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Davis E, Fagnano M, Halterman JS, Frey SM. Utilization of the emergency department as a routine source of care among children with asthma. J Asthma 2023; 60:1377-1385. [PMID: 36399630 PMCID: PMC10192056 DOI: 10.1080/02770903.2022.2149409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/28/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
Objective: To describe characteristics of children with persistent asthma in the ED who receive most of their healthcare in emergency settings; and determine whether recent asthma experiences or historic patterns of care are associated with identifying the ED as a typical location for care.Methods: We conducted a sub-analysis of baseline data from Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED), an RCT of children (3-12 years) presenting to the ED with persistent asthma (2016-2020). Caregivers identified reasons for seeking emergency care, including if their child received most overall healthcare in the ED ('ED Care'; primary outcome) or not ('Other Care'). Independent variables included demographics, recent symptoms and quality of life (QOL), and historic preventive care and healthcare use. We compared responses between ED Care and Other Care groups using bivariate and multivariate analyses.Results: We analyzed data for 355 children (31% ED Care, 69% Other Care). Compared with Other Care, ED Care respondents were more likely to identify the ED as the closest source of healthcare; report fewer symptom nights but a poorer quality of life; and describe the ED as a usual place for sick care, despite most having a PCP.Conclusions: Many children with asthma use the ED as a typical source of healthcare, and are distinguished by need for proximity, poorer caregiver QOL, and historic patterns of care-seeking. Efforts to improve timely access to outpatient care and reinforce the role of PCP-directed asthma management, such as through telemedicine, may reduce preventable morbidity including ED visits.
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Affiliation(s)
- Erin Davis
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Maria Fagnano
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Jill S. Halterman
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sean M. Frey
- University of Rochester School of Medicine and Dentistry, Rochester, NY
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2
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Holmes LC, Orom H, Lehman HK, Lampkin S, Halterman JS, Akiki V, Supernault-Sarker AA, Butler SB, Piechowski D, Sorrentino PM, Chen Z, Wilding GE. A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools. J Asthma 2022; 59:523-535. [PMID: 33322963 PMCID: PMC8281495 DOI: 10.1080/02770903.2020.1864823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To test the feasibility and effectiveness of a multifaceted intervention administered through school-based health centers (SBHCs) to improve asthma control for children in high-poverty schools with not well controlled asthma. METHODS Students 4-14 years old with persistent asthma were enrolled from three SBHCs. The centers' advanced practice providers received training on evidence-based asthma guidelines. Students randomized to the intervention received directly observed therapy of their asthma controller medication, medication adjustments as needed by the centers' providers, and daily self-management support. Students randomized to usual care were referred back to their primary care provider (PCP) for routine asthma care. RESULTS We enrolled 29 students. Students in the intervention group received their controller medication 92% of days they were in school. Ninety-four percent of follow-up assessments were completed. During the study, 11 of 12 intervention students had a step-up in medication; 2 of 15 usual care students were stepped up by their PCP. Asthma Control Test scores did not differ between groups, although there were significant improvements from baseline to the 7 month follow-up within each group (both p < .01). Both FEV1% predicted and FEV1/FVC ratio significantly worsened in the usual care group (both p = .001), but did not change in the intervention group (p = .76 and .28 respectively). CONCLUSIONS Our pilot data suggest that a multifaceted intervention can be feasibly administered through SBHCs in communities with health disparities. Despite the small sample size, spirometry detected advantages in the intervention group. Further study is needed to optimize the intervention and evaluate outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT03032744.
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Affiliation(s)
- Lucy C. Holmes
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA,Corresponding author: Lucy C. Holmes, Department of Pediatrics, 1001 Main Street, Buffalo, New York 14203, (716) 323-0034,
| | - Heather Orom
- Department of Community Health and Health Behavior, University at Buffalo School of Public Health and Health Professions, Buffalo, NY, USA
| | - Heather K. Lehman
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Stacie Lampkin
- Department of Pharmacy Practice, D’Youville College, Buffalo, NY, USA
| | - Jill S. Halterman
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Vanessa Akiki
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Alicia A. Supernault-Sarker
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | | | - Denise Piechowski
- John R. Oishei Children’s Hospital, Kaleida Health, Buffalo, NY, USA
| | | | - Ziqiang Chen
- Department of Biostatistics, University at Buffalo School of Public Health and Health Professions, Buffalo, NY USA
| | - Gregory E. Wilding
- Department of Biostatistics, University at Buffalo School of Public Health and Health Professions, Buffalo, NY USA
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Nichols M, Miller S, Treiber F, Ruggiero K, Dawley E, Teufel Ii R. Patient and Parent Perspectives on Improving Pediatric Asthma Self-Management Through a Mobile Health Intervention: Pilot Study. JMIR Form Res 2020; 4:e15295. [PMID: 32442127 PMCID: PMC7367526 DOI: 10.2196/15295] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 12/20/2019] [Accepted: 04/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Asthma is a common chronic pediatric disease that can negatively impact children and families. Self-management strategies are challenging to adopt but critical for achieving positive outcomes. Mobile health technology may facilitate self-management of pediatric asthma, especially as adolescents mature and assume responsibility for their disease. OBJECTIVE This study aimed to explore the perceptions of youths with high-risk asthma and their caregivers on the use of a smartphone app, Smartphone Asthma Management System, in the prevention and treatment of asthma symptoms, possible use of the app to improve self-management of asthma outside traditional clinical settings, and the impact of asthma on everyday life to identify potential needs for future intervention development. METHODS Key informant interviews were completed with parent-child dyads post participation in an asthma management feasibility intervention study to explore the perceptions of users on a smartphone app designed to monitor symptoms and medication use and offer synchronous and asynchronous provider encounters. A thematic qualitative analysis was conducted inductively through emergent findings and deductively based on the self-determination theory (SDT), identifying 4 major themes. RESULTS A total of 19 parent-child dyads completed the postintervention interviews. The major themes identified included autonomy, competence, relatedness, and the impact of asthma on life. The participants also shared their perceptions of the benefits and challenges associated with using the app and in the self-management of asthma. Both children and parents conveyed a preference for using technology to facilitate medication and disease management, and children demonstrated a strong willingness and ability to actively engage in their care. CONCLUSIONS Our study included support for the app and demonstrated the feasibility of enhancing the self-management of asthma by youth in the community. Participant feedback led to intervention refinement and app improvements, and the use of the SDT allowed insight into motivational drivers of behavioral change. The use of mobile apps among high-risk children with asthma and their parents shows promise in improving self-management, medication adherence, and disease awareness and in reducing overall disease morbidity.
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Affiliation(s)
- Michelle Nichols
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Sarah Miller
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Frank Treiber
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Kenneth Ruggiero
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Erin Dawley
- College of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Ronald Teufel Ii
- College of Medicine, Medical University of South Carolina, Charleston, SC, United States
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4
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Cappotelli K, Frey SM, Fagnano M, Holderness H, Halterman JS. Internet Use Among Caregivers of Urban Children With Persistent Asthma. Clin Pediatr (Phila) 2020; 59:719-722. [PMID: 32146822 PMCID: PMC9897735 DOI: 10.1177/0009922820910820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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5
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Booster GD, Oland AA, Bender BG. Treatment Adherence in Young Children with Asthma. Immunol Allergy Clin North Am 2019; 39:233-242. [PMID: 30954173 DOI: 10.1016/j.iac.2018.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Treatment nonadherence in young children with asthma involves multiple factors and should be viewed within an ecological framework. Few interventions have targeted multiple bidirectional factors, however, and little research has examined which interventions may be most appropriate for young children. Additional research is needed to identify essential intervention components, and to determine how to sustain such interventions in at-risk communities. Pediatric psychologists, with training in psychosocial intervention, screening, and primary prevention models, may be uniquely equipped to partner with communities and medical settings to develop and sustain targeted interventions for young children with asthma.
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Affiliation(s)
- Genery D Booster
- National Jewish Health, Pediatric Behavioral Health, 1400 Jackson Street, Denver, CO 80206, USA.
| | - Alyssa A Oland
- National Jewish Health, Pediatric Behavioral Health, 1400 Jackson Street, Denver, CO 80206, USA
| | - Bruce G Bender
- National Jewish Health, Pediatric Behavioral Health, 1400 Jackson Street, Denver, CO 80206, USA
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Weinberger SJ, Cowan KJ, Robinson KJ, Pellegrino CA, Frankowski BL, Chmielewski MV, Shaw JS, Harder VS. A primary care learning collaborative to improve office systems and clinical management of pediatric asthma. J Asthma 2019; 58:395-404. [PMID: 31838923 DOI: 10.1080/02770903.2019.1702199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Pediatric asthma is a common, relapsing-remitting, chronic inflammatory airway disease that when uncontrolled often leads to substantial patient and health care system burden. Improving management of asthma in primary care can help patients stay well controlled. METHODS The Vermont Child Health Improvement Program (VCHIP) developed a quality improvement (QI) learning collaborative with a primary objective to improve clinical asthma management measures through improvement in primary care office systems to support asthma care. Seven months of medical record review data were evaluated for improvements on eight clinical asthma management measures. Pre and post office systems inventory (OSI) self-assessments detailing adherence to improvement strategies were analyzed for improvement. Logistic regressions were used to test for associations between OSI strategy post scores and the corresponding clinical asthma management measures by month seven. RESULTS This study found significant improvement from baseline to month seven on seven of the eight clinical asthma management measures and between pre and post OSI for seven of the nine strategies assessed (N = 19 practices). Additionally, one point higher average OSI scores on the assessment and monitoring of asthma severity, asthma control, asthma action plans, and asthma education strategies were associated with significantly greater odds of improvement in their respective clinical asthma management measures. CONCLUSIONS A QI learning collaborative approach in primary care can improve office systems and corresponding clinical management measures for pediatric patients with asthma. This suggests that linking specific office systems strategies to clinical measures may be a helpful tactic within the learning collaborative model.
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Affiliation(s)
- Stanley J Weinberger
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Primary Care, University of Vermont Children's Hospital, Burlington, VT, USA
| | - Kelly J Cowan
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Pulmonology, University of Vermont Children's Hospital, Burlington, VT, USA
| | - Keith J Robinson
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Pulmonology, University of Vermont Children's Hospital, Burlington, VT, USA
| | | | - Barbara L Frankowski
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.,Pediatric Primary Care, University of Vermont Children's Hospital, Burlington, VT, USA
| | | | - Judith S Shaw
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Valerie S Harder
- Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
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Bian J, Cristaldi KK, Summer AP, Su Z, Marsden J, Mauldin PD, McElligott JT. Association of a School-Based, Asthma-Focused Telehealth Program With Emergency Department Visits Among Children Enrolled in South Carolina Medicaid. JAMA Pediatr 2019; 173:1041-1048. [PMID: 31498379 PMCID: PMC6735423 DOI: 10.1001/jamapediatrics.2019.3073] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Telehealth may improve access to care for populations in rural communities. However, little is known about the effectiveness of telehealth programs designed for children. OBJECTIVE To examine the associations of a school-based telehealth program in Williamsburg county (South Carolina) with all-cause emergency department (ED) visits made by children enrolled in Medicaid. DESIGN, SETTING, AND PARTICIPANTS This Medicaid claims data analysis was conducted in Williamsburg county and 4 surrounding counties in South Carolina and included children aged 3 to 17 years who were enrolled in Medicaid and living in any of the 5 counties from January 2012 to December 2017. Williamsburg served as the intervention and the 4 surrounding counties without a telehealth program as the control; 2012 to 2014 was designated as the preintervention period, whereas 2015 to 2017 served as the postintervention period. The study was designed with a difference-in-differences specification, in which the unit-of-analysis was a child-month, and a subsample included children with asthma. The data analysis was performed from July 2018 to February 2019. EXPOSURES The school-based telehealth program implemented in Williamsburg county in 2015. MAIN OUTCOMES AND MEASURES The binary outcome was the status of at least 1 all-cause ED visit by a child in a given month. RESULTS The full sample included 2 443 405 child-months from 23 198 children in Williamsburg county and 213 164 children in the control counties. The mean (SD) proportions of monthly ED visits in Williamsburg were 3.65% (0.10%) during the preintervention and 3.87% (0.11%) during the postintervention. The corresponding proportions of the 4 control counties were 3.37% preintervention (0.04%), and 3.56% postintervention (0.04%), respectively. The trends in the proportion were paralleled. In the asthma subsample, the proportions in Williamsburg were 3.16% (0.31%) during the preintervention and 3.38% (0.34%) during the postintervention, respectively. The proportions for the control counties were 3.02% preintervention (0.10%) and 3.90% postintervention (0.11%), respectively. There was an interaction of the proportions between the pre/postintervention period and the intervention/control counties in this subsample. The regression analysis of the full sample showed no association of the telehealth program with ED visits. The additional analysis of the asthma subsample showed that this program was associated with a reduction of 0.66 (95% CI, -1.16 to -0.17; P < .01) percentage point per 100 children per month in ED visits, representing an approximately 21% relative decrease. CONCLUSIONS AND RELEVANCE Although we found no association of this program with the ED visits of the overall studied population, this study suggests that telehealth with a focus on chronic pediatric diseases, such as asthma, may deliver substantial health benefits to rural and medically underserved communities.
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Affiliation(s)
- John Bian
- Department of Medicine, Medical University of South Carolina, Charleston
| | | | - Andrea P. Summer
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | - Zemin Su
- Department of Medicine, Medical University of South Carolina, Charleston
| | - Justin Marsden
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | - Patrick D. Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston
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Teufel Ii RJ, Patel SK, Shuler AB, Andrews AL, Nichols M, Ebeling MD, Dawley E, Mueller M, Ruggiero KJ, Treiber FA. Smartphones for Real-time Assessment of Adherence Behavior and Symptom Exacerbation for High-Risk Youth with Asthma: Pilot Study. JMIR Pediatr Parent 2018; 1:e8. [PMID: 31518299 PMCID: PMC6716478 DOI: 10.2196/pediatrics.9796] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/24/2018] [Accepted: 06/28/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Youth with asthma who have poor medication adherence, have limited access to care, and are frequently seen in the acute care setting are often termed "high risk." OBJECTIVE This study aimed to design and test the feasibility of using smartphone technology to assess contextual factors that may impact changes in daily medication adherence and to identify new symptom episodes among high-risk youth with asthma in their home environment. METHODS Youth aged 8-17 years with high-risk asthma from 2 children's hospitals were eligible for the 2-month study. An app was downloaded on participants' phones at enrollment. Daily text message (short message service) reminders were sent to complete ecological momentary assessment of asthma symptoms and other contextual factors such as emotional state using the app. Bluetooth inhaler devices were used to record timestamps of inhaler use with the ability to review and manually enter data. The acceptability was assessed with surveys, key informant interviews (KII), and frequency of days with asthma data. KII data were used in an iterative design approach to identify challenges, strengths, and suggestions for maximizing use. Generalized linear mixed modeling was used to preliminarily explore contextual factors associated with changes in daily adherence. RESULTS We enrolled 14 children aged 8-16 years (13/14, 93% were African Americans). Over the 2-month study period, participants reported coughing (42/110, 38%), wheezing (8/111, 7%), chest tightness (9/109, 8%), boredom (57/109, 52%), and 10 new asthma symptom episodes. The controller medication adherence was 30%, which increased significantly on days with asthma symptoms or boredom. Data were received on 89% (606/681) of study days. Surveys and KIIs suggest acceptability among youth and their caregivers. Challenges reported during the study included lost or damaged phones and available memory. CONCLUSIONS Youth and their caregivers reported the acceptability of using smartphones for real-time asthma monitoring. Overall, the controller medication adherence was low but increased significantly on days with reported asthma symptoms or boredom, suggesting that daily contextual factors may be associated with a change in the adherence behavior.
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Affiliation(s)
- Ronald John Teufel Ii
- Division of General Pediatrics, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Sachin K Patel
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Anita B Shuler
- Children's Hospital, Medical University of South Carolina, Charleston, SC, United States
| | - Anne L Andrews
- Division of General Pediatrics, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Michelle Nichols
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Myla D Ebeling
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Erin Dawley
- Division of General Pediatrics, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Martina Mueller
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Kenneth J Ruggiero
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, United States.,Department of Psychiatry, Medical University of South Carolina, Charleston, SC, United States
| | - Frank A Treiber
- Technology Applications Center for Healthful Lifestyles, College of Nursing, Medical University of South Carolina, Charleston, SC, United States.,Department of Psychiatry, Medical University of South Carolina, Charleston, SC, United States
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9
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Bhagat D, Fagnano M, Halterman JS, Reznik M. Asthma symptoms, interactive physical play and behavioral and academic outcomes in urban children with persistent asthma. J Asthma 2018; 56:711-718. [PMID: 29969924 DOI: 10.1080/02770903.2018.1488978] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Asthma may lead to reduced participation in interactive physical play (IPP). Urban youth with asthma are also at risk for behavioral and academic difficulties. Exploring associations between asthma, IPP and socio-emotional and academic outcomes in children with asthma is important. Study objectives are to: (1) describe IPP participation among school children with persistent asthma; (2) determine if IPP varies with asthma severity (3) determine independent associations of both asthma severity and IPP with socio-emotional and academic outcomes. METHODS We analyzed data from children with persistent asthma enrolled in the SB-TEAM trial (Rochester, NY). Caregiver surveys assessed asthma severity, IPP participation (gym ≥3 days/week, running at recess, sports team participation), socio-emotional and academic outcomes. Bivariate and regression analyses assessed relationships between variables. RESULTS Of 324 children in the study (59% Black, 31% Hispanic, mean age 7.9), 53% participated in any IPP at school. Compared to those with mild persistent asthma, fewer children with moderate-severe asthma had no limitation in gym (44% vs. 58%, p < .01), and fewer ran at recess (29% vs. 42%, p < .01) or engaged in any IPP (48% vs. 58%, p = .046). Asthma severity was not associated with socio-emotional or academic outcomes. However, children participating in IPP had better positive peer social and task orientation skills, were less shy/anxious, and more likely to meet academic standards (all p < .05). Results were consistent in multivariable analyses. CONCLUSIONS Urban children with moderate-severe asthma partake in less IPP, which is associated with socio-emotional and academic outcomes. Further efforts are needed to optimize asthmatic children's participation in IPP.
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Affiliation(s)
- Dhristie Bhagat
- a School of Medicine and Dentistry , University of Rochester , Rochester , NY , USA
| | - Maria Fagnano
- b Department of Pediatrics , University of Rochester , Rochester , NY , USA
| | - Jill S Halterman
- b Department of Pediatrics , University of Rochester , Rochester , NY , USA
| | - Marina Reznik
- c Department of Pediatrics, Albert Einstein College of Medicine , Children's Hospital at Montefiore , Bronx NY , USA
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10
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Goldstein NPN, Frey SM, Fagnano M, Okelo SO, Halterman JS. Identifying Which Urban Children With Asthma Benefit Most From Clinician Prompting: Subgroup Analyses From the Prompting Asthma Intervention in Rochester-Uniting Parents and Providers (PAIR-UP) Trial. Acad Pediatr 2018; 18:305-309. [PMID: 28899842 PMCID: PMC5844785 DOI: 10.1016/j.acap.2017.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/30/2017] [Accepted: 08/31/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Clinician prompts increase the likelihood of guideline-recommended corrective actions (preventive medication prescription, dose change, and/or adherence promotion) for symptomatic children with poorly controlled or persistent asthma in the primary care setting, but it is unclear if all children equally benefit. The objectives of this study were to identify whether asthma severity, visit type, and current preventive medication use were predictive of corrective actions during visits for children with symptomatic asthma, and determine whether these factors modified the effect of a prompting intervention. METHODS We conducted prespecified subgroup analyses of a cluster randomized controlled trial of physician prompting that promoted guideline-based asthma management for urban children with symptomatic asthma. We tested predictors of corrective actions with bivariate and multivariate multilevel logistic regressions, compared intervention effects across factor categories via stratified analyses, and characterized effect modification with interaction term analyses. RESULTS Prompting intervention exposure, moderate/severe disease, asthma-focused visits, and current preventive medication use were predictive of corrective actions. The prompting intervention significantly increased the rate of corrective actions for children across categories of disease severity, visit type, and preventive medication use. However, the intervention effect was significantly smaller for children already using a preventive medication (adjusted odds ratio [OR], 2.01; 95% confidence interval [CI], 1.19-3.38) compared with children without preventive medication use (adjusted OR, 6.25; 95% CI, 3.39-11.54). CONCLUSIONS Prompting increases the likelihood of corrective actions during clinic encounters; however, children already using preventive medication benefit less. It is critical for providers to recognize the need for corrective actions among these symptomatic children.
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Affiliation(s)
- Nicolas P N Goldstein
- Division of General Pediatrics, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Sean M Frey
- Division of General Pediatrics, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Maria Fagnano
- Division of General Pediatrics, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sande O Okelo
- Division of Pediatric Pulmonology, Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Jill S Halterman
- Division of General Pediatrics, Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
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11
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Diep J, Fagnano M, Tremblay P, Halterman JS. The relationship between caregivers' subjective social status and asthma symptoms and management for urban children. J Asthma 2018; 56:211-217. [PMID: 29494268 DOI: 10.1080/02770903.2018.1437176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Subjective social status (SSS) is a person's perception of his/her social standing among others. We explored the relationship between caregivers' SSS and asthma symptoms, visits, and medication use among children with persistent asthma. METHODS We analyzed baseline data of children (3-10 years) from the SB-TEAM trial in Rochester, NY. Using a modified MacArthur Scale of SSS, caregivers rated themselves "a lot worse off" to "a lot better off" compared to 4 groups (e.g., neighbors). "Low SSS" was defined by a response of "a lot worse off" or "somewhat worse off" for any of the referent groups. Caregivers reported their child's asthma symptoms, healthcare visits for asthma, and medication use. Bivariate and multivariate statistics were used. RESULTS We found that, of the 230 children enrolled (participation rate:78%, 62% Black, 72% Medicaid), 29% of caregivers had low SSS. Caregivers with low SSS had more depressive symptoms (46% vs. 28%) and lower social support (69.1 vs. 77.7). In multivariable analyses, children of caregivers with low SSS had fewer symptom-free days/2 weeks (5.8 vs. 7.9, p = .01). While they were more likely to have a routine asthma visit in the past year (35% vs. 23%, adjusted p = .03), there was no difference in their use of preventive medication. CONCLUSIONS Many caregivers of children with persistent asthma report low SSS. While children of these caregivers had fewer symptom-free days, they were not more likely to use preventive medications. Efforts are needed to support these caregivers to ensure optimal preventive care and reduce morbidity.
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Affiliation(s)
- Judy Diep
- a University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Maria Fagnano
- a University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Paul Tremblay
- a University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Jill S Halterman
- a University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
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12
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Halterman JS, Fagnano M, Tajon RS, Tremblay P, Wang H, Butz A, Perry TT, McConnochie KM. Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) Program on Asthma Morbidity: A Randomized Clinical Trial. JAMA Pediatr 2018; 172:e174938. [PMID: 29309483 PMCID: PMC5885835 DOI: 10.1001/jamapediatrics.2017.4938] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Poor adherence to recommended preventive asthma medications is common, leading to preventable morbidity. We developed the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program to build on school-based supervised therapy programs by incorporating telemedicine at school to overcome barriers to preventive asthma care. OBJECTIVE To evaluate the effect of the SB-TEAM program on asthma morbidity among urban children with persistent asthma. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, children with persistent asthma aged 3 to 10 years in the Rochester City School District in Rochester, New York, were stratified by preventive medication use at baseline and randomly assigned to the SB-TEAM program or enhanced usual care for 1 school year. Participants were enrolled at the beginning of the school year (2012-2016), and outcomes were assessed through the end of the school year. Data were analyzed between May 2017 and November 2017 using multivariable modified intention-to-treat analyses. INTERVENTIONS Supervised administration of preventive asthma medication at school as well as 3 school-based telemedicine visits to ensure appropriate assessment, preventive medication prescription, and follow-up care. The school site component of the telemedicine visit was completed by telemedicine assistants, who obtained history and examination data. These data were stored in a secure virtual waiting room and then viewed by the primary care clinician, who completed the assessment and communicated with caregivers via videoconference or telephone. Preventive medication prescriptions were sent to pharmacies that deliver to schools for supervised daily administration. MAIN OUTCOMES AND MEASURES The primary outcome was the mean number of symptom-free days per 2 weeks, assessed by bimonthly blinded interviews. RESULTS Of the 400 enrolled children, 247 (61.8%) were male and 230 (57.5%) were African American, and the mean (SD) age was 7.8 (1.7) years. Demographic characteristics and asthma severity in the 2 groups were similar at baseline. Among children in the SB-TEAM group, 196 (98.0%) had 1 or more telemedicine visits, and 165 (82.5%) received supervised therapy through school. We found that children in the SB-TEAM group had more symptom-free days per 2 weeks postintervention compared with children in the enhanced usual care group (11.6 vs 10.97; difference, 0.69; 95% CI, 0.15-1.22; P = .01), with the largest difference observed at the final follow-up (difference, 0.85; 95% CI, 0.10-1.59). In addition, children in the SB-TEAM group were less likely to have an emergency department visit or hospitalization for asthma (7% vs 15%; odds ratio, 0.52; 95% CI, 0.32-0.84). CONCLUSIONS AND RELEVANCE The SB-TEAM intervention significantly improved symptoms and reduced health care utilization among urban children with persistent asthma. This program could serve as a model for sustainable asthma care among school-aged children. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01650844.
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Affiliation(s)
- Jill S. Halterman
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - Maria Fagnano
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - Reynaldo S. Tajon
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - Paul Tremblay
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - Hongyue Wang
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Arlene Butz
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Tamara T. Perry
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock
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Ménard S, Jbilou J, Lauzier S. Family caregivers' reported nonadherence to the controller medication of asthma in children in Casablanca (Morocco): Extent and associated factors. J Asthma 2018; 55:1362-1372. [PMID: 29336706 DOI: 10.1080/02770903.2017.1414235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Recent statistics show a relatively high prevalence of asthma among Moroccan children and a weak control over their symptoms. To our knowledge, no research has been carried out to document adherence to the controller treatment in this population. This study aims 1) to assess the extent of children's nonadherence to the controller treatment of asthma in an urban region of Morocco as reported by a family caregiver, and 2) to identify the associated factors. METHODS We conducted a cross-sectional study among caregivers of asthmatic children (2-12 years old) in different health and education facilities of Casablanca-Settat. We administered face-to-face questionnaires incorporating validated instruments (Medication Adherence Rating Scale-Asthma (MARS-A), Beliefs about Medicines Questionnaire (BMQ), Asthma Knowledge Questionnaire). Univariate and multivariate log-binomial regressions evaluating the association between several factors and reported nonadherence were performed (prevalence ratios (PR) and 95% confidence intervals (CI)). RESULTS Through two public hospitals, three private medical clinics, and one private school, 103 caregivers were recruited. Low adherence to the controller treatment of asthma was reported by 48% of the caregivers (MARS-A <45). In the multivariate model, caregivers with the lowest level of knowledge about asthma were almost three times more likely to report low adherence compared to caregivers with the highest level (PR = 2.93; 95% CI: 1.14-7.52). CONCLUSIONS This study highlights the finding that low adherence is widespread in this context and also the importance of targeting caregivers' knowledge of asthma for interventions.
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Affiliation(s)
- Sandra Ménard
- a Department of Social and Preventive Medicine, Faculty of Medicine , Laval University , Quebec , QC , Canada
| | - Jalila Jbilou
- b Research Professor, Centre de formation médicale du Nouveau-Brunswick , Moncton , NB , Canada ; Associate Professor, School of Psychology, Université de Moncton , Monction , NB , Canada
| | - Sophie Lauzier
- c Researcher, Population Health and Optimal Health Practices Research Unit, CHU de Québec-Université Laval Research Center , QC , Canada ; Assistant Professor, Faculty of Pharmacy, Laval University , Quebec , QC , Canada
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14
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Teufel II 2nd RJ, Patel SK, Shuler AB, Andrews AL, Nichols M, Ebeling MD, Dawley E, Mueller M, Ruggiero KJ, Treiber FA. Feasibility of Smartphones for Real-time Assessment of Adherence Behavior and Symptom Exacerbation for High Risk Youth and Adolescents with Asthma: A Pilot Study (Preprint). JMIR Mhealth Uhealth 2018. [DOI: 10.2196/mhealth.9796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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15
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Oland AA, Booster GD, Bender BG. Psychological and lifestyle risk factors for asthma exacerbations and morbidity in children. World Allergy Organ J 2017; 10:35. [PMID: 29075362 PMCID: PMC5644196 DOI: 10.1186/s40413-017-0169-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/13/2017] [Indexed: 12/13/2022] Open
Abstract
Asthma is the most common childhood illness and disproportionately affects low-income, minority children who live in urban areas. A range of risk factors are associated with asthma morbidity and mortality, such as treatment non-adherence, exposure to environmental triggers, low-income households, exposure to chronic stress, child psychological problems, parental stress, family functioning, obesity, physical inactivity, and unhealthy diets. These risk factors often have complex interactions and inter-relationships. Comprehensive studies that explore the inter-relationships of these factors in accounting for asthma morbidity and mortality are needed and would help to inform clinical intervention. Considerable research has focused on interventions to improve adherence, asthma management, asthma symptoms, and quality of life for patients with asthma. Educational interventions combined with psychosocial interventions, such as behavioral, cognitive-behavioral, or family interventions, are beneficial and provide care in schools, homes, and emergency rooms can help to address barriers to accessing care for children and families. Additional recent research has explored the use of multidisciplinary, collaborative, integrated care with pediatric asthma patients, providing promising results. Integrated care could be ideal for addressing the multitude of complex psychosocial and wellness factors that play a role in childhood asthma, for increasing patient-centered care, and for promoting collaborative patient-provider relationships. Further research in this area is essential and would be beneficial.
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Halterman JS, Tajon R, Tremblay P, Fagnano M, Butz A, Perry T, McConnochie K. Development of School-Based Asthma Management Programs in Rochester, New York: Presented in Honor of Dr Robert Haggerty. Acad Pediatr 2017; 17:595-599. [PMID: 28434913 PMCID: PMC5599804 DOI: 10.1016/j.acap.2017.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/08/2017] [Indexed: 12/28/2022]
Abstract
In the spirit of Dr. Haggerty's teachings, we present an overview of our work to improve care for children with asthma in the context of 3 lessons learned: 1) the importance of providing integrated services across disciplinary boundaries for children with chronic illness, 2) the need to move from a care model focused only on the individual child to a model focused on the child, family, and community, and 3) the need to expand beyond the local community and take a broad perspective on improving health on a national level. The goal of our program is to develop sustainable models to overcome the multiple obstacles to effective preventive care for urban children with asthma. The primary intervention for our original School-Based Asthma Therapy program was directly observed administration of preventive asthma medications in school (with dose adjustments on the basis of National Heart, Lung, and Blood Institute guidelines). We found that children who received preventive medications in school through directly observed therapy had improved outcomes across multiple outcome measures. Our subsequent asthma programs have focused on dissemination and sustainability, with the incorporation of communication technology to enhance the system of care. We are currently testing the 'School-Based Telemedicine Enhanced Asthma Management' program, including 400 children with persistent asthma from the Rochester City School District. This program includes directly observed administration of preventive asthma medication at school, and school-based telemedicine to assure appropriate evaluation, preventive medication prescription, and follow-up care. It is designed to implement and sustain guideline-based asthma care through existing community infrastructure, and could serve as a model for the integration of services in rural as well as urban communities.
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Affiliation(s)
| | - Reynaldo Tajon
- Pediatrics, University of Rochester, Rochester, New York, United States
| | - Paul Tremblay
- Pediatrics, University of Rochester, Rochester, New York, United States
| | - Maria Fagnano
- Pediatrics, University of Rochester, Rochester, New York, United States
| | - Arlene Butz
- Pediatrics, Johns Hopkins Children’s Center, Baltimore, Maryland, United States
| | - Tamara Perry
- Pediatrics, University of Arkansas, Little Rock, AR, United States
| | - Ken McConnochie
- Pediatrics, University of Rochester, Rochester, New York, United States
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17
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Dolins JC, Powell J, Wise E, Giuliano K, Stemmler P, Stubblefield W, White PC, Wiley J, Kuo DZ. Improving Asthma Care by Building Statewide Quality Improvement Infrastructure. Pediatrics 2017; 140:peds.2016-1612. [PMID: 28739651 DOI: 10.1542/peds.2016-1612] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric medical professionals have an increasing desire for quality improvement (QI) methods that produce sustainable changes in health care delivery. Previous reports have described QI in single settings or single coordinating entities that work with multiple sites. The objectives of this project are (1) to improve care for children with asthma across multiple practice settings and (2) to develop state-level expertise to support QI projects across entities in multiple states. METHODS Using a multiwave approach, the Chapter Quality Network of the American Academy of Pediatrics implemented statewide learning collaboratives in several states. For each cycle, a national leadership team coached multiple American Academy of Pediatrics chapter leadership teams, which, in turn, coached individual pediatric practices through 2 nested learning collaboratives. State chapters received data and reporting tools and a curriculum fostering QI learning and support change at the practice level. Practices implemented an asthma assessment tool and registry, analyzed work flows, and implemented self-management tools in plan-do-study-act cycles. Sixteen process and outcome measures, including optimal asthma care, were collected and analyzed by using run charts on a monthly dashboard. Chapter leaders provided feedback on sustainable QI change through surveys and interviews. RESULTS Optimal asthma care improved from 42% to 81% across the 4 waves. The percentage of patients rated by physicians as well controlled rose from 59% to 74%. CONCLUSIONS Asthma care can be improved by supporting practice change through statewide QI learning collaboratives.
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Affiliation(s)
- Judith C Dolins
- American Academy of Pediatrics, Elk Grove Village, Illinois;
| | | | - Edward Wise
- American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Kimberly Giuliano
- Department of General Pediatrics, Cleveland Clinic Children's, Cleveland, Ohio
| | | | - Wes Stubblefield
- American Academy of Pediatrics, Alabama Chapter, Montgomery, Alabama
| | | | - James Wiley
- American Academy of Pediatrics, Alabama Chapter, Montgomery, Alabama
| | - Dennis Z Kuo
- Department of Pediatrics, University at Buffalo, Buffalo, New York
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Zahran HS, Bailey CM, Qin X, Johnson C. Long-term control medication use and asthma control status among children and adults with asthma. J Asthma 2017; 54:1065-1072. [PMID: 28282217 DOI: 10.1080/02770903.2017.1290105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Uncontrolled asthma decreases quality of life and increases health care use. Most people with asthma need daily use of long-term control (LTC) medications for asthma symptoms and to prevent asthma attacks. Ongoing assessment of a person's level of asthma control and medication use is important in determining the effectiveness of current treatment to decrease the frequency and intensity of symptoms and functional limitations. OBJECTIVE To assess the use of LTC medication among children and adults with current asthma and identify contributing factors for LTC medication use. METHODS We used the 2006-2010 Behavioral Risk Factor Surveillance System (BRFSS) child and adult Asthma Call-back Survey (ACBS) data to assess the level of asthma control and LTC medication use. Asthma control was classified as well controlled and uncontrolled using guideline-based measures. We used multivariable logistic regression models to identify contributing factors for LTC medication use and having uncontrolled asthma. RESULTS Among persons with current asthma, 46.0% of children and 41.5% of adults were taking LTC medications and 38.4% of children and 50.0% of adults had uncontrolled asthma. Among children who had uncontrolled asthma (38.4%), 24.1% were taking LTC medications and 14.3% were not taking LTC medications. Among adults who had uncontrolled asthma (50.0%), 26.7% were taking LTC medications and 23.3% were not taking LTC medications. CONCLUSIONS Using BRFSS ACBS data to assess the level of asthma control and LTC medication use can identify subpopulations of persons with asthma who receive suboptimal treatment, for which better asthma-related medical treatment and management are needed.
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Affiliation(s)
- Hatice S Zahran
- a Division of Environmental Hazards and Health Effects, National Center for Environmental Health , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Cathy M Bailey
- a Division of Environmental Hazards and Health Effects, National Center for Environmental Health , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Xiaoting Qin
- a Division of Environmental Hazards and Health Effects, National Center for Environmental Health , Centers for Disease Control and Prevention , Atlanta , GA , USA
| | - Carol Johnson
- a Division of Environmental Hazards and Health Effects, National Center for Environmental Health , Centers for Disease Control and Prevention , Atlanta , GA , USA
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19
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Pool AC, Kraschnewski JL, Poger JM, Smyth J, Stuckey HL, Craig TJ, Lehman EB, Yang C, Sciamanna CN. Impact of online patient reminders to improve asthma care: A randomized controlled trial. PLoS One 2017; 12:e0170447. [PMID: 28158200 PMCID: PMC5291361 DOI: 10.1371/journal.pone.0170447] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/06/2017] [Indexed: 12/05/2022] Open
Abstract
Importance Asthma is one of the most burdensome chronic illnesses in the US. Despite widespread dissemination of evidence-based guidelines, more than half of the adults with asthma have uncontrolled symptoms. Objective To examine the efficacy of an online tool designed to improve asthma control. Design 12-month single blind randomized controlled trial of the online tool (Intervention condition, IC) versus an active control tool (CC). Setting Patients enrolled in an insurance plan. Participants Participants were 408 adults (21–60 years of age) with persistent asthma. Intervention At least once each month and before provider visits, participants in the IC answered questions online about their asthma symptoms, asthma medications and asthma care received from providers, such as an asthma management plan. The tool then provided tailored feedback to remind patients 1) to ask health care providers specific questions that may improve asthma control (e.g., additional controller medications) and 2) to consistently perform specific self-care behaviors (e.g., proper inhaler technique). Participants in the CC received similar questions and feedback, yet focused instead on preventive services unrelated to asthma control (e.g., cancer screening). Main outcome measures The main outcome measure was asthma control, as assessed by the 5-question Asthma Control Test (ACT). Secondary outcomes included quality of life, medication use and healthcare utilization (e.g., emergency department visits). Results After 12 months, 323 participants completed follow-up measures (79.2%). Participants in the IC reported a greater mean improvement in the ACT score than participants in the CC (2.3 vs. 1.2; p = 0.02) and 9 of 11 individual asthma control survey items showed non-significant improvements favoring the IC. No differences were observed in medication adherence, number of asthma controller medications or health care utilization. Conclusion and relevance Simple and brief online patient reminders improved asthma control among insured patients. Although future studies are needed to understand the mechanism of the improvement, the magnitude of the effect on asthma control was similar to the addition of an additional controller medication. Given the widespread use of the Internet, simple tools such as this may be useful for improving the control of other chronic diseases as well. Trial registration This study is registered at clinicaltrials.gov, NCT00921401, “Improving the Quality of Asthma Care Using the Internet”
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Affiliation(s)
- Andrew C. Pool
- Department of Public Health, Temple University College of Health Professions and Social Work Philadelphia, Pennsylvania, United States of America
- Center for Obesity Research and Education (CORE), Temple University School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Jennifer L. Kraschnewski
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Jennifer M. Poger
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Joshua Smyth
- Department of Biobehavioral Health, Pennsylvania State University, State College, Pennsylvania, United States of America
| | - Heather L. Stuckey
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Timothy J. Craig
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Erik B. Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Chengwu Yang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
| | - Christopher N. Sciamanna
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, United States of America
- * E-mail:
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Zhang Q, Lamichhane R, Diggs LA. Disparities in emergency department visits in American children with asthma: 2006-2010. J Asthma 2016; 54:679-686. [PMID: 27880053 DOI: 10.1080/02770903.2016.1263315] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This article was to examine the trends in emergency department (ED) visits for asthma among American children in 2006-2010 across sociodemographic factors, parental smoking status, and children's body weight status. METHODS We analyzed 5,535 children aged 2-17 years with current asthma in the Asthma Call-Back Survey in 2006-2010. Multivariate log binomial regression was used to examine the disparities of ED visits by demographics, socioeconomic status, parental smoking status, children's body weight status, and the level of asthma control. We controlled for average state-level air pollutants. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were reported. RESULTS Minority children with current asthma had higher risks of ED visits compared with white children in 2009 and 2010, e.g., the PR (95% CI) for black children in 2009 was 3.64 (1.79, 7.41). Children who had current asthma and more highly educated parents experienced a higher risk of ED visits in 2007 (PRs [95% CI] = 2.15 [1.02, 4.53] and 2.97 [1.29, 6.83] for children with some college or college-graduated parents), but not significant in other years. Children with uncontrolled asthma were significantly more likely to visit the ED in 2008 (PRs [95% CI] = 2.79 [1.44, 5.41] and 6.96 [3.55, 13.64] for not-well-controlled and very poorly controlled children with asthma). CONCLUSIONS Minority children with current asthma or children with uncontrolled asthma were more likely to visit EDs for asthma treatment. However, the disparities in ED visits across sociodemographics, health status, or asthma control vary in scale and significance across time. More research is needed to explain these differences.
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Affiliation(s)
- Qi Zhang
- a School of Community and Environmental Health, Old Dominion University , Norfolk , VA , USA
| | - Rajan Lamichhane
- b Department of Mathematics , Texas A&M University-Kingsville , Kingsville , TX , USA
| | - Leigh Ann Diggs
- a School of Community and Environmental Health, Old Dominion University , Norfolk , VA , USA
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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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Elevated burden for caregivers of children with persistent asthma and a developmental disability. Matern Child Health J 2015; 18:2080-8. [PMID: 24619226 DOI: 10.1007/s10995-014-1455-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
To evaluate how having a child with both persistent asthma and a developmental disability (DD) affects caregiver burden and quality of life (QOL). 3-10 year old children with persistent asthma in urban Rochester, NY. Cross-sectional baseline survey (2006-2009). Parent report of autism spectrum disorder or other behavioral disorder requiring medication. Caregiver burden and QOL as measured by scores on previously validated depression, parenting confidence, and asthma-related QOL scales as well as an assessment of competing demands on the caregiver. Bivariate and multivariate regression analyses controlling for caregiver age, education, marital status, race, ethnicity, and child asthma symptom severity. We enrolled 530 children as part of a larger study (response rate: 74; 63 % Black, 73 % Medicaid). Of this sample, 70 children (13 %) were defined as having a DD. There were no differences in asthma symptom severity between children with and without a DD diagnosis. However, even after adjusting for potential confounders, caregivers of children with a DD reported worse scores on the depression (p = .003), parenting confidence (p < .001), and competing demands (p = .013) scales and worse asthma-related QOL (p = .035) compared to caregivers of typically developing children with asthma. Despite having similar asthma symptom severity, caregivers of children with both persistent asthma and a DD diagnosis report more burden and lower QOL compared to that of caregivers of typically developing children and persistent asthma. Further attention to this subgroup is needed to promote optimal support for caregivers.
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Zahran HS, Bailey CM, Qin X, Moorman JE. Assessing asthma control and associated risk factors among persons with current asthma - findings from the child and adult Asthma Call-back Survey. J Asthma 2014; 52:318-26. [PMID: 25144551 DOI: 10.3109/02770903.2014.956894] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Monitoring the level of asthma control is important in determining the effectiveness of current treatment which may decrease the frequency and intensity of symptoms and functional limitations. Uncontrolled asthma has been associated with decreased quality of life and increased health care use. The objectives of this study were to assess the level of asthma control and identify related risk factors among persons with current asthma. METHODS Using the 2006 to 2010 BRFSS child and adult Asthma Call-back Survey, asthma control was classified as well-controlled or uncontrolled (not-well-controlled or very-poorly-controlled) using three impairment measures: daytime symptoms, night-time symptoms, and taking short-acting β2-agonists for symptom control. Multivariate logistic regression identified predictors of asthma control. RESULTS Fifty percent of adults and 38.4% of children with current asthma had uncontrolled asthma. About 63% of children and 53% of adults with uncontrolled asthma were on long-term asthma control medications. Among children, uncontrolled asthma was significantly associated with being younger than 5 years, having annual household income <$15,000, and reporting cost as barriers to medical care. Among adults, it was significantly associated with being 45 years or older, having annual household income of <$25,000, being "other" race, having less than a 4-year college degree, being a current or former smoker, reporting cost as barriers, being obese, and having chronic obstructive pulmonary disease or depression. CONCLUSION Identifying and targeting modifiable predictors of uncontrolled asthma (low educational attainment, low income, cigarette smoking, and co-morbid conditions including obesity and depression) could improve asthma control.
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Affiliation(s)
- Hatice S Zahran
- Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention , Atlanta, GA , USA
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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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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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Zahran HS, Bailey CM, Qin X, Moorman JE. Assessing asthma severity among children and adults with current asthma. J Asthma 2014; 51:610-7. [PMID: 24506700 DOI: 10.3109/02770903.2014.892966] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Asthma severity is a key indicator to assess asthma care and management. Severity status may vary over time. Assessing asthma severity periodically is important for monitoring the health and well-being of people with asthma. OBJECTIVE To assess population-based asthma severity and to identify related-risk factors among children and adults with asthma. METHODS We used the 2006-2010 BRFSS child and adult Asthma Call-back Survey. Asthma severity was classified as intermittent or persistent. We performed multivariate logistic regression to identify related-risk factors. RESULTS Overall, 63.8% of persons with asthma had persistent asthma. Persistent asthma was more prevalent among children aged 0-4 years (71.8%; prevalence rate ratio [PR] = 1.3). Among adults with current asthma, persistent asthma was more prevalent among those who were 45 years or older (aged 45-54: 69.4%; PR = 1.1, aged 55-64: 72.6%; PR = 1.2, and aged 65+: 77.8%; PR = 1.3); annual household incomes of <$15 000 (74.1%; PR = 1.1); and first diagnosed at age 55 years or older (first diagnosed at age 55-64: 80.4%; PR = 1.1, at age 65 + : 81.5%; PR = 1.1). The prevalence of persistent asthma was also higher among current smokers who were also exposed to secondhand smoke (SHS) (74.7%; PR = 1.1); and among those with Chronic Obstructive Pulmonary Disease (COPD) (77.1%; PR = 1.2). CONCLUSIONS Nearly two-thirds of children and adults with asthma had persistent asthma. Identifying related-risk factors could help improve targeted interventions or strategies to reduce modifiable predictors (low income, smoking, and SHS) of increased asthma severity. Such strategies could improve asthma care and quality of life.
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Affiliation(s)
- Hatice S Zahran
- Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention , Atlanta, GA , USA
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Gutiérrez SJ, Fagnano M, Wiesenthal E, Koehler AD, Halterman JS. Discrepancies between medical record data and parent reported use of preventive asthma medications. J Asthma 2014; 51:446-50. [PMID: 24404799 DOI: 10.3109/02770903.2013.878351] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess whether medical record documentation reflects actual home practices regarding the administration of preventive medications to urban children with persistent asthma. METHODS Baseline data from a prompting asthma intervention were used for this cross-sectional analysis. As part of the larger study, we enrolled children (2-12 years) with persistent asthma in the waiting room at 12 primary care offices (2009-2012). Prior to their visit with a healthcare provider, caregivers reported information regarding their child's asthma symptom severity and current preventive medications (i.e. name and frequency of use). We compared caregiver-reported medication information with medical record data to determine the rate of complete concordance, defined as total consistency between the prescribed medication data documented in the medical record and parent report describing how the child is actually using the medication at home. RESULTS According to 310 completed medical record reviews, 194 (62%) children had a current prescription for a daily preventive asthma medication. Of these children, 110 (57%) had caregivers who reported complete concordance. Those reporting complete concordance were more likely to have children with greater symptom severity, including fewer symptom-free days in the prior two weeks (6.9 vs. 8.7, p = 0. 018), and ≥1 asthma-related hospitalization in the prior year (16% vs. 6%, p = 0. 042). CONCLUSIONS Medical records may poorly reflect actual home practices and providers should specifically inquire about medication use and barriers to adherence at the time of an office visit to promote guideline-based, consistent treatment for children with persistent asthma.
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Affiliation(s)
- Susana J Gutiérrez
- Department of Pediatrics and the Strong Children's Research Center, University of Rochester School of Medicine and Dentistry , Rochester, NY , USA
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28
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Rhee H, Fairbanks E, Butz A. Symptoms, feelings, activities and medication use in adolescents with uncontrolled asthma: lessons learned from asthma diaries. J Pediatr Nurs 2014; 29:39-46. [PMID: 23685266 PMCID: PMC3805759 DOI: 10.1016/j.pedn.2013.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 04/10/2013] [Accepted: 04/18/2013] [Indexed: 11/28/2022]
Abstract
This study was to describe symptoms, feelings, activities and medication use reported by adolescents with uncontrolled asthma on their 24-hour asthma diaries. Adolescents with uncontrolled asthma (13-17 years, N=29) completed asthma diaries and audio-recorded symptom sounds for 24 hours. A variety of symptoms were reported, and the most frequently reported symptoms were coughing followed by wheezing. Most self-reported coughing and wheezing were verified by audio-recordings. Participants reported predominantly negative feelings and low levels of activities. High discordance between self-reports and medical records in medications was noted, raising a concern of poor treatment adherence in this vulnerable group.
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Li Z, Huang IC, Thompson L, Tuli S, Huang SW, DeWalt D, Revicki D, Shenkman E. The relationships between asthma control, daytime sleepiness, and quality of life among children with asthma: a path analysis. Sleep Med 2013; 14:641-7. [PMID: 23684939 DOI: 10.1016/j.sleep.2013.04.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 04/04/2013] [Accepted: 04/06/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES We aimed to examine the relationships between asthma control, daytime sleepiness, and asthma-specific health-related quality of life (HRQOL) among children with asthma. Path analyses were conducted to test if daytime sleepiness can mediate the effect of asthma control status on asthma-specific HRQOL. METHODS 160 dyads (pairs) of asthmatic children and their parents were collected for analyses. The Asthma Control and Communication Instrument (ACCI) was used to categorize adequate and poor asthma control status. The Cleveland Adolescent Sleepiness Questionnaire (CASQ) was used to measure children's daytime sleepiness, including sleep in school, awake in school, sleep in evening, and sleep during transport. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale was used to measure asthma-specific HRQOL. RESULTS Poorly controlled asthma was associated with daytime sleepiness and impaired asthma-specific HRQOL. Asthma control status was directly associated with asthma-specific HRQOL (P<.05), whereas sleep in school and sleep in evening domains of daytime sleepiness significantly mediated the relationship between poor asthma control and impaired HRQOL (P<.01). CONCLUSIONS Asthma control status was associated with pediatric asthma-specific HRQOL, and the association was significantly mediated by daytime sleepiness. Healthcare providers need to address pediatric sleep needs related to poor asthma control to reduce the negative impact on HRQOL.
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Affiliation(s)
- Zheng Li
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL 32610, USA
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30
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Yee AB, Fagnano M, Halterman JS. Preventive asthma care delivery in the primary care office: missed opportunities for children with persistent asthma symptoms. Acad Pediatr 2013; 13:98-104. [PMID: 23294977 PMCID: PMC3602410 DOI: 10.1016/j.acap.2012.10.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 10/27/2012] [Accepted: 10/29/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe which National Heart Lung and Blood Institute preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery varies by asthma symptom severity. METHODS We approached children (2 to 12 years old) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit. RESULTS We identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009 to January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs non-asthma-related visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14-0.84), trigger reduction discussion (OR 0.39, 95% CI 0.19-0.82), recommendation of follow-up (OR 0.40, 95% CI 0.19-0.87), and receipt of action plan (OR 0.37, 95% CI 0.16-0.86). CONCLUSIONS Many children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.
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Affiliation(s)
- Alison B Yee
- Department of Pediatrics and the Strong Children's Research Center, University of Rochester School of Medicine and Dentistry, Rochester, NY 11642, USA.
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31
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Akinbami LJ, Kit BK, Simon AE. Impact of environmental tobacco smoke on children with asthma, United States, 2003-2010. Acad Pediatr 2013; 13:508-16. [PMID: 24021528 PMCID: PMC4756763 DOI: 10.1016/j.acap.2013.07.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 07/03/2013] [Accepted: 07/09/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Given widespread interventions to reduce environmental tobacco smoke (ETS) exposure and improve asthma control, we sought to assess the current impact of ETS exposure on children with asthma. METHODS We analyzed 2003-2010 data for nonsmoking children aged 6 to 19 years with asthma from the National Health and Nutrition Examination Survey. Outcomes (sleep disturbance, missed school days, health care visits, activity limitation, and wheezing with exercise) were compared between ETS exposed children (serum cotinine levels 0.05 to 10 ng/mL) and unexposed children (<0.05 ng/mL) using ordinal regression adjusted for demographic characteristics. We also assessed whether associations were observable with low ETS exposure levels (0.05 to 1.0 ng/mL). RESULTS Overall, 53.3% of children aged 6 to 19 years with asthma were ETS exposed. Age-stratified models showed associations between ETS exposure and most adverse outcomes among 6- to 11-year-olds, but not 12- to 19-year-olds. Even ETS exposure associated with low serum cotinine levels was associated with adverse outcomes for 6- to 11-year-olds. Race-stratified models for children aged 6 to 19 years showed an association between ETS exposure and missing school, health care visits, and activity limitation due to wheezing among non-Hispanic white children, and disturbed sleep among non-Hispanic white and Mexican children. Among non-Hispanic black children, there was no elevated risk between ETS exposure and the assessed outcomes: non-Hispanic black children had high rates of adverse outcomes regardless of ETS exposure. CONCLUSIONS Among children with asthma 6 to 11 years of age, ETS exposure was associated with most adverse outcomes. Even ETS exposure resulting in low serum cotinine levels was associated with risks for young children with asthma.
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Affiliation(s)
- Lara J. Akinbami
- Office of Analysis and Epidemiology, National Center for Health Statistics, Centers for Disease Control and Prevention Hyattsville, MD
,United States Public Health Service, Rockville, MD
| | - Brian K. Kit
- Division of Health and Nutrition Examination Surveys, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD
,United States Public Health Service, Rockville, MD
| | - Alan E. Simon
- Office of Analysis and Epidemiology, National Center for Health Statistics, Centers for Disease Control and Prevention Hyattsville, MD
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Halterman JS, Fagnano M, Montes G, Fisher S, Tremblay P, Tajon R, Sauer J, Butz A. The school-based preventive asthma care trial: results of a pilot study. J Pediatr 2012; 161:1109-15. [PMID: 22785264 PMCID: PMC3470823 DOI: 10.1016/j.jpeds.2012.05.059] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 04/25/2012] [Accepted: 05/24/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To test the feasibility and preliminary effectiveness of the School-Based Preventive Asthma Care Technology (SB-PACT) program, which includes directly observed therapy of preventive asthma medications in school facilitated by Web-based technology for systematic symptom screening, electronic report generation, and medication authorization from providers. STUDY DESIGN We conducted a pilot randomized trial of SB-PACT versus usual care with 100 children (aged 3-10 years) from 19 inner-city schools in Rochester, New York. Outcomes were assessed longitudinally by blinded interviewers. Analyses included bivariate statistics and linear regression models, adjusting for baseline symptoms. RESULTS There were data for 99 subjects for analysis. We screened all children using the Web-based system, and 44 of 49 treatment group children received directly observed therapy as authorized by their providers. Treatment group children received preventive medications 98% of the time they were in school. Over the school year, children in the treatment group experienced nearly 1 additional symptom-free day over 2 weeks versus the usual care group (11.33 vs 10.40, P = .13). Treatment children also experienced fewer nights with symptoms (1.68 vs 2.20, P = .02), days requiring rescue medications (1.66 vs 2.44, P = .01), and days absent from school due to asthma (0.37 vs 0.85, P = .03) compared with usual care. Further, treatment children had a greater decrease in exhaled nitric oxide (-9.62 vs -0.39, P = .03), suggesting reduction in airway inflammation. CONCLUSION The SB-PACT intervention demonstrated feasibility and improved outcomes across multiple measures in this pilot study. Future work will focus on further integration of preventive care delivery across community and primary care systems.
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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
| | | | - Susan Fisher
- Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Paul Tremblay
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Reynaldo Tajon
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Joseph Sauer
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Arlene Butz
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
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McDaniel MK, Waldfogel J. Racial and ethnic differences in the management of childhood asthma in the United States. J Asthma 2012; 49:785-91. [PMID: 22784007 DOI: 10.3109/02770903.2012.702840] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES We examined racial and ethnic differences in the management of childhood asthma in the United States and the extent that care conformed to clinical best practices. METHODS Two years of pooled data from the National Health Interview Survey were analyzed using logistic regression. The sample included all children between ages 2 and 17 years who had asthma currently and had been diagnosed with asthma by a doctor or health professional (n = 1757; 465 African-American, 212 Mexican-American, 190 Puerto Rican and other Hispanic, 806 white, non-Hispanic, and 84 children of other and multiple races and ethnicities). RESULTS African-American children with asthma were significantly less likely than white, non-Hispanic children to have taken preventive asthma medication, but more likely to have had an asthma management plan. Mexican-American and Puerto Rican and other Hispanic children did not differ significantly from white, non-Hispanic children in either receiving preventive asthma medication or having an asthma management plan. Caregivers of African-American and Puerto Rican and other Hispanic children were more likely to report that they or their child had taken a course or class on how to manage their child's asthma. We did not find racial or ethnic differences in the extent children used quick-relief asthma medication or received advice about reducing asthma triggers in their home, school, or work environments. CONCLUSIONS This work highlights a need for more research on racial and ethnic differences in asthma management. Implications for public health responses and racial and ethnic disparities in asthma morbidity are discussed.
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Affiliation(s)
- Marla K McDaniel
- Center on Labor, Human Services, and Population, Urban Institute, Washington, DC 20037, USA.
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Seeleman C, Stronks K, van Aalderen W, Bot MLE. Deficiencies in culturally competent asthma care for ethnic minority children: a qualitative assessment among care providers. BMC Pediatr 2012; 12:47. [PMID: 22551452 PMCID: PMC3393627 DOI: 10.1186/1471-2431-12-47] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 05/02/2012] [Indexed: 11/21/2022] Open
Abstract
Background Asthma outcomes are generally worse for ethnic minority children. Cultural competence training is an instrument for improving healthcare for ethnic minority patients. To develop effective training, we explored the mechanisms in paediatric asthma care for ethnic minority patients that lead to deficiencies in the care process. Methods We conducted semi-structured interviews on care for ethnic minority children with asthma (aged 4-10 years) with paediatricians (n = 13) and nurses (n = 3) in three hospitals. Interviews were analysed qualitatively with a framework method, using a cultural competence model. Results Respondents mentioned patient non-adherence as the central problem in asthma care. They related non-adherence in children from ethnic minority backgrounds to social context factors, difficulties in understanding the chronic nature of asthma, and parents’ language barriers. Reactions reported by respondents to patients’ non-adherence included retrieving additional information, providing biomedical information, occasionally providing referrals for social context issues, and using informal interpreters. Conclusions This study provides keys to improve the quality of specialist paediatric asthma care to ethnic minority children, mainly related to non-adherence. Care providers do not consciously recognise all the mechanisms that lead to deficiencies in culturally competent asthma care they provide to ethnic minority children (e.g. communicating mainly from a biomedical perspective and using mostly informal interpreters). Therefore, the learning objectives of cultural competence training should reflect issues that care providers are aware of as well as issues they are unaware of.
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Affiliation(s)
- Conny Seeleman
- Department of Public Health, Academic Medical Centre/University of Amsterdam, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
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Yee AB, Halterman JS. Improving pediatric asthma care: a familiar question and the search for new answers. Acad Pediatr 2012; 12:255-6. [PMID: 22682717 DOI: 10.1016/j.acap.2012.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 04/17/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Alison B Yee
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, NY 14642, USA.
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Herndon JB, Mattke S, Evans Cuellar A, Hong SY, Shenkman EA. Anti-inflammatory medication adherence, healthcare utilization and expenditures among Medicaid and children's health insurance program enrollees with asthma. PHARMACOECONOMICS 2012; 30:397-412. [PMID: 22268444 DOI: 10.2165/11586660-000000000-00000] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Underuse of controller therapy among Medicaid-enrolled children is common and leads to more emergency department (ED) visits and hospitalizations. However, there is little evidence about the relationship between medication adherence, outcomes and costs once controller therapy is initiated. OBJECTIVE This study examined the relationship between adherence to two commonly prescribed anti-inflammatory medications, inhaled corticosteroids (ICS) and leukotriene inhibitors (LI), and healthcare utilization and expenditures among children enrolled in Medicaid and the Children's Health Insurance Program in Florida and Texas in the US. METHODS The sample for this retrospective observational study consisted of 18,456 children aged 2-18 years diagnosed with asthma, who had been continuously enrolled for 24 months during 2004-7 and were on monotherapy with ICS or LI. State administrative enrolment files were linked to medical claims data. Children were grouped into three adherence categories based on the percentage of days per year they had prescriptions filled (medication possession ratio). Bivariate and multivariable regression analyses that adjusted for the children's demographic and health characteristics were used to examine the relationship between adherence and ED visits, hospitalizations, and expenditures. RESULTS Average adherence was 20% for ICS-treated children and 28% for LI-treated children. Children in the highest adherence category had lower odds of an ED visit than those in the lowest adherence category (p<0.001). We did not detect a statistically significant relationship between adherence and hospitalizations; however, only 3.7% of children had an asthma-related hospitalization. Overall asthma care expenditures increased with greater medication adherence. CONCLUSIONS Although greater adherence was associated with lower rates of ED visits, higher medication expenditures outweighed the savings. The overall low adherence rates suggest that quality improvement initiatives should continue to target adherence regardless of the class of medication used. However, low baseline hospitalization rates may leave little opportunity to significantly decrease costs through better disease management, without also decreasing medication costs.
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Affiliation(s)
- Jill Boylston Herndon
- Institute for Child Health Policy and Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL 32610-0147, USA
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Halterman JS, Sauer J, Fagnano M, Montes G, Fisher S, Tremblay P, Tajon R, Butz A. Working toward a sustainable system of asthma care: development of the School-Based Preventive Asthma Care Technology (SB-PACT) trial. J Asthma 2012; 49:395-400. [PMID: 22455402 DOI: 10.3109/02770903.2012.669441] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We previously conducted the School-Based Asthma Therapy trial to improve adherence to national asthma guidelines for urban children through directly observed administration of preventive asthma medications in school. The trial successfully improved outcomes among these children; however, several factors limit its potential for dissemination. To enhance sustainability, we subsequently developed a new model of care using web-based guides for efficient communications and integration within school and community systems. This article describes the development of the School-Based Preventive Asthma Care Technology (SB-PACT) trial. METHOD We developed the SB-PACT web-based system based on stakeholder feedback, and conducted a pilot randomized trial with 100 children to establish its feasibility in facilitating preventive asthma care for high-risk children. The SB-PACT system represents a new model of care using web-based guides for asthma symptom screening, follow-up control assessments, and electronic communications with providers. RESULT We enrolled and successfully screened all children using the web-based system. Most providers used the electronic communication system without difficulty, and the majority of children in the intervention group received preventive medications through school as planned and dose adjustments as needed. Several challenges to implementation also were encountered. CONCLUSIONS This program is designed to promote sustainability of school-based asthma care, reduce program costs, and ultimately succeed in a real-world setting. With further refinements, it has the potential to be implemented nationally in schools.
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Affiliation(s)
- Jill S Halterman
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Kit BK, Simon AE, Ogden CL, Akinbami LJ. Trends in preventive asthma medication use among children and adolescents, 1988-2008. Pediatrics 2012; 129:62-9. [PMID: 22144697 DOI: 10.1542/peds.2011-1513] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine trends in preventive asthma medication (PAM) use among children with current asthma in the United States from 1988 to 2008. METHODS We performed a cross-sectional analysis of PAM use among 2499 children aged 1 to 19 years with current asthma using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) during 3 time periods: 1988-1994, 1999-2002, and 2005-2008. PAMs included inhaled corticosteroids, leukotriene receptor antagonists, long-acting β-agonists, mast-cell stabilizers, and methylxanthines. RESULTS Among children with current asthma, there was an increase in the use of PAMs from 17.8% (SE: 3.3) in 1988-1994 to 34.9% (SE: 3.3) in 2005-2008 (P < .001 for trend). Adjusting for age, gender, race/ethnicity, and health insurance status, the odds of PAM use were higher in 2005-2008 compared with 1988-1994 (adjusted odds ratio [aOR] = 2.6; 95% confidence interval [CI]: 1.5-4.5). A multivariate analysis, combining all 3 time periods, showed lower use of PAMs among non-Hispanic black (aOR = 0.5 [95% CI: 0.4-0.7]) and Mexican American (aOR = 0.6 [95% CI: 0.4-0.9]) children compared to non-Hispanic white children. PAM use was also lower in 12 to 19 year olds compared with 1 to 5 year olds and also in children who did not have health insurance compared with those who did. CONCLUSIONS Between 1988 and 2008, the use of PAM increased among children with current asthma. Non-Hispanic black and Mexican American children, adolescents aged 12 to 19 years, and uninsured children with current asthma had lower use of PAM.
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Affiliation(s)
- Brian K Kit
- Division of Health and Nutrition Examination Surveys, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, USA.
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Grover C, Armour C, Asperen PPV, Moles R, Saini B. Medication use in children with asthma: not a child size problem. J Asthma 2011; 48:1085-103. [PMID: 22013989 DOI: 10.3109/02770903.2011.624234] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The global burden of pediatric asthma is high. Governments and health-care systems are affected by the increasing costs of childhood asthma--in terms of direct health-care costs and indirect costs due to loss of parental productivity, missed school days, and hospitalizations. Despite the availability of effective treatment, the current use of medications in children with asthma is suboptimal. The purpose of this review is to scope the empirical literature to identify the problems associated with the use of pediatric asthma medications. The findings will help to design interventions aiming to improve the use of asthma medications among children. METHODS A literature search using electronic search engines (i.e., Medline, International Pharmaceutical Abstracts (IPA), PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) and the search terms "asthma," "children," and "medicines" (and derivatives of these keywords) was conducted. RESULTS The search terms were expanded to include emergent themes arising out of search findings. Content themes relating to parents, children themselves, health-care professionals, organizational systems, and specific medications and devices were found. Within these themes, key issues included a lack of parental knowledge about asthma and asthma medications, lack of information provided to parents, parental beliefs and fears, parental behavioral problems, the high costs of medications and devices, the child's self-image, the need for more child responsibility, physician nonadherence to prescribing guidelines, "off-label" prescribing, poor understanding of teachers, lack of access to educational resources, and specific medications. CONCLUSION These key issues should be taken into account when modifying the development of educational tools. These tools should focus on targeting the children themselves, the parent/carers, the health-care professionals, and various organizational systems.
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Affiliation(s)
- Charu Grover
- Faculty of Pharmacy, University of Sydney, Camperdown Campus, Sydney, New South Wales, Australia
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Abstract
OBJECTIVES To outline the prevalence and disparities of asthma among school-aged urban minority youth, causal pathways through which poorly controlled asthma adversely affects academic achievement, and proven or promising approaches for schools to address these problems. METHODS Literature review. RESULTS Asthma is the most common chronic disease affecting youth in the United States; almost 10 million youth under 18 (14%) have received a diagnosis and 6.8 million (9%) have active asthma. Average annual prevalence estimates were approximately 45% higher for Black versus White children (12.8% vs. 8.8%), as were average annual estimates of asthma attacks (8.4% vs. 5.8%). Urban minority youth have highly elevated prevalence of poorly controlled asthma as evidenced by overuse of emergency departments and under-use of efficacious medications. Poorly controlled asthma has functional consequences on cognition, connectedness with school, and absenteeism. Exemplary asthma programs include management and support systems, school health and mental health services, asthma education, healthy school environments, physical education and activity, and coordination of school, family, and community efforts. CONCLUSIONS Asthma and, more importantly, poorly controlled asthma are highly and disproportionately prevalent among school-aged urban minority youth, has a negative impact on academic achievement through its effects on cognition, school connectedness, and absenteeism, and effective practices are available for schools to address this problem. To reduce the adverse effects of poorly controlled asthma on learning, a multifaceted approach to asthma control and prevention in which schools can and must play a central role is essential.
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Affiliation(s)
- Charles E Basch
- Department of Health and Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, New York, NY 10027, USA.
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Bruzzese JM, Unikel LH, Shrout PE, Klein RG. Youth and Parent Versions of the Asthma-Related Anxiety Scale: Development and Initial Testing. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2011; 24:95-105. [PMID: 22276225 DOI: 10.1089/ped.2011.0076] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 04/01/2011] [Indexed: 11/12/2022]
Abstract
Among adults, anxiety related to asthma has been acknowledged to influence asthma self-management. However, it has not been addressed in pediatric samples and there have been no measures developed to assess asthma-related anxiety in youth or parents. The objective of this study was to develop and test the psychometric properties of novel instruments assessing asthma-related anxiety: the Youth Asthma-Related Anxiety Scale (YAAS) and Parent Asthma-Related Anxiety Scale (PAAS). Scale items were analyzed for content validity. We determined the factor structure using exploratory factor analysis and tested the scales' psychometric properties with 285 Hispanic and African American early adolescents with uncontrolled asthma (mean age=12.8) and their parents (n=230) who participated in a larger randomized control trial testing the efficacy of an asthma intervention; control group families (134 youth and 103 parents) provided follow-up data to assess temporal stability. Both the YAAS and PAAS contained 2 factors with Cronbach alpha coefficients ranging from 0.75 to 0.90. The 2 factors, anxiety about asthma severity and about disease-related restrictions, were highly correlated within each measure. The measures displayed content and construct validity and demonstrated moderate temporal stability over 2-3 months (range: 0.36-0.42). The YAAS and PAAS have adequate psychometric properties and can meaningfully contribute to the assessment of asthma-related anxiety in adolescents and their parents, filling a clinical need in this population.
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Wu BH, Cabana MD, Hilton JF, Ly NP. Race and asthma control in the pediatric population of Hawaii. Pediatr Pulmonol 2011; 46:442-51. [PMID: 21194172 DOI: 10.1002/ppul.21387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 08/09/2010] [Accepted: 09/21/2010] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The racially unique population of Hawaii has one of the highest prevalences of childhood asthma in America. We estimate the prevalence of impaired asthma control among asthmatic children in Hawaii and determine which factors are associated with impaired control. PATIENTS AND METHODS We analyzed data from 477 asthmatic children living in Hawaii participating in the 2006-2008 Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-Back Surveys. Impaired asthma control was modeled after 2007 National Asthma Education and Prevention Program guidelines. Univariate and multivariate analyses were used to identify factors associated with impaired asthma control. RESULTS Children (53.8%) with asthma were either part or full Native Hawaiian/Pacific Islander. While 35.6% of asthmatic children met criteria for impaired asthma control, being part or full Native Hawaiian/Pacific Islander was not associated with impaired control. Only 31.1% of children with impaired control reported the use of inhaled corticosteroids despite >80% having had a routine checkup for asthma in the past year and receipt of asthma education from a healthcare provider. CONCLUSION A large proportion of asthmatic children in Hawaii have impaired asthma control that does not appear to be associated with race but may be associated with inadequate pharmacologic therapy. While a significant percentage reported receiving routine asthma care and asthma education, a minority reported using inhaled corticosteroids. Reasons for this discrepancy between asthma assessment and treatment are unclear. However, additional education on part of the physician, community, and healthcare system are likely to improve management and reduce morbidity in this population.
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Affiliation(s)
- Brian H Wu
- Division of Pediatric Pulmonary Medicine, Department of Pediatrics, University of California San Francisco, California.
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Akinbami LJ, Parker JD, Merkle S. Factors Associated with School Absence Among Children with Symptomatic Asthma, United States, 2002–2003. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2010. [DOI: 10.1089/ped.2010.0013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lara J. Akinbami
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
- U.S. Public Health Service, Rockville, Maryland
| | - Jennifer D. Parker
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Sarah Merkle
- National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Liu AH, Gilsenan AW, Stanford RH, Lincourt W, Ziemiecki R, Ortega H. Status of asthma control in pediatric primary care: results from the pediatric Asthma Control Characteristics and Prevalence Survey Study (ACCESS). J Pediatr 2010; 157:276-281.e3. [PMID: 20472251 DOI: 10.1016/j.jpeds.2010.02.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 11/23/2009] [Accepted: 02/15/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To estimate the prevalence of uncontrolled asthma in pediatric patients with asthma visiting their primary care provider for any medical reason. STUDY DESIGN This was a cross-sectional survey conducted at 29 pediatric care sites across the United States. Children age 4-17 years with self- or caregiver-reported asthma completed the Childhood Asthma Control Test (C-ACT) or the Asthma Control Test (ACT) and responded to demographic and health-related questions. Uncontrolled asthma was defined as a C-ACT or ACT score <or=19. RESULTS A total of 2429 children with a diagnosis of asthma (or caregivers) completed the survey. The prevalence of uncontrolled asthma was 46%. The prevalence of uncontrolled asthma was 35% in patients seen for a nonrespiratory complaint versus 54% in those seen for a respiratory complaint. Children seen for a non-respiratory-related complaint with uncontrolled asthma were more likely to have missed 1 or more school days in the previous 4 weeks compared with children with controlled asthma (53% vs 24%). CONCLUSIONS These findings highlight the impact of uncontrolled asthma not only in children seen for respiratory complaints, but also in those seen for nonrespiratory complaints. Pediatric care providers should consider evaluating asthma control on a regular basis regardless of the reason for the visit.
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Affiliation(s)
- Andrew H Liu
- Department of Pediatrics, National Jewish Health and University of Colorado Denver School of Medicine, Denver, CO, USA
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Components of recommended asthma care and the use of long-term control medication among urban children with asthma. Med Care 2009; 47:940-7. [PMID: 19704351 DOI: 10.1097/mlr.0b013e318199300c] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous research has documented an underuse of long-term control medications among children with asthma, in nonadherence with national guidelines on asthma care. OBJECTIVES To determine if factors related to access and quality of asthma care are associated with underuse of long-term control medication among children with asthma. RESEARCH DESIGN A parent-report cross-sectional survey conducted in 26 randomly selected New York City public elementary schools. SUBJECTS Five thousand two hundred fifty children, of whom 912 had asthma. RESULTS Twenty-nine percent of children with asthma reported using a long-term control medication. Among children with persistent asthma, defined as having one or more sleep disturbances due to asthma per week, 59.0% reported using a long-term control medication. After adjusting for demographic factors, children who had an asthma plan, had visited a doctor in the previous 6 months for nonurgent asthma care, or were enrolled in an asthma education program were more likely to use long-term control medication (odds ratios: 6.00, 4.11, 2.88, respectively). Children of Spanish-speaking parents, African American children, and children with no health insurance were the least likely to use long-term control medication (odds ratios: 0.51, 0.49, 0.20, respectively). Children who reported recommended components of asthma care were the most likely to use their medication with appropriate frequency. CONCLUSIONS Children who reported markers of high quality, personalized medical care, were more likely to use long-term control medication. These findings illustrate that components of the medical care received, and not only the demographic characteristics of the patient, are key factors in understanding the underuse of long-term control medication in urban children with asthma.
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Watts B. Outpatient management of asthma in children age 5-11 years: guidelines for practice. ACTA ACUST UNITED AC 2009; 21:261-9. [PMID: 19432910 DOI: 10.1111/j.1745-7599.2009.00403.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To increase awareness among nurse practitioners (NPs) regarding diagnostic and treatment guidelines for asthma for the 5-11 year age group recently updated by the National Asthma Education Prevention Program-Expert Panel 3 (NAEPP-EPR3). DATA SOURCES NAEPP-EPR3 guidelines for the diagnosis and management of asthma released from the National Heart, Lung, and Blood Institute in August 2007, selected clinical trials, meta-analyses, and clinical reviews. CONCLUSIONS Recent research has revealed that children suffering from asthma in the United States are underdiagnosed and their asthma is poorly controlled. Compelling evidence supports that children classified as having persistent asthma following NAEPP-EPR3 guidelines benefit from daily inhaled corticosteroid therapy, yet many are misclassified and undertreated. IMPLICATIONS FOR PRACTICE With application of current guidelines from NAEPP-EPR3, NPs can more effectively assess, diagnose, treat, and foster a collaborative self-management plan for children age 5-11 years. These interventions will result in an improved quality of life and decreased health risks for this young population.
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Affiliation(s)
- Barbara Watts
- Tri-County Internal Medicine, 807 Jackson Trace Road, Wetumpka, AL 36092, USA.
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Shone LP, Conn KM, Sanders L, Halterman JS. The role of parent health literacy among urban children with persistent asthma. PATIENT EDUCATION AND COUNSELING 2009; 75:368-75. [PMID: 19233588 PMCID: PMC3712512 DOI: 10.1016/j.pec.2009.01.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2008] [Revised: 01/13/2009] [Accepted: 01/14/2009] [Indexed: 05/27/2023]
Abstract
UNLABELLED Health literacy (HL) affects adult asthma management, yet less is known about how parent HL affects child asthma care. OBJECTIVE To examine associations between parent HL and measures related to child asthma. METHODS Parents of 499 school-age urban children with persistent asthma in Rochester, New York completed home interviews. MEASURES the Rapid Estimate of Adult Literacy in Medicine (REALM) for parent HL; National Heart Lung and Blood Institute (NHLBI) criteria for asthma severity, and validated measures of asthma knowledge, beliefs, and experiences. ANALYSES bivariate and multivariate analyses of associations between parent HL measures related to child asthma. RESULTS Response rate: 72%, mean child age: 7.0 years. Thirty-two percent had a Hispanic parent; 88% had public insurance. Thirty-three percent had a parent with limited HL. Low parent HL was independently associated with greater parent worry, parent perception of greater asthma burden, and lower parent-reported quality of life. MEASURES of health care use (e.g., emergency care and preventive medicines) were not associated with parent HL. CONCLUSIONS Parents with limited HL worried more and perceived greater overall burden from the child's asthma, even though reported health care use did not vary. PRACTICE IMPLICATIONS Improved parent understanding and provider-parent communication about child asthma could reduce parent-perceived asthma burden, alleviate parent worry, and improve parent quality of life.
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Affiliation(s)
- Laura P Shone
- University of Rochester School of Medicine, Rochester, NY 14642, USA.
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Boyd M, Lasserson TJ, McKean MC, Gibson PG, Ducharme FM, Haby M. Interventions for educating children who are at risk of asthma-related emergency department attendance. Cochrane Database Syst Rev 2009; 2009:CD001290. [PMID: 19370563 PMCID: PMC7079713 DOI: 10.1002/14651858.cd001290.pub2] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Asthma is the most common chronic childhood illness and is a leading cause for paediatric admission to hospital. Asthma management for children results in substantial costs. There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management. OBJECTIVES To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma. SEARCH STRATEGY We searched the Cochrane Airways Group Trials Register, including the MEDLINE, EMBASE and CINAHL databases, and reference lists of trials and review articles (last search May 2008). SELECTION CRITERIA We included randomised controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We pooled dichotomous data with a fixed-effect risk ratio. We used a random-effects risk ratio for sensitivity analysis of heterogenous data. MAIN RESULTS A total of 38 studies involving 7843 children were included. Following educational intervention delivered to children, their parents or both, there was a significantly reduced risk of subsequent emergency department visits (RR 0.73, 95% CI 0.65 to 0.81, N = 3008) and hospital admissions (RR 0.79, 95% CI 0.69 to 0.92, N = 4019) compared with control. There were also fewer unscheduled doctor visits (RR 0.68, 95% CI 0.57 to 0.81, N = 1009). Very few data were available for other outcomes (FEV1, PEF, rescue medication use, quality of life or symptoms) and there was no statistically significant difference between education and control. AUTHORS' CONCLUSIONS Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.
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Affiliation(s)
- Michelle Boyd
- Royal Children's Hospital , Herston Road, Herston , Queensland , Australia, 4029.
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Smith LA, Bokhour B, Hohman KH, Miroshnik I, Kleinman KP, Cohn E, Cortés DE, Galbraith A, Rand C, Lieu TA. Modifiable risk factors for suboptimal control and controller medication underuse among children with asthma. Pediatrics 2008; 122:760-9. [PMID: 18829799 DOI: 10.1542/peds.2007-2750] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Our aims were (1) to describe rates of suboptimal control and controller medication underuse in a diverse population of children with asthma and (2) to identify potentially modifiable parental behaviors and beliefs associated with these outcomes. METHODS We conducted telephone interviews with parents of 2- to 12-year-old children with persistent asthma, in a Medicaid plan and a large provider group. Suboptimal control was defined as >or=4 symptom days, >or=1 symptom night, or >or=4 albuterol use days in the previous 2 weeks. Controller medication underuse was defined as suboptimal control and parent report of <6 days/week of inhaled steroid use. Multivariate analyses identified factors that were independently associated with suboptimal control and controller medication underuse. RESULTS Of the 754 study children, 280 (37%) had suboptimal asthma control; this problem was more common in Hispanic children (51%) than in black (37%) or white (32%) children. Controller medication underuse was present for 133 children (48% of those with suboptimal asthma control and 18% overall). Controller medication underuse was more common among Hispanic (44%) and black (34%) children than white (22%) children. In multivariate analyses, suboptimal control was associated with potentially modifiable factors including low parental expectations for symptom control and high levels of worry about competing household priorities. Controller medication underuse was associated with potentially modifiable factors including parental estimation of asthma control that was discordant with national guidelines and no set time to administer asthma medications. CONCLUSIONS Deficiencies in asthma control and controller medication use are associated with potentially modifiable parental beliefs, which seem to mediate racial/ethnic and socioeconomic disparities in suboptimal control and controller medication underuse.
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Affiliation(s)
- Lauren A Smith
- Department of Pediatrics, School of Medicine, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, Massachusetts, USA.
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[Bronchial asthma in children. Furthering compliance]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2008; 51:621-8. [PMID: 18446299 DOI: 10.1007/s00103-008-0540-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Success in treating and managing bronchial asthma in children and adolescents is known to rely on active cooperation on behalf of both the patients and their parents. Compliance in terms of pharmaceutical or behavioural intervention is often insufficient to prevent further aggravation and exacerbation. Specific measures for enhancing therapy compliance have been well received in the German Health Care System, and research results indicate their effectiveness in reducing health care utilization and in improving quality of life. Studies that would ascribe such effects to regular medication intake or reduced exposure to allergic elicitors, however, are still lacking.
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