51
|
Martin CG, Andrade AA, Vila D, Acosta-Pérez E, Canino G. The development of a community-based family asthma management intervention for Puerto Rican children. Prog Community Health Partnersh 2010; 4:315-24. [PMID: 21169709 PMCID: PMC3113604 DOI: 10.1353/cpr.2010.0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Puerto Rican children maintain disproportionately high asthma prevalence rates and effective asthma management interventions are needed. OBJECTIVES This article describes how community-based participatory research (CBPR) was implemented in the development of a culturally tailored family asthma management intervention for Puerto Rican children: CALMA (a Spanish acronym for Take Control, Empower Yourself, and Achieve Asthma Management). METHOD CALMA was developed according to CBPR principles and contemporary asthma guidelines through the collaboration of diverse members of the local, professional, and medical communities, academia, and local government. All group members contributed unique perspectives, making CALMA's development a collaborative effort. LESSONS LEARNED The CALMA community dealt with challenges in both incorporating and managing a diverse group of stakeholders and maintaining equity in decision making power. However, the community maintained strengths, such as incorporating culturally accepted remedies and addressing culturally specific myths in the intervention, as well as having the medical community directly involved in overseeing the accuracy of the intervention. CONCLUSION A CBPR approach enhanced the cultural sensitivity of the intervention as well as its potential for sustainability.
Collapse
Affiliation(s)
- Christina Gamache Martin
- Behavioral Sciences Research Institute, University of Puerto Rico, Medical Sciences Campus San Juan, Puerto Rico
| | | | - Doryliz Vila
- Behavioral Sciences Research Institute, University of Puerto Rico, Medical Sciences Campus San Juan, Puerto Rico
| | - Edna Acosta-Pérez
- Behavioral Sciences Research Institute, University of Puerto Rico, Medical Sciences Campus San Juan, Puerto Rico
| | - Glorisa Canino
- Behavioral Sciences Research Institute, University of Puerto Rico, Medical Sciences Campus San Juan, Puerto Rico
| |
Collapse
|
52
|
Stingone JA, Claudio L. Components of recommended asthma care and the use of long-term control medication among urban children with asthma. Med Care 2009; 47:940-7. [PMID: 19704351 PMCID: PMC2732665 DOI: 10.1097/mlr.0b013e318199300c] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous research has documented an underuse of long-term control medications among children with asthma, in nonadherence with national guidelines on asthma care. OBJECTIVES To determine if factors related to access and quality of asthma care are associated with underuse of long-term control medication among children with asthma. RESEARCH DESIGN A parent-report cross-sectional survey conducted in 26 randomly selected New York City public elementary schools. SUBJECTS Five thousand two hundred fifty children, of whom 912 had asthma. RESULTS Twenty-nine percent of children with asthma reported using a long-term control medication. Among children with persistent asthma, defined as having one or more sleep disturbances due to asthma per week, 59.0% reported using a long-term control medication. After adjusting for demographic factors, children who had an asthma plan, had visited a doctor in the previous 6 months for nonurgent asthma care, or were enrolled in an asthma education program were more likely to use long-term control medication (odds ratios: 6.00, 4.11, 2.88, respectively). Children of Spanish-speaking parents, African American children, and children with no health insurance were the least likely to use long-term control medication (odds ratios: 0.51, 0.49, 0.20, respectively). Children who reported recommended components of asthma care were the most likely to use their medication with appropriate frequency. CONCLUSIONS Children who reported markers of high quality, personalized medical care, were more likely to use long-term control medication. These findings illustrate that components of the medical care received, and not only the demographic characteristics of the patient, are key factors in understanding the underuse of long-term control medication in urban children with asthma.
Collapse
Affiliation(s)
| | - Luz Claudio
- Mount Sinai School of Medicine, New York, NY Department of Community and Preventive Medicine
| |
Collapse
|
53
|
Yoon EY, Freed GL, Davis MM, Clark SJ. Formulary coverage for lipid-lowering drugs recommended for children. Clin Pediatr (Phila) 2009; 48:609-13. [PMID: 19286618 DOI: 10.1177/0009922809332683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE/METHODS A cross-sectional assessment to describe availability, coverage, and pediatric labeling status of lipid-lowering drugs offered by 1 private and 1 public insurance plan formularies. RESULTS Both insurance plans had equal medication availability of bile acid sequestrants (7), statins (10), and cholesterol-absorption blockers (CAB; 1). The private plan had 3 bile acid sequestrants and 3 statins listed as preferred drugs; the CAB was not preferred. In contrast, the public plan had 5 bile acid sequestrants, 7 statins, and the CAB as preferred drugs. For medications with pediatric labeling, the private plan covered 50% as preferred drugs whereas the public plan covered 70% as preferred drugs. CONCLUSIONS If new recommendations of the American Academy of Pediatrics for treatment of dyslipidemia in children were implemented today, children with the public plan would have equal choice but better coverage of lipid-lowering drugs as preferred drugs, including those with FDA approval, compared with children with the private plan.
Collapse
Affiliation(s)
- Esther Y Yoon
- Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan, USA.
| | | | | | | |
Collapse
|
54
|
Bryant-Stephens T. Asthma disparities in urban environments. J Allergy Clin Immunol 2009; 123:1199-206; quiz 1207-8. [PMID: 19501229 DOI: 10.1016/j.jaci.2009.04.030] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 03/26/2009] [Accepted: 04/14/2009] [Indexed: 11/26/2022]
Abstract
Asthma continues to disproportionately affect minority and low-income groups, with African American and Latino children who live in low-socioeconomic-status urban environments experiencing higher asthma morbidity and mortality than white children. This uneven burden in asthma morbidity has been ever increasing despite medical advancement. Many factors have contributed to these disparities in the areas of health care inequities, which result in inadequate treatment; poor housing, which leads to increased exposure to asthma allergens; and social and psychosocial stressors, which are often unappreciated. Interventions to reduce individual areas of disparities have had varying successes. Because asthma is a complex disease that affects millions of persons, multifaceted comprehensive interventions that combine all evidence-based successful strategies are essential to finally closing the gap in asthma morbidity.
Collapse
Affiliation(s)
- Tyra Bryant-Stephens
- Department of General Pediatrics, Community Asthma Prevention Program, the Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
| |
Collapse
|
55
|
Physician behavior in the care of pediatric chronic illness: association with health outcomes and treatment adherence. J Dev Behav Pediatr 2009; 30:246-54. [PMID: 19525719 DOI: 10.1097/dbp.0b013e3181a7ed42] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Physician behavior is an important but understudied influence on child and parental adherence to medical treatment. METHOD To address this need, research was reviewed in the following topic areas: child and adolescent perceptions of physicians' behavior in pediatric chronic illness management, parental perceptions of physicians' behavior in pediatric chronic illness management; physicians' adherence to guidelines for pediatric chronic illness management; physicians' communication of information concerning pediatric chronic illness treatment; the relationship of physician behavior to treatment adherence; and interventions to enhance physicians' management of pediatric chronic illness. RESULTS Findings underscore discrepancies between the needs of parents and adolescents and physician behavior as well as inconsistencies in physician behavior, including adherence to practice guidelines, which may limit children's adherence to medical treatment. However, results of interventions designed to enhance physicians' management of pediatric asthma have been promising. CONCLUSIONS Future research should be guided by a comprehensive model of physician behavior in chronic illness management that considers contextual determinants (e.g., culture and socioeconomic status), identifies clinically relevant targets for intervention, and documents the impact on health outcomes. Approaches to chronic illness management that involve physicians in active communication, support, and decision making with children with chronic illness and their parents should be developed and evaluated.
Collapse
|
56
|
Canino G, McQuaid EL, Rand CS. Addressing asthma health disparities: a multilevel challenge. J Allergy Clin Immunol 2009; 123:1209-17; quiz 1218-9. [PMID: 19447484 PMCID: PMC2693441 DOI: 10.1016/j.jaci.2009.02.043] [Citation(s) in RCA: 167] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 02/05/2009] [Accepted: 02/06/2009] [Indexed: 12/17/2022]
Abstract
Substantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared with non-Latino white subjects. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex, and interrelated sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Several strategies that could be applied in clinical settings to reduce asthma disparities are described, including the need for routine assessment of the patient's beliefs, financial barriers to disease management, and health literacy and the provision of cultural competence training and communication skills to health care provider groups.
Collapse
Affiliation(s)
- Glorisa Canino
- Behavioral Sciences Research Institute and the Department of Pediatrics, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico.
| | | | | |
Collapse
|
57
|
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: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [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.
Collapse
Affiliation(s)
- Arlene Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | | | | | | | | | | |
Collapse
|
58
|
Peterson JW, Sterling YM. Children's perceptions of asthma: African American children use metaphors to make sense of asthma. J Pediatr Health Care 2009; 23:93-100. [PMID: 19232925 DOI: 10.1016/j.pedhc.2007.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 10/04/2007] [Accepted: 10/04/2007] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Children's views of their illness often are absent in decisions that affect their lives. This research, which is a component of a larger study, reports how African American children described their asthma. METHOD The study's design was descriptive and longitudinal, using an ethnographic approach. A subsample of 10 children diagnosed with asthma who resided in one of two study sites spontaneously described their asthma. The study was conducted in various settings where the researchers observed/participated in selected activities. Participants were interviewed several times, and field notes were recorded. RESULTS The qualitative findings are from participant observation and interviews of 10 children ages 9 to 12 years. Four of the most developed metaphors are reported here. Out of their experiences, children created their own metaphors for asthma that are concrete, familiar, and multi-vocal, allowing for embellishment. DISCUSSION Not all children use metaphors to explain or describe their asthma. Children who explain asthma in their own terms will feel valued and invested in their own health care as they find that their voices make a difference in decisions about their care.
Collapse
Affiliation(s)
- Jane W Peterson
- College of Nursing, Seatle University, Seattle, WA 98122-1090, USA.
| | | |
Collapse
|
59
|
Medical management of children with primary hypertension by pediatric subspecialists. Pediatr Nephrol 2009; 24:147-53. [PMID: 18781337 DOI: 10.1007/s00467-008-0970-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Accepted: 07/30/2008] [Indexed: 01/22/2023]
Abstract
Our aim was to characterize medical management of children with primary hypertension (HTN) by pediatric subspecialists. We performed a medical-record review of children < or = 18 years with primary HTN seen at pediatric cardiology or pediatric nephrology clinics at an academic center. Main outcomes were whether treatment decision was in agreement with national guidelines, whether an antihypertensive medication was prescribed, and medication choice. One hundred and eighty children had > or = 1 visit to a pediatric cardiology or nephrology clinic. The majority (83%) of children were pharmacologically managed according to national guidelines. However, only 1/3 children with stage 2 HTN received appropriate antihypertensive therapy from either subspecialty. Only 26 children were prescribed an antihypertensive drug. Children evaluated by pediatric nephrologists were fourfold more likely to receive an antihypertensive than children seen by pediatric cardiologists (29% vs. 7%; p < 0.001). However, all antihypertensive prescriptions were prescribed according to guidelines by both subspecialties. Medical management of children with primary HTN by pediatric cardiologists and pediatric nephrologists is largely consistent with guidelines. However, initiation of appropriate antihypertensive drugs for children with highest severity of HTN is equally poor for both subspecialties. Future studies should explore the factors underlying physicians' reluctance to initiate recommended chronic pharmacologic therapy in children and its associated outcomes.
Collapse
|
60
|
Abstract
PURPOSE The major purpose of this study was to explore the effect of routines on asthma management and morbidity outcomes for children with asthma and their parents. DESIGN AND METHODS This study is a secondary data analysis in a sample of 150 children, which was originally used for an intervention study. RESULTS Parents who had fewer routines in their homes had lower quality-of-life scores and higher burden of asthma scores when compared to parents in households with more routines. More routines were associated with improved asthma morbidity outcomes as measured by nurse rankings of routines. PRACTICE IMPLICATIONS Assisting families to establish routines may result in improved asthma morbidity outcomes.
Collapse
Affiliation(s)
- Kathleen Peterson-Sweeney
- Department of Nursing, The College at Brockport, State University of New York, Brockport, New York, USA.
| |
Collapse
|
61
|
Affiliation(s)
- Meyer Kattan
- Department of Pediatrics, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY 10032, USA.
| |
Collapse
|
62
|
Smith LA, Bokhour B, Hohman KH, Miroshnik I, Kleinman KP, Cohn E, Cortés DE, Galbraith A, Rand C, Lieu TA. Modifiable risk factors for suboptimal control and controller medication underuse among children with asthma. Pediatrics 2008; 122:760-9. [PMID: 18829799 DOI: 10.1542/peds.2007-2750] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Our aims were (1) to describe rates of suboptimal control and controller medication underuse in a diverse population of children with asthma and (2) to identify potentially modifiable parental behaviors and beliefs associated with these outcomes. METHODS We conducted telephone interviews with parents of 2- to 12-year-old children with persistent asthma, in a Medicaid plan and a large provider group. Suboptimal control was defined as >or=4 symptom days, >or=1 symptom night, or >or=4 albuterol use days in the previous 2 weeks. Controller medication underuse was defined as suboptimal control and parent report of <6 days/week of inhaled steroid use. Multivariate analyses identified factors that were independently associated with suboptimal control and controller medication underuse. RESULTS Of the 754 study children, 280 (37%) had suboptimal asthma control; this problem was more common in Hispanic children (51%) than in black (37%) or white (32%) children. Controller medication underuse was present for 133 children (48% of those with suboptimal asthma control and 18% overall). Controller medication underuse was more common among Hispanic (44%) and black (34%) children than white (22%) children. In multivariate analyses, suboptimal control was associated with potentially modifiable factors including low parental expectations for symptom control and high levels of worry about competing household priorities. Controller medication underuse was associated with potentially modifiable factors including parental estimation of asthma control that was discordant with national guidelines and no set time to administer asthma medications. CONCLUSIONS Deficiencies in asthma control and controller medication use are associated with potentially modifiable parental beliefs, which seem to mediate racial/ethnic and socioeconomic disparities in suboptimal control and controller medication underuse.
Collapse
Affiliation(s)
- Lauren A Smith
- Department of Pediatrics, School of Medicine, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, Massachusetts, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
63
|
Cloutier MM, Jones GA, Hinckson V, Wakefield DB. Effectiveness of an asthma management program in reducing disparities in care in urban children. Ann Allergy Asthma Immunol 2008; 100:545-50. [PMID: 18592817 DOI: 10.1016/s1081-1206(10)60058-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine differences in the effectiveness of a program to reduce use of health care services in urban-dwelling black and Hispanic children as a way to understand the origins of disparities. METHODS We examined hospitalization rates, emergency department (ED) visits, outpatient visits (OPVs), and bronchodilator and inhaled corticosteroid (ICS) prescriptions in 2,362 children receiving Medicaid who were enrolled in an asthma management program (Easy Breathing) from June 1, 1998, through May 31, 2001. We used generalized estimating equations to fit multivariate marginal Poisson regression models, controlling for sex, ethnicity, asthma severity, and secular trends. RESULTS Hospitalization rates were high and decreased 53% for black children and 33% for Hispanic children after the intervention. The ED visits decreased for Hispanic children, and OPVs decreased for both black and Hispanic children after Easy Breathing. The ICS prescription rates increased, with a decrease in the bronchodilator to ICS ratio from 5.81 to 2.16 in black children and from 4.74 to 2.17 in Hispanic children. Hispanic children filled more prescriptions for bronchodilators and ICSs (odds ratio, 1.29; 95% confidence interval, 1.05-1.59; P = .01; and odds ratio, 1.55; 95% confidence interval, 1.14-2.11; P = .005; respectively) 3 and 12 months after Easy Breathing. Black children were more likely than Hispanic children not to fill any asthma prescription. A total of 12% of children filled no asthma prescriptions. CONCLUSIONS Hispanic children seek more medical services than black children, whereas black children fill fewer prescriptions for bronchodilators and ICSs than Hispanic children. Easy Breathing reduces overall hospitalizations and OPVs in black and Hispanic children and asthma-specific ED visits in Hispanic children; the benefits of Easy Breathing are different in Hispanic and black children.
Collapse
Affiliation(s)
- Michelle M Cloutier
- Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut, USA.
| | | | | | | |
Collapse
|
64
|
Racial/Ethnic variation in parent perceptions of asthma. ACTA ACUST UNITED AC 2008; 8:89-97. [PMID: 18355737 DOI: 10.1016/j.ambp.2007.10.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 10/25/2007] [Accepted: 10/26/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Black and Latino children with asthma have worse morbidity and receive less controller medication than their white peers. Scant information exists on racial/ethnic differences in parent perceptions of asthma. To compare parent perceptions among black, Latino, and white children with asthma in 4 domains: (1) expectations for functioning with asthma; (2) concerns about medications; (3) interactions with providers; and (4) competing family priorities. METHODS In this cross-sectional study, we conducted telephone interviews with parents of children with persistent asthma in a Medicaid health plan and a multispecialty provider group in Massachusetts. To measure expectations for functioning and other domains, we adapted multi-item scales from past studies. Associations between race/ethnicity and these domains were evaluated in multivariate analyses that controlled for age, gender, household income, parental education, insurance, and language. The response rate was 72%. RESULTS Of the 739 study children, 24% were black, 21% Latino, and 43% white. Parents of black and Latino children had lower expectations for their children's functioning with asthma (P < .001), higher levels of worry about their children's asthma (P < .001), and more competing family priorities (P = .004) compared with parents of white children. Parents of Latino children had higher levels of concern about medications for asthma than parents of black or white children (P = .002). There were no differences among racial/ethnic groups in reports of interactions with the provider of their children's asthma care. CONCLUSIONS Efforts to eliminate disparities in childhood asthma may need to address variation in expectations and competing priorities between minority and white families.
Collapse
|
65
|
Janson SL, Earnest G, Wong KP, Blanc PD. Predictors of asthma medication nonadherence. Heart Lung 2008; 37:211-8. [PMID: 18482633 PMCID: PMC2447544 DOI: 10.1016/j.hrtlng.2007.05.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Accepted: 05/29/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND The purpose of this study was to describe asthma medication adherence behavior and to identify predictors of inhaled corticosteroid (ICS) underuse and inhaled beta-agonist (IBA) overuse. METHODS Self-reported medication adherence, spirometry, various measures of status, and blood for immunoglobulin E measurement were collected on 158 subjects from a larger cohort of adults with asthma and rhinitis who were prescribed an ICS, an IBA, or both. RESULTS There was a positive association between ICS underuse and higher forced expiratory volume in one second percent (FEV1%) predicted (P = .01) and a negative association with lower income (P = 0.04). IBA overuse was positively associated with greater perceived severity of asthma (P = 0.004) and negatively with higher education level (P = 0.02). CONCLUSIONS Nonadherence to prescribed asthma therapy seems to be influenced by socioeconomic factors and by perceived and actual severity of disease. These factors are important to assess when trying to estimate the degree of medication adherence and its relationship to clinical presentation.
Collapse
Affiliation(s)
- Susan L Janson
- School of Nursing, University of California San Francisco, San Francisco, CA 94143-0608, USA
| | | | | | | |
Collapse
|
66
|
Koinis-Mitchell D, McQuaid EL, Friedman D, Colon A, Soto J, Rivera DV, Fritz GK, Canino G. Latino caregivers' beliefs about asthma: causes, symptoms, and practices. J Asthma 2008; 45:205-10. [PMID: 18415827 PMCID: PMC2590764 DOI: 10.1080/02770900801890422] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE This study examined belief systems of Latino caregivers who have children with asthma from Puerto Rican and Dominican backgrounds who resided on the Island of PR and the Mainland. The goal of this study was to document similarities and differences in beliefs about the causes, symptoms, and treatments of asthma across two sites and two Latino ethnic sub-groups of children who remain the most at risk for asthma morbidity. METHODS Participants included 100 primary caregivers of a child with asthma; 50 caregivers from Island PR and 50 caregivers from mainland RI were interviewed (at each site; 25 caregivers were from Puerto Rican backgrounds and 25 caregivers were from Dominican backgrounds). The interview included an assessment of demographic information and beliefs about the causes and symptoms of asthma and asthma practices. RESULTS Results indicated more similarities in beliefs about the causes and symptoms of asthma across site and ethnic group. The majority of differences were among beliefs about asthma practices by site and ethnic group. For example, a higher proportion of caregivers from Island PR, particularly those of Dominican descent, endorsed that a range of home and botanical remedies are effective for treating asthma. CONCLUSIONS Results from this study point to several interesting directions for future research including larger samples of Latino caregivers with children who have asthma. A discussion of the importance of understanding cultural beliefs about asthma and asthma practices is also reviewed.
Collapse
Affiliation(s)
- Daphne Koinis-Mitchell
- Bradley/Hasbro Children's Research Center, Brown Medical School, Providence, Rhode Island 02903, USA.
| | | | | | | | | | | | | | | |
Collapse
|
67
|
Le TT, Bilderback A, Bender B, Wamboldt FS, Turner CF, Rand CS, Bartlett SJ. Do asthma medication beliefs mediate the relationship between minority status and adherence to therapy? J Asthma 2008; 45:33-7. [PMID: 18259993 DOI: 10.1080/02770900701815552] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Minority status has been associated with lower asthma medication adherence. We evaluated whether medication beliefs mediated this association. 86 adults with asthma on inhaled corticosteroid therapy completed surveys regarding selected beliefs about asthma medications. Medication adherence for 1 month was electronically measured. Mean daily adherence was lower in minority patients than in Caucasians (p < .001). Multiple negative asthma medication beliefs were associated with lower adherence (p's < .05). Minorities had increased adjusted odds of having a high negative medication beliefs score. Finally, a bootstrapped estimate demonstrated a mediating effect by negative asthma beliefs on the minority status-adherence association (-.073 [95% CI: -.16, -.01]).
Collapse
Affiliation(s)
- Tao T Le
- University of Louisville, Louisville, Kentucky, USA.
| | | | | | | | | | | | | |
Collapse
|
68
|
Canino G, Vila D, Normand SLT, Acosta-Pérez E, Ramírez R, García P, Rand C. Reducing asthma health disparities in poor Puerto Rican children: the effectiveness of a culturally tailored family intervention. J Allergy Clin Immunol 2008; 121:665-70. [PMID: 18061648 PMCID: PMC3136215 DOI: 10.1016/j.jaci.2007.10.022] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 10/09/2007] [Accepted: 10/15/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Island and mainland Puerto Rican children have the highest rates of asthma and asthma morbidity of any ethnic group in the United States. OBJECTIVE We evaluated the effectiveness of a culturally adapted family asthma management intervention called CALMA (an acronym of the Spanish for "Take Control, Empower Yourself and Achieve Management of Asthma") in reducing asthma morbidity in poor Puerto Rican children with asthma. METHODS Low-income children with persistent asthma were selected from a national health plan insurance claims database by using a computerized algorithm. After baseline, families were randomly assigned to either the intervention or a control group. RESULTS No significant differences between control and intervention group were found for the primary outcome of symptom-free days. However, children in the CALMA intervention group had 6.5% more symptom-free nights, were 3 times more likely to have their asthma under control, and were less likely to visit the emergency department and be hospitalized as compared to the control group. Caregivers receiving CALMA were significantly less likely to feel helpless, frustrated, or upset because of their child's asthma and more likely to feel confident to manage their child's asthma. CONCLUSION A home-based asthma intervention program tailored to the cultural needs of low income Puerto Rican families is a promising intervention for reducing asthma morbidity.
Collapse
Affiliation(s)
- Glorisa Canino
- University of Puerto Rico, Medical Sciences Campus, Behavioral Sciences Institute, San Juan, Puerto Rico 00936-5067.
| | | | | | | | | | | | | |
Collapse
|
69
|
Garbutt J, Bloomberg G, Banister C, Sterkel R, Epstein J, Bruns J, Swerczek L, Wells S. What constitutes maintenance asthma care? The pediatrician's perspective. ACTA ACUST UNITED AC 2008; 7:308-12. [PMID: 17660103 DOI: 10.1016/j.ambp.2007.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 03/27/2007] [Accepted: 03/30/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe how pediatricians report they provide maintenance care for children with persistent asthma, and to identify opportunities for improvement. METHODS An anonymous 34-item survey was completed by community pediatricians in St Louis, Missouri, between June 2005 and October 2005. Physicians reported the percentage of patients for whom they would prescribe inhaled corticosteroids, and selected from checklists the activities and questions they would use during a maintenance care visit. RESULTS A total of 135 (60%) of 225 eligible pediatricians responded. Respondents reported they prescribed inhaled corticosteroids for most patients (median 80% patients, range, 10%-100%). Although most respondents used specific questions to assess recent asthma burden including inquiring about the frequency of daytime (86%) and nighttime (83%) symptoms, fewer asked about activity limitations such as school absences (58%). Some reported using specific questions to assess medication adherence such as how often doses were missed (49%), or included collaborative activities to support daily self-management such as setting asthma care goals (60%), but fewer asked how symptoms were monitored (44%) or assessed the effect of the child's asthma on the parent and family (24%). CONCLUSIONS Findings from this self-reported physician survey suggest that asthma management practices fall short of optimal standards. Opportunities for improvement include more comprehensive and detailed assessment of asthma control and medication adherence, collaborative goal setting, and better collaboration with the parent to support effective self-management. Further interventions to reduce asthma morbidity need to support physicians with these activities.
Collapse
Affiliation(s)
- Jane Garbutt
- Department of Medicine, Washington University School of Medicine, St Louis, MO 63110, USA.
| | | | | | | | | | | | | | | |
Collapse
|
70
|
Diette GB, Rand C. The contributing role of health-care communication to health disparities for minority patients with asthma. Chest 2008; 132:802S-809S. [PMID: 17998344 DOI: 10.1378/chest.07-1909] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Asthma is a common, chronic illness with substantial morbidity, especially for racial and ethnic minorities in the United States. The care of the patient with asthma is complex and depends ideally on excellent communication between patients and health-care providers. Communication is essential for the patient to communicate the severity of his or her illness, as well as for the health-care provider to instruct patients on pharmacologic and nonpharmacologic care. This article describes evidence for poor provider/patient communication as a contributor to health-care disparities for minority patients with asthma. Communication problems stem from issues with patients, health-care providers, and health-care systems. It is likely that asthma disparities can be improved, in part, by improving patient/provider communication. While much is known presently about the problem of patient/provider communication in asthma, there is a need to improve and extend the evidence base on the role of effective communication of asthma care and the links to outcomes for minorities. Additional studies are needed that document the extent to which problems with doctor/patient communication lead to inadequate care and poor outcomes for minorities with asthma, as well as mechanisms by which these disparities occur.
Collapse
Affiliation(s)
- Gregory B Diette
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 5th Floor, 1830 E Monument St, Baltimore, MD 21205, USA.
| | | |
Collapse
|
71
|
Williams LK, Joseph CL, Peterson EL, Wells K, Wang M, Chowdhry VK, Walsh M, Campbell J, Rand CS, Apter AJ, Lanfear DE, Tunceli K, Pladevall M. Patients with asthma who do not fill their inhaled corticosteroids: a study of primary nonadherence. J Allergy Clin Immunol 2007; 120:1153-9. [PMID: 17936894 DOI: 10.1016/j.jaci.2007.08.020] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 08/08/2007] [Accepted: 08/10/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adherence to inhaled corticosteroids (ICSs) is known to be poor among patients with asthma; however, little is known about patients who do not fill their ICS prescriptions (ie, primary nonadherence). OBJECTIVE To estimate rates of primary nonadherence and to explore associated factors. METHODS The study population was members of a large health maintenance organization in southeast Michigan who met the following criteria: age 5 to 56 years; previous diagnosis of asthma; at least 1 electronic prescription for an ICS between February 17, 2005, and June 1, 2006; and at least 3 months follow-up after the ICS prescription. Adherence was estimated by using electronic prescription information and pharmacy claims data. Multivariable stepwise analysis was used to identify factors associated with primary nonadherence compared with adherent patients. RESULTS One thousand sixty-four patients met the study criteria and had calculable adherence. Of these patients, 82 (8%) never filled their ICS prescription. Stepwise regression identified the following factors to be associated with an increased likelihood of primary nonadherence: younger age, female sex, African American race-ethnicity, and lower rescue medication use. Factors associated with primary nonadherence differed between race-ethnic groups. CONCLUSION Primary nonadherence was associated with lower baseline rescue medication use, which may reflect lower perceived need for ICS therapy in patients with milder asthma. Rates of primary nonadherence and the factors which influenced this outcome differed by race-ethnicity. CLINICAL IMPLICATIONS Understanding patient characteristics associated with primary nonadherence may be important for disease management, because many patients with asthma do not fill their ICS prescriptions.
Collapse
Affiliation(s)
- L Keoki Williams
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
72
|
Wittich AR, Mangan J, Grad R, Wang W, Gerald LB. Pediatric asthma: caregiver health literacy and the clinician's perception. J Asthma 2007; 44:51-5. [PMID: 17365205 DOI: 10.1080/02770900601125672] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Health literacy was assessed in pediatric asthma caregivers attending a university-based clinic. The medical provider's perception of caregiver health literacy was also examined. Eighty-six percent of the caregivers had adequate health literacy, 4% and 10% had marginal and inadequate health literacy, respectively. Health literacy was significantly higher for caregivers who were younger (p = 0.039) and had a higher level of education (p = 0.037). An agreement analysis revealed moderate agreement between provider perception of caregiver's health literacy and measured health literacy (Kappa = 0.51). The results suggest that medical providers may not accurately assess caregivers' actual health literacy level.
Collapse
Affiliation(s)
- Angelina R Wittich
- School of Health Professions, Department of Critical Care/Lung Health Center, University of Alabama at Birmingham. Birmingham, Alabama 35233, USA
| | | | | | | | | |
Collapse
|
73
|
Horky SC, Kleinman SH, Firth DG. A Comparison of Parent And Provider Beliefs about Asthma in Children. ACTA ACUST UNITED AC 2007. [DOI: 10.1089/pai.2005.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
74
|
Thyne SM, Rising JP, Legion V, Love MB. The Yes We Can Urban Asthma Partnership: a medical/social model for childhood asthma management. J Asthma 2007; 43:667-73. [PMID: 17092847 DOI: 10.1080/02770900600925288] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pediatric asthma programs have struggled to integrate children's medical and social needs. We developed and piloted an integrated team model for asthma care for low-income children through the Yes We Can Urban Asthma Partnership. Program evaluation demonstrated increases in prescribing controller medications (p <0.05), use of action plans (p<0.001), and the use of mattress covers (p<0.001); and decrease in asthma symptoms (p<0.01). Additional changes occurred within the local system of asthma care to support ongoing efforts to improve asthma management. We conclude that pediatric asthma programs can effectively target the social and medical needs of children in a sustainable manner.
Collapse
Affiliation(s)
- Shannon M Thyne
- Department of Pediatrics, University of California, San Francisco, California 94110, USA.
| | | | | | | |
Collapse
|
75
|
Kachru R, Morphew T, Kehl S, Clement LT, Hanley-Lopez J, Kwong KYC, Guterman JJ, Jones CA. Validation of a single survey that can be used for case identification and assessment of asthma control: the Breathmobile Program. Ann Allergy Asthma Immunol 2007; 97:775-83. [PMID: 17201237 DOI: 10.1016/s1081-1206(10)60969-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Underdiagnosis of asthma and underrecognition of disease severity in lower socioeconomic populations continue to be significant health care concerns despite national efforts to better educate health care providers. OBJECTIVE To validate a 1-page survey as a point-in-time tool identifying uncontrolled vs controlled asthma and moderate-to-severe disease activity in an urban, lower-socioeconomic pediatric population. METHODS A previously validated survey (the Breathmobile Case Identification Survey) was evaluated as a point-in-time tool for identifying children with poorly controlled disease. Clinical validation was achieved in children (n = 1,826) presenting to a school-based asthma program for either an initial (n = 666) or a follow-up (n = 1,170) visit. Responses were compared with a comprehensive evaluation by a physician specialist as the gold standard. Response patterns were used to construct multimodel tiered scoring algorithms for baseline and follow-up visits that identify children with uncontrolled asthma, and children are likely to have moderate-to-severe disease activity at that time. RESULTS Surveys scored using the developed algorithms identified children with uncontrolled asthma (sensitivity: baseline, 77.0%; follow-up, 71.6%; specificity: baseline, 72.7%; follow-up, 71.5%) and detected moderate-to-severe disease activity (sensitivity: baseline, 69.2%; follow-up, 77.4%; specificity: baseline, 70.2%; follow-up, 70.3%). CONCLUSIONS The Breathmobile Case Identification Survey can be used in lower-socioeconomic, urban populations as a point-in-time tool for identifying children with uncontrolled vs controlled asthma and moderate-to-severe disease activity.
Collapse
Affiliation(s)
- Rita Kachru
- Division of Allergy and Immunology, Department of Pediatrics, Los Angeles County + University of Southern California Medical Center, Los Angeles, California 90033, USA
| | | | | | | | | | | | | | | |
Collapse
|
76
|
Mudd K, Bollinger ME, Hsu VD, Donithan M, Butz A. Pharmacy fill patterns in young urban children with persistent asthma. J Asthma 2006; 43:597-600. [PMID: 17050224 DOI: 10.1080/02770900600878537] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Medication adherence impacts healthcare utilization. Pharmacy records are useful to establish fill patterns. OBJECTIVE Use pharmacy records to establish medication patterns fill patterns for comparison to healthcare utilization. Methods. Pharmacy records of 175 children with persistent asthma were collected and compared to healthcare utilization. RESULTS Majority of subjects had significant healthcare utilization, low numbers of rescue medications, and poor controller medication fill rates. Those with more rescue medications had more healthcare utilization and more controller medications. CONCLUSIONS Pharmacy fill patterns demonstrate few rescue and/or controller medication fills. Those with more rescue medications reported increased healthcare utilization despite controller medications.
Collapse
Affiliation(s)
- Kim Mudd
- Division of Pediatric Allergy/Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
| | | | | | | | | |
Collapse
|
77
|
Abstract
Asthma is one of the most common chronic diseases in children and is frequently noted as the reason for school absences. The purpose of this pilot study was to determine the differences in demands and resources reported by African American (AA) and European American (EA) parents of school-age children with asthma. A convenience sample of 37 parents participated in the study. Data were collected from 19 AA and 18 EA parents. Family stress theory provided the framework for this study. All subjects completed a demographic questionnaire, the Care of My Child With Asthma Scale, and the Family Inventory of Resources for Management (FIRM). Descriptive statistics were used to analyze the data. The most time-consuming caregiving demand reported by EA parents was providing emotional support for the child. For AA parents, the most time-consuming caregiving demand was managing work or school outside the home and organizing asthma treatments at the same time. AA parents had limited resources in the area of extended family social support. The Mann-Whitney U test found no statistically significant differences between AA and EA parents in relation to demands and resources. Nursing implications are presented.
Collapse
|
78
|
Lehman HK, Lillis KA, Shaha SH, Augustine M, Ballow M. Initiation of maintenance antiinflammatory medication in asthmatic children in a pediatric emergency department. Pediatrics 2006; 118:2394-401. [PMID: 17142524 DOI: 10.1542/peds.2006-0871] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite National Asthma Education and Prevention Program guidelines recommending the use of daily controller medication in patients with persistent asthma, less than half of children requiring emergency department treatment for asthma exacerbations are receiving antiinflammatory therapy. OBJECTIVE The purpose of this study was to evaluate a pediatric emergency department-based intervention designed to affect the prescribing practices of primary care physicians to better comply with national asthma guidelines. The intervention involved initiating maintenance antiinflammatory therapy in children with an asthma exacerbation who met guidelines for persistent disease but were not on antiinflammatory medications. METHODS Guardians of children 2 to 18 years of age presenting to the pediatric emergency department with an asthma exacerbation were asked to complete an asthma survey. Patients were classified into severity categories. Those with persistent disease not on antiinflammatory medications were given a 2-week supply of medication and were instructed to follow-up with their primary care physicians to obtain a prescription for the antiinflammatory medication. Patient adherence information was obtained through telephone calls, pharmacy claims data, and physician office records. RESULTS Forty-seven of 142 patients met criteria and were enrolled in the intervention. Seven patients were lost to follow-up. Of the remaining 40 patients, 28 followed-up with their primary care physician. Of these patients, 75% were continued on an antiinflammatory medication. Primary care physicians were significantly more likely to continue an antiinflammatory prescription in patients with severe persistent asthma (88.9% vs 68.4% of mild- or moderate-persistent asthmatics). Of the 28 patients who followed-up with their primary care physician, 13 had a prescription written, dispensed, and reported using the medication at the time of follow-up. CONCLUSIONS Pediatric emergency department physicians can successfully partner with primary care physicians to implement national guidelines for children requiring maintenance antiinflammatory asthma therapy. Patient nonadherence continues to be a significant barrier for asthma management.
Collapse
Affiliation(s)
- Heather K Lehman
- Division of Allergy and Immunology, Department of Pediatrics, University at Buffalo School of Medicine and Biomedical Sciences, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222, USA.
| | | | | | | | | |
Collapse
|
79
|
Spahn JD, Liu AH. The inner-city asthma epidemic reaches far and wide. Ann Allergy Asthma Immunol 2006; 96:759-61. [PMID: 16802759 DOI: 10.1016/s1081-1206(10)61334-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
80
|
Valerio M, Cabana MD, White DF, Heidmann DM, Brown RW, Bratton SL. Understanding of asthma management: Medicaid parents' perspectives. Chest 2006; 129:594-601. [PMID: 16537856 DOI: 10.1378/chest.129.3.594] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE This article explores parental caregiver perspectives on barriers to asthma care in the Medicaid system. METHODS Focus groups were held for parents of children with persistent asthma to identify barriers to asthma care for children insured by Medicaid in the Ypsilanti, MI area. Semistructured questions regarding health goals, asthma care, and access were used. Themes were defined as distinct categories or concepts regarding aspects of asthma care and coded. RESULTS Thirty-six adults participated in four focus groups, 89% were the biological mother, and 64% were African American. Major themes identified included caregiver emotions, caregiver/patient knowledge, environmental issues, school/daycare support, Medicaid health-care system issues, the role of medical providers, and emerging adolescence. Parents demonstrated asthma awareness but were not confident in their role as the child's disease manager. A specific gap was seen in the caregiver's level of self-efficacy to control exposure to asthma triggers, monitor the child's symptoms, and modify medications based on asthma symptoms. CONCLUSION Medicaid-insured families face unique barriers related to income and insurance limitations as well as issues common to others with asthma. Caregivers demonstrated a high level of asthma knowledge, but like other caregivers gaps between knowledge and behavior existed. Barriers to asthma care that may be specific to Medicaid-insured patients included difficulty maintaining continuity of care due to physician participation in Medicaid programs, and concerns about possible differences in asthma care from health-care providers due to their Medicaid insurance status.
Collapse
Affiliation(s)
- Melissa Valerio
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan Health System, Ann Arbor, MI 48109, USA.
| | | | | | | | | | | |
Collapse
|
81
|
Sockrider MM, Abramson S, Brooks E, Caviness AC, Pilney S, Koerner C, Macias CG. Delivering tailored asthma family education in a pediatric emergency department setting: a pilot study. Pediatrics 2006; 117:S135-44. [PMID: 16777829 DOI: 10.1542/peds.2005-2000k] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Many children are brought to the pediatric emergency department (ED) with acute asthma symptoms. Emergency asthma care is costly, and many ED visits may be preventable. Families often do not have written asthma action plans and lack asthma self-management skills. This study tests a tailored self-management intervention delivered in the ED for families of children with asthma. The primary hypotheses were that the intervention group would have greater confidence to manage asthma 14 days postintervention and more well-asthma visits and fewer urgent care/ED visits at 9 and 12 months. METHODS This randomized intervention/usual-care study was part of a larger ED asthma surveillance project in 4 urban pediatric ED sites. Asthma educators used a computer-based resource to tailor the intervention messages and provide a customized asthma action plan and educational summary. Children with acute asthma were enrolled during an ED visit, and follow-up telephone interviews were conducted during the next 9 months. The ED clinician classified the child's acute and chronic severity. RESULTS To date, 464 subjects aged 1 to 18 years have been enrolled. The ED clinicians reported that 46% had intermittent and 54% had persistent chronic severity with 51% having mild acute severity episodes. The confidence level to prevent asthma episodes and keep them from getting worse was significantly higher in the intervention group at 14 days postintervention. More subjects in the intervention group reported well-asthma visits by 9 months. Return ED visits were significantly lower in the intervention group in those with intermittent asthma. Twelve-month follow-up is in process. CONCLUSIONS The tailored ED self-management intervention demonstrates significant effects on caregiver self-confidence and well-visit follow-up. Additional evaluation is needed to determine what impact this intervention has long-term.
Collapse
Affiliation(s)
- Marianna M Sockrider
- Department of Pediatrics, Baylor College of Medicine, 6621 Fannin, MC 1040.00, Houston, Texas 77030, USA.
| | | | | | | | | | | | | |
Collapse
|
82
|
Gustafsson PM, Watson L, Davis KJ, Rabe KF. Poor asthma control in children: evidence from epidemiological surveys and implications for clinical practice. Int J Clin Pract 2006; 60:321-34. [PMID: 16494648 DOI: 10.1111/j.1368-5031.2006.00798.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The objectives of this study is to compile current knowledge about asthma control in children in relation to goals proposed in international guidelines, to elucidate the factors associated with insufficient asthma control and to address the implications for clinical practice. Review of recent worldwide large population epidemiological surveys and clinical asthma studies of more than 20,000 children are the methods used in this study. The studies report high frequencies of sleep disturbances, emergency visits, school absence and limitations of physical activity due to asthma. Only a small percentage of children with asthma reach the goals of good asthma control set out by Global Initiative for Asthma (GINA). There is evidence of underuse of inhaled corticosteroids even in children with moderate or severe persistent asthma and over-reliance on short-acting beta(2)-agonist rescue medication. Both parents and physicians generally overestimate asthma control and have low expectations about the level of achievable control. Many children with asthma are not being managed in accordance with guideline recommendations, and asthma management practices vary widely between countries. Asthma control falls short of guideline recommendations in large proportions of children with asthma worldwide. Simple methods for assessing asthma control in clinical practice are needed. Treatment goals based on raised expectations should be established in partnership with the asthmatic child and the parents. Effective anti-inflammatory treatment should be used more frequently, and patients should be reviewed regularly.
Collapse
Affiliation(s)
- P M Gustafsson
- Queen Silvia Children's Hospital, University of Gothenburg, Gothenburg, Sweden.
| | | | | | | |
Collapse
|
83
|
Jones CA, Clement LT, Hanley-Lopez J, Morphew T, Kwong KYC, Lifson F, Opas L, Guterman JJ. The Breathmobile Program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program. ACTA ACUST UNITED AC 2006; 8:205-22. [PMID: 16117716 DOI: 10.1089/dis.2005.8.205] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Despite more than a decade of education and research-oriented intervention programs, inner city children with asthma continue to engage in episodic "rescue" patterns of healthcare and experience a disproportionate level of morbidity. The aim of this study was to establish and evaluate a sustainable community-wide pediatric asthma disease management program designed to shift inner city children in Los Angeles from acute episodic care to regular preventive care in accordance with national standards. In 1995 the Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA), the Los Angeles County Department of Health Services (LAC DHS), and the Los Angeles Unified School District (LAUSD) established an agreement to initiate and sustain the Breathmobile Program. This program includes automated case identification, mobile school-based clinics, and highly structured clinical encounters supported by an advanced information technology solution. Interdisciplinary teams of asthma care specialists provide regular and ongoing care to children at school and county clinic sites over a wide geographic area of urban Los Angeles. Each team operates in a specially equipped mobile clinic (Breathmobile), efficiently moving a structured healthcare process to school and county clinic sites with large numbers of children. Demographic, clinical, and participation data is tracked carefully in an electronic medical record system. Program operations, clinical oversight, and patient tracking are centralized at a care coordination center. Clinical operations and methods have been replicated in fixed specialty clinic sites at the Los Angeles County + University of Southern California Medical Center. Clinical and process measures are regularly evaluated to assure quality, plan iterative improvement, and support evidence-based care. Four Breathmobiles deliver ongoing care at more than 90 school sites. The program has engaged over five thousand patients and their families in a continuity care model that has demonstrated efficacy over usual episodic care. More than 90% of patients in all asthma severity categories achieved clinical control of asthma with significant reductions in inpatient (IP) and emergency department (ED) use. On February 14, 2002, the program became the first program in the United States to receive the award of disease-specific care certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Proper design and resource allocation can sustain a school-based community-wide pediatric asthma disease management program and shift a population of inner city children from acute episodic care to routine preventive care in accordance with national standards. An evidence-based approach to evaluating and maintaining quality, coupled with stratified care delivery, can assure the efficient use of safety net healthcare resources.
Collapse
Affiliation(s)
- Craig A Jones
- Division of Allergy and Immunology, Department of Pediatrics at the Los Angeles County and University of Southern California Medical Center, USA.
| | | | | | | | | | | | | | | |
Collapse
|
84
|
|
85
|
Feldman JM, Siddique MI, Morales E, Kaminski B, Lu SE, Lehrer PM. Psychiatric disorders and asthma outcomes among high-risk inner-city patients. Psychosom Med 2005; 67:989-96. [PMID: 16314605 DOI: 10.1097/01.psy.0000188556.97979.13] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the rate of psychiatric disorders among patients attending an ethnically diverse, inner-city asthma clinic for an initial visit and assess the association between psychiatric disorders and asthma morbidity. METHODS A semistructured psychological interview was conducted to assess for psychiatric diagnoses. A pulmonary physician, who was blind to psychiatric disorder, established diagnosis of asthma based on national guidelines. RESULTS Sixty-four percent of 85 participants received at least 1 psychiatric diagnosis. The pulmonary physician rated patients with a psychiatric disorder as achieving fewer goals (M = 2.3 +/- 1.3) for asthma control than patients without a psychiatric disorder (M = 3.6 +/- 1.5, p = .0002). Patients with a psychiatric diagnosis more frequently reported an emergency room visit for asthma during the past 6 months (OR = 4.89; 95% CI, 1.76-13.39) and greater use of short-acting beta2-agonist medication (M = 1.5 +/- 0.9 canisters per month) than patients without a psychiatric diagnosis (M = 0.9 +/- 0.8, p = .003). These findings were independent of demographics, health insurance, and asthma severity. No differences emerged between patients with and without a mental disorder on percent predicted FEV1. Patients with a psychiatric disorder reported a higher severity level for asthma symptoms than the severity level indicated by their pulmonary function in comparison to patients without a psychiatric diagnosis (OR = 3.52; 95% CI, 1.23-10.10). Health insurance appeared to be a confounding factor in this relationship. CONCLUSION A high rate of psychiatric disorders was found among inner-city asthma patients. Psychiatric diagnoses were associated with greater perceived impairment from asthma but not objective measurement of pulmonary function.
Collapse
Affiliation(s)
- Jonathan M Feldman
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York 10461, USA.
| | | | | | | | | | | |
Collapse
|
86
|
Rao VU, Apter AJ. Steroid Phobia and Adherence—Problems, Solutions, Impact on Benefit/Risk Profile. Immunol Allergy Clin North Am 2005; 25:581-95. [PMID: 16054544 DOI: 10.1016/j.iac.2005.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Adherence is important with all medications. It can be more difficult with inhaled steroids in light of concern about adverse effects. Although the degree of fear regarding inhaled steroids is difficult to quantify, it appears to be an important factor in adherence. These fears exist for several reasons, including misinformation obtained from such sources as the Internet. To improve adherence and decrease morbidity and mortality, it is vital that health care providers are aware of potential barriers to adherence. Measures such as simplifying and properly explaining medication regimens are helpful. Just as important is the establishment of a strong patient-provider relationship. This makes it easier to convince patients of the need for recommended medications. If the provider is able to effectively communicate and convince the patient of the benefit/risk ratio of steroids, improved patient outcomes can be achieved.
Collapse
Affiliation(s)
- Vivek U Rao
- Division of Pulmonary, Allergy, Critical Care, Department of Medicine, 829 Gates Building, Hospital of the University of Pennsylvania, 3600 Spruce Street, Philadelphia, PA 19104, USA
| | | |
Collapse
|
87
|
Abstract
AIM In this paper, we present the findings of a recent research project in which we explored self- management with older people who were diagnosed with asthma. BACKGROUND Asthma self-management literature has focused on the need for the patient to 'adhere' to prescribed therapies, in particular the taking of medications, monitoring of respiratory function or recognizing and avoiding triggers. METHOD Data were generated during a period of 9 months from three sources; in-depth interviews with 24 older participants, an open-ended questionnaire and two mixed-gender participatory action research groups. FINDINGS Based on current literature, our previous research findings which have 'unpacked' what is 'self'-management, and data generated in this project, we propose that three asthma management models are in operation: Medical Model of Self-management, Collaborative Model of Self-management and Self-Agency Model of Self-management. Locating the 'self' in self-management means acknowledging that many people living with a chronic condition are already self-determining and their expertise should be acknowledged as such. CONCLUSION Health care professionals can best facilitate people toward self-agency by embracing new understandings of self-management in long-term illness. This process is enhanced when the expertise a person brings to the management of their condition is given the respect it deserves. There needs to be a focus on providing people with the means to grow and learn in a participative relationship that cannot be fully realized with 'off the shelf' self-management solutions.
Collapse
Affiliation(s)
- Tina Koch
- RDNS, Research Unit, Glenside, South Australia, Australia.
| | | | | |
Collapse
|
88
|
|
89
|
Costello I, Wong ICK, Nunn AJ. A literature review to identify interventions to improve the use of medicines in children. Child Care Health Dev 2004; 30:647-65. [PMID: 15527475 DOI: 10.1111/j.1365-2214.2004.00478.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND It is estimated that 200 million prescriptions for children and adolescents were issued in the UK during 2002. Therefore, it is important for the National Service Framework for Children (NSFC) to include advice on managing medicines effectively for children. This literature review was performed at the request of the NSFC Medicines External Working Group in order to provide underpinning evidence in the development of advice on managing medicines. METHODS Detabases, websites and conference abstracts were searched systematically to identify information on managing medicines in children in 2003. This article reported the results on medication review, concordance, enhanced medicines access through community pharmacy services and the use of medicines in schools. RESULTS AND CONCLUSIONS Although there is little evidence specific to paediatrics, the objectives and rationale of medication review could be expected to apply to chronic diseases in children. Issues such as polypharmacy, wastage, repeat prescriptions and medication problems could be similar. The benefits seen in adults may also occur in children, and medication review may possibly have a role in the management of medicines in children. There is an obvious role for pharmacists in ensuring the safety of over-the-counter medications and provision of information and education to parents, carers and adolescents. Evaluation and provision of necessary education and training to community pharmacists is needed, even in the most basic paediatric issues such as sugar-free medications. The evidence suggests that treatment compliance and adherence are generally lower in children than in adults, particularly in adolescents as they approach independence. Those with learning disabilities and infants are likely to be at risk of non-compliance, although little work has been done in these populations. Children and adolescents need appropriate parental and professional support in taking control of their medication and treatment. The management of medicines in school would appear to be far from ideal. Further research into school-based medicines education and outreach clinics would also be beneficial.
Collapse
Affiliation(s)
- I Costello
- Centre for Paediatric Pharmacy Research, School of Pharmacy, University of London & the Institute of Child Health, University College London, London, UK
| | | | | |
Collapse
|
90
|
Butler K, Cooper WO. Adherence of pediatric asthma patients with oral corticosteroid prescriptions following pediatric emergency department visit or hospitalization. Pediatr Emerg Care 2004; 20:730-5. [PMID: 15502653 DOI: 10.1097/01.pec.0000144914.78124.6f] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine caregiver adherence to oral corticosteroids prescribed in the emergency department for pediatric patients with an acute asthma exacerbation and to identify caregivers' perceived barriers to adherence with prescribed oral corticosteroids. METHOD We conducted telephone interviews 7 to 9 days following a patient's presentation to an urban children's hospital emergency department for an acute asthma exacerbation. The telephone interview conducted with caregivers of pediatric asthma patients included questions regarding whether caregivers filled a prescription for an oral corticosteroid, the number of days the caregiver gave the medication, and the perceived barriers to adherence by the caregiver. RESULTS During the study period, oral corticosteroid prescriptions were written for 161 of 172 patients completing the phone interview (93.6%). Of these patients, 98.7% reported filling the prescription, with caregivers of female patients and adolescent patients less likely to fill prescriptions than caregivers of male and younger patients. Asthma patient caregivers, however, reported adherence to the prescribed length of oral corticosteroid therapy only 64% of the time. Caregivers worried about the side effects of oral corticosteroids 60% of the time. CONCLUSIONS Efforts to increase corticosteroid adherence in children with acute asthma exacerbations should consider the causes for variation in caregiver adherence with length of therapy as well as caregiver perceptions regarding corticosteroid side effects.
Collapse
Affiliation(s)
- Kelly Butler
- Division of Pediatric Emergency Medicine and The Vanderbilt Center for Health Services Research, Vanderbilt University, Nashville, TN, USA.
| | | |
Collapse
|
91
|
Abstract
PURPOSE OF REVIEW The incidence of atopic diseases, including atopic dermatitis, allergic rhinitis, and asthma, has increased in developed countries over the past several decades. These diseases comprise a large component of general pediatric practice. This review will highlight some of the recent advances in understanding the pathogenesis and natural history of these diseases, as well as the current approaches to the treatment of children with atopic diseases. RECENT FINDINGS Recent studies have identified multiple risk factors for the development and progression of atopic diseases. As a result, much research is focused on identifying therapies that can be initiated at a young age to prevent disease progression. New treatment options have become available in recent years, such as topical immunomodulators for atopic dermatitis, leukotriene antagonists for seasonal allergic rhinitis, and alpha-immunoglobulin E therapy for asthma. The importance of viewing allergic rhinitis and asthma as disorders of a single airway has been emphasized. Finally, an update on the national asthma guidelines was recently released in an effort to promote optimal asthma care. SUMMARY This review summarizes many of the recent advances in the diagnosis and treatment of atopic diseases in children. Although not intended to be a comprehensive review of this broad field, it provides a framework for appreciating the complexity of these diseases and for effectively managing them.
Collapse
Affiliation(s)
- Kelly D Stone
- Children's Hospital Boston, Department of Pediatrics, Harvard Medical School, Massachusetts, USA.
| |
Collapse
|