Factors associated with increased healthcare utilization among adults with asthma

A 360 degree mixed-methods evaluation of a specialized COVID-19 outpatient clinic and remote patient monitoring program

BACKGROUND

Our goals are to quantify the impact on acute care utilization of a specialized COVID-19 clinic with an integrated remote patient monitoring program in an academic medical center and further examine these data with stakeholder perceptions of clinic effectiveness and acceptability.

METHODS

A retrospective cohort was drawn from enrolled and unenrolled ambulatory patients who tested positive in May through September 2020 matched on age, presence of comorbidities and other factors. Qualitative semi-structured interviews with patients, frontline clinician, and administrators were analyzed in an inductive-deductive approach to identify key themes.

RESULTS

Enrolled patients were more likely to be hospitalized than unenrolled patients (N = 11/137 in enrolled vs 2/126 unenrolled, p = .02), reflecting a higher admittance rate following emergency department (ED) events among the enrolled vs unenrolled, though this was not a significant difference (46% vs 25%, respectively, p = .32). Thirty-eight qualitative interviews conducted June to October 2020 revealed broad stakeholder belief in the clinic's support of appropriate care escalation. Contrary to beliefs the clinic reduced inappropriate care utilization, no difference was seen between enrolled and unenrolled patients who presented to the ED and were not admitted (N = 10/137 in enrolled vs 8/126 unenrolled, p = .76). Administrators and providers described the clinic's integral role in allowing health services to resume in other areas of the health system following an initial lockdown.

CONCLUSIONS

Acute care utilization and multi-stakeholder interviews suggest heightened outpatient observation through a specialized COVID-19 clinic and remote patient monitoring program may have contributed to an increase in appropriate acute care utilization. The clinic's role securing safe reopening of health services systemwide was endorsed as a primary, if unmeasured, benefit.

Asthma in the Americas: An Update: A Joint Perspective from the Brazilian Thoracic Society, Canadian Thoracic Society, Latin American Thoracic Society, and American Thoracic Society

Asthma affects a large number of people living in the Americas, a vast and diverse geographic region comprising 35 nations in the Caribbean and North, Central, and South America. The marked variability in the prevalence, morbidity, and mortality from asthma across and within nations in the Americas offers a unique opportunity to improve our understanding of the risk factors and management of asthma phenotypes and endotypes in children and adults. Moreover, a better assessment of the causes and treatment of asthma in less economically developed regions in the Americas would help diagnose and treat individuals migrating from those areas to Canada and the United States. In this focused review, we first assess the epidemiology of asthma, review known and potential risk factors, and examine commonalities and differences in asthma management across the Americas. We then discuss future directions in research and health policies to improve the prevention, diagnosis, and management of pediatric and adult asthma in the Americas, including standardized and periodic assessment of asthma burden across the region; large-scale longitudinal studies including omics and comprehensive environmental data on racially and ethnically diverse populations; and dissemination and implementation of guidelines for asthma management across the spectrum of disease severity. New initiatives should recognize differences in socioeconomic development and health care systems across the region while paying particular attention to novel or more impactful risk factors for asthma in the Americas, including indoor pollutants such as biomass fuel, tobacco use, infectious agents and the microbiome, and psychosocial stressor and chronic stress.

The Impact of Biofeedback on Self-Efficacy in Adults with Asthma: A Cross-Sectional Descriptive Survey

PURPOSE

Educating patients to self-manage chronic diseases such as asthma is a key role for nurses. The success of this education is often limited by low patient self-efficacy. In this study, we hypothesized that the self-efficacy of patients could be enhanced if their education was based on biofeedback of their own self-management, following a nurse led educational intervention.

PATIENTS AND METHODS

Patients with severe and uncontrolled asthma from one centre who participated in an eight-month, nurse-led asthma education and dose adjustment Randomised Control Trial (RCT) were studied (NCT02307669). Inhaler adherence and technique of use were objectively assessed using a validated digital device. The data recorded on this device was used as the basis for the individualised biofeedback. The Asthma Self-efficacy Questionnaire was used to assess self-efficacy.

RESULTS

A total of 88 participants (44 in each group) completed the asthma self-efficacy questionnaire at the end of the study. The mean overall level of self-efficacy was high across both groups; 91 (8.7), with both biofeedback and standard care groups having similarly high levels of self-efficacy, biofeedback group: 89 (10) and standard care group 93 (6). Self-efficacy was not related to objective measures of adherence at either the start of the study, 68 (26), p=0.23, or the end of the study, 58 (32), p=0.62. It was also not related to peak expiratory flow (PEF) at the end of the study in either group (r²= 0.0245, p=0.14). Self-efficacy was related to asthma control test (ACT), 18 (5.5), p=0.0014 and quality-of-life measures; EuroQol (EQ5D3L) 6.4 (1.5) p=0.02.

CONCLUSION

Repeated nurse-delivered education results in high levels of self-efficacy among patients with severe asthma. A high level of perceived self-efficacy should not be assumed to result in higher inhaler adherence.

The comparison between pulmonary rehabilitation with music therapy and pulmonary rehabilitation alone on respiratory drive, cortisol level and asthma control in patients hospitalized with asthma exacerbation

INTRODUCTION

Much emphasis is being placed on the role of music therapy as an easy-to-use, noninvasive and relatively cheap method of asthma treatment. The objective of this interventional double-blinded randomized controlled trial was to assess whether music therapy, as a complementary modality to pulmonary rehabilitation, can help to improve respiratory drive, asthma control and quality of life in patients with asthma exacerbation.

METHODS

Hospitalized patients with asthma exacerbation enrolled in the study were randomly assigned to experimental (music therapy) or control (popular science program) group. Both groups during hospitalization received standard pharmacotherapy accompanied by respiratory physiotherapy. Respiratory drive, asthma control, quality of life and serum cortisol in all participants were assessed at the beginning and at the end of their hospitalizations.

RESULTS

The experimental group consisted of 39 asthmatics and 34 subjects with asthma were assigned to the control group. During the hospitalization, the levels of the inspiratory occlusion pressure for the first 0.1 s of inspiration (P0.1) decreased (p = 0.004) and the maximum P0.1 increased (p = 0.041) only in the experimental group. The serum cortisol level decreased in both groups (p = 0.001). The changes in asthma control and quality of life did not reach significant levels in either subject group.

CONCLUSION

Passive music therapy and its effects on the mental state of patients seem to improve the efficiency of the respiratory system. The results of this experimental study demonstrate that a complementary music therapy has beneficial effects on the treatment of asthma exacerbations in adults.

Integration of neuropsychology services in a sickle cell clinic and subsequent healthcare use for pain crises

Objective: Growing literature has documented the clinical utility of neuropsychological evaluations for predicting functional outcomes, including reduced healthcare service utilization, in a variety of clinical samples. The present study investigates the relationship between the integration of clinical neuropsychology services into an existing outpatient sickle cell clinic and frequency of emergency department (ED) visits and hospitalizations for pain crises. Method: Participants included 144 adults diagnosed with sickle cell disease (SCD) who either underwent neuropsychological evaluation (NP+), including interview, neuropsychological testing, and feedback, or treatment as usual (NP-). Medical records were reviewed for a two-year period, one year prior to study enrollment (pre-assessment) and one year post-study enrollment (post-assessment), to track the number of ED visits and hospitalizations related to sickle cell pain crises. Results: When examining pain crises ED visits prior to and following neuropsychological evaluation, there was a significant decrease in ED visits for the NP + group, but no change for the NP - group. No significant changes in pain crises hospitalizations were observed for the NP + and NP - groups. For the NP + group, the decreased incidence of pain crises ED visits and hospitalizations was associated with an estimated total cost savings of $994,821. Discussion: Results highlight that integration of neuropsychology services into an existing outpatient sickle cell clinic may reduce healthcare costs, particularly use of pain crises ED services, for adults with SCD.

Obesity and emergency care in the French CONSTANCES cohort

Context

Obese patients are raising specific questions in emergency care such as equipment issues or urgent procedures. Even though obesity prevalence and subsequent health expenditure are increasing worldwide, there is scarce literature about their specific resource utilization of Emergency Departments (ED). These few studies do not take into account both socio-economic situation and comorbidities which are well-known factors influencing healthcare use. Our objective was to assess the emergency care resource utilization of obese individuals (Body Mass Index (BMI) ≥ 30kg.m^-2) compared to normal-weight individuals taking into account comorbidities and social-economic situations.

Methods

The French CONSTANCES epidemiologic cohort is a randomly selected sample of French adults. Participants data are linked to the National Health Insurance Database collecting all medical acts. The rate of ED visits of obese (and each obesity class) and normal-weight participants were compared considering confounding factors (comorbidities, various socio-economic data). The primary endpoint was to have visited the ED between 2010 and 2013. Sex-separated analysis and multivariate logistic regression models were performed and adjusted odds-ratios [OR] (95% Confidence Intervals [CI]) were calculated.

Results

We included 21,035 normal-weight and 5,003 obese participants. Obese participants visited the ED more often than normal-weight participants (men: 30.5% vs. 26.7%; women: 30.3% vs. 24.4%, P<0.001). Obese participants presented more comorbidities and a lower socio-economic situation than normal-weight participants. After adjustment, obese participants had a higher risk of visiting ED (men: OR = 1.18; 95% CI: 1.04–1.33; and women: OR = 1.36; 95% CI: 1.22–1.52), with a higher risk for class III participants (BMI ≥ 40 kg.m^-2) (men: OR = 2.18; CI 95%: 1.32–3.63; and women: OR = 1.85; 95% CI: 1.38–2.49).

Conclusion

Obese individuals have a higher level of emergency care resource utilization than normal-weight individuals and it increases with severe obesity. Further studies are needed to better understand their healthcare pathways leading to EDs.

Relationships Between Quality of Life in the Psychological Domain, Acceptance of Illness, and Healthcare Services in Patients with Asthma

Asthma patients should be considered not only in terms of the medical aspects, but also the nonmedical issues associated with the psychological domain, since these are factors that can significantly improve patients' health state, quality of life, and illness acceptance, and can contribute to the reduction of healthcare utilization. The purpose of this study was to assess the acceptance of illness among asthma patients and their quality of life in the psychological domain, as well as to identify factors that influence illness acceptance and quality of life in the psychological domain. We examined 172 patients with asthma (median age: 58; range: 18-89 years) recruited from two pulmonology wards. We demonstrate that the patients with low levels of illness acceptance and a high healthcare service index had low quality of life in the mental domain. Older age; being separated, divorced, or widowed; and having BMI > 25, all significantly affect the levels of quality of life and illness acceptance. In conclusion, measurements of health-related quality of life and illness acceptance are useful for estimating the impact and progression of asthma. These results confirm that psychological functioning should be taken into account alongside the somatic state.

Overweight adolescents and asthma: Revealing motivations and challenges with adolescent-provider communication

OBJECTIVE

Among teens with asthma, challenges of disease management may be greater in those with a body mass index (BMI) >85th percentile compared to youth within the parameters for normal weight-for-age. This mixed-methods study assessed teens' awareness of the link between weight and asthma management, and perspectives on how medical providers might open a discussion about managing weight.

METHOD

Teens aged 13-18, having BMI >85 percentile and chronic asthma, identified using health system databases and a staff email message board, were invited to complete a semi-structured, in-depth phone interview. Interviews were audio taped, transcribed, and qualitatively analyzed, using the Framework Method. Responses were summarized and themes identified. Descriptive summaries were generated for a 16-item survey of weight conversation starters.

RESULTS

Of 35 teens interviewed, 24 (69%) were girls, 11 (31%) boys, 20 (63%) African-American. All teens reported having "the weight conversation" with their doctors, and preferred that parents be present. Half knew from their doctor about the link between being overweight and asthma, others knew from personal experience. Nearly all expressed the importance of providers initiating a weight management conversation. Most preferred conversation starters that recognized challenges and included parents' participation in weight management; least liked referred to "carrying around too much weight."

CONCLUSIONS

Most teens responded favorably to initiating weight loss if it impacted asthma management, valued their provider addressing weight and family participation in weight management efforts. Adolescents' views enhance program development fostering more effective communication targeting weight improvement within the overall asthma management plan.