The Asthma Control and Communication Instrument: a clinical tool developed for ethnically diverse populations

Keys to Successful Survey Research in Health Professions Education

Background

Survey research is well suited to measuring the knowledge, behavior, and attitudes of study participants and has been widely used in medical education and pulmonary and critical care medicine research. Although the ease of survey administration via electronic platforms has led to an increased volume of survey publications, improving the quality of this work remains an important challenge.

Objective

To provide an overview of key steps for rigorous survey design and conduct.

Methods

Narrative review.

Results

Conducting survey research begins with a clearly defined research question pertaining to a specified population that is accessible for sampling. Survey investigators may choose to adapt relevant preexisting survey instruments, an approach with the potential for conducting more valid, generalizable, and comparable studies. If a new survey tool is used, more extensive piloting and psychometric analysis of the survey instruments may be needed to assess if they accurately measure the concepts of interest. When administering the survey, the use of appropriate methods for sample recruitment maximizes the chances of a high response rate in a generalizable study population. Finally, when writing up and disseminating survey research, careful attention to reporting guidelines can increase the clarity of survey reports and assist readers in interpreting the results and conclusions.

Conclusion

With careful attention to study design and conduct, the quality of survey research can be improved and lead to higher impact and more generalizable studies in the fields of medical education and pulmonary and critical care medicine.

The Asthma Impairment and Risk Questionnaire enhances the assessment of asthma control

BACKGROUND

Asthma control is often overestimated in routine practice, and despite advances in the understanding of immunopathology and the availability of new precision therapies, the burden of disease remains unacceptably high.

OBJECTIVE

To compare the performance of the Asthma Impairment and Risk Questionnaire (AIRQ) with patient and physician assessments and the Asthma Control Test (ACT) in identifying asthma control.

METHODS

Baseline data from a longitudinal study of the AIRQ were analyzed. Patients with asthma in the United States aged 12 years and older followed in 24 specialty practices and 1 specialty-affiliated primary care clinic were enrolled between May and November 2019. At entry, participants completed AIRQ and ACT, and participants and physicians completed 5-point Likert scale assessments of control.

RESULTS

A total of 1112 participants were enrolled (mean [SD] age = 43.9 [19.3] years, 70% of the female sex, 78% White). Overall, 62% of participants rated themselves as well- or completely controlled, and 54% were rated comparably by physicians. The ACT classified 49% of participants as well-controlled, with 35% similarly categorized by AIRQ. Previous-year exacerbations were experienced by 32% of participants who self-rated as well- or completely controlled, 30% who were rated as well- or completely controlled by physicians, and 29% assessed as well-controlled by ACT, but only 15% of those classified as well-controlled by AIRQ.

CONCLUSION

The burden of asthma is substantial in patients cared for by asthma specialists, and asthma control is overestimated by patients, physicians, and the symptom-based ACT. The AIRQ assesses risk in addition to symptom control and may serve to improve asthma control determination by assessing previous exacerbations.

The Asthma Impairment and Risk Questionnaire (AIRQ) Control Level Predicts Future Risk of Asthma Exacerbations

BACKGROUND

The Asthma Impairment and Risk Questionnaire (AIRQ) is a 10-item, equally weighted, yes/no control tool validated in patients with asthma aged 12 years and older.

OBJECTIVE

To evaluate AIRQ's ability to predict patient-reported exacerbations over 12 months.

METHODS

Patients completed a baseline AIRQ during an in-person enrollment visit and reported exacerbations (ie, asthma-related courses of oral corticosteroids, emergency department/urgent care visits, and hospitalizations) via monthly online surveys. Logistic regressions were performed using AIRQ control level (well-controlled [WC], not well-controlled [NWC], very poorly controlled [VPC]), age, sex, race, and body mass index as covariates and 1 or more and 2 or more exacerbations as the dependent variables (adjusted odds ratios [OR] and 95% Wald CIs). Kaplan-Meier analyses of time to first exacerbation by AIRQ control level were performed.

RESULTS

A total of 1,112 patients were enrolled; 1,070 completed 1 or more surveys over 12 months (mean ± SD 10.5 ± 2.8 months); 70.5% female; age 43.9 ± 19.3 years; 20.4% non-White; body mass index 30.6 ± 8.7 kg/m²; AIRQ: WC 35.2%, NWC 38.1%, VPC 26.6%. A total of 45.7% of patients reported 1 or more exacerbations and 26.7% 2 or more exacerbations (WC 28.4% ≥ 1, 11.1% ≥ 2; NWC 46.3% ≥ 1, 27.9% ≥ 2; VPC 67.7% ≥ 1, 45.6% ≥ 2). The ORs for 1 or more exacerbations NWC versus WC were 2.1 (CI 1.6-2.9), and VPC versus WC were 4.6 (CI 3.3-6.5). The ORs for 2 or more exacerbations NWC versus WC were 3.1 (CI 2.1-4.6), and VPC versus WC were 6.1 (CI 4.0-9.1). Kaplan-Meier curves demonstrated clear differentiation of time to first exacerbation by AIRQ control level (P < .001).

CONCLUSIONS

The AIRQ control level predicts exacerbation risk over 12 months and probability of time to first exacerbation.

What Parents Want Doctors to Know: Responses to an Open-Ended Item on an Asthma Questionnaire

OBJECTIVE

Unstructured parental comments could solicit important information about children's asthma, yet are rarely captured in clinical asthma questionnaires. This mixed-methods study describes parents' written responses to an open-ended question in a validated asthma questionnaire.

METHODS

The Pediatric Asthma Control and Communication Instrument (PACCI) asthma questionnaire was administered to parents of children with asthma symptoms presenting to 48 pediatric primary care offices (PPCP), 1 pediatric pulmonology office, and 1 emergency department (ED). Responses to the question, "Please write down any concern or anything else you would like your doctor to know about your child's asthma" were analyzed using a phenomenological approach until thematic saturation was achieved for each site. Logistic regressions tested whether sociodemographic and clinical characteristics were associated with responding to the open-ended question.

RESULTS

Of 7,988 parents who completed the PACCI, 954 (12%) responded to the open-ended question-2% in PPCP, 31% in the ED, and 50% in the pulmonary setting. More severe asthma was associated with higher odds of responding (odds ratio, 2.01; 95% confidence interval, 1.42-2.84). Based on responses provided, we identified 3 communication types: 1) clarifying symptoms, 2) asking questions, and 3) communicating distress. Responses also covered 5 asthma-related themes: 1) diagnostic uncertainty, 2) understanding asthma etiology and prognosis, 3) medication management, 4) impact on child function, and 5) personal asthma characteristics.

CONCLUSION

Parents of children with severe asthma provided clarifying details, asked questions, and relayed health concerns and distress. None of these topics may be easily captured by closed-ended asthma questionnaires.

Evaluating construct validity of the Asthma Impairment and Risk Questionnaire using a 3-month exacerbation recall

BACKGROUND

Recurrent assessment of asthma control is essential to evaluating disease stability and intervention impacts. An assessment that can be administered between annual clinic visits is needed. The Asthma Impairment and Risk Questionnaire (AIRQ) is a cross-sectionally validated, 10-item, yes or no, composite control tool evaluating previous 2-week symptoms and previous 12-month exacerbations.

OBJECTIVE

To evaluate the construct validity of the AIRQ using a 3-month recall period for exacerbation-based risk questions and retaining the 2-week recall for symptom-based impairment items.

METHODS

At baseline, patients completed the AIRQ with 12-month recall exacerbation items, Asthma Control Test (ACT), St. George's Respiratory Questionnaire (SGRQ), and global self-assessments of asthma risk, control, and symptom severity. Patient-reported exacerbations were captured monthly. The AIRQ with 3-month recall exacerbation items, ACT, and global self-assessments was administered at months 3, 6, and 9, and SGRQ at month 6.

RESULTS

A total of 1112 patients aged 12 years or older were enrolled (mean [SD] age, 43.9 [19.5] years). The AIRQ and each administration of the AIRQ with 3-month recall exacerbation items classified asthma control similarly to an ACT plus exacerbation validation standard. For both AIRQ versions, SGRQ scores were higher with worsening asthma control (P < .001). At months 3, 6, and 9, worse AIRQ control levels were associated with higher proportions of patients with 1 or more and 2 or more exacerbations in the previous 3 months and patient global self-assessments indicating greater asthma morbidity (all P < .001).

CONCLUSION

The AIRQ using exacerbation risk items with a 3-month recall period exhibits construct validity for classifying current asthma control and can be administered between annual AIRQ assessments.

Children with under-diagnosed asthma presenting to a pediatric emergency department

BACKGROUND

Undiagnosed asthma in children presenting to the emergency department (ED) for respiratory illnesses might be associated with subsequent asthma morbidity and repeat ED visits.

OBJECTIVE

To examine the prevalence of undiagnosed asthma among children presenting for ED care, and explore associations with sociodemographic and clinical characteristics.

METHODS

We surveyed parents of children ages 2-17 years seeking ED care for respiratory symptoms (including asthma) regarding sociodemographic characteristics, asthma symptoms, prior asthma care and morbidity, and prior asthma diagnosis. Undiagnosed asthma was defined as a positive screening for asthma and no prior diagnosis. We compared sociodemographic and clinical factors of those with diagnosed versus undiagnosed asthma using chi-square, t-tests and multivariable logistic regression model.

RESULTS

Of 362 children, 36% had undiagnosed asthma. Undiagnosed children were younger, had younger parents, and had parents less likely to speak English versus diagnosed children (all p < 0.05). Among undiagnosed children, 42% had moderate or severe asthma and 66% reported ≥1 exacerbation in the prior 12 months. Parent-reported controller medication use was higher among diagnosed versus undiagnosed children (60% vs. 21%, p=.001). In a multivariable logistic regression (adjusting for insurance, education, income and preferred language), no controller usage (aOR 4.26), no asthma exacerbations in the prior year (aOR 2.41) and younger age (aOR 0.76) were significantly associated with undiagnosed asthma.

CONCLUSION

Children presenting to the ED with undiagnosed asthma commonly experience significant prior asthma morbidity. Strategies to improve asthma diagnosis and messaging to their parents may reduce future morbidity.

Psychometric evaluation of the Brazilian version of the pediatric asthma control and communication instrument

BACKGROUND

There is a lack of questionnaires capable of evaluating the clinical control of Brazilian children and adolescents with asthma over a wide age range. The Pediatric Asthma Control and Communication Instrument (PACCI) has been validated, but only with English- and Spanish-speaking children in the United States.

OBJECTIVES

To evaluate the psychometric properties of the Brazilian version of the PACCI questionnaire.

METHODS

A cross-sectional psychometric study conducted with children and adolescents aged 01 to 19 years with a clinical diagnosis of asthma, and their respective parents/guardians. The following assessments were conducted: socioeconomic status; clinical control using the Childhood Asthma Control Test (c-ACT), Asthma Control Test (ACT); caregiver quality of life using the Pediatric Asthma Caregivers Quality of Life Questionnaire (PACQLQ); and pulmonary function test (spirometry). Validity was evaluated as follows: exploratory and confirmatory factor analysis; Cronbach's alpha analysis (α); floor and ceiling effects; receiver operator characteristic curve analysis.

RESULTS

A total of 128 participants were included, most of them male (54.7%). The Brazilian version of PACCI had adequate internal consistency (α = .76) and moderate floor and ceiling effects. The internal structure presented acceptable adjustment indices, considering the extraction of four factors. The factors presented adequate α values. Asthma control factor 1 correlated with c-ACT/ACT and PACQLQ. Control domain scores greater than four points (sum of score) and above 1 point (problem index) were indicative of uncontrolled asthma.

CONCLUSION

The Brazilian version of PACCI was able to provide valid and reliable measures in evaluating the clinical control of asthma in Brazilian children and adolescents.

Development of the Asthma Impairment and Risk Questionnaire (AIRQ): A Composite Control Measure

BACKGROUND

Asthma exacerbation risk increases with worsening asthma control. Prevailing numerical control tools evaluate only current symptom impairment despite the importance of also assessing risk based on exacerbation history. An easy-to-use questionnaire addressing impairment and risk domains of control is needed.

OBJECTIVE

To validate a composite asthma control tool that includes impairment and risk assessments (Asthma Impairment and Risk Questionnaire [AIRQ]).

METHODS

Four-hundred forty-two patients aged ≥12 years with physician-diagnosed asthma who were followed in specialty practices completed 15 impairment and risk questions with dichotomized yes/no responses. Patients spanned all Global Initiative for Asthma severities and were classified as well-controlled, not well-controlled, or very poorly controlled according to a standard of Asthma Control Test (ACT) score plus prior-year exacerbations. Logistic regression analyses identified questions with the greatest predictive validity to discriminate among patients and determine cut points for these 3 classifications.

RESULTS

The final AIRQ comprises 10 equally weighted yes/no impairment and risk questions. The final 10-item models yielded receiver operating characteristic curves of 0.94 to identify well-controlled versus not well-/very poorly controlled and 0.93 to identify well-/not well-controlled versus very poorly controlled asthma, as reflected by the ACT plus prior-year exacerbations standard. Cut points of 0-1, 2-4, and 5-10 best represented well-, not well-, and very poorly controlled asthma.

CONCLUSIONS

AIRQ is a rigorously validated composite measure designed to identify adults and adolescents with varying degrees of asthma control. Ongoing investigations will determine test-retest reliability, responsiveness to change, and predictive ability for future exacerbations.

Parental perception of a picture-based chronic asthma care management tool in an urban pediatric emergency department

BACKGROUND

National asthma guidelines recommend use of an asthma action plan (AAP) as part of chronic asthma care. Unfortunately, AAPs have not been tailored for use in acute care settings, where many patients at risk for poor chronic asthma care are seen, including those who are non-English-speaking or have low literacy levels. We previously developed a picture-based medication plan (PBMP), a unique type of AAP for use in an ambulatory setting and designed to increase patient use and understanding. However, little is known about how parents seeking emergency department (ED) asthma care would perceive the PBMP.

OBJECTIVE

To assess parental attitudes toward an asthma PBMP in the largest pediatric ED in Los Angeles County.

METHODS

We surveyed a consecutive sample of English- or Spanish-speaking parents of children 2-17 years seeking ED asthma care. Parents used a 5-point Likert scale for various statements regarding their perceptions of the PBMP. Responses were analyzed by sociodemographics, asthma control, and health literacy using Chi-squared and t-tests.

RESULTS

90 parents provided feedback on the PBMP. The majority of parents endorsed the PBMP. Endorsement was 20%-30% higher among Spanish-speaking parents and those who did not complete high-school compared to English-speaking parents and parents with a high school education or higher (p < 0.05 for both comparisons).

CONCLUSION

Spanish-speaking parents and parents with less than a high-school education overwhelmingly endorsed the PBMP. It may be useful to consider incorporating the PBMP as part of patient-centered chronic asthma care strategies for populations seen in ED settings.

Longitudinal Effect of Ambient Air Pollution and Pollen Exposure on Asthma Control: The Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Asthma Study

OBJECTIVE

Although exposure to air pollution and pollen is associated with asthma exacerbation and increased health care use, longitudinal effects of fine particulate matter 2.5 (PM_2.5), ozone (O₃), and pollen exposure on asthma control status in pediatric patients are understudied. This study investigated effects of exposure to PM_2.5, O₃, and pollen on asthma control status among pediatric patients with asthma.

METHODS

A total of 229 dyads of pediatric patients with asthma and their parents were followed for 15 months. The Asthma Control and Communication Instrument was used to measure asthma control, which was reported weekly by parents during a 26-week period. PM_2.5 and O₃ data were collected from the US Environmental Protection Agency Air Quality System. Pollen data were obtained from Intercontinental Marketing Services Health. Mean air pollutant and pollen exposures within 7 days before the reporting of asthma control were used to estimate weekly exposures for each participant. Linear mixed-effects models were performed to test associations of PM_2.5, O₃, and pollen exposure with asthma control status. Sensitivity analyses were performed to evaluate the robustness of findings by different exposure monitoring days per week and distances between monitoring sites and participants' residences.

RESULTS

Elevated PM_2.5 concentration and pollen severity were associated with poorer asthma control status (P < .05), yet elevated O₃ concentration was marginally associated with better asthma control (P < .1).

CONCLUSIONS

Poorer asthma control status was associated with elevated PM_2.5 and pollen severity. Reducing harmful outdoor environmental ambient exposure may improve asthma outcomes in children and adolescents.

Pediatric Asthma Control and Communication Instrument: translation into Portuguese and cross-cultural adaptation for use in Brazil

Objective:

To translate the Pediatric Asthma Control and Communication Instrument (PACCI) to Portuguese and adapt it for use in Brazil, ensuring the cultural validity of the content and semantic equivalence of the target version.

Methods:

The Brazilian Portuguese-language version of the PACCI was developed according to the most commonly used methodology, which included the following steps: translation; synthesis of the translation; review by the author of the original questionnaire; back-translation; synthesis of the back-translation; review by a native external researcher who is a native speaker of English; approval of the author of the original questionnaire; review by a specialist in Portuguese; review by a multidisciplinary committee of experts to determine the agreement of the items, considering the clarity of each and its appropriateness in the cultural context; cognitive debriefing; and development of the final version. The cognitive debriefing involved 31 parents/legal guardians of children 1-21 years of age with a clinical diagnosis of asthma, as defined by the Global Initiative for Asthma, with the objective of determining the comprehensibility and clarity of the items for the target population.

Results:

The multidisciplinary committee of experts indicated that the items on the questionnaire were clear and comprehensible, with kappa values above 0.61, indicating substantial agreement. In the cognitive debriefing, the parents/legal guardians presented no difficulties in understanding any of the items (agreement > 0.90); therefore, no further changes were needed.

Conclusions:

The translation and cross-cultural adaptation of the PACCI for use in Brazil were successful.

Translation and cultural adaptation of a specific instrument for measuring asthma control and asthma status: the Asthma Control and Communication Instrument

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.

Validation of Asthma Control Assessment Among Urban Adolescents Using the Asthma Control and Communication Instrument

BACKGROUND

The National Institutes of Health guidelines recommend questionnaires to assess asthma control, but there are few self-reported asthma morbidity surveys validated among urban, African American, Hispanic, and/or poor adolescents. The Asthma Control and Communication Instrument (ACCI) is a 12-item self-reported questionnaire previously validated among a diverse adult population, but not among adolescents.

OBJECTIVE

To assess the ability of the ACCI to accurately describe asthma control in an urban adolescent population.

METHODS

Between November 13, 2014, and March 2, 2017, we collected information using the ACCI, the Asthma Control Test, the Pediatric Asthma Quality of Life Questionnaire, and lung function among adolescents enrolled in a school-based asthma intervention study. The ACCI measure of asthma control was validated by evaluating accuracy (on the basis of receiver operating characteristic curve), internal reliability, and concurrent and discriminative validity.

RESULTS

We collected information on 280 adolescents (mean age, 13.4 years; 56% males; and 51% African American). ACCI control showed good internal reliability and strong concurrent and discriminative validity with the Asthma Control Test and the Pediatric Asthma Quality of Life Questionnaire. The accuracy of the ACCI in classifying adolescents with uncontrolled asthma was good (area under the curve, 0.83; 95% CI, 0.79-0.88).

CONCLUSION

The ACCI, a clinical tool developed to assist communication about asthma control, has demonstrated strong construct validity as a self-reported questionnaire within an urban, African American, and Hispanic sample of adolescents. It has the potential to assist in the assessment of asthma control in urban, minority, and/or poor adolescents.

Determinants of longitudinal health-related quality-of-life change in children with asthma from low-income families: a report from the PROMIS® Pediatric Asthma Study

BACKGROUND

How the longitudinal asthma control status and other socio-demographic factors influence the changes of health-related quality of life (HRQOL) among asthmatic children, especially from low-income families, has not been fully investigated.

OBJECTIVES

This study aimed to describe the trajectories of asthma-specific HRQOL over 15 months and examine the effect of asthma control status on HRQOL by taking socio-demographic factors into consideration.

METHODS

A total of 229 dyads of asthmatic children and their parents enroled in public insurance programs were recruited for assessing asthma control status and HRQOL over four time points of assessment. Asthma control status was measured using the Asthma Control and Communication Instrument, and asthma-specific HRQOL was assessed using the Patient-Reported Outcomes Measurement Information System's Pediatric Asthma Impact Scale. Latent growth models (LGMs) were applied to examine the trajectory of HRQOL and the factors contributing to the changes of HRQOL.

RESULTS

Unconditional LGM revealed that HRQOL was improved over time. Conditional LGM suggested that accounting for asthma control and participants' socio-demographic factors, the variation in the initial level of HRQOL was significant, yet the rate of change was not. Conditional LGM also revealed that poorly controlled asthma status was associated with poor HRQOL at each time point (P's < 0.05). Lower parental education was associated with lower baseline HRQOL (P < 0.05). Hispanic children had a larger increase in HRQOL over time (P < 0.01) than non-Hispanic White children.

CONCLUSIONS

Vulnerable socio-demographic characteristics and poorly controlled asthma status affect HRQOL in children. This finding encourages interventions to improve asthma control status and HRQOL in minority children.

An item-level response shift study on the change of health state with the rating of asthma-specific quality of life: a report from the PROMIS(®) Pediatric Asthma Study

PURPOSE

To examine item-level response shift associated with the change in asthma-related health state (i.e., change in asthma control status and global rating of change (GRC) in breathing problems).

METHODS

Study sample comprised 238 asthmatic children who were between 8 and 17.9 years and completed the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) symptoms, emotion function, and activity limitation domains at baseline and a follow-up assessment. Structural equation modeling was implemented to assess item-level response shift associated with the change in asthma-related health state with the adjustment for the influence of confounding variables. The magnitude of item-level response shift and its influence on the change of domain scores was estimated using Cohen's effect sizes.

RESULTS

We found no instances of item-level response shift. However, two items were identified with measurement bias related to GRC due to breathing problems. Specifically, asthmatic children with better/about the same GRC due to breathing problems reported lower scores for one item in the emotional domain at follow-up compared to those with deteriorated GRC due to breathing problems. In addition, asthmatic children with better/about the same GRC due to breathing problems reported better scores for another item in the symptom domain at baseline compared to those with deteriorated GRC due to breathing problems. The impact of measurement bias was small and did not bias the change of domain scores over time.

CONCLUSIONS

No item-level response shift, but two instances of measurement bias, appears in asthmatic children. However, the impact of these measurement issues is negligible.

Responsiveness to Change in PROMIS(®) Measures among Children with Asthma: A Report from the PROMIS(®) Pediatric Asthma Study

OBJECTIVE

To compare the responsiveness to change of the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) asthma impact, pain interference, fatigue, depressive symptoms, mobility, and peer relationship scales to a legacy scale, the Paediatric Asthma Quality of Life Questionnaire (PAQLQ).

METHODS

Two hundred and twenty-nine child-parent dyads from public insurance programs were enrolled. PROMIS pediatric short forms (SFs) and the PAQLQ were used to measure health-related quality of life across four time points (T1-T4) over 2 years. The Asthma Control and Communication Instrument was used to measure the change in asthma control, and the Global Rating of Change (GRC) Index for breathing problems and overall health was used to measure the change in health status. Responsiveness was tested by comparing the changes in health-related quality of life with the changes in asthma control and health status over time using t tests, generalized estimating equations, and relative validity approaches. Magnitudes of the responsiveness between the Pediatric PROMIS and PAQLQ were assessed through statistical significance, Cohen's d effect size (ES), and standardized response mean (SRM).

RESULTS

The PROMIS asthma impact scale and all PAQLQ scales exhibited significant responsiveness (p's<0.05) and small to medium ES/SRM when anchored to asthma control, GRC breathing problems, and overall health. Relative validity, especially related to change in asthma control status and GRC breathing problems, was equivalent. PROMIS pain interference, fatigue, and mobility SFs also indicated adequate responsiveness.

CONCLUSIONS

The PROMIS asthma impact SF indicated similar responsiveness to the PAQLQ scales. Due to its brevity and responsiveness, the PROMIS asthma impact SF is useful for clinical practice or research.

Predicting future emergency department visits and hospitalizations for asthma using the Pediatric Asthma Control and Communication Instrument - Emergency Department version (PACCI-ED)

OBJECTIVE

Emergency departments (EDs) are potential settings for interventions to improve asthma outcomes. Screening tools can identify children at risk of future morbidity. Our objective was to determine the predictive validity of the Pediatric Asthma Control and Communication Instrument - Emergency Department version (PACCI-ED) for future asthma-related ED visits and hospitalizations.

METHODS

This was a retrospective cohort study of 108 children 1-17 years old who visited an ED for asthma and completed the PACCI-ED. The PACCI-ED queries parents about prior 12-month ED visits, hospitalizations, steroid use, perceived asthma morbidity and burden, and asthma control (over prior 1-2 weeks). The primary outcome was subsequent ED visits and hospitalizations within 1 year of enrollment. Poisson regression was used to model PACCI-ED questions for future ED visits controlling for age and socioeconomic status.

RESULTS

Reported ED visits predicted future ED visits (adjusted incidence rate ratio (aIRR) 3.1, 95% confidence interval (CI): 1.3-7.2) but not future hospitalizations. Reported hospitalizations predicted future ED visits (aIRR 3.3; 95% CI 1.7-6.3) and hospitalizations (aIRR 6.4; 95% CI 2.3-17.6). The remaining PACCI-ED questions did not predict future ED visits or hospitalizations.

CONCLUSIONS

The PACCI-ED risk domain was the only domain that predicted future asthma ED visits and hospitalizations. Questions about previous ED visits and hospitalizations are the most effective questions when screening children with asthma in EDs for the risk of future health-care use.

Longitudinal associations among asthma control, sleep problems, and health-related quality of life in children with asthma: a report from the PROMIS(®) Pediatric Asthma Study

OBJECTIVES

Few studies have investigated the complex relationship among asthma control, sleep problems, and health-related quality of life (HRQOL) among children with asthma. This study aimed to test the longitudinal effect of asthma control status on asthma-specific HRQOL through the mechanism of nighttime sleep quality and daytime sleepiness.

METHODS

The Patient-Reported Outcomes Measurement Information System (PROMIS(®)) Pediatric Asthma Study included 229 dyads of asthmatic children and their parents with two years of follow-up for assessing the change in asthma control, sleep problems, and asthma-specific HRQOL. The Asthma Control and Communication Instrument was used to measure asthma control status. Nighttime sleep quality assessment was based on difficulty falling asleep and getting up, and sleep disturbance. The Iowa Pediatric Daytime Sleeping Scale was used to assess daytime sleepiness. The PROMIS Asthma Impact Scale was used to measure asthma-specific HRQOL. Multilevel structural equation modeling was performed to quantify the direct and indirect effects of asthma control status on asthma-specific HRQOL through nighttime sleep quality and daytime sleepiness.

RESULTS

Poorer asthma control status was directly associated with lower asthma-specific HRQOL at within-subject and between-subject levels (p < 0.05); however, effects of asthma control on asthma-specific HRQOL were indirectly influenced through daytime sleepiness at the within-subject level (p < 0.05), and through nighttime sleep quality and daytime sleepiness at the between-subject level (p < 0.05).

CONCLUSIONS

Asthma control status is associated with asthma-specific HRQOL, and this association is mediated by nighttime sleep quality and daytime sleepiness. Clinicians should address sleep problems related to asthma control to improve HRQOL for asthmatic children.

The Impact of Parent's Health Literacy on Pediatric Asthma Outcomes

Background: Health literacy has been associated with health disparities in many disease outcomes, including children's asthma. Parents are responsible for most of children's healthcare. Therefore, parents' health literacy may impact children's health outcomes, including asthma control. This study sought to determine the association between parent health literacy and children's asthma control among a cohort of predominately minority urban children aged between 6 and 12 years. Methods: This cross-sectional study assessed children with asthma and their parents at a single outpatient visit. English-speaking parents and their children, aged between 6 and 12 years with physician-diagnosed asthma, were eligible for this study. Healthcare providers assessed asthma control and severity, and parents completed demographic, health literacy, asthma control, and asthma knowledge measures. Children completed a pulmonary function test as part of the Asthma Control Questionnaire (ACQ) scoring. Results: A total of 281 parent-child dyads provided data, with the majority of parents being mothers and African American, with a high school level education or less. Lower parent health literacy was associated with worse asthma control as rated both by the provider (p=0.007) and the ACQ (p=0.013), despite only moderate concordance between ratings (ρ=0.408, p<0.0001). Lower parent health literacy also was associated with less asthma knowledge, which was associated with worse asthma control. Conclusions: Higher parent health literacy was associated with more parent asthma knowledge and better child asthma control. Pediatric providers should consider tailoring education or treatment plans or utilizing universal precautions for low health literacy.

Validation of parental reports of asthma trajectory, burden, and risk by using the pediatric asthma control and communication instrument

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.

Asthma treatment decisions by pediatric residents do not consistently conform to guidelines or improve with level of training

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.

The Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) improves physician assessment of asthma morbidity in pediatric emergency department patients

OBJECTIVES

To determine whether the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED), a 12-item questionnaire, can help ED attendings accurately assess a patient's asthma control and morbidity.

METHODS

This was a randomized-controlled trial performed at an urban pediatric ED of children aged 1-17 years presenting with an asthma exacerbation. Parents answered PACCI-ED questions about their children's asthma. Attendings were randomized to view responses to the PACCI-ED (intervention group) or to be blinded to the completed PACCI-ED (control group). The two groups were compared on their empirical clinical assessment of: (1) chronic asthma control categories, (2) asthma trajectory (stable, worsening or improving), (3) patient adherence to controller medications, and (4) burden of disease for the patient's family. The validated PACCI algorithm was used as the criterion standard for these four outcomes. Accuracy of clinical assessment was compared between intervention and control groups using chi-squared tests and an intention-to-treat approach.

RESULTS

Seventeen ED attendings were enrolled in the study and 77 children visits were included in the analysis. There were no significant differences between the intervention and the control groups for child's gender, age, race, and asthma characteristics. Intervention group attendings were more accurate than control group attendings in assessing the category of chronic asthma control (43% versus 19%; p = 0.03), disease trajectory (72% versus 45%; p = 0.02), and the disease burden for families (74% versus 35%; p = 0.001) over the past 12 months. There was a trend towards more accuracy of intervention versus control attendings for estimating patient adherence to controller medications (72% versus 48%; p = 0.06).

CONCLUSIONS

The PACCI-ED improves the assessment of asthma control, trajectory, and burden by ED attendings, and may help assessment of asthma medication adherence and prior asthma exacerbations. The PACCI-ED can be used to improve provider assessment of asthma morbidity during pediatric ED visits for asthma exacerbations, and to identify children who may benefit from interventions to reduce asthma morbidity.

The relationships between asthma control, daytime sleepiness, and quality of life among children with asthma: a path analysis

OBJECTIVES

We aimed to examine the relationships between asthma control, daytime sleepiness, and asthma-specific health-related quality of life (HRQOL) among children with asthma. Path analyses were conducted to test if daytime sleepiness can mediate the effect of asthma control status on asthma-specific HRQOL.

METHODS

160 dyads (pairs) of asthmatic children and their parents were collected for analyses. The Asthma Control and Communication Instrument (ACCI) was used to categorize adequate and poor asthma control status. The Cleveland Adolescent Sleepiness Questionnaire (CASQ) was used to measure children's daytime sleepiness, including sleep in school, awake in school, sleep in evening, and sleep during transport. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale was used to measure asthma-specific HRQOL.

RESULTS

Poorly controlled asthma was associated with daytime sleepiness and impaired asthma-specific HRQOL. Asthma control status was directly associated with asthma-specific HRQOL (P<.05), whereas sleep in school and sleep in evening domains of daytime sleepiness significantly mediated the relationship between poor asthma control and impaired HRQOL (P<.01).

CONCLUSIONS

Asthma control status was associated with pediatric asthma-specific HRQOL, and the association was significantly mediated by daytime sleepiness. Healthcare providers need to address pediatric sleep needs related to poor asthma control to reduce the negative impact on HRQOL.

Exploring factors influencing asthma control and asthma-specific health-related quality of life among children

BACKGROUND

Little is known about factors contributing to children's asthma control status and health-related quality of life (HRQoL). The study objectives were to assess the relationship between asthma control and asthma-specific HRQoL in asthmatic children, and to examine the extent to which parental health literacy, perceived self-efficacy with patient-physician interaction, and satisfaction with shared decision-making (SDM) contribute to children's asthma control and asthma-specific HRQoL.

METHODS

This cross-sectional study utilized data collected from a sample of asthmatic children (n = 160) aged 8-17 years and their parents (n = 160) who visited a university medical center. Asthma-specific HRQoL was self-reported by children using the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Asthma Impact Scale. Satisfaction with SDM, perceived self-efficacy with patient-physician interaction, parental health literacy, and asthma control were reported by parents using standardized measures. Structural equation modeling (SEM) was performed to test the hypothesized pathways.

RESULTS

Path analysis revealed that children with better asthma control reported higher asthma-specific HRQoL (β = 0.4, P < 0.001). Parents with higher health literacy and greater perceived self-efficacy with patient-physician interactions were associated with higher satisfaction with SDM (β = 0.38, P < 0.05; β = 0.58, P < 0.001, respectively). Greater satisfaction with SDM was in turn associated with better asthma control (β = -0.26, P < 0.01).

CONCLUSION

Children's asthma control status influenced their asthma-specific HRQoL. However, parental factors such as perceived self-efficacy with patient-physician interaction and satisfaction with shared decision-making indirectly influenced children's asthma control status and asthma-specific HRQoL.

The Pediatric Asthma Control and Communication Instrument asthma questionnaire: for use in diverse children of all ages

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.

Intimate partner violence exposure, salivary cortisol, and childhood asthma

OBJECTIVES

Neuroendocrine alterations may help explain health differences between intimate partner violence (IPV) exposed children and non-exposed children. We sought to determine the feasibility of having families, recruited at a child asthma visit, collect at home and return via mail child salivary samples, and whether socio-demographic variables were associated with sample return. For those returning samples, we examined whether past-year IPV exposure was associated with total cortisol output (AUC) and the magnitude of the cortisol awakening response (CAR), and whether these cortisol values were associated with asthma control.

METHODS

Fifty-five families with an asthmatic child of any age were recruited from 2 pediatric asthma clinics. At the time of the visit, parents completed a survey packet which included a modified version of the Conflict Tactics Scale to assess IPV. Parents were given supplies to collect 3 child salivary cortisol samples (awakening, 30-min after awakening, bedtime) at home on a typical day, and return them via mail. Medical records also were abstracted.

RESULTS

Fifty-three percent (n=29) returned child salivary samples. Families who returned samples typically returned them within 2 weeks, most commonly before we made a reminder call. Parental male sex was associated (p=.06) with increased rate of return at the trend level. In multivariable models, a 1-unit increase in IPV was significantly associated with a .93 SD increase in root-transformed total cortisol output (AUC) (un-standardized beta=2.5; SE .59; p=.001). The odds of uncontrolled asthma were marginally higher for every nmol/l increase in CAR (OR 1.04; 95% CI 1.0, 1.1; p=.06).

CONCLUSIONS

This study provides support for the feasibility of obtaining a moderate return of salivary specimens from a convenience sample. Findings that IPV was associated with elevated total cortisol output and uncontrolled asthma was marginally associated with cortisol awakening response suggest that future studies should investigate whether cortisol mediates the IPV-child asthma relationship.

Asthma outcomes: composite scores of asthma control

BACKGROUND

Current asthma guidelines recommend assessing the level of a patient's asthma control. Consequently, there is increasing use of asthma control as an outcome measure in clinical research studies. Several composite assessment instruments have been developed to measure asthma control.

OBJECTIVE

National Institutes of Health institutes and federal agencies convened an expert group to propose the most appropriate standardized composite score of asthma control instruments to be used in future asthma studies.

METHODS

We conducted a comprehensive search of PubMed using both the National Library of Medicine's Medical Subject Headings and key terms to identify studies that attempted to develop and/or test composite score instruments for asthma control. We classified instruments as core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at a National Institutes of Health-organized workshop convened in March 2010 and finalized in September 2011.

RESULTS

We identified 17 composite score instruments with published validation information; all had comparable content. Eight instruments demonstrated responsiveness over time; 3 demonstrated responsiveness to treatment. A minimal clinically important difference has been established for 3 instruments. The instruments have demographic limitations; some are proprietary, and their use could be limited by cost.

CONCLUSION

Two asthma composite score instruments are sufficiently validated for use in adult populations, but additional research is necessary to validate their use in nonwhite populations. Gaps also exist in validating instruments for pediatric populations.

How Do Perceptions of Asthma Control and Severity Relate to Indicators of Asthma Status and Treatment Recommendations by Pediatricians?

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.

Asthma control assessed in the EGEA epidemiological survey and health-related quality of life

BACKGROUND

The aims were to assess 1) the relationship of asthma control assessed by combining epidemiological survey questions and lung function to Health-Related Quality of Life (HRQL) and 2) whether individuals with controlled asthma reach similar generic HRQL levels as individuals without asthma.

METHODS

The analysis included 584 individuals without asthma and 498 with asthma who participated in the follow-up of the Epidemiological study on Genetics and Environment of Asthma (EGEA). Asthma control was assessed from survey questions and lung function, closely adapted from the 2006-2009 Global Initiative for Asthma guidelines. The Asthma Quality of Life Questionnaire (AQLQ, scores range:1-7) and the generic SF-36 (scores range: 0-100) were used.

RESULTS

Adjusted mean total AQLQ score decreased by 0.5 points for each asthma control steps (6.4, 5.9 and 5.4 for controlled, partly-controlled and uncontrolled asthma respectively, p < 0.0001). The differences in SF-36 scores between individuals with controlled asthma and those without asthma were minor and not significant for the PCS (-1, p = 0.09), borderline significant for the MCS (-1.6, p = 0.05) and small for the 8 domains (<5.1) although statistically significant for 4 domains.

CONCLUSION

These results support the discriminative properties of the proposed asthma control grading system and its use in epidemiology.

Asthma

This article presents the complexity of asthma and its ensuing management. The author details the clinical presentation of asthma, discussing its variability of presentation over time and within and among individuals. Pathophysiology is discussed, including immunohistopathologic features and inflammatory mediators, risk factors, comorbid conditions, natural history, and triggers. Diagnosis is presented in light of the challenging history of patients suspected of the disorder; pulmonary function testing, symptom assessment, impairment assessment, and risk assessment. Categories of asthma severity, controlling triggers, pharmacotherapy, stepwise approaches, and ongoing assessment are discussed, with a review of a clinical trial assessing efficacy of management.

Blowing the whistle: what do African American adolescents with asthma and their caregivers understand by "wheeze?"

AIMS

To investigate what African American adolescents with asthma and their caregivers understand by "wheeze".

METHODS

Caregivers (n = 35) and adolescents (n = 35) were each asked to describe what they understood by "wheeze". Respondents were also shown a video clip of an adolescent wheezing and asked: a) to describe the breathing of the adolescent in the video; and, b) whether the adolescent respondent's breathing had ever been similar to the video-presented symptoms.

RESULTS

Most caregivers described wheeze in terms of sound alone (61.8%) while the majority of adolescents described wheeze as something that is felt (55.8%). Few caregivers and adolescents (5.8% each) included "whistling" in their descriptions of "wheeze". Most caregivers and adolescents used the word "wheeze" when describing the video clip, but nearly one-quarter of the caregivers and one-third of the adolescents felt that the adolescent's breathing was never similar to the video.

CONCLUSION

Caregiver and adolescents descriptions of wheeze are different from each other and both may be different from clinical definitions of the term. Study findings have implications for the ways in which questions about "wheeze" are framed and interpreted.

Does higher body mass index contribute to worse asthma control in an urban population?

BACKGROUND

Epidemiologic findings support a positive association between asthma and obesity.

OBJECTIVE

Determine whether obesity or increasing level of body mass index (BMI) are associated with worse asthma control in an ethnically diverse urban population.

METHODS

Cross-sectional assessment of asthma control was performed in patients with asthma recruited from primary care offices by using 4 different validated asthma control questionnaires: the Asthma Control and Communication Instrument (ACCI), the Asthma Control Test (ACT), the Asthma Control Questionnaire (ACQ), and the Asthma Therapy Assessment Questionnaire (ATAQ). Multiple linear regression analysis was performed to evaluate the association between obesity and increasing BMI level and asthma control.

RESULTS

Of 292 subjects with a mean age of 47 years, the majority were women (82%) and African American (67%). There was a high prevalence of obesity with 63%, with only 15% normal weight. The mean score from all 4 questionnaires showed an average suboptimal asthma control (mean score/maximum possible score): ACCI (8.3/19), ACT (15.4/25), ACQ (2.1/6), and ATAQ (1.3/4). Regression analysis showed no association between obesity or increasing BMI level and asthma control using all 4 questionnaires. This finding persisted even after adjusting for FEV(1), smoking status, race, sex, selected comorbid illnesses, and long-term asthma controller use.

CONCLUSION

Using 4 validated asthma control questionnaires, we failed to find an association between obesity and asthma control in an urban population with asthma. Weight loss may not be an appropriate strategy to improve asthma control in this population.

Advances in adult asthma diagnosis and treatment and health outcomes, education, delivery, and quality in 2008

In 2008 the Journal reported new findings in management of asthma. Dosing schedules of inhaled steroids have been modified and individualized. New, more costly propellants are replacing ozone-depleting chlorofluorocarbons. An association of asthma with pneumococcal disease has been observed. Smoking bans in public places are eliminating second-hand smoke and reducing asthma-related emergency department visits among adults. In contrast with these advances, however, disparity in asthma morbidity persists: black persons compared with white persons have a 4-fold greater risk of an asthma-related emergency department visit.