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Santino TA, Holanda HDS, de Souza JCS, Jácome MCA, Menescal FEPDS, Barbosa JVDS, Jácome AC, Amaral CTD, Alchieri JC, de Mendonça KMPP. Pediatric Asthma Therapy Assessment Questionnaire for the Brazilian population: Cross-cultural adaptation and measurement properties. Pediatr Pulmonol 2024; 59:1596-1605. [PMID: 38411380 DOI: 10.1002/ppul.26941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 02/02/2024] [Accepted: 02/14/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To cross-culturally adapt the Pediatric Asthma Therapy Assessment Questionnaire (ATAQ) into Brazilian Portuguese and analyze its measurement properties. METHODS This exploratory methodological study included eight experts and 30 caregivers in the translation and cross-cultural adaptation steps. Thereafter, 118 caregivers of pediatric patients with asthma aged between 5 and 17 years were involved in the analysis of measurement properties. We analyzed the content, structural (exploratory and confirmatory factorial), construct (convergent and discriminant), and known-groups validities; floor and ceiling effects; and determined the cut-off point (receiver operator characteristic curve) to identify pediatric patients with uncontrolled asthma. Intraclass correlation coefficient (ICC) analyzed test-retest reliability with 54 caregivers, whereas Cronbach's α and composite reliability verified the internal consistency of the items. RESULTS The committee of experts and caregivers found the instructions and response options relevant, understandable, and clear (K > 0.75). During the cross-cultural adaptation, three items (2, 4, and 12) were slightly modified by including terms to facilitate understanding. A two-factor structure (asthma control and patient-provider communication) was identified. Internal consistency (α > .67; composite reliability > 0.73) and test-retest reliability (ICC > 0.80) were acceptable. For construct and know-groups validities, 85.71% of the hypothesis were confirmed. A cut-off point of >3 for the control domain was considered adequate to identify pediatric patients with uncontrolled asthma (sensitivity: 86.21%; specificity: 80.90%). CONCLUSION The Pediatric ATAQ was adequately adapted for Brazilian pediatric patients with asthma and produced valid and reliable measures for assessing asthma control. Therefore, it may be considered an adequate instrument for monitoring asthma control in the Brazilian pediatric population.
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Affiliation(s)
- Thayla Amorim Santino
- Department of Physical Therapy, State University of Paraiba, Campina Grande, Paraíba, Brazil
- Graduate Program of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Hesli de Sousa Holanda
- Graduate Program of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
- Brazilian Company of Hospital Services (EBSERH), Natal, Rio Grande do Norte, Brazil
| | | | - Maria Clara Almeida Jácome
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | | | | | - Ada Cristina Jácome
- Graduate Program of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Cleia Teixeira do Amaral
- Department of Pediatric Pulmonology, Child and Adolescent Health Care Unit of the University Hospital Onofre Lopes, Natal, Rio Grande do Norte, Brazil
| | - João Carlos Alchieri
- Department of Psychology, Graduate Program in Science, Technology, and Innovation, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Karla Morganna Pereira Pinto de Mendonça
- Graduate Program of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
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Hall K, Barry F, Thompson LR, Ravandi B, Hall JE, Chang TP, Halterman JS, Szilagyi PG, Okelo SO. Feasibility of text message follow-up for pediatric asthma care after an emergency department visit. J Asthma 2024; 61:140-147. [PMID: 37610221 DOI: 10.1080/02770903.2023.2248507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
Background: Many children seen in the Emergency Department (ED) for asthma do not follow-up with their primary care provider. Text messaging via short message service (SMS) is a ubiquitous, but untested means of providing post-ED asthma follow-up care.Objective: To evaluate responses to an asthma assessment survey via SMS following an ED visit and estimate the likelihood of response by sociodemographic and clinical characteristics. Methods: We recruited 173 parents of children 2-17 years-old presenting for ED asthma care to receive a follow-up text (participation rate: 85%). One month later, parents received via SMS a 22-item survey that assessed asthma morbidity. We assessed response rates overall and by various sociodemographic and clinical characteristics, including age, parental education, and indicators of asthma severity.Results: Overall, 55% of parents (n = 95) responded to the SMS survey. In multivariable logistic regression (MLR), parents who graduated high school had a four-fold higher response rate compared to parents with less than a high school degree (OR: 4.05 (1.62, 10.13)). More parents of children with oral steroid use in the prior 12 months responded to survey items (OR: 2.53 (1.2, 5.31)). Reported asthma characteristics included: 48% uncontrolled, 22% unimproved/worse, 21% with sleep disruption, and 10% who were hospitalized for asthma.Conclusions: Text messaging may be a viable strategy to improve post-ED asthma assessment and to identify children with persistent symptoms in need of enhanced care or modification of care plans.
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Affiliation(s)
- Kaitlin Hall
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Frances Barry
- Frances Barry Psychotherapy Practice, Santa Monica, CA, USA
| | - Lindsey R Thompson
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Bahareh Ravandi
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern CA, Los Angeles, CA, USA
| | - Jeanine E Hall
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern CA, Los Angeles, CA, USA
| | - Todd P Chang
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern CA, Los Angeles, CA, USA
| | - Jill S Halterman
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Peter G Szilagyi
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Sande O Okelo
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Zhou G, Thompson LR, Barry F, Flores-Vazquez J, Holifield C, Ravandi B, Chang TP, Halterman JS, Szilagyi PG, Okelo SO. Parent Perceptions of a Validated Asthma Questionnaire in the Emergency Department. Acad Pediatr 2024; 24:124-131. [PMID: 31785379 DOI: 10.1016/j.acap.2019.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE While a number asthma questionnaires have been validated, most have not been used in an emergency department (ED) setting, nor evaluated patient feedback or clinical benefit. We sought to evaluate parent feedback on an asthma questionnaire used in an ED setting. METHODS We recruited parents of children 2-17 years old presenting to a tertiary pediatric ED for asthma care. Parents first completed then rated the Pediatric Asthma Control and Communication Instrument (PACCI-ED). RESULTS One hundred seventy-four parents (84%) completed surveys. Approximately two-thirds were Latinx, and 82% completed high school. Ninety-three percent of children had uncontrolled asthma. Parents endorsed the PACCI-ED: as easy to answer (94%); useful in understanding their child's asthma (83%); used the right words to describe their child's condition (95%); and would help the ED physician (93%) and primary care provider (PCP) (89%) better understand their child's asthma. Eleven percent reported that the PACCI-ED interfered with ED care. Parents with lower health literacy were more likely to agree the PACCI-ED asked more complete questions about their child's asthma than the ED physician (64% vs 45%, P = .02). Parents of children with uncontrolled asthma were more likely to agree that the PACCI-ED should become part of regular ED care (88% vs 62%, P = .02). Parents were more likely to agree that the PACCI-ED would help their PCP understand their child's asthma if they had a lower income (92% vs 50%, P < .001), less education (100% vs 88%, P = .004), were Latinx (94% vs 83%, P = .006), or were not using controller medication (93% vs 83%, P = .03). CONCLUSIONS Parents endorse an asthma questionnaire as valuable during an ED encounter. Because it is endorsed to be valuable to parents, this questionnaire could be used to facilitate patient-centered asthma care.
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Affiliation(s)
- Geena Zhou
- USCF School of Medicine (G Zhou), San Francisco, Calif
| | - Lindsey R Thompson
- Department of Pediatrics (LR Thompson, F Barry, J Flores-Vazquez, C Holifield, PG Szilagyi, SO Okelo), UCLA David Geffen School of Medicine, Los Angeles, Calif
| | - Frances Barry
- Department of Pediatrics (LR Thompson, F Barry, J Flores-Vazquez, C Holifield, PG Szilagyi, SO Okelo), UCLA David Geffen School of Medicine, Los Angeles, Calif
| | - Jessica Flores-Vazquez
- Department of Pediatrics (LR Thompson, F Barry, J Flores-Vazquez, C Holifield, PG Szilagyi, SO Okelo), UCLA David Geffen School of Medicine, Los Angeles, Calif
| | - Chloe Holifield
- Department of Pediatrics (LR Thompson, F Barry, J Flores-Vazquez, C Holifield, PG Szilagyi, SO Okelo), UCLA David Geffen School of Medicine, Los Angeles, Calif
| | - Bahareh Ravandi
- Children's Hospital Los Angeles (B Ravandi, TP Chang), Los Angeles, Calif
| | - Todd P Chang
- Children's Hospital Los Angeles (B Ravandi, TP Chang), Los Angeles, Calif
| | | | - Peter G Szilagyi
- Department of Pediatrics (LR Thompson, F Barry, J Flores-Vazquez, C Holifield, PG Szilagyi, SO Okelo), UCLA David Geffen School of Medicine, Los Angeles, Calif
| | - Sande O Okelo
- Department of Pediatrics (LR Thompson, F Barry, J Flores-Vazquez, C Holifield, PG Szilagyi, SO Okelo), UCLA David Geffen School of Medicine, Los Angeles, Calif.
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Venegas M, Dudovitz R, Thompson L, Barry F, Holifield C, Flores-Vasquez J, Chang TP, Halterman J, Szilagyi P, Okelo S. Parent-Centered Perspectives on a Validated Asthma Questionnaire in the Emergency Department. Acad Pediatr 2024; 24:132-138. [PMID: 32058107 DOI: 10.1016/j.acap.2020.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 01/28/2020] [Accepted: 02/03/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although national asthma guidelines recommend use of validated questionnaires to improve asthma care, little is known about the extent to which these questionnaires are patient-centered. This qualitative study evaluated parent perceptions of a validated asthma questionnaire. METHODS We administered the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) to parents of children 2 to 17 years old presenting to a large urban pediatric ED for asthma care and assessed their perceptions of the tool's utility and acceptability via a structured interview. Responses were recorded, transcribed, and analyzed using a phenomenological approach. RESULTS Eighty-three parents participated. Qualitative analysis revealed 2 major themes (with 5 subthemes). The first major theme (and 3 subthemes) was that the PACCI-ED facilitated communication with the health care team and caregivers: improving communication 1) with ED providers, 2) in other settings such as schools, and 3) in the primary care setting where the relationship with primary care providers was felt to be variable. The second major theme (and 2 subthemes) was that the PACCI-ED increased parents' capacity to manage their child's asthma: by helping parents understand 1) what symptoms were related to asthma and 2) how those symptoms might change over time. CONCLUSIONS Parents perceive that the PACCI-ED is acceptable and useful for facilitating communication in the ED and other health care settings, and for building parent capacity to track and manage their child's asthma. A validated structured asthma questionnaire in the ED may facilitate patient-centered asthma care.
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Affiliation(s)
- Melanie Venegas
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Rebecca Dudovitz
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif.
| | - Lindsey Thompson
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Frances Barry
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Chloe Holifield
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Jessica Flores-Vasquez
- Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, University of Southern California (J Flores-Vasquez and TP Chang), Los Angeles, Calif
| | - Todd P Chang
- Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, University of Southern California (J Flores-Vasquez and TP Chang), Los Angeles, Calif
| | - Jill Halterman
- Division of General Pediatrics, Department of Pediatrics, University of Rochester School of Medicine (J Halterman), Rochester, NY
| | - Peter Szilagyi
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
| | - Sande Okelo
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (M Venegas, R Dudovitz, L Thompson, F Barry, C Holifield, P Szilagyi, and S Okelo), Los Angeles, Calif
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Chipps B, Zeiger RS, Beuther DA, Reibman J, Wise RA, McCann W, Gilbert I, Eudicone JM, Gandhi HN, Harding G, Cutts K, George M, Murphy KR. The Asthma Impairment and Risk Questionnaire enhances the assessment of asthma control. Ann Allergy Asthma Immunol 2023; 131:436-443.e1. [PMID: 37105501 DOI: 10.1016/j.anai.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/29/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023]
Abstract
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.
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Affiliation(s)
- Bradley Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, California.
| | - Robert S Zeiger
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - David A Beuther
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - Joan Reibman
- Department of Medicine, New York University (NYU) Grossman School of Medicine, New York, New York
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ileen Gilbert
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, Delaware
| | | | - Hitesh N Gandhi
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, Delaware
| | - Gale Harding
- Patient-Centered Research, Evidera, Bethesda, Maryland
| | - Katelyn Cutts
- Patient-Centered Research, Evidera, Bethesda, Maryland
| | - Maureen George
- Department of Nursing, Columbia University School of Nursing, New York, New York
| | - Kevin R Murphy
- Division of Allergy, Asthma and Immunology, Boys Town National Research Hospital, Boys Town, Nebraska
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Beuther DA, Murphy KR, Zeiger RS, Wise RA, McCann W, Reibman J, George M, Gilbert I, Eudicone JM, Gandhi HN, Ross M, Coyne KS, Chipps B. The Asthma Impairment and Risk Questionnaire (AIRQ) Control Level Predicts Future Risk of Asthma Exacerbations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:3204-3212.e2. [PMID: 35998877 DOI: 10.1016/j.jaip.2022.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 07/01/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- David A Beuther
- Department of Medicine, National Jewish Health, Denver, Colo.
| | - Kevin R Murphy
- Department of Pediatrics, Boys Town National Research Hospital, Boys Town, Neb
| | - Robert S Zeiger
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Joan Reibman
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Maureen George
- Department of Nursing, Columbia University, New York, NY
| | | | | | | | | | | | - Bradley Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, CA
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Okelo SO. Racial Inequities in Asthma Care. Semin Respir Crit Care Med 2022; 43:684-708. [DOI: 10.1055/s-0042-1756492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractRacial inequities in asthma care are evolving as a recognized factor in long-standing inequities in asthma outcomes (e.g., hospitalization and mortality). Little research has been conducted regarding the presence or absence of racial inequities among patients seen in asthma specialist settings, this is an important area of future research given that asthma specialist care is recommended for patients experiencing the poor asthma outcomes disproportionately experienced by Black and Hispanic patients. This study provides a systematic review of racial asthma care inequities in asthma epidemiology, clinical assessment, medication prescription, and asthma specialist referral practices.
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Affiliation(s)
- Sande O. Okelo
- Division of Pediatric Pulmonology and Sleep Medicine, The David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
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Ghimire JJ, Jat KR, Sankar J, Lodha R, Iyer VK, Gautam H, Sood S, Kabra SK. Azithromycin for Poorly Controlled Asthma in Children: A Randomized Controlled Trial. Chest 2022; 161:1456-1464. [PMID: 35202621 DOI: 10.1016/j.chest.2022.02.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/04/2022] [Accepted: 02/12/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Azithromycin has immunomodulatory actions, and its beneficial effects have been demonstrated in asthmatic adults. Data on children are limited. RESEARCH QUESTION Does the addition of oral azithromycin to standard therapy in children with poorly controlled asthma improve asthma control compared with standard treatment alone? STUDY DESIGN AND METHODS This open-label randomized controlled trial included children (5-15 years of age) with poorly controlled asthma defined by Asthma Control Test (ACT) and Childhood Asthma Control Test (CACT) score of ≤ 19. They were randomized to receive azithromycin (10 mg/kg) three times weekly for 3 months along with standard treatment or standard treatment alone. The primary outcome was the ACT and CACT scores at 3 months. Secondary outcomes were asthma control according to Global Initiative for Asthma (GINA) guidelines, the number of exacerbations, change in spirometry parameters, change in fractional exhaled nitric oxide (Feno) level, positive throat swab results, and side effects. RESULTS The trial included 120 children (89 boys; 60 in each group). The mean ± SD age was 9.9 ± 3 years. The baseline parameters were similar between the groups. Mean ± SD ACT and CACT scores (available for 115 children) at 3 months of intervention were 21.71 ± 2.17 vs 18.33 ± 2.19 (P < .001) in the azithromycin and control groups, respectively. The numbers of children with well-controlled asthma according to GINA guidelines were 41 of 56 vs 10 of 56 in the azithromycin and control groups, respectively (P < .001). The median number of exacerbations requiring emergency visit and steroid use were fewer in the azithromycin group: 0 (interquartile range [IQR], 3) vs 1 [IQR, 6]; P < .001). No difference was found in Feno level, spirometry parameters, positive throat swab results, and adverse effects between the groups. INTERPRETATION The use of azithromycin in children with poorly controlled asthma resulted in improved asthma control and reduced exacerbations. TRIAL REGISTRY Clinical Trials Registry - India; No.: CTRI/2019/06/019727; URL: www.ctri.nic.in.
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Affiliation(s)
- Jagat Jeevan Ghimire
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India
| | - Kana Ram Jat
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India.
| | - Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India
| | - Venkat K Iyer
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Hitender Gautam
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Sood
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, New Delhi, India
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Zhang Y, Clegg JL, Keith S, McFadden S, Symonds T, Kumar R, Khan AH, Kamat S, Chao J. Content validity of a newly developed observer-reported measure for pediatric asthma in children aged 2-5 years. J Patient Rep Outcomes 2022; 6:55. [PMID: 35633412 PMCID: PMC9148329 DOI: 10.1186/s41687-022-00461-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/04/2022] [Indexed: 11/24/2022] Open
Abstract
Background An observer-reported outcome (ObsRO) measure assessing both symptom control and health-related quality of life (HRQoL) in children with asthma younger than 6 years is lacking. The objective of this study was to evaluate the content validity of the Pediatric Asthma Questionnaire (PAQ), a newly developed 6-item ObsRO measure for caregivers of children aged 2–5 years diagnosed with asthma. Results In-depth, qualitative interviews were conducted with 15 parents or caregivers. The first part of the interview was an open-ended discussion whereby participants were asked to describe their observations of their child’s asthma symptoms and HRQoL impacts followed by a cognitive debriefing of a draft version of the PAQ. The most frequently reported symptoms were coughing (n = 15, 100%), wheezing (n = 14, 93%), and trouble breathing (n = 10, 67%). Overall, participants found the PAQ easy to complete and relevant to their child’s experience with asthma, with most reporting the instructions, response scales, and recall period for the items to be appropriate. The majority of participants (93%) believed they could accurately report on the items included in the PAQ based on their observations of their child’s asthma symptoms and impacts, or reliably get the information from the child’s teacher, school, or caregiver when their child was not in their presence. One item was modified based on feedback about the phrase “oral steroids” to clarify modes of administration. A few other minor changes were incorporated into the PAQ following suggestions from participants, including replacing the phrase “how often” with “how many days” in one of the items to improve clarity and overall consistency with the response options. Conclusion Qualitative data support the content validity of the PAQ as a fit-for-purpose and well-understood 6-item observer-reported outcome measure to evaluate both symptoms and asthma-specific HRQoL impacts experienced by pediatric asthma patients aged 2–5 years for use in clinical and real-world studies.
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Affiliation(s)
- Yi Zhang
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | - Jennifer L Clegg
- Clinical Outcomes Assessment, Clinical Outcomes Solutions, 53 W Jackson Blvd, Suite 1150, Chicago, IL, 60604, USA.
| | - Shannon Keith
- Clinical Outcomes Assessment, Clinical Outcomes Solutions, 53 W Jackson Blvd, Suite 1150, Chicago, IL, 60604, USA
| | - Shehan McFadden
- Clinical Outcomes Assessment, Clinical Outcomes Solutions, 53 W Jackson Blvd, Suite 1150, Chicago, IL, 60604, USA
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Delgado-Martinez R, Barry MF, Porras-Javier L, Thompson LR, Howard BJ, Sturner R, Halterman JS, Szilagyi PG, Okelo SO, Dudovitz RN. What Parents Want Doctors to Know: Responses to an Open-Ended Item on an Asthma Questionnaire. Acad Pediatr 2022; 22:657-666. [PMID: 34800723 DOI: 10.1016/j.acap.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Roxana Delgado-Martinez
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (R Delgado-Martinez, M Venegas, F Barry, L Porras-Javier, PG Szilagyi, SO Okelo, and RN Dudovitz), Los Angeles, Calif.
| | - Melanie Frances Barry
- Department of Pediatrics, The Johns Hopkins University School of Medicine (BJ Howard and R Sturner), Baltimore, Md
| | - Lorena Porras-Javier
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (R Delgado-Martinez, M Venegas, F Barry, L Porras-Javier, PG Szilagyi, SO Okelo, and RN Dudovitz), Los Angeles, Calif
| | - Lindsey R Thompson
- Kaiser Permanente Bernard J. Tyson School of Medicine (LR Thompson), Pasadena, Calif
| | - Barbara J Howard
- Department of Pediatrics, The Johns Hopkins University School of Medicine (BJ Howard and R Sturner), Baltimore, Md
| | - Raymond Sturner
- Department of Pediatrics, The Johns Hopkins University School of Medicine (BJ Howard and R Sturner), Baltimore, Md
| | - Jill S Halterman
- Department of Pediatrics, University of Rochester School of Medicine (JS Halterman), Rochester, NY
| | - Peter G Szilagyi
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (R Delgado-Martinez, M Venegas, F Barry, L Porras-Javier, PG Szilagyi, SO Okelo, and RN Dudovitz), Los Angeles, Calif
| | - Sande O Okelo
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (R Delgado-Martinez, M Venegas, F Barry, L Porras-Javier, PG Szilagyi, SO Okelo, and RN Dudovitz), Los Angeles, Calif
| | - Rebecca N Dudovitz
- Department of Pediatrics, The David Geffen School of Medicine at UCLA (R Delgado-Martinez, M Venegas, F Barry, L Porras-Javier, PG Szilagyi, SO Okelo, and RN Dudovitz), Los Angeles, Calif
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11
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Chipps BE, Murphy KR, Wise RA, McCann WA, Beuther DA, Reibman J, George M, Gilbert I, Eudicone JM, Gandhi HN, Harding G, Ross M, Zeiger RS. Evaluating construct validity of the Asthma Impairment and Risk Questionnaire using a 3-month exacerbation recall. Ann Allergy Asthma Immunol 2022; 128:544-552.e3. [PMID: 35123077 DOI: 10.1016/j.anai.2022.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/23/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
| | - Kevin R Murphy
- Division of Allergy, Asthma and Immunology, Boys Town National Research Hospital, Boys Town, Nebraska
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - David A Beuther
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | - Joan Reibman
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Maureen George
- Department of Nursing, Columbia University School of Nursing, New York, New York
| | - Ileen Gilbert
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, Delaware
| | | | - Hitesh N Gandhi
- BioPharmaceuticals Medical, AstraZeneca, Wilmington, Delaware
| | | | | | - Robert S Zeiger
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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12
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Moreno-Córdova V, Berra-Romani R, Flores Mendoza LK, Reyes-Leyva J. Th17 Lymphocytes in Children with Asthma: Do They Influence Control? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2021; 34:147-152. [PMID: 34958246 PMCID: PMC8817680 DOI: 10.1089/ped.2021.0067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/22/2021] [Indexed: 06/14/2023]
Abstract
Background: Allergic asthma was considered as an inflammation mediated by specific CD4+ helper lymphocytes (Th2); however, this paradigm changed in 2005, when a third group of helper cells called Th17 cells were identified. Th17 lymphocytes are the main source of interleukin (IL)-17A-F, IL-21, and IL-22; however, their physiological role in children is unclear. This study aimed to determine the percentage of Th17 cells and IL-17A in pediatric patients diagnosed with asthma and to associate it with disease control using a validated questionnaire. Methods: This cross-sectional, prospective, comparative study included 92 asthma-diagnosed children 4-18 years of age. The Asthma Control Test was used as an assessment measure to classify patients as controlled (n = 30), partially controlled (n = 31), and uncontrolled (n = 31). Th17 cells and IL-17A were analyzed by flow cytometry. Patients receiving inhaled steroid therapy as monotherapy or associated with a long-acting bronchodilator were included. Results: The mean percentage of Th17 cells in the participants was 4.55 ± 7.34 (Controlled), 5.50 ± 8.09 (Partially Controlled), and 6.14 ± 7.11 (Uncontrolled). There was no significant difference between the 3 groups (P = 0.71). The mean percentage of IL-17A in all the participants was 9.84 ± 9.4 (Controlled), 10.10 ± 10.5 (Partially Controlled), and 11.42 ± 8.96 (Uncontrolled); no significant difference between the 3 groups (P = 0.79) was observed. Th17 lymphocyte levels were similar among the 3 groups and the same trend was observed with IL-17A. A significant correlation between Th17 or IL-17A and the degree of asthma control (Th17, P = 0.24; IL-17A, P = 0.23) was not found. Conclusions: The percentages of both Th17 lymphocytes and IL-17A found in children with asthma were not significantly different in the 3 groups, which suggests that they do not play an important role in asthma control. Our findings may contribute to the knowledge related to non-Th2 inflammation in children. Clinical-Trials.gov ID: 2015-2102-85.
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Affiliation(s)
- Verónica Moreno-Córdova
- Department of Pediatric Pulmonology, Instituto Mexicano del Seguro Social (IMSS) Centro Médico Nacional “Manuel Ávila Camacho” Puebla, Puebla, México
| | - Roberto Berra-Romani
- Department of Biomedicine, School of Medicine, Benemérita Universidad Autónoma de Puebla, Puebla, México
| | - Lilian K. Flores Mendoza
- Clinical and Research Laboratory (LACIUS, URS), Department of Chemical, Biological, and Agricultural Sciences (DC-QB), Division of Sciences and Engineering, University of Sonora, Navojoa, México
| | - Julio Reyes-Leyva
- Centro de Investigación Biomédica de Oriente (CIBIOR), Instituto Mexicano del Seguro Social (IMSS), Puebla, México
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13
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Pade KH, Thompson LR, Ravandi B, Chang TP, Barry F, Halterman JS, Szilagyi PG, Okelo SO. Children with under-diagnosed asthma presenting to a pediatric emergency department. J Asthma 2021; 59:1353-1359. [PMID: 34034597 DOI: 10.1080/02770903.2021.1934696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Kathryn H Pade
- Rady Children's Hospital San Diego, UCSD School of Medicine, San Diego, CA, USA
| | | | - Bahareh Ravandi
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Todd P Chang
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Frances Barry
- UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | | | | | - Sande O Okelo
- UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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14
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Shaikhan FM, Makhlouf MM. Quality of life among caregivers of asthmatic children attending pulmonology clinics at Hamad General Hospital, Qatar. SAGE Open Med 2020; 8:2050312120973500. [PMID: 33282299 PMCID: PMC7691908 DOI: 10.1177/2050312120973500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/26/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction: Chronic paediatric diseases, as bronchial asthma, affect the quality of life,
which can be defined as the ability to preserve personal well-being despite
sickness. These diseases have a huge impact on the quality of life of both
the children, their parents and or caregivers. Methodology: A cross-sectional study using convenient sampling was conducted in the
paediatric pulmonology clinics at Hamad General Hospital in Qatar aiming to
evaluate the quality of life among caregivers of asthmatic children. The
quality of life of caregivers was assessed using the standard Paediatric
Asthma Caregiver Quality of Life questionnaire. Depression and asthma
control were assessed using the Beck Depression Inventory; second edition
and the Paediatric Asthma Control and Communication Instrument,
respectively. Results: Total number of the caregivers was 330. Majority of the asthmatic children
had controlled or partially controlled asthma (47% and 44%, respectively).
Most of the caregivers had either very good or good quality of life (63% and
31%, respectively). Mean quality of life score was 5.55 ± 1.14. Males,
married and father caregivers had significantly higher mean quality of life.
In addition, gender, getting bothered about child’s asthma, asthma control
score and depression score were significant predictors of quality of life
among the caregivers. Conclusion: Most of the caregivers had either very good or good quality of life. Being a
female, degree of asthma control and depression were important determinants
of the quality of life of the caregivers. Provision of needed support to
caregivers and effective approach to controlling asthma are recommended to
improve the quality of life of caregivers.
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Affiliation(s)
| | - Mohamed M Makhlouf
- High Institute of Public Health, Alexandria University, Alexandria, Egypt
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15
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Ravandi B, Thompson LR, Barry F, Pade KH, Chang TP, Halterman JS, Szilagyi PG, Okelo SO. Use of a validated asthma questionnaire to increase inhaled corticosteroid prescribing in the pediatric emergency department. J Asthma 2020; 59:378-385. [PMID: 33185486 DOI: 10.1080/02770903.2020.1841225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Asthma guidelines recommend assessment of asthma control and treatment with an ICS when appropriate. Children seen for asthma in the ED often have poorly controlled asthma. Validated questionnaires are rarely used in the ED and ICS are prescribed at less than 5% of ED asthma encounters, leaving many children at risk for continued poor outcomes. OBJECTIVE To determine if use of a validated asthma questionnaire can increase the proportion of children who receive an ICS prescription during an ED asthma visit. METHODS We administered a validated asthma questionnaire (Pediatric Asthma Control and Communication Instrument-ED version [PACCI-ED]) to parents of children 2 - 17 years old presenting for asthma care at a large, urban, academic pediatric ED. Based on national asthma guidelines, the PACCI-ED results were used to determine ICS dose recommendations. ED physicians reviewed the PACCI-ED results and ICS dose recommendations and chose whether to prescribe an ICS upon discharge. ICS prescribing rates during the intervention period were assessed via medical record review and compared to historical controls. We also surveyed parents to examine the association of sociodemographic factors with receipt of an ICS prescription, and surveyed physicians regarding their prescribing decisions. RESULTS Thirteen physicians and seventy-nine children participated. Historically, the ICS prescribing rate for asthma exacerbations discharged from the ED was 13%. The intervention increased ICS prescribing to 56% (p < 0.001). Children with ≥2 asthma exacerbations in the prior year (p < 0.02) and those with moderate-severe persistent asthma (p < 0.02) were more likely to receive an ICS prescription. There were no statistically significant differences in ICS prescribing by sociodemographic characteristics. CONCLUSION A validated asthma questionnaire increased ICS prescribing for children presenting for to the ED for asthma care. Additional strategies are needed to promote prescribing in this setting and ensure that all eligible children receive guideline-based asthma care.
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Affiliation(s)
- Bahareh Ravandi
- Pediatric Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,University of Southern California, Los Angeles, CA, USA
| | - Lindsey R Thompson
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Frances Barry
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kathryn H Pade
- UCSD, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Todd P Chang
- Pediatric Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Peter G Szilagyi
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Sande O Okelo
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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16
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Santino TA, de França Mendes Alves RE, Monteiro KS, Okelo SO, Patino CM, Alchieri JC, Mendonça KMPP. Psychometric evaluation of the Brazilian version of the pediatric asthma control and communication instrument. Pediatr Pulmonol 2020; 55:1900-1907. [PMID: 32450011 DOI: 10.1002/ppul.24851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 05/12/2020] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Thayla Amorim Santino
- Department of Physical Therapy, Graduate Program in Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | | | - Karolinne Souza Monteiro
- Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Sande O Okelo
- Department of Pediatrics, University of California, Los Angeles, California
| | - Cecília M Patino
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - João Carlos Alchieri
- Department of Psychology, Graduate Program in Science, Technology and Innovation, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | - Karla Morganna P P Mendonça
- Department of Physical Therapy, Graduate Program in Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.,Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
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17
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Ravandi B, George M, Thompson L, Vangala SV, Chang T, Okelo S. Inhaled corticosteroid beliefs, complementary and alternative medicine in children presenting to the emergency department for asthma. J Asthma 2020; 58:1359-1366. [PMID: 32646322 DOI: 10.1080/02770903.2020.1786113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Negative beliefs about inhaled corticosteroids (ICS) and endorsement of complementary and alternative medicine (CAM) have been associated with medication non-adherence and uncontrolled asthma. The association of CAM and negative health beliefs is not described in children in acute care settings. Our study objective is to determine the relationship between negative ICS beliefs, CAM use and poorly controlled asthma among a predominantly Latino population in an acute care setting. METHODS The study was conducted in the pediatric emergency department of a children's hospital. During an ED asthma encounter, validated questionnaires surveyed parents about negative ICS beliefs, CAM use, and asthma health and control. We compared asthma health reports between parents who did or did not endorse negative ICS beliefs or CAM use, by chi-squared test (or a Fisher's exact test where appropriate). RESULTS Parents of 174 children identified mostly as Latino with Medicaid insurance and high asthma morbidity. CAM endorsement and negative ICS beliefs were both associated with increased use of lifetime glucocorticoid (p = 0.03 and p=0.01 respectively). While CAM endorsement was associated with less hospitalizations (p = 0.04) and parental report of asthma "getting better" (p = 0.01), CAM users reported trouble with paying for rent or food (p = 0.02). Negative ICS beliefs and CAM endorsement were not associated with medication adherence. CONCLUSIONS Negative ICS beliefs are associated with higher number of oral glucocorticoid courses. The association between CAM endorsement and asthma control is varied, but mostly in favor of improved control. Financial difficulties may make CAM use more likely.
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Affiliation(s)
- Bahareh Ravandi
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Maureen George
- Columbia University School of Nursing, Columbia University Medical Center, New York, NY, USA
| | - Lindsey Thompson
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | | | - Todd Chang
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Sande Okelo
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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18
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Development of the Asthma Impairment and Risk Questionnaire (AIRQ): A Composite Control Measure. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2263-2274.e5. [PMID: 32387166 DOI: 10.1016/j.jaip.2020.02.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 02/08/2023]
Abstract
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.
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19
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Pade KH, Thompson LR, Ravandi B, Chang TP, Barry F, Halterman JS, Szilagyi PG, Okelo SO. Parental perception of a picture-based chronic asthma care management tool in an urban pediatric emergency department. J Asthma 2020; 58:1013-1023. [PMID: 32249659 DOI: 10.1080/02770903.2020.1753210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- K H Pade
- UCSD School of Medicine, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - L R Thompson
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - B Ravandi
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - T P Chang
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - F Barry
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - J S Halterman
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - P G Szilagyi
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - S O Okelo
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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20
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Barry F, Thompson LR, Ravandi B, Chang TP, Halterman JS, Szilagyi PG, Okelo SO. Parental preferences for survey mode of administration, interview versus self-administered, with an asthma management questionnaire. J Asthma 2020; 58:665-673. [PMID: 32052668 DOI: 10.1080/02770903.2020.1728766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: National asthma guidelines encourage use of patient surveys to aid clinical assessment. Little is known about how these should be administered in acute care settings such as the emergency department (ED).Objective: Evaluate if parents have a preference for interview versus self-administered surveys in an ED, understand the sociodemographic and clinical characteristics by choice of survey mode of administration, and assess if there is a difference by mode in the parent's perception of an asthma management tool.Methods: A research assistant (RA) surveyed parents of children 2-17 years of age seeking ED asthma care. Parents chose to either self-administer or have an RA-administered survey that included the Pediatric Asthma Control and Communication Instrument-ED version (PACCI-ED). We compared sociodemographic and clinical characteristics and perceptions about the PACCI-ED by mode of survey administration.Results: Of 174 parent participants, 60% chose interviewer-administered surveys. Parents who chose interviewer-administered versus self-administered surveys had lower income, lower educational attainment, and children with uncontrolled asthma (p < .05). Bivariate and multivariate analyses showed that parents who chose interviewer-administered versus self-administered surveys tended to rate the PACCI-ED more favorably.Conclusions: EDs wishing to systematically use an asthma survey may need to plan appropriate resources for staff to administer them, particularly if they serve populations of lower socioeconomic status.
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Affiliation(s)
- Frances Barry
- Department of Pediatric Pulmonology and Sleep Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Lindsey R Thompson
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Bahareh Ravandi
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Todd P Chang
- Division of Emergency Medicine and Transport, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Jill S Halterman
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Peter G Szilagyi
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Sande O Okelo
- Department of Pediatric Pulmonology and Sleep Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Asthma control in the quality of life levels of asthmatic patients’ caregivers: a systematic review with meta‐analysis and meta‐regression. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2019. [DOI: 10.1016/j.jpedp.2019.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Asthma control in the quality of life levels of asthmatic patients' caregivers: a systematic review with meta-analysis and meta-regression. J Pediatr (Rio J) 2019; 95:401-409. [PMID: 30540924 DOI: 10.1016/j.jped.2018.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 09/05/2018] [Accepted: 09/06/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To perform a systematic review with meta-analysis and meta-regression to correlate the total scores of asthma control with the increase in the total scores of health-related quality of life levels of parents of asthmatic children. SOURCES The search was carried out in the following databases: PubMed (MEDLINE); Embase and ScienceDirect (Elsevier); SciELO and LILACs (Bireme) in June 2017. The included studies assessed asthma control through the Asthma Control Questionnaire (ACQ), Asthma Control Test (C-ACT/ACT), and Global Initiative for Asthma (GINA) questionnaires, whereas the Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ) was applied to assess the HRQoL of parents and family members. SUMMARY OF THE FINDINGS 294 articles were evaluated in the selected databases, of which (n=38) were excluded for duplicity; (n=239) after the reading of the titles and abstracts and (n=5) after reading the studies in full, totaling 12 studies eligible for the meta-analysis. Of the 12 eligible articles, 11 (92%) were published in the last five years, and evaluated children and adolescents aged 1-20 years, totaling 2804 samples. In the evaluation of the correlation between the disease control scores by ACQ and C-ACT/ACT, the results were satisfactory for both ACQ analyses [R2: -0.88; p<0.001], and for C-ACT/ACT [R2: 0.82; p<0.001]. CONCLUSIONS The results show that asthma control levels can influence the total HRQoL scores of parents or relatives of children and adolescents with asthma.
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Santino TA, Alchieri JC, Mendes REDF, Jácome AC, Santos TZDM, Kahn-D'Angelo L, Patino CM, Mendonça KMPPD. Pediatric Asthma Control and Communication Instrument: translation into Portuguese and cross-cultural adaptation for use in Brazil. ACTA ACUST UNITED AC 2019; 45:e20180169. [PMID: 31271602 PMCID: PMC6715034 DOI: 10.1590/1806-3713/e20180169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 01/10/2019] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Thayla Amorim Santino
- . Programa de Pós-Graduação em Fisioterapia, Universidade Federal do Rio Grande do Norte - UFRN - Natal (RN) Brasil
| | - João Carlos Alchieri
- . Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte - UFRN - Natal (RN) Brasil
| | | | - Ada Cristina Jácome
- . Programa de Pós-Graduação em Fisioterapia, Universidade Federal do Rio Grande do Norte - UFRN - Natal (RN) Brasil
| | | | - Linda Kahn-D'Angelo
- . Zuckerberg College of Health Sciences, University of Massachussets Lowell, Lowell (MA) USA
| | - Cecilia M Patino
- . Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles (CA) USA
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Pade KH, Agnihotri NT, Vangala S, Thompson LR, Wang VJ, Okelo SO. Asthma specialist care preferences among parents of children receiving emergency department care for asthma. J Asthma 2019; 57:188-195. [PMID: 30663904 DOI: 10.1080/02770903.2019.1565768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To learn factors associated with desire for asthma specialist care among parents of children seeking emergency department (ED) care for asthma, and if referral was indicated based on national asthma guidelines. Methods: We surveyed parents of children ages 0-18 years seeking pediatric ED asthma care, then comparisons were made according to parental level of interest in asthma specialist care, with regard to socio-demographics, asthma morbidity and care, by chi-squared and logistic regression. Results: Of 149 children, 20% reported specialist care, but 75% met guideline criteria for referral. About 80% of parents not seeing an asthma specialist expressed a desire to see one. Higher rates of prior urgent care visits (48% vs. 22%, p = 0.03), ED visits (82% vs. 35%, p < 0.001) and oral steroid use (53% vs. 22%, p = 0.009) were reported by parents who desired an asthma specialist compared with parents who did not. 87% of parents not seeing a specialist attributed this to a perceived lack of necessity by their primary care provider. An ED visit within the prior 12 months was the most significant predictor in parental desire for specialist care (odds ratio 9.75; 95% CI 3.42-27.76) in adjusted logistic regression models. Conclusion: High rates of parental preference for asthma specialist care suggest that directly querying parents may be an efficient method to identify children appropriate for specialist care in the ED.
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Affiliation(s)
- Kathryn H Pade
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
| | - Neha T Agnihotri
- Division of Internal Medicine & Pediatrics, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sitaram Vangala
- Division of General Internal Medicine and Health Services Research, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lindsey R Thompson
- Department of Pediatrics, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Vincent Joseph Wang
- Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Sande O Okelo
- Department of Pediatrics, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Agnihotri NT, Pade KH, Vangala S, Thompson LR, Wang VJ, Okelo SO. Predictors of prior asthma specialist care among pediatric patients seen in the emergency department for asthma. J Asthma 2018; 56:816-822. [PMID: 29972331 DOI: 10.1080/02770903.2018.1493600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Asthma guidelines recommend specialist care for patients experiencing poor asthma outcomes during emergency department (ED) visits. The prevalence and predictors of asthma specialist care among an ED population seeking pediatric asthma care are unknown. Objective: To examine, in an ED population, factors associated with prior asthma specialist use based on parental reports of prior asthma morbidity and asthma care. Methods: Parents of children ages 0 to 17 years seeking ED asthma care were surveyed regarding socio-demographics, asthma morbidity, asthma management and current asthma specialist care status. We compared prior asthma care and morbidity between those currently cared for by an asthma specialist versus not. Multivariable logistic regression models to predict factors associated with asthma specialist use were adjusted for parent education and insurance type. Results: Of 150 children (62% boys, mean age 4.7 years, 69% Hispanic), 22% reported asthma specialist care, 75% did not see a specialist and for 3% specialist status was unknown. Care was worse for those not seeing a specialist, including under-use of controller medications (24% vs. 64%, p < 0.001) and asthma action plans (20% vs. 62%, p < 0.001). Multivariable logistic regression revealed that lack of recommendation by the primary care physician reduced the odds of specialist care (OR 0.01, 95% CI <0.01, 0.05, p < 0.001). Conclusions: Asthma specialist care was infrequent among this pediatric ED population, consistent with the sub-optimal chronic asthma care we observed. Prospective trials should further investigate if systematic referral to asthma specialists during/after an ED encounter would improve asthma outcomes.
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Affiliation(s)
- Neha T Agnihotri
- a Department of Internal Medicine and Pediatrics, The David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
| | - Kathryn H Pade
- b Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, University of Southern California , Los Angeles , CA , USA
| | - Sitaram Vangala
- c Division of General Internal Medicine and Health Services Research, The David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
| | - Lindsey R Thompson
- d Department of Pediatrics, The David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
| | - Vincent J Wang
- b Division of Emergency & Transport Medicine, Children's Hospital Los Angeles, University of Southern California , Los Angeles , CA , USA
| | - Sande O Okelo
- d Department of Pediatrics, The David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
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Shepperd JA, Lipsey NP, Pachur T, Waters EA. Understanding the Cognitive and Affective Mechanisms that Underlie Proxy Risk Perceptions among Caregivers of Asthmatic Children. Med Decis Making 2018; 38:562-572. [PMID: 29629847 DOI: 10.1177/0272989x18759933] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Medical decisions made on behalf of another person-particularly those made by adult caregivers for their minor children-are often informed by the decision maker's beliefs about the treatment's risks and benefits. However, we know little about the cognitive and affective mechanisms influencing such "proxy" risk perceptions and about how proxy risk perceptions are related to prominent judgment phenomena. METHODS Adult caregivers of minor children with asthma ( N = 132) completed an online, cross-sectional survey assessing 1) cognitions and affects that form the basis of the availability, representativeness, and affect heuristics; 2) endorsement of the absent-exempt and the better-than-average effect; and 3) proxy perceived risk and unrealistic comparative optimism of an asthma exacerbation. We used the Pediatric Asthma Control and Communication Instrument (PACCI) to assess asthma severity. RESULTS Respondents with higher scores on availability, representativeness, and negative affect indicated higher proxy risk perceptions and (for representativeness only) lower unrealistic optimism, irrespective of asthma severity. Conversely, respondents who showed a stronger display of the better-than-average effect indicated lower proxy risk perceptions but did not differ in unrealistic optimism. The absent-exempt effect was unrelated to proxy risk perceptions and unrealistic optimism. CONCLUSION Heuristic judgment processes appear to contribute to caregivers' proxy risk perceptions of their child's asthma exacerbation risk. Moreover, the display of other, possibly erroneous, judgment phenomena is associated with lower caregiver risk perceptions. Designing interventions that target these mechanisms may help caregivers work with their children to reduce exacerbation risk.
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Affiliation(s)
- James A Shepperd
- Department of Psychology, University of Florida, Gainesville, GL, USA
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Abstract
Asthma affects an estimated 7 million children and causes significant health care and disease burden. The most recent iteration of the National Heart, Lung and Blood Institute asthma guidelines, the Expert Panel Report 3, emphasizes the assessment and monitoring of asthma control in the management of asthma. Asthma control refers to the degree to which the manifestations of asthma are minimized by therapeutic interventions and the goals of therapy are met. Although assessment of asthma severity is used to guide initiation of therapy, monitoring of asthma control helps determine whether therapy should be maintained or adjusted. The nuances of estimation of asthma control include understanding concepts of current impairment and future risk and incorporating their measurement into clinical practice. Impairment is assessed on the basis of frequency and intensity of symptoms, variations in lung function, and limitations of daily activities. "Risk" refers to the likelihood of exacerbations, progressive loss of lung function, or adverse effects from medications. Currently available ambulatory tools to measure asthma control range are subjective measures, such as patient-reported composite asthma control score instruments or objective measures of lung function, airway hyperreactivity, and biomarkers. Because asthma control exhibits short- and long-term variability, health care providers need to be vigilant regarding the fluctuations in the factors that can create discordance between subjective and objective assessment of asthma control. Familiarity with the properties, application, and relative value of these measures will enable health care providers to choose the optimal set of measures that will adhere to national standards of care and ensure delivery of high-quality care customized to their patients.
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Mitchell SJ, Bilderback AL, Okelo SO. Feasibility of Picture-Based Asthma Medication Plans in Urban Pediatric Outpatient Clinics. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2016; 29:95-99. [PMID: 27583171 PMCID: PMC4984975 DOI: 10.1089/ped.2016.0640] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 05/12/2016] [Indexed: 11/13/2022]
Abstract
Picture-based Asthma Action Plans show promise for overcoming parental literacy barriers and improving child asthma outcomes, but it is uncertain how parents respond to pictures of specific medications, which may be particularly important for improving disease self-management. Thus, we assessed parent attitudes toward an asthma-related picture-based medication plan (PBMP) in an urban academic pediatric clinic and examined attitudes by literacy level. Surveys were administered to a convenience sample of parents of children presenting to an urban pediatric pulmonary clinic for asthma consultation between March and August 2011. The Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF) was administered to parents. Parents indicated their level of agreement with 9 statements on the potential usefulness of the PBMP: (1) before being shown a PBMP; and (2) after seeing the doctor. McNemar's tests showed that the proportion of high-literate parents (≥9th grade reading level) who endorsed the potential benefits of the PBMP after the clinical encounter was significantly higher than before the clinical encounter. A high proportion of low-literate parents (<9th grade reading level) consistently endorsed the PBMP before and after the clinical encounter. Among a diverse sample seen in an urban asthma clinic, parents of all literacy levels endorse PBMPs as useful, especially after using them in clinical encounters.
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Affiliation(s)
| | | | - Sande O. Okelo
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
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Warman K, Silver E. A primary care-based asthma program improves recognition and treatment of persistent asthma in inner-city children compared to routine care. J Asthma 2016; 53:930-7. [PMID: 27187499 DOI: 10.3109/02770903.2016.1161051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine whether a primary care-based asthma program that applies the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-2007 criteria to classify asthma severity increases detection of persistent asthma in inner-city children and affects "step of care" compared to routine care. METHODS A retrospective chart review was conducted of 97 consecutive children referred to the asthma program from 2011-2013. Asthma severity documented during routine health care maintenance visits was compared to the asthma severity assessed during the asthma program visit using five standardized questions and spirometry. Medication plan "step of care" was compared pre- and post- the asthma program visit. RESULTS 79 children, ages 5-19 years old (mean = 9.6), had spirometry tracings meeting American Thoracic Society criteria and were included in this study. 53% were male. The majority of children were Latino (45.6%) or African American (35.4%). At the asthma program visit, more children were identified with moderate or severe persistent asthma based upon clinical questions (47.9%), spirometry (56.9%) or combined criteria (75.3%) than had been identified during routine care (15.2%); all p < .05. After the asthma program visit, more children were prescribed controller medications (82.3% vs 63.3%; p < .05) and 40.6% had their medication plan stepped up. CONCLUSIONS In this population of inner-city children, asthma severity was under-recognized and undertreated during routine care. A primary care based asthma program, which formalized applying EPR-3 criteria, increased detection of persistent asthma and led to "step-ups" in treatment plans.
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Affiliation(s)
- Karen Warman
- a Department of Pediatrics, The Children's Hospital at Montefiore , Albert Einstein College of Medicine , Bronx , NY , USA
| | - Ellen Silver
- a Department of Pediatrics, The Children's Hospital at Montefiore , Albert Einstein College of Medicine , Bronx , NY , USA
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Howell CR, Thompson LA, Gross HE, Reeve BB, DeWalt DA, Huang IC. Responsiveness to Change in PROMIS(®) Measures among Children with Asthma: A Report from the PROMIS(®) Pediatric Asthma Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:192-201. [PMID: 27021753 PMCID: PMC4814775 DOI: 10.1016/j.jval.2015.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 11/28/2015] [Accepted: 12/12/2015] [Indexed: 06/05/2023]
Abstract
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.
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Affiliation(s)
- Carrie R Howell
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Lindsay A Thompson
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Heather E Gross
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bryce B Reeve
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Darren A DeWalt
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Wu DJ, Hipolito E, Bilderback A, Okelo SO, Garro A. Predicting future emergency department visits and hospitalizations for asthma using the Pediatric Asthma Control and Communication Instrument - Emergency Department version (PACCI-ED). J Asthma 2016; 53:387-91. [PMID: 26667853 DOI: 10.3109/02770903.2015.1115520] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Dominic J Wu
- a W. Alpert Medical School of Brown University , Providence , RI , USA
| | | | | | - Sande O Okelo
- d University of California Los Angeles , Los Angeles , CA , USA and
| | - Aris Garro
- e Rhode Island Hospital and Brown University , Providence , RI , USA
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Mitchell SJ, Bilderback AL, Okelo SO. Racial Disparities in Asthma Morbidity Among Pediatric Patients Seeking Asthma Specialist Care. Acad Pediatr 2016; 16:64-7. [PMID: 26329015 DOI: 10.1016/j.acap.2015.06.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 05/30/2015] [Accepted: 06/10/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To elucidate whether there may be a higher morbidity threshold for African American versus white children to be referred to or seek asthma specialist care. METHODS Secondary analysis of registry data captured from children presenting for an initial routine outpatient asthma consultation. Parents completed standard survey instruments, and spirometry was conducted when deemed appropriate by the provider. RESULTS Wilcoxon rank sum tests revealed that African American patients had been hospitalized twice as often and admitted to the intensive care unit or intubated significantly more than 1½ times more frequently than their white patient counterparts. t tests indicated African American patients' forced expiratory volume in 1 second (FEV1) percentage predicted was significantly worse than that of whites, but there was no significant difference for FEV1/forced vital capacity ratio. t tests suggested that African American patients had statistically worse asthma control than did white patients at the time of initial presentation to the pulmonologist, but there was no difference in the distribution of asthma severity categories. Multivariate regression models indicated that racial differences in parent education did not explain the disparities in asthma morbidity. CONCLUSIONS African American patients had significantly worse asthma morbidity than their white counterparts, including higher rates of hospitalization and intensive care unit admission and poorer lung functioning. Given that receipt of asthma specialist care can improve those outcomes that are disparately experienced by African American children, methods of increasing their access to and use of asthma specialist care need to be developed.
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Affiliation(s)
| | | | - Sande O Okelo
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif.
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Ducharme FM, Jensen ME, Mendelson MJ, Parkin PC, Desplats E, Zhang X, Platt R. Asthma Flare-up Diary for Young Children to monitor the severity of exacerbations. J Allergy Clin Immunol 2015; 137:744-9.e6. [PMID: 26341275 DOI: 10.1016/j.jaci.2015.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/18/2015] [Accepted: 07/03/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Few instruments exist to ascertain the severity of a preschool-aged child's asthma exacerbations managed at home. OBJECTIVE We sought to develop and validate a functional status instrument to assess asthma exacerbation severity in preschoolers. METHODS The parent-completed Asthma Flare-up Diary for Young Children (ADYC), which was developed systematically, comprises 17 items, each scored from 1 (best) to 7 (worst). The ADYC was completed daily from the onset of an upper respiratory tract infection (URTI) until asthma symptom resolution; the cumulative daily score was reported. The ADYC was examined for key psychometric properties in a randomized placebo-controlled trial of pre-emptive high-dose fluticasone in preschoolers with URTI-induced asthma. RESULTS In 121 children aged 2.7 ± 1.1 years (59.5% male), the ADYC's internal consistency (Cronbach α = .97), feasibility (97% completion), and test-retest reliability (r = 0.71; 95% CI, 0.59-0.80) were demonstrated. The ADYC was responsive to change between 2 consecutive days (Guyatt statistic = 0.77) with a minimal important difference of 0.22 (0.17-0.27). Of 871 episodes, the cumulative ADYC score was significantly higher during exacerbations than during URTIs (mean difference [MD], 7.6; 95% CI, 6.4-8.9) and for exacerbations with an acute-care visit (MD, 9.1; 95% CI, 7.6-10.7), systemic corticosteroids (MD, 10.1; 95% CI, 8.3-12.0), and hospitalization (MD, 6.8; 95% CI, 2.9-10.7) versus those without. In children receiving fluticasone, the ADYC score was significantly lower versus that in the placebo group (MD, 5.1; 95% CI, 1.8-8.3). CONCLUSIONS The 17-item ADYC proved feasible, responsive to day-to-day changes, and discriminative across exacerbations of different severities. In a trial testing effective therapy in preschoolers, it identified a significant reduction in asthma exacerbation severity.
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Affiliation(s)
- Francine M Ducharme
- Departments of Pediatrics and Social and Preventive Medicine, Sainte-Justine University Health Centre, Université de Montréal, Montreal, Quebec, Canada; Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre, Université de Montréal, Montreal, Quebec, Canada.
| | - Megan E Jensen
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre, Université de Montréal, Montreal, Quebec, Canada
| | | | - Patricia C Parkin
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eve Desplats
- Unité de recherche clinique appliquée, Research Center, Sainte-Justine University Health Centre, Université de Montréal, Montreal, Quebec, Canada
| | - Xun Zhang
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Robert Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University Health Centre, Montreal, Quebec, Canada; Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
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Lucas RW, Dees J, Reynolds R, Rhodes B, Hendershot RW. Cloud-computing and smartphones: tools for improving asthma management and understanding environmental triggers. Ann Allergy Asthma Immunol 2015; 114:431-2. [PMID: 25952637 DOI: 10.1016/j.anai.2015.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/30/2015] [Accepted: 02/09/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Richard W Lucas
- Department of Forest Ecology and Management, Swedish University of Agricultural Sciences, Umeå, Sweden; OSIA Medical, Sandy, Utah.
| | | | - Robert Reynolds
- OSIA Medical, Sandy, Utah; Database Consulting Group, Orem, Utah
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Szefler SJ. Advances in pediatric asthma in 2013: coordinating asthma care. J Allergy Clin Immunol 2014; 133:654-61. [PMID: 24581430 DOI: 10.1016/j.jaci.2014.01.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 01/22/2014] [Accepted: 01/24/2014] [Indexed: 01/06/2023]
Abstract
Last year's "Advances in pediatric asthma: moving toward asthma prevention" concluded that "We are well on our way to creating a pathway around wellness in asthma care and also to utilize new tools to predict the risk for asthma and take steps to not only prevent asthma exacerbations but also to prevent the early manifestations of the disease and thus prevent its evolution to severe asthma." This year's summary will focus on recent advances in pediatric asthma on prenatal and postnatal factors altering the natural history of asthma, assessment of asthma control, and new insights regarding potential therapeutic targets for altering the course of asthma in children, as indicated in Journal of Allergy and Clinical Immunology publications in 2013 and early 2014. Recent reports continue to shed light on methods to understand factors that influence the course of asthma, methods to assess and communicate levels of control, and new targets for intervention, as well as new immunomodulators. It will now be important to carefully assess risk factors for the development of asthma, as well as the risk for asthma exacerbations, and to improve the way we communicate this information in the health care system. This will allow parents, primary care physicians, specialists, and provider systems to more effectively intervene in altering the course of asthma and to further reduce asthma morbidity and mortality.
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Affiliation(s)
- Stanley J Szefler
- Pediatric Asthma Research Program, Section of Pediatric Pulmonary Medicine, Breathing Institute, Department of Pediatrics, Children's Hospital Colorado, and the Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colo.
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Okelo SO, Eakin MN, Riekert KA, Teodoro AP, Bilderback AL, Thompson DA, Loiaza-Martinez A, Rand CS, Thyne S, Diette GB, Patino CM. Validation of parental reports of asthma trajectory, burden, and risk by using the pediatric asthma control and communication instrument. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:186-92. [PMID: 24607047 DOI: 10.1016/j.jaip.2013.10.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/29/2013] [Accepted: 10/15/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Despite a growing interest, few pediatric asthma questionnaires assess multiple dimensions of asthma morbidity, as recommended by national asthma guidelines, or use patient-reported outcomes. OBJECTIVE To evaluate a questionnaire that measures multiple dimensions of parent-reported asthma morbidity (Direction, Bother, and Risk). METHODS We administered the Pediatric Asthma Control and Communication Instrument (PACCI) and assessed asthma control (PACCI Control), quality of life, and lung function among children who presented for routine asthma care. The PACCI was evaluated for discriminative validity. RESULTS A total of 317 children participated (mean age, 8.2 years; 58% boys; 44% African American). As parent-reported PACCI Direction changed from "better" to "worse," we observed poorer asthma control (P < .001), mean Pediatric Asthma Caregiver Quality of Life Questionnaire (PACQLQ) scores (P < .001), and FEV1% (P = .025). Linear regression showed that, for each change in PACCI Direction, the mean PACQLQ score decreased by -0.6 (95% CI, -0.8 to -0.4). As parent-reported PACCI Bother changed from "not bothered" to "very bothered," we observed poorer asthma control (P < .001) and lower mean PACQLQ scores (P < .001). Linear regression showed that, for each change in PACCI Bother category, the mean PACQLQ score decreased by -1.1 (95% CI, -1.3 to -0.9). Any reported PACCI Risk event (emergency department visit, hospitalization, or use of an oral corticosteroid) was associated with poorer asthma control (P < .05) and PACQLQ scores (P < .01). CONCLUSIONS PACCI Direction, Bother, and Risk are valid measures of parent-reported outcomes and show good discriminative validity. The PACCI is a simple clinical tool to assess multiple dimensions of parent-reported asthma morbidity, in addition to risk and control.
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Affiliation(s)
- Sande O Okelo
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif.
| | - Michelle N Eakin
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Kristin A Riekert
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Alvin P Teodoro
- Department of Pediatrics, New York Presbyterian/Weill Medical College of Cornell University, New York, NY
| | | | | | | | - Cynthia S Rand
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Shannon Thyne
- Department of Pediatrics, University of California San Francisco, San Francisco, Calif
| | - Gregory B Diette
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Md
| | - Cecilia M Patino
- Department of Preventive Medicine, University of Southern California, Los Angeles, Calif
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