Caregiver education to promote appropriate use of preventive asthma medications: what is happening in primary care?

[Educational interventions in childhood asthma: A systematic review]

OBJECTIVE

To analyze educational interventions in pediatric asthmatic patients to achieve an adequate inhalation technique and improve their self-management.

DESIGN

Systematic review based on the PRISMA recommendations.

DATA SOURCES

Pubmed, Scopus, Cuiden, Web of Science and Google Scholar databases were reviewed.

STUDY SELECTION

Sixteen articles published between 2014 and 2021 were included, with access to full text, languages: English, French and Spanish and pediatric population: 0-18 years.

DATA EXTRACTION

Two thousand three hundred and thirteen children were participated. The variables analyzed were: level of care, type of intervention, correct performance of the inhalation technique, follow-up of the technique, delivery of written recommendations, professional-educator category, variables related to respiratory pathology, school absenteeism, quality of life and economic costs.

RESULTS

The health care level was primary, hospital and community care, where specialist doctors, nurses and pharmacists stood out as educators. The most prevalent educational interventions are on-site demonstration and delivery of recommendations or multimedia interventions. Several articles report that asthma education is not carried out correctly, others state that their technique improves after the intervention, but most of them highlight the importance of periodic review of the technique.

CONCLUSIONS

The authors report improvement in the inhalation technique in all of them, as well as greater self-management of the disease and adherence to treatment. It is necessary to intensify the education of patients in the correct handling of the devices, and the follow-up and subsequent review to optimize the control of the disease.

Utilization of the emergency department as a routine source of care among children with asthma

Objective: To describe characteristics of children with persistent asthma in the ED who receive most of their healthcare in emergency settings; and determine whether recent asthma experiences or historic patterns of care are associated with identifying the ED as a typical location for care.Methods: We conducted a sub-analysis of baseline data from Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED), an RCT of children (3-12 years) presenting to the ED with persistent asthma (2016-2020). Caregivers identified reasons for seeking emergency care, including if their child received most overall healthcare in the ED ('ED Care'; primary outcome) or not ('Other Care'). Independent variables included demographics, recent symptoms and quality of life (QOL), and historic preventive care and healthcare use. We compared responses between ED Care and Other Care groups using bivariate and multivariate analyses.Results: We analyzed data for 355 children (31% ED Care, 69% Other Care). Compared with Other Care, ED Care respondents were more likely to identify the ED as the closest source of healthcare; report fewer symptom nights but a poorer quality of life; and describe the ED as a usual place for sick care, despite most having a PCP.Conclusions: Many children with asthma use the ED as a typical source of healthcare, and are distinguished by need for proximity, poorer caregiver QOL, and historic patterns of care-seeking. Efforts to improve timely access to outpatient care and reinforce the role of PCP-directed asthma management, such as through telemedicine, may reduce preventable morbidity including ED visits.

Racial Inequities in Asthma Care

Racial inequities in asthma care are evolving as a recognized factor in long-standing inequities in asthma outcomes (e.g., hospitalization and mortality). Little research has been conducted regarding the presence or absence of racial inequities among patients seen in asthma specialist settings, this is an important area of future research given that asthma specialist care is recommended for patients experiencing the poor asthma outcomes disproportionately experienced by Black and Hispanic patients. This study provides a systematic review of racial asthma care inequities in asthma epidemiology, clinical assessment, medication prescription, and asthma specialist referral practices.

Association of Asthma Exacerbation Risk and Physician Time Expenditure With Provision of Asthma Action Plans and Education for Pediatric Patients

OBJECTIVE

To provide information about factors underlying provision of asthma action plans (AAPs) to a minority of pediatric patients with asthma, assess whether risk of exacerbation acts on provision of AAP and asthma education directly, suggesting targeting to highest-risk patients, or indirectly by influencing physician-patient interaction time.

METHODS

This study was a retrospective cross-sectional analysis of a nationally representative sample of physician office visits that consisted of patients aged 2 to 18 years with asthma. Exacerbation risk comprised proxy indicators of control and severity. Direct and time-mediated effects of exacerbation risk on provision of AAP and education were calculated from logistic regression models.

RESULTS

Asthma action plans were provided in 14.3% of visits, education in 23.9%. Total direct effects of exacerbation risk (ORs = 3.88-4.69) far exceeded indirect, time-mediated effects (both ORs = 1.03) on AAPs. Direct effects on education were similar but smaller. After adjusting for risk, physician time expenditure of ≥30 minutes was associated with nearly doubled odds of providing AAP or education (ORs = 1.90-1.99). Visits that included allied health professionals alongside physician care were significantly associated with all 4 outcomes in multivariate analyses (ORs = 3.06-5.28).

CONCLUSIONS

Exacerbation risk has a strong, direct association with AAP provision in pediatric asthma, even controlling for physician time expenditure. Provision of AAP and education to pediatric patients with asthma may be facilitated by increasing available time for office visits and involving allied health professionals.

Clinical Outcomes for Young Children Diagnosed With Asthma Versus Reactive Airway Disease

OBJECTIVE

Clinical diagnoses of asthma and reactive airway disease (RAD) in young children are subjective. We examined how often children were diagnosed with asthma versus RAD, and whether preventive care and 2-year clinical outcomes differed based on initial diagnosis.

METHODS

We conducted a retrospective cohort analysis of children (2-7 years) from a university-based general pediatrics practice who had been diagnosed with RAD or asthma. We performed adjusted comparisons between groups for time until subsequent asthma-related care. We also compared delivery of asthma-related healthcare services, corticosteroid and controller prescriptions, and action plans within 2 years of index diagnosis, using bivariate and regression analyses.

RESULTS

Four hundred three children were included (64% male, 67% Black, 25% Hispanic). RAD was diagnosed in 62% of index visits, and was more likely than asthma to be diagnosed in emergency settings. In the full sample, the time between index visit and subsequent asthma care did not differ between groups, after adjustment for index location. For subjects with complete 24-month follow-up (N = 300), no between-group differences were found in adjusted analyses. Most children with RAD received action plans and controller medications only after a subsequent asthma diagnosis, on average, 9 months after their index visit.

CONCLUSIONS

RAD diagnoses were linked to delayed delivery of preventive care measures, but within 2 years of initial diagnosis, clinical outcomes for those diagnosed with RAD and asthma did not differ. To facilitate clear communication and timely treatment, a prompt diagnosis of asthma, rather than RAD, should be considered for children with asthma symptoms.

Effect of family caregiver nursing education on patients with rheumatoid arthritis and its impact factors: A randomized controlled trial

BACKGROUND

Rheumatoid arthritis (RA) is a common autoimmune disease. Nursing education for family caregivers is considered a workable and effective intervention, but the validity of this intervention in RA has not been reported.

AIM

To explore whether family caregiver nursing education (FCNE) works on patients with RA and the factors that influence FCNE.

METHODS

In this randomized controlled study, a sample of 158 pairs was included in the study with 80 in the intervention group and 78 in the control group. Baseline data of patients and caregivers was collected. The FCNE intervention was administered to caregivers, and inflammation level indicators, disease activity indicators and mood disorder indicators of patients were followed up and analyzed.

RESULTS

Baseline characteristics of the intervention and the control groups had no significant difference. Indicators were significantly reduced in the intervention group compared to the control group. The intervention group showed significant differences in stratification of relationship, education duration and age.

CONCLUSION

The effect of FCNE on RA is multifaceted, weakening inflammation level, alleviating disease activity and relieving mood disorder. Relationship between caregiver and patient, caregiver’s education level and patient’s age may act as impact factors of FCNE.

Well-Child Care Attendance and Risk of Asthma Exacerbations

BACKGROUND

Asthma remains a leading cause of hospitalization in US children. Well-child care (WCC) visits are routinely recommended, but how WCC adherence relates to asthma outcomes is poorly described.

METHODS

We conducted a retrospective longitudinal cohort study using electronic health records among 5 to 17 year old children residing in Durham County with confirmed asthma and receiving primary care within a single health system, to compare the association between asthma exacerbations and previous WCC exposure. Exacerbations included any International Classification of Diseases, Ninth Revision, or International Classification of Diseases, 10th Revision, coded asthma exacerbation encounter with an accompanying systemic glucocorticoid prescription. Exacerbations were grouped by severity: ambulatory encounter only, urgent care, emergency department, hospital encounters <24 hours, and hospital admissions ≥24 hours. In the primary analysis, we assessed time to asthma exacerbation based on the presence or absence of a WCC visit in the preceding year using a time-varying covariate Cox model.

RESULTS

A total of 5656 children met eligibility criteria and were included in the primary analysis. Patients with the highest WCC visit attendance tended to be younger, had a higher prevalence of private insurance, had greater asthma medication usage, and were less likely to be obese. The presence of a WCC visit in the previous 12 months was associated with a reduced risk of all-cause exacerbations (hazard ratio: 0.90; 95% confidence interval: 0.83-0.98) and severe exacerbations requiring hospital admission (hazard ratio: 0.53; 95% confidence interval: 0.39-0.71).

CONCLUSIONS

WCC visits were associated with a lower risk of subsequent severe exacerbations, including asthma-related emergency department visits and hospitalizations. Poor WCC visit adherence predicts pediatric asthma morbidity, especially exacerbations requiring hospitalization.

Health-related internet use among adolescents with uncontrolled persistent asthma

OBJECTIVES

To describe internet use for health information among adolescents with uncontrolled persistent asthma, and to examine whether health-related internet use is associated with responsibility for home asthma management.

METHODS

We analyzed baseline data from the School-Based Asthma Care for Teens (SB-ACT) Trial, which included adolescents (12-16 years) in an urban school district who had uncontrolled persistent asthma per caregiver report. We asked adolescents whether they had ever used the Internet to look for health or medical information (Y/N). Teens then described family responsibility for 9 asthma management tasks (e.g. full caregiver responsibility, shared responsibility, or full teen responsibility). We examined responsibility sum scores in addition to responsibility for individual management tasks. We used bivariate and multivariate analyses to compare health-related internet use with participant characteristics, teen-reported asthma symptoms, and management responsibility.

RESULTS

We examined data for 425 adolescents (mean age 13.4 years). Almost half (45%) reported seeking health information on the Internet. In adjusted analyses, health-related internet use was strongly associated with teen responsibility (sum score and tasks relating to carrying and using medications); internet use was also more likely among teens who were older, female, or reported uncontrolled disease.

CONCLUSIONS

Adolescents with persistent asthma who share responsibility for home management or report uncontrolled disease are more likely to seek health information online. Future interventions to support teens who co-manage asthma should work to engage patients in both clinical and digital spaces, and ensure that all patients can access accurate, patient-centered asthma information when needed.

Psychological and Socioeconomic Burdens Faced by Family Caregivers of Children With Asthma: An Integrative Review

INTRODUCTION

Asthma affects nearly 1 in every 12 children in the United States. Caring for a child with asthma poses significant challenges for the parent or caregiver. The purpose of this integrative review was to identify the psychological and socioeconomic burdens faced by family caregivers of children with asthma.

METHOD

An integrative review was conducted to review and appraise 80 studies.

RESULTS

Psychosocial burdens included decreased mental health, quality of life, sleep, family stress, educational deficits, cultural and health disparities, and health care communication challenges. Socioeconomic burdens included poor access to care, as well as work and financial challenges. Studies demonstrated a link between family caregiver health and child health outcomes. Facilitators included education and empowerment, social support, and use of technology.

DISCUSSION

As the family caregiver's health directly affects the asthmatic child's health, addressing the burdens of family caregivers should be a key consideration in pediatric asthma care.

Nurse-delivered outpatient asthma education for children and caregivers: a pilot study to promote shared asthma management

OBJECTIVES

To assess the feasibility of nurse-delivered asthma education for caregiver/child dyads in a busy clinic setting, and measure the preliminary effectiveness of the intervention.

METHODS

We conducted a pilot study of nurse-delivered asthma education in a busy outpatient clinic. We enrolled a convenience sample of children (7-16 years) with uncontrolled persistent asthma who had a prescription for an inhaled controller medication and public health insurance. After provider visits, nurses taught dyads using picture-based materials, teach-back methods, and colored labels applied to asthma medications. The intervention was repeated at 1-month follow-up. We assessed feasibility by reviewing nurse documentation in the electronic medical record, detailing whether each component was implemented and the time required for education at each visit. We measured preliminary effectiveness by surveying children and caregivers separately before each clinic visit about asthma management responsibility, self-efficacy, caregiver quality of life, and symptoms; caregivers also completed a final telephone survey 2 months after the follow-up visit. We examined pre-post differences in continuous outcomes within-subjects using Wilcoxon signed rank tests.

RESULTS

We enrolled 22 child/caregiver dyads. Nursing documentation indicated a high rate of component delivery at each visit; the initial and 1-month visits required 25 and 15 min, respectively. We observed significant increases in child responsibility, child/caregiver self-efficacy, caregiver quality of life, and child symptoms at each follow-up.

CONCLUSION

This intervention of patient-centered asthma education can be delivered by nurses to caregiver/child dyads with high fidelity in a busy pediatric practice. Preliminary data indicate potential benefit for both children and caregivers.

Identifying which children with persistent asthma have preventive medications available at home

Objective: To compare caregiver-reported preventive medication use and pharmacy data with medications available at home for children with persistent asthma, and identify factors associated with having preventive medication at home.Methods: We analyzed baseline data from the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) study, including medication use, symptoms, and demographics. Research assistants documented all asthma medications available during home visits. We reviewed pharmacy records for a subset of children. Bivariate and multivariate analyses identified factors associated with having any preventive medication in the home.Results: We included 335 children (mean 7.7 years, 56% Black, 34% Hispanic, 77% Medicaid; participation 79%). Most caregivers (69%) reported preventive medication use, yet only 45% had preventive medication at home. Compared to families with preventive medication at home, more families without preventive medication reported discontinuous insurance in the prior year (7% vs. 15%, p = .02) and medication sharing (22% vs. 32%, p = .04). For the subset with pharmacy records (n = 192), 40% filled a preventive medication in the past year and 15% had a preventive medication at home. In multivariate analyses, children were less likely to have preventive medication at home when caregivers reported no preventive medication use in the past 2 weeks (OR 0.25; 95% CI 0.14, 0.43), discontinuous insurance (OR 0.42; 95% CI 0.19, 0.97), medication sharing (OR 0.54; 95% CI 0.32, 0.91), or caregiver education ≥ HS (OR 0.59; 95% CI 0.35, 0.99).Conclusion: Among urban children with persistent asthma, neither caregiver report nor pharmacy data reflect home preventive medication availability. Inquiring about insurance coverage and medication sharing may improve preventive medication availability for these children.

A qualitative study of parent perspectives on barriers, facilitators and expectations for school asthma care among urban, African-American children

Objectives: Minority children experience the disproportionate burden of asthma and its consequences. Studies suggest ethnic groups may experience asthma differently with varied perceptions and expectations among parents of African-American and Latino children. Because parents coordinate asthma care with the school, where children spend a significant amount of their day, this study's goal was to determine parents' perspectives on school asthma management. Methods: Focus groups were conducted with parents of children with asthma at four urban schools whose student population is predominantly African-American. A semi-structured guide was utilized focusing on barriers, facilitators and expectations for asthma care at school. Grounded theory principles were applied in this study. Results: Twenty-two parents (91% females) representing 13 elementary and 10 middle school children with asthma (61% boys) participated in four focus groups. Most children (87%) had persistent asthma. The identified barriers to effective school-based asthma care included limited awareness of children with asthma by teachers/staff, communication issues (e.g. school/parent, within school), inadequate education and lack of management plans or systems in place. In contrast, the identified facilitators included steps that fostered education, communication and awareness, as supported by management plans and parent initiative. Parents described their expectations for increased communication and education about asthma, better systems for identifying children with asthma, and a trained asthma point person for school-based asthma care. Conclusions: Parents of children with asthma identified important barriers, facilitators and expectations that must be considered to advance school asthma management. Improved school-based asthma care could lead to better health and academic outcomes.

Medication administration by caregiving youth: An inside look at how adolescents manage medications for family members

INTRODUCTION

Children take on the role of family caregiver throughout the world. No prior published research exists surrounding the particular circumstances of the task of medication administration and management by these youth, which was explored in this study.

METHODS

A series of focus groups were conducted using semi-structured interviews of 28 previously identified caregiving youth ages 12-19 years old who live in the United States. Data analysis followed guidelines of conventional content analysis.

RESULTS

The following categories emerged about youth caregivers handling medications: 1) tasks involve organizational and administrative responsibilities; 2) youth have varying degrees of knowledge pertaining to these medications; 3) most share responsibility with other family members; 4) they lack formal education about their responsibilities; 5) multiple challenges exist relating to this task; 6) managing medications is associated with emotional responses; and 7) possible safety issues exist.

CONCLUSIONS

These responsibilities represent a unique hardship and merit support and research from the medical, healthcare, legislative, and public health communities, among others.

Effect of family education program on cognitive impairment, anxiety, and depression in persons who have had a stroke: A randomized, controlled study

People who have had a stroke face high risks of cognitive impairment, anxiety, and depression. Health education for family members contributes to better outcomes in various diseases, but the effects of health education on family members of people who have had a stroke are unclear. The aim of the present study was to evaluate the effects of the family member education program (FMEP) on cognitive impairment, anxiety, and depression in persons who have had a stroke. In total, 144 persons who experienced a stroke were randomly allocated to the FMEP group or control group (1:1 ratio). In the FMEP group, the FMEP and conventional treatment were provided, while in control group only conventional treatment was provided. The increase in the Montreal Cognitive Assessment (MOCA) score from baseline to 12 months (M12 - baseline) in the FMEP group was higher compared with the control group, and the FMEP led to a decreased cognitive impairment rate (MOCA score ≤26) after 12 months compared to the control group. Changes in the Hospital Anxiety and Depression Scale anxiety and depression score (M12 - baseline) decreased in the FMEP group compared with the control group. Fewer participants with depression and a lower depression grade were observed in the FMEP group compared with the control group. The FMEP could reduce cognitive impairment, anxiety, and depression in persons who have had a stroke.

Evaluating the implementation of a multicomponent asthma education program for Head Start staff

OBJECTIVE

Asthma disproportionately affects minority groups, low income populations, and young children under 5. Head Start (HS) programs predominantly serve this high-risk population, yet staff are not trained on asthma management. The objective of this study was to assess a 5-year, multicomponent HS staff asthma education program in Baltimore City HS programs.

METHODS

All HS programs were offered annual staff asthma education by a medical research team that included didactic lectures and hands-on training. Attendees received continuing education credits. HS staff were anonymously surveyed on asthma knowledge and skills and asthma medication management practices in Year 1 (preimplementation) and Year 5.

RESULTS

There was an estimated response rate of 94% for Year 1 and 82% for Year 5. Compared to staff in Year 1, Year 5 staff were significantly more likely to report they had very good knowledge and skills related to asthma [odds ratio (OR) 1.63; p < 0.05] and were engaged in asthma care activities (OR 2.02; p < 0.05). Self-reported presence of asthma action plans for all children with asthma was 82% at Year 1 and increased to 89% in Year 5 (p = 0.064).

CONCLUSIONS

Year 5 HS staff reported higher self-assessed knowledge and skills, self-reports of asthma medication management practices, and self-reports of asthma activities compared to Year 1 staff. HS serves high-risk children with asthma, and a multicomponent program can adequately prepare staff to manage asthma in the child care setting. Our results indicate the feasibility of providing efficacious health skill education into child care provider training to reduce asthma knowledge gaps.

Concordance among children, caregivers, and clinicians on barriers to controller medication use

OBJECTIVE

While much research has addressed asthma medication adherence, few have combined quantitative and qualitative data, and none has addressed the triad of child, caregiver, and clinician simultaneously. This study assessed, with mixed methods, barriers to medication adherence within this triad.

METHODS

We conducted interviews with publicly-insured children with asthma, their caregivers, and their primary-care clinicians. Children (7-17 years) had been prescribed daily inhaled corticosteroids and visited the ED for asthma (past year). Participants answered open-ended and survey questions, rating suggested barriers to medication use (never vs. ever a barrier). McNemar's tests compared report of barriers by each group (children, caregivers, clinicians), and assessed concordance within triads.

RESULTS

Fifty child-caregiver dyads participated (34 clinicians). Children (40% female; median age 10 years) had mostly non-Hispanic black (90%) caregivers with less than or equal to high-school education (68%). For barriers, children and clinicians were more likely than caregivers to report medications running out. Clinicians were also more likely to cite controllers being a "pain to take" (vs. children) and forgetfulness (vs. caregivers) (all p < .05). There was a lack of within-triad concordance regarding barriers to adherence, especially regarding medication running out, worrying about taking a daily medication, and medication being a pain to take. Qualitative data revealed themes of competing priorities, home routines, and division of responsibility as prominent contributors to medication adherence.

CONCLUSIONS

There was significant disagreement among children, caregivers, and clinicians regarding barriers to daily use of asthma medications. To tailor asthma management conversations, clinicians should understand family-specific barriers and child-caregiver disagreements.

Medication identification in pediatric asthma (MED ID): The reliability and validity of a novel screening tool

OBJECTIVES

To evaluate the reliability and validity of medication identification (MED ID), a novel survey assessing caregiver-perceived ability to identify inhaled asthma medications.

METHODS

We analyzed baseline data from the School-Based Asthma Care for Teens trial in Rochester, NY. Caregivers of adolescents with persistent asthma named the inhaled medications used by their child and identified medications on a pictorial chart. Accurate identification was defined as completed matches between listed names and selected images. Caregivers answered the MED ID survey of four scaled questions on perceived ability to identify inhaled medications. We determined internal consistency reliability using Cronbach's alpha; examined concurrent validity by comparing MED ID sum scores with accurate identification using bivariate and multivariate analyses; and assessed the diagnostic utility of MED ID through receiver operating characteristic analysis.

RESULTS

126 caregivers (76% of enrolled) reported >1 inhaled medication; 52% of caregivers accurately identified medications. Two MED ID questions were removed during analysis. The two remaining questions had a score range of 2-10 points; higher scores indicate greater caregiver-perceived ability to identify medications. The Cronbach's alpha was 0.603. Accurate identification of medications was associated with a higher mean MED ID score (8.6 vs 7.6, p = 0.01). Accuracy was most strongly associated with MED ID scores ≥8 points (88% vs 60%, p < 0.001, Phi 0.32); findings were consistent in regression analysis. The greatest area under the curve was seen with MED ID scores ≥8 points (0.638).

CONCLUSIONS

The two-item MED ID survey is a reliable and valid way to assess caregiver's ability to identify inhaled asthma medications.