Seventeen years of asthma guidelines: why hasn't the outcome improved for children?

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.

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.

A primary care learning collaborative to improve office systems and clinical management of pediatric asthma

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.

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 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.

Parents and adolescents preferences for asthma control: a best-worst scaling choice experiment using an orthogonal main effects design

Background

The preferences of parents and children with asthma influence their ability to manage a child’s asthma and achieve good control. Potential differences between parents and adolescents with respect to specific parameters of asthma control are not considered in clinical asthma guidelines. The objective was to measure and compare the preferences of parents and adolescents with asthma with regard to asthma control parameters using best worst scaling (BWS).

Methods

Fifty-two parents of children with asthma and 44 adolescents with asthma participated in a BWS study to quantify preferences regarding night-time symptoms, wheezing/chest tightening, changes in asthma medications, emergency visits and physical activity limitations. Conditional logit regression was used to determine each group’s utility for each level of each asthma control parameter.

Results

Parents displayed the strongest positive preference for the absence of night-time symptoms (β = 2.09, p < 0.00001) and the strongest negative preference for 10 emergency room visits per year (β = −2.15, p < 0.00001). Adolescents displayed the strongest positive preference for the absence of physical activity limitations (β = 2.17, p < 0.00001) and the strongest negative preference for ten physical activity limitations per month (β = −1.97). Both groups were least concerned with changes to medications.

Conclusion

Parents and adolescents placed different weights on the importance of asthma control parameters and each group displayed unique preferences. Understanding the relative importance placed on each parameter by parents and adolescents is essential for designing effective patient-focused disease management plans.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-015-0141-9) contains supplementary material, which is available to authorized users.

InSpire to Promote Lung Assessment in Youth: Evolving the Self-Management Paradigms of Young People With Asthma

Background

Asthma is the most common chronic disease in childhood, disproportionately affecting urban, minority, and disadvantaged children. Individualized care plans supported by daily lung-function monitoring can reduce morbidity and mortality. However, despite 20 years of interventions to increase adherence, only 50% of US youth accurately follow their care plans, which leads to millions of preventable hospitalizations, emergency room visits, and sick days every year. We present a feasibility study of a novel, user-centered approach to increasing young people’s lung-function monitoring and asthma self-care. Promoting Lung Assessment in Youth (PLAY) helps young people become active managers of their asthma through the Web 2.0 principles of participation, cocreation, and information sharing. Specifically, PLAY combines an inexpensive, portable spirometer with the motivational power and convenience of mobile phones and virtual-community gaming.

Objective

The objective of this study was to develop and pilot test InSpire, a fully functional interface between a handheld spirometer and an interactive game and individualized asthma-care instant-messaging system housed on a mobile phone.

Methods

InSpire is an application for mobile smartphones that creates a compelling world in which youth collaborate with their physicians on managing their asthma. Drawing from design-theory on global timer mechanics and role playing, we incentivized completing spirometry maneuvers by making them an engaging part of a game young people would want to play. The data can be sent wirelessly to health specialists and return care recommendations to patients in real-time. By making it portable and similar to applications normally desired by the target demographic, InSpire is able to seamlessly incorporate asthma management into their lifestyle.

Results

We describe the development process of building and testing the InSpire prototype. To our knowledge, the prototype is a first-of-its kind mobile one-stop shop for asthma management. Feasibility testing in children aged 7 to 14 with asthma assessed likability of the graphical user interface as well as young people’s interest in our incentivizing system. Nearly 100% of children surveyed said they would play games like those in PLAY if they involved breathing into a spirometer. Two-thirds said they would prefer PLAY over the spirometer alone, whereas 1/3 would prefer having both. No children said they would prefer the spirometer over PLAY.

Conclusions

Previous efforts at home-monitoring of asthma in children have experienced rapid decline in adherence. An inexpensive monitoring technology combined with the computation, interactive communication, and display ability of a mobile phone is a promising approach to sustainable adherence to lung-function monitoring and care plans. An exciting game that redefines the way youth conduct health management by inviting them to collaborate in their health better can be an incentive and a catalyst for more far-reaching goals.

Improving clinician self-efficacy does not increase asthma guideline use by primary care clinicians

OBJECTIVE

The purpose of this study was to show the association between changes in clinician self-efficacy and readiness to change and implementation of an asthma management program (Easy Breathing).

METHODS

A 36 month randomized, controlled trial was conducted involving 24 pediatric practices (88 clinicians). Randomized clinicians received interventions designed to enhance clinician self-efficacy and readiness to change which were measured at baseline and 3 years. Interventions consisted of an educational toolbox, seminars, teleconferences, mini-fellowships, opinion leader visits, clinician-specific feedback, and pay for performance. The primary outcome was program utilization (number of children enrolled in Easy Breathing/year); secondary outcomes included development of a written treatment plan and severity-appropriate therapy.

RESULTS

At baseline, clinicians enrolled 149 ± 147 (mean ± SD) children/clinician/year; 84% of children had a written treatment plan and 77% of plans used severity-appropriate therapy. At baseline, higher self-efficacy scores were associated with greater program utilization (relative rate [RR], 1.34; 95% confidence interval [CI], 1.04-1.72; P = .04) but not treatment plan development (RR, 0.63; 95% CI, 0.29-1.35; P = .23) or anti-inflammatory use (RR, 1.76; 95% CI, 0.92-3.35; P = .09). Intervention clinicians participated in 17 interventions over 36 months. At study end, self-efficacy scores increased in intervention clinicians compared to control clinicians (P = .01) and more clinicians were in an action stage of change (P = .001) but these changes were not associated with changes in primary or secondary outcomes.

CONCLUSIONS

Self-efficacy scores correlated with program use at baseline and increased in the intervention arm, but these increases were not associated with greater program-related activities. Self-efficacy may be necessary but not sufficient for behavior change.

Early administration of systemic corticosteroids reduces hospital admission rates for children with moderate and severe asthma exacerbation

STUDY OBJECTIVE

The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes.

METHODS

We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders.

RESULTS

Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval -1.3 to -0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score.

CONCLUSION

In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness.

Translation of a pediatric asthma-management program into a community in Connecticut

OBJECTIVES

We assessed whether a successful asthma-management program could be translated into pediatrician's offices, improve care, and reduce medical services use.

METHODS

Pediatrician's offices from 6 communities in Connecticut were trained, and all children aged 6 months or older were eligible for enrollment. Quality measures included enrollment numbers, appropriate use of anti-inflammatory therapy, and distribution of a written treatment plan. Medical services utilization data for Medicaid-insured children were expressed as relative rates (RRs) (95% confidence intervals [CIs]) before and after enrollment, and we used historical and contemporaneous comparisons and generalized estimating equations.

RESULTS

A total of 51 practices and 297 clinicians enrolled 32 680 children from 2002 to 2007; 10 467 had asthma, of whom 4354 were insured with Medicaid. Children with persistent asthma experienced decreases in the number of hospitalizations (RR: 0.51 [95% CI: 0.39-0.65]) and emergency-department visits (RR: 0.70 [95% CI: 0.68-0.84]), and there was no change in number of outpatient visits (RR: 0.99 [95% CI: 0.9-1.10]). Inhaled corticosteroid use doubled, appropriate use of anti-inflammatory therapy increased to 96%, and 94% of the children were given a written treatment plan.

CONCLUSIONS

General pediatricians can successfully implement an asthma-management program that is effective in improving care for large numbers of children.

North American practice patterns of intravenous magnesium therapy in severe acute asthma in children

OBJECTIVES

Although intravenous (IV) magnesium (Mg) can decrease hospitalizations in children with severe acute asthma, its use is often limited to resistant disease, and disposition may be determined prior to its use. Since knowledge about practice patterns of IV Mg would enhance knowledge translation and guide future research, we surveyed pediatric emergency physicians with interest in clinical research to determine the frequency, indications, adverse events, and barriers to use of IV Mg in children with severe acute asthma.

METHODS

A cross-sectional online survey of two national pediatric emergency physician associations in Canada and the United States was conducted using a modified Dillman technique.

RESULTS

Response rates were 124 of 180 (69%) in Canada and 75 of 108 (69%) in the United States. Although 88% of participants report knowing that Mg is effective, only 14 of 199 (7%) give it to prevent hospitalizations and 142 of 199 (71%) give it to prevent admissions to the intensive care unit (ICU). Thirty-eight percent of respondents use Mg in < 5% of stable children with severe acute asthma, while 79% use it in 50% or more of the ICU candidates with concern about impending respiratory failure. Seventy-nine percent of the participants report that < 5% of their patients given Mg are discharged home from the ED. Twenty-four percent of respondents who administer Mg have encountered associated severe hypotension requiring therapy, and 2% have witnessed-related apnea. Factors affecting Mg use include concern about side effects expressed by 24% of physicians and a belief that IV therapy is not necessary, expressed by 31%.

CONCLUSIONS

Intravenous Mg appears to be uncommonly used in stable children with severe acute asthma and does not frequently play a role in reducing hospitalizations. Further research to justify its enhanced use and to better establish its true adverse effect profile is indicated.

Illness perceptions: impact on self-management and control in asthma

PURPOSE OF REVIEW

Outcome in asthma is determined not only by pulmonary function or other biomedical characteristics. An important determinant of asthma outcome is illness perceptions: patients' subjective beliefs and emotional responses to their illness. Illness perceptions influence patients' coping and self-management behavior, and thereby outcome.

RECENT FINDINGS

We review recent studies on associations between illness perceptions and outcome in patients with asthma, with a range of respondents and caregivers, with varying degree of asthma severity, and in different settings of medical care. Most studies pertain to substantial numbers of patients, and have been performed in different countries, adding to the external validity of the findings. All studies report substantial effects of illness perceptions on various categories of outcome: illness perceptions reflecting personal control over the illness are associated with a positive outcome, that is, asthma control. Findings point at the importance and clinical relevance of addressing patients' illness perceptions, and suggest that this may improve outcome in asthma care. Well conducted intervention studies on this topic are called for in order to improve outcomes and quality of life in asthma patients.

SUMMARY

Illness perceptions influence the way in which patients with asthma cope and their self-management of the illness. Illness perceptions can be assessed quite easily and directly, they inform healthcare providers about the psychosocial responses of patients towards their asthma, they are responsive to change in the clinical encounter or via self-management intervention training. Exploring patient's illness perceptions, therefore, is a crucial component of good clinical care.

Asthma: time to confront some inconvenient truths

Despite major advances in the understanding of the pathogenesis of asthma and improvements in management, the accompanying benefits from public health initiatives and clinical practice have arguably been less than expected. For example, there are no effective public health strategies or treatment regimes that reduce the risk of developing asthma or influence its natural history. These represent priority areas for future translational research, which would need to investigate genetic and environmental interactions and vaccine strategies. In terms of asthma management it is tempting to focus on novel drug therapies; however, a case can be made that the priority is to undertake research that leads to improvements in the use of existing treatments through public health and primary care initiatives. Guidelines represent an important component of this approach, with recommendations for asthma imbedded within respiratory guidelines that can be implemented in the developing world where other acute and chronic respiratory disorders are common. This approach offers the best opportunity to close the gap between what is currently achieved in asthma management and that which is potentially achievable.

Airway obstruction at time of symptoms prompting use of reliever therapy in children with asthma

BACKGROUND

In asthma treatment, doses of inhaled corticosteroids are often adapted to symptoms and need for bronchodilators. However, in cross-sectional studies in emergency room settings, lung function and respiratory symptoms are not always concordant. Available longitudinal data are based on written peak flow diaries, which are unreliable. Using home spirometry, we studied prospectively whether mild respiratory symptoms, prompting reliever therapy are accompanied by a clinically relevant drop in lung function in children with asthma.

METHODS

For 8 weeks, children with asthma scored symptoms and measured peak expiratory flow (PEF) and forced expiratory volume in 1 sec (FEV(1)) on a home spirometer twice daily. Additional measurements were recorded when respiratory symptoms prompted them to use bronchodilators.

RESULTS

The mean difference between symptom free days and at times of symptoms was 6.6% of personal best for PEF (95% CI: 3.2-10.0; p = 0.0004) and 6.0% of predicted for FEV(1) (95% CI: 3.0-9.0; p = 0.0004). There was complete overlap in PEF and FEV(1) distributions between symptom free days and at times of symptoms.

CONCLUSIONS

Although statistically significant, the degree of airway narrowing at times of respiratory symptoms, prompting the use of reliever therapy, is highly variable between patients, limiting the usefulness of home spirometry to monitor childhood asthma.

The effectiveness of computerized clinical guidelines in the process of care: a systematic review

BACKGROUND

Clinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.This systematic review assesses the impact of CCG on the process of care compared with non-computerized clinical guidelines.

METHODS

Specific features of CCG were studied through an extensive search of scientific literature, querying electronic databases: Pubmed/Medline, Embase and Cochrane Controlled Trials Register. A multivariable logistic regression was carried out to evaluate the association of CCG's features with positive effect on the process of care.

RESULTS

Forty-five articles were selected. The logistic model showed that Automatic provision of recommendation in electronic version as part of clinician workflow (Odds Ratio [OR]= 17.5; 95% confidence interval [CI]: 1.6-193.7) and Publication Year (OR = 6.7; 95%CI: 1.3-34.3) were statistically significant predictors.

CONCLUSIONS

From the research that has been carried out, we can conclude that after implementation of CCG significant improvements in process of care are shown. Our findings also suggest clinicians, managers and other health care decision makers which features of CCG might improve the structure of computerized system.