School absence and productivity outcomes associated with childhood asthma in the USA

Stock Inhalers: A Qualitative Data Analysis of Illinois Health Policy Trials and Triumphs

BACKGROUND

Asthma reliever medication access is critical, especially in schools. Policies that "stock" reliever inhalers in schools provide failsafe medication access. This research aims to understand barriers and facilitators to Illinois stock inhaler policy implementation.

METHODS

We conducted 18 semi-structured interviews in 2021-2022 with key school-based and non-school-based partners (school administrators, nurses, governmental agencies, and advocacy leaders). Through Atlas.ti, code frequencies compared (Fisher's exact test), and a thematic analysis performed.

RESULTS

Four themes emerged: facilitators, barriers, program rationale, and process considerations. The common facilitators were "Finding a provider," having a "Champion," and "Funding". Barriers included "Not enough school nurses," "Pharmacy refusal to fill prescriptions," and "Feeling overwhelmed." All were supportive of the rationale for stock inhalers. Non-school-based informants (p < .01) were more likely to mention medication donations, while school staff reported having enough nurses as a facilitator (p < .01). School staff reported concerns about children with asthma not having their medication significantly more than other partners (p = .02).

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Our analysis revealed that school partners recognize the value of stock inhalers. Barrier mitigation to support the funding, prescription access and processing, and training are essential to success of stock inhaler programming. Multilevel collaborative efforts through coalitions could be a potential solution.

Using Cost Conversations to Address Financial Toxicity in Pediatric Asthma Care: Findings From a Survey of Caregivers

INTRODUCTION

Asthma care teams are well-positioned to help caregivers address financial toxicity in pediatric asthma care, although discussing cost can be challenging. We sought to characterize cost conversations in pediatric asthma specialty care.

METHOD

We surveyed 45 caregivers of children aged 4-17 with asthma. Eligible caregivers reported costs concerns and had accompanied their child to a multisite asthma specialty practice in North Carolina.

RESULTS

About one-third of caregivers reported a cost conversation (36%). Cost conversations were less common among caregivers whose child had public versus private health insurance (16% vs. 56%), who attended a telehealth versus in-person visit (6% vs. 52%), or who did not versus did want a conversation (19% vs. 77%, all p < .05). Common cost conversation topics were medications and equipment like spacers.

DISCUSSION

Our findings suggest cost conversations may be relatively uncommon in pediatric asthma care, particularly for publicly insured patients and telehealth visits.

Economic costs associated with unhealthy weight control behaviors among Australian adolescents

OBJECTIVE

This study explored the relationship between unhealthy weight control behaviors (UWCBs) and their associated economic costs among adolescents using the 2014-2018 Longitudinal Study of Australian Children (LSAC).

METHODS

LSAC data in Wave 6 (n = 3538 adolescents aged 14-15 years), Wave 7 n = 3089 adolescents aged 16-17 years), and Wave 8 (n = 3037 adolescents aged 18-19 years) were derived from a representative sample of Australian adolescents. UWCBs were measured using the self-reported Branched Eating Disorder Test questionnaire. UWCBs were sub-classified into having fasting behaviors, using weight loss supplements or purging behaviors. Economic costs include healthcare and productivity costs to caregivers. Healthcare costs were measured using data from the Medicare and Pharmaceutical Benefits, which includes both medical and pharmaceutical costs. Productivity losses were measured using caregivers' lost leisure time due to UWCBs among adolescents.

RESULTS

The mixed effect model identified statistically significant higher economic costs (mean difference = $453, 95% CIs $154, $752), higher health care costs (mean difference = $399, 95% CIs $102, $695), and higher productivity costs (mean difference = $59, 95% CIs $29, $90) for adolescents with UWCBs compared to their peers with no UWCBs. Subgroup analysis revealed that higher costs were associated with fasting and purging behaviors.

DISCUSSION

UWCBs were associated with increased economic costs during adolescence. Our finding suggests there should be a policy focus on tackling UWCBs to reduce the economic burden on the healthcare system and society.

PUBLIC SIGNIFICANCE

The study contributes to existing knowledge by investigating the direct healthcare costs and productivity losses associated with unhealthy weight control behaviors in Australian adolescents (14-18 years old) using a dataset that follows Australian adolescents over time. We found that engaging in unhealthy weight control behaviors such as fasting, using weight loss supplements, and purging was linked to higher costs among adolescents, suggesting policies should focus on addressing these behaviors.

Methods used to account for caregivers' sex and gender within studies examining the financial burden of caregivers of children and adolescents : Results from a scoping review

Background

Interest in the financial burden of informal caregivers has been growing. Unfortunately, it remains unclear which method(s) should be used when quantifying this burden.

Purpose

We conducted a scoping review aimed at identifying which methods have been used to conduct such work and quantified their performance. We were also interested in examining how sex and gender considerations were considered within selected studies.

Data Sources

Using a standardized approach, we identified studies published between 2012 and 2022 that aimed to document the financial burden of caregivers to child and adolescent patients. Our search strategy was applied to the MEDLINE, Embase, CINHAL, and Academic Search Premier databases.

Study Selection

Manuscript selection was performed by pairs of reviewers.

Data Extraction

Data extraction was performed by one reviewer with a second reviewer performing quality control. Results were reported using a narrative approach.

Data Synthesis

We identified 9801 unique citations, of which 200 were included in our review. Selected studies covered various disease area (eg, infection/parasitic diseases [n = 31, 16%]) and included quantitative (n = 180, 90%), qualitative (n = 4, 2%) and mixed study designs (n = 16, 8%). Most studies (n = 182, 91%) used questionnaires/surveys, either alone or in combination with other methods, to assess caregivers' financial burden. Less than half (n = 93, 47%) of studies reported on caregivers' sex and none reported on their gender.

Conclusion

We conducted an unrestricted review of published studies examining caregiver's financial burden which allowed us to identify general methodological trends observed in this literature. We believe this work may help improve future studies focusing on this important issue.

Resilience in children with chronic illness: Tests of the shift-and-persist and skin-deep resilience theories

This study investigated, and discusses the integration of, the shift-and-persist (SAP) and skin-deep resilience (SDR) theories. The SAP theory states that the combination of shifting (adjusting oneself to stressful situations through strategies like emotion regulation) and persisting (enduring adversity with strength by finding meaning and maintaining optimism) will be beneficial to physical health in children experiencing adversity. The SDR theory states that high striving/self-control will be beneficial to mental health but detrimental to physical health among those confronting adversity. This study investigated 308 children ages 8-17 experiencing the adversity of a chronic illness (asthma). SAP and SDR (striving/self-control) were assessed via questionnaires, and physical health (asthma symptoms, inflammatory profiles), mental health (anxiety/depression, emotional functioning), and behavioral (medication adherence, activity limitations, collaborative relationships with providers) outcomes were measured cross-sectionally. SAP was associated with better physical health, whereas SDR was associated with worse physical health. Both were associated with better mental health. Only SDR was associated with better behavioral outcomes. Implications of findings and discussion of how to integrate these theories are provided. We suggest that future interventions might seek to cultivate both SAP and SDR to promote overall better health and well-being across multiple domains in children experiencing adversity.

Asthma disparities among U.S. children and adults

OBJECTIVE

To assess factors that are associated with asthma prevalence and asthma attacks among children (0-17 years) and adults (18 years and over) in the United States of America.

METHODS

The 2019-2021 National Health Interview Survey data were analyzed using multivariable logistic regression models to determine associations between health outcomes (i.e. current asthma and asthma attacks) and demographic and socioeconomic factors. Each health outcome was regressed over each characteristic variable, adjusting for age, sex, and race/ethnicity for adults and sex and race/ethnicity for children.

RESULTS

Asthma was more common among children who were male, blacks, parental education less than bachelor's, or had public health insurance, and among adults who had less than a bachelor's degree, do not own a home, or not in the workforce. Persons in families facing difficulty paying medical bills were more likely to have current asthma (children: aPR = 1.62[1.40-1.88]; adults: aPR = 1.67[1.55-1.81]) and asthma attacks (children: aPR = 1.34[1.15-1.56]; adults: aPR = 1.31[1.20-1.43]). Persons with family income <100% federal poverty threshold (FPT) (children: aPR = 1.39[1.17-1.64]; adults: aPR = 1.64[1.50-1.80]) or adults 100-199% FPT (aPR = 1.28[1.19-1.39]) were more likely to have current asthma. Children and adults with family income <100% FPT and adults 100-199% FPT were also more likely to have asthma attacks. Having asthma attacks was common among adults not in the workforce as well (aPR = 1.17[1.07-1.27]).

CONCLUSIONS

Asthma affects certain groups disproportionately. The findings of this paper suggesting asthma disparities continue to persist may increase public health programs awareness to better deliver effective and evidence-based interventions.

Determinants of Childhood Asthma: A Case Control Study from a Tertiary Care Hospital in Bengaluru, South India

BACKGROUND

Childhood asthma is a common, and often serious, chronic disease with episodic exacerbations in infants and children. There is an increasing trend in the prevalence of childhood asthma in developing countries. Objectives: To identify the determinants of childhood asthma.

METHODS

A case control study with 30 cases of childhood asthma and 30 gender- and aged-matched controls selected from the paediatric outpatient department and paediatric ward of a tertiary hospital. The primary caregiver was interviewed to capture sociodemographic details, prenatal and birth history, and history of exposure to environmental risk factors. Odds ratios with 95% confidence intervals were calculated to determine the strength of association between childhood asthma and independent co-variates, followed by subgroup multiple logistic regression analysis.

RESULTS

We found that children with a parental history of allergy/atopy [OR=2.88 (1.94-4.27), P<0.001], residence in houses located in industrial areas [AOR=2.72 (2.6-323.1), P<0.001], exposure to incense at home [AOR=2.03 (1.14-29.42), P<0.001], or a history of allergic rhinitis [AOR=3.09 (2.22-243.25), P<0.001] had significantly higher odds of developing childhood asthma.

CONCLUSION

Our study found that having homes located in industrial areas, burning incense at home, parental history of allergy, and history of allergic rhinitis in the child are determinants of childhood asthma. The findings from our study can be used to generate awareness regarding risk factors that are linked to childhood asthma.

Prenatal bisphenol A and S exposure and atopic disease phenotypes at age 6

BACKGROUND

Atopic disease may be influenced by prenatal and early life exposure to endocrine disrupting chemicals, including bisphenols, but results from epidemiological studies have been mixed. This study aimed to extend the epidemiological literature, hypothesizing that children with higher prenatal bisphenol exposure are more likely to have childhood atopic disease.

METHODS

Urinary bisphenol A (BPA) and S (BPS) concentrations were measured in each trimester from 501 pregnant women in a multi-center, prospective pregnancy cohort. Ever asthma, current asthma, wheeze, and food allergy) were assessed at age six via standardized ISAAC questionnaire. We constructed generalized estimating equations to examine BPA and BPS exposure jointly at each trimester for each atopy phenotype. BPA was modeled as a log-transformed continuous variable, whereas BPS was modeled as detected versus not detected. We also modeled pregnancy-averaged BPA values and a categorical indicator for number of detectable BPS values over pregnancy (0-3) in logistic regression models.

RESULTS

First trimester BPA was associated with inverse odds of food allergy among the entire study sample (OR = 0.78, 95% CI = 0.64-0.95, p = 0.01) and females only (OR = 0.69, 95% CI = 0.52-0.90, p = 0.006). The inverse relationship persisted in pregnancy-averaged models of BPA among females (OR = 0.56, 95% CI = 0.35-0.90, p = 0.006). Second trimester BPA was associated with greater odds of food allergy in the entire sample (OR = 1.27, 95% CI = 1.02-1.58, p = 0.03) and among males only (OR = 1.48, 95% CI = 1.02-2.14, p = 0.04). Odds of current asthma increased among males in the pregnancy-averaged BPS models (OR = 1.65, 95% CI = 1.01-2.69, p = 0.045).

CONCLUSION

We saw opposite effects of BPA on food allergy that were trimester- and sex-specific. These divergent associations warrant further investigation. There is some evidence to suggest that prenatal BPS is associated with asthma among males, but further research is required in cohorts with a greater proportion of prenatal urine samples with detectable BPS to validate these results.

Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee

The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.

What are the respiratory health research priorities in Alberta, Canada? A stakeholder consultation

OBJECTIVE

The Respiratory Health Strategic Clinical Network (RHSCN) was launched to facilitate respiratory and sleep health through implementation of innovative, patient-centred, evidence-informed coordinated services in Alberta. In collaboration with project partners, the RHSCN aimed to determine the respiratory research priorities for Alberta.

DESIGN

The four phases of this research prioritisation project were (1) identifying research questions from stakeholders, (2) determining which research questions had been answered in existing literature, (3) prioritising unanswered questions and (4) finalising the priorities through an inperson workshop.

SETTING

The study occurred in Alberta, Canada over a 2-year period beginning in March 2017.

PARTICIPANTS

A total of 448 patients, clinicians and other stakeholders consented to participate in the survey.

RESULTS

A total of 595 possible questions were submitted, with 343 unique questions identified. Of the questions, 94 were out of scope, 155 answered by existing literature and 10 were combined with others, while 83 were determined to be unanswered in the literature. Stakeholders were surveyed again to prioritise the remaining 83 questions and they were reviewed by the project's Steering Committee (clinicians and patients). At the inperson workshop, the Steering Committee identified 17 research topics as priority areas for respiratory and sleep research in Alberta.

CONCLUSION

A stakeholder-led research prioritisation process identified optimal clinical management/follow-up, equitable access to services, and management of social, psychological and mental health issues related to respiratory/sleep health as priority research areas.

The Association of Mental Health, Asthma Control and Acute Care Visits Among Rural Adolescents with Poorly Controlled Asthma

Anxiety and depressive symptoms are associated with asthma-related acute care utilization. Few studies include rural adolescents. Asthma control may be the mechanism by which mental health affects acute care. This study explored associations between generalized anxiety, asthma-related anxiety, depressive symptoms, and acute care visits, and tested if asthma control mediates these associations among 197 rural adolescents with asthma. Data analysis included descriptive statistics and regression. Controlling for age, sex and race/ethnicity, asthma-related anxiety was associated with higher odds of acute care visits (OR = 2.09, 95% CI [1.42, 3.07]). Asthma control mediated this relationship: one unit increase in anxiety, on average, increased the odds of having any acute care visit by 5%. Generalized anxiety and depressive symptoms were not associated with acute care visits. Helping adolescents reduce their concerns regarding asthma while improving their self-management skill may potentially to reduce acute care among rural adolescents.

lncRNA-NEAT1 Sponges miR-128 to Promote Inflammatory Reaction and Phenotypic Transformation of Airway Smooth Muscle Cells

OBJECTIVE

Pediatric asthma is still a health threat to the children. Long noncoding RNA-NEAT1 (lncRNA-NEAT1) was reported to be positively correlated with the severity of asthma. We aimed to study the effects and mechanism of lncRNA-NEAT1on inflammatory reaction and phenotypic transformation of airway smooth muscle cells (ASMCs) in the bronchial asthma.

METHOD

The degree of lncRNA-NEAT1 and miR-128 mRNA in children with bronchial asthma and healthy individuals was tested by qRT-PCR. After the inflammatory reaction and phenotypic transformation of PDGF-BB-induced ASMCs, the expression of lncRNA-NEAT1 or miR-128 in the AMSC was disturbed in the AMSC. Subsequently, the expression of lncRNA-NEAT1 and miR-128 was detected by the way of qRT-PCR, and western blot was applied to measure the expression of MMP-2, MMP-9, α-SMA, calponin, NF-κB, and so on in the cells. The content of TNF-α, IL-1β, IL-6, and IL-8 in the cell culture supernatant was checked by ELISA. MTT, Transwell, and flow cytometry were used to detect cell proliferation, migration, and apoptosis. Further, the targeting relations between lncRNA-NEAT1 and miR-128 were evaluated by the dual-luciferase reporter assay.

RESULT

In the sputum of children with bronchial asthma, lncRNA-NEAT1 was significantly upregulated while miR-128 was rapidly downregulated. Besides, lncRNA-NEAT1 and miR-128 were competitively combined and, for their expression, negatively correlated.

CONCLUSION

lncRNA-NEAT1 sponges miR-128 to boost PDGF-BB-induced inflammatory reaction and phenotypic transformation of ASMCs to aggravate the occurrence and development of childhood bronchial asthma.

Telemedicine use for pediatric asthma care: a mixed methods study

OBJECTIVES

To identify factors associated with telemedicine use for asthma care among children and young adults, and to describe the parent and patient experience of asthma care over telemedicine.

METHODS

Our mixed methods study consisted of an electronic health record analysis and a qualitative focus group analysis. We analyzed records for all patients aged 2-24 seen at UC Davis Health between March 19, 2020 and September 30, 2020 for a primary diagnosis of asthma. We performed multivariable logistic regression to quantify the relationships between patient characteristics and telemedicine use. We also conducted focus groups with parents and patients who received asthma care during the study period and used qualitative content analysis to identify themes from the transcripts.

RESULTS

502 patients met the inclusion criteria. Telemedicine use was significantly lower among patients with a primary language other than English (OR = 0.12, 95% CI: 0.025-0.54, p = 0.006), school-aged children (OR = 0.43, 95% CI: 0.24-0.77, p = 0.005), and patients who received asthma care from a primary care provider instead of a specialist (OR = 0.55, 95% CI: 0.34-0.91, p = 0.020). Six thematic categories emerged from focus groups: engaging with the patient, improving access to care, experience of visit, measurements, scheduling, and the future of telemedicine in asthma care.

CONCLUSIONS

Alternating telemedicine with in-person visits for asthma care may result in improved access to care and reduced burdens on patients and families. Providers and researchers should work to understand the specific reasons for low telemedicine use among non-English speaking patients so that these patients receive equitable access to care.

Child and caregiver experiences and perceptions of asthma self-management

Asthma is the most common chronic condition of childhood. Self-management is integral to good asthma control. This qualitative paper explores how children with asthma and their parents perceive asthma, their experience with asthma, and how they manage symptoms, preventions and medications within and outside the home. We undertook 15 focus groups with 41 school-aged (6-11 years) children with asthma and 38 parents. Parents and their children attended the same focus groups. We used thematic analysis to analyse the transcripts. Our findings show the impact asthma can have on children's social and emotional wellbeing and highlight how reliant school-aged children are on their parents to effectively manage their asthma. Parents reported being unsure when their child's symptoms warranted visiting their doctor or hospital. Schools were identified as a source of difficulty regarding asthma management; families reported that children may be self-conscious about their asthma and using their inhaler at school. School policies and teachers' lack of asthma knowledge were reported to exacerbate children's reluctance to use their inhaler at school. Our results have implications for the design and implementation of children's self-management interventions for their asthma, particularly when they are at school and away from their parents.

A Comparison of Activity Participation between Children with and without Asthma

Background

Asthma affects approximately 6 million children in the United States and can greatly impact quality of life and occupational engagement. Although occupational therapists are well-equipped to address participation limitations, insufficient evidence exists to support the role of occupational therapists in asthma treatment.

Method

The purpose of this study was to further understand the occupational limitations experienced by children with asthma. We also explored a dual diagnosis of asthma and obesity. The participants included children with (n = 84) and without (n = 63) asthma living in New York City. The Child Behavior Checklist, Youth Self Report, Brief Respiratory Questionnaire, and accelerometer data were used to examine occupational participation.

Results

Although accelerometry data demonstrated that children with asthma were equally as active as their non-asthmatic peers, the participants with asthma perceived themselves as participating more in sedentary occupations and were less likely to be members of sports teams. They also had more missed school days and nights of troubled sleep. The children with both asthma and obesity reported the highest level of activity limitations.

Conclusion

This study illustrates specific limitations experienced by children with asthma and supports the need for occupational therapy intervention. Future studies are needed to design and assess interventions that will support the addition of occupational therapists to multidisciplinary asthma treatment teams.

Not Breathing Easy: "Disarticulated Homework" in Asthma Management

Recent health policy in the United States encourages an outsourcing of labor from professional practice into domestic spaces, where in theory, medical professionals supply the training, technologies, and guidance needed to discharge responsibility for care to patients or caregivers. Mattingly et al. (2011) term this labor "chronic homework," describing the relationship between the assigning and undertaking of medical care at the borders of professional and domestic domains. This is a system predicated on relationships between professional and caregiver. However, in our research with families and providers in two U.S. sites, we observed a "disarticulation" of asthma care from professional medicine. Caregivers may undertake routine asthma management with little physician oversight, transforming chronic homework into what we term "disarticulated homework." We argue that expanding the concept of chronic homework to theorize disarticulation processes can help elucidate how health disparities are reproduced in the gap between medical systems and domestic life. [asthma, self-management, caregiving pharmaceuticalization, health disparities].

The Development and Preliminary Impact of CAMP Air: A Web-based Asthma Intervention to Improve Asthma Among Adolescents

OBJECTIVE

Describe the development and preliminary impact of CAMP Air, a web-based intervention for adolescents with uncontrolled asthma.

MATERIALS AND METHODS

CAMP Air was developed using an iterative process with input from stakeholders and incorporating usability testing results (n = 14 adolescents). To test CAMP Air's initial impact, 61 adolescents from two New York City public high schools (n = 37) and from clinics, community-based organizations, and third-party recruitment services (i.e., community sample; n = 24) were enrolled in a randomized pilot trial. Participants were randomized to CAMP Air (n = 30) or information-and-referral control intervention (n = 31). A point-person worked with school participants to complete CAMP Air.

RESULTS

CAMP Air participants were satisfied with the intervention and its value for supporting self-management, completing on average 6 of 7 modules. Relative to controls, CAMP Air participants demonstrated significantly improved asthma knowledge, asthma control, night wakening and school absences, and less risk for urgent care visits. Adolescents enrolled in schools completed more modules and had significantly fewer nights woken and school absences than community enrollees.

CONCLUSION

CAMP Air improves asthma outcomes among adolescents with uncontrolled asthma.

PRACTICE IMPLICATIONS

A web-based intervention CAMP Air is a promising intervention. When a point-person works with adolescents, CAMP Air's access and impact are improved.

The Association of Asthma, Sexual Identity, and Inhaled Substance Use among U.S. Adolescents

Rationale: Minority sexual identity appears to confer asthma risks. Although associations between inhaled substances and asthma are established, these have not been examined among sexual minority youths. Given sexual minority adolescents' disproportionately high rates of substance use, research is needed to fill this important gap.Objectives: Using a representative sample of adolescents from the United States, we 1) examined associations among asthma, sexual identity, and inhaled substance use and tested 2a) whether sexual identity moderates relationships between asthma and inhaled substance use and 2b) whether inhaled substance use mediates associations between sexual identity and asthma.Methods: Data are from the 2015 and 2017 Youth Risk Behavior Surveillance Survey. Adolescents (n = 30,113) reported if they were ever diagnosed with asthma, current use of cigarettes, cigars and/or cigarillos, marijuana, and electronic vapor products and if they ever used inhalants or synthetic marijuana. We used logistic regression to examine associations between asthma, sexual identity, and inhaled substance use controlling for age, race or ethnicity, and body mass index percentile, stratified by sex.Results: Lesbian, gay, and bisexual respondents had higher relative risks for asthma than heterosexual youth. Sexual minority female youths had significantly higher relative risks than heterosexual female youths for use of every inhaled substance. There were few sexual identity differences in inhaled substance use among male youths. Inhaled substance use was significantly associated with higher risks for asthma. In general, associations between each individual inhaled substance and asthma did not differ between sexual minority and heterosexual youths. However, when all inhaled substances were added into the models concurrently, inhaled substance use appeared to mediate associations with asthma among lesbian and bisexual female youths, and partially mediated these associations among sexual minority male youths.Conclusions: Sexual identity and inhaled substance use appear to play important roles in asthma risk. However, these variables do not fully explain the risk, suggesting that other unmeasured variables (e.g., stress and victimization) may be implicated in risks for both inhaled substance use and asthma. It is important that clinicians providing care to adolescents ask about sexual identity and inhaled substance use. Effective approaches to reducing inhaled substance use among adolescents, especially sexual minorities, are needed.

Telemedicine and adherence monitoring in children with asthma

PURPOSE OF REVIEW

Telemedicine, defined as synchronous video visits between a provider and a child with asthma, often takes place in the school setting. This review examines the new electronic sensors for adherence monitoring and studies that used telemedicine in the school setting to improve asthma outcomes.

RECENT FINDINGS

School-based telemedicine provides an important service to families of school-aged children who have difficulty due to time and distance in planning and keeping in-person appointments with primary or specialty providers. Significant improvements in objective measures of asthma control are inconsistently observed although caregiver and parent quality of life and child self-management behaviors are improved and satisfaction is high. Assessment and outcomes related to adherence are mentioned in studies but results are not often reported. However, it appears that adherence interventions are beneficial while maintained but the effects are not sustained upon intervention discontinuation.

SUMMARY

The school setting provides a convenient and suitable environment to conduct telemedicine visits between school-aged children and their primary care or specialty provider. Electronic adherence sensors allow review of controller and rescue medication use through a cloud-based dashboard and provides an opportunity for real-time assessment and intervention by providers to improve asthma outcomes.

Models for estimating and projecting global, regional and national prevalence and disease burden of asthma: a systematic review

Background

Statistical models are increasingly being used to estimate and project the prevalence and burden of asthma. Given substantial variations in these estimates, there is a need to critically assess the properties of these models and assess their transparency and reproducibility. We aimed to critically appraise the strengths, limitations and reproducibility of existing models for estimating and projecting the global, regional and national prevalence and burden of asthma.

Methods

We undertook a systematic review, which involved searching Medline, Embase, World Health Organization Library and Information Services (WHOLIS) and Web of Science from 1980 to 2017 for modelling studies. Two reviewers independently assessed the eligibility of studies for inclusion and then assessed their strengths, limitations and reproducibility using pre-defined quality criteria. Data were descriptively and narratively synthesised.

Results

We identified 108 eligible studies, which employed a total of 51 models: 42 models were used to derive national level estimates, two models for regional estimates, four models for global and regional estimates and three models for global, regional and national estimates. Ten models were used to estimate the prevalence of asthma, 27 models estimated the burden of asthma – including, health care service utilisation, disability-adjusted life years, mortality and direct and indirect costs of asthma – and 14 models estimated both the prevalence and burden of asthma. Logistic and linear regression models were most widely used for national estimates. Different versions of the DisMod-MR- Bayesian meta-regression models and Cause Of Death Ensemble model (CODEm) were predominantly used for global, regional and national estimates. Most models suffered from a number of methodological limitations – in particular, poor reporting, insufficient quality and lack of reproducibility.

Conclusions

Whilst global, regional and national estimates of asthma prevalence and burden continue to inform health policy and investment decisions on asthma, most models used to derive these estimates lack the required reproducibility. There is a need for better-constructed models for estimating and projecting the prevalence and disease burden of asthma and a related need for better reporting of models, and making data and code available to facilitate replication.

Community health workers providing asthma education

Objectives: Children living in urban areas experience disproportionate rates of asthma. Substandard housing conditions in some urban areas contribute to greater exposure to household asthma triggers. This article examines the geographic connection between pediatric asthma and substandard housing in one mid-sized city in Pennsylvania and the effectiveness of a home-based Community Health Worker (CHW) intervention targeted at this high-risk area to improve families' abilities to manage their children's asthma.Methods: The CHWs provided education and resources to families of children diagnosed with mild, moderate or severe persistent asthma. A pre and post-test design was implemented to evaluate if the CHW intervention improved the family's ability to successfully manage their child's asthma. Eighty-one patients completed the program over a six-month period.Results: Results showed significant improvements in the areas of asthma knowledge, fewer missed days of school, fewer days with asthma symptoms, reduction in wheezing and fewer sleep disturbances. There was also a significant decrease in the number of Emergency Department visits and hospital days.Conclusions: By teaching asthma management skills and by addressing in-home triggers, home-based CHW led interventions can be an affordable and effective way for caregivers and children with asthma to improve asthma management.

Estimating Lifetime Cost of Illness. An Application to Asthma

Rationale: Approximately 8% of the U.S. population suffers from asthma, a chronic condition. It poses a substantial economic burden to society in the form of lost productivity and healthcare costs.Objectives: We use the Medical Expenditure Panel Survey 2002-2010 to quantify the lifetime costs of asthma at each age, the impact of adult asthma on earnings and choice of occupation, and the impact of childhood asthma on parental income.Methods: We developed a framework to estimate the present discounted value of the cumulative lifetime asthma-related healthcare costs and lost productivity experienced by an individual after onset. This approach allows for age- and asthma duration-related variability in annual costs as well as for the intermittent nature of asthma symptoms.Results: Estimated asthma-related annual healthcare expenditures across all life stages are $700-$2,200 (2010 U.S. dollars). Lost annual earnings among individuals aged 30-49 are over $4,000 (2010 U.S. dollars). The present discounted value of the cumulative lifetime healthcare costs and lost productivity for a new case of asthma is estimated at $36,500 using the 3% discount rate (2010 U.S. dollars).Conclusions: The economic burden of asthma is substantial and larger than previously estimated, reflecting expenditures on treatment and lost earnings.

Developing and evaluating ASTHMAXcel adventures: A novel gamified mobile application for pediatric patients with asthma

BACKGROUND

The ASTHMAXcel mobile application has been linked to favorable outcomes among adult patients with asthma.

OBJECTIVE

To assess the impact of ASTHMAXcel Adventures, a gamified, guideline-based, pediatric version on asthma control, knowledge, health care utilization, and patient satisfaction.

METHODS

Pediatric patients with asthma received the ASTHMAXcel Adventures mobile intervention on-site only at baseline (visit 1), 4 months (visit 2), and 6 months (visit 3). The asthma control test, asthma illness representation scale-self-administered, pediatric asthma impact survey, and Client Satisfaction Questionnaire-8 were used to assess asthma control, knowledge, and patient satisfaction. Patients reported the number of asthma-related emergency department (ED) visits, hospitalizations, and oral prednisone use.

RESULTS

A total of 39 patients completed the study. The proportion of controlled asthma increased from visit 1 to visits 2 and 3 (30.8% vs 53.9%, P = .04; 30.8% vs 59.0%, P = .02), and largely seen in boys. The mean asthma illness representation scale-self-administered scores increased from baseline pre- to postintervention, with sustained improvements at visits 2 and 3 (3.55 vs 3.76, P < .001; 3.55 vs 3.80, P = .001; 3.55 vs 3.99, P < .001). The pediatric asthma impact survey scores improved from baseline to visits 2 and 3 (43.33 vs 34.08, P < .001; 43.33 vs 31.74, P < .001). ED visits and prednisone use significantly decreased from baseline to visits 2 and 3 (ED: 0.46 vs 0.13, P = .03; 0.46 vs 0.02, P = .02; prednisone use, 0.49 vs 0.13, P = .02; 0.49 vs 0.03, P = .003. Satisfaction was high with mean client satisfaction questionnaire score of approximately 30 (out of 32) at all visits.

CONCLUSION

ASTHMAXcel Adventures improved asthma control, knowledge, and quality of life, and reduced ED visits and prednisone use with high satisfaction scores.

Medical Costs and Productivity Loss Due to Mild, Moderate, and Severe Asthma in the United States

Background

Little is known about economic and productivity loss by severity of asthma. We investigate health-care utilization, direct medical costs, and indirect costs due to productivity loss from asthma by severity.

Methods

We conducted a cross-sectional analysis of the Medical Expenditure Panel Survey database (2010–2017) of patients with asthma aged ≥12 years and categorized them into mild, moderate, and severe asthma groups based on symptom control medications. Study outcomes included health-care utilization, direct medical costs, and indirect costs of asthma-related absenteeism. We used zero-inflated Poisson regression models to estimate incremental health-care utilization and generalized linear models to estimate incremental annual direct medical costs compared to patients without asthma.

Results

An estimated 139 million persons had an asthma diagnosis. Of patients with asthma, 77.1%, 22.2%, and 0.7% had mild, moderate, and severe asthma, respectively. Compared to patients without asthma, patients with asthma had incremental mean differences of 4.16 outpatient visits, 0.18 emergency department visits, and 0.07 hospitalizations per year. Annual direct medical costs were significantly associated with asthma severity ($3305 in mild, $7250 in moderate, and $9175 in severe asthma) (P < 0.05). Patients with mild, moderate, and severe asthma reported 0.76, 2.31, and 7.19 missed work or school days, resulting in $106, $321, and $1000 indirect costs per person per year, respectively.

Conclusion

Asthma-related direct and indirect costs are significantly associated with asthma severity, with severe asthma medical costs being about three times higher than mild. Controlling asthma symptoms is important to reduce the economic and social burden of asthma.

School-Based Telemedicine for Asthma Management

Asthma affects 10% of school-age children in the United States. These numbers nearly double in high-risk populations such as low-income and minority populations. Patients in these populations frequently live in communities that are medically underserved, with limited resources to implement comprehensive asthma interventions. It is important for researchers and clinicians to explore avenues to reduce the burden of illness in this population. Incorporating innovative strategies such as school-based telemedicine programs can potentially reduce morbidity, health care utilization, work absenteeism for caregivers, and school absenteeism for children with asthma. The aim of this review is to discuss the potential benefits of school-based asthma telemedicine programs, explore potential implementation models, and provide a comprehensive review of the literature including programs that use telemedicine in schools to assist with the management of asthma. Telemedicine is a feasible approach to increasing access to primary and specialty asthma care; however, there is a need for future randomized trials to establish best practices for implementation of telemedicine programs to aid in the care for children in school settings.

Residential green space and medication sales for childhood asthma: A longitudinal ecological study in Belgium

BACKGROUND

Living in green environments has been associated with various health benefits, but the evidence for positive effects on respiratory health in children is ambiguous.

OBJECTIVE

To investigate if residential exposure to different types of green space is associated with childhood asthma prevalence in Belgium.

METHODS

Asthma prevalence was estimated from sales data of reimbursed medication for obstructive airway disease (OAD) prescribed to children between 2010 and 2014, aggregated at census tract level (n = 1872) by sex and age group (6-12 and 13-18 years). Generalized log-linear mixed effects models with repeated measures were used to estimate effects of relative covers of forest, grassland and garden in the census tract of the residence on OAD medication sales. Models were adjusted for air pollution (PM₁₀), housing quality and administrative region.

RESULTS

Consistent associations between OAD medication sales and relative covers of grassland and garden were observed (unadjusted parameter estimates per IQR increase of relative cover, range across four strata: grassland, β = 0.15-0.17; garden, β = 0.13-0.17). The associations remained significant after adjusting for housing quality and chronic air pollution (adjusted parameter estimates per IQR increase of relative cover, range across four strata: grassland, β = 0.10-0.14; garden, β = 0.07-0.09). There was no association between OAD medication sales and forest cover.

CONCLUSIONS

Based on aggregated data, we found that living in close proximity to areas with high grass cover (grasslands, but also residential gardens) may negatively impact child respiratory health. Potential allergic and non-allergic mechanisms that underlie this association include elevated exposure to grass pollen and fungi and reduced exposure to environmental biodiversity. Reducing the dominance of grass in public and private green space might be beneficial to reduce the childhood asthma burden and may simultaneously improve the ecological value of urban green space.

School Absence Associated With Childhood Pain in the United States

OBJECTIVE

The objective of this study was to estimate the national burden of school absenteeism associated with pain among 6 to 17-year-old children in the United States.

METHODS

Data were analyzed from a large, nationally representative sample from the 2012 National Health Interview Survey. Associations between pain and school absence were analyzed using multivariate negative binomial models controlling for sociodemographic and clinical characteristics.

RESULTS

The sample contained 8641 participants, of whom 30.3% reported pain over the preceding 12 months. Mean number of parent-reported school days missed across the entire sample was 3 per child; however pain was associated with an additional 1.5 reported missed school days per child. Furthermore, pain was associated with higher rates of chronic absenteeism (missing >15 d of school): 6.1% of children with pain was chronically absent as compared with 1.3% of children without pain. Extrapolated to the nation, childhood pain in the United States was associated with 22.2 million additional days of missed school, whereas childhood asthma, in comparison, was associated with 8 million additional days of school missed.

DISCUSSION

Associations between pain and school absenteeism highlight the need for interventions aimed at improving school attendance among children with pain.

Neighborhood Environment and Asthma Exacerbation in Washington, DC

Approximately one in eight people in the United States have been diagnosed with asthma. Asthma is associated with significant medical expenditure and has been implicated as a leading reason for chronic school absences. Environmental risk factors such as access to green space and exposure to poor air quality are patterned such that some vulnerable populations may be at higher risk. Using data from DC Health, the Washington, DC, department of public health, this study investigated associations between neighborhood social, built, and natural environments and rates of asthma-related healthcare encounters by ZIP code between 2014 and 2017. We found that significant differences in rates exist between ZIP codes and for different subpopulations. Black boys had the highest overall rate, with 58.49 visits per 1,000 population, ranging by ZIP code from 0 to 88.56 visits. We found that the ZIP code Social Vulnerability Index was consistently associated with rates of healthcare encounters, but not access to green/open space or exposure to high traffic. However, we discuss how the ZIP code level may not be an appropriate level at which to investigate such built/natural environment features because of the proportion of variability that is found within rather than between ZIP codes. We end with a short discussion of ways that nurses, in particular school nurses, could help to address neighborhood environmental risk factors.

Role of Inhaled Corticosteroids for Asthma Exacerbation in Children: An Updated Meta-Analysis

Background:

Several studies showed that inhaled corticosteroids (ICS) may be a potential treatment in acute asthma exacerbation in children. This study was an update meta-analysis on the roles of ICS in the management of acute asthma exacerbation in children presenting to the hospital.

Materials and Methods:

Published articles with key words of ICS for asthma exacerbation, asthma attacks, and acute asthma in children aged under 18 years in the hospital setting with outcome of hospital admission between 2009 and 2018 were enrolled. The databases used in this study were Medline, Scopus, and Web of Science. Odds ratio of comparison between ICS and other treatments on hospital admissions was calculated.

Results:

There were 311 eligible studies met the searching criteria; seven eligible studies for the analysis; comprised of three meta-analysis and four added studies. The ICS had a significant reduction in hospital admission compared with placebo in overall with odds ratio of 0.63 (95% confidence interval [CI]: 0.41–0.96) and in moderate-to-severe group with odds ratio of 0.17 (95% CI: 0.05–0.51). Comparing with systemic corticosteroid (SC), ICS had significantly lower hospital admissions overall and in mild-to-moderate group with odds ratios of 0.63 and 0.26, respectively. The combination of ICS and SC had odds ratio of 0.75 (95% CI: 0.57–0.99) over SC in moderate-to-severe asthma exacerbation.

Conclusions:

ICS significantly reduced hospital admission in asthma exacerbation in children. It may be used alone for mild-to-moderate asthma exacerbation and combination with SC for moderate-to-severe asthma exacerbation.

Evaluating outcomes of children's asthma self-management education through sustainable community-university partnerships

OBJECTIVE

To evaluate the outcomes of a children's asthma management education program delivered through a community-university partnership.

DESIGN

Quasi-experimental pretest/posttest.

SAMPLE

Convenience sample of 50 children with asthma, grades 2-5, and their parent/caregiver from nine elementary schools in New York State.

MEASUREMENTS

Child Asthma Management Self-Efficacy Survey, Child Asthma Control Test^© , Parent Asthma Knowledge Test.

INTERVENTION

Nursing students certified as Open Airways for Schools facilitators administered the program once weekly for 5 weeks. Parent handouts were sent home after each session. Pre/posttests for all measures were completed prior to Open Airways and at completion.

RESULTS

Improved asthma management self-efficacy (p < .001) and improved asthma control (p = .013) for children with asthma were noted. Parent asthma knowledge was high pre- and posttest with no significant change. Parental knowledge regarding inhaled corticosteroids was consistently low.

CONCLUSIONS

Collaboration between universities and local school systems allows for mutually beneficial exchange of knowledge and resources to address the need for asthma self-management for children with asthma. Nursing students trained in asthma management develop expertise and provide sustainable resources for this education.

Tiotropium in children and adolescents with asthma

BACKGROUND

Asthma is a major cause of morbidity in children, despite the availability of various treatments. In adults, tiotropium-a long-acting muscarinic antagonist-as add-on therapy to an inhaled corticosteroid with or without a long-acting β₂-agonist provides clinical benefit with a safety profile similar to placebo.

OBJECTIVE

To review published evidence on the efficacy and safety of tiotropium as add-on a long-acting muscarinic antagonist therapy in children and adolescents with asthma that is uncontrolled despite use of an inhaled corticosteroid with or without additional controller medication(s).

METHODS

We searched PubMed from inception until June 12, 2018, for randomized controlled trials of children and adolescents aged 1 to 17 years treated with tiotropium and reporting a primary outcome of any pulmonary function test and a secondary outcome of adverse events.

RESULTS

Overall, 7 randomized controlled trials of 1902 preschool children (aged 1-5 years; n = 102), school-age children (aged 6-11 years; n = 905), and adolescents (aged 12-17 years; n = 895) with moderate to severe asthma were included in the analysis. Once-daily tiotropium (5, 2.5, or 1.25 μg) improved lung function parameters, including peak and trough forced expiratory volume in 1 second, vs placebo. Commonly reported adverse events across treatment groups included asthma worsening or exacerbations, decreased peak expiratory flow rate, nasopharyngitis, viral respiratory tract infection, and respiratory tract infection.

CONCLUSION

Once-daily tiotropium as add-on therapy is efficacious and safe in adolescents and children with moderate to severe asthma. These results support the expanded indication by regulatory authorities for add-on tiotropium in patients 6 years or older.

Asthma impacts on workplace productivity in employed patients who are symptomatic despite background therapy: a multinational survey

Background: Asthma affects millions of people worldwide, with many patients experiencing symptoms that affect their daily lives despite receiving long-term controller medication.

Purpose: Work is a large part of most people’s lives, hence this study investigated the impact of uncontrolled asthma on work productivity in adults receiving asthma maintenance therapy.

Patients and methods: An online survey was completed by employed adults in Brazil, Canada, Germany, Japan, Spain and the UK. Participants were confirmed as symptomatic using questions from the Royal College of Physicians’ 3 Questions for Asthma tool. The survey contained the Work Productivity and Activity Impairment – Specific Health Problem questionnaire and an open-ended question on the effect of asthma at work.

Results: Of the 2,055 patients on long-term maintenance therapy screened, 1,598 were symptomatic and completed the survey. The average percentage of work hours missed in a single week due to asthma symptoms was 9.3%, ranging from 3.5% (UK) to 17.4% (Brazil). Nearly three-quarters of patients reported an impact on their productivity at work caused by asthma. Overall work productivity loss (both time off and productivity whilst at work) due to asthma was 36%, ranging from 21% (UK) to 59% (Brazil). When asked how asthma made participants feel at work, many respondents highlighted how their respiratory symptoms affect them. Tiredness, weakness and mental strain were also identified as particular challenges, with respondents describing concerns about the perception of colleagues and feelings of inferiority.

Conclusions: This study emphasizes the extent to which work time is adversely affected by asthma in patients despite the use of long-term maintenance medication, and provides unique personal insights. Strategies to improve patients’ lives may include asthma education, optimizing asthma management plans and running workplace well-being programs. Clinicians, employers and occupational health teams should be more aware of the impact of asthma symptoms on employees, and work together to help overcome these challenges.

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Ambulatory Management of Childhood Asthma Using a Novel Self-management Application

BACKGROUND AND OBJECTIVES

Pediatric ambulatory asthma control is suboptimal, reducing quality of life (QoL) and causing emergency department (ED) and hospital admissions. We assessed the impact of the electronic-AsthmaTracker (e-AT), a self-monitoring application for children with asthma.

METHODS

Prospective cohort study with matched controls. Participants were enrolled January 2014 to December 2015 in 11 pediatric clinics for weekly e-AT use for 1 year. Analyses included: (1) longitudinal changes for the child (QoL, asthma control, and interrupted and missed school days) and parents (interrupted and missed work days and satisfaction), (2) comparing ED and hospital admissions and oral corticosteroid (OCS) use pre- and postintervention, and (3) comparing ED and hospital admissions and OCS use between e-AT users and matched controls.

RESULTS

A total of 327 children and parents enrolled; e-AT adherence at 12 months was 65%. Compared with baseline, participants had significantly (P < .001) increased QoL, asthma control, and reduced interrupted and missed school and work days at all assessment times. Compared with 1 year preintervention, they had reduced ED and hospital admissions (rate ratio [RR]: 0.68; 95% confidence interval [CI]: 0.49-0.95) and OCS use (RR: 0.74; 95% CI: 0.61-0.91). Parent satisfaction remained high. Compared with matched controls, participants had reduced ED and hospital admissions (RR: 0.41; 95% CI: 0.22-0.75) and OCS use (RR: 0.65; 95% CI: 0.46-0.93).

CONCLUSIONS

e-AT use led to high and sustained participation in self-monitoring and improved asthma outcomes. Dissemination of this care model has potential to broadly improve pediatric ambulatory asthma care.