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Nkoy FL, Stone BL, Zhang Y, Luo G. A Roadmap for Using Causal Inference and Machine Learning to Personalize Asthma Medication Selection. JMIR Med Inform 2024; 12:e56572. [PMID: 38630536 PMCID: PMC11063904 DOI: 10.2196/56572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/12/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024] Open
Abstract
Inhaled corticosteroid (ICS) is a mainstay treatment for controlling asthma and preventing exacerbations in patients with persistent asthma. Many types of ICS drugs are used, either alone or in combination with other controller medications. Despite the widespread use of ICSs, asthma control remains suboptimal in many people with asthma. Suboptimal control leads to recurrent exacerbations, causes frequent ER visits and inpatient stays, and is due to multiple factors. One such factor is the inappropriate ICS choice for the patient. While many interventions targeting other factors exist, less attention is given to inappropriate ICS choice. Asthma is a heterogeneous disease with variable underlying inflammations and biomarkers. Up to 50% of people with asthma exhibit some degree of resistance or insensitivity to certain ICSs due to genetic variations in ICS metabolizing enzymes, leading to variable responses to ICSs. Yet, ICS choice, especially in the primary care setting, is often not tailored to the patient's characteristics. Instead, ICS choice is largely by trial and error and often dictated by insurance reimbursement, organizational prescribing policies, or cost, leading to a one-size-fits-all approach with many patients not achieving optimal control. There is a pressing need for a decision support tool that can predict an effective ICS at the point of care and guide providers to select the ICS that will most likely and quickly ease patient symptoms and improve asthma control. To date, no such tool exists. Predicting which patient will respond well to which ICS is the first step toward developing such a tool. However, no study has predicted ICS response, forming a gap. While the biologic heterogeneity of asthma is vast, few, if any, biomarkers and genotypes can be used to systematically profile all patients with asthma and predict ICS response. As endotyping or genotyping all patients is infeasible, readily available electronic health record data collected during clinical care offer a low-cost, reliable, and more holistic way to profile all patients. In this paper, we point out the need for developing a decision support tool to guide ICS selection and the gap in fulfilling the need. Then we outline an approach to close this gap via creating a machine learning model and applying causal inference to predict a patient's ICS response in the next year based on the patient's characteristics. The model uses electronic health record data to characterize all patients and extract patterns that could mirror endotype or genotype. This paper supplies a roadmap for future research, with the eventual goal of shifting asthma care from one-size-fits-all to personalized care, improve outcomes, and save health care resources.
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Affiliation(s)
- Flory L Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Bryan L Stone
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Yue Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, United States
- Division of Biostatistics, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, United States
| | - Gang Luo
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
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2
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Salo PM, Akinbami LJ, Cloutier MM, Wilkerson JC, Elward KS, Mazurek JM, Diette GB, Mitchell TA, Williams S, Zeldin DC. Environmental management of asthma in clinical practice: Results from the 2012 National Ambulatory Medical Care Survey. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100192. [PMID: 38187868 PMCID: PMC10770720 DOI: 10.1016/j.jacig.2023.100192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/25/2023] [Accepted: 09/12/2023] [Indexed: 01/09/2024]
Abstract
Background The National Asthma Education and Prevention Program guidelines emphasize environmental control as an integral part of asthma management; however, limited national-level data exist on how clinicians implement environmental control recommendations. Objective We analyzed data on clinicians' self-reported use of recommended environmental control practices in a nationally representative sample (n = 1645) of primary care physicians, asthma specialists, and advanced practice providers from the National Asthma Survey of Physicians, a supplemental questionnaire to the 2012 National Ambulatory Medical Care Survey. Methods We examined clinician and practice characteristics as well as clinicians' decisions and strategies regarding environmental trigger assessment and environmental control across provider groups. Regression modeling was used to identify clinician and practice characteristics associated with implementation of guideline recommendations. Results A higher percentage of specialists assessed asthma triggers at home, school, and/or work than primary care or advanced practice providers (almost always: 53.6% vs 29.4% and 23.7%, respectively, P < .001). Almost all clinicians (>93%) recommended avoidance of secondhand tobacco smoke, whereas recommendations regarding cooking appliances (eg, proper ventilation) were infrequent. Although assessment and recommendation practices differed between clinician groups, modeling results showed that clinicians who reported almost always assessing asthma control were 5- to 6-fold more likely to assess environmental asthma triggers. Use of asthma action plans was also strongly associated with implementation of environmental control recommendations. Conclusions Environmental assessment and recommendations to patients varied among asthma care providers. High adherence to other key guideline components, such as assessing asthma control, was associated with environmental assessment and recommendation practices on environmental control.
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Affiliation(s)
- Paivi M. Salo
- Division of Intramural Research, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC
| | - Lara J. Akinbami
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Md
- United States Public Health Service, Rockville, Md
| | | | | | - Kurtis S. Elward
- Department of Family Medicine and Population Health, The Virginia Commonwealth University, Richmond, Va
| | - Jacek M. Mazurek
- National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV
| | - Gregory B. Diette
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Md
| | | | - Sonja Williams
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Md
| | - Darryl C. Zeldin
- Division of Intramural Research, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC
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3
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Zhang Y, Wu Y, Zhang X, Lv C, Lin J, Zhao L, Lin Y, Zhang M, Bao W. Circadian rhythm and variability of large and small airway spirometric variables in healthy individuals. Digit Health 2024; 10:20552076241254698. [PMID: 38766367 PMCID: PMC11100386 DOI: 10.1177/20552076241254698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/26/2024] [Indexed: 05/22/2024] Open
Abstract
Objective To assess the diurnal rhythm and variability of lung function in healthy individuals, encompassing both large and small airways. Methods A prospective study enrolled 35 healthy adults without a history of smoking. Initial spirometry and a bronchodilation test were performed using the Jaeger spirometer, followed by a seven-day continuous home monitoring using the GOSPT2000. We evaluated repeatability using the intraclass correlation coefficient and agreement through linear regression and Bland-Altman analyses. Circadian rhythm and variability in spirometric measurements were analyzed using the coefficient of variation (CV) and daily variation rate. Results The GOSPT2000 demonstrated strong repeatability and high agreement with the Jaeger spirometer. Notable findings included a decrease in nocturnal forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV3 by 44, 59, and 53 mL, respectively. In contrast, peak expiratory flow at noon showed an increase of 0.143L/min. Small-airway variables, including forced expiratory flow at 50% and 75% of the FVC and maximum midexpiratory flow, showed no significant diurnal variation. The nocturnal CV for large-airway variables was ≤ 4%, while for small-airway variables, it was ≤ 11.89%. Conclusion This study has established a spectrum of variability for both large and small airways in healthy populations. The variability of small-airway variables is higher than that of large-airway variables. The investigation into the diurnal rhythms and variability characteristics of both large and small airway variables in the healthy population can serve as a foundation for diagnosing asthma or assessing the efficacy of asthma treatments.
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Affiliation(s)
- Yingying Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiting Wu
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xue Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengjian Lv
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingwang Lin
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Zhao
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanmei Lin
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wuping Bao
- Wuping Bao, Department of Respiratory and Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, No. 100, Haining Road, Hongkou District, Shanghai 200080, China.
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Kaplan A, Boivin M, Bouchard J, Kim J, Hayes S, Licskai C. The emerging role of digital health in the management of asthma. Ther Adv Chronic Dis 2023; 14:20406223231209329. [PMID: 38028951 PMCID: PMC10657529 DOI: 10.1177/20406223231209329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
The most common reasons seen for lack of asthma control include misconceptions about disease control, low controller treatment adherence, poor inhaler technique, and the resulting underuse of controllers and overuse of short-acting beta2 agonists (SABAs). Narrowing these care gaps may be achieved through well-designed patient education that considers the patient's motivation, beliefs, and capabilities regarding their asthma and its management and empowers the patient to become an active participant in treatment decisions. Digital health technologies (DHTs) and digital therapeutic (DT) devices provide new opportunities to monitor treatment behaviors, improve communication between healthcare providers and patients, and generate data that inform educational interactions. DHT and DT have been proven effective in enhancing patient self-management in other chronic conditions, particularly diabetes. Accelerated integration of DHT and DT into the management of asthma patients is facilitated by the use of digital inhalers that employ sensor technology ("smart" inhalers). These devices efficiently provide real-time feedback on controller adherence, SABA use, and inhaler technique that have the strong potential to optimize asthma control.
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Affiliation(s)
- Alan Kaplan
- Department of Family and Community Medicine, University of Toronto, 14872 Yonge Street, Aurora, Toronto, ON L4G 1N2, Canada
- Family Physician Airways Group of Canada, Markham, ON, Canada
| | | | | | - James Kim
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Christopher Licskai
- Division of Respirology, Department of Medicine, Western University, London, ON, Canada
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Lugogo N, O'Connor M, George M, Merchant R, Bensch G, Portnoy J, Oppenheimer J, Castro M. Expert Consensus on SABA Use for Asthma Clinical Decision-Making: A Delphi Approach. Curr Allergy Asthma Rep 2023; 23:621-634. [PMID: 37991672 PMCID: PMC10716188 DOI: 10.1007/s11882-023-01111-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE OF REVIEW A modified Delphi process was undertaken to provide a US expert-led consensus to guide clinical action on short-acting beta2-agonist (SABA) use. This comprised an online survey (Phase 1), forum discussion and statement development (Phase 2), and statement adjudication (Phase 3). RECENT FINDINGS In Phase 1 (n = 100 clinicians), 12% routinely provided patients with ≥4 SABA prescriptions/year, 73% solicited SABA use frequency at every patient visit, and 21% did not consult asthma guidelines/expert reports. Phase 3 experts (n = 8) reached consensus (median Likert score, interquartile range) that use of ≥3 SABA canisters/year is associated with increased risk of exacerbation and asthma-related death (5, 4.75-5); SABA use history should be solicited at every patient visit (5, 4.75-5); usage patterns over time, not absolute thresholds, should guide response to SABA overuse (5, 4.5-5). Future asthma guidelines should include clear recommendations regarding SABA usage, using expert-led thresholds for action.
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Affiliation(s)
- Njira Lugogo
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Maeve O'Connor
- Allergy Asthma and Immunology Relief, Charlotte, NC, USA
| | - Maureen George
- Columbia University School of Nursing, New York, NY, USA
| | - Rajan Merchant
- Woodland Clinic Medical Group, Allergy Department, Dignity Health, Woodland, CA, USA
| | - Greg Bensch
- Allergy Immunology and Asthma Medical Group, Stockton, CA, USA
| | - Jay Portnoy
- Section of Allergy, Asthma & Immunology, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - John Oppenheimer
- Department of Internal Medicine, New Jersey Medical School, Newark, NJ, USA
- Pulmonary and Allergy Associates, Morristown, NJ, USA
| | - Mario Castro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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Fukuda Y, Homma T, Sagara H. Clinical inertia in asthma. NPJ Prim Care Respir Med 2023; 33:34. [PMID: 37838773 PMCID: PMC10576819 DOI: 10.1038/s41533-023-00356-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/06/2023] [Indexed: 10/16/2023] Open
Abstract
Despite advances in pharmaceutical treatment in recent years, a relatively high proportion of patients with asthma do not have adequate asthma control, causing chronic disability, poor quality of life, and multiple emergency department visits and hospitalizations. A multifaceted approach is needed to overcome the problems with managing asthma, and clinical inertia (CI) is a crucial concept to assist with this approach. It divides clinical inertia into three main categories, which include healthcare provider-related, patient-related, and healthcare system-related CI. The strategies to overcome these CI are complex, and the M-GAP approach, which combines a multidisciplinary approach, dissemination of guidelines, utilization of applications, and development and promotion of low-cost prescriptions, will help clinicians.
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Affiliation(s)
- Yosuke Fukuda
- Department of Medicine, Division of Respiratory Medicine, Yamanashi Red Cross Hospital, 6663-1 Funatsu, Fujikawaguchiko-machi, Yamanashi, Japan.
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan.
| | - Tetsuya Homma
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Hironori Sagara
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan
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7
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Fedele DA, Hollenbach J, Sinisterra M, LeFave E, Fishe J, Salloum RG, Bian J, Gurka MJ. Implementation of a pediatric asthma management program in rural primary care clinics. J Asthma 2023; 60:1080-1087. [PMID: 36194428 PMCID: PMC10115910 DOI: 10.1080/02770903.2022.2132954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Rural communities experience a significant asthma burden. We pilot tested the implementation of Easy Breathing, a decision support program for improving primary care provider adherence to asthma guidelines in a rural community, and characterized asthma risk factors for enrollees. METHODS We implemented Easy Breathing in two rural primary care practices for two years. Patient demographics, exposure histories, asthma severity, asthma medications, and treatment plans were collected. Providers' adherence to guidelines included the frequency of children with persistent asthma who were prescribed guidelines-based therapy and the frequency of children with a written asthma treatment plan on file. Clinicians provided feedback on the feasibility and acceptability of Easy Breathing using a validated survey tool and through semi-structured interviews. RESULTS Two providers implemented the program. Enrollment included 518 children, of whom 135 (26%) had physician-confirmed asthma. After enrollment into Easy Breathing, 75% of children with asthma received a written asthma treatment plan All children with persistent asthma were prescribed an anti-inflammatory drug as part of their treatment plan. Providers (n = 2) rated Easy breathing as highly acceptable (M = 4.5), feasible (M = 4.5), and appropriate (M = 4.5). Qualitative feedback was positive, with suggestions to integrate the paper-based program into the electronic health record system for broader uptake. Enrollees with asthma were more likely to have a family history of asthma and endorse exposure to tobacco smoke and cockroaches. CONCLUSIONS Easy Breathing shows promise as a decision support system that can be implemented in rural, medically underserved communities via primary care.
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Affiliation(s)
- David A. Fedele
- Department of Clinical & Health Psychology, University of Florida, Gainesville, FL
| | - Jessica Hollenbach
- Department of Pediatrics, Connecticut Children’s Medical Center, Hartsford, CT
| | - Manuela Sinisterra
- Department of Clinical & Health Psychology, University of Florida, Gainesville, FL
| | - Elizabeth LeFave
- Department of Pediatrics, University of Florida, Gainesville, FL
| | - Jennifer Fishe
- Department of Emergency Medicine, University of Florida, Jacksonville, FL
| | - Ramzi G. Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL
| | - Matthew J. Gurka
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL
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Kligler SK, Vargas-Torres C, Abbott EE, Lin M. Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care. J Emerg Med 2023; 64:555-563. [PMID: 37041095 PMCID: PMC10192099 DOI: 10.1016/j.jemermed.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/31/2023] [Accepted: 02/17/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Guidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations. OBJECTIVE We sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians. METHODS This was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering. RESULTS Among 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99-12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08-3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51-0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62-0.91) or no insurance (OR 0.54; 95% CI 0.35-0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period. CONCLUSIONS An ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.
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Affiliation(s)
- Sophie Karwoska Kligler
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, 1 Gustave L. Levy Place, New York, NY 10029
| | - Carmen Vargas-Torres
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, 1 Gustave L. Levy Place, New York, NY 10029
| | - Ethan E Abbott
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, 1 Gustave L. Levy Place, New York, NY 10029
| | - Michelle Lin
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, 1 Gustave L. Levy Place, New York, NY 10029
- Icahn School of Medicine at Mount Sinai, Department of Population Health Science and Policy, 1 Gustave L. Levy Place, New York, NY 10029
- Icahn School of Medicine at Mount Sinai, Institute for Health Equity Research, 1 Gustave L. Levy Place, New York, NY 10029
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Reeves PT, Kenny TM, Mulreany LT, McCown MY, Jacknewitz-Woolard JE, Rogers PL, Echelmeyer S, Welsh SK. Development and assessment of a low literacy, pictographic asthma action plan with clinical automation to enhance guideline-concordant care for children with asthma. J Asthma 2023; 60:655-672. [PMID: 35658804 DOI: 10.1080/02770903.2022.2087188] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Asthma is characterized by reversible pulmonary symptoms, frequent hospitalizations, poor quality of life, and varied treatment. Parents with low health literacy (HL) is linked to poor asthma outcomes in children. Recent practice updates recommended inhaled corticosteroids for the management of persistent asthma, but guideline-concordant care is suboptimal. Our aim was to develop and assess an Asthma Action Plan (AAP) that could serve as an individualized plan for low HL families and facilitate guideline-concordant care for clinicians. METHODS We followed the National Institute of Health 5-step "Clear & Simple" approach to develop the Uniformed Services AAP. Our AAP included symptom pictographs (dyspnea, cough, sleep, activity) and guideline-concordant clinical automation tools. Caregivers assessed the pictograms for validity (transparency of ≥ 85%; translucency score ≥ 5; and ≥ 85% recall). Readability was assessed using 7 formulas. (<6th Grade was acceptable). Comprehensibility, design quality, and usefulness was assessed by caregivers using the Consumer Information Rating Form (CIRF) (>80% was acceptable). Understandability and actionability was assessed by medical librarians using the Patient Education Materials Assessment Tool-Printable (>80% was acceptable). Suitability was assessed by clinicians using the modified Suitability Assessment of Materials (SAM) instrument (>70% was superior). RESULTS All 12 pictograms were validated (N = 118 respondents). Readability demonstrated a 4th grade level. Overall CIRF percentile score = 80.4%. Understandability and Actionability = 100%. Suitability score = 75%. CONCLUSIONS Our AAP was formally endorsed by the Allergy & Asthma Network. The Uniformed Services AAP is a novel tool with embedded clinical automation that can address low HL and enhance guideline-concordant care.
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Affiliation(s)
- Patrick T Reeves
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Department of Pediatrics, Division of Pulmonology, Brooke Army Medical Center, San Antonio, TX, USA
| | - Timothy M Kenny
- Department of Pediatrics, Division of Pulmonology, Brooke Army Medical Center, San Antonio, TX, USA
| | - Laura T Mulreany
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michael Y McCown
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jane E Jacknewitz-Woolard
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Philip L Rogers
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sofia Echelmeyer
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sebastian K Welsh
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Department of Pediatrics, Division of Pulmonology, Brooke Army Medical Center, San Antonio, TX, USA
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10
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Frey SM, Fagnano M, Halterman JS. Adolescent Knowledge of When to Use Inhaled Asthma Medications: Implications for Management. J Adolesc Health 2023; 72:623-628. [PMID: 36528520 PMCID: PMC10033387 DOI: 10.1016/j.jadohealth.2022.10.034] [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: 05/26/2022] [Revised: 09/04/2022] [Accepted: 10/24/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE It is unclear how often adolescents with persistent asthma know when to use different inhaled medications (as-needed rescue vs. daily controller; 'accurate use'), or whether this knowledge is associated with clinical asthma outcomes. This study aimed to characterize adolescent knowledge of accurate use; examine whether accurate use is associated with controller medication adherence, asthma symptoms, or exacerbations requiring acute health care services; and determine whether knowledge of accurate use improves following regular exposure to controller medications with school-based directly observed therapy (DOT). METHODS We analyzed baseline and 7-month data from the School-Based Asthma Care for Teens trial. Adolescents (12-16 years) identified inhaled medications on a chart and stated when each is used. We compared accurate use with adolescent-reported adherence, recent symptoms, and asthma-related acute health care visits; and exposure to DOT. Analyses were limited to subjects with controller medication. RESULTS Of 430 participants, 252 had controller medication at baseline. Knowledge of accurate use was described by 62%, and associated with adherence (odds ratio [OR]: 2.06, 95% confidence interval [CI]: 1.12-3.83). By 7 months, 313 adolescents had controller medication; 75% described accurate use, which was associated with adherence (OR: 3.46, 95% CI: 1.83-6.54), health care (OR: 0.39, 95% CI: 0.20-0.79), and DOT exposure (OR: 1.83, 95% CI: 1.10-3.32). Associations with adherence and health care at 7 months persisted in adjusted analyses. DISCUSSION Adolescent knowledge of accurate medication use was linked with greater adherence (baseline, 7 months), less acute health care (7 months), and exposure to in-school DOT. Interventions to support adolescents with persistent asthma should consider school-based care strategies and facilitate adolescent understanding of when to use different medications.
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Affiliation(s)
- Sean M Frey
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York.
| | - Maria Fagnano
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Jill S Halterman
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
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11
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Carroll AJ, Mohanty N, Wallace AS, Langman C, Smith JD. Perspectives of Primary Care Clinicians on the Diagnosis and Treatment of Pediatric Hypertension. FAMILY & COMMUNITY HEALTH 2023; 46:123-127. [PMID: 36799945 PMCID: PMC9942119 DOI: 10.1097/fch.0000000000000358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The purpose of this study was to contextualize the challenges of diagnosing and managing pediatric hypertension (pHTN) in federally qualified health centers. We conducted a survey among primary care clinicians (N = 72) who treat children (3-17 years old) in a national network of health centers. Clinicians reported practices of blood pressure (BP) measurement, barriers to diagnosis and management of pHTN, and use of population health tools. Most clinicians (83%) used electronic devices to measure BP, only 49% used manual BP readings for follow-up measurements, and more than half measured BP at each encounter. The highest-rated barrier to pHTN management was lack of comfort with antihypertensive medications (71% of respondents). Few clinicians (10%) had used population health tools, but most (78%) indicated they would like to use them for pHTN. These results offer clinician-level insights regarding implementation of the pHTN guideline in pediatric primary care settings.
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Affiliation(s)
- Allison J. Carroll
- Psychiatry and Behavioral Sciences and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago IL USA
| | - Nivedita Mohanty
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and AllianceChicago, Chicago IL USA
| | | | - Craig Langman
- Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago IL USA
| | - Justin D. Smith
- Department of Population Health Sciences, Division of Health System Innovation and Research, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City UT USA
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Carroll OR, Pillar AL, Brown AC, Feng M, Chen H, Donovan C. Advances in respiratory physiology in mouse models of experimental asthma. Front Physiol 2023; 14:1099719. [PMID: 37008013 PMCID: PMC10060990 DOI: 10.3389/fphys.2023.1099719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/07/2023] [Indexed: 03/18/2023] Open
Abstract
Recent advances in mouse models of experimental asthma coupled with vast improvements in systems that assess respiratory physiology have considerably increased the accuracy and human relevance of the outputs from these studies. In fact, these models have become important pre-clinical testing platforms with proven value and their capacity to be rapidly adapted to interrogate emerging clinical concepts, including the recent discovery of different asthma phenotypes and endotypes, has accelerated the discovery of disease-causing mechanisms and increased our understanding of asthma pathogenesis and the associated effects on lung physiology. In this review, we discuss key distinctions in respiratory physiology between asthma and severe asthma, including the magnitude of airway hyperresponsiveness and recently discovered disease drivers that underpin this phenomenon such as structural changes, airway remodeling, airway smooth muscle hypertrophy, altered airway smooth muscle calcium signaling, and inflammation. We also explore state-of-the-art mouse lung function measurement techniques that accurately recapitulate the human scenario as well as recent advances in precision cut lung slices and cell culture systems. Furthermore, we consider how these techniques have been applied to recently developed mouse models of asthma, severe asthma, and asthma-chronic obstructive pulmonary disease overlap, to examine the effects of clinically relevant exposures (including ovalbumin, house dust mite antigen in the absence or presence of cigarette smoke, cockroach allergen, pollen, and respiratory microbes) and to increase our understanding of lung physiology in these diseases and identify new therapeutic targets. Lastly, we focus on recent studies that examine the effects of diet on asthma outcomes, including high fat diet and asthma, low iron diet during pregnancy and predisposition to asthma development in offspring, and environmental exposures on asthma outcomes. We conclude our review with a discussion of new clinical concepts in asthma and severe asthma that warrant investigation and how we could utilize mouse models and advanced lung physiology measurement systems to identify factors and mechanisms with potential for therapeutic targeting.
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Affiliation(s)
- Olivia R. Carroll
- Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia
| | - Amber L. Pillar
- Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia
| | - Alexandra C. Brown
- Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia
| | - Min Feng
- Faculty of Science, School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
| | - Hui Chen
- Faculty of Science, School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
| | - Chantal Donovan
- Hunter Medical Research Institute, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Science, School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
- *Correspondence: Chantal Donovan,
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Ortega H, Bharmal N, Khatri S. Primary care referral patterns for patients with asthma: analysis of real-world data. J Asthma 2023; 60:609-615. [PMID: 35620831 DOI: 10.1080/02770903.2022.2082308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify features related to management of patients prior to referral from primary care physicians (PCPs) to pulmonologists and allergists. METHODS This is an analysis of patient claims data from Symphony Health (2013-2018). To characterize referrals, a longitudinal cohort included 12 months with no asthma claims prior to the index date, followed by 36 months of observation. We also assessed a cross-sectional cohort for 12 months at the end of the observational period to characterize disease control and treatment patterns. Referral was defined as the first appearance of a claim from an allergist or pulmonologist for a patient's initial visit for asthma. Descriptive statistics were used to analyze the data. RESULTS The majority of patients with asthma were managed by PCPs (60%), followed by pulmonologists (16%) and allergists (8%). Forty-three percent had uncontrolled asthma. Only 8% were referred to specialists within the first 24 months after initial diagnosis, of which 76% were seen by pulmonologists and 24% by allergists. Referrals resulted in treatment change in 55%-68% of the cases. Patients who received a referral were more likely to be on oral corticosteroids (OCS) and/or have more hospitalizations/ED visits. CONCLUSIONS About one-third of the patients managed by PCPs received intermittent and/or chronic OCS prior to referral, which may be an indication of uncontrolled disease. The referral patterns in this analysis illustrate underutilization of specialists in the consultation and management of patients with uncontrolled asthma.
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Affiliation(s)
- Hector Ortega
- Clinical Development, Nexstone Immunology, Inc, San Diego, CA, USA
| | - Nazleen Bharmal
- Community Health & Partnership, Cleveland Clinic, Community Care, Cleveland, OH, USA
| | - Sumita Khatri
- Cleveland Clinic, Asthma Center, Respiratory Institute, Cleveland, OHSA
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García-Marcos L, Chiang CY, Asher MI, Marks GB, El Sony A, Masekela R, Bissell K, Ellwood E, Ellwood P, Pearce N, Strachan DP, Mortimer K, Morales E, Ajeagah GA, Alkhayer G, Alomary SA, Ambriz-Moreno MJ, Arias-Cruz A, Awasthi S, Badellino H, Behniafard N, Bercedo-Sanz A, Brożek G, Bucaliu-Ismajli I, Cabrera-Aguilar A, Chinratanapisit S, Del-Río-Navarro BE, Douros K, El Sadig H, Escalante-Dominguez AJ, Falade AG, Gacaferri-Lumezi B, García-Almaráz R, Garcia-Muñoz R, Ghashi V, Ghoshal AG, González-Díaz C, Hana-Lleshi L, Hernández-Mondragón LO, Huang JL, Jiménez-González CA, Juan-Pineda MÁ, Kochar SK, Kuzmicheva K, Linares-Zapien FJ, Lokaj-Berisha V, López-Silvarrey A, Lozano-Sáenz JS, Mahesh PA, Mallol J, Martinez-Torres AE, Masekela R, Mérida-Palacio JV, Mohammad Y, Moreno-Gardea HL, Navarrete-Rodriguez EM, Ndikum AE, Noor M, Ochoa-Lopez G, Pajaziti L, Pellegrini-Belinchon J, Perez-Fernández V, Priftis K, Ramos-García BC, Ranasinghe JC, Robertson S, Rodriguez-Perez N, Rutter CE, Sacre-Hazouri JA, Salvi S, Sanchez JF, Sánchez JF, Sanchez-Coronel MG, Saucedo-Ramirez OJ, Singh M, Singh N, Singh V, Sinha S, Sit N, Sosa-Ferrari SM, Soto-Martínez ME, Urrutia-Pereira M, Yeh KW, Zar HJ, Zhjeqi V. Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study. Lancet Glob Health 2023; 11:e218-e228. [PMID: 36669806 PMCID: PMC9885426 DOI: 10.1016/s2214-109x(22)00506-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 11/02/2022] [Accepted: 11/09/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Asthma is one of the most common non-communicable diseases globally. This study aimed to assess asthma medicine use, management plan availability, and disease control in childhood, adolescence, and adulthood across different country settings. METHODS We used data from the Global Asthma Network Phase I cross-sectional epidemiological study (2015-20). A validated, written questionnaire was distributed via schools to three age groups (children, 6-7 years; adolescents, 13-14 years; and adults, ≥19 years). Eligible adults were the parents or guardians of children and adolescents included in the surveys. In individuals with asthma diagnosed by a doctor, we collated responses on past-year asthma medicines use (type of inhaled or oral medicine, and frequency of use). Questions on asthma symptoms and health visits were used to define past-year symptom severity and extent of asthma control. Income categories for countries based on gross national income per capita followed the 2020 World Bank classification. Proportions (and 95% CI clustered by centre) were used to describe results. Generalised structural equation multilevel models were used to assess factors associated with receiving medicines and having poorly controlled asthma in each age group. FINDINGS Overall, 453 473 individuals from 63 centres in 25 countries were included, comprising 101 777 children (6445 [6·3%] with asthma diagnosed by a doctor), 157 784 adolescents (12 532 [7·9%]), and 193 912 adults (6677 [3·4%]). Use of asthma medicines varied by symptom severity and country income category. The most used medicines in the previous year were inhaled short-acting β2 agonists (SABA; range across age groups, 29·3-85·3% participants) and inhaled corticosteroids (12·6-51·9%). The proportion of individuals with severe asthma symptoms not taking inhaled corticosteroids (inhaled corticosteroids alone or with long-acting β2 agonists) was high in all age groups (934 [44·8%] of 2085 children, 2011 [60·1%] of 3345 adolescents, and 1142 [55·5%] of 2058 adults), and was significantly higher in middle-to-low-income countries. Oral SABA and theophylline were used across age groups and country income categories, contrary to current guidelines. Asthma management plans were used by 4049 (62·8%) children, 6694 (53·4%) adolescents, and 3168 (47·4%) adults; and 2840 (44·1%) children, 6942 (55·4%) adolescents, and 4081 (61·1%) adults had well controlled asthma. Independently of country income and asthma severity, having an asthma management plan was significantly associated with the use of any type of inhaled medicine (adjusted odds ratio [OR] 2·75 [95% CI 2·40-3·15] for children; 2·45 [2·25-2·67] for adolescents; and 2·75 [2·38-3·16] for adults) or any type of oral medicine (1·86 [1·63-2·12] for children; 1·53 [1·40-1·68] for adolescents; and 1·78 [1·55-2·04] for adults). Poor asthma control was associated with low country income (lower-middle-income and low-income countries vs high-income countries, adjusted OR 2·33 [95% CI 1·32-4·14] for children; 3·46 [1·83-6·54] for adolescents; and 4·86 [2·55-9·26] for adults). INTERPRETATION Asthma management and control is frequently inadequate, particularly in low-resource settings. Strategies should be implemented to improve adherence to asthma treatment guidelines worldwide, with emphasis on access to affordable and quality-assured essential asthma medicines especially in low-income and middle-income countries. FUNDING International Union Against Tuberculosis and Lung Disease, Boehringer Ingelheim New Zealand, AstraZeneca, UK National Institute for Health Research, UK Medical Research Council, European Research Council, the Spanish Instituto de Salud Carlos III. TRANSLATION For the Spanish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Luis García-Marcos
- Paediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children‘s Hospital, University of Murcia and IMIB Bio-medical Research Institute, Murcia, Spain,ARADyAL Allergy Network, Murcia, Spain,Correspondence to: Prof Luis García-Marcos, Paediatric Allergy and Pulmonology Units, Virgen de la Arrixaca University Children‘s Hospital, University of Murcia and IMIB Bio-medical Research Institute, 30120 Murcia, Spain
| | - Chen-Yuan Chiang
- International Union Against Tuberculosis and Lung Disease, Paris, France,Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, and Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - M Innes Asher
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Guy B Marks
- Respiratory and Environmental Epidemiology, University of New South Wales, Sydney, NSW, Australia
| | - Asma El Sony
- Epidemiological Laboratory for Public Health, Research and Development, Khartoum, Sudan
| | - Refiloe Masekela
- Inkosi Albert Luthuli Central Hospital, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Karen Bissell
- School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Eamon Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Philippa Ellwood
- Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - David P Strachan
- Population Health Research Institute, St George's, University of London, London, UK
| | - Kevin Mortimer
- Department of Paediatrics and Child Health, College of Health Sciences, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK,Respiratory Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Eva Morales
- Department of Public Health Sciences, University of Murcia and IMIB Bio-medical Research Institute, Murcia, Spain
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Nanda A, Siles R, Park H, Louisias M, Ariue B, Castillo M, Anand MP, Nguyen AP, Jean T, Lopez M, Altisheh R, Pappalardo AA. 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. J Allergy Clin Immunol 2023; 151:869-880. [PMID: 36720288 DOI: 10.1016/j.jaci.2023.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/08/2023] [Accepted: 01/19/2023] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Anil Nanda
- Asthma and Allergy Center, Lewisville-Flower Mound; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Roxana Siles
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland
| | - Henna Park
- Department of Pediatrics, University of Illinois Hospital, Chicago
| | - Margee Louisias
- Department of Medicine, Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Cleveland; Department of Immunology, Boston Children's Hospital, Boston; Harvard Medical School, Boston
| | - Barbara Ariue
- Department of Pediatrics, Division of Allergy/Immunology, Loma Linda Children's Hospital, Loma Linda
| | - Maria Castillo
- Department of Medical Education at Driscoll Children's Hospital, Corpus Christi
| | - Mahesh Padukudru Anand
- Department of Respiratory Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysore
| | - Anh P Nguyen
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, School of Medicine, University of California Davis, Sacramento
| | - Tiffany Jean
- Division of Basic and Clinical Immunology, Department of Medicine, University of California Irvine, Orange
| | - Michael Lopez
- Division of Basic and Clinical Immunology, Department of Medicine, University of California Irvine, Orange
| | - Roula Altisheh
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation, Cleveland
| | - Andrea A Pappalardo
- Department of Pediatrics, Department of Medicine, University of Illinois at Chicago, Chicago
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16
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Hollenbach JP, Collins MS, Wasser C, Fedele D. Implementation of standardized asthma management programs in outpatient settings. Ann Allergy Asthma Immunol 2023; 130:571-576. [PMID: 36702245 DOI: 10.1016/j.anai.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW This article reviews new approaches, facilitators, barriers, and opportunities to increasing adoption of standardized asthma management programs in the outpatient care setting. RECENT FINDINGS Primary care clinicians providing asthma care in the outpatient setting are challenged by the complexity of guidelines and want standardization of tools that are easy to use and that can be integrated within their practice's workflow. Programs that integrate clinical decision support tools within a practice's electronic health record and provide support from specialists may enhance uptake of asthma management programs in the outpatient setting and reduce asthma morbidity. Lack of an implementation science framework, consideration for organizational context, and clinician buy-in are recently recognized barriers to adoption of asthma programs and improved asthma outcomes. In addition, many of these interventions are labor intensive, costly, and may not be capable of wide dissemination because of the EHR interoperability problem. CONCLUSION Programs that simplify the guidelines, integrate clinical decision support within the EHR, and ground their approach with an implementation science framework may improve the quality of asthma care provided in the outpatient setting.
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Affiliation(s)
- Jessica P Hollenbach
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut.
| | - Melanie Sue Collins
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut; Division of Pediatric Pulmonary and Sleep Medicine, Connecticut Children's Medical Center, Hartford, Connecticut; Central Connecticut Cystic Fibrosis Center, Hartford, Connecticut
| | - Caleb Wasser
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut
| | - David Fedele
- Department of Clinical & Health Psychology, University of Florida, Gainesville, Florida
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17
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Salinas GD, Wiley S, Stacy S, Gall R, Wright L, Mandarakas A, Ruiz-Cordell K, Gilbride J. Understanding decision-making and educational need in the management of pediatric patients with moderate-to-severe asthma: analysis of a US-based clinician survey. J Asthma 2022; 60:1171-1182. [PMID: 36251048 DOI: 10.1080/02770903.2022.2137037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Asthma creates a substantial burden on the pediatric healthcare system, particularly by those with moderate-to-severe disease. As few studies have been published specific to clinician evaluation and management of this population, this analysis serves to begin to identify educational needs and potential clinical impact. METHODS We conducted a case-based survey of US general pediatric (n = 227), allergy (n = 158), and pediatric pulmonology (n = 70) clinicians to understand the current approach to management of pediatric patients with moderate-to-severe asthma. RESULTS Results show inconsistencies in guideline adherence, identification of disease severity and control, referral practices, and knowledge of phenotypes, which may impact clinical decision making. While most clinicians refer to guidelines when managing pediatric patients with moderate-to-severe asthma, there is no preferred set, and they find the guidelines to be moderately useful. General pediatricians are more likely than specialists to have difficulty distinguishing control and severity and may not be familiar with the concept of asthma phenotype. Most surveyed pediatricians indicated they refer patients to a specialist, but did not always do so in the cases. Clinicians have little consensus on the best approach to manage patients with uncontrolled symptoms after optimized therapy. Many clinicians may have uncertainty about how elevated eosinophils or FeNO could affect patient management. Further, there may be gaps in incorporating parents and pediatric patients into shared decision-making in their care. CONCLUSIONS Understanding the needs of those managing patients with moderate-to-severe asthma is critical to developing effective continuing education activities to improve patient outcomes.
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Affiliation(s)
- Gregory D Salinas
- CE Outcomes LLC, NA, 2101 Highland Ave S, STE 300A, Birmingham, 35205-4009 United States
| | - Shereta Wiley
- CE Outcomes LLC, NA, 2101 Highland Ave S, STE 300A, Birmingham, 35205-4009 United States
| | - Sylvie Stacy
- CE Outcomes LLC, NA, 2101 Highland Ave S, STE 300A, Birmingham, 35205-4009 United States
| | - Rebecca Gall
- Regeneron Pharmaceuticals Inc, Medical Affairs, Tarrytown, 10591 United States
| | - Lakiea Wright
- Sanofi, Medical Affairs, Cambridge, 02142 United States
| | - Anthia Mandarakas
- Regeneron Pharmaceuticals Inc, Medical Affairs, Tarrytown, 10591 United States
| | - Karyn Ruiz-Cordell
- Regeneron Pharmaceuticals Inc, Medical Affairs, Tarrytown, 10591 United States
| | - Joseph Gilbride
- Regeneron Pharmaceuticals Inc, Medical Affairs, Tarrytown, 10591 United States
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18
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Mustafa G. How Do Pediatricians Diagnose Asthma in Tertiary Care Hospitals? Cureus 2022; 14:e29768. [PMID: 36324352 PMCID: PMC9618029 DOI: 10.7759/cureus.29768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/29/2022] Open
Abstract
Objective: There is a lot of disparity in the guidelines and the practice of pediatricians globally for diagnosing asthma in children. To find out if pediatricians are diagnosing asthma in children according to best standard practices. Methodology: A cross-sectional study was conducted at tertiary care hospitals' emergency and outpatient departments (OPDs). All the parents accompanying the asthmatic children to the emergency or outpatient departments of the tertiary care hospitals were asked questions regarding the diagnosis of their children's asthma on a prescribed performa. This performa had all the components of the best standard practices for the diagnosis of asthma in children. The data were entered into SPSS version 27 (SPSS Inc., Chicago, IL) and analyzed. Results: Among the 234 children, the diagnosis of asthma was based on only one component out of three, i.e., recurrence (100%) of symptoms or signs. The objective measurement of the second component, i.e., reversibility with a peak flow meter (PFM) or spirometry, was assessed in only 6% of children. The third component, i.e., the presence of inflammation, was not assessed at all (0.0%). Conclusions: The diagnosis of asthma in children lacks precision. This is far from the evidence-based best standard practices. There is a need to provide motivation, training, and equipment to the staff.
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Sagheb E, Wi CI, Yoon J, Seol HY, Shrestha P, Ryu E, Park M, Yawn B, Liu H, Homme J, Juhn Y, Sohn S. Artificial Intelligence Assesses Clinicians' Adherence to Asthma Guidelines Using Electronic Health Records. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1047-1056.e1. [PMID: 34800704 PMCID: PMC9007821 DOI: 10.1016/j.jaip.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 10/20/2021] [Accepted: 11/07/2021] [Indexed: 05/25/2023]
Abstract
BACKGROUND Clinicians' asthma guideline adherence in asthma care is suboptimal. The effort to improve adherence can be enhanced by assessing and monitoring clinicians' adherence to guidelines reflected in electronic health records (EHRs), which require costly manual chart review because many care elements cannot be identified by structured data. OBJECTIVE This study was designed to demonstrate the feasibility of an artificial intelligence tool using natural language processing (NLP) leveraging the free text EHRs of pediatric patients to extract key components of the 2007 National Asthma Education and Prevention Program guidelines. METHODS This is a retrospective cross-sectional study using a birth cohort with a diagnosis of asthma at Mayo Clinic between 2003 and 2016. We used 1,039 clinical notes with an asthma diagnosis from a random sample of 300 patients. Rule-based NLP algorithms were developed to identify asthma guideline-congruent elements by examining care description in EHR free text. RESULTS Natural language processing algorithms demonstrated a sensitivity (0.82-1.0), specificity (0.95-1.0), positive predictive value (0.86-1.0), and negative predictive value (0.92-1.0) against manual chart review for asthma guideline-congruent elements. Assessing medication compliance and inhaler technique assessment were the most challenging elements to assess because of the complexity and wide variety of descriptions. CONCLUSIONS Natural language processing technologies may enable the automated assessment of clinicians' documentation in EHRs regarding adherence to asthma guidelines and can be a useful population management and research tool to assess and monitor asthma care quality. Multisite studies with a larger sample size are needed to assess the generalizability of these NLP algorithms.
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Affiliation(s)
- Elham Sagheb
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minn
| | - Chung-Il Wi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Jungwon Yoon
- Department of Pediatrics, Myongji Hospital, Goyang, South Korea
| | - Hee Yun Seol
- Pusan National University, Yangsan Hospital, Yangsan, South Korea
| | - Pragya Shrestha
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Euijung Ryu
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Barbara Yawn
- Department of Family and Community Health, University of Minnesota, Minneapolis, Minn
| | - Hongfang Liu
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minn
| | - Jason Homme
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Young Juhn
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn.
| | - Sunghwan Sohn
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, Minn.
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Afolabi T, Fairman KA. Association of Asthma Exacerbation Risk and Physician Time Expenditure With Provision of Asthma Action Plans and Education for Pediatric Patients. J Pediatr Pharmacol Ther 2022; 27:244-253. [PMID: 35350158 DOI: 10.5863/1551-6776-27.3.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/14/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To provide information about factors underlying provision of asthma action plans (AAPs) to a minority of pediatric patients with asthma, assess whether risk of exacerbation acts on provision of AAP and asthma education directly, suggesting targeting to highest-risk patients, or indirectly by influencing physician-patient interaction time. METHODS This study was a retrospective cross-sectional analysis of a nationally representative sample of physician office visits that consisted of patients aged 2 to 18 years with asthma. Exacerbation risk comprised proxy indicators of control and severity. Direct and time-mediated effects of exacerbation risk on provision of AAP and education were calculated from logistic regression models. RESULTS Asthma action plans were provided in 14.3% of visits, education in 23.9%. Total direct effects of exacerbation risk (ORs = 3.88-4.69) far exceeded indirect, time-mediated effects (both ORs = 1.03) on AAPs. Direct effects on education were similar but smaller. After adjusting for risk, physician time expenditure of ≥30 minutes was associated with nearly doubled odds of providing AAP or education (ORs = 1.90-1.99). Visits that included allied health professionals alongside physician care were significantly associated with all 4 outcomes in multivariate analyses (ORs = 3.06-5.28). CONCLUSIONS Exacerbation risk has a strong, direct association with AAP provision in pediatric asthma, even controlling for physician time expenditure. Provision of AAP and education to pediatric patients with asthma may be facilitated by increasing available time for office visits and involving allied health professionals.
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Affiliation(s)
- Titilola Afolabi
- Midwestern University College of Pharmacy-Glendale (TA, KAF), Glendale, AZ.,Phoenix Children's Hospital (TA), Phoenix, AZ
| | - Kathleen A Fairman
- Midwestern University College of Pharmacy-Glendale (TA, KAF), Glendale, AZ
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21
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Louis R, Satia I, Ojanguren I, Schleich F, Bonini M, Tonia T, Rigau D, Ten Brinke A, Buhl R, Loukides S, Kocks JWH, Boulet LP, Bourdin A, Coleman C, Needham K, Thomas M, Idzko M, Papi A, Porsbjerg C, Schuermans D, Soriano JB, Usmani OS. European Respiratory Society Guidelines for the Diagnosis of Asthma in Adults. Eur Respir J 2022; 60:2101585. [PMID: 35169025 DOI: 10.1183/13993003.01585-2021] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 01/10/2022] [Indexed: 12/20/2022]
Abstract
Although asthma is very common affecting 5-10% of the population, the diagnosis of asthma in adults remains a challenge in the real world that results in both over- and under-diagnosis. A task force (TF) was set up by the European Respiratory Society to systematically review the literature on the diagnostic accuracy of tests used to diagnose asthma in adult patients and provide recommendation for clinical practice.The TF defined eight PICO (Population, Index, Comparator, and Outcome) questions that were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach, The TF utilised the outcomes to develop an evidenced-based diagnostic algorithm, with recommendations for a pragmatic guideline for everyday practice that was directed by real-life patient experiences.The TF support the initial use of spirometry followed, and if airway obstruction is present, by bronchodilator reversibility testing. If initial spirometry fails to show obstruction, further tests should be performed in the following order: FeNO, PEF variability or in secondary care, bronchial challenge. We present the thresholds for each test that are compatible with a diagnosis of asthma in the presence of current symptoms.The TF reinforce the priority to undertake spirometry and recognise the value of measuring blood eosinophils and serum IgE to phenotype the patient. Measuring gas trapping by body plethysmography in patients with preserved FEV1/FVC ratio deserves further attention. The TF draw attention on the difficulty of making a correct diagnosis in patients already receiving inhaled corticosteroids, the comorbidities that may obscure the diagnosis, the importance of phenotyping, and the necessity to consider the patient experience in the diagnostic process.
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Affiliation(s)
- Renaud Louis
- CHU de Liege University Hospital Centre Ville, Liege, Belgium
- First author, Task force chair
| | - Imran Satia
- McMaster University, Hamilton, Canada
- All authors contributed equally
| | - Inigo Ojanguren
- Vall d'Hebron University Hospital Barcelona, Barcelona, Spain
- All authors contributed equally
| | - Florence Schleich
- Department of Pulmonary Medicine, University of Liege, Liège, Belgium
- All authors contributed equally
| | - Matteo Bonini
- Sapienza University of Rome, Rome, Italy
- All authors contributed equally
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Anne Ten Brinke
- CHU de Liege University Hospital Centre Ville, Liege, Belgium
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | | | - Louis-Philippe Boulet
- Pneumologie, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Canada
| | | | | | | | - Mike Thomas
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Marco Idzko
- Department of Respiratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Celeste Porsbjerg
- Respiratory Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen NV, Denmark
| | - Daniel Schuermans
- Respiratory Division, Academic Hospital UZBrussel, Brussels, Belgium
| | - Joan B Soriano
- Universidad Autónoma de Madrid, Hospital Universitario de la Princesa, Madrid, Spain
| | - Omar S Usmani
- Asthma Lab, National Heart and Lung Institute, London, UK
- Corresponding author, Task force co-chair
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22
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Abstract
ABSTRACT This article discusses recent updates on the clinical management of asthma and outlines ways for nurses to engage patients in the management of their disease.
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Affiliation(s)
- Christine M Galante
- Christine M. Galante has practiced in acute, primary, and long-term care, and has worked in nursing education
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23
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Reyes-Angel J, Han YY, Forno E, Celedón JC, Rosser FJ. Parental knowledge and usage of air quality in childhood asthma management. Front Pediatr 2022; 10:966372. [PMID: 36440347 PMCID: PMC9687089 DOI: 10.3389/fped.2022.966372] [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: 06/10/2022] [Accepted: 10/06/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The current United States asthma management guidelines recommend usage of the Air Quality Index (AQI) for outdoor activity modification when air pollution is high. Little is known about parental knowledge and usage of air quality including the AQI in managing childhood asthma. METHODS Forty parents (or legal guardians) of children with persistent asthma completed a questionnaire designed to assess 4 areas related to outdoor air pollution: awareness, perception, behavioral modification, and prior healthcare provider discussion. Descriptive statistics were obtained and Fisher's exact test was used for analysis of behavioral change by selected variables. RESULTS Almost all parents reported awareness of air quality alerts or AQI, however, only 20% checked the AQI on the AirNow app or website. Most parents reported air pollution as a trigger (65%), yet few parents reported behavioral modification of their child's outdoor activity based on the perception of poor air quality (43%) or based on AQI or alerts (40%). Over half of parents reported a healthcare provider had ever discussed air pollution as a trigger, with few parents (23%) reporting recommendations for behavior change. Perception of air pollution as a trigger, healthcare provider discussion and recommendations, and usage of AirNow were associated with increased reported activity change. CONCLUSION Healthcare providers should discuss outdoor air pollution during asthma management in children and should discuss AirNow as a source for AQI information and behavioral recommendations.
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Affiliation(s)
- Jessica Reyes-Angel
- Department of Pediatrics, Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Yueh-Ying Han
- Department of Pediatrics, Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Erick Forno
- Department of Pediatrics, Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Juan C Celedón
- Department of Pediatrics, Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Franziska J Rosser
- Department of Pediatrics, Division of Pulmonary Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
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24
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Management of Pediatric Atopic Dermatitis by Primary Care Providers: A Systematic Review. Acad Pediatr 2021; 21:1318-1327. [PMID: 34280477 DOI: 10.1016/j.acap.2021.07.008] [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: 02/03/2021] [Revised: 06/14/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Primary care providers (PCPs), including pediatricians and general practitioners, are often the first to see children with eczema/atopic dermatitis (AD). Little is known about management of pediatric AD by PCPs and adherence to national guidelines. OBJECTIVE To review existing literature examining management components of pediatric AD (topical corticosteroids [TCS], topical calcineurin inhibitors [TCIs], antihistamines, bathing, emollients, and diet) by PCPs. DATA SOURCES PubMed/Medline and Embase. STUDY ELIGIBILITY CRITERIA English-language articles dated 2015 to 2020 reporting outcomes addressing management of pediatric AD by PCPs. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors independently screened titles/abstracts, reviewed full-text articles, extracted relevant data, and evaluated study quality. Disagreements were resolved by a third author. RESULTS Twenty articles were included. Surveys and national database analyses were the most common methodologies (n = 7 each). PCPs commonly prescribed TCS but had a preference for low-potency agents, overprescribed nonsedating antihistamines, and avoided TCIs. PCPs commonly recommended emollients, although this was not universal. Data characterizing nonmedication management were limited. LIMITATIONS Most studies did not examine individual patient encounters, but rather relied on providers reporting their general behaviors. Provider behavior may vary based on country of practice. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Knowledge and management gaps exist among PCPs in treating pediatric AD in key areas including knowledge of TCS safety profiles and prescribing of TCIs. The current literature is largely limited to small studies that evaluate prescribing behaviors with limited data characterizing nonmedication management, highlighting the need for future research in this area.
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25
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Mathioudakis AG, Tsilochristou O, Adcock IM, Bikov A, Bjermer L, Clini E, Flood B, Herth F, Horvath I, Kalayci O, Papadopoulos NG, Ryan D, Sanchez Garcia S, Correia-de-Sousa J, Tonia T, Pinnock H, Agache I, Janson C. ERS/EAACI statement on adherence to international adult asthma guidelines. Eur Respir Rev 2021; 30:30/161/210132. [PMID: 34526316 DOI: 10.1183/16000617.0132-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 06/26/2021] [Indexed: 12/20/2022] Open
Abstract
Guidelines aim to standardise and optimise asthma diagnosis and management. Nevertheless, adherence to guidelines is suboptimal and may vary across different healthcare professional (HCP) groups.Further to these concerns, this European Respiratory Society (ERS)/European Academy of Allergy and Clinical Immunology (EAACI) statement aims to: 1) evaluate the understanding of and adherence to international asthma guidelines by HCPs of different specialties via an international online survey; and 2) assess strategies focused at improving implementation of guideline-recommended interventions, and compare process and clinical outcomes in patients managed by HCPs of different specialties via systematic reviews.The online survey identified discrepancies between HCPs of different specialties which may be due to poor dissemination or lack of knowledge of the guidelines but also a reflection of the adaptations made in different clinical settings, based on available resources. The systematic reviews demonstrated that multifaceted quality improvement initiatives addressing multiple challenges to guidelines adherence are most effective in improving guidelines adherence. Differences in outcomes between patients managed by generalists or specialists should be further evaluated.Guidelines need to consider the heterogeneity of real-life settings for asthma management and tailor their recommendations accordingly. Continuous, multifaceted quality improvement processes are required to optimise and maintain guidelines adherence. Validated referral pathways for uncontrolled asthma or uncertain diagnosis are needed.
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Affiliation(s)
- Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK .,North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,These authors were Task Force Co-chairs and are equal authors
| | - Olympia Tsilochristou
- Dept of Allergy, Guy's and St Thomas' Foundation Trust, London, UK.,Peter Gorer Dept of Immunobiology, King's College London, London, UK.,These authors were Task Force Co-chairs and are equal authors
| | - Ian M Adcock
- National Heart and Lung Institute, Imperial College London and the NIHR Imperial Biomedical Research Centre, London, UK
| | - Andras Bikov
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK.,North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Leif Bjermer
- Respiratory Medicine and Allergology, Dept of Clinical Sciences, Lund University, Lund, Sweden
| | - Enrico Clini
- Dept of Medical Specialities, University Hospital of Modena, University of Modena-Reggio Emilia, Modena, Italy
| | - Breda Flood
- European Federation of Allergy and Airways Diseases Patients Association (EFA), Dublin, Ireland
| | - Felix Herth
- Dept of Pneumology and Critical Care Medicine, Thoraxklinik and Translational Lung Research Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Ildiko Horvath
- National Koranyi Institute for Pulmonology, Budapest, Hungary.,Institute of Public Health, Semmelweis University, Budapest, Hungary
| | - Omer Kalayci
- Hacettepe University School of Medicine, Ankara, Turkey
| | - Nikolaos G Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK.,Allergy Dept, Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Dermot Ryan
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Jaime Correia-de-Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Guimarães, Portugal
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Hillary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Ioana Agache
- Allergy & Clinical Immunology, Transylvania University, Brasov, Romania.,These authors were Task Force Co-chairs and are equal authors
| | - Christer Janson
- Dept of Medical Science, Respiratory, Allergy and Sleep Research, Uppsala University and University Hospital, Uppsala, Sweden.,These authors were Task Force Co-chairs and are equal authors
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26
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Mammen JR, McGovern CM. Summary of the 2020 focused updates to U.S. asthma management guidelines: What has changed and what hasn't? J Am Assoc Nurse Pract 2021; 34:238-241. [PMID: 34469362 DOI: 10.1097/jxx.0000000000000619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/22/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Despite the availability of effective medications, the majority of pediatric and adult patients with persistent asthma have uncontrolled symptoms. This has been attributed to patient nonadherence and poor self-management, but clinicians also contribute through inaccurate assessment of asthma and lack of familiarity with best practice guidelines for medication management. Thus, improving patient outcomes will require improving clinical management by health care providers, including utilization of evidence-based practice guidelines. In this report, we briefly summarize key points of the national guidelines for asthma management and delineate important changes enacted by 2020 Expert Panel Report-4 updates. These include revised recommendations on the use of fractional exhaled nitric oxide testing, indoor allergen mitigation, bronchial thermoplasty, adjunctive immunotherapy, and important modifications to medication management that are likely to have widespread impact on prescribing throughout the United States. In particular, for all patients aged five years and older taking stepwise therapy levels 3-4, it is now recommended to use Single Maintenance and Reliever Therapy, whereas the use of intermittent inhaled corticosteroids (ICSs) administered at the same time as short-acting beta agonist is recommended for step 2 to reduce symptom burden, improve control, and minimize total ICS dose.
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Affiliation(s)
- Jennifer R Mammen
- College of Nursing, University of Rhode Island, Kingston, Rhode Island
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27
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Tosca MA, Schiavetti I, Duse M, Marseglia GL, Ciprandi G. A Survey on the Management of Children with Asthma in Primary Care Setting in Italy. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2021; 34:39-42. [PMID: 34143687 DOI: 10.1089/ped.2021.0031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Maria A Tosca
- Pediatrics Department, Pediatric Allergy Center, Istituto Giannina Gaslini, Genoa, Italy
| | | | - Marzia Duse
- Pediatrics Department, Università la Sapienza, Rome, Italy
| | - G L Marseglia
- Pediatrics Clinic, Pediatrics Department, Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Giorgio Ciprandi
- Outpatients Clinics Department, Allergy Clinic, Casa di Cura Villa Montallegro, Genoa, Italy
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28
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Charriot J, Maravic M, Huguet M, Vachier I, Suehs C, Bourdin A. "Real-life" management of patients with severe asthma in the biologics era: Can we do better? World Allergy Organ J 2021; 14:100528. [PMID: 33815653 PMCID: PMC7985558 DOI: 10.1016/j.waojou.2021.100528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/02/2021] [Accepted: 02/16/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Discrepancies exist between guidelines and real-life practice in severe asthma. Objectives: To establish profiles for severe asthma patients according to their maintenance therapies and identify unmet needs. METHODS 2432 French lung specialists and allergists were invited to participate in a severe asthma survey between March and April 2018. Retrospective data were collected using an electronic case report form developed by IQVIA. RESULTS 71 respiratory physicians and/or allergists participated in the study, providing data for 736 severe asthma patients. The annual mean rates of hospitalization and exacerbation in the previous year were 0.65 (SD = 0.5) and 2.25 (SD = 1.0), respectively. One hundred one (13.7%) patients were treated with oral steroids; the mean dosage regimen was 16.1 mg per day (SD = 11.2). ICS-LABA-LAMA triple inhaled therapy was reported for 288 patients (39%); 231 patients (31.4%) had one biologic in their maintenance treatment. Among patients hospitalized at least once in the previous year (n = 311), 89 (28.5%) were currently treated with biologics, and 61 (19.6%) with oral steroids. One hundred sixty-six patients with uncontrolled asthma and no current biologic therapy had data for "T2 status"; 78 (47%), 89 (53.6%) and 137 (82.5%) of them had treatment criteria respectively for an anti-IgE, anti-IL5-pathway or anti-IL-4/IL-13 pathway therapy; 22 (13.2%) were ineligible for any current biologic according to biomarkers. CONCLUSION Our study updated "real-life" therapeutic management data for severe asthma in France in 2018. We highlighted a need for improved patient-phenotyping. This work also gives a striking insight of the position of current and forthcoming biologics.
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Affiliation(s)
- Jeremy Charriot
- Department of Respiratory Diseases, Univ Montpellier, CHU Montpellier, Montpellier, France
- University of Montpellier, PhyMedExp, INSERM, CNRS UMR, CHRU Montpellier, Montpellier France
| | - Milka Maravic
- Rheumatology, Hôpital Lariboisière, APHP, Paris, France
- Real World Solutions, IQVIA, La Défense, France
| | | | - Isabelle Vachier
- Department of Respiratory Diseases, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Carey Suehs
- Department of Respiratory Diseases, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Arnaud Bourdin
- Department of Respiratory Diseases, Univ Montpellier, CHU Montpellier, Montpellier, France
- University of Montpellier, PhyMedExp, INSERM, CNRS UMR, CHRU Montpellier, Montpellier France
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29
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Mosnaim G, Safioti G, Brown R, DePietro M, Szefler SJ, Lang DM, Portnoy JM, Bukstein DA, Bacharier LB, Merchant RK. Digital Health Technology in Asthma: A Comprehensive Scoping Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2377-2398. [PMID: 33652136 DOI: 10.1016/j.jaip.2021.02.028] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND A variety of digital intervention approaches have been investigated for asthma therapy during the past decade, with different levels of interactivity and personalization and a range of impacts on different outcome measurements. OBJECTIVE To assess the effectiveness of digital interventions in asthma with regard to acceptability and outcomes and evaluate the potential of digital initiatives for monitoring or treating patients with asthma. METHODS We evaluated digital interventions using a scoping review methodology through a literature search and review. Of 871 articles identified, 121 were evaluated to explore intervention characteristics, the perception and acceptability of digital interventions to patients and physicians, and effects on asthma outcomes. Interventions were categorized by their level of interactivity with the patient. RESULTS Interventions featuring non-individualized content sent to patients appeared capable of promoting improved adherence to inhaled corticosteroids, but with no identified improvement in asthma burden; and data-gathering interventions appeared to have little effect on adherence or asthma burden. Evidence of improvement in both adherence and patients' impairment due to asthma were seen only with interactive interventions involving two-way responsive patient communication. Digital interventions were generally positively perceived by patients and physicians. Implementation was considered feasible, with certain preferences for design and features important to drive use. CONCLUSIONS Digital health interventions show substantial promise for asthma disease monitoring and personalization of treatment. To be successful, future interventions will need to include both inhaler device and software elements, combining accurate measurement of clinical parameters with careful consideration of ease of use, personalization, and patient engagement aspects.
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Affiliation(s)
- Giselle Mosnaim
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, North Shore University Health System, Evanston, Ill
| | | | - Randall Brown
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pa
| | - Michael DePietro
- Teva Branded Pharmaceutical Products R&D, Inc, West Chester, Pa.
| | - Stanley J Szefler
- The Breathing Institute and Pulmonary Medicine Section, Children's Hospital Colorado and University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jay M Portnoy
- Pediatric Allergy and Immunology, Children's Mercy Hospital, Kansas City School of Medicine, Kansas City, Mo
| | - Don A Bukstein
- Allergy, Asthma and Sinus Center, Milwaukee, Greenfield, Wis
| | - Leonard B Bacharier
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt University Medical Center, Nashville, Tenn
| | - Rajan K Merchant
- Woodland Clinic Medical Group, Allergy Department, Dignity Health, Woodland, Calif
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30
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Chelabi K, Balli F, Bransi M, Gervais Y, Marthe C, Tse SM. Validation of a Portable Game Controller to Assess Peak Expiratory Flow Against Conventional Spirometry in Children: Cross-sectional Study. JMIR Serious Games 2021; 9:e25052. [PMID: 33512326 PMCID: PMC7880812 DOI: 10.2196/25052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/19/2020] [Accepted: 12/23/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND International asthma guidelines recommend the monitoring of peak expiratory flow (PEF) as part of asthma self-management in children and adolescents who poorly perceive airflow obstruction, those with a history of severe exacerbations, or those who have difficulty controlling asthma. Measured with a peak flow meter, PEF represents a person's maximum speed of expiration and helps individuals to follow their disease evolution and, ultimately, to prevent asthma exacerbations. However, patient adherence to regular peak flow meter use is poor, particularly in pediatric populations. To address this, we developed an interactive tablet-based game with a portable game controller that can transduce a signal from the user's breath to generate a PEF value. OBJECTIVE The purpose of this study was to evaluate the concordance between PEF values obtained with the game controller and various measures derived from conventional pulmonary function tests (ie, spirometry) and to synthesize the participants' feedback. METHODS In this cross-sectional multicenter study, 158 children (aged 8-15 years old) with a diagnosis or suspicion of asthma performed spirometry and played the game in one of two hospital university centers. We evaluated the correlation between PEF measured by both the game controller and spirometry, forced expiratory volume at 1 second (FEV1), and forced expiratory flow at 25%-75% of pulmonary volume (FEF25-75), using Spearman correlation. A Bland-Altman plot was generated for comparison of PEF measured by the game controller against PEF measured by spirometry. A post-game user feedback questionnaire was administered and analyzed. RESULTS The participants had a mean age of 10.9 (SD 2.5) years, 44% (71/158) were female, and 88% (139/158) were White. On average, the pulmonary function of the participants was normal, including FEV1, PEF, and FEV1/forced vital capacity (FVC). The PEF measured by the game controller was reproducible in 96.2% (152/158) of participants according to standardized criteria. The PEF measured by the game controller presented a good correlation with PEF measured by spirometry (r=0.83, P<.001), with FEV1 (r=0.74, P<.001), and with FEF25-75 (r=0.65, P<.001). The PEF measured by the game controller presented an expected mean bias of -36.4 L/min as compared to PEF measured by spirometry. The participants' feedback was strongly positive, with 78.3% (123/157) reporting they would use the game if they had it at home. CONCLUSIONS The game controller we developed is an interactive tool appreciated by children with asthma, and the PEF values measured by the game controller are reproducible, with a good correlation to values measured by conventional spirometry. Future studies are necessary to evaluate the clinical impact this novel tool might have on asthma management and its potential use in an out-of-hospital setting.
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Affiliation(s)
| | - Fabio Balli
- Breathing Games Association, Geneva, Switzerland.,Milieux Institute, Concordia University, Montreal, QC, Canada
| | - Myriam Bransi
- Faculty of Medicine, Laval University, Quebec, QC, Canada.,Department of Pediatrics, Centre mère-enfant Soleil du CHU de Québec, Quebec, QC, Canada
| | | | | | - Sze Man Tse
- Division of Respiratory Medicine, Department of Pediatrics, Sainte-Justine University Hospital Center, Montreal, QC, Canada.,Faculty of Medicine, University of Montreal, Montreal, QC, Canada
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31
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Bowman AF, Copeland DJ, Miller KS. Asthma Health Policies in Schools: Implications for Nurse Practitioners. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Ödling M, Jonsson M, Janson C, Melén E, Bergström A, Kull I. Lost in the transition from pediatric to adult healthcare? Experiences of young adults with severe asthma. J Asthma 2019; 57:1119-1127. [PMID: 31328590 DOI: 10.1080/02770903.2019.1640726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objective: Asthma is a multifaceted disease, and severe asthma is likely to be persistent. Patients with severe asthma have the greatest burden and require more healthcare resources than those with mild-to-moderate asthma. The majority with asthma can be managed in primary care, while some patients with severe asthma warrant referral for expert advice regarding management. In adolescence, this involves a transition from pediatric to adult healthcare. This study aimed to explore how young adults with severe asthma experienced the transition process.Methods: Young adults with severe asthma were recruited from an ongoing Swedish population-based cohort. Qualitative data were obtained through individual interviews (n = 16, mean age 23.4 years), and the transcribed data were analyzed with systematic text condensation.Results: Four categories emerged based on the young adults' experiences: "I have to take responsibility", "A need of being involved", "Feeling left out of the system", and "Lack of engagement". The young adults felt they had to take more responsibility, did not know where to turn, and experienced fewer follow-ups in adult healthcare. Further, they wanted healthcare providers to involve them in self-management during adolescence, and in general, they felt that their asthma received insufficient support from healthcare providers.Conclusions: Based on how the young adults with severe asthma experienced the transition from pediatric to adult healthcare, it is suggested that healthcare providers together with each patient prepare, plan, and communicate in the transition process for continued care in line with transition guidelines.
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Affiliation(s)
- Maria Ödling
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Marina Jonsson
- Centre for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Erik Melén
- Institute of Environmental Medicine, Karolinska Institutet, Solna, Sweden.,Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Anna Bergström
- Centre for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Solna, Sweden
| | - Inger Kull
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm, Sweden
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