Modifiable factors associated with severe asthma exacerbations in urban patients

Treatment and outcome of adult patients with acute asthma in emergency departments in Australasia, South East Asia and Europe: Are guidelines followed? AANZDEM/EuroDEM study

OBJECTIVE

Asthma exacerbations are common presentations to ED. Key guideline recommendations for management include administration of inhaled bronchodilators, systemic corticosteroids and titrated oxygen therapy. Our aim was to compare management and outcomes between patients treated for asthma in Europe (EUR) and South East Asia/Australasia (SEA) and compliance with international guidelines.

METHODS

In each region, prospective, interrupted time series studies were performed including adult (age >18 years) patients presenting to ED with the main complaint of dyspnoea during three 72 h periods. This was a planned sub-study that included those with an ED primary diagnosis of asthma. Data was collected on demographics, clinical features, treatment in ED, diagnosis, disposition and in-hospital outcome. The results of interest were differences in treatment and outcome between EUR and SEA cohorts.

RESULTS

Five hundred and eighty-four patients were identified from 112 EDs (66 EUR and 46 SEA). The cohorts had similar demographics and co-morbidity patterns, with 89% of the cohort having a previous diagnosis of asthma. There were no significant differences in treatment between EUR and SEA patients - inhaled beta-agonists were administered in 86% of cases, systemic corticosteroids in 66%, oxygen therapy in 44% and antibiotics in 20%. Two thirds of patients were discharged home from the ED.

CONCLUSION

The data suggests that compliance with guideline-recommended therapy in both regions, particularly corticosteroid administration, is sub-optimal. It also suggests over-use of antibiotics.

Young Muslim Women Living with Asthma in Denmark: A Link between Religion and Self-Efficacy

Asthma is a chronic respiratory disease that can be controlled with appropriate medicinal treatment. Adherence to pharmacological treatment is therefore critical. Self-efficacy plays a key role in adherence to medicine in chronic diseases, including asthma. Additionally, ethnic minorities have poor adherence to medicines. However, the impact of religion on self-efficacy and adherence is understudied. Therefore, the aim of this study was to explore the role of self-efficacy in adherence to asthma medicine treatment and the influence of religion on self-efficacy among young, Muslim minority women. A focus group and individual interviews with 10 Muslim minority women (14–24 years of age) living in Denmark were conducted. Data analysis was deductive using Bandura’s theory of self-efficacy and modes of agency. Overall, religion was shown to affect self-efficacy. The women reported changes in self-perceived self-efficacy during the holy month of Ramadan. In addition, praying was used as an alternative to medicine for controlling asthma symptoms. However, the women did not perceive religion and treating asthma with medicine as mutually exclusive, but rather as coexisting for the shared goal of controlling asthma symptoms. It is important for healthcare professionals (HCPs) to be aware of the link between self-efficacy, religion and adherence to asthma medicine treatment. This awareness can aid HCPs in giving advice regarding adherence to asthma treatment, and when monitoring treatment to improve the quality of asthma care for young Muslim minority women.

Near Fatal Asthma in an Inner City Population

Near-fatal asthma (NFA) is highly prevalent in inner city population. Patients who present with NFA require timely intervention, which necessitates knowledge of appropriate associated risk factors. The purpose of the study was to look and identify the salient features of an asthma exacerbation that are more likely to be associated with NFA in inner city population. We conducted a retrospective analysis of patients who were discharged from the hospital with a diagnosis of acute asthma exacerbation. Two hundred eighteen patients were included in the study. Patients who required intubation during the course of their hospitalization were defined as NFA and the rest were defined as non-near-fatal asthma (NNFA). Multiple patient parameters were compared between the 2 groups; 60 patients met the definition of NFA. There was no difference between NFA and NNFA groups with respect to sex, race, and history of smoking and asthma treatment modalities before presentation. NFA was seen more commonly in heroin (40% vs. 25.9%; P < 0.05) and cocaine users (28.3% vs. 16.5%; P < 0.05). A history of exacerbation requiring intensive care unit (ICU) care was more common among the NFA patients (55% vs. 40.5%; P = 0.05). A history of intubation for an exacerbation was more commonly seen in patients presenting with NFA (51.7% vs. 35.4%; P < 0.05). The NNFA group was more likely to have a primary care physician and to be discharged home (65.6% vs. 51.7%, P < 0.05; and 71.7 vs. 79.1%, P < 0.05). In a multi-logistic regression model, including age, sex, race, heroin and cocaine use, history of intubation and ICU admission, medications, use of noninvasive ventilation, primary care physician, and pH <7.35, PCO2 >45 mm Hg, and FiO2 >40% on initial blood gas, NFA was predicted only by PaCO2 >45 [odds ratio (OR = 6.7; P < 0.001)] and FiO2 >40% (OR = 3.5; P = 0.002). Use of noninvasive ventilation was a negative predictor of NFA (OR = 0.2; P < 0.001). Asthmatic patients who carry a history of intubation with mechanical ventilation for an asthma exacerbation, admissions to the ICU, or those who indulge in recreational drugs like cocaine or heroin should be closely monitored for clinical deterioration.

Towards tailored and targeted adherence assessment to optimise asthma management

In this paper, we aim to emphasise the need for a more comprehensive and tailored approach to manage the broad nature of non-adherence, to personalise current asthma management. Although currently several methods are available to measure the extent of asthma patients' adherence, the vast majority do not incorporate confirmation of the actual inhalation, dose and inhalation technique. Moreover, most current measures lack detailed information on the individual consequences of non-adherence and on when and how to take action if non-adherence is identified. Notably, one has to realise there are several forms of non-adherence (erratic non-adherence, intelligent non-adherence and unwitting non-adherence), each requiring a different approach. To improve asthma management, more accurate methods are needed that integrate measures of non-adherence, asthma disease control and patient preferences. Integrating information from the latest inhaler devices and patient-reported outcomes using mobile monitoring- and feedback systems ('mHealth') is considered a promising strategy, but requires careful implementation. Key issues to be considered before large-scale implementation include patient preferences, large heterogeneity in patient and disease characteristics, economic consequences, and long-term persistence with new digital technologies.

Proximity to busy highways and local resident perceptions of air quality

This study investigated variations in perceptions of air quality as a function of residential proximity to busy highways, across two suburbs of South Auckland, New Zealand. While plenty is known about the spatial gradients of highway emissions, very little is known about variation of lay understanding at the fine spatial scale and whether there are gradients in severity of concerns. One-hundred and four near-highway residents agreed to participate in a semi-structured interview on their knowledge and attitudes towards highway traffic emissions. Proximity to the highway edge varied within 5-380 m at the predominantly downwind side of the highway and 13-483 m at the upwind side. Likert-type ordered response questions were analysed using multivariate regression. Inverse linear relationships were identified for distance from highway and measures of concern for health impacts, as well as for noise (p<0.05). Positive linear relationships were identified for distance from highway and ratings of both outdoor and indoor air quality (p<0.05). Measures of level of income had no conclusive statistically significant effect on perceptions. Additional discussion was made surrounding participant's open-ended responses, within the context of limited international research. Findings indicate that there may be quantifiable psychological benefits of separating residents just a short distance (40 m+) from highways and that living within such close proximity can be detrimental to wellbeing by restricting local outdoor activity. This work lends additional rationale for a residential separation buffer of ~100 m alongside major highways in the interests of protecting human health.

Persistent differences in asthma self-efficacy by race, ethnicity, and income in adults with asthma

OBJECTIVE

The objective of this population-based study was to determine if and to what extent there are differences in asthma self-efficacy by race/ethnicity and income, and whether health status, levels of acculturation, and health care factors may explain these differences.

METHODS

We conducted a secondary data analysis of asthma self-efficacy using the 2009 and 2011-2012 California Health Interview Survey, in adults with asthma (n=7874). In order to examine if and how the effect of race/ethnicity and income on asthma self-efficacy may have been altered by health status, acculturation, and health care factors, we used staged multivariable logistic regression models. We conducted mediation analyses to evaluate which of these factors might mediate disparities in self-efficacy by race/ethnicity and income.

RESULTS

69.8% of adults reported having high asthma self-efficacy. Latinos (OR 0.66; 95% CI 0.51-0.86), African-Americans (OR 0.50; 95% CI 0.29-0.83), American Indian/Alaskan Natives (OR 0.55; 95% CI 0.31-0.98) and Asian/Pacific Islanders (OR 0.34; 95% CI 0.23-0.52) were less likely to report high self-efficacy compared to Whites. Individuals with income below the federal poverty level (OR 0.56; 95% CI 0.40-0.78) were less likely to report high self-efficacy compared to higher income individuals. The relationship between income and self-efficacy was no longer significant after further adjustment for health care factors; however, the differences in race and ethnicity persisted. Receiving an asthma management plan mediated the relationship in certain subgroups.

CONCLUSIONS

Addressing modifiable health care factors may play an important role in reducing disparities in asthma self-efficacy.

The active patient role and asthma outcomes in an underserved rural community

PURPOSE

Patient activation, an individual's knowledge, skills, and confidence for managing their own health and health care, can play an important role in the management of chronic conditions. However, few studies have examined patient activation in underserved rural communities. The purpose of this study was to describe patient activation and examine how patient activation is associated with adherence to asthma maintenance medication and disease control in a low-income rural population with asthma.

METHODS

We conducted a cross-sectional telephone survey with 98 adults. Patient activation was assessed with the Patient Activation Measure. Adherence to long-term controller (LTC) medications and asthma control were examined using the Morisky Medication Adherence Scale (MMAS) and Asthma Control Test (ACT). Multivariate regression analyses were used to assess the associations between patient activation and: (1) adherence to LTC medications and (2) asthma control.

FINDINGS

The majority of participants (50%) were classified in the highest level of patient activation. The least activated participants had lower mean MMAS and ACT scores in comparison to participants who were classified in higher patient activation levels. Multivariate analyses found significant positive associations between patient activation and adherence and asthma control.

CONCLUSIONS

Patient activation may be instrumental in low-income rural patients' use of asthma medication and disease control. Study results inform interventions to help patients use asthma medications appropriately and achieve better asthma control. In addition to increasing access to health care services in rural communities, health care professionals also may develop and implement strategies to positively impact rural patients' involvement in care.