilization were observed among trained practices including a 10% decrease in emergency department visits, 35% decrease in hospital admissions, and 29% decrease in oral corticosteroid prescriptions (Effectiveness). Comparison practices showed no significant reductions in health care utilization. Participating providers reported that having the training in their own community, intense practice, a team-based approach, and cost-free materials including the spirometer and patient education materials were particularly helpful.

CONCLUSIONS

The Asthma Toolkit Bootcamp improved pediatric asthma care given by rural providers and reduced health care utilization among their patients.