A framework for measuring self-management effectiveness and health care use among pediatric asthma patients and families

Development and Validation of the Parents' Health Literacy Scale for Children with Asthma (PHLSCA)

OBJECTIVE

This study aimed to develop and validate an instrument to assess the health literacy of parents of children with asthma in a Chinese context.

METHODS

The preliminary Parents' Health Literacy Scale for Children with Asthma (PHLSCA) was developed based on a literature review and refined to 45 items through two rounds of expert consultation using the Delphi method. A total of 481 parents of children with asthma were recruited from seven hospitals across four provinces in China between February and April 2019. Principal component analysis (PCA) and confirmatory factor analysis were conducted to evaluate the structural and construct validity of the scale.

RESULTS

The development and validation processes led to a 38 items scale comprising three subscales, namely: Health Knowledge (11 items), Health Skills (19 items) and Health Behavior (8 items). The scale demonstrated good reliability, with an internal consistency of Cronbach's α = 0.956 and a split-half reliability of r = 0.887 (p < 0.01). The Item Content Validity Index (I-CVI) ranged from 0.81 to 1.00, and the Scale-CVI was 0.842. The correlation coefficients and factor analysis results indicated good construct validity, with the factors explaining 59.33% to 62.90% of the variance in each subscale.

CONCLUSIONS

The final version of the questionnaire (PHLSCA) has been demonstrated to be a valid and reliable tool for assessing the health literacy of parents of Chinese children with asthma.

Effect of Disease Severity, Age of Child, and Clinic No-Shows on Unscheduled Healthcare Use for Childhood Asthma at an Academic Medical Center

This study examines the influence of various individual demographic and risk factors on the use of unscheduled healthcare (emergency and inpatient visits) among pediatric outpatients with asthma over three retrospective timeframes (12, 18, and 24 months) at an academic health center. Out of a total of 410 children who visited an academic medical center for asthma outpatient care between 2019 and 2020, 105 (26%) were users of unscheduled healthcare for childhood asthma over the prior 12 months, 131 (32%) over the prior 18 months, and 147 (36%) over the prior 24 months. multiple logistic regression (MLR) analysis of the effect of individual risk factors revealed that asthma severity, age of child, and clinic no-shows were statistically significant predictors of unscheduled healthcare use for childhood asthma. Children with higher levels of asthma severity were significantly more likely to use unscheduled healthcare (compared to children with lower levels of asthma severity) across all three timeframes. Likewise, children with three to four clinic no-shows were significantly more likely to use unscheduled healthcare compared to children with zero clinic no-shows in the short term (12 and 18 months). In contrast, older children were significantly less likely to use unscheduled healthcare use compared to younger children in the longer term (24 months). By virtue of its scope and design, this study provides a foundation for addressing a need identified in the literature for short- and long-term strategies for improving supported self-management and reducing unscheduled healthcare use for childhood asthma at the patient, provider, and organizational levels, e.g., (1) implementing telehealth services for asthma outpatient care to reduce clinic no-shows across all levels of asthma severity in the short term; (2) developing a provider-patient partnership to enable patient-centered asthma control among younger children with higher asthma severity in the long term; and (3) identifying hospital-community linkages to address social risk factors influencing clinic no-shows and unscheduled healthcare use among younger children with higher asthma severity in the long term.

Impact of adherence to treatment with inhaled corticosteroids/long-acting β-agonists on asthma outcomes in the United States

BACKGROUND

Suboptimal adherence to maintenance medication has been associated with poor outcomes in asthma. This study examined single-inhaler inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA) adherence and asthma-related outcomes.

METHODS

This retrospective observational study of patients with asthma initiating ICS/LABA used data from IQVIA PharMetrics Plus (1 January 2014-31 March 2019). Patients included were ⩾18 years old and had ⩾12 months continuous eligibility before, and ⩾180 days follow-up after, the index date. Adherence was measured as proportion of days covered ([PDC] adherent ⩾ 0.8; non-adherent <0.8) each quarter, with outcomes measured each subsequent quarter. Endpoints were asthma-related overall and severe (inpatient/emergency department [ED] visit) exacerbations, rescue medication use, and asthma-related healthcare resource utilization and costs. Regression models evaluated associations between adherence and outcomes, controlling for repeated measures and differences in baseline characteristics.

RESULTS

Overall, 50,037 patients were included (mean age 45.3 years; mean follow-up 23.3 months). Adherent patients were less likely to experience asthma-related overall (adjusted odds ratio [aOR] 95% confidence interval [CI]: 0.942 [0.890, 0.998]; p = 0.041), or severe exacerbations (aOR [95% CI]: 0.778 [0.691, 0.877]; p < 0.001) per quarter versus non-adherent patients. Adherent patients had lower severe exacerbation rates (adjusted rate ratio [aRR] [95% CI]: 0.792 [0.702, 0.893]; p < 0.001) but similar overall exacerbation rates (aRR [95% CI]: 0.993 [0.945, 1.044]; p = 0.783) versus non-adherent patients. The odds of rescue medication use were lower per 20% PDC increase (aOR [95% CI] short-acting β2 agonist: 0.991 [0.985, 0.996]; p = 0.001; oral corticosteroid: 0.988 [0.982, 0.995]; p < 0.001). Adherent patients were less likely to visit EDs per quarter (aOR [95% CI]: 0.775 [0.680, 0.883]; p < 0.001) and odds of hospitalization were lower per 20% PDC increase (aOR [95% CI]: 0.930 [0.881, 0.982]; p = 0.009). Across most measures, adherent patients incurred lower costs.

CONCLUSION

This real-world study highlights the short-term clinical and economic benefits of ICS/LABA adherence in asthma, particularly in reducing severe exacerbations.

Demographic and Risk Factor Differences between Children with "One-Time" and "Repeat" Visits to the Emergency Department for Asthma

This retrospective study examines demographic and risk factor differences between children who visited the emergency department (ED) for asthma once (“one-time”) and more than once (“repeat”) over an 18-month period at an academic medical center. The purpose is to contribute to the literature on ED utilization for asthma and provide a foundation for future primary research on self-management effectiveness (SME) of childhood asthma. For the first round of analysis, an 18-month retrospective chart review was conducted on 252 children (0–17 years) who visited the ED for asthma in 2019–2020, to obtain data on demographics, risk factors, and ED visits for each child. Of these, 160 (63%) were “one-time” and 92 (37%) were “repeat” ED patients. Demographic and risk factor differences between “one-time” and “repeat” ED patients were assessed using contingency table and logistic regression analyses. A second round of analysis was conducted on patients in the age-group 8–17 years to match another retrospective asthma study recently completed in the outpatient clinics at the same (study) institution. The first-round analysis indicated that except age, none of the individual demographic or risk factors were statistically significant in predicting of “repeat” ED visits. More unequivocally, the second-round analysis revealed that none of the individual factors examined (including age, race, gender, insurance, and asthma severity, among others) were statistically significant in predicting “repeat” ED visits for childhood asthma. A key implication of the results therefore is that something other than the factors examined is driving “repeat” ED visits in children with asthma. In addition to contributing to the ED utilization literature, the results serve to corroborate findings from the recent outpatient study and bolster the impetus for future primary research on SME of childhood asthma.

Implementing Telehealth in Pediatric Asthma

Pediatric patients with uncontrolled asthma often live in underserved areas such as rural communities where few pediatric asthma specialists exist. There are significant costs associated with acute asthma exacerbations, which are increasingly prevalent in these high-risk populations. Telemedicine is a viable option when addressing barriers in access to care and cost-efficiency. Implementing telemedicine in schools and other local community settings, as well as implementing innovative technology such as smartphone applications, can reduce the burden of asthma; increase patient satisfaction; and, most importantly, improve pediatric asthma outcomes.

Demographic and Risk-Factor Differences between Users and Non-Users of Unscheduled Healthcare among Pediatric Outpatients with Persistent Asthma

This study assesses differences between users and non-users of unscheduled healthcare for persistent childhood asthma, with regard to select demographic and risk factors. The objectives are to provide important healthcare utilization information and a foundation for future research on self-management effectiveness (SME), informed by a recently developed "holistic framework" for measuring SME in childhood asthma. An 18-month retrospective chart review was conducted on 59 pediatric outpatients with persistent asthma-mild, moderate, or severe, to obtain data on various demographic and risk factors, and healthcare use for each child. The study examined five types of "unscheduled" healthcare use. Users had non-zero encounters (at least one) in any of the five types; non-users had zero encounters (not even one) in all five types. Differences between users and non-users were assessed using contingency table and logistic regression analysis. There were 25 users and 34 non-users of unscheduled healthcare. Each severity category contained users and non-users. The only statistically significant finding was that the mild persistent category had fewer users than severe persistent (p < 0.05). There were no significant differences between users and non-users for any other demographic or risk factor examined. After adjusting for asthma severity, there were no other significant differences between users and non-users of unscheduled healthcare. This is a crucial finding which suggests that something else is driving unscheduled healthcare use in these children, given there were users and non-users in each asthma severity category. These results provide impetus for future research on the role of other aspects of the "holistic framework" in explaining differences in uses of unscheduled healthcare in persistent childhood asthma.

Measurement of Key Constructs in a Holistic Framework for Assessing Self-Management Effectiveness of Pediatric Asthma

The 2007 U.S. National Institutes of Health EPR-3 guidelines emphasize the importance creating a provider-patient partnership to enable patients/families to monitor and take control of their asthma, so that treatment can be adjusted as needed. However, major shortfalls continue to be reported in provider adherence to EPR-3 guidelines. For providers to be more engaged in asthma management, they need a comprehensive set of resources for measuring self-management effectiveness of asthma, which currently do not exist. In a previously published article in the Journal of Asthma and Allergy, the authors conducted a literature review, to develop a holistic framework for understanding self-management effectiveness of pediatric asthma. The essence of this framework, is that broad socioecological factors can influence self-agency (patient/family activation), to impact self-management effectiveness, in children with asthma. A component of socio-ecological factors of special relevance to providers, would be the quality of provider-patient/family communication on asthma management. Therefore, the framework encompasses three key constructs: (1) Provider-patient/family communication; (2) Patient/family activation; and (3) Self-management effectiveness. This paper conducts an integrative review of the literature, to identify existing, validated measures of the three key constructs, with a view to operationalizing the framework, and discussing its implications for asthma research and practice.

Real-world evaluation of a mobile health application in children with asthma

BACKGROUND

Mobile health applications for asthma are increasingly being developed. However, there are no published randomized controlled trials evaluating efficacy in decreasing exacerbations.

OBJECTIVE

To evaluate the impact of a mobile asthma application for asthma-related urgent health care usage.

METHODS

We conducted a 6-month prospective randomized controlled trial for patients (6 months-21 years old) with persistent asthma presenting with an asthma exacerbation to the emergency department of a pediatric academic medical center. Participants were randomized to AsthmaCare (application providing medication and trigger reminders and treatment plan) or the control (online asthma information). Primary outcome measures were comparison of emergency department and urgent care visits and hospitalizations 6 months before and after randomization.

RESULTS

AsthmaCare participants (n = 98) were slightly older (7.84 vs 6.24 years; P = .02) than controls (n = 95) but similar for sex (55% vs 62% boys), race (83% vs 77% African American), and insurer (89% vs 98% Medicaid). The 2 groups were similar in having more than 2 comorbidities (34% vs 32%) and receiving National Heart, Lung, and Blood Institute step 3 treatment or higher (69% vs 57%). There was no significant decrease in emergency department or urgent care visits or hospitalizations between the intervention and control groups. AsthmaCare participants were more likely to report improvement in asthma management 6 months after study enrollment (79% vs 64%; P = .06).

CONCLUSION

This randomized controlled trial did not demonstrate a significant decrease in asthma-related emergency department visits or hospitalizations among children who used a mobile health application.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier NCT02333630.