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Hardy RY, Liu GC, Kelleher K. Contribution of Social Determinant of Health Factors to Rural-Urban Preventive Care Differences Among Medicaid Enrollees. Acad Pediatr 2021; 21:93-100. [PMID: 32891801 DOI: 10.1016/j.acap.2020.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/14/2020] [Accepted: 08/30/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE 1) Assess whether rural-urban disparities are present in pediatric preventive health care utilization; and 2) use regression decomposition to measure the contribution of social determinants of health (SDH) to those disparities. METHODS With an Ohio Medicaid population served by a pediatric Accountable Care Organization, Partners For Kids, between 2017 and 2019, we used regression decomposition (a nonlinear multivariate regression decomposition model) to analyze the contribution of patient, provider, and SDH factors to the rural-urban well-child visit gap among children in Ohio. RESULTS Among the 453,519 eligible Medicaid enrollees, 61.2% of urban children received a well-child visit. Well-child visit receipt among children from large rural cities/towns and small/isolated towns was 58.2% and 55.5%, respectively. Comparing large rural towns to urban centers, 55.8% of the 3.0 percentage-point difference was explained by patient, provider, and community-level SDH factors. In comparing small/isolated town to urban centers, 89.8% of the 5.7 percentage-point difference was explained by these characteristics. Of provider characteristics, pediatrician providers were associated with increased well visit receipt. Of the SDH factors, unemployment and education contributed the most to the explained difference in large rural towns while unemployment, education, and food deserts contributed significantly to the small/isolated town difference. CONCLUSIONS The receipt of pediatric preventive care is slightly lower in rural communities. While modest, the largest part of the rural-urban preventive care gap can be explained by differences in provider type, poverty, unemployment, and education levels. More could be done to improve pediatric preventive care in all communities.
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Affiliation(s)
- Rose Y Hardy
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Innovation in Pediatric Practice (RY Hardy and K Kelleher), Columbus, Ohio.
| | - Gilbert C Liu
- Partners For Kids, Nationwide Children's Hospital (GC Liu), Columbus, Ohio
| | - Kelly Kelleher
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Innovation in Pediatric Practice (RY Hardy and K Kelleher), Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital (K Kelleher), Columbus, Ohio
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Nurse practitioners' recommendations for pharmacotherapy in the management of adolescent concussion. J Am Assoc Nurse Pract 2019; 30:499-510. [PMID: 30113534 DOI: 10.1097/jxx.0000000000000070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Nurse practitioners (NPs) frequently treat acute conditions presenting in children and adolescents in the outpatient setting. No evidence-based guidance exists pertaining to the treatment of concussion with medications. The purpose of this study was to examine recommendations by NPs for pharmacotherapy of acute symptoms for adolescent concussion. METHODS This is a secondary analysis of data from a web-based census survey of all licensed NPs in Oregon and Washington State, where they practice as independent providers with prescriptive authority. Based on a standardized adolescent patient scenario video, NPs were asked to indicate prescription or nonprescription medication recommendations for concussion symptoms. Open-ended descriptions of medication recommendations were coded, summarized, and described. CONCLUSIONS In narrative text, 78.4% of the 991 respondents recommended at least one type of prescription or nonprescription medication. Prescription medications (recommended by 17.2%) included antiemetics and antimigraine medications; nonprescription medications (recommended by 75.5%) included nonsteroidal anti-inflammatory drugs, over-the-counter pain relievers, and herbal medications. Pharmacotherapy recommendations varied by NP practice setting and rurality. IMPLICATIONS FOR PRACTICE Nurse practitioners have full prescriptive authority in many states. No guidelines inform medication use in managing acute concussion symptoms, yet many providers recommend their use.
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Carpenter DM, Estrada RD, Roberts CA, Elio A, Prendergast M, Durbin K, Jones GC, North S. Urban-Rural Differences in School Nurses' Asthma Training Needs and Access to Asthma Resources. J Pediatr Nurs 2017; 36:157-162. [PMID: 28888497 PMCID: PMC6050021 DOI: 10.1016/j.pedn.2017.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/19/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Few studies have examined school nurses preferences' for asthma training. Our purpose was to: 1) assess school nurses' perceived asthma training needs, 2) describe nurses' access to asthma educational resources, and 3) identify urban-rural differences in training needs and access to resources in southern states. DESIGN AND METHODS A convenience sample of school nurses (n=162) from seven counties (two urban and five rural) in North Carolina and South Carolina completed an online, anonymous survey. Chi-square tests were used to examine urban-rural differences. RESULTS Although most nurses (64%) had received asthma training within the last five years, urban nurses were more likely to have had asthma training than rural nurses (χ2=10.84, p=0.001). A majority of nurses (87%) indicated they would like to receive additional asthma training. Approximately half (45%) of nurses reported access to age-appropriate asthma education materials, but only 16% reported that their schools implemented asthma education programs. Urban nurses were more likely than rural nurses to have access to asthma education programs (χ2=4.10, p=0.04) and age-appropriate asthma education materials (χ2=8.86, p=0.003). CONCLUSIONS Few schools are implementing asthma education programs. Rural nurses may be disadvantaged in terms of receiving asthma training and having access to asthma education programs and materials. PRACTICE IMPLICATIONS Schools are an ideal setting for delivering age-appropriate asthma education. By providing school nurses with access to age-appropriate asthma education resources and additional asthma training, we can help them overcome several of the barriers that impede their ability to deliver asthma care to their students.
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Affiliation(s)
- Delesha M Carpenter
- University of North Carolina, Eshelman School of Pharmacy (Asheville Satellite Campus), Asheville, NC, USA.
| | | | - Courtney A Roberts
- University of North Carolina, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
| | - Alice Elio
- Mountain Area Health Education Center, Asheville, NC, USA.
| | | | - Kathy Durbin
- Lancaster County School District, Lancaster, SC, USA.
| | | | - Steve North
- Health-e-Schools, Center for Rural Health Innovation, Spruce Pine, NC, USA.
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Balakrishnan L, Rennie D, Dosman J, Pahwa P, Karunanayake C, Hagel L, Lawson J. Lung function in relation to farm dwelling and farming activities in rural dwelling children. Respirology 2017; 22:1320-1328. [PMID: 28653785 DOI: 10.1111/resp.13097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/10/2017] [Accepted: 03/13/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE The relationship between farming exposures and pulmonary function in a rural paediatric population was evaluated. METHODS Baseline data collection records of the Saskatchewan Rural Health Study (SRHS), a population-based study, were used. A subset of children (6-14 years old) participated in clinical testing, including anthropometric measures and pulmonary function testing (PFT), using spirometry (n = 584). PFTs followed ATS criteria and all statistical analyses were controlled for age, sex and height. RESULTS Among clinical testing participants, 47.5% were females and 54.5% were farm dwelling. Of those living on farms, 77.5% were livestock farms. Mean percent predicted value (PPV) for forced expiratory volume in 1 s (FEV1 ) and forced vital capacity (FVC) among children living on a farm were 104.8% and 105.4%, respectively. Mean PPV for FEV1 and FVC among children not living on a farm were 102.7% and 101.4%, respectively. After adjustment, higher FEV1 (=0.079, SE = 0.033, P = 0.03) and FVC (=0.110, SE = 0.039, P = 0.006) were seen among children living on a farm. A trend towards lower FEV1 /FVC ratio (-0.013, SE = 0.008, P = 0.09) among children living on a farm was seen compared with children not living on a farm. Higher FVC and lower FEV1 /FVC ratio were seen in children who regularly emptied grain bins (P < 0.05). Trends towards higher FEV1 (P = 0.14) and FVC (P = 0.08) were also seen with children living on a farm in the first year of life. Since the majority of the population was Caucasian (91%), the results were not race-corrected. CONCLUSION We addressed the lack of knowledge regarding the association between lung function and rural exposures, and found that differences in lung function were seen between children living on a farm and not living on a farm in rural areas and certain farming activities, specifically emptying grain bins, where lung function was generally better in those living on a farm.
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Affiliation(s)
- Lakshmi Balakrishnan
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Donna Rennie
- Canadian Center for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Department of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - James Dosman
- Canadian Center for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Punam Pahwa
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Chandima Karunanayake
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Louise Hagel
- Canadian Center for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Department of Surgery, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Joshua Lawson
- Canadian Center for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.,Department of Surgery, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Barry RJ, Pickett W, Rennie DC, Dosman JA, Pahwa P, Hagel L, Karunanayake C, Lawson JA. The role of farm operational and rural environments as potential risk factors for pediatric asthma in rural Saskatchewan. Pediatr Pulmonol 2014; 49:842-51. [PMID: 24167097 DOI: 10.1002/ppul.22903] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 08/13/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND Researchers have historically reported that farm children have a lower prevalence of asthma compared to more urban children. Potential explanations include theories surrounding differences in personal factors, access to health care, engagement in health risk behaviors, and differences in the environment. OBJECTIVE The aims of this study were to: (1) confirm whether the prevalence of asthma varies between farm and small town status among children living in Saskatchewan; (2) identify risk and protective factors for asthma, and use this information to infer which of the above theories is most explanatory for any observed geographic variations in pediatric asthma. METHODS Rural students (N = 2383, 42% participation rate) from the province of Saskatchewan participated in a 2011 cross-sectional study. Parents completed a survey that included questions about location of residence, respiratory symptoms, potential risk factors for respiratory disease, and exposures to farm activities. Multiple logistic regression was used to examine relations between respiratory outcomes (asthma, wheeze) with farm type and farm activities, while accounting for factors that may underlie such relations. RESULTS Asthma and wheeze prevalence did not differ by residential status. Living on a grain farm (OR = 0.64, 95% CI = 0.43-0.96), cleaning or playing in pens (OR = 0.69, 95% CI = 0.46-1.02), filling grain bins (OR = 0.56, 95% CI = 0.32-0.96), and riding horses (OR = 0.65, 95% CI = 0.40-1.05) were protective factors for ever diagnosis with asthma. CONCLUSIONS We identified a number of risk and protective factors for asthma and associated wheeze. This suggests the need to focus on specific environmental explanations to better understand previously observed associations between farm residential status and asthma.
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Affiliation(s)
- Rebecca J Barry
- Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada
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Yawn BP, Bertram S, Kurland M, Wollan P, Graham D, Littlefield D, Smail C, Pace W. Protocol for the asthma tools study: a pragmatic practice-based research network trial. Pragmat Obs Res 2013; 4:7-18. [PMID: 27774020 PMCID: PMC5045012 DOI: 10.2147/por.s43161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Asthma is common among children, adolescents, and adults. However, management of asthma often fails to follow evidence-based guidelines. Control assessments have been developed, validated against expert opinion, and disseminated. However, in primary care, assessment of control is only one step in asthma management. To facilitate integration of the evidence-based guidelines into practice, tools should also guide the next steps in care. The Asthma APGAR tools do just that, incorporating a control assessment as well as assessment of the most common reasons for inadequate and poor control. The Asthma APGAR tool is also linked to a care algorithm based on the 2007 National Heart, Lung, and Blood Institute asthma guidelines. The objective of this study is to assess the impact of implementation of the Asthma APGAR on patient asthma outcomes in primary care practices. Methods A total of 1400 patients aged 5–60 years with physician-diagnosed asthma are enrolled in 20 practice-based research network (PBRN) practices randomized to intervention or usual care. The primary outcomes are changes in patient self-reported asthma control, asthma-related quality of life, and rates of exacerbations documented in medical records over the 18–24 months of enrollment. Process measures related to implementation of the Asthma APGAR system into daily care will also be assessed using review of medical records. Qualitative assessments will be used to explore barriers to and facilitators for integrating the Asthma APGAR tools into daily practice in primary care. Discussion Data from this pivotal pragmatic study are intended to demonstrate the importance of linking assessment of asthma and management tools to improve asthma-related patient outcomes. The study is an effectiveness trial done in real-world PBRN practices using patient-oriented outcome measures, making it generalizable to the largest possible group of asthma care providers and primary care clinics.
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Affiliation(s)
- Barbara P Yawn
- Department of Research, Olmsted Medical Center, Rochester, MN
| | - Susan Bertram
- Department of Research, Olmsted Medical Center, Rochester, MN
| | - Margary Kurland
- Department of Research, Olmsted Medical Center, Rochester, MN
| | - Peter Wollan
- Department of Research, Olmsted Medical Center, Rochester, MN
| | - Deborah Graham
- National Research Network, American Academy of Family Physicians, Leawood, KS, USA
| | | | - Craig Smail
- National Research Network, American Academy of Family Physicians, Leawood, KS, USA
| | - Wilson Pace
- National Research Network, American Academy of Family Physicians, Leawood, KS, USA
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Factors contributing to risks for pediatric asthma in rural Saskatchewan. Ann Allergy Asthma Immunol 2012; 109:255-9. [PMID: 23010231 DOI: 10.1016/j.anai.2012.07.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 07/03/2012] [Accepted: 07/21/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Rural children have lower reported rates of asthma compared with urban children. Although reasons for these differences remain unclear, 3 possible explanations exist: (1) environmental differences, (2) variations in health care access, and (3) variations in health risk behaviors. OBJECTIVE We investigated asthma among children living on farms and in small towns and its potential determinants, including personal, behavioral, and environmental factors. METHODS School children (n = 842, ages 6-13; participation rate = 72.0%) were involved in a 2003 cross-sectional study. Their parents completed a lung health survey that included questions about asthma, asthma-like symptoms, and potential determinants of asthma (demographic, environmental, health risk behaviors). Participating children were classified into farm dwellers (live on farm or acreage) and small town dwellers. Multiple logistic regression was used to investigate the association between asthma and wheeze with demographic, environmental, and behavioral exposures with simultaneous adjustment for confounders. RESULTS Asthma and wheeze prevalence was not significantly different between farm and small town areas (current asthma: 16% vs 13%, respectively; current wheeze: 27% vs 21%, respectively) and followed consistent patterns. Factors associated with diagnosed asthma were dampness (odds ratio [OR] = 1.85; 95% confidence interval [CI] = 1.08-3.17), with enrollment in daycare found to be protective (OR = 0.53; 95% CI = 0.33-0.85). Being obese or overweight was associated with wheeze (OR = 1.77; 95% CI = 1.06-2.97). CONCLUSION Given the differences between areas and the associations between environmental risk factors and obesity with asthma and wheeze, the study findings support environment and health risk behavior explanations for the observed geographic variations.
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Antai D. Rural-urban inequities in childhood immunisation in Nigeria: The role of community contexts. Afr J Prim Health Care Fam Med 2011. [PMCID: PMC4565435 DOI: 10.4102/phcfm.v3i1.238] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Context Childhood vaccinations are one of the most cost-effective means of reducing negative child health outcomes. Despite the benefits of immunisation, inequities persist both between and within rural-urban areas in Nigeria. Objectives To assess the role of community contexts on rural-urban inequities in full immunisation uptake amongst children 12 months of age and older. Methods Data from the 2003 Nigeria Demographic and Health Survey including 6029 live born children from 3725 women aged 15–49 years were examined using multilevel regression analysis. Results Rural children were disadvantaged both in the proportion receiving full immunisation and individual vaccines. Contextual or community-level factors such as community prenatal care by doctor, community hospital delivery, and region of residence accounted for significant rural-urban inequities in full immunisation. Conclusion This study stresses the need for community-level interventions aimed at closing rural-urban inequities in the provision of maternal and child health care services.
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Affiliation(s)
- Diddy Antai
- Division of Epidemiology, Institute of Environmental Medicine, Karolinska Institute, Sweden
- Division of Global Health & Inequalities, The Angels Trust, Nigeria
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Lu N, Samuels ME, Kletke PR, Whitler ET. Rural-Urban Differences in Health Insurance Coverage and Patterns Among Working-Age Adults in Kentucky. J Rural Health 2010; 26:129-38. [PMID: 20446999 DOI: 10.1111/j.1748-0361.2010.00274.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ning Lu
- Department of Health Administration, College of Health and Human Services, Governors State University, University Park, Illinois 60466, USA.
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Mayer ML, Skinner AC, Freed GL. Interspecialty differences in the care of children with chronic or serious acute conditions: a review of the literature. J Pediatr 2009; 154:164-8. [PMID: 19150672 PMCID: PMC3733246 DOI: 10.1016/j.jpeds.2008.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Revised: 09/22/2008] [Accepted: 11/03/2008] [Indexed: 01/15/2023]
Affiliation(s)
- Michelle L Mayer
- Cecil G. Sheps Center for Health Services Research and Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, NC
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11
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Walker J, Winkelstein M, Land C, Lewis-Boyer L, Quartey R, Pham L, Butz A. Factors that influence quality of life in rural children with asthma and their parents. J Pediatr Health Care 2008; 22:343-50. [PMID: 18971080 PMCID: PMC2592842 DOI: 10.1016/j.pedhc.2007.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 07/23/2007] [Accepted: 07/31/2007] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Among rural children with asthma and their parents, this study examined the relationship between parental and child reports of quality of life and described the relationship of several factors such as asthma severity, missed days of work, and asthma education on their quality of life. METHODS Two hundred one rural families with asthma were enrolled in a school-based educational program. Intervention parents and children participated in interactive asthma workshop(s) and received asthma devices and literature. Parent and child quality of life measurements were obtained before and after the intervention using Juniper's Paediatric Caregivers Quality of Life and Juniper's Paediatric Quality of Life Questionnaires. Asthma severity was measured using criteria from the National Asthma Education and Prevention Program guidelines. RESULTS There was no association between parent and child total quality of life scores, and mean parental total quality of life scores were higher at baseline and follow-up than those of the children. All the parents' quality of life scores were correlated with parental reports of missed days of work. For all children, emotional quality of life (EQOL) was significantly associated with parental reports of school days missed (P = .03) and marginally associated with parental reports of hospitalizations due to asthma (P = .08). Parent's EQOL and activity quality of life (AQOL) were significantly associated with children's asthma severity (EQOL, P = .009; AQOL, P = .03), but not the asthma educational intervention. None of the child quality of life measurements was associated with asthma severity. DISCUSSION Asthma interventions for rural families should help families focus on gaining and maintaining low asthma severity levels to enjoy an optimal quality of life. Health care providers should try to assess the child's quality of life at each asthma care visit independently of the parents.
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Affiliation(s)
- Jennifer Walker
- Johns Hopkins University, School of Medicine, 200 N Wolfe St, Baltimore, MD 21205, USA.
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Abstract
During the last 3 decades, asthma prevalence and morbidity in the United States have dramatically increased. The impact of this chronic respiratory disease has been disproportionately high among inner city residents, particularly lower socioeconomic groups, ethnic minorities, and children. A wide variety of factors have been shown to have an influence-indeed, the asthma epidemic is a chronicle of the ways in which environmental, social, and economic factors superimposed on inadequate health care delivery systems can converge to influence health status and the course of a chronic disease. Effective intervention strategies for this controllable disease must circumvent existing societal barriers to care and provide a comprehensive, structured program that emphasizes asthma controller therapy, disease-specific education, and regular periodic assessment of asthma control, preferably in a convenient, familiar setting that promotes patient engagement.
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Dougherty D, Simpson LA, McCormick MC. Rural Areas and Children’s Health Care Coverage, Use, Expenditures, and Quality: Policy Implications. ACTA ACUST UNITED AC 2006; 6:265-7. [PMID: 17000415 DOI: 10.1016/j.ambp.2006.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 06/30/2006] [Accepted: 06/30/2006] [Indexed: 11/19/2022]
Affiliation(s)
- Denise Dougherty
- Agency for Healthcare Research and Quality, Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850, USA.
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Abstract
OBJECTIVES To examine current trends of asthma prevalence, diagnosis, and utilization of care in rural areas, increase awareness about asthma disease burden, and provide general recommendations for improving care in this setting. DATA SOURCES MEDLINE searches were conducted for articles published from 1966 onward, with human subjects and the English language as descriptors. Other terms used included undiagnosed frequent wheezing, hygiene hypothesis, atopic sensitization, endotoxin, telemedicine, and asthma prevalence and care in rural or urban areas. STUDY SELECTION Review and original research studies that reported on asthma care in rural areas were selected for evaluation. RESULTS Contrary to common belief, evidence suggests that asthma prevalence of rural and urban youth is comparable in the United States and may indeed be higher in rural areas. Data are not available to determine prevalence rates for rural adults in the United States. This review presents data suggesting that the utilization of asthma care among rural and urban residents may not be comparable. Rural residents are confronted with certain barriers to care that are not as common in the urban setting. These include lack of health care insurance, geographic obstacles to obtaining care, inability of getting suitable appointments, scarcity of health care professionals, and poor access to information about asthma. CONCLUSIONS Current literature suggests that asthma in rural areas may be underdiagnosed and deserves additional study. Improving formal and continuing education of health care professionals, compensating for health care shortages by using existing resources, and facilitating patient support and education are some of the ways to address the special needs faced by rural residents.
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Affiliation(s)
- Dennis R Ownby
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia 30912, USA.
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Couchman GR, Forjuoh SN, Rajab MH, Phillips CD, Yu J. Nonclinical factors associated with primary care physicians' ordering patterns of magnetic resonance imaging/computed tomography for headache. Acad Radiol 2004; 11:735-40. [PMID: 15217590 DOI: 10.1016/j.acra.2004.03.050] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2004] [Revised: 02/25/2004] [Accepted: 03/22/2004] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of ordering an imaging test for headache, which is one of the most common reasons for patient consultation with a primary care physician (PCP), include medical indications as well as patient anxiety and medico-legal concerns. The impact of nonclinical factors on PCPs' ordering patterns of magnetic resonance imaging/computed tomography for patients presenting with a headache was examined. MATERIALS AND METHODS A retrospective record review of all patients treated for headache as their primary complaint by a PCP from a multispecialty group practice associated with an 180,000-member Health Maintenance Organization during calendar year 2000 was examined. The practice included 18 clinics. Logistic regression was used to estimate the association between physician ordering patterns of imaging tests and patient, physician, and clinic setting characteristics. RESULTS Of the total study subjects (n = 4,372), a magnetic resonance imaging/computed tomography imaging test was ordered for 5.3%. At their first encounter, patient's gender, site of care, and insurance status under the health care system's Health Maintenance Organization had statistically significant associations with the likelihood of imaging test orders. Female physicians were less likely to order an imaging test (OR = 0.65; 95% confidence interval, 0.39-1.08). For subsequent encounters, however, site of care was the only nonclinical factor that had a consistent association with the likelihood of having a magnetic resonance imaging/computed tomography ordered. CONCLUSION These data show that a number of nonclinical factors may have been associated with having an imaging test ordered by a PCP when patients presented with a headache. These factors were more significant when the patient was being seen for the first time with this complaint.
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Affiliation(s)
- Glen R Couchman
- Department of Family & Community Medicine, Scott & White Hospital and Clinic, Texas A & M University System Health Science Center, College of Medicine, Century Square, 1402 West Ave H, Temple, TX 76504, USA
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Weiss KB, Liljas B, Schoenwetter W, Schatz M, Luce BR. Effectiveness of budesonide administered via dry-powder inhaler versus triamcinolone acetonide administered via pressurized metered-dose inhaler for adults with persistent asthma in managed care settings. Clin Ther 2004; 26:102-14. [PMID: 14996523 DOI: 10.1016/s0149-2918(04)90011-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2003] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical studies have demonstrated the efficacy and relative safety of inhaled corticosteroids in the treatment of asthma. However, effectiveness and cost-effectiveness comparisons of available inhaled corticosteroids in real-life clinical settings are lacking. OBJECTIVE This study compared the effectiveness and safety of budesonide administered via dry-powder inhaler versus that of triamcinolone acetonide administered via pressurized metered-dose inhaler in the treatment of adult patients with persistent asthma treated in a managed care setting. METHODS This was a randomized, open-labe, 52-week study of adult patients (aged >or= 18 years) with persistent asthma enrolled in 25 US health plans. The primary study outcome was mean change from baseline to the end of treatment in symptom-free days. Secondary variables were changes from baseline in number of episode-free days, episode-free days at 52 weeks, forced expiratory volume in 1 second (FEV(1)), forced vital capacity, asthma symptom scores, breakthrough bronchdilator use, patient discontinuations, and health-related quality of life. Patients were issued diaries in which to record use of study medication and concomitant asthma medication use, as well as daytime and nighttime asthma symptom severity. Patients were assessed at weeks 4, 13, 26, 39, and 52. Safety was assessed based on adverse events and changes in laboratory tests, vital signs, and physical examinations. RESULTS A total of 945 patients (344 men, 601 women; mean [SD] age, 46.8 [14] years) were enrolled; 631 received budesonide and 314 received triacinolane acetonide. Improvements in all effectiveness variables were observed with both treatments. The mean increase from baseline in the number of symptom-free days per month assessed at month 12 was 7.74 (95% CI, 6.81-8.66) for patients receiving budesonide and 3.78 (95% CI, 2.47-5.09) for patients receiving triamcinoline acetonide ( P<0.001). The estimated annual mean (SD) number symptom-free days for patients receiving budesonide was 141.1 (125.0) over the treatment phase, compared with 99.3 (112.1) for those receiving triamcinolone acetonide (P<0.001). Patients receiving budesonide demonstrated significant improvements (compared with those receiving triamcinolone acetonide) in overall quality of life, daytime and nighttime asthma symptom severity, breakthrough bronchodilator use, and FEV(1) (all P<0.001). Safety measures were similar between groups. CONCLUSION In these managed care settings, budesonide inhalation powder administered via dry-powder inhaler was significantly more effective than triamcinolone acetonide administered via pressurized metered-dose inhaler in the treatment of adults with persistent asthma.
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Affiliation(s)
- Kevin B Weiss
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Yawn B, Zyzanski SJ, Goodwin MA, Gotler RS, Stange KC. The anatomy of asthma care visits in community family practice. J Asthma 2002; 39:719-28. [PMID: 12507192 DOI: 10.1081/jas-120015795] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND We know little about the activities that occur during asthma-related visits with primary care physicians. A better understanding of how time is spent during visits for asthma may facilitate the design of programs to enhance asthma disease management. OBJECTIVE To describe the content of asthma visits made to family physicians. METHODS Research nurses directly observed consecutive outpatient visits during two separate days in the offices of 138 community family physicians. Time was classified into 20 different behavioral categories using the Davis Observation Code, and compared for visits for asthma, visits for other chronic conditions, and visits for non-asthma-related acute illnesses during 3035 visits by patients of all ages. RESULTS Visits for asthma shared several characteristics with visits for other chronic conditions but were longer than visits for other chronic illnesses or for acute illness. Asthma visits were distinguished from both acute care and other chronic care visits by a greater percentage of time spent discussing patient compliance, evaluating patient knowledge, and providing smoking assessment and cessation advice. CONCLUSIONS Visits for asthma are structured differently than acute care visits and specifically address issues important to asthma self-management. Future quality improvement initiatives should recognize, affirm, and enhance many current behaviors by family physicians, while working to expand specific areas of care that still fall short of asthma care guidelines.
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Affiliation(s)
- Barbara Yawn
- Department of Research, Olmsted Medical Center, Rochester, Minnesota 55904, USA.
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