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Venegas M, Dudovitz R, Thompson L, Barry F, Holifield C, Flores-Vasquez J, Chang TP, Halterman J, Szilagyi P, Okelo S. Parent-Centered Perspectives on a Validated Asthma Questionnaire in the Emergency Department. Acad Pediatr 2024; 24:132-138. [PMID: 32058107 DOI: 10.1016/j.acap.2020.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 01/28/2020] [Accepted: 02/03/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although national asthma guidelines recommend use of validated questionnaires to improve asthma care, little is known about the extent to which these questionnaires are patient-centered. This qualitative study evaluated parent perceptions of a validated asthma questionnaire. METHODS We administered the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) to parents of children 2 to 17 years old presenting to a large urban pediatric ED for asthma care and assessed their perceptions of the tool's utility and acceptability via a structured interview. Responses were recorded, transcribed, and analyzed using a phenomenological approach. RESULTS Eighty-three parents participated. Qualitative analysis revealed 2 major themes (with 5 subthemes). The first major theme (and 3 subthemes) was that the PACCI-ED facilitated communication with the health care team and caregivers: improving communication 1) with ED providers, 2) in other settings such as schools, and 3) in the primary care setting where the relationship with primary care providers was felt to be variable. The second major theme (and 2 subthemes) was that the PACCI-ED increased parents' capacity to manage their child's asthma: by helping parents understand 1) what symptoms were related to asthma and 2) how those symptoms might change over time. CONCLUSIONS Parents perceive that the PACCI-ED is acceptable and useful for facilitating communication in the ED and other health care settings, and for building parent capacity to track and manage their child's asthma. A validated structured asthma questionnaire in the ED may facilitate patient-centered asthma care.
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Affiliation(s)
- Melanie Venegas
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Rebecca Dudovitz
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif.
| | - Lindsey Thompson
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Frances Barry
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Chloe Holifield
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Jessica Flores-Vasquez
- Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, University of Southern California (J Flores-Vasquez and TP Chang), Los Angeles, Calif
| | - Todd P Chang
- Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, University of Southern California (J Flores-Vasquez and TP Chang), Los Angeles, Calif
| | - Jill Halterman
- Division of General Pediatrics, Department of Pediatrics, University of Rochester School of Medicine (J Halterman), Rochester, NY
| | - Peter Szilagyi
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Sande Okelo
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
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Ravandi B, Thompson LR, Barry F, Pade KH, Chang TP, Halterman JS, Szilagyi PG, Okelo SO. Use of a validated asthma questionnaire to increase inhaled corticosteroid prescribing in the pediatric emergency department. J Asthma 2020; 59:378-385. [PMID: 33185486 DOI: 10.1080/02770903.2020.1841225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Asthma guidelines recommend assessment of asthma control and treatment with an ICS when appropriate. Children seen for asthma in the ED often have poorly controlled asthma. Validated questionnaires are rarely used in the ED and ICS are prescribed at less than 5% of ED asthma encounters, leaving many children at risk for continued poor outcomes. OBJECTIVE To determine if use of a validated asthma questionnaire can increase the proportion of children who receive an ICS prescription during an ED asthma visit. METHODS We administered a validated asthma questionnaire (Pediatric Asthma Control and Communication Instrument-ED version [PACCI-ED]) to parents of children 2 - 17 years old presenting for asthma care at a large, urban, academic pediatric ED. Based on national asthma guidelines, the PACCI-ED results were used to determine ICS dose recommendations. ED physicians reviewed the PACCI-ED results and ICS dose recommendations and chose whether to prescribe an ICS upon discharge. ICS prescribing rates during the intervention period were assessed via medical record review and compared to historical controls. We also surveyed parents to examine the association of sociodemographic factors with receipt of an ICS prescription, and surveyed physicians regarding their prescribing decisions. RESULTS Thirteen physicians and seventy-nine children participated. Historically, the ICS prescribing rate for asthma exacerbations discharged from the ED was 13%. The intervention increased ICS prescribing to 56% (p < 0.001). Children with ≥2 asthma exacerbations in the prior year (p < 0.02) and those with moderate-severe persistent asthma (p < 0.02) were more likely to receive an ICS prescription. There were no statistically significant differences in ICS prescribing by sociodemographic characteristics. CONCLUSION A validated asthma questionnaire increased ICS prescribing for children presenting for to the ED for asthma care. Additional strategies are needed to promote prescribing in this setting and ensure that all eligible children receive guideline-based asthma care.
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Affiliation(s)
- Bahareh Ravandi
- Pediatric Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,University of Southern California, Los Angeles, CA, USA
| | - Lindsey R Thompson
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Frances Barry
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kathryn H Pade
- UCSD, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Todd P Chang
- Pediatric Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Peter G Szilagyi
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Sande O Okelo
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Lu D, Qiao Y, Johnson KC, Wang J. Racial and ethnic disparities in meeting MTM eligibility criteria among patients with asthma. J Asthma 2016; 54:504-513. [PMID: 27676212 DOI: 10.1080/02770903.2016.1238927] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Asthma is one of the most frequently targeted chronic diseases in the medication therapy management (MTM) programs of the Medicare prescription drug (Part D) benefits. Although racial and ethnic disparities in meeting eligibility criteria for MTM services have been reported, little is known about whether there would be similar disparities among adults with asthma in the United States. METHODS Adult patients with asthma (age ≥ 18) from Medical Expenditure Panel Survey (2011-2012) were analyzed. Bivariate analyses were conducted to compare the proportions of patients who would meet Medicare MTM eligibility criteria between non-Hispanic Blacks (Blacks), Hispanics and non-Hispanic Whites (Whites). Survey-weighted logistic regression was performed to adjust for patient characteristics. Main and sensitivity analyses were conducted to cover the entire range of the eligibility thresholds used by Part D plans in 2011-2012. RESULTS The sample included 4,455 patients with asthma, including 2,294 Whites, 1,218 Blacks, and 943 Hispanics. Blacks and Hispanics had lower proportions of meeting MTM eligibility criteria than did Whites (P < 0.001). According to the main analysis, Blacks and Hispanics had 36% and 32% lower, respectively, likelihood of MTM eligibility than Whites (odds ratio [OR]: 0.64, 95% confidence interval [CI]: 0.45-0.90; OR: 0.68, 95% CI: 0.47-0.98, respectively). Similar results were obtained in sensitivity analyses. CONCLUSIONS There are racial and ethnic disparities in meeting Medicare Part D MTM eligibility criteria among adult patients with asthma. Future studies should examine the implications of such disparities on health outcomes of patients with asthma and explore alternative MTM eligibility criteria.
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Affiliation(s)
- Degan Lu
- a Department of Respiratory Medicine , Shandong Provincial Qianfoshan Hospital, Shandong University , Shandong , China
| | - Yanru Qiao
- b University of Tennessee College of Pharmacy , Memphis , TN , USA
| | - Karen C Johnson
- c Department of Preventive Medicine , University of Tennessee Health Science Center College of Medicine , Memphis , TN , USA
| | - Junling Wang
- b University of Tennessee College of Pharmacy , Memphis , TN , USA
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Charrois TL, Newman SC, Senthilselvan A, Tsuyuki RT. Improving Asthma Control in the Rural Setting: The BREATHE (Better Respiratory Education and Asthma Treatment in Hinton and Edson) Study. Can Pharm J (Ott) 2016. [DOI: 10.1177/171516350613900410] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Overuse of β-agonists is a risk factor for poor control of asthma. Pharmacists can identify high-risk patients through refill information and can then initiate disease-management programs for these patients. Methods: The Better Respiratory Education and Asthma Treatment in Hinton and Edson (BREATHE) study was a randomized, controlled trial in high-risk asthma patients. The intervention included an educational program (with focus on development of a written action plan), assessment of asthma therapy, and referral to a respiratory therapist and primary care physician. The primary objective was to determine the effect of this program (initiated by community pharmacists) on asthma control, as measured by the Asthma Control Questionnaire. Secondary objectives included determining the effect of the program on numbers of emergency department visits and hospital admissions, use of inhaled corticosteroids, courses of oral steroids, and lung function. Endpoints were measured at baseline, 2 months, and 6 months. Results: A total of 70 patients were randomized (34 to usual care, 36 to the intervention). At 6 months, there was no significant difference in asthma control between the usual care and inter-vention groups (change in ACQ score 0.33 and 0.43 respectively, p = 0.66). There were no significant differences in the secondary endpoints. Generally, pharmacist compliance with the intervention was poor. Conclusions: Although no differences were found in asthma control, this model, which uses a multidisciplinary, community-based approach, offers a unique management strategy for rural asthma patients. Can Pharm J 2006;139(4):44–50.
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Affiliation(s)
- Theresa L. Charrois
- Theresa L. Charrois is with the Department of Medicine; Stephen C. Newman is with the Department of Psychiatry; Ambikaipakan Senthilselvan is with the Department of Public Health Sciences; and Ross T. Tsuyuki is with the Department of Medicine, University of Alberta. Contact
| | - Stephen C. Newman
- Theresa L. Charrois is with the Department of Medicine; Stephen C. Newman is with the Department of Psychiatry; Ambikaipakan Senthilselvan is with the Department of Public Health Sciences; and Ross T. Tsuyuki is with the Department of Medicine, University of Alberta. Contact
| | - Ambikaipakan Senthilselvan
- Theresa L. Charrois is with the Department of Medicine; Stephen C. Newman is with the Department of Psychiatry; Ambikaipakan Senthilselvan is with the Department of Public Health Sciences; and Ross T. Tsuyuki is with the Department of Medicine, University of Alberta. Contact
| | - Ross T. Tsuyuki
- Theresa L. Charrois is with the Department of Medicine; Stephen C. Newman is with the Department of Psychiatry; Ambikaipakan Senthilselvan is with the Department of Public Health Sciences; and Ross T. Tsuyuki is with the Department of Medicine, University of Alberta. Contact
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Warman K, Silver E. A primary care-based asthma program improves recognition and treatment of persistent asthma in inner-city children compared to routine care. J Asthma 2016; 53:930-7. [PMID: 27187499 DOI: 10.3109/02770903.2016.1161051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine whether a primary care-based asthma program that applies the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-2007 criteria to classify asthma severity increases detection of persistent asthma in inner-city children and affects "step of care" compared to routine care. METHODS A retrospective chart review was conducted of 97 consecutive children referred to the asthma program from 2011-2013. Asthma severity documented during routine health care maintenance visits was compared to the asthma severity assessed during the asthma program visit using five standardized questions and spirometry. Medication plan "step of care" was compared pre- and post- the asthma program visit. RESULTS 79 children, ages 5-19 years old (mean = 9.6), had spirometry tracings meeting American Thoracic Society criteria and were included in this study. 53% were male. The majority of children were Latino (45.6%) or African American (35.4%). At the asthma program visit, more children were identified with moderate or severe persistent asthma based upon clinical questions (47.9%), spirometry (56.9%) or combined criteria (75.3%) than had been identified during routine care (15.2%); all p < .05. After the asthma program visit, more children were prescribed controller medications (82.3% vs 63.3%; p < .05) and 40.6% had their medication plan stepped up. CONCLUSIONS In this population of inner-city children, asthma severity was under-recognized and undertreated during routine care. A primary care based asthma program, which formalized applying EPR-3 criteria, increased detection of persistent asthma and led to "step-ups" in treatment plans.
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Affiliation(s)
- Karen Warman
- a Department of Pediatrics, The Children's Hospital at Montefiore , Albert Einstein College of Medicine , Bronx , NY , USA
| | - Ellen Silver
- a Department of Pediatrics, The Children's Hospital at Montefiore , Albert Einstein College of Medicine , Bronx , NY , USA
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Pardue Jones B, Fleming GM, Otillio JK, Asokan I, Arnold DH. Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit. J Asthma 2016; 53:607-17. [PMID: 27116362 DOI: 10.3109/02770903.2015.1067323] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The goal of this report is to review available modalities for assessing and managing acute asthma exacerbations in pediatric patients, including some that are not included in current expert panel guidelines. While it is not our purpose to provide a comprehensive review of the National Asthma Education and Prevention Program (NAEPP) guidelines, we review NAEPP-recommended treatments to provide the full range of treatments available for managing exacerbations with an emphasis on the continuum of care between the ER and ICU. DATA SOURCES We searched PubMed using the following search terms in different combinations: asthma, children, pediatric, exacerbation, epidemiology, pathophysiology, guidelines, treatment, management, oxygen, albuterol, β2-agonist, anticholinergic, theophylline, corticosteroid, magnesium, heliox, BiPAP, ventilation, mechanical ventilation, non-invasive mechanical ventilation and respiratory failure. We attempted to weigh the evidence using the hierarchy in which meta-analyses of randomized controlled trials (RCTs) provide the strongest evidence, followed by individual RCTs, followed by observational studies. We also reviewed the NAEPP and Global Initiative for Asthma expert panel guidelines. RESULTS AND CONCLUSIONS Asthma is the most common chronic disease of childhood, and acute exacerbations are a significant burden to patients and to public health. Optimal assessment and management of exacerbations, including appropriate escalation of interventions, are essential to minimize morbidity and prevent mortality. While inhaled albuterol and systemic corticosteroids are the mainstay of exacerbation management, escalation may include interventions discussed in this review.
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Affiliation(s)
| | | | | | | | - Donald H Arnold
- a Department of Pediatrics , Division of Emergency Medicine.,d Center for Asthma Research, Vanderbilt University School of Medicine , Nashville , TN , USA
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Gupta S, Awasthi S. Assessment of treatment pattern of childhood asthma reporting to outpatients’ facility of a tertiary care hospital in Lucknow, North India: A cross-sectional study. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2016. [DOI: 10.1016/j.cegh.2016.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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8
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Frey SM, Fagnano M, Halterman JS. Caregiver education to promote appropriate use of preventive asthma medications: what is happening in primary care? J Asthma 2015; 53:213-9. [PMID: 26288255 DOI: 10.3109/02770903.2015.1075549] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe actions taken by providers at primary care visits to promote daily use of preventive asthma medication, and determine whether patient or encounter variables are associated with the receipt of asthma medication education. METHODS As part of a larger study in Rochester, NY, caregivers of children (2-12 years old) with asthma were approached before an office visit for well-child, asthma-specific or other illness care from October 2009 to January 2013. Eligibility required persistent symptoms and a prescription for an inhaled asthma controller medication. Caregivers were interviewed within two weeks to discuss the health care encounter. RESULTS We identified 185 eligible children from six urban primary care offices (27% Black, 38% Hispanic, 65% Medicaid). Overall, 42% of caregivers reported a discussion of appropriate preventive medication use, fewer than 25% received an asthma action plan, and 17% reported "ideal" medication education (both discussing proper medication use and completing an asthma action plan); no differences were seen upon comparing well-child and asthma-specific visits with other visits. Well-child and asthma-specific visits together were more likely, compared with other visits, to include a recommendation for a follow-up visit (43% versus 23%, p = 0.007). No patient factors were associated with report of preventive medication education. CONCLUSIONS Guideline-recommended education for caregivers about preventive-asthma medication is not occurring in the majority of primary care visits for urban children with symptomatic persistent asthma. Novel methods to deliver asthma education may be needed to promote appropriate preventive medication use and reduce asthma morbidity.
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Affiliation(s)
- Sean M Frey
- a Department of Pediatrics , University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Maria Fagnano
- a Department of Pediatrics , University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
| | - Jill S Halterman
- a Department of Pediatrics , University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
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Harper FWK, Eggly S, Crider B, Kobayashi H, Kathleen RN, Meert L, Ball A, Penner LA, Gray H, Albrecht TL. Patient- and Family-Centered Care as an approach to reducing disparities in asthma outcomes in urban African American children: A review of the literature. J Natl Med Assoc 2015; 107:4-17. [PMID: 27269485 PMCID: PMC4901523 DOI: 10.1016/s0027-9684(15)30019-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We thank Cathy Eames (Director, Library Services, Detroit Medical Center) for valuable input and assistance with the search strategy. Funding for this research was supported by a grant from Children's Hospital of Michigan Research Foundation (Principal Investigator: Terrance L. Albrecht, Ph.D.). BACKGROUND Patient- and family-centered care (PFCC) has the potential to address disparities in access and quality of healthcare for African American pediatric asthma patients by accommodating and responding to the individual needs of patients and families. STUDY OBJECTIVES To identify and evaluate research on the impact of family-provider interventions that reflect elements of PFCC on reducing disparities in the provision, access, quality, and use of healthcare services for African American pediatric asthma patients. METHODS Electronic searches were conducted using PubMed, CINAHL, and Psyclnfo databases. Inclusion criteria were peer-reviewed, English-language articles on family-provider interventions that (a) reflected one or more elements of PFCC and (b) addressed healthcare disparities in urban African American pediatric asthma patients (≤18years). RESULTS Thirteen interventions or programs were identified and reviewed. Designs included randomized clinical trials, controlled clinical trials, pre- and post-interventions, and program evaluations. CONCLUSIONS Few interventions were identified as explicitly providing PFCC in a pediatric asthma context, possibly because of a lack of consensus on what constitutes PFCC in practice. Some studies have demonstrated that PFCC improves satisfaction and communication during clinical interactions. More empirical research is needed to understand whether PFCC interventions reduce care disparities and improve the provision, access, and quality of asthma healthcare for urban African American children. ELECTRONIC DATABASES USED PubMed, CINAHL, and Psyclnfo ABBREVIATIONS AA-African American: CCT-Controlled clinical trial; ED-Emergency Department; ETS-Environmental tobacco smoke; FCC- Family Centered Care; PFCC-Patient and Family Centered Care; RCT- Randomized, controlled trial.
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Affiliation(s)
- Felicity W K Harper
- Karmanos Cancer Institute Population Studies and Disparities Research Program, Department of Oncology, Wayne State University School of Medicine.
| | - Susan Eggly
- Karmanos Cancer Institute Population Studies and Disparities Research Program, Department of Oncology, Wayne State University School of Medicine
| | | | | | - R N Kathleen
- Children's Hospital of Michigan, Department of Pediatrics, Wayne State University School of Medicine
| | - L Meert
- Children's Hospital of Michigan, Department of Pediatrics, Wayne State University School of Medicine
| | - Allison Ball
- Children's Hospital of Michigan, Department of Pediatrics, Wayne State University School of Medicine
| | - Louis A Penner
- Karmanos Cancer Institute Population Studies and Disparities Research Program, Department of Oncology, Wayne State University School of Medicine
| | - Herman Gray
- Children's Hospital of Michigan, Department of Pediatrics, Wayne State University School of Medicine
| | - Terrance L Albrecht
- Karmanos Cancer Institute Population Studies and Disparities Research Program, Department of Oncology, Wayne State University School of Medicine
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Laforest L, Van Ganse É, Devouassoux G, Chatté G, Tamberou C, Belhassen M, Chamba G. [Deliberate interruptions and changes of dose of inhaled corticosteroids by asthma patients: "a community pharmacy study"]. Rev Mal Respir 2014; 32:8-17. [PMID: 25618199 DOI: 10.1016/j.rmr.2014.04.103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 04/13/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adherence to inhaled corticosteroids (ICS) remains a major issue for asthma management, even among patients receiving a regular prescription from their doctor. The frequency of deliberate interruption of ICS, and of spontaneous changes of dose, were studied in a population of asthma patients recruited in community pharmacies. METHODS Asthma patients (aged 18-50) recruited in community pharmacies reported in self-administered questionnaires their spontaneous interruptions and changes of doses of ICS during the past 3 months. The characteristics of patients who interrupted their therapy or who modified the dose were compared with other patients. RESULTS The studied population included 252 patients (mean age 35 year-old, females: 59%), of whom 62% had inadequately controlled asthma. Among these patients, 25% had interrupted ICS therapy during the past 3 months, while 21% spontaneously changed the dose. The most reported reason for interrupting ICS was the cessation of symptoms (50%). In multivariate analysis, interrupting ICS was mainly associated with inadequate asthma control (OR=3.1, 95% CI 1.5-6.4), while the strongest association with changing ICS doses was the patients' perception of asthma as a concern in their lives (OR=3.2, 95% CI 1.2-8.4). CONCLUSION These results underline a poor understanding of the purpose of ICS therapy by patients. They also highlight the need of therapeutic education to improve the management of the disease.
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Affiliation(s)
- L Laforest
- UMR 5558-CNRS, unité de pharmacoépidémiologie, faculté d'odontologie, 11, rue Guillaume-Paradin, 69372 Lyon cedex 08, France
| | - É Van Ganse
- UMR 5558-CNRS, unité de pharmacoépidémiologie, faculté d'odontologie, 11, rue Guillaume-Paradin, 69372 Lyon cedex 08, France; Service de pneumologie, hôpital de la Croix-Rousse, HCL, 69004 Lyon, France.
| | - G Devouassoux
- Service de pneumologie, hôpital de la Croix-Rousse, HCL, 69004 Lyon, France
| | | | - C Tamberou
- UMR 5558-CNRS, unité de pharmacoépidémiologie, faculté d'odontologie, 11, rue Guillaume-Paradin, 69372 Lyon cedex 08, France
| | - M Belhassen
- UMR 5558-CNRS, unité de pharmacoépidémiologie, faculté d'odontologie, 11, rue Guillaume-Paradin, 69372 Lyon cedex 08, France
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Abstract
There are three major problems with asthma care in the USA and misuse of asthma drug therapy contributes to each. Asthma patients suffer from symptoms regularly partly because healthcare providers do not understand the Expert Panel Report III (EPR3) recommendations on assessing asthma symptoms to determine drug treatment and, consequently, undertreat the disease. Asthma patients experience exacerbations often in part because the EPR3 provides limited guidance on using exacerbation risk to guide asthma treatment, again leading to undertreatment. The EPR3 recommends inhaled corticosteroids as the preferred therapy for mild persistent asthma but American healthcare providers disregard this recommendation based on different perceptions about the risks and benefits of inhaled corticosteroids and choose drug treatments with higher healthcare costs.
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Affiliation(s)
- Gene L Colice
- The George Washington University School of Medicine, Director, Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, 110 Irving St., NW, Washington, DC 20010, USA.
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Management of asthma: the current US and European guidelines. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 795:81-103. [PMID: 24162904 DOI: 10.1007/978-1-4614-8603-9_6] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Asthma management guidelines aim to improve the implementation of current knowledge into daily clinical practice by establishing a consensus of scientific practices for the management of asthma. Initial guidelines were based on consensus of expert opinion in order to employ a severity-based classification system as a guide to treatment. However, advances in asthma research led to the development of evidence-based guidelines and a major paradigm shift to control-based asthma management. Control-based management is central to the published guidelines developed by The National Heart, Lung, and Blood Institute (NHLBI), The Global Initiative for Asthma (GINA), and The British Thoracic Society (BTS), each one using the same volume of evidence but emphasizing aspects particular to their specific patient populations and socioeconomic needs. This chapter summarizes the evolution of these guidelines and summarizes the key points and evidence used in the recommendations for the assessment, monitoring, and management of asthma in all ages, with particular emphasis on the NHLBI guidelines.
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Sarpong EM, Miller GE. Racial and ethnic differences in childhood asthma treatment in the United States. Health Serv Res 2013; 48:2014-36. [PMID: 23800044 PMCID: PMC3876393 DOI: 10.1111/1475-6773.12077] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine racial-ethnic differences in asthma controller medication use among insured U.S. children. DATA SOURCES Linked nationally representative data from the Medical Expenditure Panel Survey (2005-2008), the 2000 Decennial Census, and the National Health Interview Survey (2004-2007). STUDY DESIGN The study quantifies the portion of racial-ethnic differences in children's controller use that are attributable to differences in need, enabling and predisposing characteristics. PRINCIPAL FINDINGS Non-Hispanic black and Hispanic children were less likely to use controllers than non-Hispanic white children. Blinder-Oaxaca decomposition results indicated that observable characteristics explain less than 40 percent of the overall differential in controller use between non-Hispanic whites and non-Hispanic blacks. In contrast, observable characteristics explain more than two-thirds (71.3 percent) of the overall non-Hispanic white-Hispanic differential in controller use. For non-Hispanic blacks, a majority of the explained differential in controller use were attributed to enabling characteristics. For Hispanics, a significant portion of the explained differential in controller use was attributed to predisposing characteristics. In addition, a larger portion of the differential in controller use was explained by observable characteristics for publicly insured non-Hispanic black and Hispanic children. CONCLUSIONS The large observed differences in controller use highlight the continuing challenges of ensuring that all U.S. children have access to quality asthma care.
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Affiliation(s)
- Eric M Sarpong
- Division of Modeling and Simulation, Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD
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Morishima T, Otsubo T, Gotou E, Kobayashi D, Lee J, Imanaka Y. Physician adherence to asthma treatment guidelines in Japan: focus on inhaled corticosteroids. J Eval Clin Pract 2013; 19:223-9. [PMID: 21689218 DOI: 10.1111/j.1365-2753.2011.01708.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Asthma treatment guidelines recommend inhaled corticosteroids (ICS) as the first-line therapy. However, ICS are prescribed to lower percentages of asthmatic patients in Japan than in other developed countries. The aim of this study was to reveal factors affecting the prescription of ICS for asthmatic adults. METHODS Using insurance claims data in Kyoto Prefecture, Japan, we performed a cross-sectional study. We assessed whether outpatients aged 15 years or older who were diagnosed with asthma had received ICS or not, and conducted logistic regression analyses to identify patients' and facilities' factors associated with ICS use. RESULTS We analysed 13,428 asthmatic adults, of which 51% were prescribed ICS. Patients receiving asthma care at facilities with respiratory or allergy specialists were more likely to receive ICS than facilities without specialists (adjusted odds ratio 2.70; 95% confidence interval 2.46-2.97). Those aged 75 years or older were less likely to receive ICS than those aged 15 to 64 (adjusted odds ratio 0.71; 95% confidence interval 0.64-0.78). An examination of the interaction between the presence or absence of specialists and facility training status suggested that whether asthmatic adults received ICS depended on the former factor rather than the latter. CONCLUSION The presence of specialists in facilities and the age of patients were strong factors affecting ICS prescription. Increases in ICS therapy for the elderly and ICS prescription by non-specialists would lead to an overall increase in patients receiving ICS and consequently achieving the goal of asthma control.
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Affiliation(s)
- Toshitaka Morishima
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan
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15
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Yee AB, Fagnano M, Halterman JS. Preventive asthma care delivery in the primary care office: missed opportunities for children with persistent asthma symptoms. Acad Pediatr 2013; 13:98-104. [PMID: 23294977 PMCID: PMC3602410 DOI: 10.1016/j.acap.2012.10.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 10/27/2012] [Accepted: 10/29/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe which National Heart Lung and Blood Institute preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery varies by asthma symptom severity. METHODS We approached children (2 to 12 years old) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit. RESULTS We identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009 to January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs non-asthma-related visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14-0.84), trigger reduction discussion (OR 0.39, 95% CI 0.19-0.82), recommendation of follow-up (OR 0.40, 95% CI 0.19-0.87), and receipt of action plan (OR 0.37, 95% CI 0.16-0.86). CONCLUSIONS Many children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.
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Affiliation(s)
- Alison B Yee
- Department of Pediatrics and the Strong Children's Research Center, University of Rochester School of Medicine and Dentistry, Rochester, NY 11642, USA.
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16
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Okelo SO, Eakin MN, Patino CM, Teodoro AP, Bilderback AL, Thompson DA, Loiaza-Martinez A, Rand CS, Thyne S, Diette GB, Riekert KA. The Pediatric Asthma Control and Communication Instrument asthma questionnaire: for use in diverse children of all ages. J Allergy Clin Immunol 2013; 132:55-62. [PMID: 23434285 DOI: 10.1016/j.jaci.2013.01.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 12/22/2012] [Accepted: 01/03/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND National Institutes of Health asthma guidelines recommend questionnaires to assess asthma control, but these questionnaires are not useable across the entire pediatric age spectrum and have not been validated among significant numbers of minority or Spanish-speaking children. OBJECTIVE We sought to evaluate a questionnaire designed to assess asthma control across a broad age range of minority and Spanish-speaking children cared for in an outpatient setting. METHODS Between July 1, 2007, and September 30, 2010, we collected information using the Pediatric Asthma Control and Communication Instrument (PACCI), the Asthma Control Test (ACT; or the childhood ACT for children 4-11 years old), the Pediatric Asthma Caregiver Quality of Life Questionnaire, and lung function and clinicians' ratings of asthma status among a population of children presenting for routine asthma specialist care. The PACCI measure of asthma control was validated by evaluating accuracy, internal reliability, and concurrent, discriminative, and known-groups validity. RESULTS We collected information on 265 English- and 52 Spanish-speaking children (mean age, 8.2 years; 58% male; 44% African American). Across all age groups and in both languages, PACCI control showed good internal reliability and strong concurrent, discriminative, and known-groups validity with ACT and Pediatric Asthma Caregiver Quality of Life Questionnaire scores and clinicians' ratings of asthma control. The accuracy of the PACCI in classifying children with uncontrolled asthma was good (area under the curve, 0.83; 95% CI, 0.79-0.88). CONCLUSIONS The PACCI accurately measures asthma control in English- and Spanish-speaking children. The PACCI should be useful to clinicians to assess and classify asthma according to National Institutes of Health asthma guidelines.
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Affiliation(s)
- Sande O Okelo
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
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Latzke-Davis B, Stout J, Smith K, Solomon C, Garrison M, Mangione-Smith R. Effectiveness of Spirometry Fundamentals™ for increasing the proper use of spirometry in patients with asthma and COPD. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2012; 20:441-7. [PMID: 21922125 DOI: 10.4104/pcrj.2011.00080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIM To examine whether exposure to the Spirometry Fundamentals™ CD-ROM results in improved quality of spirometry testing in primary care. METHODS Spirometry tests performed in 20 intervention and 19 control practices were analysed using American Thoracic Society grades A and B for 'passing' and grades C, D and F for 'failing'. Intervention effects on spirometry quality were assessed using random effects multivariate logistic regression. RESULTS Adjusted analyses revealed no intervention effect. The likelihood of passing tests was higher in paediatrics-only practices (adjusted odds ratio (AOR) 2.60, 95% confidence interval (CI) 1.32 to 5.12; p=0.01). Hospital or university-based clinics had a lower performance than private or community-based practices in unadjusted analysis (7% vs. 22% passing tests; p=0.05). However, this relationship was not significant in adjusted analyses. CONCLUSIONS Spirometry Fundamentals™ is insufficient to improve the quality of spirometry in primary care, suggesting the need for more comprehensive multifaceted training resources.
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Affiliation(s)
- Brooke Latzke-Davis
- Center for Child Health, Behavior and Development, Seattle Children's Hospital Research Institute, Seattle, Washington 98101, USA.
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18
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Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are common diseases which cause patients and society considerable difficulties. These are costly diseases which cause substantial morbidity and death. Health care policy makers have made improving outcomes in asthma and COPD a priority. Application of guideline recommended approaches to asthma and COPD care in the real-life setting has been emphasized but outcomes have not improved. Failure to improve outcomes may not be because of inconsistent applications of guideline recommendations, but rather because there are difficulties implementing the Expert Panel Report III (EPR 3) method for categorizing asthma severity and the Global Initiative for Obstructive Lung Disease (GOLD) method for diagnosing COPD. As these serve as the foundation for treatment recommendations for these diseases, alternative approaches should be considered for categorizing asthma severity and identifying COPD patients. Claims-based algorithms provide an intriguing option for identifying persistent asthma patients and symptomatic COPD patients in administrative databases. These methods could be used as the basis for pragmatic research, both retrospective and prospective, on assessing outcomes of guideline recommended treatment approaches in asthma and COPD. Important questions urgently need to be answered about how guideline recommended approaches regarding use of long-acting inhaled β-agonist/inhaled corticosteroid (LABA/ICS) in asthma and long-acting inhaled anti-muscarinic agent (LAMA) and LABA/ICS in COPD affect outcomes in real-life situations.
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Affiliation(s)
- Gene L Colice
- The George Washington University School of Medicine, Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, Washington DC, USA
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19
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The CHOICE survey: high rates of persistent and uncontrolled asthma in the United States. Ann Allergy Asthma Immunol 2012; 108:157-62. [DOI: 10.1016/j.anai.2011.12.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 12/29/2011] [Accepted: 12/29/2011] [Indexed: 11/24/2022]
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20
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Stout JW, Smith K, Zhou C, Solomon C, Dozor AJ, Garrison MM, Mangione-Smith R. Learning from a distance: effectiveness of online spirometry training in improving asthma care. Acad Pediatr 2012; 12:88-95. [PMID: 22424397 DOI: 10.1016/j.acap.2011.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 11/15/2011] [Accepted: 11/19/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We evaluated the effectiveness of a virtually delivered quality improvement (QI) program designed to improve primary care management for children with asthma. METHODS Thirty-six physicians, nurses, and medical assistants from 14 primary care pediatric practices (7 matched practice pairs) participated in a cluster randomized trial from October 2007 to September 2008. All practices received a spirometer and standard vendor training. A 7-month QI program delivered during the study period included: 1) Spirometry Fundamentals™ CD-ROM, a multimedia tutorial; 2) case-based, interactive webinars led by clinical experts; and 3) an internet-based spirometry quality feedback reporting system. Practice pairs were compared directly to each other, and between-group differences were analyzed with the use of mixed effects regression models. Our main outcome measures were the frequency of spirometry testing, percentage of acceptable quality spirometry tests, asthma severity documentation, and appropriate controller medication prescribing. RESULTS Participating practices uploaded a total of 1028 spirometry testing sessions, of which 340 (33.1%) were of acceptable quality. During the 7-month intervention period, there was no difference between intervention and control practices in the frequency of spirometry tests performed. Intervention practices were estimated to have significantly greater odds of conducting tests with acceptable quality compared with matched control practices, adjusting for quality in the baseline period (odds ratio 2.85; 95% confidence interval 1.78-4.56, P < .001). Intervention providers also had significantly greater odds of documenting asthma severity during the intervention period (odds ratio 2.9, 95% confidence interval 1.8-4.5; P < .001). Although use of controller medications among patients with persistent asthma approached 100% for both groups, the proportion of asthma patients labeled as persistent increased from 43% to 62% among intervention practices, and decreased from 57% to 50% among controls (NS). CONCLUSIONS A multifaceted distance QI program resulted in increased spirometry quality and improved assessment of asthma severity levels. Successful participation in QI programs can occur over distance.
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Affiliation(s)
- James W Stout
- Department of Pediatrics and Health Services, University of Washington, Seattle, USA.
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21
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Lim KG, Rank MA, Cabanela RL, Furst JW, Rohrer JE, Liesinger J, Muller L, Wagie AE, Naessens JM. The asthma ePrompt: a novel electronic solution for chronic disease management. J Asthma 2012; 49:213-8. [PMID: 22304226 DOI: 10.3109/02770903.2012.654419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study tested the ability of an electronic prompt to promote an asthma assessment during primary care visits. METHODS We performed a prospective study of all eligible adult patients with previously diagnosed asthma in three geographically distinct ambulatory family medicine clinics within a 4-month period. The usual clinic visit process was performed at two geographically distinct control sites (n = 75 and n = 55 patients, respectively). The intervention group site (n = 64) had an electronic flag embedded in the Patient Check-in Locator field which prompted the distribution of a self-administered Asthma Management Questionnaire (AMQ) in the waiting room. The primary outcome measure was a documented asthma severity assessment. RESULTS The front desk distributed the AMQ successfully in 100% of possible opportunities and the AMQ was completed by 84% of patients. Providers in the intervention group were significantly more likely than providers in the two non-intervention groups to document asthma severity in the medical record during a non-asthma ambulatory clinic visit (63.3% vs. 18.7% vs. 3.6%; p < .001). CONCLUSION The provision of standardized asthma information triggered by an electronic prompt at the time of check-in effectively initiates an asthma assessment during the primary care visits.
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Affiliation(s)
- Kaiser G Lim
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Diette GB, Fuhlbrigge AL, Allen-Ramey F, Hopper A, Sajjan SG, Markson LE. Asthma Severity in patients initiating controller monotherapy versus combination therapy. J Asthma 2011; 48:304-10. [PMID: 21391882 DOI: 10.3109/02770903.2011.555034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Asthma treatment guidelines recommend medications based on the level of asthma control. OBJECTIVE To evaluate differences in asthma control between patients who initiated asthma controller monotherapy versus combination therapy. PATIENTS AND METHODS Children (5-16 years; n = 488) and adults (17-80 years; n = 530) with asthma and no controller therapy in the prior 6 months were included. Telephone surveys were conducted within 5 days of filling a new asthma controller prescription with either the caregiver of children or the adult patient. Demographics, asthma control before therapy, and asthma-related resource use were assessed for patients initiating monotherapy (filling one asthma controller prescription) and combination therapy (filling more than one controller medication or a fixed-dose combination). RESULTS Mean pediatric age was 10 years; 53% were male. Mean adult age was 47 years; 25% were male. There were no significant differences in asthma control score between patients receiving monotherapy and combination therapy. Children on combination therapy did not have more nighttime awakening or short-acting β-agonist use but were more likely to have been hospitalized due to asthma attack (p = .05) and have more unscheduled (p = .0374) and scheduled (p = .009) physician visits. Adults on combination therapy were more likely to have been hospitalized due to asthma attack (p < .05) and have regular doctor visits for asthma (p < .01). CONCLUSIONS Assessment of asthma control scores in the 4 weeks before index medication suggests that asthma severity during a treatment-free period did not differ significantly for patients initiating controller monotherapy versus combination therapy. From these findings, it appears that although physicians may not focus on asthma control when choosing the intensity of initial controller therapy, the intensity of health-care encounters may be an influence.
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Affiliation(s)
- Gregory B Diette
- Pulmonary and Critical Care Medicine, The Johns Hopkins University, Baltimore, MD 21205, USA.
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Zolnoori M, Zarandi MHF, Moin M, Teimorian S. Fuzzy rule-based expert system for assessment severity of asthma. J Med Syst 2010; 36:1707-17. [PMID: 21128097 DOI: 10.1007/s10916-010-9631-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 11/16/2010] [Indexed: 10/18/2022]
Abstract
Prescription medicine for asthma at primary stages is based on asthma severity level. Despite major progress in discovering various variables affecting asthma severity levels, disregarding some of these variables by physicians, variables' inherent uncertainty, and assigning patients to limited categories of decision making are the major causes of underestimating asthma severity, and as a result low quality of life in asthmatic patients. In this paper, we provide a solution of intelligence fuzzy system for this problem. Inputs of this system are organized in five modules of respiratory symptoms, bronchial obstruction, asthma instability, quality of life, and asthma severity. Output of this system is degree of asthma severity in score (0-10). Evaluating performance of this system by 28 asthmatic patients reinforces that the system's results not only correspond with evaluations of physicians, but represent the slight differences of asthmatic patients placed in specific category introduced by guidelines.
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Affiliation(s)
- Maryam Zolnoori
- Department of Information Technology Management, Tarbiat Modares University, Tehran, Iran.
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Yoo KH, Jeong JW, Yoon HJ, Chang SI, Moon HB, Choi BH, Kim YY, Cho SH. Customized Asthma Control Test with reflection on sociocultural differences. J Korean Med Sci 2010; 25:1134-9. [PMID: 20676322 PMCID: PMC2908780 DOI: 10.3346/jkms.2010.25.8.1134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 02/04/2010] [Indexed: 11/20/2022] Open
Abstract
We evaluated the utility and feasibility of customizing Asthma Control Test (ACT) items to generate a Korean Asthma Control Test (KACT) specific for Korean patients. We surveyed 392 asthma patients with 19 items, selected to reflect the Korean sociocultural context. Guideline ratings were integrated with the evaluations of specialists (i.e., using both guide base rating together with specialist's rating), and items with the greatest discriminating validity were identified. Stepwise regression methods were used to select items. KACT scale scores showed significant differences between the asthma control ratings generated by integrating ratings (r=0.77, P<0.001), by specialist's evaluations (r=0.54, P<0.001), or by FEV(1) percent predicted (r=0.39, P<0.001). Specialist's and guideline ratings detected 56% and 48.6% of patients with well-controlled asthma, respectively. However, the integrated ratings indicated that only 34.3% of the patients in the test sample were well controlled. The overall agreement between KACT and the integrated rating ranged from 45% to 78%, depending on the cut-off points used. It is possible to formulate a valid, useful country-specific diagnostic tool for the assessment of asthma patients based on the original ACT that reflect differences in sociocultural context.
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Affiliation(s)
- Kwang-Ha Yoo
- Department of Internal Medicine, Konkuk University College of Medicine, Seoul, Korea
- Asthma Allergy Foundation, Seoul, Korea
| | - Jae-Won Jeong
- Asthma Allergy Foundation, Seoul, Korea
- Department of Internal Medicine, Inje University College of Medicine, Ilsan, Korea
| | - Ho-Joo Yoon
- Asthma Allergy Foundation, Seoul, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Suk-Il Chang
- Asthma Allergy Foundation, Seoul, Korea
- Department of Internal Medicine, Sung-Ae General Hospital, Bucheon, Korea
| | - Hee-Bom Moon
- Asthma Allergy Foundation, Seoul, Korea
- Department of Medicine and CPI (Clinical Performance Improvement), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byoung-Hwui Choi
- Asthma Allergy Foundation, Seoul, Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - You-Young Kim
- Asthma Allergy Foundation, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Institute of Allergy & Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Sang-Heon Cho
- Asthma Allergy Foundation, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Institute of Allergy & Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
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Glick SB, Fernandez L, Irby DM, Harleman E, Fernandez A. Teaching about health care disparities in the clinical setting. J Gen Intern Med 2010; 25 Suppl 2:S95-101. [PMID: 20352501 PMCID: PMC2847100 DOI: 10.1007/s11606-009-1203-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Clinical teachers often observe interactions that may contribute to health care disparities, yet may hesitate to teach about them. A pedagogical model could help faculty structure teaching about health care disparities in the clinical setting, but to our knowledge, none have been adapted for this purpose. In this paper, we adapt an established model, Time-Effective Strategies for Teaching (TEST), to the teaching of health care disparities. We use several case scenarios to illustrate the core components of the model: diagnose the learner, teach rapidly to the learner's need, and provide feedback. The TEST model is straightforward, easy to use, and enables the incorporation of teaching about health care disparities into routine clinical teaching.
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Affiliation(s)
- Susan B Glick
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA.
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Roxo JPF, Ponte EV, Ramos DCB, Pimentel L, D'Oliveira Júnior A, Cruz ÁA. Validação do Teste de Controle da Asma em português para uso no Brasil: validation for use in Brazil. J Bras Pneumol 2010; 36:159-66. [DOI: 10.1590/s1806-37132010000200002] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 11/17/2009] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Desenvolver e validar uma versão do Asthma Control Test (ACT, Teste de Controle da Asma) em português para uso no Brasil. MÉTODOS: Foram estudados 290 pacientes ambulatoriais com asma maiores que 12 anos. Os pacientes responderam ao ACT e foram examinados por um pneumologista para avaliar o controle da asma em duas visitas. Na primeira visita, também realizaram prova de função pulmonar. A segunda visita foi realizada ao menos quatro semanas depois da primeira. RESULTADOS: Utilizando-se como ponto de corte um escore de 18 para diferenciar asma controlada de asma não controlada, foram encontradas sensibilidade de 93%, especificidade de 74%, valor preditivo negativo de 86% e valor preditivo positivo de 85%. As razões de verossimilhança positiva e negativa foram, respectivamente, 3,58 e 0,09. O questionário tem grande capacidade de discriminar asma controlada de asma não controlada, com uma área sob a curva ROC de 0,904. Os pacientes que mantiveram os sintomas estáveis na segunda avaliação tiveram pontuação semelhante no questionário, indicando uma boa reprodutibilidade teste-reteste, com um coeficiente de correlação intraclasse de 0,93. Os pacientes que melhoraram os sintomas na segunda avaliação tiveram pontuação do questionário significativamente melhor, indicando uma boa responsividade do questionário para identificar mudanças no controle da doença. CONCLUSÕES: A versão em português do ACT apresentou boa reprodutibilidade teste-reteste e foi capaz de discriminar o nível de controle da asma, assim como detectar mudanças no controle da asma em uma população de baixa escolaridade e renda familiar em um serviço público de saúde no Brasil.
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Arnold DH, Jenkins CA, Hartert TV. Noninvasive assessment of asthma severity using pulse oximeter plethysmograph estimate of pulsus paradoxus physiology. BMC Pulm Med 2010; 10:17. [PMID: 20350320 PMCID: PMC2855526 DOI: 10.1186/1471-2466-10-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 03/29/2010] [Indexed: 12/01/2022] Open
Abstract
Background Pulsus paradoxus estimated by dynamic change in area under the oximeter plethysmograph waveform (PEP) might provide a measure of acute asthma severity. Our primary objective was to determine how well PEP correlates with forced expiratory volume in 1-second (%FEV1) (criterion validity) and change of %FEV1 (responsiveness) during treatment in pediatric patients with acute asthma exacerbations. Methods We prospectively studied subjects 5 to 17 years of age with asthma exacerbations. PEP, %FEV1, airway resistance and accessory muscle use were recorded at baseline and at 2 and 4 hours after initiation of corticosteroid and bronchodilator treatments. Statistical associations were tested with Pearson or Spearman rank correlations, logistic regression using generalized estimating equations, or Wilcoxon rank sum tests. Results We studied 219 subjects (median age 9 years; male 62%; African-American 56%). Correlation of PEP with %FEV1 demonstrated criterion validity (r = - 0.44, 95% confidence interval [CI], - 0.56 to - 0.30) and responsiveness at 2 hours (r = - 0.31, 95% CI, - 0.50 to - 0.09) and 4 hours (r = - 0.38, 95% CI, - 0.62 to - 0.07). PEP also correlated with airway resistance at baseline (r = 0.28 for ages 5 to 10; r = 0.45 for ages 10 to 17), but not with change over time. PEP was associated with accessory muscle use (OR 1.16, 95% CI, 1.11 to 1.21, P < 0.0001). Conclusions PEP demonstrates criterion validity and responsiveness in correlations with %FEV1. PEP correlates with airway resistance at baseline and is associated with accessory muscle use at baseline and at 2 and 4 hours after initiation of treatment. Incorporation of this technology into contemporary pulse oximeters may provide clinicians improved parameters with which to make clinical assessments of asthma severity and response to treatment, particularly in patients who cannot perform spirometry because of young age or severity of illness. It might also allow for earlier recognition and improved management of other disorders leading to elevated pulsus paradoxus.
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Affiliation(s)
- Donald H Arnold
- Departments of Pediatrics and Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
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O'Byrne PM, Reddel HK, Colice GL. Does the current stepwise approach to asthma pharmacotherapy encourage over-treatment? Respirology 2010; 15:596-602. [PMID: 20384969 DOI: 10.1111/j.1440-1843.2010.01728.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
For the past 20 years, asthma pharmacotherapy has been described in clinical practice guidelines in terms of a stepwise approach, with medications and/or doses increased if asthma is not well-controlled, and reduced once good control is achieved and maintained. Although many patients with asthma are untreated, there are also significant problems with over-treatment once regular controller therapy is commenced. This increases the cost of treatment and exposes patients to unnecessary risks of side-effects. The present pro-con debate addresses the question of whether the stepwise approach itself leads to over-treatment. Two asthma experts discuss factors for and against this proposition, identify issues on which more research is needed, and suggest areas in which guidelines can be changed in order to facilitate more appropriate prescribing of asthma medications. These strategies include better validation of the concepts underlying asthma treatment recommendations, stronger recommendations that every treatment change should be followed up with a scheduled review using evidence-based assessment tools and incorporation of phenotype-specific considerations into treatment recommendations. In addition, the process for development and dissemination of clinical practice guidelines should ensure that recommendations are easily understood, feasible to implement, and relevant to everyday asthma care and the needs and concerns of patients and clinicians.
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Affiliation(s)
- Paul M O'Byrne
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Abstract
PURPOSE OF REVIEW To highlight recent literature that informs our understanding of severe asthma. Severe asthma is an increasingly important part of specialty practice, is responsible for disproportionate healthcare utilization, and contributes significantly to the costs of care. Better recognition of this subset of asthma can lead to improved healthcare. RECENT FINDINGS Key recent observations in severe asthma include demographic characterizations of several large study populations and the increasing understanding that relative steroid resistance is a virtually universal feature. In addition, strong associations with interleukin-13 and mammalian chitinase have emerged, and abnormalities of endogenous anti-inflammatory pathways have been examined. The role of protein biomarkers to identify and delineate severe asthma is now being investigated. The pathogenic significance of each of these observations is still being clarified, but it appears that severe asthma may have mechanistic underpinnings distinct from that of mild or moderate asthma. SUMMARY Severe asthma is a discrete, but variably defined phenotype of asthma. Steroid resistance is extremely common, patients may require doses of inhaled steroids for control that exceed usual guidelines and may also require multiple controller agents. New mechanistic insights could provide important avenues for novel therapeutic interventions.
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Chan M, Sitaraman S, Dosanjh A. Asthma control test and peak expiratory flow rate: independent pediatric asthma management tools. J Asthma 2010; 46:1042-4. [PMID: 19995144 DOI: 10.3109/02770900903331101] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Management of asthma reflects the complexity of the pathogenesis. According to current National Heart Lung Blood Institute (NHLBI) guidelines, asthma control can be assessed using the validated asthma control test, measures of airway function, and overall assessment of risk and quality of life. We hypothesized that the asthma control test and measures of airway function are independent tools in asthma management. We also studied whether the presence of nasal symptoms is correlated to these measures. METHODS Serial visits (n = 45) to a pediatric respiratory clinic in an underserved area of San Diego County with a predominantly Hispanic population were reviewed. Patients were included if they were able to perform airway function tests and had more than one provider visit. Patients with other major diseases were excluded. We determined whether uncontrolled asthmatics, defined as an Asthma Control test (ACT) score of 19 or less, had lower % predicted peak expiratory flow Measurements as a group compared to those with higher scores. In addition, the individual ACT and airway function results were analyzed. Patients with and without nasal symptoms at the time of presentation were sub-analyzed to determine differences in ACT and peak flow measurements. RESULTS Based on n = 45 physician visits, the mean ACT score was 21 +/- 3.3 (range 12-25) and the mean peak expiratory flow rate (PEFR) was 87.4% +/- 11 (range 65-109%). Patients with ACT scores < or = to 19 or lower (< or = 90%) PEFRs were determined not to have more nasal symptoms. The measures of ACT and peak expiratory flow were independent and not correlated. CONCLUSIONS Our study indicates that ACT and PEFR are distinct parameters used to manage patients in a pediatric outreach asthma clinic.
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Affiliation(s)
- M Chan
- Department of Pediatrics, University of California School of Medicine, La Jolla, California, USA
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Renzi PM, Howard LA, Ortega HG, Ahmad FF, Chapman KR. Low-dose fluticasone propionate with and without salmeterol in steroid-naïve patients with mild, uncontrolled asthma. Respir Med 2009; 104:510-7. [PMID: 19944581 DOI: 10.1016/j.rmed.2009.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 10/29/2009] [Accepted: 10/29/2009] [Indexed: 12/30/2022]
Abstract
BACKGROUND The role of combination ICS/LABA as initial controller therapy in mild, persistent asthma is uncertain. Therefore, the objective of this study was to compare the efficacy of initial controller therapy with fluticasone propionate (FP) 100 microg twice daily to the efficacy of fluticasone propionate/salmeterol xinafoate (FSC) 100/50 microg twice daily in patients with persistent asthma symptoms while using as-needed SABA alone. METHODS This randomized, double-blind, parallel-group study was conducted at 45 general practice and 15 specialist centers. A total of 526 adult patients were randomized to receive FP or FSC for 24 weeks. The primary efficacy endpoint was change in morning peak expiratory flow (PEF) from baseline. Secondary efficacy endpoints included symptom- and rescue-free days; asthma exacerbation rate; asthma-related health-care utilization; and the onset of effect. Safety was assessed by monitoring adverse events. RESULTS Mean morning PEF was significantly greater in the FSC versus the FP group (P<0.001); this greater effect was evident as early as the first week of treatment (P<0.001). The percentages of symptom-free days and rescue-free days in the FSC group were 7.7% (P=0.009) and 8.4% (P=0.001) higher than the FP group, respectively. Trends toward lower exacerbation-related health care-utilization for FSC versus FP were not statistically significant and exacerbation rates were not significantly different. The incidence of adverse events was low with both treatments. CONCLUSIONS :Treatment with FSC was a more effective initial controller therapy than FP monotherapy in ICS-naïve patients who had uncontrolled asthma while using as-needed SABA alone.
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Crocker D, Brown C, Moolenaar R, Moorman J, Bailey C, Mannino D, Holguin F. Racial and ethnic disparities in asthma medication usage and health-care utilization: data from the National Asthma Survey. Chest 2009; 136:1063-1071. [PMID: 19567492 DOI: 10.1378/chest.09-0013] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Despite the availability of effective treatment, minority children continue to experience disproportionate morbidity from asthma. Our objective was to identify and characterize racial and ethnic disparities in health-care utilization and medication usage among US children with asthma in a large multistate asthma survey. METHODS We analyzed questions from the 2003-2004 four-state sample of the National Asthma Survey to assess symptom control, medication use, and health-care utilization among white, black, and Hispanic children < 18 years old with current asthma who were residing in Alabama, California, Illinois, or Texas. RESULTS Of the 1,485 children surveyed, 55% were white, 25% were Hispanic, and 20% were black. Twice as many black children had asthma-related ED visits (39% vs 18%, respectively; p < 0.001) and hospitalizations (12% vs 5%, respectively; p = 0.02) compared with white children. Significantly fewer black and Hispanic children reported using inhaled corticosteroids (ICSs) in the past 3 months (21% and 22%, respectively) compared to white children (33%; p = 0.001). Additionally, 26% of black children and 19% of Hispanic children reported receiving a daily dose of a short-acting beta-agonist compared with 12% of white children (p = 0.001). ED visits were positively correlated with short-acting beta-agonist use and were negatively correlated with ICS use when stratified by race/ethnicity. CONCLUSIONS Children with asthma in this large, multistate survey showed a dramatic underuse of ICSs. Black and Hispanic children compared with white children had more indicators of poorly controlled asthma, including increased emergency health-care utilization, more daily rescue medication use, and lower use of ICSs, regardless of symptom control.
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Affiliation(s)
- Deidre Crocker
- Air Pollution and Respiratory Health Branch, Centers for Disease Control and Prevention, Atlanta GA.
| | - Clive Brown
- Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta GA
| | - Ronald Moolenaar
- Division of Global Public Health Capacity Development, Centers for Disease Control and Prevention, Atlanta GA
| | - Jeanne Moorman
- Air Pollution and Respiratory Health Branch, Centers for Disease Control and Prevention, Atlanta GA
| | - Cathy Bailey
- Air Pollution and Respiratory Health Branch, Centers for Disease Control and Prevention, Atlanta GA
| | - David Mannino
- Division of Pulmonary and Critical Care Medicine, University of Kentucky, Lexington KY
| | - Fernando Holguin
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
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Dallinga JW, Robroeks CMHHT, van Berkel JJBN, Moonen EJC, Godschalk RWL, Jöbsis Q, Dompeling E, Wouters EFM, van Schooten FJ. Volatile organic compounds in exhaled breath as a diagnostic tool for asthma in children. Clin Exp Allergy 2009; 40:68-76. [PMID: 19793086 DOI: 10.1111/j.1365-2222.2009.03343.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The correct diagnosis of asthma in young children is often hard to achieve, resulting in undertreatment of asthmatic children and overtreatment in transient wheezers. OBJECTIVES To develop a new diagnostic tool that better discriminates between asthma and transient wheezing and that leads to a more accurate diagnosis and hence less undertreatment and overtreatment. A first stage in the development of such a tool is the ability to discriminate between asthmatic children and healthy controls. The integrative analysis of large numbers of volatile organic compounds (VOC) in exhaled breath has the potential to discriminate between various inflammatory conditions of the respiratory tract. METHODS Breath samples were obtained and analysed for VOC by gas chromatography-mass spectrometry from asthmatic children (n=63) and healthy controls (n=57). A total of 945 determined compounds were subjected to discriminant analysis to find those that could discriminate diseased from healthy children. A set of samples from both asthmatic and healthy children was selected to construct a model that was subsequently used to predict the asthma or the healthy status of a test group. In this way, the predictive value of the model could be tested. MEASUREMENTS AND MAIN RESULTS The discriminant analyses demonstrated that asthma and healthy groups are distinct from one another. A total of eight components discriminated between asthmatic and healthy children with a 92% correct classification, achieving a sensitivity of 89% and a specificity of 95%. Conclusion The results show that a limited number of VOC in exhaled air can well be used to distinguish children with asthma from healthy children.
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Affiliation(s)
- J W Dallinga
- Department of Health Risk Analysis and Toxicology, Nutrition and Toxicology Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
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Emanuel IA, Parker MJ, Traub O. Undertreatment of allergy: exploring the utility of sublingual immunotherapy. Otolaryngol Head Neck Surg 2009; 140:615-21. [PMID: 19393398 DOI: 10.1016/j.otohns.2009.01.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Revised: 01/06/2009] [Accepted: 01/15/2009] [Indexed: 10/20/2022]
Abstract
Allergic syndromes are highly prevalent and are comprised of a wide variety of clinical problems, including rhinitis, conjunctivitis, atopic dermatitis and urticaria, asthma, and food allergies. Numerous studies have shown that allergic syndromes are both underdiagnosed and undertreated. This is related to many factors, including trivialization of allergic conditions by physicians and patients, failure to adhere to diagnostic and treatment guidelines, and dissatisfaction with conventional pharmacologic treatments. Immunotherapy involves the administration of allergen extracts in an attempt to induce immunologic tolerance and has been used for the treatment of allergic syndromes and the prevention of long-term complications. Conventional subcutaneous immunotherapy is effective but is also associated with a risk of serious adverse events, requires administration by a trained health care professional, and is contraindicated in certain populations. By contrast, sublingual immunotherapy has been used extensively in Europe and possesses most of the benefits of subcutaneous immunotherapy along with increased safety, tolerability, and convenience. This narrative review explores data from selected clinical studies and concludes that sublingual immunotherapy may be well suited to fill the gap posed by the undertreatment of allergic syndromes in the United States.
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Affiliation(s)
- Ivor A Emanuel
- Department of Otolaryngology, University of California San Francisco, San Francisco, CA, USA.
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Nichols B, Scott L, Jones S, Kwong K, Morphew T, Jones CA. Detection of undiagnosed and poorly controlled asthma in a hospital-based outpatient pediatric primary care clinic using a health risk assessment system. J Asthma 2009; 46:498-505. [PMID: 19544172 DOI: 10.1080/02770900902866776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the rate of undiagnosed and poorly controlled asthma detected by a computerized health risk assessment (HRA) survey system in an urban pediatric hospital-based outpatient teaching clinic. METHODS A software-based HRA system uses survey answer patterns to identify children with (1) probable, (2) uncontrolled, and (3) moderate to severe asthma. Parents of patients > or = 2 years of age were asked by clinic staff to complete the touch screen computer survey before seeing their physician from August 2005 through July 2006. RESULTS The HRA survey predicted 26% (282/1,098) to have probable asthma. Of these, 51% (144/282) were controlled and the parents reported a previous diagnosis of asthma; 14% (40/282) were controlled and the parents did not report a previous diagnosis of asthma; 25% (71/282) were uncontrolled and the parents reported a previous diagnosis of asthma; and 10% (27/282) were uncontrolled and no previous diagnosis of asthma was reported by the parents. Among active cases completing the baseline version survey (N = 217), 68% reported emergency department (ED) visits / hospitalizations in the last 2 years (44% > or =2), while 59% reported missed school days during the previous year (23% > or =5 days). Impairment, as defined by the 2007 National Heart, Lung, and Blood Institute/National Asthma Education and Prevention Program (NHLBI/NAEPP) asthma guidelines, tended to be higher in patients without a previous diagnosis of asthma, per parental report, but this trend only achieved significance in two measures: daytime symptoms > or =2 days per week in the last 4 weeks (p = 0.028) and more than 5 missed school days in the past year (p = 0.001). CONCLUSION A previously validated HRA system can consistently identify a high rate of undiagnosed and poorly controlled asthma in an urban pediatric hospital-based teaching clinic. The utility of such a system would be to reduce missed opportunities for delivery of care and morbidity for the patients who currently have undiagnosed and/or uncontrolled asthma in the pediatric primary care outpatient setting.
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Affiliation(s)
- B Nichols
- Allergy Immunology Division, LAC+USC Medical Center, 1240 N. Mission Road, Los Angeles, CA 90033, USA.
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36
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Pacheco-Galván A. [Asthma control: from myth to reality]. Arch Bronconeumol 2009; 45:306-7. [PMID: 19328611 DOI: 10.1016/j.arbres.2008.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Accepted: 09/02/2008] [Indexed: 11/25/2022]
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Lenoir M, McGill CLW, Graham LM, Foggs M, Robinson S, Crim C, Stempel DA. A new focus on assessing and treating asthma control in the African-American community: a call to action. J Natl Med Assoc 2008; 100:1-23. [PMID: 18924317 DOI: 10.1016/s0027-9684(15)30098-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Asthma continues to be a highly prevalent disease characterized by significant morbidity, unnecessary mortality, and substantial cost to the health care system. After decades of increasing prevalence, the number of current asthmatics in recent years has plateaued at approximately 22 million people in the United States. An additional 10 million Americans have a past history of asthma that is not active. The burden of asthma is higher among African Americans than in any other racial or ethnic group in America. The African-American community continues to experience a disproportional increase in asthma prevalence, morbidity, and mortality. The educational initiatives stemming from the newly revised National Heart Lung and Blood Institute (NHLBI) guidelines provide the opportunity to address the increased burden of asthma in the African American community. These new guidelines, released in August 2007, focus on asthma control as the primary goal of therapy, routine monitoring of asthma control, and use of asthma control assessments to direct treatment. The present review discusses the following: I. The impact of health disparities on outcomes of African Americans with asthma, II. The barriers that prevent asthmatic patients from achieving optimal control, III. The unique factors that challenge practitioners and patients in achieving optimal asthma control in the African American Community, IV. The impact of good asthma control and the need for patients and clinicians to assess asthma control in with a standardized assessment tool, and V. Strategic initiatives and the role of the End The Attacks NOW program in improving outcomes for African American patients with asthma.
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Affiliation(s)
- Michael Lenoir
- Bay Area Pediatrics, 401 29th St, Oakland, CA 94609-3581, USA.
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38
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Cope SF, Ungar WJ, Glazier RH. International differences in asthma guidelines for children. Int Arch Allergy Immunol 2008; 148:265-78. [PMID: 19001786 DOI: 10.1159/000170380] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Over the last decade, a number of clinical practice guidelines that include guidance for the management of pediatric asthma have been introduced. The consistency across pediatric asthma guidelines is unknown and the emphasis on establishing asthma control may vary. The objective of this paper was to depict the evolution of guidelines for pediatric asthma and to compare current international guidelines in terms of their organization, presentation of evidence and consideration of children, with special emphasis on definitions of asthma control and severity. METHODS A systematic search to identify asthma guidelines was conducted, and guidelines were searched for pediatric terms. The approaches used by guidelines to define assessments of asthma severity and control were compared between the United States, the Global Initiative for Asthma, Canada, the United Kingdom and Australia. RESULTS Pediatric considerations in the management of asthma have been integrated into the various guidelines to different degrees and through varied strategies. There were differences in the conceptual and operational approach used to assess asthma which emphasized either asthma severity or control. CONCLUSIONS It will be important for future guidelines to clearly define whether the primary assessment parameter is asthma severity or control. Delineating the guideline development process and supporting evidence may improve transparency, consistency and guideline adherence.
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Affiliation(s)
- Shannon F Cope
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont., Canada
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Patino CM, Okelo SO, Rand CS, Riekert KA, Krishnan JA, Thompson K, Quartey RI, Perez-Williams D, Bilderback A, Merriman B, Paulin L, Hansel N, Diette GB. The Asthma Control and Communication Instrument: a clinical tool developed for ethnically diverse populations. J Allergy Clin Immunol 2008; 122:936-943.e6. [PMID: 18848721 PMCID: PMC5516631 DOI: 10.1016/j.jaci.2008.08.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Revised: 08/22/2008] [Accepted: 08/25/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND Lower levels of quality asthma care among racially diverse populations might be due to inaccurate disease status assessments. The Asthma Control and Communication Instrument (ACCI) is a new tool that captures patient report of disease status during routine care. OBJECTIVE We sought to test the ACCI's psychometric properties in a racially diverse population. METHODS We performed a cross-sectional study. Subjects were recruited from specialist and generalist urban outpatient clinics. The ACCI and measures of asthma control, quality of life, lung function, and specialist rating of asthma status were collected. Four ACCI domains were separately validated: Acute Care, Bother, Control, and Direction. Principal component analysis, internal consistency, concurrent, discriminative, known-groups validity, and accuracy were evaluated. RESULTS Two hundred seventy asthmatic patients (77% female subjects, 55% black) participated. ACCI Control domain internal consistency was 0.80. ACCI Bother, Control, and Direction domains showed strong concurrent validity with asthma control and quality-of-life measures (all P < .001). ACCI Acute Care and Direction domains showed strong concurrent validity with individual validation items (all P < .001). The ACCI Control domain discriminated clinically important levels of disease status measured by asthma control, quality of life (both P < .001), and percent predicted peak expiratory flow rate (P = .005) and was associated with specialist rating of disease status (P < .001), confirming known-groups validity. The accuracy of the ACCI Control domain in classifying patients with uncontrolled asthma was very good (area under the curve, 0.851; 95% CI, 0.742-0.95870). Results were similar for both black and white subjects. CONCLUSION The ACCI is a promising clinical tool that measures asthma disease status during routine health care and is valid for use in both black and white populations.
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Affiliation(s)
- Cecilia M. Patino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore
| | - Sande O. Okelo
- School of Medicine, University of Massachusetts, Worcester
| | - Cynthia S. Rand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore
| | - Kristin A. Riekert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore
| | - Jerry A. Krishnan
- Section of Pulmonary and Critical Care Medicine, University of Chicago
| | - Kathy Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore
| | | | | | - Andrew Bilderback
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore
| | - Barry Merriman
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore
| | - Laura Paulin
- Department of Pediatrics, Johns Hopkins University, Baltimore
| | - Nadia Hansel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore
| | - Gregory B. Diette
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore
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Thorsteinsdottir B, Volcheck GW, Enemark Madsen B, Patel AM, Li JTC, Lim KG. The ABCs of asthma control. Mayo Clin Proc 2008; 83:814-20. [PMID: 18613998 DOI: 10.4065/83.7.814] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The new asthma guidelines have introduced impairment and risk assessments into the management of asthma. Impairment assessment is based on symptom frequency and pulmonary function, whereas risk assessment is based on exacerbation frequency and severity. These 2 measures determine the initial severity of asthma in the untreated patient as well as the degree of control in asthma once treatment has been initiated. The focus on asthma control is important because the attainment of control correlates with a better quality of life and reduction in health care use. We describe 4 easy steps to achieving asthma control in the ambulatory practice setting: (1) a standardized assessment of asthma symptoms using a 5-question assessment tool called the Asthma Control Test, (2) a simple mnemonic that provides a systematic review of the comorbidities and clinical variables that contribute to uncontrolled asthma, (3) directed patient education, and (4) a schedule for ongoing care. Most if not all patients can achieve good control of their asthma with optimal care through an active partnership with their health care professionals.
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Breekveldt-Postma NS, Koerselman J, Erkens JA, van der Molen T, Lammers JWJ, Herings RMC. Treatment with inhaled corticosteroids in asthma is too often discontinued. Pharmacoepidemiol Drug Saf 2008; 17:411-22. [PMID: 18205251 DOI: 10.1002/pds.1552] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
PURPOSE To study persistence with inhaled corticosteroids (ICS) and its determinants in asthma-patients. METHODS From the PHARMO database, asthma-patients (age < 35 years) with a first dispensing for ICS in 1999-2002 and > or = 2 dispensings in the first year were included. Persistence during the first year was defined as the number of days from start to time of first failure to continue renewal of the initial ICS. Potential determinants of persistence were assessed at ICS-start and 1 year before. RESULTS The study-cohort included 5563 new users of single ICS and 297 of fixed-combined ICS. Less than 10% of patients using single ICS and 15% of patients using fixed-combined ICS were persistent at 1 year. Similar persistence-rates were observed when stratified for age (children/adolescents: 0-18 years and adults: 19-34 years). Increased persistence with single ICS was observed with the type of ICS (budesonide), prescriber (specialist), prior use of long-acting beta-agonists, previous hospitalization for asthma, metered-dose inhaler, low starting-dose and once-daily dosing regimen at start. Persistence with fixed combined ICS-treatment increased with younger age and was decreased in patients having high starting-dose of ICS and prior use of antibiotics. CONCLUSION New users of both single and fixed combined ICS have alarming low persistence rates with ICS-treatment in the first year of follow-up. Persistence was mainly related to patient factors, such as severity of disease, and to treatment-related factors, such as once-daily dosing frequency.
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Cowen MK, Wakefield DB, Cloutier MM. Classifying asthma severity: objective versus subjective measures. J Asthma 2007; 44:711-5. [PMID: 17994399 DOI: 10.1080/02770900701595576] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
National guidelines recommend the use of clinical history and spirometry to determine asthma severity. We examined the usefulness of the six guideline-recommended clinical questions in determining asthma severity and then compared guideline-determined severity to clinician-reported and spirometry-determined severity in a cross-sectional study of 201 children with asthma who were not receiving controller therapy. Four guideline-recommended questions (daytime and nocturnal symptoms, school absenteeism, and exercise impairment) determined asthma severity. Concordance between clinician-reported and spirometry-determined asthma severity was poor (kappa = 0.02). Clinical history alone underestimated spirometry-determined disease severity in 27% of children while spirometry results alone underestimated clinician-determined severity in 40% of children.
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Affiliation(s)
- Melissa K Cowen
- Asthma Center, Connecticut Children's Medical Center, Hartford, Connecticut, USA
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44
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Hayden ML. Immunoglobulin E-mediated airway inflammation is active in most patients with asthma. ACTA ACUST UNITED AC 2007; 19:439-49. [PMID: 17760568 DOI: 10.1111/j.1745-7599.2007.00251.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the role of immunoglobulin E (IgE)-mediated inflammation in the pathogenesis of asthma, limitations of standard therapies, and IgE as a logical target for therapy with omalizumab aimed at attaining asthma symptom control. DATA SOURCES Review of worldwide scientific literature on the role of IgE-mediated inflammation in patients with asthma, supplemented with a clinical case study. CONCLUSIONS Clinical trials point to an important role for IgE blocker therapy as an add-on to current therapy to reduce exacerbations and corticosteroid use and to improve quality of life in patients with moderate-to-severe asthma. Omalizumab, a monoclonal antibody that binds IgE, has been shown to be an effective, well-tolerated treatment in these patients. IMPLICATIONS FOR PRACTICE A significant number of patients with moderate-to-severe asthma do not achieve asthma symptom control, despite adhering to current guidelines-based standards of therapy, including the use of inhaled corticosteroids, beta-agonists, and leukotriene modifiers. None of these therapies directly addresses IgE-mediated inflammation. Therefore, patients with persistent symptoms of moderate-to-severe asthma should be evaluated and considered for therapy with the IgE blocker omalizumab.
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Affiliation(s)
- Mary Lou Hayden
- School of Nursing, University of Virginia, Richmond, Virginia, USA.
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45
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Mogil J. Many asthma patients experience persistent symptoms despite appropriate clinical and guideline-based treatment with inhaled corticosteroids. ACTA ACUST UNITED AC 2007; 19:459-70. [PMID: 17760570 DOI: 10.1111/j.1745-7599.2007.00247.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To review possible reasons for persistence of asthma symptoms despite appropriate use of clinical and guideline-based treatments, including the use of inhaled corticosteroids. DATA SOURCES Review of the worldwide scientific literature on factors related to persistent symptoms in patients with asthma. CONCLUSIONS Patients with asthma may not respond as expected to therapy because of factors that include poor adherence, improper inhaler technique, persistent exposure to symptom triggers, and limitations of current standard therapy, including steroid insensitivity or the steroid plateau effect. Persistent symptoms may also be associated with IgE-mediated airway inflammation, as current standard asthma therapies do not directly address the IgE-mediated component of the inflammatory cascade. Asthma is a complex disease and its treatment requires the full cooperation and participation of the patient. IMPLICATIONS FOR PRACTICE Healthcare professionals can play a key role by educating patients and their family members about the nature of asthma and rationale for treatment, supporting the importance of strict adherence to prevention measures and the prescribed treatment regimen.
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Affiliation(s)
- Joan Mogil
- Nassau Chest Physicians, P.C., Massapequa, New York, USA.
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Garcia G, Perez T, Didier A. [Lung function tests in refractory asthma]. Presse Med 2007; 37:143-54. [PMID: 18036771 DOI: 10.1016/j.lpm.2007.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2007] [Accepted: 10/10/2007] [Indexed: 11/27/2022] Open
Abstract
Obstructive airway disorders and bronchial hyperreactivity are part of the definition of asthma. Lung function tests (LFT) are therefore essential in the diagnosis and follow-up of patients with asthma. Maximum forced expiratory volume in one second (FEV1) is the essential functional indicator of severity and reversibility, according to the Global Initiative for Asthma (Gina). FEV1 has some limitations: it is poorly correlated with dyspnea, symptom control, and lung distention. In severe asthma, FEV1 is the only functional indicator included in the diagnostic criteria. It is one minor criterion among 2 major and 7 minor criteria. Other indicators measured during standard LFT and new functional indicators not yet sufficiently validated should provide important supplementary information to help to characterize the different clinical phenotypes and the pathophysiologic mechanisms involved in refractory asthma.
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Affiliation(s)
- Gilles Garcia
- Service des explorations fonctionnelles multidisciplinaires, AP-HP, Hôpital Antoine Béclère, Université Paris-Sud, F-92140 Clamart, France.
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Robroeks CMHHT, van de Kant KDG, Jöbsis Q, Hendriks HJE, van Gent R, Wouters EFM, Damoiseaux JGMC, Bast A, Wodzig WKWH, Dompeling E. Exhaled nitric oxide and biomarkers in exhaled breath condensate indicate the presence, severity and control of childhood asthma. Clin Exp Allergy 2007; 37:1303-11. [PMID: 17845410 DOI: 10.1111/j.1365-2222.2007.02788.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Exhaled nitric oxide and inflammatory biomarkers in exhaled breath condensate may be useful to diagnose and monitor childhood asthma. Their ability to indicate an asthma diagnosis, and to assess asthma severity and control, is largely unknown. OBJECTIVE To study (1) the ability of exhaled nitric oxide and inflammatory markers in exhaled breath condensate (nitrite, nitrate, hydrogen peroxide, 8-isoprostane, IFN-gamma, TNF-alpha, IL-2, -4, -5, -10 and acidity) to discriminate between childhood asthma and controls. (2) The ability of these biomarkers to indicate asthma severity and control. METHODS One-hundred and fourteen children were included: 64 asthmatics (10.7+/-3.0 years, 67.2% atopic) and 50 controls (10.0+/-0.4 years). Condensate was collected using a glass condenser. RESULTS Exhaled nitric oxide, IFN-gamma and IL-4 in exhaled breath condensate differed significantly between asthma and controls. Multivariate backward logistic regression models demonstrated that IL-4 (odds ratio 7.9, 95% confidence interval 1.2-51.0) was the only significant indicator of an asthma diagnosis. Asthma control was best assessed by exhaled nitric oxide, 8-isoprostane, IFN-gamma and IL-4 (sensitivity 82%, specificity 80%, P<0.05), whereas exhaled nitric oxide, 8-isoprostane, nitrate and nitrite in condensate were the best indicators of asthma severity (sensitivity 89%, specificity 72%, P<0.05). CONCLUSION Different markers in condensate are of an additional value to exhaled nitric oxide, and are needed in non-invasive inflammometry. They could be useful to diagnose asthma and to indicate asthma control and severity in childhood.
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Affiliation(s)
- C M H H T Robroeks
- Department of Paediatric Pulmonology, University Hospital Maastricht, Maastricht, The Netherlands.
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Colice G, Wu EQ, Birnbaum H, Daher M, Maryna M. Use of inhaled corticosteroids and healthcare costs in mild persistent asthma. J Asthma 2007; 44:479-83. [PMID: 17654136 DOI: 10.1080/02770900701424124] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Healthcare costs were determined for mild persistent asthma patients (n=796) who used inhaled corticosteroids infrequently (0 to 2 claims) or consistently (3 or more claims). Study patients, selected from a privately insured claims database (1999-2003), had at least one asthma diagnosis, no diagnosis of chronic obstructive pulmonary disease (COPD), and mild persistent asthma as defined by the 2005 Health Plan Employer Data and Information Set (HEDIS), Leidy's reliever and oral steroid methods, and the 2004 Global Initiative for Asthma (GINA) guidelines. Healthcare and asthma-specific costs were significantly higher for the infrequent inhaled corticosteroid users than the consistent users. The infrequent inhaled corticosteroid users had significantly more hospitalizations and emergency department visits compared with consistent users.
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Affiliation(s)
- Gene Colice
- Washington Hospital Center, Washington, DC, USA
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49
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Irvin CG, Kaminsky DA, Anthonisen NR, Castro M, Hanania NA, Holbrook JT, Lima JJ, Wise RA. CORRESPONDENCE. Am J Respir Crit Care Med 2007. [DOI: 10.1164/ajrccm.176.5.521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Okelo SO, Wu AW, Merriman B, Krishnan JA, Diette GB. Are physician estimates of asthma severity less accurate in black than in white patients? J Gen Intern Med 2007; 22:976-81. [PMID: 17453263 PMCID: PMC2583798 DOI: 10.1007/s11606-007-0209-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2005] [Revised: 03/07/2006] [Accepted: 04/09/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Racial differences in asthma care are not fully explained by socioeconomic status, care access, and insurance status. Appropriate care requires accurate physician estimates of severity. It is unknown if accuracy of physician estimates differs between black and white patients, and how this relates to asthma care disparities. OBJECTIVE We hypothesized that: 1) physician underestimation of asthma severity is more frequent among black patients; 2) among black patients, physician underestimation of severity is associated with poorer quality asthma care. DESIGN, SETTING AND PATIENTS We conducted a cross-sectional survey among adult patients with asthma cared for in 15 managed care organizations in the United States. We collected physicians' estimates of their patients' asthma severity. Physicians' estimates of patients' asthma as being less severe than patient-reported symptoms were classified as underestimates of severity. MEASUREMENTS Frequency of underestimation, asthma care, and communication. RESULTS Three thousand four hundred and ninety-four patients participated (13% were black). Blacks were significantly more likely than white patients to have their asthma severity underestimated (OR = 1.39, 95% CI 1.08-1.79). Among black patients, underestimation was associated with less use of daily inhaled corticosteroids (13% vs 20%, p < .05), less physician instruction on management of asthma flare-ups (33% vs 41%, p < .0001), and lower ratings of asthma care (p = .01) and physician communication (p = .04). CONCLUSIONS Biased estimates of asthma severity may contribute to racially disparate asthma care. Interventions to improve physicians' assessments of asthma severity and patient-physician communication may minimize racial disparities in asthma care.
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Affiliation(s)
- Sande O Okelo
- Department of Pediatrics, Johns Hopkins University, 200 N. Wolfe Street, Suite 3025, Baltimore, MD 21287, USA.
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