Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children

A Primary Care-Based Quality Improvement Project to Reduce Asthma Emergency Department Visits

BACKGROUND AND OBJECTIVES

Asthma exacerbation is a common and often preventable cause of Emergency Department (ED) utilization. Children eligible for Medicaid are at increased risk of poor asthma control and subsequent ED visits. In 2010, we implemented a multicomponent longitudinal quality improvement project to improve pediatric asthma care for our primary care population, which was 90% Medicaid-eligible. Our goal was to reduce asthma-related ED visits by patients ages 2 to 18 years by 3% annually.

METHODS

The setting was a multisite large urban high-risk primary care network affiliated with a children's hospital. We implemented 5 sequential interventions within our network of pediatric primary care centers to increase: use of asthma action plans by clinicians, primary care-based Asthma Specialty Clinic visits (extended asthma visits in the main primary care site), use of a standard asthma note at all visits, documentation of the Asthma Control Test, and step-up therapy for children with poorly controlled asthma.

RESULTS

At baseline in 2010, there were 21.7 asthma-related ED visits per 1000 patients per year. By 2019, asthma-related ED visits decreased to 14.5 per 1000 patients per year, a 33% decrease, with 2 center line shifts over time. We achieved and sustained our goal metrics for 4 of 5 key interventions.

CONCLUSIONS

We reduced ED utilization for asthma in a large, high-risk pediatric population. The interventions implemented and used over time in this project demonstrate that sustainable outcomes can be achieved in a large network of primary care clinics.

Ethnic variation in asthma healthcare utilisation and exacerbation: systematic review and meta-analysis

Background

Patients from ethnic minority groups (EMGs) frequently report poorer asthma outcomes; however, a broad synthesis summarising ethnic disparities is yet to be undertaken. What is the magnitude of ethnic disparities in asthma healthcare utilisation, exacerbations and mortality?

Methods

MEDLINE, Embase and Web of Science databases were searched for studies reporting ethnic variation in asthma healthcare outcomes (primary care attendance, exacerbation, emergency department (ED) visits, hospitalisation, hospital readmission, ventilation/intubation and mortality) between White patients and those from EMGs. Estimates were displayed using forest plots and random-effects models were used to calculate pooled estimates. We conducted subgroup analyses to explore heterogeneity, including by specific ethnicity (Black, Hispanic, Asian and other).

Results

65 studies, comprising 699 882 patients, were included. Most studies (92.3%) were conducted in the United States of America (USA). Patients from EMGs had evidence suggestive of lower levels of primary care attendance (OR 0.72, 95% CI 0.48-1.09), but substantially higher ED visits (OR 1.74, 95% CI 1.53-1.98), hospitalisations (OR 1.63, 95% CI 1.48-1.79) and ventilation/intubation (OR 2.67, 95% CI 1.65-4.31) when compared to White patients. In addition, we found evidence suggestive of increased hospital readmissions (OR 1.19, 95% CI 0.90-1.57) and exacerbation rates (OR 1.10, 95% CI 0.94-1.28) among EMGs. No eligible studies explored disparities in mortality. ED visits were much higher among Black and Hispanic patients, while Asian and other ethnicities had similar rates to White patients.

Conclusions

EMGs had higher secondary care utilisation and exacerbations. Despite the global importance of this issue, the majority of studies were performed in the USA. Further research into the causes of these disparities, including whether these vary by specific ethnicity, is required to aid the design of effective interventions.

Implementation of a pediatric asthma management program in rural primary care clinics

OBJECTIVE

Rural communities experience a significant asthma burden. We pilot tested the implementation of Easy Breathing, a decision support program for improving primary care provider adherence to asthma guidelines in a rural community, and characterized asthma risk factors for enrollees.

METHODS

We implemented Easy Breathing in two rural primary care practices for two years. Patient demographics, exposure histories, asthma severity, asthma medications, and treatment plans were collected. Providers' adherence to guidelines included the frequency of children with persistent asthma who were prescribed guidelines-based therapy and the frequency of children with a written asthma treatment plan on file. Clinicians provided feedback on the feasibility and acceptability of Easy Breathing using a validated survey tool and through semi-structured interviews.

RESULTS

Two providers implemented the program. Enrollment included 518 children, of whom 135 (26%) had physician-confirmed asthma. After enrollment into Easy Breathing, 75% of children with asthma received a written asthma treatment plan All children with persistent asthma were prescribed an anti-inflammatory drug as part of their treatment plan. Providers (n = 2) rated Easy breathing as highly acceptable (M = 4.5), feasible (M = 4.5), and appropriate (M = 4.5). Qualitative feedback was positive, with suggestions to integrate the paper-based program into the electronic health record system for broader uptake. Enrollees with asthma were more likely to have a family history of asthma and endorse exposure to tobacco smoke and cockroaches.

CONCLUSIONS

Easy Breathing shows promise as a decision support system that can be implemented in rural, medically underserved communities via primary care.

Involvement of methodological experts and the quality of clinical practice guidelines: a critical appraisal of clinical practice guidelines and a questionnaire survey of the development groups in Japan

OBJECTIVE

To evaluate whether the involvement of methodological experts improves the quality of clinical practice guidelines (CPGs) after adjusting for other factors.

SETTING

The quality of Japanese CPGs published in 2011-2019 was assessed using the Appraisal of Guidelines, Research, and Evaluation (AGREE) II instrument. A questionnaire survey targeting CPG development groups was conducted through postal mail.

PARTICIPANTS

405 CPGs were retrieved from a Japanese CPG clearinghouse. Questionnaires were distributed to the 405 CPG development groups. Of the 178 respondents, 22 were excluded because of missing values. Finally, 156 participants representing their CPG development groups were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

CPG quality was assessed using the AGREE II tool. The characteristics of CPGs, including publication year, development organisation, versions, number of members in the development group and involvement of methodological experts, were corrected from the description in the CPGs and the questionnaire survey. We performed multiple logistic regressions using the quality of CPGs as the dependent variable and the involvement of experts as the independent variable, adjusting for other possible factors.

RESULTS

A total of 156 CPGs were included. Expert involvement was significantly associated with the AGREE II instrument scores in domains 1 (β=0.207), 2 (β=0.370), 3 (β=0.413), 4 (β=0.289), 5 (β=0.375), 6 (β=0.240) and overall (β=0.344).

CONCLUSION

This study revealed that the involvement of methodological experts in the CPG development process improves the quality of CPGs. The results suggest the importance of establishing a training and certification programme for experts and constructing expert referral systems that meet CPG developers' needs to improve the quality of CPGs.

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

BACKGROUND

Clinicians' asthma guideline adherence in asthma care is suboptimal. The effort to improve adherence can be enhanced by assessing and monitoring clinicians' adherence to guidelines reflected in electronic health records (EHRs), which require costly manual chart review because many care elements cannot be identified by structured data.

OBJECTIVE

This study was designed to demonstrate the feasibility of an artificial intelligence tool using natural language processing (NLP) leveraging the free text EHRs of pediatric patients to extract key components of the 2007 National Asthma Education and Prevention Program guidelines.

METHODS

This is a retrospective cross-sectional study using a birth cohort with a diagnosis of asthma at Mayo Clinic between 2003 and 2016. We used 1,039 clinical notes with an asthma diagnosis from a random sample of 300 patients. Rule-based NLP algorithms were developed to identify asthma guideline-congruent elements by examining care description in EHR free text.

RESULTS

Natural language processing algorithms demonstrated a sensitivity (0.82-1.0), specificity (0.95-1.0), positive predictive value (0.86-1.0), and negative predictive value (0.92-1.0) against manual chart review for asthma guideline-congruent elements. Assessing medication compliance and inhaler technique assessment were the most challenging elements to assess because of the complexity and wide variety of descriptions.

CONCLUSIONS

Natural language processing technologies may enable the automated assessment of clinicians' documentation in EHRs regarding adherence to asthma guidelines and can be a useful population management and research tool to assess and monitor asthma care quality. Multisite studies with a larger sample size are needed to assess the generalizability of these NLP algorithms.

A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools

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.

Are primary care and continuity of care associated with asthma-related acute outcomes amongst children? A retrospective population-based study

BACKGROUND

Having a primary care provider and a continuous relationship may be important for asthma outcomes. In this study, we sought to determine the association between 1) having a usual provider of primary care (UPC) and asthma-related emergency department (ED) visits and hospitalization in Québec children with asthma and 2) UPC continuity of care and asthma outcomes.

METHODS

Population-based retrospective cohort study using Québec provincial health administrative data, including children 2-16 years old with asthma (N = 39, 341). Exposures and outcomes were measured from 2010-2011 and 2012-2013, respectively. Primary exposure was UPC stratified by the main primary care models in Quebec (team-based Family Medicine Groups, family physicians not in Family Medicine Groups, pediatricians, or no assigned UPC). For those with an assigned UPC the secondary exposure was continuity of care, measured by the UPC Index (high, medium, low). Four multivariate logistic regression models examined associations between exposures and outcomes (ED visits and hospitalizations).

RESULTS

Overall, 17.4% of children had no assigned UPC. Compared to no assigned UPC, having a UPC was associated with decreased asthma-related ED visits (pediatrician Odds Ratio (OR): 0.80, 95% Confidence Interval (CI) [0.73, 0.88]; Family Medicine Groups OR: 0.84, 95% CI [0.75,0.93]; non-Family Medicine Groups OR: 0.92, 95% CI [0.83, 1.02]) and hospital admissions (pediatrician OR: 0.66, 95% CI [0.58, 0.75]; Family Medicine Groups OR: 0.82, 95% CI [0.72, 0.93]; non-Family Medicine Groups OR: 0.76, 95% CI [0.67, 0.87]). Children followed by a pediatrician were more likely to have high continuity of care. Continuity of care was not significantly associated with asthma-related ED visits. Compared to low continuity, medium and high continuity of care decreased asthma-related hospital admissions, but none of these associations were significant.

CONCLUSION

Having a UPC was associated with reduced asthma-related ED visits and hospital admissions. However, continuity of care was not significantly associated with outcomes. The current study provides ongoing evidence for the importance of primary care in children with asthma.

Impact of integrated care coordination on pediatric asthma hospital presentations

INTRODUCTION

Frequent asthma attacks in children result in unscheduled hospital presentations. Patient centered care coordination can reduce asthma hospital presentations. In 2016, The Sydney Children's Hospitals Network launched the Asthma Follow up Integrated Care Initiative with the aim to reduce pediatric asthma emergency department (ED) presentations by 50% through developing and testing an integrated model of care led by care coordinators (CCs).

METHODS

The integrated model of care was developed by a multidisciplinary team at Sydney Children's Hospital Randwick (SCH,R) and implemented in two phases: Phase I and Phase II. Children aged 2-16 years who presented ≥4 times to the ED of the SCH,R in the preceding 12 months were enrolled in Phase I and those who had ≥4 ED presentations and ≥1 hospital admissions with asthma attack were enrolled in Phase II. Phase I included a suite of interventions delivered by CCs including encouraging parents/carers to schedule follow-up visits with GP post-discharge, ensuring parents/carers are provided with standard asthma resource pack, offering referrals to asthma education sessions, sending a letter to the child's GP advising of the child's recent hospital presentation and coordinating asthma education webinar for GPs. In addition, in Phase II CCs sent text messages to parents/carers reminding them to follow-up with the child's GP. We compared the change in ED visits and hospital admissions at baseline (6 months pre-enrolment) and at 6-and 12-months post-enrolment in the program.

RESULTS

During December 2016-January 2021, 160 children (99 in Phase I and 61 in Phase II) were enrolled. Compared to baseline at 6- and 12-months post-enrolment, the proportion of children requiring ≥1 asthma ED presentations reduced by 43 and 61% in Phase I and 41 and 66% in Phase II. Similarly, the proportion of children requiring ≥1 asthma hospital admissions at 6- and 12-months post-enrolment reduced by 40 and 47% in Phase I and 62 and 69% in Phase II.

CONCLUSION

Our results support that care coordinator led integrated model of asthma care which enables integration of acute and primary care services and provides families with asthma resources and education can reduce asthma hospital presentations in children.

Identification of asthma control factor in clinical notes using a hybrid deep learning model

BACKGROUND

There are significant variabilities in guideline-concordant documentation in asthma care. However, assessing clinician's documentation is not feasible using only structured data but requires labor-intensive chart review of electronic health records (EHRs). A certain guideline element in asthma control factors, such as review inhaler techniques, requires context understanding to correctly capture from EHR free text.

METHODS

The study data consist of two sets: (1) manual chart reviewed data-1039 clinical notes of 300 patients with asthma diagnosis, and (2) weakly labeled data (distant supervision)-27,363 clinical notes from 800 patients with asthma diagnosis. A context-aware language model, Bidirectional Encoder Representations from Transformers (BERT) was developed to identify inhaler techniques in EHR free text. Both original BERT and clinical BioBERT (cBERT) were applied with a cost-sensitivity to deal with imbalanced data. The distant supervision using weak labels by rules was also incorporated to augment the training set and alleviate a costly manual labeling process in the development of a deep learning algorithm. A hybrid approach using post-hoc rules was also explored to fix BERT model errors. The performance of BERT with/without distant supervision, hybrid, and rule-based models were compared in precision, recall, F-score, and accuracy.

RESULTS

The BERT models on the original data performed similar to a rule-based model in F1-score (0.837, 0.845, and 0.838 for rules, BERT, and cBERT, respectively). The BERT models with distant supervision produced higher performance (0.853 and 0.880 for BERT and cBERT, respectively) than without distant supervision and a rule-based model. The hybrid models performed best in F1-score of 0.877 and 0.904 over the distant supervision on BERT and cBERT.

CONCLUSIONS

The proposed BERT models with distant supervision demonstrated its capability to identify inhaler techniques in EHR free text, and outperformed both the rule-based model and BERT models trained on the original data. With a distant supervision approach, we may alleviate costly manual chart review to generate the large training data required in most deep learning-based models. A hybrid model was able to fix BERT model errors and further improve the performance.

Impact of guideline adherence and race on asthma control in children

BACKGROUND

Asthma control in African Americans (AA) is considered more difficult to achieve than in Caucasian Americans (CA). The aim of this study was to compare asthma control over time among AA and CA children whose asthma is managed per NAEPP (EPR-3) guidelines.

METHODS

This was a one-year prospective study of children referred by their primary care physicians for better asthma care in a specialty asthma clinic. All children received asthma care per NAEPP guidelines. Results were compared between CA and AA children at baseline and then at three-month intervals for one year.

RESULTS

Of the 345 children, ages 2-17 years (mean = 6.2 ± 4), 220 (63.8%) were CA and 125 (36.2%) were AA. There were no significant differences in demographics other than greater pet ownership in CA families. At baseline, AA children had significantly more visits to the Emergency Department for acute asthma symptoms (mean = 2.3 [Formula: see text] compared to CA (1.4 ± 2.3, P = 0.003). There were no other significant differences in acute care utilization, asthma symptoms (mean days/month), or mean asthma control test (ACT) scores at baseline. Within 3-6 months, in both groups, mean ACT scores, asthma symptoms and acute care utilization significantly improved (P < 0.05 for all) and change over time in both groups was comparable except for a significantly greater decrease in ED visits in AA children compared to CA children (P = 002).

CONCLUSION

Overall, improvement in asthma control during longitudinal assessment was similar between AA and CA children because of  consistent use of NAEPP asthma care guidelines.

Targeted Clinical Interventions for Reducing Pediatric Readmissions

BACKGROUND

In this interventional study, we addressed the selection and application of clinical interventions on pediatric patients identified as at risk by a predictive model for readmissions.

METHODS

A predictive model for readmissions was implemented, and a team of providers expanded corresponding clinical interventions for at-risk patients at a freestanding children's hospital. Interventions encompassed social determinants of health, outpatient care, medication reconciliation, inpatient and discharge planning, and postdischarge calls and/or follow-up. Statistical process control charts were used to compare readmission rates for the 3-year period preceding adoption of the model and clinical interventions with those for the 2-year period after adoption of the model and clinical interventions. Potential financial savings were estimated by using national estimates of the cost of pediatric inpatient readmissions.

RESULTS

The 30-day all-cause readmission rates during the periods before and after predictive modeling (and corresponding 95% confidence intervals [CI]) were 12.5% (95% CI: 12.2%-12.8%) and 11.1% (95% CI: 10.8%-11.5%), respectively. More modest but similar improvements were observed for 7-day readmissions. Statistical process control charts indicated nonrandom reductions in readmissions after predictive model adoption. The national estimate of the cost of pediatric readmissions indicates an associated health care savings due to reduced 30-day readmission during the 2-year predictive modeling period at $2 673 264 (95% CI: $2 612 431-$2 735 364).

CONCLUSIONS

A combination of predictive modeling and targeted clinical interventions to improve the management of pediatric patients at high risk for readmission was successful in reducing the rate of readmission and reducing overall health care costs. The continued prioritization of patients with potentially modifiable outcomes is key to improving patient outcomes.

Community Health Worker Asthma Interventions for Children: Results From a Clinically Integrated Randomized Comparative Effectiveness Trial (2016‒2019)

Objectives. To compare asthma control for children receiving either community health worker (CHW) or certified asthma educator (AE-C) services. Methods. The Asthma Action at Erie Trial is a comparative effectiveness trial that ran from 2016 to 2019 in Cook County, Illinois. Participants (aged 5‒16 years with uncontrolled asthma) were randomized to 10 home visits from clinically integrated asthma CHWs or 2 in-clinic sessions from an AE-C. Results. Participants (n = 223) were mainly Hispanic (85%) and low-income. Both intervention groups showed significant improvement in asthma control scores over time. Asthma control was maintained after interventions ended. The CHW group experienced a greater improvement in asthma control scores. One year after intervention cessation, the CHW group had a 42% reduction in days of activity limitation relative to the AE-C group (b = 0.58; 95% confidence interval = 0.35, 0.96). Conclusions. Both interventions were associated with meaningful improvements in asthma control. Improvements continued for 1 year after intervention cessation and were stronger with the CHW intervention. Public Health Implications. Clinically integrated asthma CHW and AE-C services that do not provide home environmental remediation equipment may improve and sustain asthma control.

Regional differences in pediatric asthma hospital admissions: National data from Israel 1996-2017

BACKGROUND

Asthma is a common chronic childhood illness and frequent cause of hospitalization. A decline in hospital admission rates was noted up to the 1990s, however, trends are not as clear since the turn of the century. This study aimed to assess the rates and regional differences of asthma admissions over more than two decades using the national Ministry of Health database, which registers data from all the hospitals.

METHODS

A retrospective cohort study, analysis of all pediatric asthma admissions, for Patients 1-14 years old, between 1996 and 2017 as recorded by the National Hospital Discharge Registry, was performed. Asthma admission rates were calculated per 1000 age adjusted residents, using the number of admission cases as the numerator, and age specific population size as the denominator.

RESULTS

The annual asthma hospitalization rate decreased in the entire pediatric population from 2.14 in 1996-0.89 in 2017. Children in the 1-4 year age group comprised most of the hospital admissions, and most of the decline was attributable to this age group. Significant differences in hospitalizations were found between different regions as well as differences in the rate of decline in asthma hospitalizations with the lowest admission rate in the Jerusalem district, highest in Haifa, northern and southern Israeli regions and the greatest rate of decline in the Tel-Aviv district.

CONCLUSION

This nationwide study, over more than two decades, shows clear regional differences in the rates of asthma admissions as well as regional differences in the rates of decline.

Impact of type of health care provider on long term asthma control

OBJECTIVE

Asthma prevalence is high and adherence to asthma guidelines is still less than adequate. The main objective of this study was to determine if there were significant differences in outcome measures if asthma care was provided per guidelines either by physicians (pediatric pulmonologists) or specialty trained advance practice nurses (APNs).

METHODS

This was a three-year, prospective cohort study of children referred by their primary care providers to a tertiary care center for better asthma control. Patients were provided asthma care per NAEPP guidelines including asthma education. Results were compared over time and between patients followed by physicians or APNs. Alpha level of significance was ≤0.05.

RESULTS

The sample included 471 children, ages 2-17 years (mean = 6.4 ± 2.4 years). Physicians and APN's provided asthma care. Of the 471 children enrolled in the study, 176 (37%) were followed for the full three-year study period. At the initial visit, physician group reported more short courses of oral steroids and more unscheduled visits to PCP for acute asthma care in the past 6 months compared to those followed by APNs (<0.05 for all). Among the total cohort and both subgroups, there were significant improvements in mean Asthma Control Test (ACT), acute care need and mean days/month with asthma symptoms over a three-year period (p < 0.05). There was significantly more improvement in use of oral steroids and urgent care visits in physician group (p < 0.05).

CONCLUSION

When asthma guidelines are followed, improvements in asthma control are achieved in children in both the MD and APN groups.

The nationwide retrospective cohort study by Health Insurance Review and Assessment Service proves that asthma management decreases the exacerbation risk of asthma

Medical costs have recently increased in South Korea due to the rising rate of asthma. Primary clinics serve an important role in asthma management, as they are the first stop for patients presenting with symptoms. The Health Insurance Review and Assessment Service (HIRA) in South Korea has assessed asthma-management quality since 2013, but studies are lacking on whether these assessments have been performed properly and contribute toward reducing asthma exacerbations. Therefore, we investigated whether the HIRA’s quality assessments have decreased asthma exacerbations using national health insurance claims data from 2013 to 2017 of 83,375 primary-clinic and 15,931 tertiary-hospital patients with asthma. These patients were classified into four groups based on disease severity according to the monthly prescribed amount of asthma medication using K-means clustering. The associations between HIRA assessments and asthma exacerbation were analyzed using a generalized estimating equation. Our results showed that exacerbation odds gradually decreased as the HIRA assessments progressed, especially in the mild-severity group, and that exacerbation risk among patients with asthma decreased in the order of assessment grades: “Unsatisfactory,” “Satisfactory,” and “Tertiary.” Therefore, we may conclude that asthma exacerbations may decrease with high quality asthma management; appropriate quality assessment could be helpful in reducing asthma exacerbations.

Association of Affordable Care Act Implementation With Ambulance Utilization for Asthma Emergencies in New York City, 2008-2018

IMPORTANCE

Emergency medical services (EMS) are an essential component of the health care system, but the effect of insurance expansion on EMS call volume remains unclear.

OBJECTIVE

This study investigated the association between health insurance expansion and EMS dispatches for asthma, an ambulatory care-sensitive condition. We hypothesized that insurance expansion under the Patient Protection and Affordable Care Act (ACA) would be associated with decreased EMS dispatches for asthma emergencies.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study examined 14 865 267 ambulance calls dispatched within New York City from 2008 to 2018, including 217 303 calls for asthma-related emergencies, and used interrupted time series analysis to study the change in the annual incidence of EMS dispatches for asthma emergencies after implementation of the ACA. Multivariable linear regression examined the association between the uninsured rate and the incidence of asthma-related dispatches, controlling for population demographic characteristics and air quality index.

EXPOSURES

Implementation of ACA on January 1, 2014.

MAIN OUTCOMES AND MEASURES

Incidence of EMS dispatches for asthma emergencies per 100 000 population per year (ie, asthma EMS dispatch rate) as classified by the 911 call-taker.

RESULTS

In this study of 217 303 EMS dispatches for asthma-related emergencies, there was a decrease in the asthma EMS dispatch rate after implementation of the ACA, from a mean (SD) of 261 (24) dispatches per 100 000 population per year preintervention to 211 (47) postintervention (P = .047). This decrease in asthma EMS dispatch rate after ACA implementation was significant on interrupted time series analysis. Prior to 2014, the annual asthma EMS dispatch rate was increasing by 11.8 calls per 100 000 population per year (95% CI, 6.1 to 17.4). After ACA implementation, the asthma EMS dispatch rate decreased annually by 28.5 calls per 100 000 population per year (95% CI, -37.6 to -19.3), a significant change in slope from the preintervention period (P < .001). Multivariable linear regression, controlling for percentage of individuals younger than age 18 years, degree of racial/ethnic diversity, median household income, and air quality index, found that a 1% decrease in the citywide uninsured rate was associated with a decrease of 98.9 asthma dispatches per 100 000 population per year (95% CI, 5.72-192.10; P = .04).

CONCLUSIONS AND RELEVANCE

Insurance expansion within New York City under the ACA was associated with a significant reduction in the asthma EMS dispatch rate. Insurance expansion may be a viable method to reduce EMS utilization for ambulatory care-sensitive conditions such as asthma.

Evidence for Exacerbation-Prone Asthma and Predictive Biomarkers of Exacerbation Frequency

Rationale: Cross-sectional studies suggest an exacerbation-prone asthma (EPA) phenotype and the utility of blood eosinophils and plasma IL-6 as predictive biomarkers.Objectives: To prospectively test for EPA phenotype and utility of baseline blood measures of eosinophils and IL-6 as predictive biomarkers.Methods: Three-year asthma exacerbation data were analyzed in 406 adults in the Severe Asthma Research Program-3. Transition models were used to assess uninformed and informed probabilities of exacerbation in year 3. Binomial regression models were used to assess eosinophils and IL-6 as predictive biomarkers.Measurements and Main Results: Eighty-three participants (21%) had ≥1 exacerbation in each year (EPA) and 168 participants (41%) had no exacerbation in any year (exacerbation-resistant asthma). The uninformed probability of an exacerbation in Year 3 was 40%, but the informed probability increased to 63% with an exacerbation in Year 2 and 82% with an exacerbation in Years 1 and 2. The probability of a Year 3 exacerbation with no Year 1 or 2 exacerbations was 13%. Compared with exacerbation-resistant asthma, EPA was characterized by lower FEV₁ and a higher prevalence of obesity, hypertension, and diabetes. High-plasma IL-6 occurred in EPA, and the incident rate ratio for exacerbation increased 10% for each 1-pg/μl increase in baseline IL-6 level. Although high blood eosinophils did not occur in EPA, the incident rate ratio for exacerbations increased 9% for each 100-cell/μl increase in baseline eosinophil number.Conclusions: Longitudinal analysis confirms an EPA phenotype characterized by features of metabolic dysfunction. Blood measures of IL-6, but not eosinophils, were significantly associated with EPA, and IL-6 and eosinophils predicted exacerbations in the sample as a whole.

Impact of asthma severity on long-term asthma control

Background: Asthma is a common childhood disease with significant morbidity. Severe asthma accounts for just 4-6% of patients, but this group is more difficult to treat and is responsible for up to 40% of asthma expenses.Objective: The relationship between asthma severity and control is not well characterized. The main objective of this study was to determine impact of asthma severity on asthma control over time.Methods: This was a three year, prospective observational cohort study at a tertiary care children's hospital. Results were compared over time and between patients with severe and non-severe persistent asthma. Intervention included therapy based on severity and control, accompanied by a NAEPP (EPR-3) guidelines based structured asthma education program.Results: The sample included 471 children referred from primary care offices with the diagnosis of persistent asthma, mean age 6.4 ± 2.4 years. Forty-one children (8.7%) had severe persistent asthma and 430 (91.3%) children had non-severe persistent asthma (mild-moderate persistent). Our sample size decreased over the three-year period and the number of patients completing the third year were 176 (38%) and among them 20 (11.4%) had severe asthma. At the initial visit, children with severe persistent asthma had significantly more acute care needs, more daily symptoms, and lower mean Asthma Control Test™ scores compared to children with non-severe persistent asthma. Differences between groups decreased within six months with significant improvements in most indicators persisting throughout three-year follow up in both groups (p < 0.05).Conclusion: Asthma control improves independent of severity if asthma guidelines are followed.

Evaluation of a shared decision-making intervention for pediatric patients with asthma in the emergency department

BACKGROUND

Asthma is a difficult-to-manage chronic disease marked with associated outcome disparities including an increase rate of emergency department (ED) visits for uncontrolled asthma among patients who are most at-risk. Shared decision making (SDM) is a process by which the patient and provider jointly make a healthcare choice. SDM improves patient outcomes; however, implementation barriers of time constraints and staff availability are limitations. The use of health IT solutions may increase the adoption of SDM, but best practices for implementation are not well understood. The Consolidated Framework for Implementation Research (CFIR) is a flexible comprehensive model used to identify barriers and facilitators influencing implementation. The goal of this study is to implement an innovative web-based pediatric SDM tool in the real-world setting of two large healthcare system EDs through the following aims: (1) convene a patient, research, and ED stakeholder advisory board to oversee review of protocol and study materials prior to implementation, (2) implement the SDM intervention where providers and staff will be trained to incorporate use of this SDM intervention, (3) conduct on-going evaluation of barriers, facilitators, and implementation outcomes to tailor implementation in the EDs, (4) evaluate patient-centered outcomes of primary care utilization and changes in ED visits and hospitalizations before and after the SDM intervention, and (5) understand and document best practices for ED implementation.

METHODS

The CFIR model will guide the implementation evaluation. Researchers will administer surveys to the clinical team and patients at baseline, 3, 6, and 12 months to inform implementation design, determine barriers and facilitators, and resource-needs to allow for real-time process adjustments within the EDs. Focus group or key-informant interviews and analysis will provide additional feedback to the stakeholder team to iterate the implementation process. Researchers will track patient-centered outcomes including increased primary care, ED, and inpatient utilization over the duration of the study.

DISCUSSION

To advance asthma care and the field of implementation science, further research is needed to assess best practices for incorporating SDM into high-need healthcare settings such as the ED. This knowledge will facilitate improved outcomes and appropriate policy changes towards further use of SDM interventions in local and national acute care settings.

A School Nurse-Led Asthma Program Reduces Absences: Evaluation of Easy Breathing for Schools

OBJECTIVE

To evaluate whether school nurses can assist pediatricians in providing asthma care and reduce school absenteeism through a program called Easy Breathing for Schools (EzBfS), a 5-element school nurse-led asthma management program and the effectiveness in reducing school absenteeism.

METHODS

Fifteen public school nurses in an urban community implemented EzBfS during the 2015-16 and 2016-17 school years. Program elements included assessment of asthma risk and asthma control, asthma education, medication review, and a pediatrician communication tool. School absence for any reason was the primary outcome; absentee rates for students with asthma enrolled in the program were compared to students with asthma in the entire school population using negative binomial regression.

RESULTS

School nurses enrolled 251/2,126 students with physician-confirmed asthma (2015-16: n = 114 and 2016-17: n = 137). Sixty eight percent of participants were Latino and 25% were Black with a mean age of 8.7 ± 2.2 years. Absentee rates were higher in children with asthma compared to children without asthma (8.3% vs 7.0% absent, respectively P < .001). Students enrolled in the program experienced a 25% decrease in absentee rate after adjusting for age, sex, race/ethnicity, and school year (rate ratio = 0.75, 95% confidence interval, 0.67, 0.85) as compared to students with asthma not enrolled in the program. Participants also demonstrated improvement in inhaler technique score (P < .001). Ninety two percent of the nurses were satisfied with the program.

CONCLUSION

EzBfS, a pragmatic, nurse-led asthma management program, was successfully implemented by school nurses and significantly decreased school absences among a sample of students with asthma.

The structure of the quality of clinical practice guidelines with the items and overall assessment in AGREE II: a regression analysis

Background

The Appraisal of Guidelines for Research & Evaluation (AGREE) II has been widely used to evaluate the quality of clinical practice guidelines (CPGs). While the relationship between the overall assessment of CPGs and scores of six domains were reported in previous studies, the relationship between items constituting these domains and the overall assessment has not been analyzed. This study aims to investigate the relationship between the score of each item and the overall assessment and identify items that could influence the overall assessment.

Methods

All Japanese CPGs developed using the evidence-based medicine method and published from 2011 to 2015 were used. They were independently evaluated by three appraisers using AGREE II. The evaluation results were analyzed using regression analysis to evaluate the influence of 6 domains and 23 items on the overall assessment.

Results

A total of 206 CPGs were obtained. All domains and all items except one were significantly correlated to the overall assessment. Regression analysis revealed that Domain 3 (Rigour of Development), Domain 4 (Clarity of Presentation), Domain 5 (Applicability), and Domain 6 (Editorial Independence) had influence on the overall assessment. Additionally, four items of AGREE II, clear selection of evidence (Item 8), specific/unambiguous recommendations (Item 15), advice/tools for implementing recommendations (Item 19), and conflicts of interest (Item 22), significantly influenced the overall assessment and explained 72.1% of the variance.

Conclusions

These four items may highlight the areas for improvement in developing CPGs.

A Longitudinal Examination of the Asthma Medication Ratio in Children with Medicaid

Background/Objective: An efficient and accurate strategy for identifying children with asthma at high-risk for exacerbation is needed. The objective of this study is to conduct a longitudinal examination of the asthma medication ratio (AMR) (#of controller medication claims/(# of controller medication claims + # of rescue medication claims)) in Medicaid-funded children with asthma. This measure has the potential to be a near real-time risk assessment tool.Methods: We conducted a retrospective analysis of 2013-2014 Truven Health Medicaid data. We analyzed pharmacy and medical claims for a cohort of children with asthma. We identified patients age 2-17 years with at least one claim for an inhaled corticosteroid. We calculated an AMR for rolling 3-month periods and examined the proportion who were classified as low risk (AMR ≥ .5), high-risk (AMR < .5) and no medication claims (no asthma medication claims). Using logistic regression, we tested how the AMR predicted severe exacerbations.Results: 214,452 eligible children were identified. The mean age is 7.8 years. 8-9% had a high-risk AMR in any given period. High-risk AMR is associated with increased odds of a severe exacerbation in the subsequent 3 months (compared to all other children) (OR 1.7-1.9 depending on time period evaluated).Conclusions: In this analysis of Medicaid-insured children with asthma, we found that the AMR is a reliable predictor of exacerbations. This will inform the development of an AMR-based risk assessment and communication intervention.

Pediatric Asthma: A Global Epidemic

The global prevalence, morbidity and mortality related to childhood asthma among children has increased significantly over the last 40 years. Although asthma is recognized as the most common chronic disease in children, issues of underdiagnosis and undertreatment persist. There are substantial global variations in the prevalence of asthma symptoms in children, with up to 13-fold differences between countries. The rising number of hospital admissions for asthma may reflect an increase in asthma severity, poor disease management and/or the effect of poverty. The financial burden of asthma is relatively high within developed countries (those for which data is available) spending 1 to 2% of their healthcare budget on this condition. Established in 1989, the Global Initiative for Asthma (GINA) attempts to raise awareness about the increasing prevalence of asthma, improve management and reduce the burden of asthma worldwide. Despite global efforts, GINA has not achieved its goal, even among developed nations. There are multiple barriers to reducing the global burden of asthma, including limited access to care and/or medications, and lack of prioritization as a public healthcare priority. In addition, the diversity of healthcare systems worldwide and large differences in access to care require that asthma management guidelines be tailored to local needs.

Documentation of asthma control and severity in pediatrics: analysis of national office-based visits

Objective: To evaluate the extent of documentation of asthma control and severity and associated characteristics among pediatric asthma patients in office-based settings. Methods: This cross-sectional study utilized data from the 2012-2015 National Ambulatory Medical Care Survey (NAMCS). Patients aged 6-17 years with a diagnosis of asthma were included. Weighted descriptive analysis examined the extent of documentation and uncontrolled asthma; while logistic regression evaluated associated characteristics. Results: Overall, there were 2.47 million (95% confidence interval, 95% CI: 2.04-2.90) average annual visits with asthma as a primary diagnosis. Asthma control and severity was documented in only 36.1% and 33.8% of the visits, respectively. An established patient (odds ratio, OR = 3.81), Hispanic ethnicity (OR = 2.10), chronic sinusitis (OR = 5.59), and visits in the Northeast (OR = 2.12) and Midwest (OR = 2.25) regions had higher odds of documented asthma control status, whereas undocumented asthma severity (OR = 0.02), and visits in spring (OR = 0.34), had lower odds. Osteopathic doctors (OR = 0.18), visits in the Northeast region (OR = 0.23), chronic sinusitis (OR = 0.08), and undocumented asthma control status (OR = 0.03) had lower odds of documented asthma severity, whereas visits in spring (OR = 3.88) and autumn (OR = 3.32) had higher odds. Moderate/severe persistent asthma (OR = 15.35) had higher odds of uncontrolled asthma (as compared to intermittent asthma), while visits in the summer (OR = 0.14) had lower odds. Conclusion: The findings of this study suggest a critical need to increase the documentation of asthma severity and control to improve quality of asthma care in children.

Is preterm birth associated with asthma among children from birth to 17 years old? -A study based on 2011-2012 US National Survey of Children's Health

BACKGROUND

Preterm birth can interrupt lung development in utero and is associated with early life factors, which adversely affects the developing respiratory system. Studies on preterm birth and asthma risk are comparatively sparse and the results are not consistent.

METHODS

Multivariate analyses were performed on a cross-sectional data from the National Survey of Children's Health (NSCH) collected in 2011 to 2012. The NSCH was a nationally representative telephone survey sponsored by the Maternal and Child Health Bureau and conducted by the National Center for Health Statistics. A cross-sectional analysis using data from the US on 90,721 children was conducted to examine the relationship between preterm birth and asthma risk.

RESULTS

A total of 90,721 children under 17 years were included and 12% of the children were reported as preterm birth. The prevalence of diagnosed asthma was 15%, with a male to female ratio of 1.26:1. Children who were born preterm were 1.64 times (95% confidence interval: 1.45-1.84) more likely to develop asthma compared with those who were born term after controlling for confounders. Similarly, children who were low birth weight were 1.43 times (95% confidence interval: 1.25-1.63) more likely for asthma, and the odds ratio increased to 1.77 for those both preborn and low birth weight. Child's gender, race/ethnicity, age, family structure, family income levels, and household smoking were significantly associated with the odds of reported asthma.

CONCLUSIONS

Preterm birth was associated with increased risk of asthma among US children, supporting the notion that preterm birth may play a critical role in asthma development.

The PIPc Study-application of indicators of potentially inappropriate prescribing in children (PIPc) to a national prescribing database in Ireland: a cross-sectional prevalence study

OBJECTIVES

Evidence is limited regarding the quality of prescribing to children. The objective of this study was to apply a set of explicit prescribing indicators to a national pharmacy claims database (Primary Care Reimbursement Service) to determine the prevalence of potentially inappropriate prescribing in children (PIPc) in primary care.

PRIMARY AND SECONDARY OUTCOMES MEASURES

To determine the overall prevalence of potentially inappropriate prescribing (PIP) in children in primary care. To examine the prevalence of PIPc by gender.

DESIGN AND SETTING

Cross-sectional study. Application of indicators of commission of PIP and omission of appropriate prescribing to a national prescribing database in Ireland.

PARTICIPANTS

Eligible children <16 years of age who were prescribed medication in 2014.

RESULTS

Overall prevalence of PIPc by commission was 3.5% (95% CI 3.5% to 3.6%) of eligible children <16 years of age who were prescribed medication in 2014. Overall prevalence of PIPc by omission was 2.5% (95% CI 2.5% to 2.6%) which rose to 11.5% (95% CI 11.4% to 11.7%) when prescribing of spacer devices for children with asthma was included. The most common individual PIPc by commission was the prescribing of carbocisteine to children (3.3% of eligible children). The most common PIPc by omission (after excluding spacer devices) was failure to prescribe an emollient to children prescribed greater than one topical corticosteroid (54% of eligible children). PIPc by omission was significantly higher in males compared with females (relative risk (RR) 1.3; 95% CI 1.0 to 1.7) but no different for PIPc by commission (RR 1.0; 95% CI 0.7 to 1.6).

CONCLUSION

This study shows that the overall prevalence of PIP in children is low, although results suggest room for improved adherence to asthma guidelines.

Medicaid Coverage of Guidelines-Based Asthma Care Across 50 States, the District of Columbia, and Puerto Rico, 2016-2017

Asthma affects more than 24 million Americans, including 6.2 million children. Although asthma cannot be cured, it can be effectively managed with care based on nationally recognized guidelines. Ensuring the availability and accessibility of guidelines-recommended treatments and services can help patients receive the most appropriate care. In this article, we describe the American Lung Association’s Asthma Guidelines-Based Care Coverage Project (the Project) to determine the extent of asthma care coverage and associated barriers in state Medicaid programs — information that has been previously unavailable. The Project tracked coverage for 7 areas of guidelines-based asthma care and 9 barriers related to accessing care in Medicaid programs for all 50 states, the District of Columbia, and Puerto Rico. Results from the Project show a lack of consistent and comprehensive coverage across states, as well as coverage-related challenges to accessing asthma care within states.

A Quality Improvement Intervention to Improve Inpatient Pediatric Asthma Controller Accuracy

OBJECTIVES

Our objective was to investigate if a rigorous quality improvement (QI) intervention could increase accuracy of pediatric asthma controller medications on discharge from an inpatient hospitalization.

METHODS

Our interprofessional QI team developed interventions such as improving documentation and creating standardized language to ensure patients were discharged on an appropriate asthma controller medication and improve assessment of asthma symptom control. Each week of 2015-2016, the first 5 patients discharged with status asthmaticus from the pediatric wards were reviewed for documentation of the 6 asthma control questions and accuracy of the discharge controller therapy. Correct discharge medication was defined as being prescribed the age-appropriate medication and dose on the basis of baseline controller therapy, compliance with baseline medication, and responses to asthma control assessment. The weekly proportion of control questions that were accessed and correct controller medications that were prescribed were analyzed by using Nelson rules and interrupted time series.

RESULTS

A total of 240 preintervention and 252 postintervention charts were reviewed. The primary outcome of the median proportion of patients discharged on appropriate controller therapy improved from 60% in preintervention data to 80% in the postintervention period. The process measure of proportion of asthma control questions that were assessed improved from 43% in the preintervention period to 98% by the final months of the intervention period. Both of these changes were statistically significant as per Nelson's rules and interrupted time series analyses (P = .02 and P < .001, respectively, for postintervention break).

CONCLUSIONS

An interdisciplinary QI team successfully improved the accuracy of asthma controller therapy on discharge and the inpatient assessment of asthma control questions.

Caring for Young Children with Asthma: Perspectives from Urban Community Health Centers

Asthma disproportionately affects low-income, minority youth, with notable disparities among children <5 years of age. Understanding the perceptions of urban community health centers (CHCs) regarding treating young children with asthma could improve care for these patients. This study uses data from semi-structured focus groups with staff from eight urban CHCs. Themes emerged in three domains. Within the parent/family domain, providers noted low rates of follow-up visits, low health literacy, and-for young children specifically-misunderstanding about the diagnosis. At the CHC level, providers needed more staff, space, and comfort with applying the guidelines to infants and young children. CHCs reported asthma registries, population health oversight, and an asthma champion improved care. At the system level, providers wanted improved communication with emergency departments and community outreach programs. Reducing these multi-level barriers may improve care.

Reducing emergency department visits utilizing a primary care asthma specialty clinic in a high-risk patient population

OBJECTIVE

Asthma is a leading cause of pediatric emergency department (ED) use. Optimizing asthma outcomes is a goal of Nationwide Children's Hospital (NCH) and its affiliated Accountable Care Organization. NCH's Primary Care Network, comprised of 12 offices serving a predominantly Medicaid population, sought to determine whether an Asthma Specialty Clinic (ASC) operated within a single primary care office could reduce ED asthma rates and improve quality measures, relative to all other network offices.

METHODS

An ASC was piloted with four components: patient monitoring, provider continuity, standardized assessment, and multi-disciplinary education. A registry was established to contact patients at recommended intervals. At extended-length visits, a general pediatrician evaluated patients and a multi-disciplinary team provided education. Novel educational tools were utilized, guideline-based templates recorded and spirometry obtained. ED asthma rate, spirometry utilization, and controller fills by intervention office patients were compared to all other network offices before and after ASC initiation.

RESULTS

At baseline, asthma ED visits by intervention and usual care populations were similar (p = 0.43). After, rates were significantly lower for intervention office patients versus usual care office patients (p < 0.001), declining in the intervention population by 26.2%, 25.2%, and 31.8% in 2013, 2014, and 2015, respectively, from 2012 baseline, versus increases of 3.8%, 16.2%, and 9.5% in the usual care population. Spirometry completion, controller fills, and patients with favorable Asthma Medication Ratios significantly increased for intervention office patient relative to the usual care population.

CONCLUSIONS

A primary care-based asthma clinic was associated with a significant and sustainable reduction in ED utilization versus usual care. What's new: This study describes a comprehensive, multi-disciplinary, and innovative model for an asthma management program within the medical home that demonstrated a significant reduction in ED visits, an increase in spirometry utilization, and an increase in controller fills in a high-risk asthma population versus comparison group.

Acute Asthma in the Pediatric Emergency Department: Infections Are the Main Triggers of Exacerbations

Background

Asthma exacerbations are a common reason for Emergency Department (ED) visits in children.

Aim

To analyze differences among age groups in terms of triggering factors and seasonality and to identify those with higher risk of severe exacerbations.

Methods

We retrospectively revised the files of children admitted for acute asthma in 2016 in our Pediatric ED.

Results

Visits for acute asthma were 603/23197 (2.6%). 76% of the patients were <6 years old and 24% ≥6. Infections were the main trigger of exacerbations in both groups; 33% of the school-aged children had a triggering allergic condition (versus 3% in <6 years; p < .01). 191 patients had a previous history of asthma; among them, 95 were ≥6 years, 67% of whom were not using any controller medication, showing a higher risk of a moderate-to-severe exacerbation than those under long-term therapy (p < .01). Exacerbations peaked in autumn and winter in preschoolers and in spring and early autumn in the school-aged children.

Conclusions

Infections are the main trigger of acute asthma in children of any age, followed by allergy in the school-aged children. Efforts for an improved management of patients affected by chronic asthma might go through individualized action plans and possibly vaccinations and allergen-avoidance measures.

Chronic obstructive pulmonary disease, bronchial asthma and allergic rhinitis in the adult population within the commonwealth of independent states: rationale and design of the CORE study

Background

Main treatable Chronic Respiratory Diseases (CRDs) like Chronic Obstructive Pulmonary Disease (COPD), Bronchial Asthma (BA) and Allergic Rhinitis (AR) are underdiagnosed and undertreated worldwide. CORE study was aimed to assess the point prevalence of COPD, BA and AR in the adult population of major cities of Commonwealth of Independent States (CIS) countries – Azerbaijan, Kazakhstan, and Ukraine based on study questionnaires and/or spirometry, and to document risk factors, characterize the COPD, BA and AR population to provide a clearer “epidemiological data”.

Methods

A descriptive, cross-sectional, population-based epidemiological study conducted from 2013 to 2015 with two-stage cluster geographical randomization. Interviewers conducted face-to-face visits at respondent’s household after informed consent and eligibility assessment including interviews, anthropometry, spirometry (with bronchodilator test) and completion of disease-specific questionnaires.

Results

Two thousand eight hundred forty-two respondents (Ukraine: 964 from Ukraine; 945 from Kazakhstan; 933 Azerbaijan) were enrolled. Mean age was 40–42 years and males were 37%–42% across three countries. In Kazakhstan 62.8% were Asians, but in Ukraine and in Azerbaijan 99.7% and 100.0%, respectively, were Caucasians. Manual labourers constituted 40.5% in Ukraine, 22.8% in Kazakhstan and 22.0% in Azerbaijan, while office workers were 16.1%, 31.6% and 36.8% respectively. 51.3% respondents in Ukraine, 64.9% in Kazakhstan and 69.7% in Azerbaijan were married.

Conclusion

CORE study collected information that can be supportive for health policy decision makers in allocating healthcare resources in order to improve diagnosis and management of CRDs. The detailed findings will be described in future publications.

Trial registration

Study Protocol Summary is disclosed at GlaxoSmithKline Clinical Study Register on Jun 06, 2013, study ID 116757.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0471-x) contains supplementary material, which is available to authorized users.

Coordinated Asthma Program Improves Asthma Outcomes in High-Risk Children

Innovative approaches within primary care are needed to reduce fragmented care, increase continuity of care, and improve asthma outcomes in children with asthma. Our objective was to assess the impact of coordinated team-based asthma care on unplanned asthma-related health care utilization. A multidisciplinary asthma team was developed to provide coordinated care to high-risk asthma patients. Patients received an in-depth diagnostic and family needs assessment, asthma education, and coordinated referral to social and community services. Over a 2-year period, 141 patients were followed. At both 1 and 2 years postintervention, there was a significant decrease from preintervention rates in urgent care visits (40%, P = .002; 50%, P < .0001), emergency department visits (63%, P < .0001; 70%, P < .0001), and inpatient hospitalization (69%, P = .002; 54%, P = .04). Our coordinated asthma care program was associated with a reduction in urgent care visits, emergency department visits, and inpatient hospitalizations among high-risk children with asthma.

Biomarkers of Airway Type-2 Inflammation and Integrating Complex Phenotypes to Endotypes in Asthma

PURPOSE OF REVIEW

Over the past decade, the most important advance in the field of asthma has been the widespread recognition that asthma is a heterogeneous disease driven by multiple molecular processes.

RECENT FINDINGS

The most well-established molecular mechanism in asthma is increased airway type-2 inflammation, and consequently, non-invasive biomarkers of increased airway type-2 inflammation, such as blood eosinophil counts or blood periostin levels, have proven important in stratifying asthma patients in clinical trials of type-2 cytokine inhibitors. However, it remains ambiguous how well these non-invasive biomarkers represent airway measures of type-2 inflammation in asthma. As a result, the utility of these biomarkers to assist with asthma management or as research tools to better understand asthma pathogenesis remains unclear. This article reviews primary data assessing biomarkers of airway type-2 inflammation in asthma and describes how the use of biomarkers can advance a precision medicine approach to asthma treatment.

Inhaled corticosteroid prescribing in a pediatric emergency department: Sustained success and prescription filling rates

OBJECTIVE

To determine if improvement in Inhaled Corticosteroid (ICS) prescribing in the pediatric emergency department (PED) can be sustained after transition from intense intervention to low-intervention phase, and to determine ICS fill rates.

METHODS

A Quality Improvement (QI) project began in Aug 2012. Results through Feb 2014 were previously published. In Feb 2014 interventions were scaled back to determine the sustainability of QI success. Eligible patients included children aged 2-17 seen in the PED for asthma between Feb 2014 and Sept 2016. The primary change when moving to the low-intervention phase was stopping monthly attending feedback. The primary outcome was the proportion of patients who were prescribed an ICS at the time of PED discharge. The secondary objective of this study was to determine the proportion of patients who filled their ICS prescription in the 6 months following Emergency Department (ED) visit.

RESULTS

The goal rate of ICS prescribing was 75%. After transition to the low-intervention phase, the ICS prescribing rate was maintained at a median of 79% through Sept 2016. ICS fill rate in the first 30 days following ED visit was 89%, although this quickly fell to below 40% for months 2-6.

CONCLUSIONS

The ICS prescribing rate remained the goal of 75% over a 2.5-year period after transition to a low-intervention phase. High ICS fill rates immediately after ED visit have been demonstrated. However, rapid decline in these rates over subsequent months suggests a need for future efforts to focus on long-term ICS adherence among children with ED visits for asthma.

A framework for measuring self-management effectiveness and health care use among pediatric asthma patients and families

Asthma is associated with substantial health care expenditures, including an estimated US$56 billion per year in direct costs. A recurring theme in the asthma management literature is that costly asthma symptoms, including hospitalizations and multiple emergency department (ED)/outpatient visits, can often be prevented through patient/family adherence to the national (National Institutes of Health Expert Panel Report-3) guidelines for effective self-management of asthma, specifically 1) medication adherence and 2) environmental trigger avoidance, as outlined in the patient's personalized Asthma-Action Plan. It is important to note however that while effective self-management of asthma is known to reduce ED visits and hospitalizations, the relationship between asthma self-management effectiveness and outpatient visit frequency remains ambiguous, reflecting a gap in the literature. For instance, do patients/families who self-manage effectively visit outpatient clinics more frequently for asthma care (compared to those who do not self-manage effectively), after accounting for differences in asthma severity, demographic characteristics, and risk factors? Do patients/families who visit outpatient clinics more frequently for asthma care, in turn have fewer ED and inpatient encounters for asthma? On the other hand, do patients/families who do not revisit outpatient clinics regularly have higher ED visits and hospitalizations? It is important to address these gaps, in order to reduce the costs and public health burden of asthma. This paper provides a foundation for addressing these gaps, by conducting an integrative review of the asthma management literature, to develop a conceptual framework for measuring self-management effectiveness and health care use among pediatric asthma patients/families. In doing so, the paper lays the groundwork for future research seeking to explicate the relationship between asthma self-management effectiveness and health care use, which in turn has potential to engage asthma providers in promoting ideal self-management and optimal health care use for pediatric asthma, in accordance with national evidence-based guidelines for asthma management.

Exposure to secondhand smoke and asthma severity among children in Connecticut

OBJECTIVE

To determine whether secondhand smoke (SHS) exposure is associated with greater asthma severity in children with physician-diagnosed asthma living in CT, and to examine whether area of residence, race/ethnicity or poverty moderate the association.

METHODS

A large childhood asthma database in CT (Easy Breathing) was linked by participant zip code to census data to classify participants by area of residence. Multinomial logistic regression models, adjusted for enrollment date, sex, age, race/ethnicity, area of residence, insurance type, family history of asthma, eczema, and exposure to dogs, cats, gas stove, rodents and cockroaches were used to examine the association between self-reported exposure to SHS and clinician-determined asthma severity (mild, moderate, and severe persistent vs. intermittent asthma).

RESULTS

Of the 30,163 children with asthma enrolled in Easy Breathing, between 6 months and 18 years old, living in 161 different towns in CT, exposure to SHS was associated with greater asthma severity (adjusted relative risk ratio (aRRR): 1.07 [1.00, 1.15] and aRRR: 1.11 [1.02, 1.22] for mild and moderate persistent asthma, respectively). The odds of Black and Puerto Rican/Hispanic children with asthma being exposed to SHS were twice that of Caucasian children. Though the odds of SHS exposure for publicly insured children with asthma were three times greater than the odds for privately insured children (OR: 3.02 [2.84,3,21]), SHS exposure was associated with persistent asthma only among privately insured children (adjusted odds ratio (aOR): 1.23 [1.11,1.37]).

CONCLUSION

This is the first large-scale pragmatic study to demonstrate that children exposed to SHS in Connecticut have greater asthma severity, clinically determined using a systematic approach, and varies by insurance status.

Does receiving care in a medical home reduce racial/ethnic disparities in ED visits among children with asthma in the United States?

Evidence has shown the implementation of medical home model improves care quality and outcomes. However, it is not clear whether receiving care from a medical home has any impact on racial/ethnic disparities in emergency department (ED) use by children with asthma. This study using the US National Survey of Children with Special Health Care Needs, 2009-2010, estimated racial/ethnic disparities in ED use. Generalized liner models were used to examine factors associated with ED use. Racial/ethnic differences in ED use were attenuated after adjusting for socio-economic variables. Ratios of prevalence ratios were calculated to examine the effect modification of medical home on ED use associated with race/ethnicity. The adjusted prevalence ratio of ED use of the Black to non-Hispanic White was 1.51 (95% confidence interval (CI): 1.36-1.67) with medical home and 1.35 (95% CI: 1.24-1.47) without medical home. Among those with care from a medical home Latino children had higher ED use compared with White children. There is no evidence that the self-reported care from a medical home narrows the gaps in ED use between non-Hispanic White and Black or Latino children with asthma.

Inhaled Corticosteroid Claims and Outpatient Visits After Hospitalization for Asthma Among Commercially Insured Children

OBJECTIVE

To determine rates of inhaled corticosteroid (ICS) claims and outpatient follow-up after asthma hospitalization among commercially insured children.

METHODS

We conducted a retrospective cohort analysis of children hospitalized for asthma using 2013 national Truven MarketScan data. Covariates included age, sex, region, length of stay, and having an ICS claim within 35 days before hospitalization. Outcome variables were a claim for any ICS-containing medication and outpatient visit within 30 days after discharge. Multivariable analysis used logistic regression.

RESULTS

A total of 5471 children aged 2 to 17 were included; 61% were boys, and mean age was 6.8 years. Forty-one percent had a claim for an ICS and 76% had an outpatient visit within 30 days after hospital discharge. In multivariable analysis, children who had an ICS claim within 35 days before the hospitalization were more likely to have an ICS claim within 30 days after discharge (relative risk [RR] 1.3, 95% confidence interval [CI] 1.2-1.5). The strongest predictor of an ICS claim within 30 days after discharge was attendance at an outpatient appointment (RR 1.4, 95% CI 1.3-1.6). Children aged 2 to 6 were more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.1-1.2). Children with an ICS claim before admission were also more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.004-1.1).

CONCLUSIONS

In this national sample of commercially insured children with asthma, rates of ICS claims after hospitalization are low despite high rates of outpatient visits. Both inpatient and outpatient physicians must play a role in increasing ICS adherence in this high-risk population of children with asthma.

Improved quality-of-life of caregivers of children with asthma through guideline-based management

OBJECTIVE

The quality of life (QOL) of caregivers of children with asthma may be related to children's responses to asthma management.

AIM

To evaluate change in QOL over time of caregivers of children with asthma through guideline-based management.

DESIGN

This was a 3-year prospective cohort study of children with asthma referred to our pediatric asthma center. Families completed Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), the Asthma Control Test™ (ACT), and reported the number of days/month of albuterol use and wheezing at each clinic visit.

RESULTS

We enrolled 143 children, ages 7-17 years (mean = 10.6 ± 2.9), 56.6% male, 70.6% Caucasian. Patients were managed by the same MD (n = 65,45.5%) or APN (n = 78,54.5%) over time. The mean total PACQLQ significantly increased over the 3-year period (F = 67.418, p < .001). Total scores at the first visit were 4.8 ± 1.6, which improved to 6.1 ± 1 at the 3-month follow-up visit. This improvement was sustained at the 1, 2, and 3-year clinic visits. PACQLQ emotional function (F = 60.798, p < .001) and activity limitation (F = 41.517, p < .001) domains significantly improved as well. PACQLQ scores were significantly associated with improved ACT scores (r = .37 to .47, p < .05), fewer days/month of albuterol use (r = -.25 to -.36., p < .05), and wheezing (r = -.28 to -.33, p < .05). There were no significant differences in PACQLQ, or asthma clinical outcome measures between MD and APN providers.

CONCLUSION

Use of National Asthma Education and Prevention Program (NAEPP) guidelines significantly improved QOL of caregivers of children with asthma and in asthma-related symptoms. Improvements over time were independent of type of providers.

Improving asthma care in a pediatric resident clinic

There is variation in pediatric asthma management in the outpatient setting. Adherence to national asthma guidelines provides a systematic standardized approach to asthma management. There is a gap between usual and guideline-consistent asthma care in resident clinics. Practice improvement modules aimed at improving resident physician adherence to asthma care guidelines have not been consistently utilized and have not yet been studied.

Our aim was to increase guideline consistent care in our pediatric resident clinic in a twelve-month period via increasing performance on the following measures to 75%: spirometry testing; influenza immunization recommendation; level of control assessed through the use of a standardized questionnaire; appropriate medications per national guideline; and use of written asthma action plans.

A summarized pediatric-specific version of the National Heart Lung and Blood Institute National Asthma Education and Prevention Program Expert Panel Report 3 (NHLBI EPR-3) guidelines was made readily available to increase provider education. Electronic health record (EHR) enhancements included adding templates to create standardized asthma action plan, asthma control test and a pediatric asthma controller medication order-set. We also addressed the education of patients by simplifying patient instructions. We monitored our progress through the use of an online practice improvement module.

We found statistically significant increases in use of a standardized instrument to determine level of control (20% to 81%); recommendation of influenza immunization (56% to 97%); use of national medication treatment guidelines (28% to 98%); distribution of asthma action plans (29% to 65%); and provision of asthma self-management education (35% to 74%).

Standardizing the implementation of national guidelines for pediatric asthma through the use of a practice improvement module and electronic health records improved adherence to guidelines. The module allowed us to identify goals for improvement, collect and analyze our group performance data over time, assess the impact of each change, and redesign our process. Improving adherence to national pediatric asthma care guidelines is especially important in settings such as resident teaching clinics which provide care to underserved populations at higher risk for complications related to asthma.

Asthma-related emergency department use: current perspectives

Asthma is one of the most common chronic pediatric diseases. Patients with asthma often present to the emergency department for treatment for acute exacerbations. These patients may not have a primary care physician or primary care home, and thus are seeking care in the emergency department. Asthma care in the emergency department is multifaceted to treat asthma patients appropriately and provide quality care. National and international guidelines exist to help drive clinical care. Electronic and paper-based tools exist for both physicians and patients to help improve emergency, home, and preventive care. Treatment of patients with asthma should include the acute exacerbation, long-term management of controller medications, and controlling triggers in the home environment. We will address the current state of asthma research in emergency medicine in the US, and discuss some of the resources being used to help provide a medical home and improve care for patients who suffer from acute asthma exacerbations.

Mismatching Among Guidelines, Providers, and Parents on Controller Medication Use in Children with Asthma

BACKGROUND

Underuse of controller medicines among children with asthma remains widespread despite national guidelines.

OBJECTIVES

To (1) assess provider prescribing patterns for asthma controller medications; (2) assess how frequently parents' reports of their child's asthma controller medicine use were mismatched with their provider's recommendations; and (3) evaluate parent attitudes and demographic characteristics associated with these mismatches.

METHODS

In this cross-sectional study, we conducted linked surveys of parents and providers of children with probable persistent asthma in a Medicaid program and 4 commercial health plans in 2011. Probable persistent asthma was defined as a diagnosis of asthma and 1 or more controller medication dispensing.

RESULTS

This study included 740 children (mean age, 8.6 years). Providers for 50% of the children reported prescribing controller medications for daily year-round use, 41% for daily use during active asthma months, and 9% for intermittent use for relief. Among parents, 72% knew which class of controller medication the provider prescribed and 49% knew the administration frequency and the medication class. Parents were less likely to report the same controller medication type as the provider, irrespective of dose and frequency, if they were Latino (odds ratio [OR], 0.23; CI, 0.057-0.90), had a household smoker (OR, 2.87; CI, 0.42-19.6), or believed the controller medicine was not helping (OR, 0.15; CI, 0.048-0.45).

CONCLUSIONS

Mismatches between parent reports and providers intentions regarding how the child was supposed to use inhaled steroids occurred for half of the children. Efforts should focus on ways to reduce mismatches between parent and provider intentions regarding controller medication use.

Improving pediatric asthma care: A partnership between pediatric primary care clinics and a free-standing Children's Hospital

BACKGROUND

Asthma is a common chronic disease of childhood. Providers' adherence to asthma guidelines is still less than optimal.

OBJECTIVES

To determine if an Asthma Education Program aimed at primary care practices can improve asthma care within practices and if the results vary by duration of the program.

METHODS

Ten practices were randomly assigned to an Early Asthma Education Intervention (EI) group or a Delayed Asthma Education Intervention (DI) group. The EI group received the intervention for 12 months and was monitored for 6 additional months. The DI group was observed without intervention for 12 months, then received the intervention for 6 months, and was monitored for 6 additional months. The program included training of asthma educators in each practice and then monitoring for improvement in medical record documentation of National Asthma Education and Prevention Program (NAEPP) asthma quality indicators by blinded random review of patient charts.

RESULTS

In the EI group, 6-, 12-, and 18-month data revealed significant improvement in documentation of asthma severity, education, action plan, night time symptoms, and symptoms with exercise compared to baseline and compared to DI group at baseline and at the 12-month interval. In the DI group, significant improvement in documentation in all of the above endpoints and also in documentation of NAEPP treatment guidelines was noted at 18 and 24 months. In both groups, documentation levels remained relatively stable at 6 months after the intervention, with no significant differences between groups. While improved, guideline adherence was <80% for half of the indicators.

CONCLUSION

In-office training of non-physician asthma providers improves the quality of asthma care.

Accuracy of caregivers' recall of hospital admissions: implications for research

AIM

To determine the accuracy of caregivers' recall of hospital admissions in early childhood.

METHODS

Prospective cohort study of babies born at risk of neonatal hypoglycaemia at Waikato Hospital, New Zealand, a regional public hospital and sole provider of acute inpatient care to over 100,000 children. Caregivers' recall of children's hospital admissions up to 4.5 years was compared with medical records. Accuracy of recall was related to neonatal and socio-demographic characteristics.

RESULTS

Of 267 children, 179 (67%) visited hospital and 106 (40%) were admitted at least once. The most frequent reasons for admission were for respiratory (29%) and gastrointestinal (18%) problems. Of 106 children admitted to hospital, 27 (25%) caregivers did not recall the admission and only 37 (35%) accurately recalled the number of admissions. The accuracy of recall was lower for gastrointestinal (38%) and surgical (40%) problems, while recall of respiratory (64%) and ear, nose and throat (60%) admissions was more accurate. Low socio-economic status and multiple admissions were associated with less accurate recall of number of admissions.

CONCLUSION

Caregivers do not accurately report hospital admissions. Questionnaire data about use of hospital facilities should be interpreted cautiously and may not be sufficiently accurate for use in research studies.

Evaluation of a statewide medical home program on children and young adults with asthma

OBJECTIVE

Asthma, the most common chronic condition among children, accounts for significant healthcare utilization and impact on quality of life. Care coordination in a medical home is considered standard practice, but has not been rigorously evaluated.

METHODS

We initiated this pilot study of children/young adults with asthma (n = 967), ages: birth to 24 years, receiving care from a subset of pediatric practices (n = 20) participating in the Pennsylvania Medical Home Initiative, Educating Practices in Community-Integrated Care (92 practices statewide). We hypothesized children and youth with asthma receiving care coordination in the context of a formal medical home program would experience favorable associations with healthcare utilization and quality of life measures.

RESULTS

A total of 9240 care coordination encounters for this cohort of children/youth occurred over 100 days. The average length of care coordination encounter was 20.7 minutes. The most common care coordination activity was referral management (21%) and the care coordinator in the practice most often contacted parent/family and specialists (75%). Children with more severe asthma had more hospitalizations and emergency department (ED) visits than children with less severe asthma. There was a significant decrease in school absences, ED visits and acute care visits for children/youth with asthma with increasing length of time in a medical home program (p < 0.05).

CONCLUSION

Care coordination for children/youth with asthma is feasible and may yield improvements in healthcare utilization, expenditures and quality of life. Larger-scale implementation of care coordination and medical home models for children/youth with asthma and other diagnoses are warranted.

Pediatricians Support Initiation of Asthma Controller Medications in the Emergency Department: A National Survey

OBJECTIVES

Although National Asthma Guidelines recommend that emergency department (ED) physicians consider initiating controller medications, research suggests that this practice occurs infrequently. The goal of this study was to assess primary care pediatricians' (PCP) beliefs and attitudes regarding ED initiation of controller medications for children with persistent asthma symptoms.

METHODS

This was a cross-sectional mail survey of a randomly selected national sample of pediatricians from the American Academy of Pediatrics. The survey posed questions regarding beliefs, barriers, and support for national guideline recommendations.

RESULTS

Eight hundred eighty-six (44.3%) of 2000 subjects responded. Five hundred seventy-two (64.5%) respondents met eligibility for analysis. When presented with a vignette of a child with persistent asthma, 476 (83%) of PCPs felt it was appropriate for the ED physician to initiate controller medications. Most (80%) PCPs supported the national guideline recommendation, although a similar proportion reported they have never or rarely experienced this practice before. Only 11% opposed the practice in all circumstances. Beliefs supporting this practice included the following: opportunity to capture patients lost to follow-up (85%), reinforcement of daily use of controller medications (83%), and controller medication may shorten an acute exacerbation (53%). Barriers included lack of time for education in ED (65%), reinforcement of ED use for primary care (64%), lack of PCP communication (62%), and inability to assess severity appropriately (41%). Most (90%) PCPs expect communication from the ED provider.

CONCLUSIONS

A majority of pediatricians support the practice of ED physicians initiating controller medication during an acute visit for asthma. Communication with the PCP, appropriate screening of severity, and education about controller medications were important considerations expressed by these providers.

The Early Childhood Obesity Prevention Program (ECHO): an ecologically-based intervention delivered by home visitors for newborns and their mothers

BACKGROUND

Obesity is a major problem in the United States, particularly among socio-economically disadvantaged Latino and Black children. Effective interventions that can be disseminated to large numbers of at-risk children and their families are needed. The goals of the Early Childhood Obesity Prevention Program (ECHO) are to examine the 12-month efficacy of a primary obesity prevention program targeting the first year of life that is delivered by home visitors and that engages mothers as agents of change to modify their own behavior and their infant's behavior through education and skill-building around nutrition, physical activity, and wellness, and then "echoes" her training with linkages to neighborhood programs and resources.

METHODS/DESIGN

Six family centers located in low-income neighborhoods in Hartford, CT were randomized into control and intervention neighborhoods. Fifty-seven mothers were recruited either prenatally or shortly after delivery into the Nurturing Families Network home visitation program; 27 lived in a control neighborhood and received the standard home visitation program and 30 lived in an intervention neighborhood and received both the standard home visitation program and the ECHO intervention. The intervention increases maternal skills in goal-setting, stimulus control and problem-solving, engages family members to support changes, links mothers to neighborhood resources and is embedded in the standard home visitation program. ECHO targets include breastfeeding, solids, juice and sugar-sweetened beverages, routines for sleep and responding to infant cues, television/screen time, and maternal diet and physical activity. We hypothesize that infants in ECHO will have been breastfed longer and exclusively, will have delayed introduction of solids and juice, have longer sleep duration, decreased television/screen time and a lower weight for length z-score at 12 months, and their mothers will have greater fruit and vegetable consumption and higher levels of physical activity.

DISCUSSION

ECHO will provide important information about whether an enhanced behavior change curriculum integrated into an existing home visitation program, focused on the mother as the agent of change and linked to neighborhood resources is effective in changing energy balance behaviors in the infant and in the mother. If effective, the intervention could be widely disseminated to prevent obesity in young children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02052518 January 30, 2014.

Children's emergency department use for asthma, 2001-2010

OBJECTIVES

Although the emergency department (ED) provides essential care for severely ill or injured children, past research has shown that children often visit the ED for potentially preventable illnesses, including asthma. We sought to determine how children's rate of ED visits for asthma has changed over the last decade and to analyze what factors are associated with a child's potentially preventable ED visit for asthma.

METHODS

We retrospectively analyzed ED visits by children aged 2 to 17 from 2001 to 2010 using data from the National Hospital Ambulatory Medical Care Survey. Visits were classified as potentially preventable asthma visits by mapping ICD-9-CM diagnosis codes to the Agency for Healthcare Research and Quality's asthma pediatric quality indicator. We examined trends in the annual rate of ED visits for asthma per 1000 children using a weighted linear regression model. Finally, we used multivariate logistic regression to determine what demographic, clinical, and structural factors were associated with a child's ED visit being for a potentially preventable asthma crisis.

RESULTS

The rate of children's ED visits for asthma increased 13.3% between 2001 and 2010, from 8.2 to 9.3 visits per 1000 children (P = .26). ED visits by children who were younger, male, racial or ethnic minorities, insured with Medicaid/Children's Health Insurance Program, and visiting between 11 pm and 7 am were more likely to be for potentially preventable asthma crises.

CONCLUSIONS

Although the overall rate of potentially preventable ED visits for asthma did not significantly change over the last decade, racial, insurance-based, and other demographic disparities in the likelihood of a preventable asthma-related ED visit persist.