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Margolis RHF, Bellin MH, Morphew T, Tsoukleris M, Bollinger ME, Butz A. Caregiver Depressive Symptoms and Primary Medication Nonadherence in Children With Asthma. J Pediatr Health Care 2022; 36:136-143. [PMID: 34011445 PMCID: PMC8594280 DOI: 10.1016/j.pedhc.2021.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/22/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The purpose of this study was to identify risk factors for primary medication nonadherence among low-income minority children with persistent asthma. METHOD Data were from an environmental control and educational intervention for children with uncontrolled asthma who were treated in the emergency department for an asthma exacerbation. Presence or absence of pharmacy records for child asthma medications was the outcome of interest. A range of sociodemographic, health, and psychosocial measures were included in the binary logistic regression. RESULTS Of the 222 youths (mean age = 6.3 years; 93.7% Black), 25 (11.3%) lacked pharmacy records of asthma medications. For every 1-point increase in caregiver depressive symptoms, the odds of the child having a pharmacy record declined by 5% (odds ratio = 0.95; p = .012). DISCUSSION Providers should systematically assess and monitor caregiver depressive symptoms as a potential contributing factor for primary medication nonadherence in low-income minority children with persistent, uncontrolled asthma.
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Butz AM, Bellin MH, Morphew T, Tsoukleris M, Bollinger ME. Factors associated with reduced time lapse of medication fills in uncontrolled childhood asthma. Ann Allergy Asthma Immunol 2019; 124:197-198. [PMID: 31765813 DOI: 10.1016/j.anai.2019.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland; The Johns Hopkins University School of Nursing, Baltimore, Maryland.
| | - Melissa H Bellin
- School of Social Work, University of Maryland, Baltimore, Maryland
| | | | - Mona Tsoukleris
- School of Pharmacy, University of Maryland, Baltimore, Maryland
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Butz AM, Tsoukleris M, Elizabeth Bollinger M, Jassal M, Bellin MH, Kub J, Mudd S, Ogborn CJ, Lewis-Land C, Thompson RE. Association between second hand smoke (SHS) exposure and caregiver stress in children with poorly controlled asthma. J Asthma 2019; 56:915-926. [PMID: 30307351 PMCID: PMC6551304 DOI: 10.1080/02770903.2018.1509989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/31/2018] [Accepted: 08/05/2018] [Indexed: 10/28/2022]
Abstract
Objective: Urban children with asthma experience high rates of second hand smoke (SHS) exposure. The objective was to examine whether SHS exposure is associated with symptom frequency in children with poorly controlled asthma. Methods: Children were enrolled in a RCT to test the efficacy of an environmental control behavioral intervention versus an attention control group and followed over 12 months. SHS exposure assessed using salivary cotinine measurement. Frequency of child asthma symptoms, healthcare utilization, household smoking and caregiver daily life stress were obtained via caregiver report. Time of enrollment was recorded to assess seasonal factors. Symptom days and nights were the primary outcomes. Multivariable models and odds ratios examined factors that best predicted increased frequency of daytime/nighttime symptoms. Results: Children (n = 222) with a mean age of 6.3 (SD 2.7) years, were primarily male (65%), African American (94%), Medicaid insured (94%), and had poorly controlled asthma (54%). The final multivariable model indicated symptoms in the fall (OR 2.78; 95% CI 1.16, 6.52) and increased caregiver daily life stress (OR 1.13, 95% CI 1.02, 1.25) were significantly associated with increased symptom days when controlling for cotinine level, intervention status, child age and home and car smoking restrictions. Conclusions: There was no impact of SHS exposure on increased symptom frequency. High caregiver daily life stress and symptoms in fall season may place children with asthma at risk for increased day/nighttime symptoms. Close monitoring of symptoms and medication use during the fall season and intervening on caregiver life stress may decrease asthma morbidity in children with poorly controlled asthma.
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Affiliation(s)
- Arlene M Butz
- a Department of Pediatrics, The Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Mona Tsoukleris
- b The Univeristy of Maryland School of Pharmacy , Baltimore , MD , USA
| | - Mary Elizabeth Bollinger
- c Department of Pediatrics, The University of Maryland School of Medicine , Baltimore , MD , USA
| | - Mandeep Jassal
- a Department of Pediatrics, The Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Melissa H Bellin
- d The University of Maryland School of Social Work , Baltimore , MD , USA
| | - Joan Kub
- e Department of Nursing, The USC Suzanne Dworak-Peck School of Social Work , Los Angeles , CA , USA
| | - Shawna Mudd
- f The Johns Hopkins University School of Nursing , Baltimore , MD , USA
| | - C Jean Ogborn
- g Department of Pediatric Emergency Medicine, The Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Cassia Lewis-Land
- a Department of Pediatrics, The Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Richard E Thompson
- h Biostatistics Department, The Johns Hopkins University Bloomberg School of Public Health , Baltimore , MD , USA
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Butz AM, Bollinger ME, Ogborn J, Morphew T, Mudd SS, Kub JE, Bellin MH, Lewis-Land C, DePriest K, Tsoukleris M. Children with poorly controlled asthma: Randomized controlled trial of a home-based environmental control intervention. Pediatr Pulmonol 2019; 54:245-256. [PMID: 30614222 PMCID: PMC6408727 DOI: 10.1002/ppul.24239] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/08/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Few trials have tested targeted environmental control (EC) interventions based on biomarkers of second hand smoke (SHS) exposure and allergen sensitization in reducing asthma emergency department (ED) visits in children with poorly controlled asthma. METHODS Overall, 222 children with poorly controlled asthma were randomized into a home-based EC intervention (INT) or control (CON) group and followed for ED visits over 12 months. All children received allergen-specific IgE serologic testing and SHS exposure biomarker testing to inform the EC intervention. Pharmacy data was examined for asthma medication fills. Cox proportional hazards and multivariate regression models were performed to examine factors associated with repeat ED visits. RESULTS There was no difference in increased risk of >1 ED visit at 12 months between INT and CON groups. Most children (75%) had moderate/severe persistent asthma. Over half (56%) had SHS exposure and 83% tested positive for >1 allergen sensitization. Among children without SHS exposure, the median time to first recurrent ED visit differed by group (CON: 195; INT: >365 days) after adjusting for child age, allergic sensitization, medication fills prior to baseline, controller medication use, and the interaction between group status and SHS exposure. Children who had positive allergic sensitizations, younger, had increased controller medication use and randomized to the CON group and had no SHS exposure had increased risk for a repeat ED visit over 12 months. CONCLUSIONS In this study, a home-based EC intervention was not successful in reducing asthma ED revisits in children with poorly controlled asthma with SHS exposure. Allergic sensitization, young age, and increased controller medication use were important predictors of asthma ED visits.
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Affiliation(s)
- Arlene Manns Butz
- Division of General Pediatrics and Adolescent Medicine, Baltimore, Maryland.,The Johns Hopkins University School of Nursing, University of Maryland, Baltimore, Maryland
| | - Mary E Bollinger
- School of Medicine, Department of Pediatrics, Baltimore, Maryland
| | - Jean Ogborn
- Department of Pediatric Emergency Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Shawna S Mudd
- The Johns Hopkins University School of Nursing, University of Maryland, Baltimore, Maryland
| | - Joan E Kub
- Department of Nursing, USC Suzanne Dworak-Peck School of Social Work, Los Angeles, California.,University of Maryland, Baltimore, Maryland
| | - Melissa H Bellin
- School of Social Work, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cassia Lewis-Land
- Division of General Pediatrics and Adolescent Medicine, Baltimore, Maryland
| | - Kelli DePriest
- The Johns Hopkins University School of Nursing, University of Maryland, Baltimore, Maryland
| | - Mona Tsoukleris
- The School of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Bollinger ME, Butz A, Tsoukleris M, Lewis-Land C, Mudd S, Morphew T. Characteristics of inner-city children with life-threatening asthma. Ann Allergy Asthma Immunol 2019; 122:381-386. [PMID: 30742915 DOI: 10.1016/j.anai.2019.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/29/2019] [Accepted: 02/02/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Intensive care unit (ICU) admission is a risk factor for fatal asthma. Little is known about risk factors for pediatric ICU admissions for asthma. OBJECTIVE To examine characteristics of underserved minority children with prior ICU admissions for asthma. METHODS Baseline survey data, salivary cotinine levels, and allergen specific IgE serologic test results were obtained from children with uncontrolled asthma enrolled in a randomized clinical trial of a behavioral education environmental control intervention. Characteristics of children with and without prior ICU admission were compared using χ2 and t tests. Logistic regression assessed significance of higher odds of prior ICU admission comparing factor-level categories. RESULTS Patients included 222 primarily African American (93.7%), male (56%), Medicaid-insured (92.8%) children with a mean (SD) age of 6.4 (2.7) years with uncontrolled asthma. Most (57.9%) had detectable cotinine levels, 82.6% were sensitized to more than 1 environmental allergen, and 27.9% had prior ICU admissions. Prior ICU patients were more likely to be very poor (<$10,000 per year) and sensitized to more than 1 allergen tested (most importantly mouse) (P < .05). Allergen sensitization in the groups did not differ for cockroach, cat, dog, Alternaria, Aspergillus, dust mite, grass, or tree. Although more ICU patients received combination controller therapy, they also overused albuterol. Only 27.4% of ICU patients received specialty care in the previous 2 years, which was not significantly different from non-ICU patients. CONCLUSION Children with high mortality risk, including history of ICU admission, were twice as likely to live in extreme poverty, have atopy (particularly mouse allergen), use combination controller therapy, and overuse albuterol. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01981564.
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Affiliation(s)
- Mary Elizabeth Bollinger
- Division of Pediatric Pulmonary and Allergy, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Arlene Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mona Tsoukleris
- University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Cassia Lewis-Land
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawna Mudd
- Department of Acute and Chronic Care, School of Nursing, University of Maryland, Baltimore, Maryland
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Butz AM, Morphew T, Bellin M, Bollinger ME, Tsoukleris M. Pattern of medication use in children with very poorly controlled asthma. Ann Allergy Asthma Immunol 2019; 122:412-413. [PMID: 30685563 DOI: 10.1016/j.anai.2019.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Johns Hopkins University School of Nursing, Baltimore, Maryland.
| | | | - Melissa Bellin
- School of Social Work, University of Maryland, Baltimore, Maryland
| | | | - Mona Tsoukleris
- School of Pharmacy, University of Maryland, Baltimore, Maryland
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Butz AM, Bellin M, Tsoukleris M, Mudd SS, Kub J, Ogborn J, Morphew T, Lewis-Land C, Bollinger ME. Very Poorly Controlled Asthma in Urban Minority Children: Lessons Learned. J Allergy Clin Immunol Pract 2018; 6:844-852. [PMID: 28958744 PMCID: PMC5862725 DOI: 10.1016/j.jaip.2017.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/20/2017] [Accepted: 08/07/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Very poorly controlled (VPC) asthma in children is associated with ongoing acute exacerbations but factors associated with VPC are understudied. OBJECTIVE To examine the risk factors associated with VPC asthma in urban minority children. METHODS This descriptive study examined asthma control levels (well-controlled [WC], not well-controlled [NWC], and VPC) at baseline and 6 months in children participating in an ongoing randomized controlled trial of an emergency department/home environmental control intervention. Data collection occurred during the index emergency department visit and included allergen-specific IgE and salivary cotinine testing and caregiver interview of sociodemographic and child health characteristics. Follow-up data were collected at 6 months. Unadjusted analyses examined the association of sociodemographic and health characteristics by level of asthma control. Multivariate analysis tested significant factors associated with VPC asthma at 6 months. RESULTS At baseline most children were categorized with VPC asthma (WC, 0%; NWC, 47%; VPC, 53%) and rates of VPC minimally improved at 6 months (WC, 13%; NWC, 41%; VPC, 46%). Risk for VPC asthma was twice as likely in children with allergic rhinitis (odds ratio [OR], 2.42), having 2 or more primary care provider asthma visits within the past 3 months (OR, 2.77), or caregiver worry about medication side effects (OR, 2.13) and 3 to 4 times more likely when asthma control was assessed during the fall or spring season (OR: fall, 3.32; spring, 4.14). CONCLUSIONS Improving asthma control in low-income, high-risk children with VPC asthma requires treatment of comorbidities, attention to caregiver medication beliefs, and adept use of stepwise therapy.
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Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Melissa Bellin
- School of Social Work, The University of Maryland, Baltimore, Md
| | - Mona Tsoukleris
- The School of Pharmacy, The University of Maryland, Baltimore, Md
| | - Shawna S Mudd
- The Johns Hopkins University School of Nursing, Baltimore, Md
| | - Joan Kub
- The Johns Hopkins University School of Nursing, Baltimore, Md
| | - Jean Ogborn
- Department of Pediatric Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Cassia Lewis-Land
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Md
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Butz A, Morphew T, Lewis-Land C, Kub J, Bellin M, Ogborn J, Mudd SS, Bollinger ME, Tsoukleris M. Factors associated with poor controller medication use in children with high asthma emergency department use. Ann Allergy Asthma Immunol 2017; 118:419-426. [PMID: 28254203 PMCID: PMC5385291 DOI: 10.1016/j.anai.2017.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/03/2017] [Accepted: 01/09/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Understanding health and social factors associated with controller medication use in children with high-risk asthma may inform disease management in the home and community. OBJECTIVE To examine health and social factors associated with the Asthma Medication Ratio (AMR), a measure of guideline-based care and controller medication use, in children with persistent asthma and frequent emergency department (ED) use. METHODS Study questionnaires, serum allergen sensitization, salivary cotinine, and pharmacy record data were collected for 222 children enrolled from August 2013 to February 2016 in a randomized clinical trial that tested the efficacy of an ED- and home-based intervention. Logistic regression was used to examine factors associated with an AMR greater than 0.50, reflecting appropriate controller medication use. RESULTS Most children were male (64%), African American (93%), Medicaid insured (93%), and classified as having uncontrolled asthma (44%). Almost half (48%) received non-guideline-based care or low controller medication use based on an AMR less than 0.50. The final regression model predicting an AMR greater than 0.50 indicated that children receiving specialty care (odds ratio [OR], 4.87; 95% confidence interval [CI], 2.06-11.50), caregivers reporting minimal worry about medication adverse effects (OR, 0.50; 95% CI, 0.25-1.00), positive sensitization to ragweed allergen (OR, 3.82; 95% CI, 1.63-8.96), and negative specific IgE for dust mite (OR, 0.33; 95% CI, 0.15-0.76) were significantly associated with achieving an AMR greater than 0.50. CONCLUSION Clinical decision making for high-risk children with asthma may be enhanced by identification of sensitization to environmental allergens, ascertaining caregiver's concerns about controller medication adverse effects and increased referral to specialty care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01981564.
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Affiliation(s)
- Arlene Butz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland; School of Nursing, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Cassia Lewis-Land
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joan Kub
- School of Nursing, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa Bellin
- School of Social Work, University of Maryland, Baltimore, Maryland
| | - Jean Ogborn
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawna S Mudd
- School of Nursing, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Elizabeth Bollinger
- Department of Pediatric Pulmonary and Allergy, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Mona Tsoukleris
- School of Pharmacy, University of Maryland, Baltimore, Maryland
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Butz A, Bellin MH, Bollinger ME, Kub J, Mudd SS, Ogborn CJ, Lewis-Land C, Thompson RE, Tsoukleris M. Salivary cotinine measurement for all children with persistent asthma: spit matters. Ann Allergy Asthma Immunol 2016; 116:463-5. [PMID: 27009437 DOI: 10.1016/j.anai.2016.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/09/2016] [Accepted: 02/19/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Arlene Butz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Melissa H Bellin
- School of Social Work, University of Maryland, Baltimore, Maryland
| | | | - Joan Kub
- School of Nursing, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawna S Mudd
- School of Nursing, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - C Jean Ogborn
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cassia Lewis-Land
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard E Thompson
- Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mona Tsoukleris
- School of Pharmacy, University of Maryland, Baltimore, Maryland
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Bellin MH, Osteen P, Kub J, Bollinger ME, Tsoukleris M, Chaikind L, Butz AM. Stress and Quality of Life in Urban Caregivers of Children With Poorly Controlled Asthma: A Longitudinal Analysis. J Pediatr Health Care 2015; 29:536-46. [PMID: 26036621 PMCID: PMC4624025 DOI: 10.1016/j.pedhc.2015.04.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 04/28/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The intent of this analysis was to examine the longitudinal effects of risk and protective factors on quality of life (QOL) in caregivers of minority children with asthma. METHOD Caregivers (n = 300) reported on demographics, child asthma characteristics, daily asthma caregiving stress, general life stress, social support, and QOL. Latent growth curve modeling examined changes in QOL across 12 months as a function of stress, asthma control, and social support. RESULTS Caregivers were primarily the biological mother (92%), single (71%), unemployed (55%), and living in poverty. Children were African American (96%), Medicaid eligible (92%), and had poorly controlled asthma (93%). Lower QOL was associated with higher life stress, greater asthma caregiving stress, and lower asthma control over time. DISCUSSION Findings underscore the importance of assessing objective and subjective measures of asthma burden and daily life stress in clinical encounters with urban, low-income caregivers of children with poorly controlled asthma.
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Butz AM, Ogborn J, Mudd S, Ballreich J, Tsoukleris M, Kub J, Bellin M, Bollinger ME. Factors associated with high short-acting β2-agonist use in urban children with asthma. Ann Allergy Asthma Immunol 2015; 114:385-92. [PMID: 25840499 PMCID: PMC4426068 DOI: 10.1016/j.anai.2015.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/10/2015] [Accepted: 03/03/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND One goal of guideline-based asthma therapy is minimal use of short-acting β₂ agonist (SABA) medications. Inner-city children with asthma are known to have high SABA use. OBJECTIVE To examine factors associated with high SABA use in inner-city children with asthma. METHODS One hundred inner-city children with persistent asthma were enrolled into a randomized controlled trial of an emergency department (ED) and home intervention. All children underwent serologic allergen specific IgE and salivary cotinine testing at the ED enrollment visit. Pharmacy records for the past 12 months were obtained. Number of SABA fills during the past 12 months was categorized into low- to moderate- vs high-use groups. SABA groups were compared by the number of symptom days and nights, allergen sensitization, and exposures. Regression models were used to predict high SABA use. RESULTS Mean number of SABA fills over 12 months was 3.12. Unadjusted bivariate analysis showed that high SABA users were more than 5 times more likely to have an asthma hospitalization, almost 3 times more likely to have an asthma intensive care unit admission, and more than 3 times more likely to have prior specialty asthma care or positive cockroach sensitization than low to moderate SABA users. In the final regression model, for every additional inhaled corticosteroid fill, a child was 1.4 times more likely and a child with positive cockroach sensitization was almost 7 times more likely to have high SABA use when controlling for prior intensive care unit admission, receipt of specialty care, child age, and income. CONCLUSION Providers should closely monitor SABA and controller medication use, allergen sensitization, and exposures in children with persistent asthma. TRIAL REGISTRATION ClinicalTrials.gov, identifier NCT01981564.
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Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Jean Ogborn
- Department of Pediatric Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawna Mudd
- The Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Jeromie Ballreich
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Mona Tsoukleris
- The University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Joan Kub
- The Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Melissa Bellin
- The University of Maryland School of Social Work, Baltimore, Maryland
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Butz AM, Halterman J, Bellin M, Kub J, Tsoukleris M, Frick KD, Thompson RE, Land C, Bollinger ME. Improving preventive care in high risk children with asthma: lessons learned. J Asthma 2014; 51:498-507. [PMID: 24517110 PMCID: PMC4428172 DOI: 10.3109/02770903.2014.892608] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Rates of preventive asthma care after an asthma emergency department (ED) visit are low among inner-city children. The objective of this study was to test the efficacy of a clinician and caregiver feedback intervention (INT) on improving preventive asthma care following an asthma ED visit compared to an attention control group (CON). METHODS Children with persistent asthma and recent asthma ED visits (N = 300) were enrolled and randomized into a feedback intervention or an attention control group and followed for 12 months. All children received nurse visits. Data were obtained from interviews, child salivary cotinine levels and pharmacy records. Standard t-test, chi-square and multiple logistic regression tests were used to test for differences between the groups for reporting greater than or equal to two primary care provider (PCP) preventive care visits for asthma over 12 months. RESULTS Children were primarily male, young (3-5 years), African American and Medicaid insured. Mean ED visits over 12 months was high (2.29 visits). No difference by group was noted for attending two or more PCP visits/12 months or having an asthma action plan (AAP). Children having an AAP at baseline were almost twice as likely to attend two or more PCP visits over 12 months while controlling for asthma control, group status, child age and number of asthma ED visits. CONCLUSIONS A clinician and caregiver feedback intervention was unsuccessful in increasing asthma preventive care compared to an attention control group. Further research is needed to develop interventions to effectively prevent morbidity in high risk inner-city children with frequent ED utilization.
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Affiliation(s)
- Arlene M. Butz
- Department of Pediatrics, School of Medicine, Baltimore, MD, USA
- School of Nursing, The Johns Hopkins University, Baltimore, MD, USA
| | - Jill Halterman
- Department of Pediatrics, School of Medicine and Dentistry, The University of Rochester, Rochester, NY, USA
| | - Melissa Bellin
- School of Social Work, The University of Maryland, Baltimore, MD, USA
| | - Joan Kub
- School of Nursing, The Johns Hopkins University, Baltimore, MD, USA
| | - Mona Tsoukleris
- School of Pharmacy, The University of Maryland, Baltimore, MD, USA
| | - Kevin D. Frick
- Department of Health Policy and Management and Carey Business School, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Richard E. Thompson
- Department of Biostatistics, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, USA
| | - Cassia Land
- Department of Pediatrics, School of Medicine, Baltimore, MD, USA
| | - Mary E. Bollinger
- Department Pediatrics, School of Medicine, The University of Maryland, Baltimore, MD, USA
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Bellin MH, Kub J, Frick KD, Bollinger ME, Tsoukleris M, Walker J, Land C, Butz AM. Stress and quality of life in caregivers of inner-city minority children with poorly controlled asthma. J Pediatr Health Care 2013; 27:127-34. [PMID: 23414978 PMCID: PMC3575578 DOI: 10.1016/j.pedhc.2011.09.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/21/2011] [Accepted: 09/30/2011] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Caregiver quality of life (QOL) is known to influence asthma management behaviors. Risk factors for low caregiver QOL in families of inner-city children with asthma remain unclear. This study evaluated the interrelationships of asthma control, stress, and caregiver QOL. METHOD Data were analyzed from a home-based behavioral intervention for children with persistent asthma after treatment for asthma in the emergency department. Caregivers reported on baseline demographics, asthma control, asthma management stress, life stress, and QOL. Hierarchical regression analysis examined the contributions of sociodemographic factors, asthma control, asthma management stress, and life stress in explaining caregiver QOL. RESULTS Children (N = 300) were primarily African American (96%) and young (mean age, 5.5 years). Caregivers were predominantly the biological mother (92%), single (70%), and unemployed (54%). Poor QOL was associated with higher caregiver education and number of children in the home, low asthma control, and increased asthma management stress and life stress. The model accounted for 28% of variance in caregiver QOL. DISCUSSION Findings underscore the need for multifaceted interventions to provide tools to caregivers of children with asthma to help them cope with asthma management demands and contemporary life stressors.
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Affiliation(s)
- Melissa H Bellin
- Health Specialization, School of Social Work, University of Maryland, Baltimore, MD 21201, USA.
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Butz AM, Halterman JS, Bellin M, Kub J, Frick KD, Lewis-Land C, Walker J, Donithan M, Tsoukleris M, Bollinger ME. Factors associated with completion of a behavioral intervention for caregivers of urban children with asthma. J Asthma 2012; 49:977-88. [PMID: 22991952 PMCID: PMC3773483 DOI: 10.3109/02770903.2012.721435] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Rates of preventive follow-up asthma care after an acute emergency department (ED) visit are low among inner-city children. We implemented a novel behavioral asthma intervention, Pediatric Asthma Alert (PAAL) intervention, to improve outpatient follow-up and preventive care for urban children with a recent ED visit for asthma. OBJECTIVE The objective of this article is to describe the PAAL intervention and examine factors associated with intervention completers and noncompleters. METHODS Children with persistent asthma and recurrent ED visits (N = 300) were enrolled in a randomized controlled trial of the PAAL intervention that included two home visits and a facilitated follow-up visit with the child's primary care provider (PCP). Children were categorized as intervention completers, that is, completed home and PCP visits compared with noncompleters, who completed at least one home visit but did not complete the PCP visit. Using chi-square test of independence, analysis of variance, and multiple logistic regression, the intervention completion status was examined by several sociodemographic, health, and caregiver psychological variables. RESULTS Children were African-American (95%), Medicaid insured (91%), and young (aged 3-5 years, 56%). Overall, 71% of children randomized to the intervention successfully completed all home and PCP visits (completers). Factors significantly associated with completing the intervention included younger age (age 3-5 years: completers, 65.4%; noncompleters, 34.1%; p < .001) and having an asthma action plan in the home at baseline (completers: 40%; noncompleters: 21%; p = .02). In a logistic regression model, younger child age, having an asthma action plan, and lower caregiver daily asthma stress were significantly associated with successful completion of the intervention. CONCLUSIONS The majority of caregivers of high-risk children with asthma were successfully engaged in this home and PCP-based intervention. Caregivers of older children with asthma and those with high stress may need additional support for program completion. Further, the lack of an asthma action plan may be a marker of preexisting barriers to preventive care.
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Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Butz AM, Halterman JS, Bellin M, Tsoukleris M, Donithan M, Kub J, Thompson RE, Land CL, Walker J, Bollinger ME. Factors associated with second-hand smoke exposure in young inner-city children with asthma. J Asthma 2011; 48:449-57. [PMID: 21545248 DOI: 10.3109/02770903.2011.576742] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To examine the association of social and environmental factors with levels of second-hand smoke (SHS) exposure, as measured by salivary cotinine, in young inner-city children with asthma. METHODS We used data drawn from a home-based behavioral intervention for young high-risk children with persistent asthma post-emergency department (ED) treatment (N = 198). SHS exposure was measured by salivary cotinine and caregiver reports. Caregiver demographic and psychological functioning, household smoking behavior, and asthma morbidity were compared with child cotinine concentrations. Chi-square and ANOVA tests and multivariate regression models were used to determine the association of cotinine concentrations with household smoking behavior and asthma morbidity. RESULTS Over half (53%) of the children had cotinine levels compatible with SHS exposure and mean cotinine concentrations were high at 2.42 ng/ml (SD 3.2). The caregiver was the predominant smoker in the home (57%) and 63% reported a total home smoking ban. Preschool aged children and those with caregivers reporting depressive symptoms and high stress had higher cotinine concentrations than their counterparts. Among children living in a home with a total home smoking ban, younger children had significantly higher mean cotinine concentrations than older children (cotinine: 3-5 year olds, 2.24 ng/ml (SD 3.5); 6-10 year olds, 0.63 ng/ml (SD 1.0); p < .05). In multivariate models, the factors most strongly associated with high child cotinine concentrations were increased number of household smokers (β = 0.24) and younger child age (3-5 years) (β = 0.23; p < .001, R(2) = 0.35). CONCLUSION Over half of the young inner-city children with asthma were exposed to SHS, and caregivers are the predominant household smokers. Younger children and children with depressed and stressed caregivers are at significant risk of smoke exposures, even when a household smoking ban is reported. Further advocacy for these high-risk children is needed to help caregivers quit and to mitigate smoke exposure.
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Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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Vibbert C, Butz A, Donithan M, Tsoukleris M, Bollinger M. High Level of SABA and OCS Use in Young Children with Poorly Controlled Asthma Prescribed Inhaled Fluticasone. J Allergy Clin Immunol 2011. [DOI: 10.1016/j.jaci.2010.12.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Butz A, Kub J, Donithan M, James NT, Thompson RE, Bellin M, Tsoukleris M, Bollinger ME. Influence of caregiver and provider communication on symptom days and medication use for inner-city children with asthma. J Asthma 2010; 47:478-85. [PMID: 20528605 DOI: 10.3109/02770901003692793] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Effective pediatric guideline-based asthma care requires the caregiver to accurately relay the child's symptom frequency, pattern of rescue and controller medication use, and level of asthma control to the child's primary care clinician. OBJECTIVE This study evaluated the longitudinal effects of a caregiver-clinician asthma communication education intervention (ACE) relative to an asthma education control group (CON) on symptom days and controller medication use in inner-city children with asthma. PARTICIPANTS AND METHODS 231 inner-city children with asthma, recruited from urban pediatric emergency departments (EDs) and community practices, were followed for 12 months. Data included number of symptom days and nights, ED visits, hospitalizations, presence of limited activity, and controller medication use over 12 months. Pharmacy records were used to calculate controller to total asthma medication ratios as a proxy of appropriate controller medication use. Multivariate logistic regression models were used to identify factors associated with number of symptom days and nights over the past 30 days at the 12-month follow-up. RESULTS Most caregivers rated the communication with their child's clinician as high. Unadjusted and adjusted rates of symptom days and nights did not differ by group at follow-up. ACE children tended towards a higher controller to total medication ratio at 12 months as compared to CON children (mean ratio: ACE: 0.54, SD 0.3; CON, 0.45, SD 0.4; p = .07). Activity limitation due to asthma and persistent asthma severity were the only factors significantly associated with reporting any symptom day within the past 30 days, adjusting for treatment group, number of oral corticosteroid courses and number of clinician visits in the last 6 months, seasonality, insurance type, and controller to total asthma medication ratio covariates. CONCLUSION A home-based caregiver asthma communication educational intervention was not associated with decreased symptom days. However, a trend was noted in higher controller to total medication ratios in the intervention group. Inner-city caregivers of children with asthma may require a health systems approach to help convey the child's asthma health information to their clinician.
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Affiliation(s)
- Arlene Butz
- School of Medicine, Department of Pediatrics, The Johns Hopkins University, Baltimore, Maryland 21287, USA.
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Butz A, Sellers MD, Land C, Walker J, Tsoukleris M, Bollinger ME. Factors affecting primary care provider and caregiver concordance for pediatric asthma medications. J Asthma 2009; 46:308-13. [PMID: 19373641 DOI: 10.1080/02770900902718845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Lack of discussion regarding actual asthma medication use by physicians with caregivers of children with asthma may result in low caregiver and physician concordance about prescribed asthma medications. OBJECTIVE The primary objective was to examine the concordance between primary care providers (PCP) and caregivers regarding child asthma medication use. METHODS Current asthma medications in the home with verification from each child's PCP were obtained for 231 underserved children with persistent asthma. Kappas and chi-square statistics were calculated to measure the strength of the concordance. Caregiver and PCP dyads were categorized as concordant or discordant based on asthma medication use. RESULTS For all asthma prescriptions N = 479, two thirds of caregiver-PCP dyads (67.8) were categorized as concordant with at least one asthma medication. Concordance for asthma medications varied by type of medication ranging from 84% agreement for albuterol and 77% agreement for Flovent. In the final regression model predicting caregiver and PCP concordance, the number of PCP visits within the past 6 months and caregiver report of no limitation of child's activity due to asthma were significantly higher in caregivers who were considered concordant with their child's PCP while controlling for child age and frequency of symptom nights and number of ED visits in prior 6 months. In a model predicting the number of PCP visits, the number of ED visits was the only significant variable associated with the number of PCP visits while controlling for caregiver and PCP concordance. CONCLUSION Caregiver and PCP concordance was significantly associated with increased number of PCP visits suggesting that increased exposure to a health care provider may increase agreement between a child's PCP and caregiver regarding prescribed asthma medications. However, there may be other important factors including increased emergency department visits that may also be associated with subsequent pediatric primary care visits for asthma.
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Affiliation(s)
- Arlene Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Abstract
Low income, urban children with asthma are experiencing community violence that may contribute to asthma morbidity. The objective of this study was to examine the relationship between caregiver report of feeling unsafe, seeing community violence or child seeing community violence and asthma morbidity and health care utilization. Two hundred thirty-one caregivers of children with asthma enrolled in an asthma,education, intervention reported perceptions of safety and violence exposure in six months and frequency of child asthma symptoms, emergency department (ED), primary care (PCP) visits and hospitalizations over 12 months. Children were primarily male (93%), black (61%), and reported income <$30,000 (56%). Violence exposure was high: feeling unsafe (25%), seeing violence themselves (22%), child saw violence (14%). If caregivers or children saw violence, there were significantly more nighttime symptoms than those who were not exposed (caregiver: yes violence = 6.72 +/- 9.19, no violence = 4.23 +/- 6.98, P = 0.03; child: yes violence = 7.09 +/- 7.15, no violence = 4.37 +/- 9.49, P = 0.05). Children who saw violence were less likely to see their PCP. Families exposed to community violence report more asthma symptoms, but are less likely to seek care for asthma. Health care providers and asthma educators should evaluate potential violence exposure with asthma patients and tailor care and education to include violence prevention and avoidance.
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Affiliation(s)
- Jennifer Walker
- Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA.
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Vibbert C, Butz A, Tsoukleris M, Hsu V, Bollinger M. Does Use of Asthma Controllers Really Indicate Asthma “Control?”. J Allergy Clin Immunol 2007. [DOI: 10.1016/j.jaci.2006.11.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Butz AM, Tsoukleris M, Donithan M, Hsu VD, Mudd K, Zuckerman IH, Bollinger ME. Patterns of inhaled antiinflammatory medication use in young underserved children with asthma. Pediatrics 2006; 118:2504-13. [PMID: 17142537 PMCID: PMC2290000 DOI: 10.1542/peds.2006-1630] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Asthma guidelines advocate inhaled corticosteroids as the cornerstone treatment of persistent asthma, yet several studies report underuse of inhaled corticosteroids in children with persistent asthma. Moreover, few studies use objective pharmacy data as a measure of drug availability of asthma medications. We examined factors associated with the use of inhaled corticosteroids in young underserved children with persistent asthma using pharmacy records as their source of asthma medications. METHODS This was a cross-sectional analysis of questionnaire and pharmacy record data over a 12-month period from participants enrolled in a randomized clinical trial of a nebulizer educational intervention. RESULTS Although exposure to > or = 1 inhaled corticosteroids refill was high at 72%, 1 of 5 children with persistent asthma had either no medication or only short-acting beta agonist fills for 12 months. Only 20% of children obtained > or = 6 inhaled corticosteroids fills over 12 months. Obtaining > or = 3 inhaled corticosteroids fills over 12 months was significantly associated with an increase in short-acting beta agonist fills and receiving specialty care in the regression models while controlling for child age, asthma severity, number of emergency department visits, having an asthma action plan, and seeking preventive care for the child's asthma. CONCLUSIONS Overreliance on short-acting beta agonist and underuse of inhaled corticosteroid medications was common in this group of young children with persistent asthma. Only one fifth of children obtained sufficient controller medication fills.
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Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, Johns Hopkins University School of Medicine, 200 N Wolfe St, Baltimore, MD 21287, USA.
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