Achieving and maintaining asthma control in an urban pediatric disease management program: the Breathmobile Program

How Schools Can Help Address Social Determinants of Health in Asthma Management

Schools are in a unique position to address social determinants of health (SDOHs) in pediatric asthma management because of their potential to provide resources and facilitate collaboration with health care providers and services for children at risk within their community. SDOHs include economic factors, educational attainment and health literacy, neighborhood factors and the built environment, social and community aspects including discrimination and racism, and health care access and quality. These factors have a significant impact on asthma health in children, and certain populations such as minoritzed populations and those living in high-poverty environments have been shown to be at greater risk for adverse effects of SDOHs on asthma outcomes. School-based asthma programs address several SDOHs including health literacy, the built environment, and health care quality and access and have been shown to improve asthma outcomes. Key components include connection between the school and the health care team, self-management education, and directly observed therapy. School nurses play a key role in directing and managing effective programs because they can evaluate and support a student's health while considering the effect of SDOHs at interpersonal, institutional, community, and policy levels.

School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

BACKGROUND

Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes.

OBJECTIVES

This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses.

SEARCH METHODS

We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017.

SELECTION CRITERIA

Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control.

DATA COLLECTION AND ANALYSIS

We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ).

MAIN RESULTS

We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence).

AUTHORS' CONCLUSIONS

School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.

Preventative health, diversity, and inclusion: a qualitative study of client experience aboard a mobile health clinic in Boston, Massachusetts

Background

There are approximately 2000 mobile health clinics operating in the United States. While researchers have established that mobile health clinics can be cost effective and improve outcomes, there is scant research examining the healthcare experience on a mobile health clinic from patients’ perspectives.

Methods

Data were gathered from interviews with 25 clients receiving care on a Boston-based mobile health clinic and analyzed using grounded theory methodology.

Results

Emerging patterns in the data revealed three relational and three structural factors most significant to participants’ experience of care on The Family Van. Relational factors include providers who 1) Communicate understandably, 2) Create a culture of respect and inclusivity, and 3) Are diverse with knowledge of the community. Structural factors include 1) A focus on preventative health and managing chronic disease, 2) Expeditious, free, and multiple services, and 3) Location.

Conclusions

The participant accounts in this report serve to expand on prior research exploring mobile health clinics’ role in patients’ healthcare, to more clearly define the most salient aspects of the mobile health clinic model for the patients they serve, and to give voice to patients too seldom heard in the academic literature.

Electronic supplementary material

The online version of this article (10.1186/s12939-017-0688-6) contains supplementary material, which is available to authorized users.

Leveraging Partnerships: Families, Schools, and Providers Working Together to Improve Asthma Management

Asthma is one of the most common illnesses of school-aged children and can lead to both health and educational disparities. Children from low socioeconomic backgrounds and racial/ethnic minorities suffer the greatest impact. They often lack the asthma self-management skills to successfully monitor, navigate, and negotiate appropriate asthma care. School settings are a strategic point of contact for this additional support. School nurses can monitor for signs of asthma worsening, manage symptoms, provide care coordination, and reinforce self-management skills. Likewise, school-based asthma programs have the potential to reduce health and educational disparities, but it is the strong linkage to the asthma care provider that is critical to successful school-based asthma management. Healthcare providers are encouraged to establish partnerships with families through patient-centered care and schools through clear communication and care coordination to ensure asthma is well controlled so the child is in school and ready to learn.

Asthma control and need for future asthma controller therapy among inner-city Hispanic asthmatic children engaged in a pediatric asthma disease management program (the Breathmobile program, Mobile Asthma Care for Kids Network)

OBJECTIVE

To determine whether significant numbers of asthmatic children with initially rated intermittent asthma later suffer poor asthma control and require the addition of controller medications.

METHODS

Inner-city Hispanic children were followed prospectively in an asthma-specific disease management system (Breathmobile) for a period of 2 years. Clinical asthma symptoms, morbidity treatment, and demographic data were collected at each visit. Treatment was based upon National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Report 3 asthma guidelines. Primary outcome was percentage of patients with intermittent asthma who had not well or poorly controlled asthma during subsequent visits and required controller agents. Secondary outcomes were factors associated with the maintenance of asthma control.

RESULTS

About 30.9% of the patients with initial rating of intermittent asthma had not well controlled and poorly controlled asthma during subsequent visits and required the addition of controller agents. Factors associated with good asthma control were compliance, no previous emergency room visits and previous visit during spring season.

CONCLUSION

Asthmatic children with intermittent asthma often lose asthma control and require controller therapy. This justifies asthma guideline recommendations to assess asthma control at follow-up visits and adjust therapy accordingly.

Factors affecting ability to achieve asthma control in adult patients with moderate to severe persistent asthma

OBJECTIVE

Despite the use of optimal therapy and guidelines, the rate of asthma control is suboptimal in adult populations. Purpose of this study is to describe factors associated with ability to achieve well-controlled asthma over time for adult patients treated in a tertiary medical center-based asthma outpatient specialty clinic.

METHODS

Existing clinical data collected for 320 adult patients enrolled in a hospital-based outpatient asthma specialty clinic from July 1, 2003 through June 30, 2011 evaluated time to achieve well-controlled asthma and factors associated with well-controlled asthma such as adherence and lack of previous exacerbations.

RESULTS

Adherence to prescribed therapy (p = 0.004) and no previous asthma related ED visits (p = 0.004) were associated with well-controlled asthma for moderate persistent baseline. BMI on a continuous spectrum (p = 0.120) and the diagnosis of allergic rhinitis (p = 0.769) were not independently significant. Body-mass-index (BMI) in combination with adherence did influence ability to achieve well-controlled asthma (p < 0.05). Adherence (p = 0.615), allergic rhinitis (p = 0.172), BMI continuous scale (p = 0.074) and visit interval <90 days (p = 0.653) were not independently associated with likelihood of achieving well-controlled asthma in severe persistent asthmatics. Significance of particular factors in combination (adherence, allergic rhinitis, sex, BMI) showed dependency on other variables in achieving well-controlled asthma.

CONCLUSIONS

Different factors are associated with asthma control for different patient subpopulations. Adherence to standard therapy did not improve obese (BMI > 30) patients' ability to achieve asthma control. Female patients were less likely to obtain well-controlled asthma per unit increase of BMI. Multiple factors must be addressed to optimize attaining asthma control.

A systematic review of the implementation and impact of asthma protocols

BACKGROUND

Asthma is one of the most common childhood illnesses. Guideline-driven clinical care positively affects patient outcomes for care. There are several asthma guidelines and reminder methods for implementation to help integrate them into clinical workflow. Our goal is to determine the most prevalent method of guideline implementation; establish which methods significantly improved clinical care; and identify the factors most commonly associated with a successful and sustainable implementation.

METHODS

PUBMED (MEDLINE), OVID CINAHL, ISI Web of Science, and EMBASE.

STUDY SELECTION

Studies were included if they evaluated an asthma protocol or prompt, evaluated an intervention, a clinical trial of a protocol implementation, and qualitative studies as part of a protocol intervention. Studies were excluded if they had non-human subjects, were studies on efficacy and effectiveness of drugs, did not include an evaluation component, studied an educational intervention only, or were a case report, survey, editorial, letter to the editor.

RESULTS

From 14,478 abstracts, we included 101 full-text articles in the analysis. The most frequent study design was pre-post, followed by prospective, population based case series or consecutive case series, and randomized trials. Paper-based reminders were the most frequent with fully computerized, then computer generated, and other modalities. No study reported a decrease in health care practitioner performance or declining patient outcomes. The most common primary outcome measure was compliance with provided or prescribing guidelines, key clinical indicators such as patient outcomes or quality of life, and length of stay.

CONCLUSIONS

Paper-based implementations are by far the most popular approach to implement a guideline or protocol. The number of publications on asthma protocol reminder systems is increasing. The number of computerized and computer-generated studies is also increasing. Asthma guidelines generally improved patient care and practitioner performance regardless of the implementation method.

Respiratory tract infections and asthma control in children

INTRODUCTION

Asthma control is considered the major goal of asthma management, while many determinants of control are difficult to modify. We studied the association between respiratory infection episodes (RTIs) of various types and asthma control.

METHODS

Cross-sectional data were used from children aged 4-18 years with physician-diagnosed asthma who participated in a web-based electronic portal for children with asthma, allergies or infections. Asthma control was measured using the Childhood Asthma Control Test (C-ACT) or the Asthma Control Test (ACT). Linear regression was used to analyse the association between categories of numbers of various types of RTIs sustained in the preceding 12 months (categorized) and asthma control, adjusted for potential confounders.

RESULTS

Asthma control was assessed in 654 children, and 68.5% were clinically well controlled (ACT ≥ 20). Higher total numbers of RTIs in the last 12 months were strongly associated with a lower level of asthma control (p(trend) < 0.001). Similarly strong statistically significant associations were found for subtypes of RTI: ≥4 vs. 0 otitis episodes: coefficient -1.7 (95% CI -3.3 to -0.2); ≥5 vs.0 colds: coefficient -2.3 (95% CI -3.0 to -1.6); ≥3 vs. 0 bronchitis episodes: coefficient -3.1 (95% CI -4.0 to -2.3), each with p(trend) < 0.05.

CONCLUSION

Higher numbers of reported respiratory tract infections are associated with lower level of asthma control. The different type of respiratory tract infections contribute equally to less controlled asthma.

Individualizing asthma therapy: application of biomarkers

New asthma guidelines of National Asthma Education and Prevention Program (NAEPP) were released recently with a special emphasis on new information in asthma management. The new asthma guidelines emphasize several key terms including severity, control, impairment, risk, and responsiveness that are relevant for advancing the care of asthma. New directions in asthma research that could advance asthma management include early diagnosis and intervention, use of combination therapy to achieve asthma control, application of biomarkers and genetics to individualize asthma therapy, and the identification of immunomodulator therapy to alter the course of the disease. This review will discuss the application of biomarkers for asthma management. One biomarker that can serve as a prototype for the application of biomarkers to asthma care is exhaled nitric oxide (eNO). Initially used as a research tool and now being applied in clinical practice, this biomarker has been available for approximately 10 years. As such, valuable lessons have been learned regarding the advantages and limitations of this biomarker for asthma care.

Asthma control, cost and race: results from a national survey

OBJECTIVE

Although interventions have been shown to alleviate symptoms in most patients suffering from asthma, only one-third of asthma patients have disease that is well-controlled. The purpose of this study is to investigate whether partly and uncontrolled asthmas are associated with increased costs for asthma-related healthcare utilization compared to well-controlled asthma and to determine whether these associations differed across racial groups.

METHODS

We classified respondents from the Asthma Insights and Management survey into those with well-, partly and uncontrolled asthma and compared utilization of healthcare services and costs among these groups, as well as between whites and non-whites.

RESULTS

Respondents categorized as having asthma that was not well-controlled reported lower income levels, higher rates of unemployment and more trouble paying for healthcare; similar results were found in analyses stratified by race. Patients whose asthma was partly or uncontrolled had greater use of asthma-related medications and medical services compared to patients whose asthma was well-controlled. Total unadjusted and adjusted costs were greater in patients whose asthma was classified as partly and uncontrolled. Similar results were found in analyses stratified on race. Across all levels of asthma control, non-whites had higher rates of utilization of emergency rooms and urgent care facilities and had greater rates of hospitalizations compared to whites.

CONCLUSIONS

Our findings indicate that patients with asthma that is not well-controlled utilized more healthcare resources and had greater medical costs, despite lacking of health insurance which may suggest less access to care.

Well-child care clinical practice redesign for young children: a systematic review of strategies and tools

BACKGROUND AND OBJECTIVE

Various proposals have been made to redesign well-child care (WCC) for young children, yet no peer-reviewed publication has examined the evidence for these. The objective of this study was to conduct a systematic review on WCC clinical practice redesign for children aged 0 to 5 years.

METHODS

PubMed was searched using criteria to identify relevant English-language articles published from January 1981 through February 2012. Observational studies, controlled trials, and systematic reviews evaluating efficiency and effectiveness of WCC for children aged 0 to 5 were selected. Interventions were organized into 3 categories: providers, formats (how care is provided; eg, non-face-to-face formats), and locations for care. Data were extracted by independent article review, including study quality, of 3 investigators with consensus resolution of discrepancies.

RESULTS

Of 275 articles screened, 33 met inclusion criteria. Seventeen articles focused on providers, 13 on formats, 2 on locations, and 1 miscellaneous. We found evidence that WCC provided in groups is at least as effective in providing WCC as 1-on-1 visits. There was limited evidence regarding other formats, although evidence suggested that non-face-to-face formats, particularly web-based tools, could enhance anticipatory guidance and possibly reduce parents' need for clinical contacts for minor concerns between well-child visits. The addition of a non-medical professional trained as a developmental specialist may improve receipt of WCC services and enhance parenting practices. There was insufficient evidence on nonclinical locations for WCC.

CONCLUSIONS

Evidence suggests that there are promising WCC redesign tools and strategies that may be ready for larger-scale testing and may have important implications for preventive care delivery to young children in the United States.

Asthma in a primary health care center serving a poor population: a descriptive and interventional study

Asthma is a common chronic disease. Due to difficulties in accessibility to the health care system, asthma affects severely to minorities. This study's objective is to describe the morbidity of asthma on a poor population and its modification after abolishing assistance barriers.

Thirty-four asthma camps were carried out between May 2004 and May 2007. Patients' socioeconomic conditions, asthma history, and symptoms in the last month were determined during the camps. Patients received free medication and were invited to come to follow-up. Fifty-six children younger than 12 years old and 53 adults with persistent asthma were evaluated in 783 visits. The mean monthly income per capita was US $28.57.

At baseline, 50% of children and 34.5% of adults received inhaled corticosteroids. After intervention, 92.7% children and 98.1% adults received inhaled corticosteroids. Treatment was associated with a significant reduction of daytime and nighttime symptoms, absences to school or work, and emergency room visits and admissions. Patients referred less interference and more control of their disease in their everyday life.

Our results suggest that this population receives an insufficient treatment of its asthma severity. For such population, moving specialized assistance to the primary health care center resulted in a better control of their illness.

Community-based care coordination: practical applications for childhood asthma

Care coordination programs have been used to address chronic illnesses, including childhood asthma, but primarily via practice-based models. An alternative approach employs community-based care coordinators who bridge gaps between families, health care providers, and support services. Merck Childhood Asthma Network, Inc. (MCAN) sites developed community-based care coordination approaches for childhood asthma. Using a community-based care coordination logic model, programs at each site are described along with program operational statistics. Four sites used three to four community health workers (CHWs) to provide care coordination, whereas one site used five school-based asthma nurses. This school-based site had the highest caseload (82.5 per year), but program duration was 3 months with 4 calls or visits. Other sites averaged fewer cases (35 to 61 per CHW per year), but families received more (7 to 17) calls or visits over a year. Retention was 43% to 93% at 6 months and 24% to 75% at 12 months. Pre-post cross-site data document changes in asthma management behaviors and outcomes. After program participation, 93% to 100% of caregivers had confidence in controlling their child's asthma, 85% to 92% had taken steps to reduce triggers, 69% to 100% had obtained an asthma action plan, and 46% to 100% of those with moderate to severe asthma reported appropriate use of controller medication. Emergency department visits for asthma decreased by 36% to 63%, and asthma-related hospitalizations declined by 26% to 78%. More than three fourths had fewer school absences. In conclusion, MCAN community-based care coordination programs improved management behaviors and decreased morbidity across all sites.

Development and validation of the Composite Asthma Severity Index--an outcome measure for use in children and adolescents

BACKGROUND

Asthma severity is reflected in many aspects of the disease, including impairment and future risks, particularly for exacerbations. According to the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, however, to assess more comprehensively the severity of asthma the level of current treatment needed to maintain a level of control should be included.

OBJECTIVE

Development and validation of a new instrument, the Composite Asthma Severity Index (CASI), which can quantify disease severity by taking into account impairment, risk, and the amount of medication needed to maintain control. At present, there is no instrument available to measure and assess the multidimensional nature of asthma.

METHODS

Twenty-six established asthma investigators, who are part of the National Institutes of Health-supported Inner City Asthma Consortium, participated in a modified Delphi consensus process to identify and weight the dimensions of asthma. Factor analysis was performed to identify independent domains of asthma by using the Asthma Control Evaluation trial. CASI was validated by using the Inner City Anti-IgE Therapy for Asthma trial.

RESULTS

CASI scores include 5 domains: day symptoms and albuterol use, night symptoms and albuterol use, controller treatment, lung function measures, and exacerbations. At Asthma Control Evaluation trial enrollment, CASI ranged from 0 to 17, with a mean of 6.2. CASI was stable, with minimal change in variance after 1 year of treatment. In external validation, CASI detected a 32% larger improvement than did symptoms alone.

CONCLUSION

CASI retained its discriminatory ability even with low levels of symptoms reported after months of guidelines-directed care. Thus, CASI has the ability to determine the level of asthma severity and provide a composite clinical characterization of asthma.

Community-based approaches to controlling childhood asthma

The prevalence and burden of childhood asthma remain high and are increasing. Asthma hot spot neighborhoods around the country face particular challenges in controlling the effects of the condition. Increasing attention is being paid to developing interventions that recognize the child and family as the primary managers of disease and to introducing assistance that reaches beyond the clinical care setting into the places where families live and work. A range of types of community-focused interventions has been assessed in the past decade in schools, homes, and community health clinics, and programs using electronic media and phone links have been evaluated. Stronger evidence for all these approaches is needed. However, school-based programs and community coalitions designed to bring about policy and systems changes show particular promise for achieving sustainable improvements in asthma control. Research is needed that emphasizes comparisons among proven asthma control interventions, translation of effective approaches to new settings and communities, and institutionalization of effective strategies.

Adherence to inhaled corticosteroids: an ancillary study of the Childhood Asthma Management Program clinical trial

BACKGROUND

Information comparing subjective and objective measurements of adherence to study medications and the effects of adherence on treatment-related differences in asthma clinical trials are limited.

OBJECTIVE

We sought to compare subjective and objective measurements of children's adherence to inhaled corticosteroids or placebo and to determine whether adherence to study medications modified treatment-related differences in outcomes.

METHODS

In an ancillary study conducted in 3 of 8 Childhood Asthma Management Program Clinical Centers, adherence was assessed by using self-reported and objective data in 5- to 12-year-old children with mild or moderate asthma who were randomly assigned to 200 μg of inhaled budesonide twice per day (n = 84) or placebo (n = 56) for 4 years. The κ statistic was used to evaluate agreement between self-reported adherence (daily diary cards) and objectively measured adherence (number of doses left in study inhalers). Multivariable analyses were used to determine whether adherence to study treatment modified treatment-related differences in outcomes.

RESULTS

Adherence of less than 80% was seen in 75% of 140 children when adherence was measured objectively but only in 6% of children when measured by means of self-report. There was poor agreement between objective and subjective measurements of adherence of at least 80% (κ = 0.00; 95% CI, -0.05 to 0.04); self-reported adherence over the 4-year period generally overestimated objectively measured adherence (93.6% vs 60.8%, P < .0001). There was little evidence to indicate that adherence modified treatment-related differences in outcomes.

CONCLUSION

Researchers should use objective rather than self-reported adherence data to identify clinical trial participants with low levels of adherence to study treatment.

Asthma in Head Start children: effects of the Breathmobile program and family communication on asthma outcomes

BACKGROUND

Asthma morbidity and mortality rates are high among young inner-city children. Lack of routine primary care provider visits, poor access to care, and poor patient-physician communication might be contributing factors.

OBJECTIVE

This study evaluated the effects of providing Breathmobile services only, a Facilitated Asthma Communication Intervention (FACI) only, or both Breathmobile plus FACI on asthma outcomes relative to standard care.

METHODS

Children with asthma (n = 322; mean age, 4 years; 53% male; 97% African American) were recruited from Head Start programs in Baltimore City and randomized into 4 groups. Outcome measures included symptom-free days (SFDs), urgent care use (emergency department visits and hospitalizations), and medication use (courses of oral steroids and proportion taking an asthma controller medication), as reported by caregivers at baseline, 6-month, and 12-month assessments. Generalized estimating equations models were conducted to examine the differential treatment effects of the Breathmobile and FACI compared with standard care.

RESULTS

Children in the combined treatment group (Breathmobile plus FACI) had an increase of 1.7 (6.6%) SFDs that was not maintained at 12 months. In intent-to-treat analyses the FACI-only group had an increase in the number of emergency department visits at 6 months, which was not present at 12 months or in the post hoc as-treated analyses. No significant differences were found between the intervention groups compared with those receiving standard care on all other outcome measures.

CONCLUSIONS

Other than a slight improvement in SFDs at 6 months in the Breathmobile plus FACI group, the intervention components did not result in any significant improvements in asthma management or asthma morbidity.

Economic burden of impairment in children with severe or difficult-to-treat asthma

BACKGROUND

The cost associated with asthma impairment in children with severe asthma has not been determined.

OBJECTIVE

To assess the asthma cost burden in children with severe or difficult-to-treat asthma based on asthma impairment.

METHODS

Children aged 6 to 12 years in The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study with available data at baseline (n = 628), month 12 (n = 385), and month 24 (n = 280) corresponding to the National Heart, Lung, and Blood Institute asthma guidelines' impairment domain were included. Children were categorized as either very poorly controlled (VPC), not well controlled (NWC), or well controlled (WC) and assessed cross-sectionally and longitudinally. Mean total asthma costs based on direct (medication usage, unscheduled office visits, emergency department visits, hospitalizations) and indirect (school/work days lost) asthma costs were assessed.

RESULTS

Mean annual total asthma costs were more than twice as high in the VPC group compared with NWC and WC groups (baseline: $7,846, $3,526, $3,766.44, respectively; month 12: $7,326, $2,959, $2,043, respectively; month 24: $8,879, $3,308, $1,861, respectively (all P < .001). Indirect costs accounted for approximately half the total asthma costs for VPC asthma patients at each time point. Significantly lower costs were observed for patients whose impairment status improved or temporarily improved from VPC after baseline.

CONCLUSION

The economic burden of severe or difficult-to-treat asthma in children is associated with VPC asthma and improvement in asthma control and is associated with reducing cost. Further attention to patients with poorly controlled asthma, through better management strategies or more effective medications, may significantly reduce this burden of illness.

Achieving and maintaining asthma control in inner-city children

BACKGROUND

Despite guidelines-defined care, inner-city children of low socioeconomic status have poor asthma control.

OBJECTIVE

This study evaluated time to achieve control, maintenance of control, and factors associated with well controlled asthma for pediatric patients receiving specialty-based asthma care in mobile asthma clinics designed to reduce barriers to delivering effective asthma care (the Breathmobile Program).

METHODS

Existing clinical data collected from January 1998 to June 2008 for 7822 pediatric patients with asthma (34,339 visits) enrolled in similarly structured mobile asthma programs across the United States evaluated the effect of asthma control on the reduction of asthma-related morbidity, time to achieve asthma control, maintenance of asthma control, and factors associated with well controlled asthma.

RESULTS

Comparison of pre and post year data for subjects enrolled in the program for at least 1 year revealed reductions in the percentage of patients reporting emergency department visits (mean, 66%), hospitalizations (mean, 84%), and missed school days ≥5/year (mean, 78%). Well controlled asthma was achieved by visit 3 for an estimated 80% of patients. Factors contributing to well controlled asthma include non-African American race, visit interval <90 days, and adherence to prescribed therapy.

CONCLUSION

This study demonstrates the ability to achieve and maintain asthma control in high-risk populations in association with intensive, accessible, guidelines-defined care with close follow-up.

Residential Proximity to Freeways is Associated with Uncontrolled Asthma in Inner-City Hispanic Children and Adolescents

Background. Proximity to heavy traffic has been linked to increased asthma severity. However, it is unknown whether exposure to heavy traffic is associated with the ability to maintain asthma control. Objectives. This study examines whether exposure to heavy traffic is associated with the ability to maintain asthma control in inner-city children. Methods. 756 inner-city asthmatic Hispanic children were followed for one year in a pediatric asthma management program (Breathmobile). At each scheduled visit, asthma specialist tracked patients' asthma severity and managed their asthma based on the NAEPP guidelines. The patients' residential distance from the nearest freeway was calculated based on residential address at study entry. Distance to nearest freeway was used as a surrogate marker for high exposure from traffic-related air pollutants. Results. Patients who lived near a freeway were significantly more likely to have asthma that was not well controlled (P = .03). Patients with intermittent and mild baseline severity have a two-fold increased risk of having asthma that is uncontrolled if they lived <2 miles from a freeway (OR = 2.2, P = .04). Conclusion. In children with asthma, residential proximity to freeways is associated with uncontrolled asthma.

Achieving asthma control in the inner city: do the National Institutes of Health Asthma Guidelines really work?

For children living in inner cities, asthma tends to be more frequent and severe. To characterize, understand, and treat children with asthma living in the inner city more effectively, the National Institute of Allergy and Infectious Diseases established an Inner-City Asthma Program in 1991. In addition, the revised National Asthma Education and Prevention Program Expert Panel 3 report was introduced with new concepts for asthma management that are now centered on asthma control. The purpose of this review is to highlight features of the National Institute of Allergy and Infectious Diseases Inner-City Asthma Consortium Asthma Control Evaluation study that enhance our knowledge regarding the application of the asthma guidelines and to provide a summary of lessons learned from that important study. We recognized that asthma symptoms and exacerbations are theoretically linked to underlying inflammation of airways but are not direct indicators of inflammation. Based on the observations from the Asthma Control Evaluation study, we were impressed that a systematic guidelines-based approach improved asthma control significantly over the course of the 1-year treatment period.

[Factors associated with asthma control in primary care patients: the CHAS study]

BACKGROUND

Asthma control is inadequate in all populations studied to date, leading to a major part of the cost of the disease. The aim of our study was to evaluate the prevalence of uncontrolled asthma in primary care patients and identify the associated factors.

METHODS

We carried out a cross-sectional study of the population of primary care asthmatic patients over 18 years old in Spain (n=2159). Asthma control was measured with the Asthma Control Questionnaire (ACQ). The sociodemographic variables and treatment compliance were measured using a questionnaire. We built logistic-regression models using Asthma control, a dichotomous variable generated from ACQ score.

RESULTS

The prevalence of uncontrolled asthma was 63.9%. Treatment with oral corticosteroids (OCS) (OR=6.55), greater asthma severity (OR=3.11), presence of a distressing event (OR=2.44), lower significance given to treatment compliance (OR=1.66) and living in a rural area (OR=1.29) are associated with uncontrolled asthma. On the contrary, sex, age, obesity, smoking, alcohol intake and educational level had no effect on asthma control.

CONCLUSIONS

In Spain asthma is still uncontrolled and some factors leading to this situation appear to be modifiable by the health system.

Long-term maintenance of pediatric asthma: focus on budesonide/formoterol inhalation aerosol

Current national and international asthma guidelines recommend treatment of children with asthma towards achieving and maintaining asthma control. These guidelines provide more stringent recommendations to increase therapy for patients with uncontrolled asthma in order to reduce asthma-related morbidity and mortality. Newer combination agents such as budesonide and formoterol have been shown to be safe and effective in treatment of asthma in children. Use of long-term controller agents like this in combination with improved compliance and treatment of co-morbid conditions have been successful in this endeavor. This review discusses control of pediatric asthma with focus on the use of budesonide in combination with formoterol.

Detection of undiagnosed and poorly controlled asthma in a hospital-based outpatient pediatric primary care clinic using a health risk assessment system

OBJECTIVE

To determine the rate of undiagnosed and poorly controlled asthma detected by a computerized health risk assessment (HRA) survey system in an urban pediatric hospital-based outpatient teaching clinic.

METHODS

A software-based HRA system uses survey answer patterns to identify children with (1) probable, (2) uncontrolled, and (3) moderate to severe asthma. Parents of patients > or = 2 years of age were asked by clinic staff to complete the touch screen computer survey before seeing their physician from August 2005 through July 2006.

RESULTS

The HRA survey predicted 26% (282/1,098) to have probable asthma. Of these, 51% (144/282) were controlled and the parents reported a previous diagnosis of asthma; 14% (40/282) were controlled and the parents did not report a previous diagnosis of asthma; 25% (71/282) were uncontrolled and the parents reported a previous diagnosis of asthma; and 10% (27/282) were uncontrolled and no previous diagnosis of asthma was reported by the parents. Among active cases completing the baseline version survey (N = 217), 68% reported emergency department (ED) visits / hospitalizations in the last 2 years (44% > or =2), while 59% reported missed school days during the previous year (23% > or =5 days). Impairment, as defined by the 2007 National Heart, Lung, and Blood Institute/National Asthma Education and Prevention Program (NHLBI/NAEPP) asthma guidelines, tended to be higher in patients without a previous diagnosis of asthma, per parental report, but this trend only achieved significance in two measures: daytime symptoms > or =2 days per week in the last 4 weeks (p = 0.028) and more than 5 missed school days in the past year (p = 0.001).

CONCLUSION

A previously validated HRA system can consistently identify a high rate of undiagnosed and poorly controlled asthma in an urban pediatric hospital-based teaching clinic. The utility of such a system would be to reduce missed opportunities for delivery of care and morbidity for the patients who currently have undiagnosed and/or uncontrolled asthma in the pediatric primary care outpatient setting.

Socioeconomic, family, and pediatric practice factors that affect level of asthma control

BACKGROUND

Multiple issues play a role in the effective control of childhood asthma.

OBJECTIVE

To identify factors related to the level of asthma control in children receiving asthma care from community pediatricians.

PATIENTS AND METHODS

Data for 362 children participating in an intervention study to reduce asthma morbidity were collected by a telephone-administered questionnaire. Level of asthma control (well controlled, partially controlled, or poorly controlled) was derived from measures of recent impairment (symptoms, activity limitations, albuterol use) and the number of exacerbations in a 12-month period. Data also included demographic characteristics, asthma-related quality of life, pediatric management practices, and medication usage. Univariable and multivariable analyses were used to identify factors associated with poor asthma control and to explore the relationship between control and use of daily controller medications.

RESULTS

Asthma was well controlled for 24% of children, partially controlled for 20%, and poorly controlled for 56%. Medicaid insurance, the presence of another family member with asthma, and maternal employment outside the home were significant univariable factors associated with poor asthma control. Medicaid insurance had an independent association with poor control. Seventy-six percent of children were reported by parents as receiving a daily controller medication. Comparison of guideline recommended controller medication with current level of asthma control indicated that a higher step level of medication would have been appropriate for 74% of these children. Significantly lower overall quality-of-life scores were observed in both parents and children with poor control.

CONCLUSIONS

Despite substantial use of daily controller medication, children with asthma continue to experience poorly controlled asthma and reduced quality of life. Although Medicaid insurance and aspects of family structure are significant factors associated with poorly controlled asthma, attention to medication use and quality-of-life indicators may further reduce morbidity.

Azithromycin or montelukast as inhaled corticosteroid-sparing agents in moderate-to-severe childhood asthma study

BACKGROUND

Clinical trials in children with moderate-to-severe persistent asthma are limited.

OBJECTIVE

We sought to determine whether azithromycin or montelukast are inhaled corticosteroid sparing.

METHODS

The budesonide dose (with salmeterol [50 microg] twice daily) necessary to achieve control was determined in children 6 to 17 years of age with moderate-to-severe persistent asthma. After a budesonide-stable period of 6 weeks, children were randomized in a double-masked, parallel, multicenter study to receive once-nightly azithromycin, montelukast, or matching placebos plus the established controlling dose of budesonide (minimum, 400 microg twice daily) and salmeterol twice daily. Primary outcome was time from randomization to inadequate asthma control after sequential budesonide dose reduction.

RESULTS

Of 292 children screened, only 55 were randomized. Inadequate adherence to study medication (n = 80) and improved asthma control under close medical supervision (n = 49) were the major reasons for randomization failure. A futility analysis was requested by the Data Safety Monitoring Board. In data available for analyses, no differences were noted for either treatment compared with placebo in time to inadequate control status (median: azithromycin, 8.4 weeks [95% confidence limit, 4.3-17.3]; montelukast, 13.9 weeks [95% confidence limit, 4.7-20.6]; placebo, 19.1 weeks [95% confidence limit, 11.7-infinity]), with no difference between the groups (log-rank test, P = .49). The futility analysis indicated that even if the planned sample size was reached, the results of this negative study were unlikely to be different, and the trial was prematurely terminated.

CONCLUSION

Based on these results, neither azithromycin nor montelukast is likely to be an effective inhaled corticosteroid-sparing alternative in children with moderate-to-severe persistent asthma.

Asthma control and future asthma-related morbidity in inner-city asthmatic children

BACKGROUND

Asthma guidelines recommend routine evaluation of asthma control, which includes measurements of impairment and risk. It is unclear whether rigorous asthma control changes risk of asthma morbidity.

OBJECTIVE

To examine whether the degree of asthma control in inner-city asthmatic children results in differential risk reduction of future asthma-related morbidity.

METHODS

This retrospective observational study examines 960 inner-city children with asthma who were highly engaged in an asthma-specific disease management program for a minimum of 2 years. Degree of asthma control was determined during the first year of enrollment and was categorized as well controlled (> or = 80% of visits in control), moderately controlled (50%-79% of visits in control), or difficult to control (< 50% of visits in control). Risk and probability of asthma-related morbidity at each visit were determined during the second year of enrollment and included self-reported asthma exacerbations requiring systemic corticosteroid rescue and emergency department visits or hospitalizations.

RESULTS

Increasing the degree of asthma control measured during the first year of enrollment led to statistically significant incremental reductions in risk of acute asthma exacerbations and emergency department visits or hospitalizations during the second year of enrollment.

CONCLUSIONS

Achieving and maintaining asthma control in inner-city children with asthma results in significant reductions in asthma-related morbidity. Systematic assessments of asthma control may be useful for predicting future risk in children with asthma.

Management of asthma based on exhaled nitric oxide in addition to guideline-based treatment for inner-city adolescents and young adults: a randomised controlled trial

BACKGROUND

Preliminary evidence is equivocal about the role of exhaled nitric oxide (NO) in clinical asthma management. We aimed to assess whether measurement of exhaled NO, as a biomarker of airway inflammation, could increase the effectiveness of asthma treatment, when used as an adjunct to clinical care based on asthma guidelines for inner-city adolescents and young adults.

METHODS

We did a randomised, double-blind, parallel-group trial at ten centres in the USA. We screened 780 inner-city patients, aged 12-20 years, who had persistent asthma. All patients completed a run-in period of 3 weeks on a regimen based on standard treatment. 546 eligible participants who adhered to treatment during this run-in period were then randomly assigned to 46 weeks of either standard treatment, based on the guidelines of the National Asthma Education and Prevention Program (NAEPP), or standard treatment modified on the basis of measurements of fraction of exhaled NO. The primary outcome was the number of days with asthma symptoms. We analysed patients on an intention-to-treat basis. This trial is registered with clinicaltrials.gov, number NCT00114413.

FINDINGS

During the 46-week treatment period, the mean number of days with asthma symptoms did not differ between the treatment groups (1.93 [95% CI 1.74 to 2.11] in the NO monitoring group vs 1.89 [1.71 to 2.07] in the control group; difference 0.04 [-0.22 to 0.29], p=0.780). Other symptoms, pulmonary function, and asthma exacerbations did not differ between groups. Patients in the NO monitoring group received higher doses of inhaled corticosteroids (difference 119 mug per day, 95% CI 49 to 189, p=0.001) than controls. Adverse events did not differ between treatment groups (p>0.1 for all adverse events).

INTERPRETATION

Conventional asthma management resulted in good control of symptoms in most participants. The addition of fraction of exhaled NO as an indicator of control of asthma resulted in higher doses of inhaled corticosteroids, without clinically important improvements in symptomatic asthma control.

Longitudinal patterns of predominant asthma disease activity in pediatric patients enrolled in an asthma-specific disease management program

To determine if patterns of predominant asthma disease activity are more closely related than baseline asthma severity to measures of morbidity (acute asthma attack, emergency room visit/hospitalization, missed school days, and/or steroid burst). Retrospective analysis was performed for inner-city Los Angeles asthmatic children (3 to 18 years of age) during their first year of enrollment in an asthma-specific disease management program. All measures of morbidity were more closely related to patterns of predominant disease activity than baseline severity. We conclude that patterns of predominant disease activity are a more significant predictor of asthma morbidity than is baseline severity.

Advances in the care of adults with asthma and allergy in 2007

In 2007 the National Asthma Education and Prevention Program published the Expert Panel Report 3, updating its 1997 and 2002 guidelines for the diagnosis and management of asthma with new emphasis on assessment and attainment of control. This review focuses on the Journal articles published in 2007 pertaining to risk and impairment in adult asthma and interventions to improve its control.

Advances in pediatric asthma in 2007

This year's summary focuses on recent advances in pediatric asthma as reported in 2007 publications in the Journal. This past year, new National Asthma Education and Prevention Program asthma guidelines were released with a special emphasis on new information in pediatric asthma. Journal theme issues in 2007 included the revised National Asthma Education and Prevention Program asthma guidelines, the accomplishments of the National Institutes of Health asthma networks, and focused discussions on environmental allergens, neutrophils, eosinophils, T cells, and epithelial cells, all of which affect pediatric asthma. The new asthma guidelines emphasize several key terms including severity, control, impairment, risk, and responsiveness that are relevant for advancing the care of children with asthma. This review highlights journal articles that relate to these guideline topics.