Using Cost Conversations to Address Financial Toxicity in Pediatric Asthma Care: Findings From a Survey of Caregivers

INTRODUCTION

Asthma care teams are well-positioned to help caregivers address financial toxicity in pediatric asthma care, although discussing cost can be challenging. We sought to characterize cost conversations in pediatric asthma specialty care.

METHOD

We surveyed 45 caregivers of children aged 4-17 with asthma. Eligible caregivers reported costs concerns and had accompanied their child to a multisite asthma specialty practice in North Carolina.

RESULTS

About one-third of caregivers reported a cost conversation (36%). Cost conversations were less common among caregivers whose child had public versus private health insurance (16% vs. 56%), who attended a telehealth versus in-person visit (6% vs. 52%), or who did not versus did want a conversation (19% vs. 77%, all p < .05). Common cost conversation topics were medications and equipment like spacers.

DISCUSSION

Our findings suggest cost conversations may be relatively uncommon in pediatric asthma care, particularly for publicly insured patients and telehealth visits.

Pediatric pulmonology 2022 year in review: Asthma

In 2022, new research studies influenced the field of pediatric asthma with improvements in diagnosis and evaluation; new treatment options including biologic therapies; changes in risk factors for asthma; and increased discussion about the impact of social determinants of health on asthma. Additionally, three years after the start of the COVID-19 pandemic, we continue to see the impact of SARS-CoV-2 virus on pediatric asthma care. In this review article, we summarize the significant findings from publications in Pediatric Pulmonology and other relevant journals from the last year. We hope this review will provide new insight within the field of pediatric asthma, as well as guidance for implementation into clinical practice.

Race-specific spirometry equations may overestimate asthma control in Black children and adolescents

BACKGROUND

A growing body of evidence suggests that use of race terms in spirometry reference equations underestimates disease burden in Black populations, which may lead to disparities in pulmonary disease outcomes. Data on asthma-specific health consequences of using race-adjusted spirometry are lacking.

METHODS

We performed a secondary analysis of 163 children from two observational asthma studies to determine the frequencies of participants with ppFEV1 < 80% (consistent with uncontrolled asthma) or ppFEV1 ≥ 80% using race-specific (GLI-African American or Caucasian) vs. race-neutral (GLI-Global) spirometry and their alignment with indicators of asthma control (Asthma Control Test™, ACT). Comparisons of mean ppFEV1 values were conducted using Wilcoxon matched-pairs signed-rank tests. Two group comparisons were conducted using Wilcoxon rank-sum tests.

RESULTS

Data from 163 children (100 Black, 63 White) were analyzed. Mean ppFEV1 was 95.4% (SD 15.8) using race-specific spirometry and 90.4% (16.3) using race-neutral spirometry (p < 0.0001). Among 54 Black children with uncontrolled asthma (ACT ≤ 19), 20% had ppFEV1 < 80% using race-specific spirometry compared to 40% using race-neutral spirometry. In Black children with controlled asthma (ACT > 19), 87% had ppFEV1 ≥ 80% using race-specific compared to 67% using race-neutral spirometry. Children whose ppFEV1 changed to ≤ 80% with race-neutral spirometry had lower FEV1/FVC compared to those whose ppFEV1 remained ≥ 80% [0.83 (0.07) vs. 0.77 (0.05), respectively; p = 0.04], suggesting greater airway obstruction. Minimal changes in alignment of ppFEV1 with ACT score were observed for White children.

CONCLUSIONS

Use of race-specific reference equations in Black children may increase the risk of inappropriately labeling asthma as controlled.

Impact of Hurricane Matthew on a Cohort of Adolescents With Asthma in North Carolina

OBJECTIVE

The aim of this study was to look at a cohort of adolescents who were already enrolled in a randomized controlled trial to see (1) how demographics were associated with hurricane impact, and (2) how hurricane impact was associated with reported asthma quality of life.

METHODS

One hundred fifty-one adolescents ages 11-17 and their parents enrolled in a randomized controlled trial at 2 sites in southeastern North Carolina completed questions about asthma quality of life, demographics, and the impact of Hurricane Matthew.

RESULTS

The most common effects of Hurricane Matthew were that the family's home was damaged or flooded (32.5%), the school was damaged or flooded (31.8%), and the home had mold or mildew as a result of flooding or damage (25.8%). Problems with access to care were more common for families whose adolescent was non-White (P = 0.04), on Medicaid (P = 0.05), or if the family spoke Spanish at home (P < 0.001). Being affected by the hurricane was negatively associated with asthma quality of life.

CONCLUSIONS

Hurricane Matthew had significant impact on the health of adolescents with asthma in the affected region, especially in the most vulnerable populations. Providers should ensure that families of adolescents with asthma have a hurricane plan to mitigate impact on their children's health.

Pediatric pulmonology 2021 year in review: Asthma

Asthma is the most common chronic disease in children, affecting an estimated 6.1 million children in the United States. SARS-CoV2 had a significant impact on asthma exacerbations and healthcare utilization of patients with asthma in 2021. Additionally, studies in 2021 influenced the field of asthma with improvements in diagnostic testing and monitoring, treatment of severe exacerbations, social determinants of health, and evaluation of medical costs. This article is part of our 2021 "Year in Review" series, in which we summarize publications in major pulmonary topics, in the context of selected literature from other journals relevant to our discipline.

Adolescent asthma management self-efficacy and responsibility: impact on asthma control and quality-of-life

OBJECTIVE

The purpose of this study was to investigate the extent to which adolescent asthma management self-efficacy, outcome expectations, and asthma responsibility were associated with asthma control and quality-of-life. Adolescent self-efficacy and outcome expectations are important components of social cognitive theory, which guided this research.

METHODS

English- and Spanish-speaking adolescents ages 11-17 with persistent asthma were recruited at four pediatric clinics. Adolescents were interviewed and parents completed questionnaires. Multiple linear regression was used to analyze the data.

RESULTS

Three hundred and fifty-nine adolescents were recruited. Older adolescent age, male gender, and higher adolescent asthma management self-efficacy were significantly associated with higher adolescent responsibility; outcome expectations were not significantly associated with responsibility. Adolescent ratings of their own responsibility were higher than parent ratings of their child's responsibility for almost all asthma management tasks. Adolescents with higher reported asthma management self-efficacy were significantly more likely to have better quality-of-life and controlled asthma. Adolescents with more positive outcome expectations were significantly more likely to have controlled asthma. Being Native American was associated with worse quality-of-life and asthma not being controlled. Being Black was associated with asthma not being controlled.

CONCLUSIONS

Parents and providers should work to improve adolescent self-efficacy in managing their asthma because it is associated with asthma responsibility, asthma control, and quality-of-life. Providers need to especially work with Native American and Black adolescents to improve quality-of-life and asthma control.

The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report

E-cigarette or vaping product use-associated lung injury (EVALI) is a severe pulmonary illness associated with the use of e-cigarettes or vaping products that was officially identified and named in 2019. This American Thoracic Society workshop was convened in 2021 to identify and prioritize research and regulatory needs to adequately respond to the EVALI outbreak and to prevent similar instances of disease associated with e-cigarette or vaping product use. An interdisciplinary group of 26 experts in adult and pediatric clinical care, public health, regulatory oversight, and toxicology were convened for the workshop. Four major topics were examined: 1) the public health and regulatory response to EVALI; 2) EVALI clinical care; 3) mechanisms contributing to EVALI; and 4) needed actions to address the health effects of EVALI. Oral presentations and group discussion were the primary modes used to identify top priorities for addressing EVALI. Initiatives including a national EVALI case registry and biorepository, integrated electronic medical record coding system, U.S. Food and Drug Administration regulation and enforcement of nicotine e-cigarette standards, regulatory authority over nontobacco-derived e-cigarettes, training in evaluating exogenous exposures, prospective clinical studies, standardized clinical follow-up assessments, ability to more readily study effects of cannabinoid e-cigarettes, and research to identify biomarkers of exposure and disease were identified as critical needs. These initiatives will require substantial federal investment as well as changes to regulatory policy. Overall, the workshop identified the need to address the root causes of EVALI to prevent future outbreaks. An integrated approach from multiple perspectives is required, including public health; clinical, basic, and translational research; regulators; and users of e-cigarettes. Improving the public health response to reduce the risk of another substantial disease-inducing event depends on coordinated actions to better understand the inhalational toxicity of these products, informing the public of the risks, and developing and enforcing regulatory standards for all e-cigarettes.

Leveraging Telemedicine to Reduce the Financial Burden of Asthma Care

One of the most compelling arguments for telemedicine is its potential to increase health care access by making care more affordable for patients and families, including those affected by asthma. This goal is critically important in the United States, where the high cost of asthma care is associated with nonadherence to preventive care regimens and suboptimal health outcomes. In this clinical commentary review, we draw from the literature and our own research to identify opportunities for and challenges to leveraging telemedicine to reduce the financial burden of asthma care. Our interviews with 42 families affected by asthma during the COVID-19 pandemic suggest that under favorable circumstances, telemedicine can meaningfully reduce costs, including those related to transportation and missed work, while offering high-quality care. However, families also identified ways in which telemedicine can increase costs. For example, some reported reduced access to support services and material resources such as medication samples, which they relied on to manage costs. In this way, our findings underscore the need for careful care coordination and communication in telemedicine. We conclude by discussing the 4Rs, a structured communication approach designed to support cost conversations, increase care coordination, and help families reduce asthma care cost burden.

Interstitial lung disease in children with Rubinstein-Taybi syndrome

INTRODUCTION

Rubinstein-Taybi syndrome (RSTS) is a rare genetic syndrome caused primarily by a mutation in the CREBBP gene found on chromosome 16. Patients with RSTS are at greater risk for a variety of medical problems, including upper airway obstruction and aspiration. Childhood interstitial lung disease (ILD) thus far has not been definitively linked to RSTS. Here we present three patients with RSTS who developed ILD and discuss possible mechanisms by which a mutation in CREBBP may be involved in the development of ILD.

METHODS

Routine hematoxylin and eosin staining was performed on lung biopsy tissue for histological analysis. Immunofluorescent staining was performed on lung biopsy tissue for markers of fibrosis, surfactant deficiency and histone acetylation. Cases 1 and 2 had standard clinical microarray analysis. Case 3 had whole exome sequencing. Bioinformatics analyses were performed to identify possible causative genes using ToppGene.

RESULTS

Computed tomography images in all cases showed consolidated densities overlying ground glass opacities. Lung histopathology revealed accumulation of proteinaceous material within alveolar spaces, evidence of fibrosis, and increased alveolar macrophages. Immunofluorescent staining showed increase in surfactant protein C staining, patchy areas of increased anti-smooth muscle antibody staining, and increased staining for acetylated histone 2 and histone 3 lysine 9.

DISCUSSION

Clinical characteristics, radiographic imaging, lung histopathology, and immunofluorescent staining results shared by all cases demonstrated findings consistent with ILD. Immunofluorescent staining suggests two possible mechanisms for the development of ILD: abnormal surfactant metabolism and/or persistent activation of myofibroblasts. These two pathways could be related to dysfunctional CREBBP protein.

Pediatric Pulmonology 2020 year in review: Asthma

Pediatric asthma is a heterogeneous and common chronic condition with significant morbidity and burden on the healthcare system. Despite advances in the field, the disease has proven to be increasingly complex to diagnose and management strategies are constantly evolving. Studies from 2020 have advanced the field even further, particularly with regard to new methods of diagnosis and monitoring, treatment of severe asthma, modifiable risk factors like exercise and obesity, aerosol delivery, and viral respiratory infections contributing to the development of asthma. Continued studies are needed to improve our care for children with asthma and we look forward to future advances. This article is part of our 2020 "Year in Review" series, in which we summarize publications in major topic areas, in the context of selected literature from other journals relevant to our discipline.

Communication About Adolescent and Caregiver Smoking and Vaping During Pediatric Asthma Visits: Implications for Providers

INTRODUCTION

Although rates of cigarette smoking among U.S. adolescents have declined, rates of vaping (i.e., using e-cigarettes) have increased. We conducted a secondary analysis of 359 transcripts of medical visits of adolescents with asthma to examine communication about caregiver and adolescent smoking and vaping.

METHOD

Adolescents aged 11-17 years with persistent asthma and their parents were enrolled from four pediatric clinics in 2015-2017. Youth were randomized to the intervention or usual care groups. Intervention group adolescents watched a video and then completed an asthma question prompt list before their visits.

RESULTS

Forty providers and 359 patients participated. Providers, adolescents, and caregivers discussed smoking during 38.2% of their visits. Vaping was never discussed.

DISCUSSION

There is room to improve how often providers in a primary care setting discuss smoking and vaping. Further investigation might focus on how a smoking and vaping prompt list for adolescents could increase tobacco discussions during visits.

Community health worker case-detection of asthma or reactive airways disease in a resource-poor community in Nicaragua

INTRODUCTION

Asthma is a major cause of morbidity and mortality in children worldwide, but many cases may remain undiagnosed. Community health worker (CHW) programs have improved detection of other diseases such as childhood pneumonia, but none have been validated for detection of asthma in resource-poor settings. We hypothesized that a CHW administered questionnaire would be effective in case-detection of asthma in a poor Nicaraguan community.

METHODS

We enrolled children aged 2-17 from a small semiurban Nicaraguan community. A trained CHW administered a questionnaire based on a previously validated school-based screening questionnaire, which was compared to pediatric pulmonologist evaluation as a reference standard. We determined the questionnaire's sensitivity, specificity, and positive and negative likelihood ratios at different score cut-points.

RESULTS

A total of 199 out of 218 eligible children were enrolled. Total asthma prevalence based on physician diagnosis was 33%. Mean scores on the CHW questionnaire were 3.6 points out of 22 (SD = 4.3) for nonasthmatics and 11.0 points (SD = 5.3) for children with asthma (p < .001). Area under the curve was 0.87. Multivariable analysis showed increased association of asthma/reactive airways disease with respiratory infection in the first 3 months of life and with family history of asthma.

CONCLUSIONS

Prevalence of asthma in this community was high compared to previously reported national prevalence (15.2%), possibly due to increased exposure to risk factors. The questionnaire had a high area under the receiver operating characteristic curve, making it an excellent screening tool. This questionnaire could greatly increase the detection of asthma, allowing for education and referral for ongoing care.

A Gut Feeling: Abdominal Symptoms as an Initial Presentation of EVALI

Electronic cigarette or vaping product use-associated lung injury (EVALI) is a disease process that has become prevalent in the United States.¹ The Centers for Disease Control and Prevention reported there have been almost 2700 cases of this condition in the United States as of January 14, 2020, with >50% of these patients aged ≤24.² We present a 13-year-old boy with a history of functional abdominal pain who presented with recurrent episodes of nausea, emesis, periodic fevers, and severe episodic abdominal pain after a 12-month history of significant electronic cigarette use. On admission, he had severe abdominal pain and appeared anxious. A computed tomography scan of the abdomen was unremarkable, but a computed tomography scan of the chest demonstrated both multifocal ground-glass and crazy-paving pulmonary opacities bilaterally, with scattered septal thickening and dependent bibasilar opacities associated with volume loss. Inflammatory markers were significantly elevated, and cell counts were remarkable for leukocytosis and neutrophilia. The patient was ultimately diagnosed with EVALI and treated with intravenous methylprednisolone, resulting in improvement. This is an example of a case of EVALI in an adolescent, in which the presenting symptoms are largely gastrointestinal. It is important to keep EVALI in the differential diagnosis of patients who exhibit gastrointestinal symptoms, have markers of increased systemic inflammation, and endorse a history of vaping or are in the age range of electronic cigarette users. Although obtaining an accurate history of vaping can be challenging in the pediatric population, it is especially critical to do so.

Provider-adolescent discussion and provider education about asthma triggers during pediatric visits: results of a randomized trial

OBJECTIVE

We examined how an asthma question prompt list with video intervention influenced discussion of and provider education about asthma triggers.

METHODS

English or Spanish-speaking adolescents ages 11-17 with persistent asthma and their caregivers were enrolled from four pediatric clinics. Adolescents were randomized to the intervention or usual care groups. Adolescents in the intervention group watched the video on an iPad and then completed a one-page asthma question prompt list before their visits. All visits were audio-recorded. Generalized Estimating Equations were used to predict the number of trigger areas discussed and the number of areas providers educated adolescents about during visits.

RESULTS

Forty providers and 359 patients participated. Triggers were discussed during 89% of intervention group visits and 81% of usual care visits; providers educated adolescents about triggers during 59% of intervention group visits and 46% of usual care visits. More triggers were significantly more likely to be discussed and providers educated about more trigger areas during visits of adolescents in the intervention group and when adolescents asked one or more questions during visits. More trigger areas were significantly more likely to be discussed if the adolescent was White and male. Providers were significantly more likely to educate adolescents whose family spoke Spanish at home about more trigger areas than adolescents who spoke English at home.

CONCLUSIONS

More trigger areas were significantly more likely to be discussed and providers educated about more trigger areas during visits of adolescents who received the intervention and when adolescents asked one or more questions.

Hemoglobin A1c and fructosamine correlate in a patient with sickle cell disease and diabetes on chronic transfusion therapy

In patients with sickle cell disease (SCD) and diabetes mellitus (DM), hemoglobin A_1c (HbA_1c ) is unreliable and the American Diabetes Association recommends monitoring long-term glycemia by measuring serum glucose, but use of serum fructosamine (SF), a measurement independent of red cell lifespan, has been reported. SF as a screen for DM in SCD, however, is not standardized and its relationship to serum glucose has not been validated. Further, screening for DM was not adequately addressed in the 2014 National Heart, Lung, and Blood Institute (NHLBI) guidelines for SCD management. Blood transfusions, an important treatment for some patients with SCD, can also impact HbA_1c . We present a case of a patient with SCD and cystic fibrosis-related diabetes on monthly chronic transfusions therapy (CTT) who had well-correlated "steady state" HbA_1c and SF levels over time, suggesting for the first time these markers may actually be useful when following long-term glycemic control in patients with SCD on CTT programs.

Questions and reported medication problems from pediatric patients and caregivers after intervention

PURPOSE

The effectiveness of an asthma question prompt list with video intervention to increase question-asking during pediatric office visits among youth who reported medication problems was evaluated.

METHODS

English- or Spanish-speaking youth age 11-17 years with persistent asthma and their caregivers were enrolled from 4 pediatric clinics in a randomized controlled trial. Youth were randomized to intervention or usual care groups. Youth in the intervention group watched an educational video with their caregivers on an iPad. The youth then received a 1-page asthma question prompt list to complete before their visits. The audio of all baseline medical visits was recorded. Youth were interviewed and caregivers completed questionnaires at baseline and 6 months later.

RESULTS

A total of 40 providers and 359 of their patients participated. Youth who reported at least 1 medication problem who were in the intervention group were significantly more likely to ask 1 or more questions about medications during their visits than youth in the usual care group (odds ratio = 3.1, 95% confidence interval = 2.0, 4.1). Seventy-four percent of youth and 71% caregivers who reported the youth had problems using asthma medications at baseline still reported 1 or more problems 6 months later.

CONCLUSION

Among youth who reported 1 or more problems with using their asthma medications, the intervention significantly increased youth question-asking. Many youth- and caregiver-reported problems with using asthma medications persisted over time.

Pediatric Pulmonology year in review 2018: Asthma, physiology/pulmonary function testing, and respiratory infections

Pediatric Pulmonology publishes original research, reviews, and case reports related to a wide range of children's respiratory disorders. In our "Year in Review" series, we summarize publications in our major topic areas from 2018, in the context of selected literature in these areas from other journals relevant to our discipline. This review covers selected articles on asthma, physiology/lung function testing, and respiratory infections.

Danger in the vapor? ECMO for adolescents with status asthmaticus after vaping

Introduction: Electronic nicotine delivery systems (ENDS) use is on the rise in the adolescent and young adult populations, especially in the wake of sweet flavored ENDS solutions and youth-targeted marketing. While the extent of effect of ENDS use and aerosolized flavorings on airway epithelium is not known, there remains significant concern that use of ENDS adversely affects airway epithelial function, particularly in populations with asthma.Case Study: In this case series, we review two cases of adolescents with history of recent and past ENDS use and asthma who required veno-venous extracorporeal membrane oxygenation (VV-ECMO) for status asthmaticus in the year 2018.Results: Both patients experienced hypercarbic respiratory failure requiring VV-ECMO secondary to their status asthmaticus, with slow recovery on extensive bronchodilator and steroid regimens. They both recovered back to respiratory baseline and were counseled extensively on cessation of ENDS use.Conclusion: While direct causation by exposure to ENDS cannot be determined, exposure likely contributed to symptoms. Based on the severity of these cases and their potential relationship with ENDS use, we advocate for increased physician screening of adolescents for ENDS use, patient and parent education on the risks of use, and family cessation counseling.

The impact of a question prompt list and video intervention on teen asthma control and quality-of-life one year later: results of a randomized trial

Objective: This study examined whether youth who received an asthma question prompt list/video intervention were more likely to have their asthma controlled and better quality-of-life at 12 months than youth who received usual care.Methods: English or Spanish-speaking youth ages 11-17 were enrolled and randomized to intervention or usual care. The 185 youth and parents in the intervention group watched the video on an iPad and then received a one-page asthma question prompt list to complete before their visits. One hundred seventy-four received usual care. Baseline and 6-month visits were audio-tape recorded. Generalized Estimating Equations were used to predict a youth's quality-of-life and whether asthma was controlled at 12 months.Results: Asthma control and quality-of-life improved significantly from baseline to 12-month follow-up in both intervention and usual care groups. Baseline asthma control and quality-of-life were significantly associated with 12-month asthma control and quality-of-life, respectively. Adolescents on a control medication at baseline were significantly more likely to have their asthma controlled at 12 months.Conclusions: Asthma control and quality-of-life did not improve significantly more in the intervention group than in the usual care group.

Effect of an Asthma Question Prompt List and Video Intervention on Adolescents' Medication Adherence 12 Months Later

BACKGROUND

Many adolescents do not obtain the maximum benefit from their asthma medications. Improving patient-provider communication may improve adolescents' asthma knowledge, adherence, and clinical outcomes.

OBJECTIVE

To determine how a question prompt list and educational video intervention affect youth- and caregiver-reported medication adherence and self-reported medication problems.

METHODS

Adolescents with persistent asthma (n = 359; 56.4% with moderate to severe asthma) and their caregivers were enrolled in a randomized controlled trial at 4 pediatric clinics. Intervention group families received a question prompt list and watched a short video before seeing the provider; control families received usual care. Youth- and caregiver-reported medication adherence was measured with a Visual Analog Scale, ranging from 0 to 100. Generalized estimating equations were used to determine how the intervention and covariates were associated with medication adherence and reported problems at 12 months.

RESULTS

The intervention was not a significant predictor of medication adherence at 12 months. Higher caregiver education was associated with higher youth-reported adherence (β = 1.1; 95% CI = 0.1, 2.1; P = 0.036) and caregiver-reported adherence (β = 1.2; 95% CI = 0.3, 2.0; P = 0.006). The intervention was associated with fewer caregiver-reported problems at 12 months (β = -0.32; 95% CI = -0.48, -0.16; P < 0.001).

CONCLUSIONS AND RELEVANCE

A question prompt list and educational video decreased the number of caregiver-reported medication problems, but did not significantly affect medication adherence. Further research is needed to develop more effective interventions to improve medication adherence and outcomes.

Age and African-American race impact the validity and reliability of the asthma control test in persistent asthmatics

Background

The Asthma Control Test (ACT) is widely used to assess asthma control, yet the validity and reliability of the test have not been specifically evaluated in adolescents or African-Americans. We conducted a prospective psychometric study of the ACT in African-American (AA) and non-African-American (nAA) adolescents with persistent asthma, with emphasis on the clinical utility of the test for medical decision making.

Methods

Participants completed the ACT and performed spirometry. A physician conducted a guidelines-based assessment of asthma control, blinded to the ACT score. Study procedures were repeated 6–8 weeks later. The ACT-based asthma control assessment was compared to physician assessment.

Results

For baseline and follow-up visits, internal consistency, as measured using Cronbach’s alpha, was 0.80 and 0.81 in AA teens and 0.80 and 0.83 in nAA teens. Intraclass correlation coefficients were 0.59 and 0.76 in AA and nAA teens, respectively, with stable asthma control over time. Agreement between ACT and physician assessment was moderate in AA teens and fair in nAA teens. An ACT score of ≤19 showed reduced sensitivity for not well controlled asthma in both groups, while a score of ≤21 had the greatest area under the ROC curve. ACT scores were marginally responsive to change in control status.

Conclusions

Concerns for the ACT’s ability to detect uncontrolled asthma in adolescents emphasizes the need for a more comprehensive evaluation of asthma control in clinical settings. A higher threshold ACT score to define not well controlled asthma may be needed if the ACT is to be used for medical decision making.

Trial registration

ClinicalTrials.gov: NCT02671643, NCT02662413.

Electronic supplementary material

The online version of this article (10.1186/s12931-018-0858-0) contains supplementary material, which is available to authorized users.

Improving youth question-asking and provider education during pediatric asthma visits

OBJECTIVE

We conducted a pragmatic randomized controlled trial to test the effectiveness of an asthma question prompt list with video intervention to increase youth question-asking and provider education during visits.

METHODS

English or Spanish-speaking youth ages 11-17 with persistent asthma and their parents were enrolled from four rural and suburban pediatric clinics. Youth were randomized to the intervention or usual care groups. Intervention group adolescents watched the video on an iPad and then completed an asthma question prompt list before their visits. Generalized estimating equations were used to analyze the data.

RESULTS

Forty providers and 359 patients participated. Intervention group youth were significantly more likely to ask one or more questions about medications, triggers, and environmental control than usual care youth. Providers were significantly more likely to educate intervention group youth about rescue medications, triggers, and environmental control. Intervention group caregivers were not significantly more likely to ask questions.

CONCLUSION

The intervention increased youth question-asking and provider education about medications, triggers, and environmental control. The intervention did not impact caregiver question-asking.

PRACTICE IMPLICATIONS

Providers/practices should consider having youth complete question prompt lists and watch the video with their parents before visits to increase youth question-asking during visits.

Factors associated with adolescent and caregiver reported problems in using asthma medications

OBJECTIVES

The purpose of this study was to: (a) describe the types of medication problems/concerns youth with asthma and their caregivers reported and (b) examine the association between sociodemographic characteristics and youth and caregiver reported medication problems/concerns.

METHODS

English- and Spanish-speaking youth ages 11-17 with persistent asthma were recruited at four pediatric clinics. Youth were interviewed and caregivers completed questionnaires about reported asthma medication concerns/problems. Multiple logistic regression was used to analyze the data.

RESULTS

Three hundred and fifty-nine youth were recruited. Eighty percent of youth and 70% of caregivers reported one or more problems in using asthma medications. The most commonly reported problems by youth were: (a) hard to remember when to take the asthma medication (54%) and (b) hard to use asthma medication at school (34%). Younger children were significantly more likely to report difficulty in understanding their asthma medication's directions and difficulty reading the print on the medication's package. Caregivers' top-reported problem was that it is hard for their child to remember to take their asthma medications (49%). Caregivers without Medicaid were significantly more likely to express difficulty paying for their child's asthma medications.

CONCLUSIONS

Difficulty remembering to take asthma medication was a significant problem for youth and their caregivers. Providers should work with youth and their caregivers to identify asthma medication problems and discuss strategies to address those problems.

Provider use of a participatory decision-making style with youth and caregivers and satisfaction with pediatric asthma visits

Background

We conducted a randomized controlled trial to test the effectiveness of an asthma question prompt list with video intervention to engage the youth during clinic visits. We examined whether the intervention was associated with 1) providers including youth and caregiver inputs more into asthma treatment regimens, 2) youth and caregivers rating providers as using more of a participatory decision-making style, and 3) youth and caregivers being more satisfied with visits.

Methods

English- or Spanish-speaking youth aged 11–17 years with persistent asthma and their caregivers were recruited from four pediatric clinics and randomized to the intervention or usual care groups. The youth in the intervention group watched the video with their caregivers on an iPad and completed a one-page asthma question prompt list before their clinic visits. All visits were audiotaped. Generalized estimating equations were used to analyze the data.

Results

Forty providers and their patients (n=359) participated in this study. Providers included youth input into the asthma management treatment regimens during 2.5% of visits and caregiver input during 3.3% of visits. The youth in the intervention group were significantly more likely to rate their providers as using more of a participatory decision-making style (odds ratio=1.7, 95% confidence interval=1.1, 2.5). White caregivers were significantly more likely to rate the providers as more participatory (odds ratio=2.3, 95% confidence interval=1.2, 4.4). Youth (beta=4.9, 95% confidence interval=3.3, 6.5) and caregivers (beta=7.5, 95% confidence interval=3.1, 12.0) who rated their providers as being more participatory were significantly more satisfied with their visits. Youth (beta=−1.9, 95% confidence interval=−3.4, −0.4) and caregivers (beta=−8.8, 95% confidence interval=−16.2, −1.3) who spoke Spanish at home were less satisfied with visits.

Conclusion

The intervention did not increase the inclusion of youth and caregiver inputs into asthma treatment regimens. However, it did increase the youth’s perception of participatory decision-making style of the providers, and this in turn was associated with greater satisfaction.

Reported Problems and Adherence in Using Asthma Medications Among Adolescents and Their Caregivers

BACKGROUND

Many factors affect youth adherence to asthma medications. Better understanding of the relationship between problems reported by youth in using asthma medications, self-efficacy, outcome expectations, and adherence is needed.

OBJECTIVE

The study examined the relationship between youth and caregiver problems in using asthma medications, asthma management self-efficacy, outcome expectations, and youth- and caregiver-reported adherence to asthma controller medications.

METHODS

Adolescents with persistent asthma and their caregivers were recruited at 4 pediatric practices. Youth were interviewed after their medical visit while caregivers completed a questionnaire. Multivariable linear regression was used to analyze the data.

RESULTS

Of 359 participating youth, 319 were on controller medications. Youth reported 60% average adherence, whereas caregivers reported 69%. Youth who reported difficulty using their inhaler correctly and youth who reported difficulty remembering to take their medications were significantly less likely to be adherent. Caregivers who reported that it was hard to remember when to give the asthma medications were significantly less likely to report their child being adherent. Both youth and caregivers with higher outcome expectations were significantly more likely to self-report being adherent.

CONCLUSIONS

Pharmacists and other health care providers should consider asking youth and caregivers about problems in using asthma medications, self-efficacy in managing asthma, and outcome expectations for following treatment regimens, so that they can help youth overcome difficulties they might have in managing their asthma.

Acceptance of a pre-visit intervention to engage teens in pediatric asthma visits

OBJECTIVE

The objectives of this study were to: (a) describe teen feedback on an asthma question prompt list/video intervention designed to motivate teens to be more engaged during visits and (b) examine teen demographics associated with teen acceptance of the intervention.

METHODS

Two hundred and fifty-nine teens ages 11 to 17 with persistent asthma were enrolled into a randomized, controlled trial and assigned to either a standard care or an intervention group where they watched an educational video with their parents and received a prompt list to complete before visits. Teens were interviewed after visits.

RESULTS

Of the 185 teens randomized to the intervention group: 93% said teens should complete the prompt lists before visits; 95% recommended teens should watch the video before visits; teens with moderate/severe persistent asthma were significantly more likely to find the prompt list useful; non-White teens were significantly more likely to find the prompt list and video more useful.

CONCLUSIONS

Teens exposed to the question prompt list/video had very positive feedback about the intervention.

PRACTICE IMPLICATIONS

Providers/practices should consider having teens complete question prompt lists during pre-visit wait time for use during visits and watch the video with their parents before visits.

Progression of Polysomnographic Abnormalities in Mucolipidosis II (I-Cell Disease)

ABSTRACT

Mucolipidosis II (Inclusion cell or I-cell disease) is an autosomal recessive lysosomal storage disorder clinically comparable to the mucopolysaccharidoses (MPS), characterized by progressive respiratory and neurologic deterioration. Sleep problems, especially obstructive sleep apnea (OSA) and disrupted sleep architecture, are observed in other lysosomal storage diseases but have not been described in mucolipidosis II. We report the progression of polysomnographic abnormalities in a child with mucolipidosis II, demonstrated by worsening sleep-related hypoventilation, OSA, and sleep state fragmentation despite advancing PAP therapy. Background slowing and reduction in spindle activity on limited EEG may reflect progressive CNS disease affecting thalamic neurons.

The development of an educational video to motivate teens with asthma to be more involved during medical visits and to improve medication adherence

OBJECTIVES

Our objective was to develop a series of short educational videos for teens and parents to watch before pediatric visits to motivate teens to be more actively involved during their visits.

METHODS

The development of the short educational videos was theoretically guided by Social Cognitive Theory. First we conducted four focus groups with teens (ages 11 to 17) with asthma, four focus groups with the teens' parents, and seven focus groups with pediatric providers from four clinics. The research team, which included two teens with asthma and their parents, analyzed the focus group transcripts for themes and then developed the initial video script. Next, a visual storyboard was reviewed by focus groups with parents and four with teens to identify areas of the script for improvement. The English videos were then produced. Focus groups with Hispanic parents and teens were then conducted for advice on how to modify the videos to make a more culturally appropriate Spanish version.

RESULTS

Based on focus group results, teen newscasters narrate six one- to two-minute videos with different themes: (a) how to get mom off your back, (b) asthma triggers, (c) staying active with asthma, (d) tracking asthma symptoms, (e) how to talk to your doctor and (f) having confidence with asthma. Each video clip has three key messages and emphasizes how teens should discuss these messages with their providers.

CONCLUSIONS

Teens, parents, and providers gave us excellent insight into developing videos to increase teen involvement during medical visits.

Provider-caregiver-child discussions about risks associated with asthma control medications: content and prevalence

OBJECTIVES

The objectives of this study were to: (1) describe the extent to which general pediatric providers discuss risks associated with asthma control medications with families, and (2) examine factors that are associated with risk discussions.

STUDY DESIGN

This study was a cross-sectional secondary analysis of audio taped medical visits involving 35 pediatric providers and 248 children with asthma with their caregivers. Transcripts of the visits were coded for discussions about asthma medication risks. Generalized estimating equations were used to analyze the data.

RESULTS

Providers discussed asthma control medication risks during 23% of visits. Risks were more likely to be discussed when the visit was longer and when the provider prescribed a new asthma control medication. When providers discussed asthma control medication risks, they were most likely to ask the family general questions and make general statements. Across all of the visits, caregivers asked a total of 16 questions and made a total of 20 statements about risks associated with asthma medications; children asked a total of 3 questions and made two statements about risks associated with asthma control medications.

CONCLUSION

Providers discussed risks associated with asthma control medications in less than one-quarter of medical visits. Providers should involve families in discussions about risks associated with medications during every visit to assess potential barriers to medication adherence.

Quality of pulmonary function testing in 3 large primary care pediatric clinics in rural North Carolina

BACKGROUND

Pulmonary function testing (eg, spirometry) is recommended by the National Heart, Lung, and Blood Institute as part of basic asthma management. Previous research has shown that spirometry is feasible in primary care settings.

OBJECTIVES

In this retrospective study, we sought to describe the proportion of spirometries meeting American Thoracic Society (ATS) and European Respiratory Society (ERS) quality criteria in children with asthma evaluated in North Carolina primary care pediatric clinics and to characterize predictors of spirometry that meets ATS/ERS quality criteria.

METHODS

Medical records and spirometries from January 1, 2001, to August 1, 2009, were reviewed and analyzed from children enrolled in a larger asthma study that focused on communication between physicians, children, and caregivers. Children were eligible for the larger study if they were between the ages of 8 and 16 years and had received a previous diagnosis of persistent asthma. Children were enrolled from primary care pediatric practices.

RESULTS

Spirometry was not acceptable, on the basis of ATS/ERS criteria, in 75% of cases. Approximately 19% of spirometries used incorrect or outdated predictive sets.

CONCLUSIONS

More than three-quarters of spirometries in these primary care pediatric clinics were unacceptable. Changes or lack of changes in asthma management may be based on unacceptable spirometry. Additional education and training regarding accurate spirometry and interpretation are warranted.

Neutrophilic inflammation is associated with altered airway hydration in stable asthmatics

BACKGROUND

Airway dehydration is a potential trigger of bronchoconstriction in exercise-induced asthma; however, its role in stable asthma has not been explored. Using sputum percent solids, as an indicator of airway hydration, we sought relationships between airway hydration and other known markers of neutrophilic (TH1) and allergic (TH2) inflammation in stable asthma.

METHODS

Thirty-seven atopic subjects with stable asthma and 15 healthy controls underwent sputum induction. Sputum was analyzed for percent solids, cell counts, cellular and biochemical markers of inflammation and purines.

RESULTS

Sputum percent solids was significantly elevated in stable asthmatics vs. controls and positively correlated with markers of neutrophilic/TH1-type inflammation (neutrophils, IL-8 and AMP). Sputum percent solids were not correlated with markers of allergic/TH2-type inflammation. These data suggest a direct relationship between neutrophil inflammation and airway hydration in stable asthmatics.

Keratinocyte growth factor stimulates CLC-2 expression in primary fetal rat distal lung epithelial cells

Keratinocyte growth factor (KGF) is mitogenic for epithelial cells and induces cystic dilation of fetal lung explants through cystic fibrosis transmembrane conductance regulator-independent chloride channels. One candidate fetal lung chloride channel that is highly expressed on the apical surface of the respiratory epithelium and markedly downregulated after birth is CLC-2. We hypothesized that KGF regulates CLC-2 expression in the fetal lung. Primary fetal rat distal lung epithelial cell monolayers were grown in medium containing 10 ng/ml KGF for 48 h. CLC-2 protein was increased by Western blot analysis of whole-cell lysates in KGF-treated cultures. Similarly, KGF stimulated CLC-2 messenger RNA (mRNA) by Northern blot analysis. This enhanced expression was dose-dependent and maximal at 48 h with 10 ng/ml KGF. Promoter-reporter gene experiments demonstrated that KGF did not stimulate gene transcription. By inhibition of new mRNA synthesis with actinomycin D, evidence was obtained that KGF stabilizes CLC-2 mRNA. We speculate that KGF may positively influence pulmonary chloride and fluid secretion by a secondary pathway affecting CLC-2 degradation.