Components of recommended asthma care and the use of long-term control medication among urban children with asthma

Psychometric evaluation of the medication adherence report scale in caregivers of low-income, urban, African American children with poorly controlled asthma

OBJECTIVE

Accurately assessing asthma medication usage among low-income, urban, African American children is essential to reduce asthma health disparities. The purpose of this study was to examine the factor structure of the five-item Medication Adherence Report Scale (MARS), in a sample of caregivers of low-income, urban, African American youth with poorly controlled asthma.

METHOD

Using baseline data from a randomized clinical trial evaluating the efficacy of an environmental control educational intervention, confirmatory factor analysis (CFA) was conducted to ascertain the MARS factor structure. Construct validity was assessed using a regression model inclusive of caregiver-reported medication adherence, Asthma Medication Ratio (AMR), asthma control, and caregiver perception of asthma control as predictors of the MARS.

RESULTS

Caregivers were female (97%) and 27.4% had an annual income under $10,000. The mean MARS score was 21.88 ± 3.33 out of a possible range of 5-25, representing high adherence. Confirmatory factor analysis indicated that a five-item one-factor model marginally fit the data based on the fit indices: χ² (5) = 31.71, p < 0.001; RMSEA ≤ 0.161; CFI = 0.986; TLI = 0.971; and WRMR = 0.979. The MARS was associated with another caregiver-reported measure of medication adherence but not associated with AMR, asthma control, or caregiver perception of asthma control.

CONCLUSIONS

The MARS demonstrated marginal fit in CFA and may not be clinically indicated in light of the lack of associations with objective measures of asthma medication adherence and asthma control.

Home Medication Readiness for Preschool Children With Asthma

BACKGROUND

Having a medication available in the home is a prerequisite to medication adherence. Our objectives with this study are to assess asthma medication readiness among low-income urban minority preschool-aged children, and the association between beliefs about medications and medication readiness.

METHODS

During a baseline assessment, a research assistant visited the home to administer a caregiver survey and observe 5 criteria in the medication readiness index: the physical presence and expiration status of medications, the counter status of metered-dose inhalers, and caregiver knowledge of medication type and dosing instructions.

RESULTS

Of 288 enrolled children (mean age 4.2 years [SD: 0.7], 92% African American, 60% boys), 277 (96%) of their caregivers reported a rescue medication, but only 79% had it in the home, and only 60% met all 5 of the medication readiness criteria. Among the 161 children prescribed a controller medication, only 79% had it in the home, and only 49% met all 5 readiness criteria. Fewer worries and concerns about medications were associated with higher odds of meeting all 5 readiness criteria for controller medications.

CONCLUSIONS

Inadequate availability of asthma medications in the home is a barrier to adherence among low-income urban preschoolers. Assessment of medication readiness should be incorporated into clinical care because this is an underrecognized barrier to adherence, and interventions are needed to improve medication management and knowledge to increase adherence.

Risk factors hindering asthma symptom control in Saudi children and adolescents

BACKGROUND

Maintaining good control of asthma symptoms can help to prevent exacerbations and its associated complications. The Asthma Control Test (ACT) can rapidly assess the effectiveness of asthma management plan and therapy. The aim of this study was therefore to identify risk factors associated with uncontrolled asthma symptoms in young Saudi asthmatic children (3-17 years old).

METHODS

In this cross-sectional hospital-based survey, the ACT was administered to 297 asthmatic children/adolescents, recruited at the emergency department (ED) of two major hospitals.

RESULTS

Most recruited patients had intermittent (63.5%) and mild persistent (27.6%) asthma; few had moderate persistent (8.9%) and none had severe asthma. These patients visited the ED four times (3.9 ± 3.2), on average. Almost half of the patients stated that they had not received education about asthma (47%) or education about medication use (43%). Most patients (60.3%) had uncontrolled symptoms (ACT score ≤19), of whom the intermittent asthma patients had better scores than those with more severe symptoms. Children ≤6 years old, with symptoms diagnosed <5 years previously and who were not attending school, had significantly worse control than older patients. Poor medication compliance and inappropriate inhaler device use were ascribed to younger patients (<12 years old) and worse scores; particularly in relation to stopping inhaled corticosteroid therapy when their symptoms improve. Patients with poor control also stated that they had not received education about inhaler device use.

CONCLUSIONS

Most Saudi asthmatic children/adolescents visiting the ED had poor control of symptoms; indeed, none achieved complete control, which is related to deficient medication compliance and improper medication inhaler device use; deficient knowledge about asthma was also another factor hindering control.

How can adherence to asthma medication be enhanced? Triangulation of key asthma stakeholders' perspectives

BACKGROUND AND OBJECTIVES

Adherence to daily asthma controller medication has been shown to be the most effective component of asthma self-management; however, patient's adherence to asthma medication remains poor. This study aimed to understand how patients' long-term asthma controller medication adherence may be improved and facilitated by comparing key asthma stakeholders' perspectives.

METHOD

Six focus group interviews including 38 asthma stakeholders (n = 13 patients, n = 13 pulmonologist physicians, and n = 12 allied healthcare professionals) were conducted. Interviews were qualitatively analysed.

RESULTS

Although similar themes were brought up across different asthma stakeholders, the way in which they were framed differed across stakeholders. The most salient discussion revolved around the content and the moment in which asthma education should be approached to facilitate patients' adherence to asthma medication.

CONCLUSION

Asthma medication adherence is a complex process and successful interventions aimed at its improvement would benefit from: (a) making an effort to understand patients' experiences and negotiate the treatment regimen, rather than imposing recommendations; (b) considering treatment as a shared responsibility involving the patient, the healthcare professional(s), and the patients' social networks; and,

Persistence with inhaled corticosteroids reduces the risk of exacerbation among adults with asthma: A real-world investigation

BACKGROUND AND OBJECTIVE

Real-world evidence suggests that persistence with inhaled corticosteroids (ICS), the mainstay of asthma drug therapy, is generally poor. The effect of persistence with ICS on the risk of asthma exacerbation was addressed in a population-based study.

METHODS

The cohort of 2335 beneficiaries of the National Health Service provided by the Italian Region of Lombardy, aged 18-40 years and newly treated with ICS during 2005-2008, was followed from their first ICS dispensation until 2010. Discontinuation of treatment with ICS and starting oral corticosteroid therapy during follow-up were respectively regarded as proxies of poor persistence with asthma medication and asthma exacerbation (outcomes). A proportional hazards model was fitted to identify predictors of ICS discontinuation. Case-crossover and case-case-time-control designs and conditional logistic regressions were used to estimate the association between persistence with ICS and asthma exacerbation.

RESULTS

Cumulative incidences of discontinuation were 36%, 57% and 78% at 6 months, 1 year and 5 years, respectively. Predictors of poor persistence were female gender, use of antibiotics during follow-up, absence of use of short-acting beta-agonists prior to and after starting treatment with ICS and starting and maintaining ICS monotherapy during follow-up. The odds ratios of asthma exacerbation (and 95% confidence intervals) associated with ICS exposure during the current period, contrasted with exposure during the reference period, were 0.4 (0.2, 0.9) and 0.3 (0.1, 1.0) from case-crossover and case-case-time-control estimates, respectively.

CONCLUSION

Persistence with ICS treatment in adults with asthma reduces the risk of exacerbation in the real-life setting.

Assessing disparities in the receipt of inhaled corticosteroid prescriptions for asthma by Hispanic and non-Hispanic white patients

RATIONALE

Inhaled corticosteroids (ICS) are widely used in the management of asthma. Prior research suggests that access to ICS among patients with asthma may vary by ethnicity.

OBJECTIVES

Study objectives were to determine if there is a difference in the proportion of Hispanic and non-Hispanic white patients with asthma in the receipt of an ICS prescription and to determine independent predictors for the receipt of an ICS prescription for asthma.

METHODS

The 2009 U.S. Medical Expenditure Panel Survey data were used to compare the receipt of ICS prescription among patients with asthma with the following inclusion criteria: Hispanic and non-Hispanic white ethnicity, age over 4 years, and diagnostic codes for asthma. Multiple logistic regression was used to determine the influence of race/ethnicity and other significant factors on the receipt of an ICS prescription.

MEASUREMENTS AND MAIN RESULTS

There were 1,469 patients with asthma, corresponding to a weighted sample of 14,401,069 U.S. patients with asthma who met the inclusion criteria, represented by 16.1% Hispanic, 59.5% female, and mean age of 39.9 years. Among non-Hispanic white patients with asthma, 39.7% (35% children and 41% adults) had a receipt of an ICS prescription compared with 22.2% of Hispanic patients (23.9% children and 21.2% adults); P < 0.001. In the multiple regression model, Hispanic patients aged 18 years or older had 43% lower odds (odds ratio, 0.6; 95% confidence interval, 0.3-0.9) of having a receipt of an ICS prescription compared with non-Hispanic white patients, independent of other factors. There was no significant difference in receipt of an ICS prescription between Hispanic and non-Hispanic white children with asthma (aged 4-17 yr).

CONCLUSIONS

The disparity in the receipt of ICS prescription between Hispanic and non-Hispanic white adult patients with asthma could result in suboptimal asthma management, a higher rate of exacerbations, and higher health care costs in this growing minority population. The differences and potential disparities in the receipt of an ICS prescription between Hispanic and non-Hispanic white patients with asthma warrant further investigation to better understand the reasons for such disparities, along with their impact on the U.S. health care burden and interventions that can be undertaken to reduce these disparities.

Frequency of asthma education in primary care in the years 2007-2010

OBJECTIVE

Recent research suggests that health disparities persist among asthmatic patients and receipt of asthma education, though recent guidelines have highlighted the importance of receiving asthma education. The purpose of this study was to identify trends in the receipt of asthma education as well as to identify disparities in asthma education using the most recently available data in National Ambulatory Medical Care Survey, 2007-2010.

METHODS

Weighted chi-square tests were conducted to identify associations between asthma education and variables of interest. A weighted multivariate logistic regression model was subsequently constructed to jointly assess the association of factors of interest on receipt of asthma education. Submission to the Campbell University Institutional Review Board resulted in expedited approval.

RESULTS

The percentage of patients who receive asthma education remains quite low. After adjusting for all variables of interest: no statistically significant difference in receipt of asthma education between year groups (2007-2008, 2009-2010) was found (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.52-1.34); patients seen by pediatricians (vs. internal medicine physicians) and Hispanic or Latino patients (vs. non-Hispanic or Latino patients) were more likely to receive asthma education (OR 2.72, 95% CI 1.11-6.66 and OR 2.33, 95% CI 1.18-4.60, respectively); and patients not prescribed a controller medication were less likely to receive asthma education than those who were (OR 0.56, 95% CI 0.37-0.82).

CONCLUSIONS

Combined with previously published results, it appears the provision of asthma education continues to be low, despite proven benefits. Additionally, some patient and physician characteristics may be associated with the delivery of asthma education.

Breathing retraining for African-American adolescents with asthma: a pilot study of a school-based randomized controlled trial

OBJECTIVE

Asthma affects approximately seven million children/adolescents in the USA, with African-American children disproportionately affected. Breathing retraining techniques have been shown to improve asthma outcomes in adults, though research in youth is limited. The purpose of this pilot study was to test the feasibility and preliminary efficacy of a school-based randomized controlled trial of breathing retraining for asthma outcomes and anxiety symptoms in a sample of urban, African-American adolescents.

METHODS

Adolescents were randomized into either the intervention group (20-min breathing retraining plus education) or control group (20-min standard education). Participants completed two study visits, one month apart. Asthma control, asthma quality of life and lung functioning (FEV1 and peak flow) were the primary outcomes, and state anxiety (pre-post the intervention) and trait anxiety (over the one-month period) were the secondary outcomes.

RESULTS

Thirty-three African-American adolescents participated in the study, with a 90% retention rate between visit 1 and visit 2. Asthma control and asthma quality of life, significantly improved over time (p ≤ 0.01) with no differences between intervention and control groups. State anxiety significantly decreased (p ≤ 0.01) immediately post intervention at both time points with no differences between groups. There were no significant differences found in lung functioning or trait anxiety over the one-month time period.

CONCLUSIONS

These preliminary results suggest that breathing retraining is a feasible, acceptable and potentially efficacious intervention (although no significant differences between groups were found) for improving asthma symptoms in urban adolescents with asthma in a school-based setting.

Patients' perspective of barriers and facilitators to taking long-term controller medication for asthma: a novel taxonomy

Background

Although asthma morbidity can be prevented through long-term controller medication, most patients with persistent asthma do not take their daily inhaled corticosteroid. The objective of this study was to gather patients’ insights into barriers and facilitators to taking long-term daily inhaled corticosteroids as basis for future knowledge translation interventions.

Methods

We conducted a collective qualitative case study. We interviewed 24 adults, adolescents, or parents of children, with asthma who had received a prescription of long-term inhaled corticosteroids in the previous year. The one-hour face-to-face interviews revolved around patients’ perceptions of asthma, use of asthma medications, current self-management, prior changes in self-management, as well as patient-physician relationship. We sought barriers and facilitators to optimal asthma management. Interviews were transcribed verbatim and transcripts were analyzed using a thematic approach.

Results

Patients were aged 2–76 years old and 58% were female. Nine patients were followed by an asthma specialist (pulmonologist or allergist), 13 patients by family doctors or pediatricians, and two patients had no regular follow-up. Barriers and facilitators to long-term daily inhaled corticosteroids were classified into the following loci of responsibility and its corresponding domains: (1) patient (cognition; motivation, attitudes and preferences; practical implementation; and parental support); (2) patient-physician interaction (communication and patient-physician relationship); and (3) health care system (resources and services). Patients recognized that several barriers and facilitators fell within their own responsibility. They also underlined the crucial impact (positive or negative) on their adherence of the quality of patient-physician interaction and health care system accessibility.

Conclusions

We identified a close relationship between reported barriers and facilitators to adherence to long-term daily controller medication for asthma within three loci of responsibility. As such, patients’ adherence must be approached as a multi-level phenomenon; moreover, interventions targeting the patient, the patient-physician interaction, and the health care system are recommended. The present study offers a potential taxonomy of barriers and facilitators to adherence to long-term daily inhaled corticosteroids therapy that, once validated, may be used for planning a knowledge translation intervention and may be applicable to other chronic conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-015-0044-9) contains supplementary material, which is available to authorized users.

The challenge of asthma in minority populations

The burden and disparity of asthma in race/ethnic minorities present a significant challenge. In this review, we will evaluate data on asthma epidemiology in minorities, examine potential reasons for asthma disparities, and discuss strategies of intervention and culturally sensitive care.

[Knowledge, attitudes and asthma quality of life of adolescents in schools. The need to educate our teaching centres]

INTRODUCTION

Knowledge and attitudes toward asthma can condition the integration of adolescents with asthma in school and affect their quality of life. Our objective was to determine the state of knowledge, attitudes on asthma in secondary schools, and its relationship to quality of life of pupils with asthma, as an early step to an educational intervention.

METHODS

Descriptive and cross-sectional study of pupils aged 13 and 14 years old and their teachers in 26 schools of Seville and province. We used, as study tools, the Newcastle Asthma Knowledge Questionnaire, the Gibson attitudes towards asthma, and the Paediatric Asthma Quality of Life Questionnaire. To assess the normality of variables, the Kolmogorov-Smirnov test was used, and for non-parametric variables the U Mann-Whitney and W Wilcoxon tests were used. For the association between variables, we use the regression coefficients and rho Spearman.

RESULTS

We studied 3827 pupils (279 with asthma) and 548 teachers. All had little knowledge about asthma. The quality of life in asthma was mild to moderately affected, and lower in girls, 5.38±1.08 (95% CI=5.20 to 5.55) than in boys 5.77 (± 1.18) (95% CI=5.56 to 5.97), P=.0000. We found no relationship between knowledge, attitudes and quality of life in asthma.

CONCLUSIONS

We found a low level of knowledge about asthma in pupils and teacher. Asthma sufferers have a mild to moderate asthma quality of life, which is worse for girls. Knowledge has no relationship with attitudes to asthma in all groups, or with the quality of life of asthma sufferers.

Trends in preventive asthma medication use among children and adolescents, 1988-2008

OBJECTIVE

To examine trends in preventive asthma medication (PAM) use among children with current asthma in the United States from 1988 to 2008.

METHODS

We performed a cross-sectional analysis of PAM use among 2499 children aged 1 to 19 years with current asthma using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) during 3 time periods: 1988-1994, 1999-2002, and 2005-2008. PAMs included inhaled corticosteroids, leukotriene receptor antagonists, long-acting β-agonists, mast-cell stabilizers, and methylxanthines.

RESULTS

Among children with current asthma, there was an increase in the use of PAMs from 17.8% (SE: 3.3) in 1988-1994 to 34.9% (SE: 3.3) in 2005-2008 (P < .001 for trend). Adjusting for age, gender, race/ethnicity, and health insurance status, the odds of PAM use were higher in 2005-2008 compared with 1988-1994 (adjusted odds ratio [aOR] = 2.6; 95% confidence interval [CI]: 1.5-4.5). A multivariate analysis, combining all 3 time periods, showed lower use of PAMs among non-Hispanic black (aOR = 0.5 [95% CI: 0.4-0.7]) and Mexican American (aOR = 0.6 [95% CI: 0.4-0.9]) children compared to non-Hispanic white children. PAM use was also lower in 12 to 19 year olds compared with 1 to 5 year olds and also in children who did not have health insurance compared with those who did.

CONCLUSIONS

Between 1988 and 2008, the use of PAM increased among children with current asthma. Non-Hispanic black and Mexican American children, adolescents aged 12 to 19 years, and uninsured children with current asthma had lower use of PAM.

Demographic disparities in patient-reported use of inhaled corticosteroids among patients with persistent asthma

Background:

Despite the presence of existing guidelines, underuse of inhaled corticosteroids (ICSs) still exists among patients with persistent asthma in the United States. Inappropriate utilization of asthma medications has been attributed as one of the reasons for the significant economic burden due to asthma.

Objectives:

To determine the demographic factors predicting patient-reported use of ICSs among patients with asthma.

Methods:

The study utilized data from the 4-state sample of the National Asthma Survey (NAS), sponsored by the National Center for Environmental Health (NCEH), Centers for Disease Control and Prevention (CDC). The study population consisted of patients with persistent asthma as defined by National Heart, Lung, and Blood Institute (NHLBI) guidelines. Frequency distributions were made to characterize the study population. Logistic regression analysis was carried out to determine the odds of reported use of ICSs across various demographic variables (age, gender, race, income level, insurance coverage, and disease severity). Data were analyzed using SAS v9.0 software.

Results:

Underutilization of ICSs was found to exist in the patients with asthma, as more than half of the study population (52.8%, n = 304) did not report the use of ICSs. African American patients were found to have much lower odds for use of ICSs (odds ratio [OR] = 0.495; confidence interval [CI], 0.248–0.987) when compared with whites. Insured patients had significantly higher odds for the use of ICSs (OR = 2.378; CI, 1.106–5.110) compared with uninsured patients. The findings held true even after adjusting for other demographic factors.

Conclusion:

Underuse of ICSs continues to be a problem in patients with asthma. Vulnerable populations identified in this study are targeted for the use of ICSs. The importance of adherence to treatment and use of ICSs is an issue that needs to be addressed.