Coordinated Asthma Program Improves Asthma Outcomes in High-Risk Children

Factors Affecting Adherence in Allergic Disorders and Strategies for Improvement

Addressing patient adherence is a key element in ensuring positive health outcomes and improving health-related quality of life for patients with atopic and immunologic disorders. Understanding the complex etiologies of patient nonadherence and identifying real-world solutions is important for clinicians, patients, and systems to design and effect change. This review serves as an important resource for defining key issues related to patient nonadherence and outlines solutions, resources, knowledge gaps, and advocacy areas across five domains: health care access, financial considerations, socioenvironmental factors, health literacy, and psychosocial factors. To allow for more easily digestible and usable content, we describe solutions based on three macrolevels of focus: patient, clinician, and system. This review and interactive tool kit serve as an educational resource and call to action to improve equitable distribution of resources, institutional policies, patient-centered care, and practice guidelines for improving health outcomes for all patients with atopic and immunologic disorders.

Changing high-risk asthma in Memphis through partnership: Results from the CHAMP program

BACKGROUND

Children in metro Shelby County, Tennessee, have disproportionally high asthma-related health care resource use (HRU) compared with those in other regions in Tennessee.

OBJECTIVE

To describe the goals, logistics, and outcomes of the Changing High-Risk Asthma in Memphis through Partnership (CHAMP) program implemented to improve pediatric asthma care in Shelby County.

METHODS

CHAMP established a multidisciplinary team with dedicated medical staff and community health workers, implemented a 24/7 call line to improve access to care, established a patient data registry to address fragmented care, assigned community health educators to improve asthma education and social needs, and partnered with services to address environmental triggers and social determinants of health. Patients eligible for CHAMP are Shelby County residents aged 2 to 18 years with high-risk asthma enrolled in Tennessee's Medicaid managed care program. Health care resource use outcomes 1-year pre- and post-CHAMP enrollment were analyzed for patients who had completed 1 year of CHAMP between January 2013 and December 2022. The 24/7 call line data between November 2013 and December 2022 were analyzed.

RESULTS

CHAMP has enrolled 1348 children; 945 have completed 1 year (63% male; 90% identified as Black). At 1-year post-CHAMP enrollment, patients had 58%, 68%, 42%, and 53% reductions in emergency department visits, inpatient and observation visits, urgent care visits, and total asthma exacerbations, respectively. The number of asthma exacerbations per patient significantly decreased from 2.97 to 1.40 at 1-year post-CHAMP enrollment. Of the calls made to the 24/7 call line, 58% occurred after hours and 52% led to issue resolution without a medical facility visit.

CONCLUSION

CHAMP successfully decreased asthma HRU in children with high-risk asthma in Shelby County by implementing initiatives that targeted barriers to asthma care.

The burden of systemic corticosteroid use in asthma management in Asia

For most patients, asthma can be effectively managed using inhaled medications. However, patients who have severe and/or uncontrolled asthma, or who experience exacerbations, may require systemic corticosteroids (SCSs) to maintain asthma control. Although SCS are highly effective in this regard, even modest exposure to these medications can increase the risk for long-term, adverse health outcomes, such as type 2 diabetes, renal impairment, cardiovascular disease and overall mortality. Clinical and real-world data from studies investigating asthma severity, control and treatment practices around the globe have suggested that SCS are overused in asthma management, adding to the already substantial healthcare burden experienced by patients. Throughout Asia, although data on asthma severity, control and SCS usage are limited and vary widely among countries, available data strongly suggest a pattern of overuse consistent with the broader global trend. Coordinated changes at the patient, provider, institutional and policy levels, such as increasing disease awareness, promoting better adherence to treatment guidelines and increasing availability of safe and effective alternatives to SCS, are likely necessary to reduce the SCS burden for patients with asthma in Asia.

Continuity of Care in Primary Care for Young Children With Chronic Conditions

OBJECTIVES

1) To assess continuity of care (CoC) within primary-care practices for children with asthma and autism spectrum disorder (ASD) compared to children without chronic conditions, and 2) to determine patient and clinical-care factors associated with CoC.

METHODS

Retrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0-1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits.

RESULTS

Of 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean = 0.58, SD 0.21) and ASD (M = 0.57, SD = 0.20) than Controls (M = 0.66, SD = 0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR = 0.90, 95% CI, 0.85-0.94). Lower overall and well-care CoC were associated with public insurance (aOR = 0.77, CI, 0.74-0.81; aOR = 0.64, CI, 0.59-0.69).

CONCLUSION

After accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary-care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC.

A multilevel perspective on goals, barriers, and facilitators of school-based asthma management

BACKGROUND

School based asthma care is being increasingly used to combat uncontrolled pediatric asthma.

OBJECTIVE

The purpose of these secondary analyses was to explore multi-level perspectives regarding school-based asthma medical management for inner city, school-aged children with poor asthma control.

METHODS

Sixty-six participants from two large U.S. urban school districts and key stakeholders participated in 1:1 interviews and focus groups. Participants were selected from across the asthma care community (children/caregivers, school personnel, nurses, pharmacists, healthcare providers, and administrators/insurers). Qualitative and descriptive techniques were used to analyze data.

RESULTS

Goals: Children/caregivers prioritized living a normal active life with few asthma worries. Other stakeholders prioritized reducing student's asthma related emergency room visits and lost learning time. Facilitators: Continuity of care, strong relationships between care community members, and incentivizers were commonly suggested facilitators. School-based asthma management was viewed as a strong facilitator, particularly in the presence of a full-time school nurse. Barriers: Four themes were identified. (1) Greater systems and policy support for asthma management is needed in general, and at school in particular. (2) Overburdened families and systems often operate in crisis-mode, and asthma management is often not a priority until crisis is reached. (3) Discordance and distrust between members of the asthma care community can hinder shared asthma management. (4) Better communication is needed at all levels to improve care.

CONCLUSION

Moving away from a crisis-based approach to asthma management for high-risk children will require increased systemic support for proactive asthma care and optimized communication within the asthma care community.

Supplemental data for this article is available online at https://dx.doi.org/10.1080/02770903.2021.2018704.

The Role of Social Determinants of Health in the Use of Telemedicine for Asthma in Children

Asthma is the most common chronic health condition among children in the United States. The adverse impacts of social determinants of health often manifest in unmet health-related social needs, potentially contributing to worse asthma outcomes. With the onset and rapid spread of coronavirus disease 2019 (COVID-19) and the identification of asthma as a potential risk factor for more severe disease, our asthma program quickly pivoted to a remote-access telemedicine asthma population management platform to best meet the needs of our most at-risk patients. Our practice provides care to a large proportion of Black and Latino/a/e children in urban areas insured by the State Medicaid Program and impacted by unmet social needs. As we pivoted to telemedicine, we consistently reached a greater number of patients and families than prepandemic and observed decreased emergency department visits and hospitalizations. About 1 in 5 families received resource touch points spanning categories of transportation, food and supplies, clothing, utilities, and rent. Overall, families reported positive experiences with telemedicine, including the ability to connect remotely with our social work and resource teams. Telemedicine may be an effective strategy for addressing both the medical and the social needs of children with asthma at risk for worse outcomes.

Community based Primary Care for Adolescents and Young Adults Transitioning From Pediatric Specialty Care: Results from a Scoping Review

Background:

Ongoing primary care during adolescence is recommended by best practice guidelines for adolescents and young adults (AYAs; ages 12-25) with chronic conditions. A synthesis of the evidence on the roles of Primary Care Physicians (PCPs) and benefits of primary care is needed to support existing guidelines.

Methods:

We used Arksey and O’Malley’s scoping review framework, and searched databases (MEDLINE, EMBASE, PsychINFO, CINAHL) for studies that (i) were published in English between 2004 and 2019, (ii) focused on AYAs with a chronic condition(s) who had received specialist pediatric services, and (iii) included relevant findings about PCPs. An extraction tool was developed to organize data items across studies (eg, study design, participant demographics, outcomes).

Results:

Findings from 58 studies were synthesized; 29 (50%) studies focused exclusively on AYAs with chronic health conditions (eg, diabetes, cancer), while 19 (33%) focused exclusively on AYAs with mental health conditions. Roles of PCPs included managing medications, “non-complex” mental health conditions, referrals, and care coordination, etc. Frequency of PCP involvement varied by AYAs; however, female, non-Black, and older AYAs, and those with severe/complex conditions appeared more likely to visit a PCP. Positive outcomes were reported for shared-care models targeting various conditions (eg, cancer, concussion, mental health).

Conclusion:

Our findings drew attention to the importance of effective collaboration among multi-disciplinary specialists, PCPs, and AYAs for overcoming multiple barriers to optimal transitional care. Highlighting the need for further study of the implementation of shared care models to design strategies for care delivery during transitions to adult care.

Development and validation of the Pediatric Asthma kNowleDge and mAnagement (P.A.N.D.A) questionnaires

OBJECTIVE

The objective of this study was to assess the validity, feasibility and reliability of the Pediatric Asthma kNowleDge and mAnagement (PANDA) questionnaires that we developed.

METHODS

We developed 3 questionnaires aimed for Children, Teenagers and Parents of children living with asthma. Experts in childhood asthma reviewed the questionnaires to evaluate face and content validity with a measure of the Scale-Content Validity Index (S-CVI). Children age 7 and up and their parents participated in the feasibility and reliability assessment. Reliability was assessed by doing a test re-test, using the Intraclass Correlation Coefficient (ICC), for each questionnaire topic.

RESULTS

Face validity was validated for the three PANDA questionnaires with a satisfactory length and comprehension level. Content validity, with a total S-CVI of 0.91, was found for the Children and Parents questionnaires. With 84 participants, the ICC were found to be higher than 0.7 with a 95%CI [0.5-0.9] for the total scores and higher than 0.5 for each topic for each questionnaire, indicating reliability.

CONCLUSION

Face and content validity and reliability of the PANDA questionnaires was established, with an appropriate comprehension level and length. Other types of validation like construct validity and responsiveness would need to be assessed to complete the validation of the questionnaires. The PANDA questionnaires could be used for research and in everyday practice.

A Comparison of Activity Participation between Children with and without Asthma

Background

Asthma affects approximately 6 million children in the United States and can greatly impact quality of life and occupational engagement. Although occupational therapists are well-equipped to address participation limitations, insufficient evidence exists to support the role of occupational therapists in asthma treatment.

Method

The purpose of this study was to further understand the occupational limitations experienced by children with asthma. We also explored a dual diagnosis of asthma and obesity. The participants included children with (n = 84) and without (n = 63) asthma living in New York City. The Child Behavior Checklist, Youth Self Report, Brief Respiratory Questionnaire, and accelerometer data were used to examine occupational participation.

Results

Although accelerometry data demonstrated that children with asthma were equally as active as their non-asthmatic peers, the participants with asthma perceived themselves as participating more in sedentary occupations and were less likely to be members of sports teams. They also had more missed school days and nights of troubled sleep. The children with both asthma and obesity reported the highest level of activity limitations.

Conclusion

This study illustrates specific limitations experienced by children with asthma and supports the need for occupational therapy intervention. Future studies are needed to design and assess interventions that will support the addition of occupational therapists to multidisciplinary asthma treatment teams.

Community-based interventions for childhood asthma using comprehensive approaches: a systematic review and meta-analysis

Objective

We conducted a systematic review and meta-analysis to determine the effectiveness of comprehensive community-based interventions with ≥ 2 components in improving asthma outcomes in children.

Methods

A systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Cochrane Library and hand search of reference collections were conducted to identify any research articles published in English between 2000 and 2019. All studies reporting community-based asthma interventions with ≥ 2 components (e.g., asthma self-management education, home environmental assessment or care coordination etc.) for children aged ≤ 18 years were included. Meta-analyses were performed using random-effects model to estimate pooled odds ratio (OR) with 95% confidence intervals (CIs).

Results

Of the 2352 studies identified, 21 studies were included in the final analysis: 19 pre-post interventions, one randomised controlled trial (RCT) and one retrospective study. Comprehensive asthma programs with multicomponent interventions were associated with significant reduction in asthma-related Emergency Department (ED) visits (OR = 0.26; 95% CI 0.20–0.35), hospitalizations (OR = 0.24; 95% CI 0.15–0.38), number of days (mean difference = − 2.58; 95% CI − 3.00 to − 2.17) and nights with asthma symptoms (mean difference = − 2.14; 95% CI − 2.94 to − 1.34), use of short-acting asthma medications/bronchodilators (BD) (OR = 0.28; 95% CI 0.16–0.51), and increase use of asthma action plan (AAP) (OR = 8.87; 95% CI 3.85–20.45).

Conclusion

Community-based asthma care using more comprehensive approaches may improve childhood asthma management and reduce asthma related health care utilization.

Primary care during the transition to adult care for adolescents involved with pediatric specialty services: a scoping review protocol

BACKGROUND

Of the 15-20% of youth in North America affected by a chronic health condition (e.g., type 1 diabetes, cystic fibrosis) and/or mental health or neurodevelopmental disorder (e.g., depression, eating disorder, Attention Deficit-Hyperactivity Disorder), many often require lifelong specialist healthcare services. Ongoing primary care during childhood and into young adulthood is recommended by best practice guidelines. To date, it is largely unknown if, how, and when primary care physicians (PCPs; such as family physicians) collaborate with specialists as AYAs leave pediatric-oriented services. The proposed scoping review will synthesize the available literature on the roles of PCPs for AYAs with chronic conditions leaving pediatric specialty care and identify potential benefits and challenges of maintaining PCP involvement during transition.

METHODS

Arksey and O'Malley's original scoping review framework will be utilized with guidance from Levac and colleagues and the Joanna Briggs Institute. A search of databases including MEDLINE (OVID), EMBASE, PsycINFO, and CINAHL will be conducted following the development of a strategic search strategy. Eligible studies will (i) be published in English from January 2004 onwards, (ii) focus on AYAs (ages 12-25) with a chronic condition(s) who have received specialist services during childhood, and (iii) include relevant findings about the roles of PCPs during transition to adult services. A data extraction tool will be developed and piloted on a subset of studies. Both quantitative and qualitative data will be synthesized.

DISCUSSION

Key themes about the roles of PCPs for AYAs involved with specialist services will be identified through this review. Findings will inform the development and evaluation of a primary-care based intervention to improve transition care for AYAs with chronic conditions.

An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations

OBJECTIVES

A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization.

METHODS

Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group.

RESULTS

From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; P = .02).

CONCLUSIONS

A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.

Providing effective asthma care at a pediatric patient-centered medical home

BACKGROUND

A recent assessment of the national annual burden of the cost of asthma among school-aged children was nearly $6 million. In a Midwestern county, the incidence of childhood asthma was 15.8%, which was above both state and national levels.

LOCAL PROBLEM

Effective asthma care was not being provided at a rural, pediatric patient-centered medical home due to a lack of standardization. This quality improvement (QI) initiative aimed to increase the mean effective asthma care score to 78% for patients with asthma over the course of 90 days.

METHODS

This right care initiative was implemented using a rapid-cycle Plan-Do-Study-Act methodology. Tests of change in the areas of team engagement, patient engagement, and two process measures were analyzed through chart audits and run charts over four cycles. Likert scale surveys were used to analyze qualitative data.

INTERVENTIONS

Interventions included developing the Asthma Patient Identification Tool, implementing an asthma education protocol with teach-back, creating standardized smart phrases for effective documentation, and initiating asthma care huddles.

RESULTS

The delivery of effective asthma care increased to 84%. The number of patients receiving the asthma education protocol increased to 65%, with 80% of the patients participating in effective teach-back sessions. The mean effective documentation score increased to 92%.

CONCLUSIONS

A standardized approach to asthma care grounded in evidence-based guidelines positively affected the delivery of care. Nurse practitioners are effective team leaders for clinical QI initiatives.

The impact of care management for high-risk pediatric asthmatics on healthcare utilization

INTRODUCTION

From 2011 to 2015, a series of quality improvement interventions were developed that targeted pediatric persistent asthmatics that included recalls for those overdue for care and access to specialist care. The objective of this study was to assess the impact on urgent care and emergency department visits and hospitalizations from enrollment into at least one intervention during the time period.

METHODS

Persistent asthmatics were identified through electronic medical records, with patients having an asthma designation containing "persistent," asthma control containing "poor", and asthma risk being "high risk." Asthma utilization events were identified for these patients between January 1, 2011, and June 30, 2015 using ICD-9 diagnosis codes. Evaluation focused on differences in utilization for patients before and after receiving interventions through the use of logistic regression for each utilization outcome.

RESULTS

The interventions were delivered to 1060 children out of a total of 2046 identified as having the persistent asthmatic criteria. The intervention group consisted of 389 (36.7%) moderate persistent asthmatics and 643 (60.7%) mild persistent asthmatics, with 976 (92.1%) identifying as a minority. Analysis of 60692 months of data showed patients who received the intervention were less likely to visit the urgent care (OR [0.80, 0.96]) or be hospitalized (OR [0.37, 0.75]) than those who did not receive any interventions. Adjustment for provider referral into the interventions resulted in slight changes for both hospitalizations (OR [0.38, 0.79]) and urgent care (OR [0.68, 0.94]).

CONCLUSION

Children receiving interventions were less likely to be hospitalized or visit urgent care clinics.

Associations Between Patient-Reported Outcome Measures of Asthma Control and Psychosocial Symptoms

There is growing emphasis on using patient-reported outcome measures to enhance clinical practice. This study was a retrospective review of scores on the Childhood Asthma Control Test (C-ACT) and the Pediatric Symptom Checklist-17 (PSC-17) at a pediatric primary care center in Boston, Massachusetts. A total of 218 patients were selected at random using billing codes for well-child (WC) care and asthma, excluding complex medical conditions. Cutoff scores were used to identify uncontrolled asthma (C-ACT ⩽19) and clinically significant psychosocial symptoms (+PSC-17). Multiple logistic regression was used to measure associations between C-ACT ⩽19 and +PSC-17, adjusting for covariates. In multivariable analysis, C-ACT ⩽19 at WC visits was associated with +PSC-17 at WC visits (adjusted odds ratio = 3.2 [95% confidence interval = 1.3-8.6]). C-ACT ⩽19 at non-WC visits was also associated with +PSC-17 at WC visits (adjusted odds ratio = 3.1 [95% confidence interval = 1.2-8.9]). Patient-reported outcome measures of asthma control and psychosocial symptoms were positively correlated in this sample.

Acute Asthma in the Pediatric Emergency Department: Infections Are the Main Triggers of Exacerbations

Background

Asthma exacerbations are a common reason for Emergency Department (ED) visits in children.

Aim

To analyze differences among age groups in terms of triggering factors and seasonality and to identify those with higher risk of severe exacerbations.

Methods

We retrospectively revised the files of children admitted for acute asthma in 2016 in our Pediatric ED.

Results

Visits for acute asthma were 603/23197 (2.6%). 76% of the patients were <6 years old and 24% ≥6. Infections were the main trigger of exacerbations in both groups; 33% of the school-aged children had a triggering allergic condition (versus 3% in <6 years; p < .01). 191 patients had a previous history of asthma; among them, 95 were ≥6 years, 67% of whom were not using any controller medication, showing a higher risk of a moderate-to-severe exacerbation than those under long-term therapy (p < .01). Exacerbations peaked in autumn and winter in preschoolers and in spring and early autumn in the school-aged children.

Conclusions

Infections are the main trigger of acute asthma in children of any age, followed by allergy in the school-aged children. Efforts for an improved management of patients affected by chronic asthma might go through individualized action plans and possibly vaccinations and allergen-avoidance measures.