The Breathmobile Program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program

Increasing Access to Medical Care for Hispanic Women Without Insurance: A Mobile Clinic Approach

The purpose of this study was to describe the health status and barriers of people who sought care on a free mobile health clinic for women without insurance in California. Participants were 221 women who attended the Salud para Mujeres (Women's Health) mobile medical clinic between 2019 and 2021. Medical chart abstractions provided data on sociodemographic factors, medical history, barriers to care, depressive symptoms, and dietary factors. Anthropometric measure, blood pressure, and biomarkers of cardiometabolic disease risk were also abstracted. Participants were young adult (29.1 [SD 9.3] years), Hispanic (97.6%), farm-working (62.2%) women from Mexico (87.0%). Prevalent barriers to accessing (non-mobile) medical care included high cost (74.5%), language (47.6%), hours of operation (36.2%), and transportation (31.4%). The majority (89.5%) of patients had overweight (34.0%) or obesity (55.5%), and 27% had hypertension. Among those (n = 127) receiving a lipid panel, 60.3% had higher than recommended levels of low-density lipoprotein and 89% had lower than recommended levels of high-density lipoprotein. Point-of-care HbA1c tests (n = 133) indicated that 9.0% had diabetes and 24.8% had prediabetes. Over half (53.1%) of patients reported prevalent occupational exposure to pesticides and 19% had moderate to severe depressive symptoms. Weekly or more frequent consumption of sugar sweetened beverages (70.9%) and fast food (43.5%) were also prevalent. Mobile health units have potential for reaching women who face several barriers to care and experience major risk factors for cardometabolic disease. Findings suggest a compelling need to assure that Hispanic and Indigenous women and farmworkers have access to healthcare.

Parent Perceptions of a Validated Asthma Questionnaire in the Emergency Department

OBJECTIVE

While a number asthma questionnaires have been validated, most have not been used in an emergency department (ED) setting, nor evaluated patient feedback or clinical benefit. We sought to evaluate parent feedback on an asthma questionnaire used in an ED setting.

METHODS

We recruited parents of children 2-17 years old presenting to a tertiary pediatric ED for asthma care. Parents first completed then rated the Pediatric Asthma Control and Communication Instrument (PACCI-ED).

RESULTS

One hundred seventy-four parents (84%) completed surveys. Approximately two-thirds were Latinx, and 82% completed high school. Ninety-three percent of children had uncontrolled asthma. Parents endorsed the PACCI-ED: as easy to answer (94%); useful in understanding their child's asthma (83%); used the right words to describe their child's condition (95%); and would help the ED physician (93%) and primary care provider (PCP) (89%) better understand their child's asthma. Eleven percent reported that the PACCI-ED interfered with ED care. Parents with lower health literacy were more likely to agree the PACCI-ED asked more complete questions about their child's asthma than the ED physician (64% vs 45%, P = .02). Parents of children with uncontrolled asthma were more likely to agree that the PACCI-ED should become part of regular ED care (88% vs 62%, P = .02). Parents were more likely to agree that the PACCI-ED would help their PCP understand their child's asthma if they had a lower income (92% vs 50%, P < .001), less education (100% vs 88%, P = .004), were Latinx (94% vs 83%, P = .006), or were not using controller medication (93% vs 83%, P = .03).

CONCLUSIONS

Parents endorse an asthma questionnaire as valuable during an ED encounter. Because it is endorsed to be valuable to parents, this questionnaire could be used to facilitate patient-centered asthma care.

Improved asthma outcomes among at-risk children in a pharmacist-led, interdisciplinary school-based health clinic: A pilot study of the CAReS program

BACKGROUND

Disparities in access to care and outcomes have been identified among children with asthma living in underserved communities. The Caring for Asthma in our Region's Schoolchildren program was established to reduce disparities by providing school-based, comprehensive asthma care by a pharmacist-led, interdisciplinary team to high-risk pediatric populations in the Greater Pittsburgh area.

OBJECTIVE

To investigate program impact on follow-up appointment attendance, delivery of guideline-based care, asthma control, asthma morbidity (emergency department [ED] visits, oral corticosteroid [OCS] requirement), and asthma-related knowledge and quality of life.

METHODS

The study enrolled 50 children with asthma from 6 elementary schools (September 2014-December 2017). Children completed 5 visits over a 3-month period. McNemar's test assessed improvement in guideline-based controller therapy use and reduced morbidity (ED visits or OCS requirement). Generalized estimating equation analyses determined the significance of monthly improvements in asthma control, asthma knowledge, and quality of life.

RESULTS

A 100% show rate was achieved in nearly all participants (92.0%). Most of the patients were African-American (56%). In children with persistent disease, only 21.4% were prescribed controller therapy at baseline, which improved to 78.5% upon enrollment (P < 0.05). Asthma control statistically significantly improved (P < 0.05), and a reduction in percentage of patients who required an ED visit or an OCS burst pre-to postintervention was also statistically significant (31.3% vs. 14.6%, P < 0.05). The goal of 100% treatment plan knowledge was achieved in 67% of caregivers within 1 month and increased from 6% to 60% in children over 3 months (P < 0.05). Asthma-related quality of life also improved statistically significantly pre-to postintervention (P < 0.05).

CONCLUSIONS

Disparities in asthma outcomes owing to inadequate access to health care can be addressed. Improved asthma control, asthma medication knowledge, quality of life, and reduced morbidity in high-risk pediatric patients are achievable as demonstrated by our study. Our findings support the feasibility and value of a pharmacist-led, interdisciplinary school-based health care delivery model in providing comprehensive asthma care to at-risk pediatric populations.

Using mobile clinics to deliver care to difficult-to-reach populations: A COVID-19 practice we should keep

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During COVID-19, pediatric preventive care visits and vaccination rates declined.

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In response, two Boston community health centers implemented mobile health clinics.

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The clinics served 50 children, gave 146 shots, and had high patient satisfaction.

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This program reached families who were hesitant to attend traditional clinic visits.

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Mobile clinics are a valuable way to deliver primary care to hard-to-reach patients.

In the United States, mobile health clinics are an important method for delivering care to medically underserved populations. Mobile clinics have long been used in pediatric primary care, but there is little published to help pediatricians disseminate this practice more widely. During the COVID-19 pandemic, reduced in-person medical visits and subsequent declines in routine pediatric vaccination rates highlighted the importance of using a variety of care delivery models to reach patients. To improve vaccination coverage among young children in Boston during summer 2020, Mattapan Community Health Center and Codman Square Health Center deployed mobile clinics as an adjunct to their in-person preventive pediatric clinical services. In total, the health centers completed 17 mobile clinic sessions and served 50 unique patients, 77% of whom were African-American/Black and 75% of whom were under the age of two. A total of 146 vaccine injections were administered. A quality improvement survey of participating families demonstrated high levels of patient satisfaction and a high likelihood of using mobile services again in the future. The mobile clinic model was most valuable in reaching families who avoided in-person care due to COVID-19 transmission concerns or faced barriers to in-person care. The health centers fostered trust and demonstrated cultural competency during this novel initiative by leveraging established patient-provider relationships, using interpreters, and involving staff who reflected the diversity of the communities. Although there are challenges to implementing mobile health clinics, this initiative demonstrates the value of mobile clinics in delivering high quality pediatric preventive care to difficult-to-reach populations.

Persistent airflow obstruction in inner-city children with asthma

Background: Airway remodeling has been shown to be persistent in patients with asthma despite treatment with controller medications. Patients with early airflow obstruction may continue to experience poor lung function despite treatment. Objectives: To determine whether early airflow obstruction in inner-city children with asthma persists despite guideline-based asthma care. Methods: In a retrospective study that used a cohort of inner-city children with asthma treated by using an asthma-specific disease management system, the patients were stratified into "low" or "high" lung function groups at the time of the initial visit (high, forced expiratory volume in the first second of expiration [FEV₁] % predicted and FEV₁/forced vital capacity [FVC] ≥ 80%; and low, FEV₁% predicted and FEV₁/FVC < 80%). These patients then received National Heart, Lung, and Blood Institute guideline-based asthma treatment at regular follow-up intervals with spirometry performed at these visits as part of regular care. FEV₁% predicted and FEV₁/FVC were followed up for up to 10 years for both the high and low cohorts. Results: Over 10 years, the patients initially in the "high" group maintained FEV₁% predicted and FEV₁/FVC at values similar to the initial visit (94 to 96% and 87 to 89%, respectively), whereas those in the low group had only slight increases of FEV₁% predicted and FEV₁/FVC over the same time (77 to 82% and 78 to 82%, respectively). Low FEV₁% predicted and FEV₁/FVC at the time of the first visit was significantly associated with an increased risk of low values of these lung functions over the next 3-5 years despite treatment. African American ethnicity and male gender were also associated with lower lung function over time. Conclusion: Early airflow obstruction in inner city children asthma is associated with poor lung function in later life despite guideline-based asthma care. Current asthma therapy may not affect pathways and leads to airway remodeling in children with asthma.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Inhaled corticosteroid beliefs, complementary and alternative medicine in children presenting to the emergency department for asthma

OBJECTIVE

Negative beliefs about inhaled corticosteroids (ICS) and endorsement of complementary and alternative medicine (CAM) have been associated with medication non-adherence and uncontrolled asthma. The association of CAM and negative health beliefs is not described in children in acute care settings. Our study objective is to determine the relationship between negative ICS beliefs, CAM use and poorly controlled asthma among a predominantly Latino population in an acute care setting.

METHODS

The study was conducted in the pediatric emergency department of a children's hospital. During an ED asthma encounter, validated questionnaires surveyed parents about negative ICS beliefs, CAM use, and asthma health and control. We compared asthma health reports between parents who did or did not endorse negative ICS beliefs or CAM use, by chi-squared test (or a Fisher's exact test where appropriate).

RESULTS

Parents of 174 children identified mostly as Latino with Medicaid insurance and high asthma morbidity. CAM endorsement and negative ICS beliefs were both associated with increased use of lifetime glucocorticoid (p = 0.03 and p=0.01 respectively). While CAM endorsement was associated with less hospitalizations (p = 0.04) and parental report of asthma "getting better" (p = 0.01), CAM users reported trouble with paying for rent or food (p = 0.02). Negative ICS beliefs and CAM endorsement were not associated with medication adherence.

CONCLUSIONS

Negative ICS beliefs are associated with higher number of oral glucocorticoid courses. The association between CAM endorsement and asthma control is varied, but mostly in favor of improved control. Financial difficulties may make CAM use more likely.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Update in Pediatric Asthma: Selected Issues

Asthma is a complex condition that affects 14% of the world's children and the approach to management includes both pharmacologic as well as non-pharmacologic strategies including attention to complex socioeconomic status phenomena. After an historical consideration of asthma, allergic and immunologic aspects of asthma in children and adolescents are presented. Concepts of socioeconomic aspects of asthma are considered along with environmental features and complications of asthma disparities. Also reviewed are links of asthma with mental health disorders, sleep disturbances and other comorbidities. A stepwise approach to asthma management is discussed that includes pharmacologic and non-pharmacologic strategies in the pediatric population. The role of immunotherapy and use of various immunomodulators are considered as well.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Asthma specialist care preferences among parents of children receiving emergency department care for asthma

Objective: To learn factors associated with desire for asthma specialist care among parents of children seeking emergency department (ED) care for asthma, and if referral was indicated based on national asthma guidelines. Methods: We surveyed parents of children ages 0-18 years seeking pediatric ED asthma care, then comparisons were made according to parental level of interest in asthma specialist care, with regard to socio-demographics, asthma morbidity and care, by chi-squared and logistic regression. Results: Of 149 children, 20% reported specialist care, but 75% met guideline criteria for referral. About 80% of parents not seeing an asthma specialist expressed a desire to see one. Higher rates of prior urgent care visits (48% vs. 22%, p = 0.03), ED visits (82% vs. 35%, p < 0.001) and oral steroid use (53% vs. 22%, p = 0.009) were reported by parents who desired an asthma specialist compared with parents who did not. 87% of parents not seeing a specialist attributed this to a perceived lack of necessity by their primary care provider. An ED visit within the prior 12 months was the most significant predictor in parental desire for specialist care (odds ratio 9.75; 95% CI 3.42-27.76) in adjusted logistic regression models. Conclusion: High rates of parental preference for asthma specialist care suggest that directly querying parents may be an efficient method to identify children appropriate for specialist care in the ED.

Can asthma be well controlled with NAEPP guideline care in morbidly obese children? The Breathmobile

BACKGROUND

Obesity is thought to be associated with poor asthma control, increased health resource utilization, and reduced responsiveness to inhaled corticosteroids.

OBJECTIVE

Based on previous experience, our hypothesis was that by improved access to comprehensive guideline care, outcomes in normal weight would be comparable in obese children with asthma.

METHODS

This was a retrospective cohort study of predominately Hispanic children (3-18 years of age) in underserved areas of Orange County, California, who enrolled in the Breathmobile Program from 2003 to 2012. Outcomes were examined by using Cox regression and generalized estimating equations analyses, adjusted for potential confounding factors.

RESULTS

Clinical outcomes in more than 1,200 children followed up for a mean of 6 visits (standard deviation [SD] = 2.2) across 403 days (SD = 112) were improved, on average, regardless of body mass index (BMI). Morbidly obese (MOB) patients were able to achieve significant reductions of approximately 60% or more in report of emergency department (ED) visits, hospitalizations, school absenteeism, usual exercise limitations, and exacerbations to levels that were comparable those of normal weight (NW) patients. The importance of close follow-up, particularly for the MOB patient, was evidenced by achieving 80% cumulative probability of well controlled asthma by visit 3, similar to patients in lower BMI risk groups with good adherence, when the visit interval did not exceed 90 days. These outcomes were achieved across all BMI groups with similar mean step of therapy, adjusted for severity (P < .001).

CONCLUSION

Access to effective community-based care where trust, education, and continuity of care consistent with National Asthma Education and Prevention Program (NAEPP) guidelines is possible, as demonstrated by the Breathmobile Program, can provide an opportunity for children with asthma in all BMI categories to achieve well-controlled disease.

Predictors of prior asthma specialist care among pediatric patients seen in the emergency department for asthma

Background: Asthma guidelines recommend specialist care for patients experiencing poor asthma outcomes during emergency department (ED) visits. The prevalence and predictors of asthma specialist care among an ED population seeking pediatric asthma care are unknown. Objective: To examine, in an ED population, factors associated with prior asthma specialist use based on parental reports of prior asthma morbidity and asthma care. Methods: Parents of children ages 0 to 17 years seeking ED asthma care were surveyed regarding socio-demographics, asthma morbidity, asthma management and current asthma specialist care status. We compared prior asthma care and morbidity between those currently cared for by an asthma specialist versus not. Multivariable logistic regression models to predict factors associated with asthma specialist use were adjusted for parent education and insurance type. Results: Of 150 children (62% boys, mean age 4.7 years, 69% Hispanic), 22% reported asthma specialist care, 75% did not see a specialist and for 3% specialist status was unknown. Care was worse for those not seeing a specialist, including under-use of controller medications (24% vs. 64%, p < 0.001) and asthma action plans (20% vs. 62%, p < 0.001). Multivariable logistic regression revealed that lack of recommendation by the primary care physician reduced the odds of specialist care (OR 0.01, 95% CI <0.01, 0.05, p < 0.001). Conclusions: Asthma specialist care was infrequent among this pediatric ED population, consistent with the sub-optimal chronic asthma care we observed. Prospective trials should further investigate if systematic referral to asthma specialists during/after an ED encounter would improve asthma outcomes.

Developing, Implementing, and Evaluating a School-Centered Asthma Program: Step-Up Asthma Program

BACKGROUND

Asthma is a significant health problem among children: 9.3% of children in the United States suffer from asthma. Children with persistent asthma in inner cities have increased health care utilization, worse health care outcomes, increased school absences, and worse academic performance.

OBJECTIVE

We sought to create and evaluate a school-centered asthma program to reduce asthma morbidity and create asthma-friendly schools.

METHODS

We developed, implemented, and evaluated the Step-Up Asthma Program, a multidisciplinary school-centered asthma program. The program was designed as an outreach program with asthma counselors as a bridge between subspecialty asthma care, primary care providers, school nurses, and children with asthma. The core components of the program involve identifying children with asthma, providing evidence-based asthma education, and case management. Students' asthma knowledge, inhaler technique, and number of asthma exacerbations were evaluated over a 2-year period (2010-2012) as a pre-post study.

RESULTS

A total of 252 students enrolled in the Step-Up Asthma Program over a 2-year period. Significant improvements were noted in number of asthma action plans, rescue medications at school, and asthma controllers. Program participants had significant improvements in asthma knowledge scores (P < .001) and inhaler technique (P < .0001). There were significant reductions in asthma exacerbations defined as oral steroid courses, urgent care visits, and missed school days (P < .05) that persisted over time.

CONCLUSIONS

A guideline-based school-centered asthma program can significantly reduce asthma morbidity. The asthma counselor is the cornerstone of the program, providing asthma education and care coordination. The Step-Up Asthma Program is in its 10th year, and we believe the key elements of this program can be implemented in other school systems.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Establishing school-centered asthma programs

Asthma is a common chronic childhood disease associated with significant morbidity and high rates of school absenteeism, along with excessive costs for the patient and society. Asthma is a leading cause of school absenteeism, but this absenteeism is not equally distributed among those with asthma. Second to their home, school-aged children spend the largest portion of their wakeful hours at school. Opportunities exist to partner with schools to reach most children with asthma and those at the highest risk for asthma burden and in need of assistance. Asthma management at schools is important for pediatric pulmonologists and allergists, primary care providers, and the whole interdisciplinary team working alongside them to provide quality asthma care. The variability of asthma care services and programs provided in schools should prompt clinicians to understand their own school system and to advocate for appropriate services. Models of asthma care that place schools at the center or core of the model and coordinate evidence-based asthma care are applicable nationwide and might serve as a model for managing other chronic illnesses.

Effectiveness of a promotora home visitation program for underserved Hispanic children with asthma

OBJECTIVE

Retention in a mobile asthma clinic, the Breathmobile™, of ≥3 visits has previously been shown to be essential for attaining asthma control in underserved children. The objective of this study in primarily Hispanic-American children was to determine the difference in retention between those seen in the Breathmobile™ compared to those receiving an additional promotora-based home visit (HV).

METHODS

Children with asthma in the Breathmobile™ program were evaluated for asthma status and aeroallergen sensitivity. Indication for HV included poor asthma control, educational and environmental control needs. An initial visit consisted of environmental assessment as well as a 3-h interactive educational session covering asthma basics. A follow-up visit 1 month later assessed implementation. The primary outcome measure of retention was ≥6 months in the Breathmobile™ program.

RESULTS

Of the 1007 asthmatic children seen between April 2002 and June of 2005, 136 received HV. These children showed significantly greater retention compared to those without HV with a median number of visits (5 visits versus 2 visits), ≥3 Breathmobile™ visits (86.0% versus 38.8%), median number of days in the program (299 versus 63 days) and percentage of patients in the program ≥6 months (67.8% versus 31.3%) p < 0.001. HV and asthma severity were each independent predictors of retention.

CONCLUSIONS

The addition of a promotora HV program proved effective in providing greater retention in the Breathmobile™ program essential for asthma control. Randomized clinical trials will be needed to show the impact on health care utilization and asthma control.

The bronchodilator response as a predictor of inhaled corticosteroid responsiveness in asthmatic children with normal baseline spirometry

RATIONALE

Although inhaled corticosteroids (ICS) are considered first line controller therapy in children with persistent asthma, heterogeneity of the ICS response can be an important clinical problem. The purpose of this study is to determine the value of the bronchodilator response (BDR) in identifying the ICS responder and establish the optimal BDR cut-point that could be particularly useful in the clinic setting when baseline spirometry is normal.

METHODS

Mexican American asthmatic children, 5-18 years, with normal baseline spirometry who required low dose (step 2), or medium dose (step 3) ICS therapy were evaluated by skin prick test for atopy, and pre- and post-bronchodilator spirometry. ICS responders were defined by a ≥7.5% improvement in the FEV1 following 4-6 weeks of therapy. The optimal cut-point was determined by Receiver Operator Characteristic (ROC) curves as the best balance between sensitivity and specificity.

RESULTS

There were 34.8% of the 132 study patients who were ICS responders. ROC curves showed the BDR ≥10% to be an optimal cut-point with sensitivity 46%, specificity 76%, positive predictive value (PPV) 50%, and negative predictive value (NPV) 72%. Atopic females with a BDR ≥10% had a PPV of 73%.

CONCLUSIONS

The composite phenotype of female gender, atopic, and the BDR of ≥10% identified 73% as ICS responders compared to 50% in our overall population with a BDR of ≥10% alone, with minimal false positives. We suggest that the BDR in conjunction with gender and atopic status be considered as potentially useful predictors of the ICS responder, particularly when baseline spirometry is normal.

Mobile health care operations and return on investment in predominantly underserved children with asthma: the breathmobile program

Underserved populations have limited access to care. Improved access to effective asthma care potentially improves quality of life and reduces costs associated with emergency department (ED) visits. The purpose of this study is to examine return on investment (ROI) for the Breathmobile Program in terms of improved patient quality-adjusted life years saved and reduced costs attributed to preventable ED visits for 2010, with extrapolation to previous years of operation. It also examines cost-benefit related to reduced morbidity (ED visits, hospitalizations, and school absenteeism) for new patients to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits). This is a retrospective analysis of data for 15,986 pediatric patients, covering 88,865 visits, participating in 4 Southern California Breathmobile Programs (November 16, 1995-December 31, 2010). The ROI calculation expressed the cost-benefit ratio as the net benefits (ED costs avoided+relative value of quality-adjusted life years saved) over the per annum program costs (∼$500,000 per mobile). The ROI across the 4 California programs in 2010 was $6.73 per dollar invested. Annual estimated emergency costs avoided in the 4 regions were $2,541,639. The relative value of quality-adjusted life years saved was $24,381,000. For patients new to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits), total annual morbidity costs avoided per patient were $1395. This study suggests that mobile health care is a cost-effective strategy to deliver medical care to underserved populations, consistent with the Triple Aims of Therapy.

The relationship of aeroallergen sensitization phenotypes to asthma control in primarily Hispanic asthmatic children

OBJECTIVE

The purpose of this study was to determine whether aeroallergen sensitization phenotypes could predict maintenance of well-controlled asthma.

METHODS

Asthmatic children age 2-18 years who enrolled in the CHOC Children's Breathmobile™ program from April 2002 to December 2011 were included in this retrospective analysis if they had been skin tested to a panel of indoor and outdoor aeroallergens and had returned for follow-up care within 6 months of their baseline visit. The study observation period encompassed all year one visits. Asthma severity and control were defined by NHLBI EPR-3 Guidelines criteria.

RESULTS

In the 1627 primarily Hispanic children evaluated, those with persistent asthma were more likely than those with intermittent disease to be sensitized to each aeroallergen tested and to have more total sensitizations. Children with intermittent, but not persistent, asthma at baseline who were sensitized to pollen2 (trees or weeds) were less likely to maintain well-controlled asthma at follow-up visits. Whereas, sensitization to dander (cat, dog or feather) showed a protective effect to maintenance of well-controlled asthma in patients with persistent, but not intermittent, baseline disease severity.

CONCLUSIONS

Our data suggest that both indoor and outdoor aeroallergens should be assessed regardless of baseline asthma severity, including those with intermittent asthma.

Challenges in providing preventive care to inner-city children with asthma

Although the scientific understanding of the pathophysiology of asthma and the quality of asthma therapies have significantly improved over the past 30 years, asthma morbidity remains high and preventive care low for inner-city children. This article focuses on 4 major challenges to providing preventive care (family and patient attitudes and beliefs, lack of access to quality medical care, psychosocial factors, environmental factors) based on prior evidence and the authors' observation of these challenges in research with inner-city children with asthma over the past decade. Cost issues related to preventive care are addressed, and recommendations provide for pediatric nurses.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship of the bronchodilator response phenotype to poor asthma control in children with normal spirometry

OBJECTIVE

To determine the relationship of poor asthma control to bronchodilator response (BDR) phenotypes in children with normal spirometry.

STUDY DESIGN

Children with asthma were assessed for clinical indexes of poorly controlled asthma. Pre- and post-bronchodilator spirometry were performed, and the percent BDR was determined. Multivariate logistic regression assessed the relationship of the clinical indices to BDR at ≥ 8%, ≥ 10%, and ≥ 12% BDR thresholds.

RESULTS

There were 510 controller naïve children and 169 on controller medication. In the controller naïve population the mean age (± 1 SD) was 9.5 (3.4); 57.1% were male, 85.7% Hispanic. Demographics were similar in both populations. In the adjusted profile, significant clinical relationships were found particularly to positive BDR phenotypes ≥ 10% and ≥ 12% versus negative responses including younger age, (OR 2.0, 2.5; P < .05), atopy (OR 1.9, 2.6; P < .01), nocturnal symptoms in females (OR 3.4, 3.8; P < .01); β₂ agonist use (OR 1.7, 2.8; P < .01); and exercise limitation (OR 2.2, 2.5; P < .01) only in the controller naïve population.

CONCLUSIONS

The BDR phenotype ≥ 10% is significantly related to poor asthma control, providing a potentially useful objective tool in controller naïve children even when the pre-bronchodilator spirometry result is normal.

Achieving and maintaining asthma control in inner-city children

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Breathmobile program: a good investment for underserved children with asthma

BACKGROUND

The Breathmobile, a specialty-based mobile asthma clinic, provides free care to underserved children. The cost of symptom-free day (SFD) improvement in this population has not been previously reported.

OBJECTIVE

To examine the clinical impact and cost-effectiveness of the Baltimore Breathmobile.

METHODS

Existing computerized data were analyzed for Breathmobile patient visits between 2002 and 2007. All SFDs were calculated, and direct medical cost savings attributable to decreased emergency department visits and hospitalizations (after program utilization vs the previous year) were compared with annual operating costs. Incremental cost-effectiveness ratios were determined by calculating the incremental costs of Breathmobile care per additional SFD gained per child per year.

RESULTS

The analysis included 255 patients enrolled in the program for at least 1 year. Most participants were black (93.3%), and 54.9% were male. At baseline, patients reported a mean (SD) of 199 (118) SFDs in the year before enrollment. After 1 year in the program, patients had a mean (SD) improvement of 44 (9) SFDs. The program resulted in overall cost savings of $79.43 per SFD gained, with greater cost savings for children aged 5 to 11 years (-$116.84 per SFD gained) and those with intermittent asthma (-$126.71 per SFD gained).

CONCLUSIONS

The Baltimore Breathmobile program has demonstrated significant improvement in SFDs, with direct medical cost savings of the program outweighing the operational costs. These data support the need to continue to sustain and expand Breathmobile programs for children at high risk for asthma exacerbations and to conduct a randomized clinical trial to estimate the cost-effectiveness of the Breathmobile.

Using information technology to reduce asthma disparities in underserved populations: a pilot study

BACKGROUND

Low health literacy has been identified as an independent predictor of poor asthma control. The Institute of Medicine considers the role of information technology (IT) as critical in providing "safe, effective, patient centered, timely, efficient, and equitable" care with the potential to reduce health disparities in underserved populations. The aim of this study was to design and evaluate an interactive computer-based questionnaire to assess asthma symptoms in children of parents with limited health literacy and/or limited English proficiency.

METHODS

Volunteer caregivers attending a mobile asthma clinic were randomly assigned to complete the electronic or the paper-and-pencil version of an asthma screening questionnaire (ASQ) in their language of choice (English or Spanish). In the electronic version, a tablet computer was used to present the ASQ questions as video clips and to collect information through the touchscreen. Participants also completed a demographic questionnaire, a brief health literacy questionnaire, and a system usability and satisfaction questionnaire. Reliability of the paper and electronic self-assessments was evaluated by comparing each participant's answers to information they provided during a nurse-guided structured interview (gold standard).

RESULTS

A total of 48 parents participated in the study, 26 completed the electronic ASQ and 21 the paper-and-pencil form. Thirty-five percent of the children had well-controlled asthma (n = 17). Most participants were Spanish speaking (67%) Hispanic (n = 44) mothers (n = 43) with a median age of 32 years. More than half had ≤8 years of education (n = 25) and earned <$20,000 per year (n = 27). The median health literacy score was 32 (range 0-36). The correlation between health literacy scores and years of education was significant (ρ = .47, p < .01). Concordance between the electronic ASQ and the nurse interview was significantly higher than concordance between the paper ASQ and the nurse interview (68% versus 54%; p < .01). All parents who completed the electronic questionnaire reported being satisfied; 96% felt comfortable using it, and found it simple to use.

CONCLUSIONS

By facilitating the assessment of asthma symptoms at manageable cost, interactive information technology tools may help reduce barriers to access due to inadequate levels of English proficiency and health literacy.

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

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

Calculating the return on investment of mobile healthcare

BACKGROUND

Mobile health clinics provide an alternative portal into the healthcare system for the medically disenfranchised, that is, people who are underinsured, uninsured or who are otherwise outside of mainstream healthcare due to issues of trust, language, immigration status or simply location. Mobile health clinics as providers of last resort are an essential component of the healthcare safety net providing prevention, screening, and appropriate triage into mainstream services. Despite the face value of providing services to underserved populations, a focused analysis of the relative value of the mobile health clinic model has not been elucidated. The question that the return on investment algorithm has been designed to answer is: can the value of the services provided by mobile health programs be quantified in terms of quality adjusted life years saved and estimated emergency department expenditures avoided?

METHODS

Using a sample mobile health clinic and published research that quantifies health outcomes, we developed and tested an algorithm to calculate the return on investment of a typical broad-service mobile health clinic: the relative value of mobile health clinic services = annual projected emergency department costs avoided + value of potential life years saved from the services provided. Return on investment ratio = the relative value of the mobile health clinic services/annual cost to run the mobile health clinic.

RESULTS

Based on service data provided by The Family Van for 2008 we calculated the annual cost savings from preventing emergency room visits, $3,125,668 plus the relative value of providing 7 of the top 25 priority prevention services during the same period, US$17,780,000 for a total annual value of $20,339,968. Given that the annual cost to run the program was $567,700, the calculated return on investment of The Family Van was 36:1.

CONCLUSION

By using published data that quantify the value of prevention practices and the value of preventing unnecessary use of emergency departments, an empirical method was developed to determine the value of a typical mobile health clinic. The Family Van, a mobile health clinic that has been serving the medically disenfranchised of Boston for 16 years, was evaluated accordingly and found to have return on investment of $36 for every $1 invested in the program.

The impact of literacy enhancement on asthma-related outcomes among underserved children

STATEMENT OF PROBLEM

Despite the availability of improved healthcare access, self-management programs, disease management protocols, and advances in pharmacologic and immunotherapy therapy, the prevalence of asthma in the urban inner city remains one of the major health disparities in the United States. Additionally, sustainability of effective intervention programs after the funding has ended remains a significant issue for asthma programs.

OBJECTIVE

This study examines the effectiveness of a longitudinal intervention program that was designed with the assumption that improved literacy plays a role in improving asthma-related health outcomes among high-risk children with the most severe forms of asthma.

METHODS

A longitudinal intervention over 6 months prospectively addressed the literacy and asthma self-management skills of 110 minority children in South Los Angeles utilizing weekly Saturday-school format.

RESULTS

The results demonstrated that there was a statistically significant decrease in both hospitalization and emergency department (ED) visits during the intervention. In addition, all the children showed significant improvement in their reading level and self-efficacy. Multivariate logistic analysis demonstrated that enhanced self-efficacy was directly related to decreased hospitalizations and ED visits.

CONCLUSION

This intervention demonstrated that literacy enhancement is an important factor in improving self-efficacy and impacting asthma-related outcomes. Improved literacy is a sustainable factor that will not only improve asthma outcomes but will enhance the potential for educational success.

Health disparities in the United States: childhood asthma

During the last 3 decades, asthma prevalence and morbidity in the United States have dramatically increased. The impact of this chronic respiratory disease has been disproportionately high among inner city residents, particularly lower socioeconomic groups, ethnic minorities, and children. A wide variety of factors have been shown to have an influence-indeed, the asthma epidemic is a chronicle of the ways in which environmental, social, and economic factors superimposed on inadequate health care delivery systems can converge to influence health status and the course of a chronic disease. Effective intervention strategies for this controllable disease must circumvent existing societal barriers to care and provide a comprehensive, structured program that emphasizes asthma controller therapy, disease-specific education, and regular periodic assessment of asthma control, preferably in a convenient, familiar setting that promotes patient engagement.

Self-management strategies to reduce pain and improve function among older adults in community settings: a review of the evidence

CONTEXT

Self-management strategies for pain hold substantial promise as a means of reducing pain and improving function among older adults with chronic pain, but their use in this age group has not been well defined.

OBJECTIVE

To review the evidence regarding self-management interventions for pain due to musculoskeletal disorders among older adults.

DESIGN

We searched the Medline and Cumulative Index to Nursing and Allied Health Literature databases to identify relevant articles for review and analyzed English-language articles that presented outcome data on pain, function, and/or other relevant endpoints and evaluated programs/strategies that could be feasibly implemented in the community. Abstracted information included study sample characteristics, estimates of treatment effect, and other relevant outcomes when present.

RESULTS

Retained articles (N = 27) included those that evaluated programs sponsored by the Arthritis Foundation and other programs/strategies including yoga, massage therapy, Tai Chi, and music therapy. Positive outcomes were found in 96% of the studies. Proportionate change in pain scores ranged from an increase of 18% to a reduction of 85% (median = 23% reduction), whereas change in disability scores ranged from an increase of 2% to a reduction of 70% (median = 19% reduction). Generalizability issues identified included limited enrollment of ethnic minority elders, as well as non-ethnic elders aged 80 and above.

CONCLUSIONS

Our results suggest that a broad range of self-management programs may provide benefits for older adults with chronic pain. Research is needed to establish the efficacy of the programs in diverse age and ethnic groups of older adults and identify strategies that maximize program reach, retention, and methods to ensure continued use of the strategies over time.

Guidelines management of asthma in a busy urban practice

PURPOSE OF REVIEW

The purpose of this article is to review how optimal asthma management can be applied in a variety of clinical settings that are used to care for high-risk, urban asthma patients, especially those who live in the inner city, utilizing the 2007 National Heart, Lung, and Blood Institute/National Asthma Education Prevention Program 'Guidelines for the diagnosis and management of asthma', and adapting them to be applied in a variety of urban clinical settings, independent of practice infrastructure.

RECENT FINDINGS

Previous asthma guidelines stressed asthma severity classification. A renewed focus on asthma control has led to better asthma outcomes. Consequently, it was deemed necessary to establish a new asthma paradigm that characterizes both asthma severity and control within the context of current impairment and future risk. This new paradigm can be effectively applied to high-risk, inner-city asthma patients, while allowing for individualization of care within systems of varied healthcare delivery infrastructures.

SUMMARY

Assessment of asthma severity and control, with special emphasis on literacy and ethno-cultural beliefs and philosophies, will facilitate appropriate adaptations of long-term asthma management to provide optimal outcomes in urban asthmatics. It is essential to anticipate the worst-case, while planning for the best-case scenario.

One gets so afraid: Latino families and asthma management--an exploratory study

INTRODUCTION

This study explored Latino family experiences, issues, and needs in caring for a child with asthma as expressed by Latino parents of children with asthma.

METHODS

Eight families represented by 7 women and 2 men, primarily of Mexican descent, participated in the study. All families had at least one child enrolled in preschools in the East Los Angeles area. The study had an exploratory design and used ethnographic group and individual interview techniques to discover the parents' experiences in managing their child's asthma and the meaning asthma has for their families. All interviews were conducted in Spanish.

RESULTS

Several common themes emerged from the data: (a) fear, "I got scared"; (b) the acute care experience, "I was not told what to do, nothing"; (c) knowledge, "I did not know anything about asthma"; and (d) parent alternative strategies or strengths, "We want to do what is best. ... we need to be prepared."

DISCUSSION

Strength emerged from fear. The parents were resourceful and began developing alternative strategies to assist them in their care for their child with asthma. The findings emphasize the need for more opportunities for culturally sensitive asthma education and community health care resources such as mobile asthma treatment centers and promotora programs.

Applications of medical informatics in allergy/immunology

OBJECTIVE

To provide a general overview of informatics and its interface with allergy/immunology.

DATA SOURCES

The PubMed interface to MEDLINE was searched with the keywords asthma, allergy, or immunology together with the keywords informatics, bioinformatics, and information technology to retrieve the articles relevant to this review.

STUDY SELECTION

The authors' knowledge of the field was used to include sources of information other than those obtained through the MEDLINE search.

RESULTS

A survey of informatics, with emphasis on the relevance to allergy, asthma, and immunology, is presented.

CONCLUSIONS

Several innovative informatics approaches have significant potential to improve health care on diverse fronts. Newer methods of information representation are poised to facilitate the impact of cutting-edge research on clinical practice.

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

BACKGROUND

National guidelines suggest that, with appropriate care, most patients can control their asthma. The probabilities of children achieving and maintaining control with ongoing care are unknown.

OBJECTIVE

We sought to evaluate the degree to which children in a lower socioeconomic urban setting achieve and maintain control of asthma with regular participation in a disease management program that provides guideline-based care.

METHODS

Interdisciplinary teams of asthma specialists use mobile clinics to offer ongoing care at schools and county clinics. A guideline-derived construct of asthma control is recorded at each visit.

RESULTS

Two thousand one hundred eighty-five enrollees were eligible to evaluate the time to first achieve control, and 1591 patients were eligible to evaluate subsequent control maintenance. Depending on severity, 70% to 87% of patients with persistent asthma achieved control by visit 3, and 89% to 98% achieved control by visit 6. Subsequent control maintenance was highly variable. Thirty-nine percent of patients displayed well-controlled asthma (control at >90% of subsequent visits), whereas 13% displayed difficult-to-control asthma (<50% of subsequent visits). Patients from each baseline severity category were found in each group. Maintenance of control was influenced by physician-estimated compliance with the treatment plan, baseline severity, and the interval between clinic visits.

CONCLUSIONS

Many children can achieve asthma control with regular visit intervals and guideline-based care; however, long-term control can be highly variable among patients in all severity categories.

CLINICAL IMPLICATIONS

These findings highlight the need and feasibility for systematically tracking each patient's clinical response to individualize therapy and guide the use of population management strategies.

Validation of a single survey that can be used for case identification and assessment of asthma control: the Breathmobile Program

BACKGROUND

Underdiagnosis of asthma and underrecognition of disease severity in lower socioeconomic populations continue to be significant health care concerns despite national efforts to better educate health care providers.

OBJECTIVE

To validate a 1-page survey as a point-in-time tool identifying uncontrolled vs controlled asthma and moderate-to-severe disease activity in an urban, lower-socioeconomic pediatric population.

METHODS

A previously validated survey (the Breathmobile Case Identification Survey) was evaluated as a point-in-time tool for identifying children with poorly controlled disease. Clinical validation was achieved in children (n = 1,826) presenting to a school-based asthma program for either an initial (n = 666) or a follow-up (n = 1,170) visit. Responses were compared with a comprehensive evaluation by a physician specialist as the gold standard. Response patterns were used to construct multimodel tiered scoring algorithms for baseline and follow-up visits that identify children with uncontrolled asthma, and children are likely to have moderate-to-severe disease activity at that time.

RESULTS

Surveys scored using the developed algorithms identified children with uncontrolled asthma (sensitivity: baseline, 77.0%; follow-up, 71.6%; specificity: baseline, 72.7%; follow-up, 71.5%) and detected moderate-to-severe disease activity (sensitivity: baseline, 69.2%; follow-up, 77.4%; specificity: baseline, 70.2%; follow-up, 70.3%).

CONCLUSIONS

The Breathmobile Case Identification Survey can be used in lower-socioeconomic, urban populations as a point-in-time tool for identifying children with uncontrolled vs controlled asthma and moderate-to-severe disease activity.

Family processes in pediatric asthma

PURPOSE OF REVIEW

Family processes are best conceptualized within an integrated, dynamic biopsychosocial model of pediatric asthma. We reviewed the literature on specific family processes proposed to influence asthma outcomes, the mechanisms of influence, and family-focused interventions to improve asthma control.

RECENT FINDINGS

Family characteristics associated with asthma outcomes include caregiver psychological functioning, parenting, and whole-family processes. These characteristics influence asthma outcomes via asthma management behaviors and/or disease-related psychophysiologic pathways. Family-focused interventions designed to promote asthma control include psychoeducation and family therapy, although alternative models have also been proposed.

SUMMARY

Despite the increasing evidence that family processes contribute to asthma outcomes, few theory-based family interventions have been developed for children with asthma. Systemic consultation models and biobehavioral family interventions, in conjunction with pediatric care, appear to hold the most promise for helping families of children with poorly controlled asthma.