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Treatment Decisions in Children with Asthma in a Real-Life Clinical Setting: The Swiss Paediatric Airway Cohort. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:1038-1046.e8. [PMID: 34695597 DOI: 10.1016/j.jaip.2021.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 09/22/2021] [Accepted: 10/13/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Asthma treatment should be modified according to symptom control and future risk, but there are scarce data on what drives treatment adjustments in routine tertiary care. OBJECTIVE We studied factors that drive asthma treatment adjustment in pediatric outpatient clinics. METHODS We performed a cross-sectional analysis of the Swiss Paediatric Airway Cohort, a clinical cohort of 0- to 16-year-old children seen by pediatric pulmonologists. We collected information on diagnosis, treatment, lung function, and FeNO from hospital records; and on symptoms, sociodemographic, and environmental factors from a parental questionnaire. We used reported symptoms to classify asthma control and categorized treatment according to the 2020 Global Initiative for Asthma guidelines. We used multivariable logistic regression to study factors associated with treatment adjustment (step-up or down vs no change). RESULTS We included 551 children diagnosed with asthma (mean age, 10 years; 37% female). At the clinical visit, most children were prescribed Global Initiative for Asthma step 3 (35%). Compared with previsit treatment, 252 children remained on the same step (47%), 227 were stepped up (42%), and 58 were stepped down (11%). Female sex (adjusted odds ratio [aOR] = 1.61; 95% confidence interval [CI], 1.05-2.47), poor asthma control (aOR = 3.08; 95% CI, 1.72-5.54), and lower FEV1 Z-score (aOR = 0.70; 95% CI, 0.56-0.86 per one Z-score increase) were independently associated with treatment step-up, and low FeNO (aOR = 2.34; 95% CI, 1.23-4.45) was associated with treatment step-down, with marked heterogeneity between clinics. CONCLUSIONS In this tertiary care real-life study, we identified main drivers for asthma treatment adjustment. These findings may help improve both asthma management guidelines and clinical practice.
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Barry F, Thompson LR, Ravandi B, Chang TP, Halterman JS, Szilagyi PG, Okelo SO. Parental preferences for survey mode of administration, interview versus self-administered, with an asthma management questionnaire. J Asthma 2020; 58:665-673. [PMID: 32052668 DOI: 10.1080/02770903.2020.1728766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: National asthma guidelines encourage use of patient surveys to aid clinical assessment. Little is known about how these should be administered in acute care settings such as the emergency department (ED).Objective: Evaluate if parents have a preference for interview versus self-administered surveys in an ED, understand the sociodemographic and clinical characteristics by choice of survey mode of administration, and assess if there is a difference by mode in the parent's perception of an asthma management tool.Methods: A research assistant (RA) surveyed parents of children 2-17 years of age seeking ED asthma care. Parents chose to either self-administer or have an RA-administered survey that included the Pediatric Asthma Control and Communication Instrument-ED version (PACCI-ED). We compared sociodemographic and clinical characteristics and perceptions about the PACCI-ED by mode of survey administration.Results: Of 174 parent participants, 60% chose interviewer-administered surveys. Parents who chose interviewer-administered versus self-administered surveys had lower income, lower educational attainment, and children with uncontrolled asthma (p < .05). Bivariate and multivariate analyses showed that parents who chose interviewer-administered versus self-administered surveys tended to rate the PACCI-ED more favorably.Conclusions: EDs wishing to systematically use an asthma survey may need to plan appropriate resources for staff to administer them, particularly if they serve populations of lower socioeconomic status.
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Affiliation(s)
- Frances Barry
- Department of Pediatric Pulmonology and Sleep Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Lindsey R Thompson
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Bahareh Ravandi
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Todd P Chang
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Jill S Halterman
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Peter G Szilagyi
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Sande O Okelo
- Department of Pediatric Pulmonology and Sleep Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Tavares MGDS, Brümmer CF, Nicolau GV, Melo JTD, Nazário NO, Steidle LJM, Patino CM, Pizzichini MMM, Pizzichini E. Translation and cultural adaptation of a specific instrument for measuring asthma control and asthma status: the Asthma Control and Communication Instrument. J Bras Pneumol 2018; 43:264-269. [PMID: 29365000 PMCID: PMC5687962 DOI: 10.1590/s1806-37562016000000182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/06/2017] [Indexed: 11/22/2022] Open
Abstract
Objective: To translate the Asthma Control and Communication Instrument (ACCI) to Portuguese and adapt it for use in Brazil. Methods: The ACCI was translated to Portuguese and adapted for use in Brazil in accordance with internationally accepted guidelines. The protocol included the following steps: permission and rights of use granted by the original author; translation of the ACCI from English to Portuguese; reconciliation; back-translation; review and harmonization of the back-translation; approval from the original author; review of the Portuguese version of the ACCI by an expert panel; cognitive debriefing (the clarity, understandability, and acceptability of the translated version being tested in a sample of the target population); and reconciliation and preparation of the final version. Results: During the cognitive debriefing process, 41 asthma patients meeting the inclusion criteria completed the ACCI and evaluated the clarity of the questions/statements. The clarity index for all ACCI items was > 0.9, meaning that all items were considered to be clear. Conclusions: The ACCI was successfully translated to Portuguese and culturally adapted for use in Brazil, the translated version maintaining the psychometric properties of the original version. The ACCI can be used in clinical practice because it is easy to understand and easily applied.
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Affiliation(s)
- Michelle Gonçalves de Souza Tavares
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC) Brasil.,. Universidade do Sul de Santa Catarina - UNISUL - Tubarão (SC) Brasil
| | - Carolina Finardi Brümmer
- . Núcleo de Pesquisa em Asma e Inflamação das Vias Aéreas - NUPAIVA - Universidade Federal de Santa Catarina, Florianópolis (SC) Brasil
| | - Gabriela Valente Nicolau
- . Núcleo de Pesquisa em Asma e Inflamação das Vias Aéreas - NUPAIVA - Universidade Federal de Santa Catarina, Florianópolis (SC) Brasil
| | - José Tavares de Melo
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC) Brasil
| | - Nazaré Otilia Nazário
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC) Brasil.,. Núcleo de Pesquisa em Asma e Inflamação das Vias Aéreas - NUPAIVA - Universidade Federal de Santa Catarina, Florianópolis (SC) Brasil
| | - Leila John Marques Steidle
- . Núcleo de Pesquisa em Asma e Inflamação das Vias Aéreas - NUPAIVA - Universidade Federal de Santa Catarina, Florianópolis (SC) Brasil
| | - Cecília Maria Patino
- . Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (CA) USA
| | - Marcia Margaret Menezes Pizzichini
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC) Brasil.,. Núcleo de Pesquisa em Asma e Inflamação das Vias Aéreas - NUPAIVA - Universidade Federal de Santa Catarina, Florianópolis (SC) Brasil
| | - Emílio Pizzichini
- . Programa de Pós-Graduação em Ciências Médicas, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC) Brasil.,. Universidade do Sul de Santa Catarina - UNISUL - Tubarão (SC) Brasil
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Yawn BP, Wollan PC, Rank MA, Bertram SL, Juhn Y, Pace W. Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized Controlled Trial. Ann Fam Med 2018; 16. [PMID: 29531100 PMCID: PMC5847347 DOI: 10.1370/afm.2179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE The purpose of this study was to assess patient and practice outcomes after introducing the Asthma APGAR (Activities, Persistent, triGGers, Asthma medications, Response to therapy) tools into primary care practices. METHODS We used a pragmatic cluster-randomized controlled design in 18 US family medicine and pediatric practices to compare outcomes in patients with persistent asthma aged 5 to 45 years after introduction of the Asthma APGAR tools vs usual care. Patient outcomes included asthma control, quality of life, and emergency department (ED), urgent care, and inpatient hospital visits. The practice outcome was adherence to asthma guidelines. RESULTS We enrolled 1,066 patients: 245 children, 174 adolescents, and 647 adults. Sixty-five percent (692 patients) completed both baseline and 12-month questionnaires, allowing analysis for patient-reported outcomes. Electronic health record data were available for 1,063 patients (99.7%) for practice outcomes. The proportion of patients reporting an asthma-related ED, urgent care, or hospital visit in the final 6 months of the study was lower in the APGAR practices vs usual care practices (10.6% vs 20.9%, P = .004). The percentage of patients with "in control" asthma increased more between baseline and 1 year in the APGAR group vs usual care group (13.5% vs 3.4%, P =.0001 vs P =.86) with a trend toward better control scores and asthma-related quality of life in the former at 1 year (P ≤.06 and P = .06, respectively). APGAR practices improved their adherence to 3 or more guideline elements compared with usual care practices (20.7% increase vs 1.9% decrease, P = .001). CONCLUSIONS Introduction of the Asthma APGAR tools improves rates of asthma control; reduces asthma-related ED, urgent care, and hospital visits; and increases practices' adherence to asthma management guidelines.
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Affiliation(s)
- Barbara P Yawn
- Department of Research, Olmsted Medical Center, Rochester, Minnesota
| | - Peter C Wollan
- Department of Research, Olmsted Medical Center, Rochester, Minnesota
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona
| | - Susan L Bertram
- Department of Research, Olmsted Medical Center, Rochester, Minnesota
| | - Young Juhn
- Department of Pediatrics and Adolescent Medicine, Asthma Epidemiology Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Wilson Pace
- National Research Network, American Academy of Family Physicians, Leawood, Kansas
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Busse WW, Dahl R, Jenkins C, Cruz AA. Long-acting muscarinic antagonists: a potential add-on therapy in the treatment of asthma? Eur Respir Rev 2016; 25:54-64. [PMID: 26929422 DOI: 10.1183/16000617.0052-2015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Asthma is a chronic inflammatory disorder of the airways that is a major global burden on both individuals and healthcare systems. Despite guideline-directed treatment, a significant proportion of patients with asthma do not achieve control. This review focuses on the potential use of long-acting anticholinergics as bronchodilators in the treatment of asthma, with results published from clinical trials of glycopyrrolate, umeclidinium and tiotropium. The tiotropium clinical trial programme is the most advanced, with data available from a number of phase II and III studies of tiotropium as an add-on to inhaled corticosteroid maintenance therapy, with or without a long-acting β2-agonist, in patients across asthma severities. Recent studies using the Respimat Soft Mist inhaler have identified 5 µg once daily as the preferred dosing regimen, which has shown promising results in adults, adolescents and children with asthma. Tiotropium Respimat has recently been incorporated into the Global Initiative for Asthma 2015 treatment strategy as a recommended alternative therapy at steps 4 and 5 in adult patients with a history of exacerbations. The increasing availability of evidence from ongoing and future clinical trials will be beneficial in determining where long-acting anticholinergic agents fit in future treatment guidelines across a variety of patient populations and disease severities.
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Affiliation(s)
- William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ronald Dahl
- Allergy Centre, Odense University Hospital, Odense, Denmark
| | | | - Alvaro A Cruz
- ProAR - Universidade Federal da Bahia, Bahia, Brazil
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Loymans RJB, Honkoop PJ, Termeer EH, Snoeck-Stroband JB, Assendelft WJJ, Schermer TRJ, Chung KF, Sousa AR, Sterk PJ, Reddel HK, Sont JK, Ter Riet G. Identifying patients at risk for severe exacerbations of asthma: development and external validation of a multivariable prediction model. Thorax 2016; 71:838-46. [PMID: 27044486 DOI: 10.1136/thoraxjnl-2015-208138] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 02/26/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preventing exacerbations of asthma is a major goal in current guidelines. We aimed to develop a prediction model enabling practitioners to identify patients at risk of severe exacerbations who could potentially benefit from a change in management. METHODS We used data from a 12-month primary care pragmatic trial; candidate predictors were identified from GINA 2014 and selected with a multivariable bootstrapping procedure. Three models were constructed, based on: (1) history, (2) history+spirometry and (3) history+spirometry+FeNO. Final models were corrected for overoptimism by shrinking the regression coefficients; predictive performance was assessed by the area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow test. Models were externally validated in a data set including patients with severe asthma (Unbiased BIOmarkers in PREDiction of respiratory disease outcomes). RESULTS 80/611 (13.1%) participants experienced ≥1 severe exacerbation. Five predictors (Asthma Control Questionnaire score, current smoking, chronic sinusitis, previous hospital admission for asthma and ≥1 severe exacerbation in the previous year) were retained in the history model (AUROC 0.77 (95% CI 0.75 to 0.80); Hosmer-Lemeshow p value 0.35). Adding spirometry and FeNO subsequently improved discrimination slightly (AUROC 0.79 (95% CI 0.77 to 0.81) and 0.80 (95% CI 0.78 to 0.81), respectively). External validation yielded AUROCs of 0.69 (95% CI 0.63 to 0.75; 0.63 to 0.75 and 0.63 to 0.75) for the three models, respectively; calibration was best for the spirometry model. CONCLUSIONS A simple history-based model extended with spirometry identifies patients who are prone to asthma exacerbations. The additional value of FeNO is modest. These models merit an implementation study in clinical practice to assess their utility. TRIAL REGISTRATION NUMBER NTR 1756.
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Affiliation(s)
- Rik J B Loymans
- Department of General Practice, Academic Medical Center-University of Amsterdam (AMC), Amsterdam, The Netherlands
| | - Persijn J Honkoop
- LUMC Quality of Care Institute, Leiden University Medical Center (LUMC), Leiden, The Netherlands Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Evelien H Termeer
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre (RUNMC), Nijmegen, The Netherlands
| | - Jiska B Snoeck-Stroband
- LUMC Quality of Care Institute, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Willem J J Assendelft
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, The Netherlands Department of Primary and Community Care, Radboud University Nijmegen Medical Centre (RUNMC), Nijmegen, The Netherlands
| | - Tjard R J Schermer
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre (RUNMC), Nijmegen, The Netherlands
| | - Kian Fan Chung
- Experimental Airway Disease, National Heart and Lung Institute, Imperial College London & Royal Brompton NIHR Biomedical Research Unit, London, UK
| | - Ana R Sousa
- Respiratory Therapeutic Unit, GlaxoSmithKline, Stockley Park, UK
| | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Center-University of Amsterdam (AMC), Amsterdam, The Netherlands
| | - Helen K Reddel
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Jacob K Sont
- LUMC Quality of Care Institute, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gerben Ter Riet
- Department of General Practice, Academic Medical Center-University of Amsterdam (AMC), Amsterdam, The Netherlands
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Yamasaki A, Tomita K, Kato K, Fukutani K, Sano H, Tohda Y, Shimizu E. Development and validation of a predictive model of failed stepping-down of inhaled corticosteroids in adult asthmatics. Patient Prefer Adherence 2016; 10:339-44. [PMID: 27051275 PMCID: PMC4807945 DOI: 10.2147/ppa.s98637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Asthma guidelines suggest stepping-down of inhaled corticosteroids (ICSs) when asthma is stable. OBJECTIVE To determine outcomes of stepping-down and prediction of outcome after stepping-down of ICSs in controlled adult asthma. METHODS We performed a retrospective study on 21-81 year-old hospital-based outpatients with asthma in Japan. Protocol for stepping-down of ICSs was performed according to the GINA guideline. Failure/success of stepping-down is judged as occurring exacerbation or not for stepping-down of ICSs. Multiple logistic regression analysis was used to develop a prediction model for failed stepping-down, and then was validated by the leave-one-out cross-validation method. Our model of prediction score was calculated using receiver-operating characteristic area under the curve (AUC) analysis. The Nelson-Aalen curve demonstrated time to failure of stepping-down of ICSs. RESULTS A total of 126 patients with asthma attempted the stepping-down of ICSs according to the guideline. Of patients with follow-up, 97 (77.0%) of stepping-down attempts were successful. Using multivariate logistic regression analysis, comorbidity with rhinitis/rhinosinusitis and phlegm grade were independent predictors of failed stepping-down of ICSs, with odds ratios of 3.8 (95% confidence interval, 1.04-13.3; P=0.04) and 1.3 (95% confidence interval, 1.01-11.5; P=0.04), respectively. These variables were then used to build a prediction score in terms of the prediction of failed stepping-down events. When the two variables were added to form the prediction score, the discriminative power of scores calculated by the prediction model using the AUC was 0.75 (range: 0.62-0.88) for naïve prediction and 0.72 (range: 0.60-0.86) after cross-validation. In the time-to-failure models, cumulative hazard ratio of failed stepping-down have fixed 1 year after stepping-down. CONCLUSION Our results suggest that comorbidity with rhinitis/rhinosinusitis and phlegm grade are imperative to predict failed stepping-down of ICSs in controlled patients with adult asthma.
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Affiliation(s)
- Akira Yamasaki
- Division of Medical Oncology and Molecular Respirology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Katsuyuki Tomita
- Department of Respiratory Medicine, Yonago Medical Centre, Tottori, Japan
| | - Kazuhiro Kato
- Department of Respiratory Medicine, Sanin Rosai Hospital, Tottori, Japan
| | - Kouji Fukutani
- Department of Respiratory Medicine, Sanin Rosai Hospital, Tottori, Japan
| | - Hiroyuki Sano
- Department of Respiratory Medicine and Allergology, Faculty of Medicine, Kinki University, Osaka, Japan
| | - Yuji Tohda
- Department of Respiratory Medicine and Allergology, Faculty of Medicine, Kinki University, Osaka, Japan
| | - Eiji Shimizu
- Division of Medical Oncology and Molecular Respirology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
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Clark NM, Lachance L, Doctor LJ, Gilmore L, Kelly C, Krieger J, Lara M, Meurer J, Milanovich AF, Nicholas E, Rosenthal M, Stoll SC, Wilkin M. Policy and system change and community coalitions: outcomes from allies against asthma. HEALTH EDUCATION & BEHAVIOR 2015; 41:528-38. [PMID: 25270178 DOI: 10.1177/1090198114547507] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives. We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. Methods. We interviewed a sample of 1,477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. Results. A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. Conclusions. Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.
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Affiliation(s)
- Noreen M Clark
- Center for Managing Chronic Disease, University of Michigan, Ann Arbor, MI, USA
| | - Laurie Lachance
- Center for Managing Chronic Disease, University of Michigan, Ann Arbor, MI, USA
| | - Linda Jo Doctor
- Center for Managing Chronic Disease, University of Michigan, Ann Arbor, MI, USA
| | - Lisa Gilmore
- Academy for Educational Development, Washington, DC, USA
| | - Cindy Kelly
- Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, VA, USA
| | - James Krieger
- Department of Public Health, Seattle and King Country, WA, USA
| | | | - John Meurer
- Medical College of Wisconsin, Children's Hospital and Health System, Milwaukee, WI, USA
| | | | | | - Michael Rosenthal
- Department of Family Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Shelley C Stoll
- Center for Managing Chronic Disease, University of Michigan, Ann Arbor, MI, USA
| | - Margaret Wilkin
- Center for Managing Chronic Disease, University of Michigan, Ann Arbor, MI, USA
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9
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Opportunities for cystic fibrosis care teams to support treatment adherence. J Cyst Fibros 2015; 14:142-8. [DOI: 10.1016/j.jcf.2014.10.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 10/02/2014] [Accepted: 10/13/2014] [Indexed: 11/20/2022]
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10
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Wilson E, McKeever T, Hargadon B, Hearson G, Anderson J, Hodgson D, Bailey H, Meakin G, Thomas M, Pavord ID, Harrison T, Shaw D. Exhaled nitric oxide and inhaled corticosteroid dose reduction in asthma: a cohort study. Eur Respir J 2014; 44:1705-7. [PMID: 25142486 DOI: 10.1183/09031936.00093614] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Emma Wilson
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Tricia McKeever
- Dept of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | | | - Glenn Hearson
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - John Anderson
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - David Hodgson
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Helen Bailey
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Garry Meakin
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Mike Thomas
- Dept of Primary Care, University of Southampton, Southampton, UK
| | | | - Tim Harrison
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Dominick Shaw
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
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Mold JW, Fox C, Wisniewski A, Lipman PD, Krauss MR, Harris DR, Aspy C, Cohen RA, Elward K, Frame P, Yawn BP, Solberg LI, Gonin R. Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial. Ann Fam Med 2014; 12:233-40. [PMID: 24821894 PMCID: PMC4018371 DOI: 10.1370/afm.1624] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined. METHODS In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute's Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar's test and multivariate modeling were used to evaluate the impact of the interventions. RESULTS Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7-3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5-3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation. CONCLUSIONS Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.
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Affiliation(s)
- James W Mold
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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12
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Hanna T, Bajorek B, Lemay K, Armour CL. Using scenarios to test the appropriateness of pharmacist prescribing in asthma management. Pharm Pract (Granada) 2014; 12:390. [PMID: 24644524 PMCID: PMC3955869 DOI: 10.4321/s1886-36552014000100009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 03/08/2014] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To explore the potential for community pharmacist prescribing in terms of usefulness, pharmacists' confidence, and appropriateness, in the context of asthma management. METHODS Twenty community pharmacists were recruited using convenience sampling from a group of trained practitioners who had already delivered asthma services. These pharmacists were asked to complete a scenario-based questionnaire (9 scenarios) modelled on information from real patients. Pharmacist interventions were independently reviewed and rated on their appropriateness according to the Respiratory Therapeutic Guidelines (TG) by three expert researchers. RESULTS In seven of nine scenarios (78%), the most common prescribing intervention made by pharmacists agreed with TG recommendations. Although the prescribing intervention was appropriate in the majority of cases, the execution of such interventions was not in line with guidelines (i.e. dosage or frequency) in the majority of scenarios. Due to this, only 47% (76/162) of the interventions overall were considered appropriate. However, pharmacists were deemed to be often following common clinical practice for asthma prescribing. Therefore 81% (132/162) of prescribing interventions were consistent with clinical practice, which is often not guideline driven, indicating a need for specific training in prescribing according to guidelines. Pharmacists reported that they were confident in making prescribing interventions and that this would be very useful in their management of the patients in the scenarios. CONCLUSIONS Community pharmacists may be able to prescribe asthma medications appropriately to help achieve good outcomes for their patients. However, further training in the guidelines for prescribing are required if pharmacists are to support asthma management in this way.
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Affiliation(s)
- Tamer Hanna
- The University of Sydney . Sydney, NSW ( Australia )
| | - Beata Bajorek
- University of Technology Sydney . Sydney, NSW ( Australia )
| | - Kate Lemay
- Woolcock Institute of Medical Research, The University of Sydney . Sydney, NSW ( Australia )
| | - Carol L Armour
- Woolcock Institute of Medical Research, The University of Sydney . Sydney, NSW ( Australia ).
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Okelo SO, Eakin MN, Riekert KA, Teodoro AP, Bilderback AL, Thompson DA, Loiaza-Martinez A, Rand CS, Thyne S, Diette GB, Patino CM. Validation of parental reports of asthma trajectory, burden, and risk by using the pediatric asthma control and communication instrument. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:186-92. [PMID: 24607047 DOI: 10.1016/j.jaip.2013.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/29/2013] [Accepted: 10/15/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Despite a growing interest, few pediatric asthma questionnaires assess multiple dimensions of asthma morbidity, as recommended by national asthma guidelines, or use patient-reported outcomes. OBJECTIVE To evaluate a questionnaire that measures multiple dimensions of parent-reported asthma morbidity (Direction, Bother, and Risk). METHODS We administered the Pediatric Asthma Control and Communication Instrument (PACCI) and assessed asthma control (PACCI Control), quality of life, and lung function among children who presented for routine asthma care. The PACCI was evaluated for discriminative validity. RESULTS A total of 317 children participated (mean age, 8.2 years; 58% boys; 44% African American). As parent-reported PACCI Direction changed from "better" to "worse," we observed poorer asthma control (P < .001), mean Pediatric Asthma Caregiver Quality of Life Questionnaire (PACQLQ) scores (P < .001), and FEV1% (P = .025). Linear regression showed that, for each change in PACCI Direction, the mean PACQLQ score decreased by -0.6 (95% CI, -0.8 to -0.4). As parent-reported PACCI Bother changed from "not bothered" to "very bothered," we observed poorer asthma control (P < .001) and lower mean PACQLQ scores (P < .001). Linear regression showed that, for each change in PACCI Bother category, the mean PACQLQ score decreased by -1.1 (95% CI, -1.3 to -0.9). Any reported PACCI Risk event (emergency department visit, hospitalization, or use of an oral corticosteroid) was associated with poorer asthma control (P < .05) and PACQLQ scores (P < .01). CONCLUSIONS PACCI Direction, Bother, and Risk are valid measures of parent-reported outcomes and show good discriminative validity. The PACCI is a simple clinical tool to assess multiple dimensions of parent-reported asthma morbidity, in addition to risk and control.
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Affiliation(s)
- Sande O Okelo
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif.
| | - Michelle N Eakin
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Kristin A Riekert
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Alvin P Teodoro
- Department of Pediatrics, New York Presbyterian/Weill Medical College of Cornell University, New York, NY
| | | | | | | | - Cynthia S Rand
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Shannon Thyne
- Department of Pediatrics, University of California San Francisco, San Francisco, Calif
| | - Gregory B Diette
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Cecilia M Patino
- Department of Preventive Medicine, University of Southern California, Los Angeles, Calif
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Okelo SO, Siberry GK, Solomon BS, Bilderback AL, Yamazaki M, Hetzler T, Ferrell CL, Dhepyasuwan N, Serwint JR. Asthma treatment decisions by pediatric residents do not consistently conform to guidelines or improve with level of training. Acad Pediatr 2014; 14:287-93. [PMID: 24629404 PMCID: PMC8923062 DOI: 10.1016/j.acap.2013.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 12/14/2013] [Accepted: 12/17/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare asthma treatment decisions by pediatric residents to current asthma guidelines and to learn whether treatment decisions vary by postgraduate year in training. METHODS We conducted a Web-based survey of residents from 10 training programs through the Continuity Research Network of the Academic Pediatric Association (CORNET). Surveys included 6 vignettes of patients receiving low-dose inhaled steroids with guideline- and non-guideline-based indicators of asthma status and 1 stable patient on high-intensity medication. RESULTS There were 369 resident respondents (65% response rate), 26% postgraduate year (PGY) 1, 38% PGY2, and 36% PGY3+. Seventy-five percent of each resident group reported seeing fewer than 1 asthma patient per continuity clinic session. A majority of residents made appropriate treatment recommendations in 2 of 4 vignettes of guideline-based indicators of asthma status: first, 97% overall stepping up treatment for mild persistent asthma; and second, 52% overall stepping down treatment for a patient with well-controlled asthma on high-intensity medications. Inconsistent with guideline recommendations, 82% of residents overall did not step down treatment for a patient with well-controlled asthma receiving low-intensity therapy; 75% of residents did not step up treatment for a patient with a recent hospitalization for asthma. Of the 3 vignettes evaluating non-guideline-based indicators of asthma status, a majority of residents (60%) stepped up treatment for parental reports of worse asthma, while a minority did so for a parental report of being bothered by their child's asthma (27%) or when wheezing was reported at physical examination (43%). There were no statistically significant differences for any of the comparisons by year in training. CONCLUSIONS Pediatric residents' management of asthma is consistent with national guidelines in some cases but not in others. There were no differences in the outpatient asthma management decisions between residents by years in training. Educational efforts should be focused on strategies to facilitate pediatric resident adherence to national asthma guideline recommendations for outpatient asthma management.
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Affiliation(s)
- Sande O. Okelo
- Division of Pediatric Pulmonology, The David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - George K Siberry
- Pediatric, Adolescent, and Maternal AIDS (PAMA) Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Barry S. Solomon
- Division of General Pediatrics & Adolescent Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew L. Bilderback
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michiyo Yamazaki
- Department of Family, Population and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Theresa Hetzler
- Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Cynthia L. Ferrell
- Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | | | - Janet R. Serwint
- Division of General Pediatrics & Adolescent Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
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15
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Okelo SO, Riekert KA, Eakin MN, Bilderback AL, Diette GB, Rand CS, Yenokyan G. Pediatrician qualifications and asthma management behaviors and their association with patient race/ethnicity. J Asthma 2013; 51:155-61. [PMID: 24256071 DOI: 10.3109/02770903.2013.860163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We sought to understand if pediatrician characteristics and asthma assessment and treatment varied in association with the proportion of African-American and Latino children in the pediatrician's practice. METHODS We conducted a cross-sectional survey of 500 American Academy of Pediatrics members between November 2005 and May 2006. Standardized vignettes were used to test how different indicators of a patient's asthma status affect pediatrician asthma assessments and recommendations. Linear and logistic regression models were used to examine the association of pediatrician assessments and treatment recommendations for these vignettes, respectively, with the proportion of reported African-American and Latino children seen in their practice. RESULTS There were 270 respondents (response rate = 54%). Based on pediatrician-reported percentage of minority patients, there were no differences in board certification status, recognition of poorly controlled asthma nor in the likelihood of appropriately increasing long-term controller medications to treat poorly controlled asthma (p > 0.05 for all analyses). CONCLUSIONS Caring primarily for minority children by AAP pediatricians appears unrelated to training qualifications or in their reported knowledge of how to appropriately assess and treat asthma. Therefore, studies of asthma care disparities should focus on understanding the knowledge-base of non-AAP pediatric providers who care for minority populations and exploring other potential contributory provider-level factors (e.g. communication skills).
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Affiliation(s)
- Sande O Okelo
- Division of Pediatric Pulmonology, The David Geffen School of Medicine at UCLA , Los Angeles, CA , USA
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16
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Yawn BP, Bertram S, Kurland M, Wollan P, Graham D, Littlefield D, Smail C, Pace W. Protocol for the asthma tools study: a pragmatic practice-based research network trial. Pragmat Obs Res 2013; 4:7-18. [PMID: 27774020 PMCID: PMC5045012 DOI: 10.2147/por.s43161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Asthma is common among children, adolescents, and adults. However, management of asthma often fails to follow evidence-based guidelines. Control assessments have been developed, validated against expert opinion, and disseminated. However, in primary care, assessment of control is only one step in asthma management. To facilitate integration of the evidence-based guidelines into practice, tools should also guide the next steps in care. The Asthma APGAR tools do just that, incorporating a control assessment as well as assessment of the most common reasons for inadequate and poor control. The Asthma APGAR tool is also linked to a care algorithm based on the 2007 National Heart, Lung, and Blood Institute asthma guidelines. The objective of this study is to assess the impact of implementation of the Asthma APGAR on patient asthma outcomes in primary care practices. Methods A total of 1400 patients aged 5–60 years with physician-diagnosed asthma are enrolled in 20 practice-based research network (PBRN) practices randomized to intervention or usual care. The primary outcomes are changes in patient self-reported asthma control, asthma-related quality of life, and rates of exacerbations documented in medical records over the 18–24 months of enrollment. Process measures related to implementation of the Asthma APGAR system into daily care will also be assessed using review of medical records. Qualitative assessments will be used to explore barriers to and facilitators for integrating the Asthma APGAR tools into daily practice in primary care. Discussion Data from this pivotal pragmatic study are intended to demonstrate the importance of linking assessment of asthma and management tools to improve asthma-related patient outcomes. The study is an effectiveness trial done in real-world PBRN practices using patient-oriented outcome measures, making it generalizable to the largest possible group of asthma care providers and primary care clinics.
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Affiliation(s)
- Barbara P Yawn
- Department of Research, Olmsted Medical Center, Rochester, MN
| | - Susan Bertram
- Department of Research, Olmsted Medical Center, Rochester, MN
| | - Margary Kurland
- Department of Research, Olmsted Medical Center, Rochester, MN
| | - Peter Wollan
- Department of Research, Olmsted Medical Center, Rochester, MN
| | - Deborah Graham
- National Research Network, American Academy of Family Physicians, Leawood, KS, USA
| | | | - Craig Smail
- National Research Network, American Academy of Family Physicians, Leawood, KS, USA
| | - Wilson Pace
- National Research Network, American Academy of Family Physicians, Leawood, KS, USA
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Baddar S, Jayakrishnan B, Al-Rawas O, George J, Al-Zeedy K. Is Clinical Judgment of Asthma Control Adequate?: A prospective survey in a tertiary hospital pulmonary clinic. Sultan Qaboos Univ Med J 2013; 13:63-8. [PMID: 23573384 DOI: 10.12816/0003197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Revised: 07/13/2012] [Accepted: 08/05/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Asthma control is often difficult to measure. The aim of this study was to compare physicians' personal clinical assessments of asthma control with the Global Initiative for Asthma (GINA) scoring. METHODS Physicians in the adult pulmonary clinics of a tertiary hospital in Oman first documented their subjective judgment of asthma control on 157 consecutive patients. Immediately after that and in the same proforma, they selected the individual components from the GINA asthma control table as applicable to each patient. RESULTS The same classification of asthma control was achieved by physicians' clinical judgment and GINA classification in 106 cases (67.5%). In the other 32.5% (n = 51), the degree of control by clinical judgment was one level higher than the GINA classification. The agreement was higher for the pulmonologists (72%) as compared to non-pulmonologists (47%; P = 0.009). Physicians classified 76 patients (48.4%) as well-controlled by clinical judgment compared to 48 (30.6%) using GINA criteria (P <0.001). Conversely, they classified 34 patients (21.7%) as uncontrolled as compared to 57 (36.3%) by GINA criteria (P <0.001). In the 28 patients who were clinically judged as well-controlled but, by GINA criteria, were only partially controlled, low peak expiratory flow rate (PEFR) (46.7%) and limitation of activity (21.4%) were the most frequent parameters for downgrading the level of control. CONCLUSION Using clinical judgment, physicians overestimated the level of asthma control and underestimated the uncontrolled disease. Since management decisions are based on the perceived level of control, this could potentially lead to under-treatment and therefore sub-optimal asthma control.
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Affiliation(s)
- Sawsan Baddar
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
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18
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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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Kelly SG, Hawley M, O'Brien J. Impact of bed availability on requesting and offering in-hospital intensive care unit transfers: a survey study of generalists and intensivists. J Crit Care 2013; 28:461-8. [PMID: 23312125 DOI: 10.1016/j.jcrc.2012.10.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 09/19/2012] [Accepted: 10/30/2012] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate whether bed availability affects a physician's decision to request or offer an intensive care unit (ICU) transfer. MATERIALS AND METHODS We administered mail-based surveys to determine the respondents' probability of either requesting an ICU transfer (generalist respondents) or offering an ICU transfer (intensivist respondents). Respondents randomly received clinical vignettes that were identical except for the number of available ICU beds (one or seven available ICU beds). Respondents also made predictions about the patient's outcomes. RESULTS Among generalists and intensivists, there were wide ranges in decisions about ICU transfer. In the Generalist ICU request study, the average probability of transfer with one versus seven available ICU beds was 52.2% and 58.5% (P = .41), respectively. In the Intensivist ICU offer study, the average probability of transfer with one versus seven available ICU beds was 62.5% and 57.4% (P = .24), respectively. The most consistent association with decisions about ICU transfer was the predicted probability that a patient would require an ICU bed in the future if not transferred currently. CONCLUSIONS There is high variability in the decision to request or offer ICU beds. There was not a significant association between bed availability and ICU transfer decisions.
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Affiliation(s)
- Sean G Kelly
- Department of Internal Medicine, University of Wisconsin Hospitals and Clinics, 4240-01A MCFB, Madison, Wisconsin 53705, USA.
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Abstract
Control-based asthma management has been incorporated in asthma guidelines for many years. This article reviews the evidence for its utility in adults, describes its strengths and limitations in real life, and proposes areas for further research, particularly about incorporation of future risk and identification of patients for whom phenotype-guided treatment would be effective and efficient. The strengths of control-based management include its simplicity and feasibility for primary care, and its limitations include the nonspecific nature of asthma symptoms, the complex role of β(2)-agonist use, barriers to stepping down treatment, and the underlying assumptions about asthma pathophysiology and treatment responses.
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Papi A, Nicolini G, Crimi N, Fabbri L, Olivieri D, Rossi A, Paggiaro P. Step-down from high dose fixed combination therapy in asthma patients: a randomized controlled trial. Respir Res 2012; 13:54. [PMID: 22731754 PMCID: PMC3431221 DOI: 10.1186/1465-9921-13-54] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/14/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Asthma guidelines suggest that therapy can be reduced once asthma is controlled. Despite these recommendations, asthmatic patients are seldom stepped down in clinical practice, and questions remain about when and how to reduce asthma therapy. The purpose of the present study was to evaluate lung function and asthma control in patients who were stepped down from the highest recommended dose of inhaled corticosteroid/long acting β2 agonist combination therapy. METHODS This was a prospective, randomised, controlled, two-arm parallel group study. Asthmatic patients who were fully controlled with a high daily dose (1000/100 μg) of fluticasone/salmeterol were randomly assigned to 6 months of open-label treatment with either 500/100 μg fluticasone/salmeterol Diskus daily or 400/24 μg extrafine beclomethasone/formoterol pMDI daily. The primary outcome was the change in morning peak expiratory flow (PEF) values between baseline and the end of treatment. The secondary outcomes included asthma control and exacerbation frequency. RESULTS Four hundred twenty-two patients were included in the analysis. The PEF values remained above 95% of the predicted values throughout the study. The end-study morning PEF rates showed equivalence between the groups (difference between means, 2.49 L/min; 95% CI, -13.43 to 18.42). No changes from baseline were detected in PEF and forced expiratory volume in 1 second measured at the clinics, in the symptom scores or in the use of rescue medication. Asthma control was maintained in 95.2% of the patients at 6 months. No significant differences between the groups were detected in any other parameter, including exacerbation frequency and adverse events. CONCLUSIONS Stepping down patients whose asthma is controlled with the highest recommended dose of fluticasone/salmeterol to either 500/100 μg fluticasone/salmeterol daily or 400/24 μg extra-fine beclomethasone/formoterol daily provides comparable maintenance of lung function and asthma control. TRIAL REGISTRATION clinicaltrials.gov NCT00497237.
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Affiliation(s)
- Alberto Papi
- Research Center on Asthma and COPD, University of Ferrara, Via Savonarola 9, 44100, Ferrara, Italy.
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Turton JA, Glasgow NJ, Brannan JD. Feasibility and acceptability of using bronchial hyperresponsiveness to manage asthma in primary care: a pilot study. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2012; 21:28-34. [PMID: 21938353 DOI: 10.4104/pcrj.2011.00079] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIMS To determine if indirect testing for bronchial hyperresponsiveness (BHR) to monitor inhaled corticosteroid (ICS) treatment in asthma is feasible and acceptable in primary care. METHODS Fourteen adult patients with asthma aged 22-70 years (4M:10F, forced expiratory volume in 1 s >70% predicted) taking ICS performed a test for BHR using mannitol on three visits 6 weeks apart. ICS dose adjustments were made based on the presence of BHR. The Asthma Quality of Life Questionnaire (AQLQ) and the Asthma Control Questionnaire were used at each visit. A semi structured interview at study exit assessed subject acceptability. RESULTS BHR did not return in those with no BHR at study entry (n=9) with decreasing ICS dose. Improvements in BHR with increasing ICS dose (n=5) were observed with clinically significant improvements in AQLQ (mean score increase >0.5, p=0.02). Feasibility and acceptability of BHR testing was demonstrated. CONCLUSIONS It is feasible and acceptable to perform BHR testing using mannitol to help identify patients with asthma who would benefit from ICS dose increases and those with no BHR who could have a dose reduction. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry ACTRN12610000807055.
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Affiliation(s)
- James A Turton
- Medical School, Australian National University, Canberra, ACT 2606, Australia.
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Demissie S, Riekert KA, Eakin MN, Bilderback A, Diette GB, Okelo SO. How Do Perceptions of Asthma Control and Severity Relate to Indicators of Asthma Status and Treatment Recommendations by Pediatricians? PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2012; 25:17-23. [PMID: 22454788 DOI: 10.1089/ped.2011.0107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 11/01/2011] [Indexed: 11/12/2022]
Abstract
BACKGROUND: According to National Institutes of Health (NIH) guidelines, asthma control and severity are unique constructs. Little is known about how asthma control and severity are distinguished by pediatricians and if they influence treatment recommendations. METHODS: We conducted a random-sample survey of 500 pediatricians using patient vignettes with different asthma status indicators (recent hospitalization, parental report of bother from asthma, frequent symptoms, parental report of worsening asthma, and wheeze during physical exam) and a visual analog scale (VAS) to rate control and severity. Regression models assessed the independent effects of these indicators on asthma control and severity ratings, and the effects of these ratings on treatment recommendations. RESULTS: A total of 270 respondents provided usable data. Compared to patients with well-controlled asthma: (1) medication intensity influenced only severity ratings; (2) frequent symptoms and recent hospitalization influenced control and severity ratings; (3) wheeze and bother influenced control ratings only (p<0.001 for all comparisons); (4) a report of worse asthma did not significantly affect any ratings (p>0.2). Poorer VAS control ratings were associated with recommendations to step-up treatment (odds ratio [OR] 2.61, 95% confidence interval [CI], 2.2-3.1, p<0.001), but more severe VAS ratings were not (OR 1.02, 95% CI, 0.9-1.2, p=0.8). Recommendations to step-down treatment were associated with poorer VAS control ratings (OR 0.70, 95% CI, 0.6-0.8, p<0.001) and more severe VAS ratings (OR 0.82, 95% CI, 0.7-0.9, p<0.001). CONCLUSIONS: Pediatricians who step-up asthma treatment base their assessments on asthma control, while assessments of both control and severity factor into their decision to step-down asthma therapy.
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Urrutia I, Aguirre U, Pascual S, Esteban C, Ballaz A, Arrizubieta I, Larrea I. Impact of anxiety and depression on disease control and quality of life in asthma patients. J Asthma 2012; 49:201-8. [PMID: 22308974 DOI: 10.3109/02770903.2011.654022] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Patients with asthma also tend to have anxiety and depression. These comorbidities may affect asthma control and quality of life. The objective of this study was to assess the impact of anxiety and depression on asthma control and quality of life. PATIENTS AND METHODS Cross-sectional study of asthma outpatients was conducted at two hospitals in the Basque Country (northern Spain). Data collected included sociodemographic variables, asthma symptoms, treatment, number of exacerbations, level of control, quality of life, presence of psychological morbidities, and level of physical activity. Spirometry was performed in accordance with the recommendations of the Spanish Society of Pneumology and Thoracic Surgery. RESULTS Among 354 asthmatics, 77% had poor or partial control of their condition, 31% had anxiety alone, 2% had depression alone, and 10% had anxiety plus depression. Poor asthma control was associated with anxiety plus depression (odds ratio (OR): 3.61; 95% confidence interval (CI): 1.05-12.41) as well as with female patients (OR: 1.85; 95% CI: 1.11-3.10). Anxiety had an independent effect on reduced quality of life across all domains; anxiety plus depression had an even greater effect. CONCLUSION Among patients with asthma, anxiety and depression adversely affect asthma control and quality of life, raising the possibility that treating these psychological comorbidities could improve asthma control and quality of life.
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Affiliation(s)
- Isabel Urrutia
- Pneumology Service, Galdakao-Usánsolo Hospital, Bizkaia, Spain.
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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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Zeiger RS, Schatz M, Zhang F, Crawford WW, Kaplan MS, Roth RM, Chen W. Association of exhaled nitric oxide to asthma burden in asthmatics on inhaled corticosteroids. J Asthma 2010; 48:8-17. [PMID: 21155706 DOI: 10.3109/02770903.2010.539295] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FENO) is a marker of airway inflammation. Its role in assessing asthma burden in clinical practice needs more study. OBJECTIVE To determine whether higher FENO levels are associated with greater asthma burden. METHODS This was a multicenter cross-sectional retrospective study of atopic 12- to 56-year-old persistent asthmatics on inhaled corticosteroids (ICS). Questionnaire and 1-year retrospective administrative data were used to analyze by unadjusted and adjusted robust Poisson regression (relative risks) and negative binomial regression [incidence rate ratios (IRRs)] the associations of masked FENO levels (NIOX MINO®) to short-acting beta-agonist (SABA) dispensings and oral corticosteroid (OCS) use in the past year independent of spirometry and an asthma control tool [Asthma Control Test (ACT)]. RESULTS FENO levels ranged from 7-215 ppb (median 28 ppb) in 325 patients. Higher FENO levels significantly correlated with more SABA dispensings and OCS courses in the past year, lower FEV(1)% predicted levels, but not ACT score. FENO highest (≥48 ppb) versus lowest (≤19 ppb) quartile values were associated independently in the past year with ≥7 SABA canisters dispensed (relative risk=2.40, 95% CI=1.25-4.62) and total number of SABA canisters dispensed (IRR=1.46, 95% CI=1.12-1.99) and with ≥1 OCS course (relative risk=1.48, 95% CI=1.06-2.07) and total number of OCS courses (IRR=1.71, 95% CI=1.09-2.66). The significant independent relationship of higher FENO levels to increasing SABA dispensings and OCS courses was confirmed by linear trend analyses. CONCLUSIONS Independent and clinically meaningful associations between higher FENO levels and greater asthma burden during a prior year in persistent asthmatics on ICS suggest that FENO measurement may be a complementary tool to help clinicians assess asthma burden.
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Affiliation(s)
- Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Harbor City, Los Angeles and Orange County, CA, USA.
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Canino G, Vila D, Cabana M, Quiñones A, Otero M, Acosta E, Pabón-Cruz K, Colón FM, Rand C. Barriers to Prescribing Controller Anti Inflammatory Medication among Puerto Rican Asthmatic Children with Public Insurance: Results of National Survey of Pediatricians. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2010; 23:169-174. [PMID: 21766048 DOI: 10.1089/ped.2010.0023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND: There are substantial disparities in dispensing patterns of long term control medications for asthma among children in Puerto Rico with public insurance as compared to those with private insurance. Public health insurance policy in Puerto Rico includes the cost of medications in the capitation paid to the primary care physicians and clinics. METHODS: Survey questionnaires were mailed to all pediatricians enrolled in the Puerto Rico College of Physicians (n=798) in addition to some pediatricians not enrolled in the College (n=25) for a total of 823 pediatricians. Of these, 722 were eligible pediatricians with 458 responding to the survey for a response rate of 63.4%. RESULTS: Most of the respondents expressed being moderately to very familiar with the National Asthma Education and Prevention Program (NAEPP) guidelines (71.7%) and with the NAEPP recommendations for controller asthma medication use (73.5%). Inadequate capitation to cover asthma medication (86.2%) and lack of adequate health insurance coverage of the patient (83.2%) however, were the most frequent barriers reported by pediatricians for prescribing controller asthma medication to children with public health insurance. The most frequent strategies used to provide controller asthma medication to these children were prescription of oral medications (59.5%) and giving away samples (44.7%). CONCLUSIONS: Current public health insurance policy in Puerto Rico creates a disincentive to the appropriate prescription of long term control medication for children with asthma. To improve the quality of asthma care of children in Puerto Rico, revision of this public health insurance policy is necessary.
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Affiliation(s)
- Glorisa Canino
- University of Puerto Rico, Medical Sciences Campus, Behavioral Sciences Research Institute, San Juan, Puerto Rico
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Hancox RJ, Le Souëf PN, Anderson GP, Reddel HK, Chang AB, Beasley R. Asthma: time to confront some inconvenient truths. Respirology 2010; 15:194-201. [PMID: 20199640 DOI: 10.1111/j.1440-1843.2009.01700.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite major advances in the understanding of the pathogenesis of asthma and improvements in management, the accompanying benefits from public health initiatives and clinical practice have arguably been less than expected. For example, there are no effective public health strategies or treatment regimes that reduce the risk of developing asthma or influence its natural history. These represent priority areas for future translational research, which would need to investigate genetic and environmental interactions and vaccine strategies. In terms of asthma management it is tempting to focus on novel drug therapies; however, a case can be made that the priority is to undertake research that leads to improvements in the use of existing treatments through public health and primary care initiatives. Guidelines represent an important component of this approach, with recommendations for asthma imbedded within respiratory guidelines that can be implemented in the developing world where other acute and chronic respiratory disorders are common. This approach offers the best opportunity to close the gap between what is currently achieved in asthma management and that which is potentially achievable.
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Affiliation(s)
- Robert J Hancox
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
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O'Brien JM, Aberegg SK, Ali NA, Diette GB, Lemeshow S. Results from the National Sepsis Practice Survey: use of drotrecogin α (activated) and other therapeutic decisions. J Crit Care 2010; 25:658.e7-15. [PMID: 20646906 DOI: 10.1016/j.jcrc.2010.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 03/24/2010] [Accepted: 04/20/2010] [Indexed: 12/01/2022]
Abstract
PURPOSE We sought to evaluate factors associated with choices about provided care for patients with septic shock, including the use of drotrecogin α (activated) (DAA). MATERIALS AND METHODS We administered a mail-based survey to a random sample of intensivists. Study vignettes presented patients with septic shock with identical severity of illness scores but different ages, body mass indices, and comorbidities. Respondents estimated outcomes and selected care beyond standardized initial care (eg, antibiotics) for each hypothetical patient. RESULTS For most vignettes (99.1%), respondents added care, most commonly low tidal volume ventilation (87.6%) and enteral nutrition (73.3%). Choosing to administer DAA was not associated with predictions about mortality or bleeding. Vignettes with early-stage lung cancer were less likely to receive DAA. Time since medical school graduation was also associated with lower odds of selecting DAA. Most respondents (52.6%) chose identical care for all 4 completed vignettes. CONCLUSIONS There was wide variability in the therapeutic choices of respondents. The use of DAA was not associated with perceived risk of mortality or bleeding, as recommended by consensus guidelines. Physicians appear to base treatment decisions in septic shock on a consistent pattern of practice rather than estimates of patient outcome.
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Affiliation(s)
- James M O'Brien
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Center for Critical Care, Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH 43210, USA.
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Clark NM, Lachance L, Doctor LJ, Gilmore L, Kelly C, Krieger J, Lara M, Meurer J, Friedman Milanovich A, Nicholas E, Rosenthal M, Stoll SC, Wilkin M. Policy and system change and community coalitions: outcomes from allies against asthma. Am J Public Health 2010; 100:904-12. [PMID: 20299641 PMCID: PMC2853617 DOI: 10.2105/ajph.2009.180869] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2009] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. METHODS We interviewed a sample of 1477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. RESULTS A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. CONCLUSIONS Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.
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Down-titration from high-dose combination therapy in asthma: Removal of long-acting beta(2)-agonist. Respir Med 2010; 104:1110-20. [PMID: 20430604 DOI: 10.1016/j.rmed.2010.04.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 03/29/2010] [Accepted: 04/05/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND Asthma guidelines recommend reducing inhaled corticosteroids (ICS) to the minimum effective dose, but the timing of long-acting beta(2)-agonist (LABA) withdrawal is unclear. Recent FDA guidelines recommend LABA withdrawal once asthma is well-controlled. This 13-month double-blind study of patients taking high-dose combination therapy investigated the effect of discontinuation of LABA before ICS down-titration. METHODS Adults using salmeterol/fluticasone combination (SFC) 50/500 microg bd were randomized to SFC 50/500 microg bd or fluticasone propionate (FP) 500 microg bd, with subsequent ICS down-titration 8-weekly using a clinical algorithm. The primary outcome was mean daily FP dose, including ICS for exacerbations. RESULTS 82 subjects were randomized. Asthma was well-controlled at baseline, with mean FEV(1) 84.8% predicted and Asthma Control Questionnaire (ACQ) score 0.9. There was no significant difference in mean daily FP dose (SFC: 721 microg, FP:816 microg, p = 0.3), but final dose was lower with SFC (534 microg cf. 724 microg, p = 0.005). ICS dose was reduced by >or=80% in 41% SFC and 15% FP patients. Ambulatory lung function was significantly higher with SFC, but there were no differences between groups in rescue beta(2)-agonist use, clinic spirometry, airway responsiveness, ACQ, sputum eosinophils or FeNO. Baseline airway responsiveness, and pre-reduction blood eosinophils, were significant predictors of mean daily FP dose and dose reduction failure respectively. CONCLUSIONS Many patients prescribed high-dose combination therapy may be over-treated. Substantial reductions in dose can be achieved with a clinical algorithm, reaching lower FP doses with SFC than FP without losing asthma control or increasing disease activity. TRIAL REGISTRATION This study was commenced before mandatory registration of clinical trials.
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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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Reddel HK, Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, Casale TB, Chanez P, Enright PL, Gibson PG, de Jongste JC, Kerstjens HAM, Lazarus SC, Levy ML, O'Byrne PM, Partridge MR, Pavord ID, Sears MR, Sterk PJ, Stoloff SW, Sullivan SD, Szefler SJ, Thomas MD, Wenzel SE. An Official American Thoracic Society/European Respiratory Society Statement: Asthma Control and Exacerbations. Am J Respir Crit Care Med 2009; 180:59-99. [DOI: 10.1164/rccm.200801-060st] [Citation(s) in RCA: 1321] [Impact Index Per Article: 88.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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O'Brien JM, Aberegg SK, Ali NA, Diette GB, Lemeshow S. Results from the national sepsis practice survey: predictions about mortality and morbidity and recommendations for limitation of care orders. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R96. [PMID: 19549300 PMCID: PMC2717468 DOI: 10.1186/cc7926] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 05/19/2009] [Accepted: 06/23/2009] [Indexed: 11/23/2022]
Abstract
Introduction Critically ill patients and families rely upon physicians to provide estimates of prognosis and recommendations for care. Little is known about patient and clinician factors which influence these predictions. The association between these predictions and recommendations for continued aggressive care is also understudied. Methods We administered a mail-based survey with simulated clinical vignettes to a random sample of the Critical Care Assembly of the American Thoracic Society. Vignettes represented a patient with septic shock with multi-organ failure with identical APACHE II scores and sepsis-associated organ failures. Vignettes varied by age (50 or 70 years old), body mass index (BMI) (normal or obese) and co-morbidities (none or recently diagnosed stage IIA lung cancer). All subjects received the vignettes with the highest and lowest mortality predictions from pilot testing and two additional, randomly selected vignettes. Respondents estimated outcomes and selected care for each hypothetical patient. Results Despite identical severity of illness, the range of estimates for hospital mortality (5th to 95th percentile range, 17% to 78%) and for problems with self-care (5th to 95th percentile range, 2% to 74%) was wide. Similar variation was observed when clinical factors (age, BMI, and co-morbidities) were identical. Estimates of hospital mortality and problems with self-care among survivors were significantly higher in vignettes with obese BMIs (4.3% and 5.3% higher, respectively), older age (8.2% and 11.6% higher, respectively), and cancer diagnosis (5.9% and 6.9% higher, respectively). Higher estimates of mortality (adjusted odds ratio 1.29 per 10% increase in predicted mortality), perceived problems with self-care (adjusted odds ratio 1.26 per 10% increase in predicted problems with self-care), and early-stage lung cancer (adjusted odds ratio 5.82) were independently associated with recommendations to limit care. Conclusions The studied clinical factors were consistently associated with poorer outcome predictions but did not explain the variation in prognoses offered by experienced physicians. These observations raise concern that provided information and the resulting decisions about continued aggressive care may be influenced by individual physician perception. To provide more reliable and accurate estimates of outcomes, tools are needed which incorporate patient characteristics and preferences with physician predictions and practices.
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Affiliation(s)
- James M O'Brien
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH 43210, USA.
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Current Opinion in Pulmonary Medicine. Current world literature. Curr Opin Pulm Med 2009; 15:79-87. [PMID: 19077710 DOI: 10.1097/mcp.0b013e32831fb1f3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Marcus P, Arnold RJG, Ekins S, Sacco P, Massanari M, Stanley Young S, Donohue J, Bukstein D. A retrospective randomized study of asthma control in the US: results of the CHARIOT study. Curr Med Res Opin 2008; 24:3443-52. [PMID: 19032126 DOI: 10.1185/03007990802557880] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The third version of the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report (EPR-3): Guidelines on the Diagnosis and Management of Asthma emphasizes the need to use asthma control rather than patient severity to base adjustments to treatment and ultimately improve patient outcomes. The objectives of the current study were to assess control of patients with moderate-to-severe asthma, examine the natural history of the disease, practice patterns and resource utilization in specialty community practices according to recently reviewed NAEPP guidelines. RESEARCH DESIGN AND METHODS This analysis represents a retrospective, multicenter, randomized study of 1009 patient charts in sixty United States allergy and pulmonary medicine community practices. The proportion of patients with controlled and uncontrolled asthma over 12 months, prevalence and characteristics of atopy, past asthma history, pulmonary function, medications and treatment patterns, patient and clinical practice characteristics were analyzed. MAIN OUTCOME MEASURES The primary outcome of interest was asthma control. RESULTS A total of 365 male and 644 female patients with moderate-to-severe persistent asthma (mean 43.2 +/- 17.1 years) were enrolled. 81.9% of patients were uncontrolled according to recent NAEPP guidelines. Importantly, a greater percentage of patients with moderate asthma vs. severe persistent asthma were uncontrolled (p < 0.0114). Atopy was detected in 92% of patients. Patients with early onset of asthma were associated with control (p < 0.0433). Atopic symptoms, such as allergic rhinitis (p < 0.0130) and rhinosinusitis (p < 0.0476), were associated with uncontrolled asthma. Uncontrolled patients were also associated with more medications (a mean of 4.05 +/- 1.87 medications) than were controlled patients (a mean of 3.40 +/- 1.37 medications (p < 0.0001), although the temporal relationship of this association was not recorded. Limitations may have included patient and/or study site selection bias and difficulty in the process of operationalizing the definitions of control and disease severity. Since the current study only examined patients from specialty practices, the results may not be generalizable to the overall asthma population. CONCLUSIONS Greater than 80% of asthma patients from specialty practices were uncontrolled with regard to asthma symptoms. Atopic symptoms, such as allergic rhinitis and rhinosinusitis, in addition to a greater number of medications, were associated with uncontrolled asthma. Moreover, patients designated as having asthma of moderate severity were associated with being uncontrolled more than were those with severe asthma (p < 0.0114), which suggests that the former population may not have received adequate assessment of impairment or risk, with subsequent changes in treatment for control of symptoms.
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Affiliation(s)
- Philip Marcus
- St Francis Hospital, The Heart Center, Roslyn, NY, USA
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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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Yawn BP, Bertram S, Wollan P. Introduction of Asthma APGAR tools improve asthma management in primary care practices. J Asthma Allergy 2008; 1:1-10. [PMID: 21436980 PMCID: PMC3121335 DOI: 10.2147/jaa.s3595] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Primary care asthma management is often not compatible with national evidence-based guidelines. The objective of this study was to assess the feasibility and impact of the Asthma APGAR tools to enhance implementation of asthma guideline-compatible management in primary care practices. SUBJECTS Twenty-four primary care practices across the US. METHODS This is a mixed methods study. Quantitative data were used to assess changes in guideline recommended asthma management including use of daily controller therapy, planned care visits, and education and information documentation before and after implementation of the Asthma APGAR. Qualitative data from focus group sessions were used to assess health care professional and patient perceived usability and value of the Asthma APGAR tools during office visits for asthma. RESULTS Implementing the Asthma APGAR tools in the 24 practices was associated with enhanced asthma visit-related medical record documentation including significant increases in recording of activity limitations due to asthma and asthma symptom frequency, asthma medication nonadherence, asthma triggers, and the patients' perceived response to therapy (p < 0.01 for each item). Some care processes also increased significantly including assessment of inhaler technique and prescribing of daily controller therapy among patients with persistent asthma. Focus groups of patients and of clinical staff reported that the Asthma APGAR tools were easy to use, "made sense" and "improved care" was given and received. CONCLUSIONS The Asthma APGAR tools are feasible to implement in primary care practices and their implementation is associated with increased guideline-compliant asthma management.
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Affiliation(s)
- Barbara P Yawn
- Department of Research, Olmsted Medical Center, Rochester, MN, USA
| | - Susan Bertram
- Department of Research, Olmsted Medical Center, Rochester, MN, USA
| | - Peter Wollan
- Department of Research, Olmsted Medical Center, Rochester, MN, USA
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Okelo SO, Patino CM, Riekert KA, Merriman B, Bilderback A, Hansel NN, Thompson K, Thompson J, Quartey R, Rand CS, Diette GB. Patient factors used by pediatricians to assign asthma treatment. Pediatrics 2008; 122:e195-201. [PMID: 18595964 PMCID: PMC2725186 DOI: 10.1542/peds.2007-2271] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Although asthma is often inappropriately treated in children, little is known about what information pediatricians use to adjust asthma therapy. The purpose of this work was to assess the importance of various dimensions of patient asthma status as the basis of pediatrician treatment decisions. PATIENTS AND METHODS We conducted a cross-sectional, random-sample survey, between November 2005 and May 2006, of 500 members of the American Academy of Pediatrics using standardized case vignettes. Vignettes varied in regard to (1) acute health care use (hospitalized 6 months ago), (2) bother (parent bothered by the child's asthma status), (3) control (frequency of symptoms and albuterol use), (4) direction (qualitative change in symptoms), and (5) wheezing during physical examination. Our primary outcome was the proportion of pediatricians who would adjust treatment in the presence or absence of these 5 factors. RESULTS Physicians used multiple dimensions of asthma status other than symptoms to determine treatment. Pediatricians were significantly more likely to increase treatment for a recently hospitalized patient (45% vs 18%), a bothered parent (67% vs 18%), poorly controlled symptoms (4-5 times per week; 100% vs 18%), or if there was wheezing on examination (45% vs 18%) compared with patients who only had well-controlled symptoms. Pediatricians were significantly less likely to decrease treatment for a child with well-controlled symptoms and recent hospitalization (28%), parents who reported being bothered (43%), or a child whose symptoms had worsened since the last doctor visit (10%) compared with children with well-controlled symptoms alone. CONCLUSIONS Pediatricians treat asthma on the basis of multiple dimensions of asthma status, including hospitalization, bother, symptom frequency, direction, and wheezing but use these factors differently to increase and decrease treatment. Tools that systematically assess multiple dimensions of asthma may be useful to help further improve pediatric asthma care.
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Affiliation(s)
- Sande O. Okelo
- Department of Pediatrics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Cecilia M. Patino
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Kristin A. Riekert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Barry Merriman
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Andrew Bilderback
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Nadia N. Hansel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Kathy Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Jennifer Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Ruth Quartey
- Department of Epidemiology, Howard University, Washington, DC
| | - Cynthia S. Rand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Gregory B. Diette
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Sterling J. Recent Publications on Medications and Pharmacy. Hosp Pharm 2007. [DOI: 10.1310/hpj4209-866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics.
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