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Overmann KM, Vukovic AA, Britto MT. A Content Analysis of Emergency Department Discharge Instructions for Acute Pediatric Febrile Illnesses: The Current State and Opportunities for Improvement. J Patient Exp 2021; 8:23743735211060773. [PMID: 34869843 PMCID: PMC8640326 DOI: 10.1177/23743735211060773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Quality emergency department (ED) discharge communication is critical to understanding of disease progression, home management, and return instructions. Addressing social aspects of disease burden are important to improving satisfaction and healthcare utilization. The objective of this study was to understand the extent to which written ED discharge instructions address multifaceted aspects of disease to meet the comprehensive needs of families with common childhood illnesses. We analyzed a national sample of 28 written discharge instructions from pediatric EDs using thematic and inductive content analysis. Seven themes were identified. Nearly all discharge instructions devoted a majority of content to themes related to disease physiology. Other themes common to instructions were related to parental instructions for caring for the child and when to return for further care. Content on caregiver reassurance, returning to daily activities, improving well-being, and promoting community health were not a focus of discharge instructions. Inclusion of multifaceted discharge materials which address both medical and social aspects of disease may help improve family-centered emergency care and the quality of care transitions for common childhood illnesses.
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Affiliation(s)
- Kevin M Overmann
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Adam A Vukovic
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Maria T Britto
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Adolescent Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Shah AY, Dooley D, Shelef DQ, Patel SJ. Improving Asthma Outcomes in Children: From the Emergency Department and Into the Community. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abir M, Truchil A, Wiest D, Nelson DB, Goldstick JE, Koegel P, Lozon MM, Choi H, Brenner J. Cluster Analysis of Acute Care Use Yields Insights for Tailored Pediatric Asthma Interventions. Ann Emerg Med 2017; 70:288-299.e2. [PMID: 28757228 DOI: 10.1016/j.annemergmed.2017.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 04/17/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE We undertake this study to understand patterns of pediatric asthma-related acute care use to inform interventions aimed at reducing potentially avoidable hospitalizations. METHODS Hospital claims data from 3 Camden city facilities for 2010 to 2014 were used to perform cluster analysis classifying patients aged 0 to 17 years according to their asthma-related hospital use. Clusters were based on 2 variables: asthma-related ED visits and hospitalizations. Demographics and a number of sociobehavioral and use characteristics were compared across clusters. RESULTS Children who met the criteria (3,170) were included in the analysis. An examination of a scree plot showing the decline in within-cluster heterogeneity as the number of clusters increased confirmed that clusters of pediatric asthma patients according to hospital use exist in the data. Five clusters of patients with distinct asthma-related acute care use patterns were observed. Cluster 1 (62% of patients) showed the lowest rates of acute care use. These patients were least likely to have a mental health-related diagnosis, were less likely to have visited multiple facilities, and had no hospitalizations for asthma. Cluster 2 (19% of patients) had a low number of asthma ED visits and onetime hospitalization. Cluster 3 (11% of patients) had a high number of ED visits and low hospitalization rates, and the highest rates of multiple facility use. Cluster 4 (7% of patients) had moderate ED use for both asthma and other illnesses, and high rates of asthma hospitalizations; nearly one quarter received care at all facilities, and 1 in 10 had a mental health diagnosis. Cluster 5 (1% of patients) had extreme rates of acute care use. CONCLUSION Differences observed between groups across multiple sociobehavioral factors suggest these clusters may represent children who differ along multiple dimensions, in addition to patterns of service use, with implications for tailored interventions.
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Affiliation(s)
- Mahshid Abir
- Department of Emergency Medicine, Acute Care Research Unit, University of Michigan, Ann Arbor, MI; RAND Corporation, Santa Monica, CA.
| | - Aaron Truchil
- Camden Coalition of Healthcare Providers, Camden, NJ
| | - Dawn Wiest
- Camden Coalition of Healthcare Providers, Camden, NJ
| | | | | | | | - Marie M Lozon
- University of Michigan Medical School, Ann Arbor, MI
| | - Hwajung Choi
- University of Michigan Medical School, Ann Arbor, MI
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Bilal M, Haseeb A, Khan MH, Saad M, Devi S, Arshad MH, Alam A, Wagley AM, Javed KMAA. Factors associated with patient visits to the emergency department for asthma therapy in Pakistan. ASIA PACIFIC FAMILY MEDICINE 2016; 15:1. [PMID: 26839510 PMCID: PMC4736181 DOI: 10.1186/s12930-016-0026-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 01/05/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND Acute asthma is a chronic condition affecting people of all ages around the world and hence, is one of the leading causes of emergency department (ED) visits and hospital admissions globally. Most of them are related to poor patient practices and a weak healthcare system. The aim of our study was to assess the reasons for the increased usage of the ED by asthmatic patients in Pakistan. METHODS A cross-sectional study was conducted on 600 asthmatic patients reporting to the ED of Civil Hospital Karachi over a 6-month period. The consenting patients were given a questionnaire to fill and the following data was collected: demographic information, duration of the disease, medications prescribed the, frequency of and reasons for outpatient clinic and ED visits for issues related to asthma. RESULT According to our results most of the participants visited the ED to obtain a nebulized bronchodilator (90 %) or oxygen (79.5 %). Moreover, 44.8 % of the people visited the ED to get treatment without any delay and 24.0 % considered that the severity of asthma does not allow the patient to wait for clinic visits. Strikingly, 92.8 % claimed that inhaled corticosteroid therapy treatment should be stopped when patients feel better. Irregular follow ups with clinics, low education about asthma and an education level higher than a Bachelors degree were the most important factors associated with three or more ED visits per year, p values = 0.0289, 0.0110 and 0.0150 respectively. CONCLUSION This study identifies several preventable risk factors responsible for recurrent visits to the ED by asthmatic patients in Pakistan.
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Affiliation(s)
| | - Abdul Haseeb
- />Dow University Of Health Sciences, Karachi, Pakistan
| | | | - Muhammad Saad
- />Jinnah Postgraduate Medical Centre, Karachi, Pakistan
| | - Sapna Devi
- />Ziauddin University and Hospital, Karachi, Pakistan
| | | | - Anusha Alam
- />Department of Biological Sciences, The Lyceum, Karachi, Pakistan
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Harrington KF, Zhang B, Magruder T, Bailey WC, Gerald LB. The Impact of Parent's Health Literacy on Pediatric Asthma Outcomes. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2015; 28:20-26. [PMID: 25852967 DOI: 10.1089/ped.2014.0379] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 09/17/2014] [Indexed: 11/12/2022]
Abstract
Background: Health literacy has been associated with health disparities in many disease outcomes, including children's asthma. Parents are responsible for most of children's healthcare. Therefore, parents' health literacy may impact children's health outcomes, including asthma control. This study sought to determine the association between parent health literacy and children's asthma control among a cohort of predominately minority urban children aged between 6 and 12 years. Methods: This cross-sectional study assessed children with asthma and their parents at a single outpatient visit. English-speaking parents and their children, aged between 6 and 12 years with physician-diagnosed asthma, were eligible for this study. Healthcare providers assessed asthma control and severity, and parents completed demographic, health literacy, asthma control, and asthma knowledge measures. Children completed a pulmonary function test as part of the Asthma Control Questionnaire (ACQ) scoring. Results: A total of 281 parent-child dyads provided data, with the majority of parents being mothers and African American, with a high school level education or less. Lower parent health literacy was associated with worse asthma control as rated both by the provider (p=0.007) and the ACQ (p=0.013), despite only moderate concordance between ratings (ρ=0.408, p<0.0001). Lower parent health literacy also was associated with less asthma knowledge, which was associated with worse asthma control. Conclusions: Higher parent health literacy was associated with more parent asthma knowledge and better child asthma control. Pediatric providers should consider tailoring education or treatment plans or utilizing universal precautions for low health literacy.
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Affiliation(s)
- Kathleen F Harrington
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
| | - Teresa Magruder
- Division of Pulmonary and Sleep Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - William C Bailey
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham , Birmingham, Alabama
| | - Lynn B Gerald
- Mel and Enid Zuckerman College of Public Health and the Arizona Respiratory Center, University of Arizona , Tucson, Arizona
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Knowlton A, Weir BW, Hughes BS, Southerland RJH, Schultz CW, Sarpatwari R, Wissow L, Links J, Fields J, McWilliams J, Gaasch W. Patient demographic and health factors associated with frequent use of emergency medical services in a midsized city. Acad Emerg Med 2013; 20:1101-11. [PMID: 24238312 DOI: 10.1111/acem.12253] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 05/10/2013] [Accepted: 08/09/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To optimize health care utilization, health outcomes, and costs, research is needed to improve an understanding of frequent users of emergency health services. Frequent use of emergency services is associated with high costs of health care and may be indicative of challenges accessing, or poor outcomes of, health care. Patient demographics and health factors related to frequent use of the emergency medical services (EMS) system of a midsized city were identified. Study findings will aid in the development of targeted interventions to improve population health. METHODS The authors reviewed 9-1-1 call dispatch data and Baltimore City Fire Department (BCFD) EMS records from 2008 through 2010. Frequent use was defined as six or more EMS incidents in the 23-month period. Analyses used census data to compare demographics of EMS users to their population distribution and examined differences in demographics and health problems of frequent EMS users compared to nonfrequent users. RESULTS Frequent EMS users (n = 1,969) had a range of six to 199 EMS incidents (mean = 11.2) during the observation period, and although they accounted for only 1.5% of EMS users, they were involved in 12.0% of incidents. Frequent users, compared to nonfrequent users and to the population, were more likely to be male, African American, and 45 years of age or older. Of frequent users, the modal age group was 45 to 54 years, accounting for 29.7% of frequent users, which represented twice this age group's population distribution. Furthermore, this age group had the greatest overrepresentation of males (63.0% of frequent users) and was the peak age group for incidents related to substance abuse (28.0% of frequent users' incidents in this age group). Frequent users, compared to nonfrequent users, had lower levels of incidents related to trauma (5.1% vs. 16.7%) and higher levels of medical incidents (94.8% vs. 82.9%). As proportions of EMS incidents among frequent versus nonfrequent users, respiratory, mental health, and seizure-related incidents were highest in the youngest age groups; substance abuse-related incidents were highest in those middle-aged (35 to 44 and 45 to 54 years). Of health problems, behavioral health (mental health or substance use) contributed most to frequent EMS use (23.4% of frequent users' incidents). Across all incidents, 65.8% of frequent users had indications of behavioral health problems, representing 6.6-fold higher odds than nonfrequent users (22.5%). Frequent compared to nonfrequent users also had higher levels of select chronic conditions (diabetes, 39.9% vs. 14.6%; asthma, 40.9% vs. 13.4%; and HIV, 9.1% vs. 2.4%), with unadjusted odds almost four to seven times higher. CONCLUSIONS The study findings revealed the major role of chronic somatic and behavioral health problems in frequent EMS use and that rates of frequent use were highest among those middle-aged, African American, and male. These results suggest the need for coordination of EMS with community-based, integrated medical and behavioral health services to improve access and use of preventive services, with implications for health outcomes and costs. This study demonstrates the value of EMS patient data in identifying at-risk populations and informing novel, targeted approaches to public health interventions.
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Affiliation(s)
- Amy Knowlton
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Brian W. Weir
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Brenna S. Hughes
- Goucher College; Post-Baccalaureate Premedical Program; Baltimore MD
| | | | - Cody W. Schultz
- Goucher College; Post-Baccalaureate Premedical Program; Baltimore MD
| | - Ravi Sarpatwari
- Goucher College; Post-Baccalaureate Premedical Program; Baltimore MD
| | - Lawrence Wissow
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- The Departments of Psychiatry and Pediatrics; Johns Hopkins School of Medicine; Baltimore MD
| | - Jonathan Links
- The Department of Environmental Health Sciences; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- The Department of Emergency Medicine; Johns Hopkins School of Medicine; Baltimore MD
| | - Julie Fields
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- The Department of Emergency Medicine; Johns Hopkins School of Medicine; Baltimore MD
| | - Junette McWilliams
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Wade Gaasch
- The Department of Emergency Medicine; University of Maryland School of Medicine; Baltimore MD
- The Baltimore City Fire Department; Baltimore MD
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Canino G, Garro A, Alvarez MM, Colón-Semidey A, Esteban C, Fritz G, Koinis-Mitchell D, Kopel SJ, Ortega AN, Seifer R, McQuaid EL. Factors associated with disparities in emergency department use among Latino children with asthma. Ann Allergy Asthma Immunol 2012; 108:266-70. [PMID: 22469447 PMCID: PMC3324101 DOI: 10.1016/j.anai.2012.02.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 01/18/2012] [Accepted: 02/01/2012] [Indexed: 01/02/2023]
Abstract
BACKGROUND Significant disparities in emergency department (ED) rates exist for Latinos; however, few studies have investigated the factors that may account for these disparities. OBJECTIVES To examine individual/family and health system factors among Latino and non-Latino white (NLW) children with asthma to explain disparities in ED rates. METHODS The study was carried out in Puerto Rico (PR) and Rhode Island (RI) with the same design: a cross-sectional, observational approach with repeated measurements of selected variables. RESULTS The sample was composed of 804 children ages 7 to 15 years, with 405 from PR and 399 from RI. Latino children from both sites had significantly higher rates of ED use as compared with NLWs from RI. Regression analyses showed site, asthma control, parental reported severity of asthma and public insurance to be significantly associated with ED use. CONCLUSION Latino ethnicity and public insurance were among the most important factors related to frequent ED use. Revisions of the policies driving public insurance to assure better access to specialists, preventive education, and evidence-based treatment are needed. The results also suggest the need for the development of interventions in the ED that are geared toward educating families on how best to use emergency services.
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Affiliation(s)
- Glorisa Canino
- University of Puerto Rico, Medical Sciences Campus, Behavioral Sciences Research Institute, San Juan, Puerto Rico.
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Clark N, Lachance L, Milanovich AF, Stoll S, Awad DF. Characteristics of successful asthma programs. Public Health Rep 2009; 124:797-805. [PMID: 19894421 DOI: 10.1177/003335490912400606] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We identified characteristics of interventions associated with positive asthma outcomes to understand how programs can be improved. METHODS We identified asthma interventions from the peer-reviewed literature or through a nomination process for unpublished programs. Initially, we identified 532 interventions. Of those, 223 met our eligibility criteria (e.g., focus on asthma, completed an evaluation, and demonstrated at least one asthma-related health outcome) and provided information on program components and processes, administration, evaluation, and findings through telephone interviews, program documents, and published reports. We analyzed bivariate relationships between programmatic factors and outcomes using Chi-square statistics, Fisher's exact tests, and unconditional logistic regression. We confirmed findings for all programs by analyzing the subset with published results in peer-reviewed journals. RESULTS Our findings indicated that programs were more likely to report a positive impact on health outcomes if they (1) were community based, (2) engaged the participation of community-based organizations, (3) provided program components in a clinical setting, (4) provided asthma training to health-care providers, (5) collaborated with other organizations and institutions and with government agencies, (6) designed a program for a specific racial/ethnic group, (7) tailored content or delivery based on individual health or educational needs, and (8) conducted environmental assessments and tailored interventions based on these assessments. CONCLUSIONS Positive asthma outcomes were associated with specific program characteristics: being community centered, clinically connected, and continuously collaborative. Program developers and implementers who build these characteristics into their interventions will be more likely to realize desired asthma outcomes.
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Affiliation(s)
- Noreen Clark
- Center for Managing Chronic Disease, University of Michigan, Ann Arbor, MI 48109-2029, USA.
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Tolomeo C, Savrin C, Heinzer M, Bazzy-Asaad A. Predictors of Asthma-related Pediatric Emergency Department Visits and Hospitalizations. J Asthma 2009. [DOI: 10.1080/02770900903162753] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Forester JP, Ong BA, Fallot A. Can equal access to care eliminate racial disparities in pediatric asthma outcomes? J Asthma 2008; 45:211-4. [PMID: 18415828 DOI: 10.1080/02770900801890448] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A survey was given to the parents of 80 children with asthma between the ages of 3 and 18 years at the Pediatric Pulmonology Clinics of three military treatment facilities to evaluate asthma management and outcomes for different racial groups. Results demonstrated that management practices for the three groups were similar and that there were no significant differences in emergency department visits, prescription of oral steroids, or in the number of hospitalizations across the three groups. These findings suggest that equal access to care may allow children of different racial backgrounds to receive similar asthma care and achieve similar outcomes.
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Affiliation(s)
- Joseph P Forester
- US Air Force Academy, 10th MDG, Department of Pediatrics, USAFA, Colorado 80840, USA.
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Rodriguez-Martinez CE, Sossa MP, Castro-Rodriguez JA. Factors associated to recurrent visits to the emergency department for asthma exacerbations in children: implications for a health education programme. Allergol Immunopathol (Madr) 2008; 36:72-8. [PMID: 18479658 DOI: 10.1157/13120391] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Recurrent emergency department (ED) visits for asthma exacerbations produce anxiety as well as high costs to the health system and the family. OBJECTIVE To identify factors associated with recurrent ED visits for asthma exacerbations in children in Bogotá, Colombia. METHODS Data obtained from a survey of parents of 223 patients with asthma (mean +/- SD: 4.8+/-3.5 years of age) attending an asthma clinic were analysed. Demographic data and a broad asthma knowledge and attitudes questionnaire were completed by the parents. RESULTS Of the 223 asthmatic patients enrolled, 60 (26.9 %) had 3 or more visits to the ED for asthma in the last 6 months ("recurrent ED visits"). After controlling by age, educational level of the father, and severity of the disease; parents of children with "recurrent ED visits" were more prone to report that they attended ED because the asthma exacerbations were severe enough to go to the primary care physician (OR, 2.45; CI 95 %, 1.13-5.30; p=0.02); that asthma medications should be administered only when the children are symptomatic (OR, 3.26; CI 95 %, 1.45-7.36; p=0.004), and conversely they were less prone to have knowledge that asthma exacerbations can be avoided if medications are administered in the asymptomatic periods (OR, 0.31; CI 95 %, 0.14-0.68; p=0.003). CONCLUSIONS An educational programme intended to reduce the recurrent ED visits for asthma exacerbations should consider the inclusion of an explanation about the chronic nature of the disease and the importance of long-term therapy.
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Affiliation(s)
- C E Rodriguez-Martinez
- Department of Pediatric Respiratory Medicine, Clínica Colsánitas, Clínica Infantil Colsubsidio, Bogotá, Colombia.
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Martinez CER, Sossa MP, Rand CS. Validation of a Questionnaire for Assessing Adherence to Metered-Dose Inhaler Use in Asthmatic Children. ACTA ACUST UNITED AC 2007. [DOI: 10.1089/pai.2007.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ng TP, Lim TK, Abisheganaden J, Eng P, Sin FL. Factors associated with acute health care use in a national adult asthma management program. Ann Allergy Asthma Immunol 2007; 97:784-93. [PMID: 17201238 DOI: 10.1016/s1081-1206(10)60970-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of acute health care resources for asthma is considerable. Disease severity is an established risk factor, but ethnicity and health care factors are less well studied. OBJECTIVE To investigate the independent associations of ethnicity and health care factors with acute resource use for asthma. METHODS Longitudinal data from a national adult asthma management program providing universal access to care were analyzed. Outcome measures were unscheduled physician visits with urgent nebulization, emergency department (ED) visits, and hospitalizations. RESULTS In multivariate analyses, markers of disease severity were found to be significantly associated with all acute resource use. After controlling for disease severity, ethnicity was associated with increased risk of all acute resource use; Indian (vs Chinese) ethnicity was associated with increased risk of unscheduled physician visits (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.03-1.70), ED visits (HR, 1.61; 95% CI, 1.12-2.32), and hospitalizations (HR, 1.49; 95% CI, 1.03-2.16). Malay ethnicity was associated with unscheduled physician visits (HR, 1.30; 95% CI, 1.01-1.68) and ED visits (HR, 1.55; 95% CI, 1.09-2.19). Default of follow-up appointments was associated with unscheduled physician visits (HR, 1.47; 95% CI, 1.08-2.00), ED visits (HR, 2.35; 95% CI, 1.59-3.45), and hospitalizations (HR, 1.74; 95% CI, 1.09-2.76). Poor inhaler technique was associated with ED visits (HR, 1.86; 95% CI, 1.05-3.30) and smoking with unscheduled physician visits (HR, 1.38; 95% CI, 1.09-1.76). CONCLUSIONS In addition to markers of asthma severity, ethnicity, smoking, discontinuity of care, and self-care behavior are risk factors for acute resource utilization and represent target groups and elements of asthma intervention for improving asthma outcomes.
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Affiliation(s)
- Tze-Pin Ng
- Gerontological Research Programme, Faculty of Medicine, and Department of Psychological Medicine, National University of Singapore, Singapore.
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Brown MD, Reeves MJ, Meyerson K, Korzeniewski SJ. Randomized trial of a comprehensive asthma education program after an emergency department visit. Ann Allergy Asthma Immunol 2006; 97:44-51. [PMID: 16892780 DOI: 10.1016/s1081-1206(10)61368-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with asthma who visit the emergency department (ED) may benefit from education that optimizes self-management and treatment. OBJECTIVE To conduct a randomized trial of asthma education (AE) after an ED visit. METHODS Patients who present with acute asthma and history consistent with moderate to severe persistent asthma or recent ED visits were stratified by age (adult, child) and randomly assigned to intervention or usual care during the ED visit. The intervention was conducted by trained asthma educators and included a facilitated office visit with the primary care physician followed by a home visit. Intention-to-treat analysis was conducted, with time to first asthma relapse (either ED or unscheduled urgent office visit) during the 6-month follow-up period used as the primary outcome. RESULTS Of the 239 patients analyzed, 46% were adults, 46% were male, 30% were African American, and 56% had moderate to severe persistent asthma. Follow-up information was obtained on 191 patients (80%) at 6 months; 23.1% of the intervention group vs 31.1% of the usual care group had an urgent asthma visit (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.48-1.29). Overall, 39% of the 117 patients assigned to the intervention group did not comply with any of the post-ED activities. Subgroup analysis suggested greater benefit among children (HR, 0.62; 95% CI, 0.33-1.19) than adults (HR, 1.08; 95% CI, 0.50-2.33). CONCLUSIONS Delivery of a comprehensive AE program after an ED visit was ineffective in adult patients; however, it may be effective in children. Further research on alternative AE delivery strategies appears warranted to reduce the burden of asthma visits to the ED.
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Affiliation(s)
- Michael D Brown
- Grand Rapids MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, Michigan, USA
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Smith SR, Jaffe DM, Highstein G, Fisher EB, Trinkaus KM, Strunk RC. Asthma coaching in the pediatric emergency department. Acad Emerg Med 2006; 13:835-9. [PMID: 16825669 DOI: 10.1197/j.aem.2006.03.565] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Coaching and monetary incentives have been used to modify medical behavior of individuals with several chronic diseases, including asthma. The authors performed a randomized, controlled trial of an intervention combining asthma coaching during an emergency department (ED) visit for asthma, and monetary incentive to improve follow-up with primary care providers (PCP). METHODS Subjects were parents of children 2-12 years of age, with Medicaid or no medical insurance, receiving treatment for asthma in the ED. The primary outcome was a verified PCP visit for asthma within two weeks of the index ED visit. All parents received 15 dollars for their time in the ED. Parents in the intervention group were told that they would receive an additional 15 dollars monetary incentive if a PCP visit was completed. The coach engaged in a dialogue with the parent during the ED visit, and discussed the importance and advantages of seeking follow-up care with the child's PCP. All parents received the usual discharge instructions, including advice to see the PCP within three days. RESULTS The authors enrolled 92 parents; outcome data were available for 86 (42 controls, 50 intervention). Demographic characteristics were similar in both groups. There was no significant difference in the proportion of patients who had follow-up PCP visits between the intervention (22.0%; 95% confidence interval [95% CI] = 11.5% to 36.0%) and control (23.8%; 95% CI = 12.0% to 39.4%) groups (p = 0.99). CONCLUSIONS An intervention combining asthma coaching during acute ED visits and a monetary incentive to return for a PCP visit does not appear to increase follow-up with the PCP.
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Affiliation(s)
- Sharon R Smith
- Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO, USA.
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Reeves MJ, Bohm SR, Korzeniewski SJ, Brown MD. Asthma care and management before an emergency department visit in children in western Michigan: how well does care adhere to guidelines? Pediatrics 2006; 117:S118-26. [PMID: 16777827 DOI: 10.1542/peds.2005-2000i] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Asthma is one of the more common reasons for children's visits to the emergency departments (EDs). Many studies show that the level of asthma care and self-management in children before an ED visit for asthma is often inadequate; however, most of these studies have been conducted in the inner cities of large urban areas. Our objectives were to describe asthma care and management in children treated for asthma in 3 EDs located in an urban, suburban, or rural setting. METHODS We studied a prospective patient cohort consisting of children aged 2 to 17 years who presented with an acute asthma exacerbation at 3 EDs in western Michigan. An in-person questionnaire was administered to the parent or guardian during the ED visit. Information was collected on demographics; asthma history; usual asthma care; frequency of symptoms during the last 4 weeks; current asthma treatment, management, and control; and past emergency asthma care. A telephone interview conducted 2 weeks after the ED visit obtained follow-up information. The 8 quality indicators of asthma care and management were defined based on recommendations from national guidelines. RESULTS Of 197 children, 70% were enrolled at the urban site, 18% at the suburban site, and 12% at the rural site. The average age was 7.9 years; 60% were male, and 33% were black. At presentation, nearly half (46%) of the children had mild intermittent asthma, 20% had mild persistent asthma, 15% had moderate persistent asthma, and 19% had severe persistent asthma. One quarter of the children had been hospitalized for asthma, and two thirds had at least 1 previous ED visit in the past year. At least 94% had health insurance coverage and 95% reported having a primary care provider. Less than half of the children had attended at least 2 scheduled asthma appointments with their regular asthma care provider in the past year. Although only 5% of the subjects reported that the ED was their only source of asthma care, at least 30% reported that they always went directly to the ED when they needed urgent asthma care. Only 3 in 5 children possessed either a spacer or a peak-flow meter, whereas approximately 2 in 5 reported having a written asthma action plan. Among those with persistent asthma, there was considerable evidence of undertreatment, with 36% not on either an inhaled corticosteroid or a suitable long-term control medication. Only 20% completed a visit with their regular asthma care provider within 1 week of their ED visit. CONCLUSIONS Despite very high levels of health care coverage and access to primary care, the overall quality of asthma care and management fell well short of that recommended by national guidelines.
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Affiliation(s)
- Mathew J Reeves
- Department of Epidemiology, B 601 West Fee Hall, College of Human Medicine, Michigan State University, East Lansing, Michigan 48824, USA.
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Sockrider MM, Abramson S, Brooks E, Caviness AC, Pilney S, Koerner C, Macias CG. Delivering tailored asthma family education in a pediatric emergency department setting: a pilot study. Pediatrics 2006; 117:S135-44. [PMID: 16777829 DOI: 10.1542/peds.2005-2000k] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Many children are brought to the pediatric emergency department (ED) with acute asthma symptoms. Emergency asthma care is costly, and many ED visits may be preventable. Families often do not have written asthma action plans and lack asthma self-management skills. This study tests a tailored self-management intervention delivered in the ED for families of children with asthma. The primary hypotheses were that the intervention group would have greater confidence to manage asthma 14 days postintervention and more well-asthma visits and fewer urgent care/ED visits at 9 and 12 months. METHODS This randomized intervention/usual-care study was part of a larger ED asthma surveillance project in 4 urban pediatric ED sites. Asthma educators used a computer-based resource to tailor the intervention messages and provide a customized asthma action plan and educational summary. Children with acute asthma were enrolled during an ED visit, and follow-up telephone interviews were conducted during the next 9 months. The ED clinician classified the child's acute and chronic severity. RESULTS To date, 464 subjects aged 1 to 18 years have been enrolled. The ED clinicians reported that 46% had intermittent and 54% had persistent chronic severity with 51% having mild acute severity episodes. The confidence level to prevent asthma episodes and keep them from getting worse was significantly higher in the intervention group at 14 days postintervention. More subjects in the intervention group reported well-asthma visits by 9 months. Return ED visits were significantly lower in the intervention group in those with intermittent asthma. Twelve-month follow-up is in process. CONCLUSIONS The tailored ED self-management intervention demonstrates significant effects on caregiver self-confidence and well-visit follow-up. Additional evaluation is needed to determine what impact this intervention has long-term.
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Affiliation(s)
- Marianna M Sockrider
- Department of Pediatrics, Baylor College of Medicine, 6621 Fannin, MC 1040.00, Houston, Texas 77030, USA.
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18
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Baren JM, Boudreaux ED, Brenner BE, Cydulka RK, Rowe BH, Clark S, Camargo CA. Randomized controlled trial of emergency department interventions to improve primary care follow-up for patients with acute asthma. Chest 2006; 129:257-265. [PMID: 16478839 DOI: 10.1378/chest.129.2.257] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Emergency department (ED) visits for asthma are frequent and may indicate increased morbidity and poor primary care access. Our objective was to compare the effect of two interventions on primary care follow-up after ED treatment for asthma exacerbations. METHODS We performed a randomized controlled trial of patients 2 to 54 years old who were judged safe for discharge receiving prednisone, and who were available for contact at 2 days and 30 days. Patients were excluded if they were previously enrolled or did not speak English. Patients received usual discharge care (group A); free prednisone, vouchers for transport to and from a primary care visit, and either a telephone reminder to schedule a visit (group B); or a prior scheduled appointment (group C). Follow-up with a primary care provider for asthma within 30 days was the main outcome. Secondary outcomes were recurrent ED visits, subsequent hospitalizations, quality of life, and use of inhaled corticosteroids 1 year later. RESULTS Three hundred eighty-four patients were enrolled. Baseline demographics, chronic asthma severity, and access to care were similar across groups. Primary care follow-up was higher in group C (65%) vs group A (42%) or group B (48%) [p = 0.002]. Group C intervention remained significant (odds ratio, 2.8; 95% confidence interval, 1.5 to 5.1) when adjusted for other factors influencing follow-up (prior primary care relationship, insurance status). There were no differences in ED, hospitalizations, quality of life, or inhaled corticosteroid use at 1 year after the index ED visit. CONCLUSION An intervention including free medication, transportation vouchers, and appointment assistance significantly increased the likelihood that discharged asthma patients obtained primary care follow-up but did not impact long-term outcomes.
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Affiliation(s)
- Jill M Baren
- Hospital of the University of Pennsylvania, Philadelphia, PA.
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- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Carlos A Camargo
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Benito-Fernández J. Short-term clinical outcomes of acute treatment of childhood asthma. Curr Opin Allergy Clin Immunol 2005; 5:241-6. [PMID: 15864082 DOI: 10.1097/01.all.0000168788.97453.02] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Acute exacerbations of asthma are the leading cause of emergency department visits in the pediatric patient. The present review is focused on the identification of those factors that may contribute to improving the short-term outcome of children after discharge from an emergency department visit for acute asthma. RECENT FINDINGS Several recent studies have documented that children treated at the emergency department because of an asthma-related event present a high morbidity at 7 and 15 days after discharge, mainly associated with symptom persistence, need for rescue bronchodilator medication, and absenteeism from school or day nursery. A better control of the disease, particularly adequate outpatient follow-up and maintenance treatment with inhaled steroids, could improve short-term clinical outcomes. SUMMARY All efforts of emergency room management of children with asthma, identification of severity of the current exacerbation episode, and intensive treatment of the acute asthma attack have usually been directed at reducing the rates of hospitalization and the return for medical care. However, according to reported data on short-term morbidity, it is necessary to define therapeutic and follow-up strategies after treatment for acute asthma and emergency department discharge. Besides standard treatment for an acute asthma exacerbation in a pediatric emergency department, action plans should include a review of the maintenance treatment of asthma to improve underlying disease control and a strong recommendation for close follow-up by the primary care pediatrician.
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Affiliation(s)
- Javier Benito-Fernández
- Department of Pediatrics, Basque Country University, Hospital de Cruces, Barakaldo, Bizkaia, Spain.
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Gendo K, Lodewick MJ. Asthma economics: focusing on therapies that improve costly outcomes. Curr Opin Pulm Med 2005; 11:43-50. [PMID: 15591887 DOI: 10.1097/01.mcp.0000146782.11092.d6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In 1998, the economic burden of asthma was estimated to be 12.7 billion dollars. Subsequent research has focused on identifying important outcomes that reflect high resource utilization and finding therapies that improve these outcomes and decrease cost. Recent developments include an update to the National Heart, Lung, and Blood Institute (NHLBI) guidelines, new treatment strategies using combination therapy, and the development of a monoclonal antibody therapy for asthma. RECENT FINDINGS Two important costly outcomes are asthma-related hospitalizations and emergency department visits. Asthma-related hospitalizations started to decline in the 1990s, primarily in white Americans, but not in young African Americans. Many hospitalizations and emergency department visits are preventable, and costs were lowered by shifting management to the ambulatory care setting. Increased asthma severity and suboptimal compliance with NHLBI asthma care guidelines can contribute to the persistence of symptoms, which triggers behaviors that increase resource utilization.A recent economic analysis was one of the first well-controlled clinical trials to show that inhaled corticosteroids provide clinical benefit at modest costs. Combination therapy, particularly that containing an inhaled corticosteroid and long-acting bronchodilator in a single inhaler, potentially can reduce overall costs by improving compliance with inhaled corticosteroids. Nonpharmacologic therapies also have been shown to be cost-effective. However, a significant number of patients with asthma continue to have symptoms even while on recommended controller therapy. Omalizumab, a monoclonal antibody treatment that binds IgE, was released in the summer of 2003. SUMMARY Many costly asthma-related hospitalizations and emergency department visits are preventable, and chronic disease care can be shifted to the ambulatory setting. Increased asthma severity and noncompliance with NHLBI guidelines are associated with increased resource utilization. Combination therapies can assist in improving patient compliance, and omalizumab potentially offers a novel but expensive way to decrease symptoms and resource utilization.
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Affiliation(s)
- Karna Gendo
- Group Health Eastside Hospital, Redmond, WA 98052, USA.
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Vlasnik JJ, Aliotta SL, DeLor B. Medication adherence: Factors influencing compliance with prescribed medication plans. ACTA ACUST UNITED AC 2005; 16:47-51. [PMID: 15818344 DOI: 10.1016/j.casemgr.2005.01.009] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Maziak W, von Mutius E, Keil U, Hirsch T, Leupold W, Rzehak P, Behrens T, Weiland SK. Predictors of health care utilization of children with asthma in the community. Pediatr Allergy Immunol 2004; 15:166-71. [PMID: 15059195 DOI: 10.1046/j.1399-3038.2003.00105.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study was to assess the pattern of use of health care services among children with asthma symptoms within the community, and assess groups at increased risk of emergency department (ED) visits or hospital admissions (HA). Using International Study of Asthma and Allergies in Childhood phase II protocol, information about asthma management and utilization of health care services was collected by parental questionnaire in a community-based random sample of 5-7- and 9-11-year-old children (n = 11,094) in Dresden and Munich. Only 11.2% of children with current wheeze did not utilize any health care facility or consultation for their asthma symptoms in the 12 months prior to survey, while 86.2%, 12.3%, and 3.6% had at least one asthma related physician's consultation, ED visits, or HA, respectively. Predictors of ED visits and HA among current wheezers were: younger age, male gender, speech-limiting wheeze, level of exposure to environmental tobacco smoke. In addition, children of low socioeconomic status were more likely to have ED visits because of their asthma. Childhood asthma is a major public health problem in Germany leading to substantial morbidity and utilization of health care services. Exposure to tobacco smoke comes out as the major modifiable risk factor related to asthma morbidity in children.
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Affiliation(s)
- Wasim Maziak
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
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Osborne M, Deffebach M. The epidemiology and natural history of asthma: Outcomes and Treatment Regimens (TENOR) study. Ann Allergy Asthma Immunol 2004; 92:3-4. [PMID: 14756457 DOI: 10.1016/s1081-1206(10)61702-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Miller K, Ward-Smith P, Cox K, Jones EM, Portnoy JM. Development of an asthma disease management program in a children's hospital. Curr Allergy Asthma Rep 2003; 3:491-500. [PMID: 14531970 DOI: 10.1007/s11882-003-0060-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The incidence, morbidity, and mortality of asthma have been increasing at an alarming rate, making asthma the most common chronic illness of childhood. An asthma disease management program was developed to improve the care and management of patients with asthma--a comprehensive health care delivery model that was designed to improve the management of patients with asthma was designed and implemented. The goal of the program was to provide high-quality interventions for those children diagnosed with asthma. The asthma disease management program at Children's Mercy Hospital improved the care received, decreased costs, and improved the quality of life for those children with asthma.
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Affiliation(s)
- Kelly Miller
- Patient Care Services, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Hartert TV. Acute asthma care interventions in improving asthma outcomes: putting guidelines into action. Ann Allergy Asthma Immunol 2003; 90:8-9. [PMID: 12546329 DOI: 10.1016/s1081-1206(10)63604-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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