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McCrossan P, Shields MD, McElnay JC. Medication Adherence in Children with Asthma. Patient Prefer Adherence 2024; 18:555-564. [PMID: 38476591 PMCID: PMC10929205 DOI: 10.2147/ppa.s445534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/06/2024] [Indexed: 03/14/2024] Open
Abstract
Asthma is the most common chronic disease in childhood. If untreated, asthma can lead to debilitating daily symptoms which affect quality of life, but more importantly can lead to fatal asthma attacks which unfortunately still occur globally. The most effective treatment strategy for controlling asthma is for the patient to follow a personalised asthma action plan (PAAP) which will invariably include regular use of an inhaled corticosteroid. To examine medication adherence in children with asthma, we collated recent evidence from systematic reviews in this area to address the following 5 key questions; What is adherence? Is there evidence that children are not adhering to preventer medication? Why is adherence poor and what are the barriers to adherence? Does good adherence improve outcomes in asthma? And lastly, how can treatment adherence be improved?
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Affiliation(s)
- Paddy McCrossan
- Paediatric Respiratory Medicine, Royal Belfast Hospital for Sick Children, Belfast, Northern Ireland
| | - Michael D Shields
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland
| | - James C McElnay
- School of Pharmacy, Queen’s University Belfast, Belfast, Northern Ireland
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2
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Raju M, Sagar M, Bush A, Quaye E, Ghamande S, Malhotra S, Arroliga ME. The role of supervised school therapy in poorly controlled asthma in children. Proc AMIA Symp 2023; 36:448-452. [PMID: 37334099 PMCID: PMC10269411 DOI: 10.1080/08998280.2023.2204522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 06/20/2023] Open
Abstract
Background In children, nonadherence to inhaled corticosteroid (ICS) therapy leads to poor asthma control and complications. Methods We evaluated the benefit from initiation of ICS administration once daily at school. We retrospectively chose patients from our pediatric pulmonary clinic who had poorly controlled asthma and prescribed ICS daily. For the study period, we examined the number of corticosteroid courses, emergency room visits, hospital admissions, symptom history, and pulmonary function tests. Results Thirty-four patients who satisfied the inclusion criteria began the intervention. Preintervention, there were a mean number of 2.6 oral corticosteroid courses compared to 2 courses in the year following intervention (P = 0.8). Postintervention emergency department visits decreased from a mean of 1.4 to 1.0 (P = 0.71), and hospital admissions decreased from 1.23 to 0.57 (P = 0.04). There was also a significant increase in forced expiratory volume in 1 second (1.69 vs 1.4 L/sec, P = 0.02), a decrease in systemic steroid-free days in a year (96 vs 141 days, P = 0.03), and an increase in symptom-free days postintervention (28 vs 26 days, P = 0.325). Conclusion These findings suggest that ICS administration in schools may help reduce hospital admissions and improve lung function in patients with poorly controlled asthma.
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Affiliation(s)
- Muppala Raju
- Department of Pediatrics, Baylor Research Institute, Temple, Texas
| | - Malvika Sagar
- Division of Pediatric Pulmonology, Department of Pediatrics, Baylor Scott and White McLane Children’s Medical Center, Temple, Texas
| | - Andrew Bush
- Department of Paediatrics, Imperial College London, London, UK
| | - Eugene Quaye
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center – Temple, Temple, Texas
| | - Shekhar Ghamande
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center – Temple, Temple, Texas
| | - Sonal Malhotra
- Pulmonary and Sleep Medicine Services, Baylor College of Medicine, Houston, Texas
| | - Mercedes E. Arroliga
- Division of Allergy and Clinical Immunology, Department of Medicine, Baylor Scott and White Center for Diagnostic Medicine, Temple, Texas
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McCrossan P, O'Donoghue D, McElnay JC, Shields MD. The use of remote video directly observed therapy to improve both inhaler technique and adherence to asthma medications. Front Public Health 2022; 10:965629. [PMID: 36276358 PMCID: PMC9581185 DOI: 10.3389/fpubh.2022.965629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/20/2022] [Indexed: 01/24/2023] Open
Abstract
Incorrect inhaler technique and non-adherence to inhaled preventer therapy often is the cause of poorly controlled asthma. Detecting and correcting non-adherence in asthma therapy has proven difficult. In addition, while patients may be able to demonstrate correct inhaler technique at the clinic recent evidence suggests that critical errors in inhaler technique occur in the home setting. Remote video directly observed therapy (vDOT) has recently been described as a potentially useful tool for addressing non-adherence while also allowing timely correction of inhaler technique errors. In this mini-review we describe the use of vDOT in asthma management.
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Affiliation(s)
- Paddy McCrossan
- Centre for Medical Education, Queen's University Belfast, Belfast, United Kingdom,Royal Belfast Hospital of Sick Children, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Dara O'Donoghue
- Centre for Medical Education, Queen's University Belfast, Belfast, United Kingdom,Royal Belfast Hospital of Sick Children, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | | | - Michael D. Shields
- Royal Belfast Hospital of Sick Children, Belfast Health and Social Care Trust, Belfast, United Kingdom,Centre for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom,*Correspondence: Michael D. Shields
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Hoque S, Luther J, Mizrahi R, Gerald LB, Phipatanakul W, Lemon SC, Rosal MC, Byatt N, Pbert L, Trivedi M. School Nurse Perspectives on School-Supervised Asthma Therapy: A Qualitative Study. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:65-73. [PMID: 35723660 PMCID: PMC9247674 DOI: 10.1089/ped.2022.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background: School-supervised asthma therapy improves asthma outcomes for children, yet this strategy is not widely utilized. School nurses play a vital role in this intervention, yet their perspectives on school-supervised asthma therapy have not been thoroughly examined. Objectives: To examine the perspectives of school nurses participating in school-supervised asthma therapy and identify key facilitators, barriers, and proposed solutions that will facilitate the uptake of this strategy. Methods: We used purposeful sampling to recruit 12 school nurses participating in Asthma Link, a real-world application of school-supervised asthma therapy, between 2017 and 2019. We performed semistructured interviews with school nurses to elicit their perspectives on the facilitators, barriers, and proposed solutions to barriers to Asthma Link implementation. Interview transcripts were analyzed using qualitative descriptive methodology to identify major themes. Results: School nurses identified facilitators for Asthma Link adoption, including the ease of integrating supervised therapy into school nurse routines, recognition of benefits for families with limited resources, and satisfaction participating in preventive care. School nurses identified barriers, including communication challenges with families and providers, families not reliably bringing medication to school, limited nursing staff in schools, and increased school nurse turnover. School nurses proposed specific solutions to these barriers, including appointing Asthma Link liaisons within pediatric practices, incentivizing families to bring medicine to school, and partnering new school nurses with those experienced in delivering Asthma Link to overcome staffing issues and promote program fidelity. Conclusions: School nurse perspectives on the facilitators, barriers, and solutions to barriers are important for understanding how to promote real-world implementation of school-supervised asthma therapy. The themes identified in this study will be utilized to refine our protocol for Asthma Link to facilitate real-world adoption of this evidence-based strategy.
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Affiliation(s)
- Shushmita Hoque
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- Address correspondence to: Shushmita Hoque, MD, MS, Department of Medicine, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Janki Luther
- Department of Internal Medicine, Washington University, St. Louis, Missouri, USA
| | - Raphael Mizrahi
- Department of Pediatric Pulmonology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Lynn B. Gerald
- Department of Health Promotion Sciences, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona, USA
| | - Wanda Phipatanakul
- Department of Asthma, Allergy, and Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Stephenie C. Lemon
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Milagros C. Rosal
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Nancy Byatt
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Lori Pbert
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Michelle Trivedi
- Department of Internal Medicine, Washington University, St. Louis, Missouri, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Shillan HN, Luther JP, Ryan GW, Hoque S, Spano MA, Lessard DM, Gerald LB, Pbert L, Phipatanakul W, Goldberg RJ, Trivedi MK. School-supervised Asthma Therapy is Associated with Improved Long-Term Asthma Outcomes for Underrepresented Minority Children. J Sch Nurs 2022:10598405221100470. [PMID: 35548948 PMCID: PMC9808969 DOI: 10.1177/10598405221100470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Asthma morbidity disproportionately impacts children from low-income and racial/ethnic minority communities. School-supervised asthma therapy improves asthma outcomes for up to 15 months for underrepresented minority children, but little is known about whether these benefits are sustained over time. We examined the frequency of emergency department (ED) visits and hospital admissions for 83 children enrolled in Asthma Link, a school nurse-supervised asthma therapy program serving predominantly underrepresented minority children. We compared outcomes between the year preceding enrollment and years one-four post-enrollment. Compared with the year prior to enrollment, asthma-related ED visits decreased by 67.9% at one year, 59.5% at two years, 70.2% at three years, and 50% at four years post-enrollment (all p-values< 0.005). There were also significant declines in mean numbers of total ED visits, asthma-related hospital admissions, and total hospital admissions. Our results indicate that school nurse-supervised asthma therapy could potentially mitigate racial/ethnic and socioeconomic inequities in childhood asthma.
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Affiliation(s)
- Holly N Shillan
- 12262University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Janki P Luther
- Department of Medicine, 12275Washington University School of Medicine, St. Louis, MO, USA
| | - Grace W Ryan
- Department of Population and Quantitative Health Sciences, 12262University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Shushmita Hoque
- Department of Medicine, 12262University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Michelle A Spano
- Division of Pulmonary Medicine, Department of Pediatrics, 12262University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Darleen M Lessard
- Department of Population and Quantitative Health Sciences, 12262University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Lynn B Gerald
- Department of Health Promotion Sciences, 48710University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, AZ, USA
- Asthma and Airway Disease Research Center, 577409University of Arizona, Tucson, AZ USA
| | - Lori Pbert
- Department of Population and Quantitative Health Sciences, 12262University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Wanda Phipatanakul
- Department of Asthma, Allergy, and Immunology, 1862Boston Children's Hospital, Boston, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, 12262University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Michelle K Trivedi
- Department of Population and Quantitative Health Sciences, 12262University of Massachusetts Chan Medical School, Worcester, MA, USA
- Division of Pulmonary Medicine, Department of Pediatrics, 12262University of Massachusetts Chan Medical School, Worcester, MA, USA
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McIntire K, Weis B, Litwin Ye L, Krugman SD. Feasibility of video observed therapy to support controller inhaler use among children in West Baltimore. J Asthma 2021; 59:1961-1972. [PMID: 34550849 DOI: 10.1080/02770903.2021.1984525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess feasibility of a novel video directly observed therapy (DOT)-based digital asthma program intended to support correct inhaled corticosteroid (ICS) use among children. METHODS We conducted a 60-day pilot study among patients 2-18 years attending a primary care clinic with prescribed ICS and sub-optimally controlled asthma (recent hospitalization, ICS nonadherence, frequent rescue inhaler use, therapy escalation, or Asthma Control Test <20). Participants used a mobile application to receive reminders, submit videos of ICS doses (video DOT), and receive asynchronous feedback on adherence and inhaler technique. We assessed enrollment, engagement, program metrics, and user experience; adherence and inhaler errors were secondary outcomes. RESULTS Of 26 eligible patients, 21 (81%) enrolled and submitted ≥1 video; median age was 11 years (8-15), 71% were male, 90% had Medicaid, and 62% experienced ≥1 exacerbation in the previous 6 months. Retention was 57% and 52% at week 5 and 8, respectively. Participants submitted 810 videos. Missed doses, inhaler errors (n = 247) and adherence issues (n = 107) prompted 543 communications; inadequate inspiration or holding breath were most common. Among 16 patients with engagement >7 days and >4 videos, median inhaler error rate (proportion of videos with ≥1 error) decreased from week 1 to week 2 (73% vs 8%, p ≤ 0.05) with median adherence >80%. Participants experienced the program as long, but easy to use; benefits included building routines, skill, and independence. CONCLUSIONS This pilot study suggests high program acceptability among our cohort. High engagement with improved inhaler technique over the first 14 days suggests shorter implementation.
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Affiliation(s)
- K McIntire
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - B Weis
- Department of Pediatrics, Herman and Walter Samuelson Children's Hospital of Sinai, Baltimore, MD, USA
| | - L Litwin Ye
- emocha Mobile Health Inc, Baltimore, MD, USA
| | - S D Krugman
- Department of Pediatrics, Herman and Walter Samuelson Children's Hospital of Sinai, Baltimore, MD, USA
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Hunleth J, Spray J, Ruiz S, Maki J, Fedele DA, Prabhakaran S, Forsyth RB, Sykes C, Crepps K, Shepperd J, Bowen D, Waters EA. Situating household management of children's asthma in the context of social, economic, and environmental injustice. J Asthma 2020; 59:70-78. [PMID: 33107771 DOI: 10.1080/02770903.2020.1837159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Structural determinants of health are social, economic, and environmental forces that generate unequal opportunities for resources and unequally distribute exposure to risk. For example, economic constraint, racial discrimination and segregation, and environmental injustice shape population-level asthma prevalence and severity. Structural determinants are especially relevant to consider in clinical settings because they affect everyday household asthma management. OBJECTIVE To examine how structural determinants shape everyday household management of pediatric asthma and offer a framework for providers to understand asthma management in social context. DESIGN Qualitative interviews of caregivers for children with asthma. PARTICIPANTS Participants included 41 caregivers in two U.S. cities: St. Louis, Missouri (n = 25) and Gainesville, Florida (n = 16). Most caregivers were women (83%), Black (73%) and/or had low socioeconomic status (SES; 78%). Caregivers cared for children with asthma aged 0-4 (32%), 5-11 (68%) and 12-17 (54%). APPROACH We carried out narrative interviews with caregivers using an adapted McGill Illness Narrative Interview and using qualitative analysis techniques (e.g. inductive and deductive coding, constant comparison). KEY RESULTS Caregivers highlighted three ways that structural determinants complicated asthma management at home: 1) housing situations, 2) competing household illnesses and issues, and 3) multi-household care. CONCLUSIONS By connecting social, economic, and environmental injustices to the everyday circumstances of asthma management, our study can help providers understand how social contexts challenge asthma management and can open conversations about barriers to adherence and strategies for supporting asthma management at home. We offer recommendations for medical system reform, clinical interactions, and policy advocacy.
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Affiliation(s)
- Jean Hunleth
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Julie Spray
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sienna Ruiz
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Julia Maki
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - David A Fedele
- Department of Clinical & Health Psychology, University of Florida, Gainesville, FL, USA
| | | | - Rachel B Forsyth
- Department of Clinical & Health Psychology, University of Florida, Gainesville, FL, USA
| | - Cassidy Sykes
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kaylah Crepps
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - James Shepperd
- Department of Clinical & Health Psychology, University of Florida, Gainesville, FL, USA
| | - Deb Bowen
- School of Public Health, University of Washington, Seattle, WA, USA
| | - Erika A Waters
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Fainardi V, Saglani S. An approach to the management of children with problematic severe asthma. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020055. [PMID: 32921752 PMCID: PMC7717010 DOI: 10.23750/abm.v91i3.9603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 12/18/2022]
Abstract
Children with poor asthma control despite high levels of prescribed treatment are described as having problematic severe asthma. Most of these children have steroid sensitive disease which improves with adherence to daily inhaled corticosteroids and after having removed modifiable factors like poor inhalation technique, persistent adverse environmental exposures and psychosocial factors. These children are described as having “difficult-to-treat asthma” while children with persistent symptoms despite above-mentioned factors having been addressed are described as having “severe therapy-resistant asthma”. In this review, we will describe the 6-step approach to the diagnosis and management of a child with problematic severe asthma adopted by The Royal Brompton Hospital (London, UK). The role of a multidisciplinary team is crucial for identification and treatment of modifiable factors and comorbidities in order to avoid invasive examinations and useless pharmacological treatments. The current knowledge on add-on therapies will be discussed.
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Affiliation(s)
| | - Sejal Saglani
- Department of Respiratory Paediatrics, Royal Brompton and Harefield NHS Foundation Trust, London, UK..
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