Racial and ethnic disparities in diagnosed and possible undiagnosed asthma among public-school children in Chicago

Evaluating inhaler education interventions for hospitalized children with asthma: A randomized controlled trial

BACKGROUND

Most children with asthma have poor inhaler technique, with detrimental morbidity effects. Guidelines recommend clinicians provide inhaler education at every opportunity, yet resources are limited. A low-cost, technology-based intervention-Virtual Teach-to-Goal (V-TTG)-was developed to deliver tailored inhaler technique education with high fidelity.

OBJECTIVE

To evaluate whether V-TTG leads to less inhaler misuse among children with asthma who are hospitalized vs brief intervention (BI, reading steps aloud).

METHODS

A single-center randomized controlled trial of V-TTG vs BI was conducted with 5-to-10-year-old children with asthma hospitalized between January 2019 and February 2020. Inhaler technique was assessed pre- and post-education using 12-step validated checklists (misuse: < 10 steps correct).

RESULTS

Among 70 children enrolled, mean age was 7.8 years (SD = 1.6). Most (86%) were Black. Most had an emergency department visit (94%) or hospitalization (90%) in the previous year. At baseline, nearly all children misused inhalers (96%). The proportion of children with inhaler misuse decreased significantly in V-TTG (100%→74%, P = .002) and BI (92%→69%, P = .04) groups, with no difference between groups at both time points (P = .2 and .9). On average, children performed 1.5 more steps correctly (SD = 2.0), with greater improvement with V-TTG (mean [SD] = 1.7 [1.6]) vs BI (mean [SD] = 1.4 [2.3]), though not significant (P = .6). Concerning pre and post technique, older children were significantly more likely than younger children to show more correct steps (mean change = 1.9 vs 1.1, P = .002).

CONCLUSION

A technology-based intervention for tailored inhaler education led to improved technique among children, similarly to reading steps aloud. Older children saw greater benefits. Future studies should evaluate the V-TTG intervention across diverse populations and disease severities to identify the greatest impact.

CLINICAL TRIAL REGISTRATION

NCT04373499.

Biomarkers of organophosphate insecticides exposure and asthma in general US adults: findings from NHANES 1999-2018 data

The limited evidence linking exposure to organophosphate insecticides (OPIs) and asthma in the general population prompted us to investigate this association. Our study focused on US adults and utilized representative samples from the National Health and Nutrition Examination Survey (NHANES). From the 7 NHANES waves (1999-2018), we detected OPIs exposure using the urinary concentrations of six metabolites of dialkyl phosphates (DAPs). To evaluate the relationship between these OPIs and asthma, we employed three statistical methods: survey-multivariable logistic regression (SMLR), generalized weighted quantile sum (WQS) regression, and Bayesian kernel machine regression (BKMR). Stratified analyses were done based on the relevant variable subgroups, and sensitivity analyses were carried out to evaluate the robustness of findings. A total of 6009 adults aged from 20 to 85 years old, representing the 313.5 million adults in the non-institutionalized US population, were included in our analyses. Among them, 842 participants were determined as asthma patients with an age-adjusted prevalence of 14.2%. Our results showed that dimethyl phosphate (DMP) (adjusted odd ratio (AOR) = 1.471, 95% CI: 1.086, 1.993), diethyl phosphate (DEP) (AOR = 1.453, 95% CI: 1.118, 1.888), dimethyl thiophosphate (DMTP) (AOR = 1.454, 95% CI: 1.071, 1.973), and dimethyl dithiophosphate (DMDTP) (AOR = 1.478, 95% CI: 1.119, 1.953) had a positive correlation with asthma in adults. This association was stronger in females, non-Hispanic White populations and those with a small amount of physical activity. Our study findings indicated that exposure to OPIs may elevate the risk of asthma in US general adults. Specifically, females, individuals from non-Hispanic White backgrounds, and those with lower levels of physical activity are more susceptible to developing asthma when exposed to OPIs.

Perceived Stress, Religiosity, and Substance Use Among African American and Latinx College Students with Asthma in the USA

This study examined associations among perceived stress, religiosity, and substance use in African American and Latinx college students with asthma. Participants included 194 college students with asthma (18-20 years, 63.4% African American, 21.1% Latinx). Eligible students completed an online questionnaire that included measures of asthma control, perceived stress, religiosity, alcohol misuse, and last 30-day tobacco use and marijuana use. Over one-quarter (25.3%) of participants reported using tobacco and 31.9% reported using marijuana in the past 30 days. Perceived stress and religiosity were each independently associated with multiple indicators of substance use. Asthma control moderated associations between religiosity and tobacco use in the past 30 days (b =  - .014, p = .002), such that the association between religiosity and tobacco use was stronger among those with better asthma control. Participant gender significantly moderated the association between perceived stress and alcohol misuse (b =  - .099, p = .029); a stronger, positive association between stress and alcohol misuse was found among men. Students' perceived stress levels were associated with marijuana use in the past 30 days and high alcohol misuse. Religiosity was inversely linked to substance use. There is a need for healthcare providers to recognize and focus on substance use prevention specifically among African American and Latinx college students with asthma.

Development and Utilization of a Diagnostic Support Tool for Asthma within the Electronic Medical Record

Asthma in childhood is a common and costly chronic disease. Quality asthma care can lead to better control of asthma thus decreasing use of health services. The gold standard for pediatric asthma diagnosis and management is the National Heart, Lung and Blood Institute (NHLBI) guidelines for Diagnosis and Management of Asthma which center on precisely establishing the severity of asthma, as this precise classification delineates appropriate therapy. However, navigating these guidelines is a challenge for primary care providers that creates a barrier to providing quality care. We aim to improve precision in asthma severity classification in the community healthcare setting through the development of an electronic asthma decision support tool (eADST) incorporating NHLBI guidelines embedded within the electronic health record system. We developed an algorithm for the eADST to guide the health care provider to the appropriate classification and subsequent therapy. We engaged our health system's electronic health record informatics team and together developed and revised the tool. We launched the tool in three academic community clinics and measured precision in asthma classification in the twelve months prior to the availability of the tool and the twelve months following the launch. We found a significant improvement in precision of asthma severity classification following the launch, a necessary first step in improvement of asthma care. The next step will be to evaluate the impact of the tool on asthma outcomes.

Trends in asthma among adults in the United States, National Health and Nutrition Examination Survey 2005 to 2018

BACKGROUND

Asthma is a common chronic disease in American adults. The prevalence of asthma has varied over time, but there are few studies on the long-term trend of asthma in American adults.

OBJECTIVE

To describe the prevalence and trend of asthma in American adults from 2005 to 2018 and analyze the risk factors for asthma.

METHODS

Data collection was performed from National Health and Nutrition Examination Survey 2005 to 2018. The unweighted number and weighted percentages of normal participants and patients with asthma and the trends of asthma were calculated. Weighted univariate logistic regression was used to analyze the risk factors for asthma.

RESULTS

A total of 39,601 adults were included in this study. From 2005 to 2018, the overall prevalence of asthma in American adults was 8.41%, whereas that in young, middle-aged, and elderly adults was 8.30%, 8.70%, and 7.92%, respectively. The estimated prevalence of asthma in the overall adults and young adults increased with time (P for trend = .03, difference = 0.023 and P for trend = .007, difference = 0.060, respectively), and the estimated prevalence of middle-aged and elderly adults remained stable with time (P for trend = .33, difference = 0.015 and P for trend = .80, difference = -0.024, respectively).

CONCLUSION

Asthma in American adults was on the rise. Female sex, non-Hispanic Blacks, individuals with low annual household income, active smokers, obese patients, patients with hypertension, patients with diabetes, and individuals with positive asthma family history were associated with a higher risk for developing 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.

Lung Function, Dietary Intake, and Weight Status in Children with Persistent Asthma from Low-Income, Urban Communities

OBJECTIVE

Asthma and obesity are prevalent chronic childhood diseases that commonly co-occur in youth from low-income, minority backgrounds. Diet is a known risk factor for obesity; however, its role in asthma/obesity comorbidity is not well established. This analysis examined the association between diet and lung function and effect modification by weight status.

METHODS

Lung function (FEV1 % predicted), anthropometric, and dietary data were collected from 95 children, ages 7-9 years old with persistent asthma, from low-income, urban communities in the United States. Associations between lung function, diet and weight status were examined using multivariable linear regression.

RESULTS

There were no significant differences in dietary intake between children with persistent asthma with and without obesity; however, >85% of participants did not meet recommendations for fruit, vegetable, and whole grain intake for their age and sex. Only intake of fruit (whole fruit and juice) was significantly associated with FEV1 % predicted (-3.36; 95% CI: -6.5 to -0.2).

CONCLUSIONS

Diet quality was poor in this sample, independent of weight status. More research is needed to understand the relationship between diet, lung function, and weight status, so that interventions can be developed to concurrently address obesity and weight.

Individual and Neighborhood Factors Associated with Undiagnosed Asthma in a Large Cohort of Urban Adolescents

Undiagnosed asthma adds to the burden of asthma and is an especially significant public health concern among urban adolescents. While much is known about individual-level demographic and neighborhood-level factors that characterize those with diagnosed asthma, limited data exist regarding these factors and undiagnosed asthma. This observational study evaluated associations between undiagnosed asthma and individual and neighborhood factors among a large cohort of urban adolescents. We analyzed data from 10,295 New York City adolescents who reported on asthma symptoms and diagnosis; a subset (n = 6220) provided addresses that we were able to geocode into US Census tracts. Multivariable regression models estimated associations between undiagnosed asthma status and individual-level variables. Hierarchical linear modeling estimated associations between undiagnosed asthma status and neighborhood-level variables. Undiagnosed asthma prevalence was 20.2%. Females had higher odds of being undiagnosed (adjusted odds ratio (AOR) = 1.25; 95% confidence interval (CI) = 1.13-1.37). Compared to White, non-Hispanic adolescents, Asian-Americans had higher risk of being undiagnosed (AOR = 1.41; 95% CI = 1.01-1.95); Latinos (AOR = 0.67; 95% CI = 0.45-0.83); and African-Americans/Blacks (AOR = 0.66; 95% CI = 0.52-0.87) had lower risk; Latinos and African-Americans/Blacks did not differ significantly. Living in a neighborhood with a lower concentration of Latinos relative to White non-Latinos was associated with lower risk of being undiagnosed (AOR = 0.66; CI = 0.43-0.95). Living in a neighborhood with health care provider shortages was associated with lower risk of being undiagnosed (AOR = 0.80; 95% CI =0.69-0.93). Public health campaigns to educate adolescents and their caregivers about undiagnosed asthma, as well as education for health care providers to screen adolescent patients for asthma, are warranted.

Burden of Illness, Primary Care Use, and Medication Utilization among US-México Border Children with Wheezing

OBJECTIVE

Among high-risk, underserved populations, such as children living along the US-México border, suffering from asthma-like symptoms without an asthma diagnosis can result in a high burden of illness. We estimated the prevalence of physician-diagnosed and possible undiagnosed asthma among students with histories of wheezing in the US-México border community of El Paso, Texas, and evaluated their burden of illness, primary care use, and medication utilization.

METHODS

We analyzed cross-sectional survey data collected in May 2012. The survey included validated International Study of Asthma and Allergies in Childhood (ISAAC) items. We performed bivariate and logistic regression analyses on data from 307 students who wheezed.

RESULTS

Forty-two percent of students had possible undiagnosed asthma and 58% had physician-diagnosed asthma based on primary caretaker reports. Children of Mexican origin were more likely to report undiagnosed vs. diagnosed asthma (p < 0.05). Children with an asthma diagnosis were more likely to report any medication use for wheezing/asthma and to experience a higher burden of illness in the last year compared to students with possible undiagnosed asthma (p < 0.05).

CONCLUSIONS

The burden of illness among these children was high; however, children with asthma-like symptoms were not faring worse than children with asthma symptoms and a diagnosis. Undiagnosed children were being evaluated and receiving treatment for their symptoms; however, by not receiving a diagnosis, they were eliciting an ameliorative rather than preventive treatment strategy.

An Examination of the Association of Multiple Acculturation Measures with Asthma Status Among Elementary School Students in El Paso, Texas

Some researchers posit that the lower prevalence of asthma among those of Mexican descent may result from an under-diagnosis and recommend a critical appraisal of factors related to race/ethnicity, like acculturation, and its influence on asthma status. Survey data were analyzed using multinomial logistic regression to examine the association of child's asthma status (no wheezing/no asthma symptoms, possible undiagnosed and diagnosed asthma) with measures of acculturation among Hispanic students (n = 1095). In this population, the prevalence of diagnosed asthma (15%) was higher than both national (7.6%) and state (6.8%) averages for Hispanic children in 2012. While bivariate analyses showed significant associations for asthma status and measures of acculturation, multivariate analyses did not. There is an underestimated burden of illness among Hispanic children in El Paso County. More research on the suitability of acculturation constructs is needed to delineate what they actually measure and how acculturation influences asthma status.

Optimizing community-level surveillance data for pediatric asthma management

Community-level approaches for pediatric asthma management rely on locally collected information derived primarily from two sources: claims records and school-based surveys. We combined claims and school-based surveillance data, and examined the asthma-related risk patterns among adolescent students. Symptom data collected from school-based asthma surveys conducted in Oakland, CA were used for case identification and determination of severity levels for students (high and low). Survey data were matched to Medicaid claims data for all asthma-related health care encounters for the year prior to the survey. We then employed recursive partitioning to develop classification trees that identified patterns of demographics and healthcare utilization associated with severity. A total of 561 students had complete matched data; 86.1% were classified as high-severity, and 13.9% as low-severity asthma. The classification tree consisted of eight subsets: three indicating high severity and five indicating low severity. The risk subsets highlighted varying combinations of non-specific demographic and socioeconomic predictors of asthma prevalence, morbidity and severity. For example, the subset with the highest class-prior probability (92.1%) predicted high-severity asthma and consisted of students without prescribed rescue medication, but with at least one in-clinic nebulizer treatment. The predictive accuracy of the tree-based model was approximately 66.7%, with an estimated 91.1% of high-severity cases and 42.3% of low-severity cases correctly predicted. Our analysis draws on the strengths of two complementary datasets to provide community-level information on children with asthma, and demonstrates the utility of recursive partitioning methods to explore a combination of features that convey asthma severity.

Frequency of health service use in the year prior to asthma death

OBJECTIVE

High frequency health service use (HSU) is associated with poorly controlled asthma, and is a recognized risk factor for near-fatal or fatal asthma. The objective of this study was to describe the frequency of HSU in the year prior to asthma death.

METHODS

Individuals aged 0-99 years who died from asthma from April 1996 to December 2011 in Ontario, Canada were identified as cases. Cases were matched to 4-5 live asthma controls by age, sex, rural/urban residence, socioeconomic status, duration of asthma and a co-diagnosis of COPD. HSU records in the year prior to death [hospitalization, emergency department (ED) and outpatient visits] were assembled. The association of prior HSU and asthma death was measured by conditional logistic regression models.

RESULTS

From 1996 to 2011, 1503 individuals died from asthma. While the majority of cases did not have increased HSU as defined in the study, compared to matched live asthma controls, the cases were 8-fold more likely to have been hospitalized two or more times (OR = 7.60; 95% CI: 4.90, 11.77), 13-fold more likely to have had three or more ED visits (OR = 13.28; 95% CI: 7.55, 23.34) and 4-fold more likely to have had five or more physician visits for asthma (OR = 4.41; 95% CI: 3.58, 5.42).

CONCLUSIONS

Frequency of HSU in the year prior was substantially higher in those died from asthma. Specifically, more than one asthma hospital admission, three ED visits or five physician visits increased the asthma mortality risk substantially and exponentially.

Avoiding Unintended Bias: Strategies for Providing More Equitable Health Care

Research shows that unintentional bias on the part of physicians can influence the way they treat patients from certain racial and ethnic groups. Most physicians are unaware that they hold such biases, which can unknowingly contribute to inequalities in health care delivery. This article explains why a person's thoughts and behaviors may not align, and provides strategies for preventing implicit biases from interfering with patient care.

Asthma deaths in a large provincial health system. A 10-year population-based study

RATIONALE

Individuals with asthma are more likely to die from chronic conditions than the general population. Measuring only mortality with asthma listed as the primary cause of death may lead to an underestimation of total asthma mortality.

OBJECTIVES

To examine mortality patterns in the asthma population over 10 years, including asthma as the primary cause of death (asthma-specific mortality) and asthma as a secondary, contributing cause of death (asthma-contributing mortality).

METHODS

Health administrative data from Ontario, Canada were used to identify mortality rates and cause of death in subjects 0 to 99 years of age. Mortality rates were calculated in the asthma and general population from 1999 to 2008. Total asthma mortality was estimated by adding rates of asthma-specific and asthma-contributing mortality for years 2003 to 2008.

MEASUREMENTS AND MAIN RESULTS

Asthma-specific mortality rates per 100,000 asthma population decreased by 54.4% from 13.6 in 1999 to 6.2 in 2008. In 2008, the asthma population had higher all-cause mortality compared with the general population (rate ratio, 1.3), asthma-specific mortality rates were 60% higher among those in the lowest compared with highest socioeconomic status, and total asthma mortality was fourfold higher than asthma-specific mortality alone (21.6 vs. 5.4 per 100,000).

CONCLUSIONS

All-cause mortality rates have decreased substantially over the past decade. Compared with the general population, the asthma population has higher all-cause mortality and is more likely to die from comorbid conditions. Total asthma mortality was fourfold higher than asthma-specific mortality, highlighting the importance of comprehensive measurement approaches that include asthma-specific and asthma-contributing mortality.

Association between adverse childhood experiences in the home and pediatric asthma

BACKGROUND

Numerous studies suggest that psychosocial factors could contribute to pediatric asthma.

OBJECTIVE

To examine the relation between single and cumulative adverse childhood experiences (ACEs), a measurement of household dysfunction, on parent report of lifetime asthma in children.

METHODS

This cross-sectional study used data from the 2011 to 2012 National Survey of Children's Health, a nationally representative sample of children 0 to 17 years old (n = 92,472). The main exposure was parent or guardian report of 6 ACE exposures (eg, witnessing domestic violence). The relation between ACE exposures and parent-reported diagnosis of childhood asthma was examined using multivariable logistic regression after controlling for demographic, socioeconomic, and behavioral covariates.

RESULTS

Overall asthma prevalence was 14.6%. Exposure prevalence to any ACE was 29.2%. Increased number of ACE exposures was associated with increased odds of asthma. In the adjusted model, the odds of reporting asthma were 1.28 (95% confidence interval [CI] 1.14-1.43) for those reporting 1 ACE, 1.73 (95% CI 1.27-2.36) for those with 4 ACEs, and 1.61 (95% CI 1.15-2.26) for those with 5 or 6 ACEs compared with those with no ACE exposures. Effects were moderated by Hispanic ethnicity. Hispanic children exposed to 4 ACEs had a 4.46 times increase in lifetime asthma (95% CI 2.46-8.08); white children had a 1.19 times increase (95% CI 0.80-1.79) compared with those exposed to 0 ACE.

CONCLUSION

This study supports the growing evidence for the biopsychosocial model of asthma onset. Future studies should examine the association between ACEs and specific asthma-related health outcomes.

Quality of asthma care under different primary care models in Canada: a population-based study

Background

Previous research has shown variations in quality of care and patient outcomes under different primary care models. The objective of this study was to use previously validated, evidence-based performance indicators to measure quality of asthma care over time and to compare quality of care between different primary care models.

Methods

Data were obtained for years 2006 to 2010 from the Ontario Asthma Surveillance Information System, which uses health administrative databases to track individuals with asthma living in the province of Ontario, Canada. Individuals with asthma (n=1,813,922) were divided into groups based on the practice model of their primary care provider (i.e., fee-for-service, blended fee-for-service, blended capitation). Quality of asthma care was measured using six validated, evidence-based asthma care performance indicators.

Results

All of the asthma performance indicators improved over time within each of the primary care models. Compared to the traditional fee-for-service model, the blended fee-for-service and blended capitation models had higher use of spirometry for asthma diagnosis and monitoring, higher rates of inhaled corticosteroid prescription, and lower outpatient claims. Emergency department visits were lowest in the blended fee-for-service group.

Conclusions

Quality of asthma care improved over time within each of the primary care models. However, the amount by which they improved differed between the models. The newer primary care models (i.e., blended fee-for-service, blended capitation) appear to provide better quality of asthma care compared to the traditional fee-for-service model.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0232-y) contains supplementary material, which is available to authorized users.

Asthma in US Mexican-Origin Children in Early Childhood: Differences in Risk and Protective Factors by Parental Nativity

OBJECTIVE

Over 900,000 Mexican-origin children in the United States have asthma, but little is known about the extent to which development of this condition reflects early childhood exposure to social and environmental risks. The objectives of this research are to demonstrate the roles of risk and protective factors in the prevalence and severity of asthma in this population and provide comparisons with other racial/ethnic groups.

METHODS

Nationally representative data from the Early Childhood Longitudinal Study, Birth Cohort (n = 6900), with county-level ozone data appended to this file were analyzed using descriptive and multivariate regression methods.

RESULTS

The odds of asthma diagnosis by 60 months are approximately 50% higher among Mexican-origin children than for non-Hispanic whites (P < .05) in multivariate analyses. Compared to those with foreign-born parents, Mexican-origin children with native-born parents have a lower likelihood of being breast-fed and greater chances of having risks including a family history of asthma, having respiratory illnesses and allergies, living with a smoker, and attending center-based child care. Mexican-origin children live in counties with over 3 times more elevated ozone days annually than non-Hispanic whites.

CONCLUSIONS

Mexican-origin children experience a constellation of risk and protective factors, but those with US-born parents have elevated asthma risks compared to those with foreign-born parents. Asthma incidence and severity will likely increase as this population becomes increasingly integrated into US society.

Biomarkers of Insecticide Exposure and Asthma in Children: A National Health and Nutrition Examination Survey (NHANES) 1999-2008 Analysis

Pesticide exposure is a potential risk factor for increased asthma prevalence among children. The authors used National Health and Nutrition Examination Survey (1999-2008) biomarker data to evaluate dialkylphosphate (DAP) urinary concentrations, serum dichlorodiphenyldichloroethylene (DDE), and asthma among school-aged children (Mexican American, Non-Hispanic Black, Non-Hispanic White). Poisson logistic regression included age, sex, nativity, poverty index ratio, tobacco smoke exposure, and body mass index covariates. No association was found between DAP (N=2,777) and asthma outcomes; adverse effect of DDE (N=940) was suggested for Current Wheeze. Subgroup analyses identified positive associations with some asthma outcomes among Non-Hispanic Blacks, whereas inverse associations were identified among Mexican Americans. Results support previous associations observed among children's DDE exposure and wheeze. Characterization of risk factors for pesticide exposure and disease recognition among Mexican Americans is needed.

Lung functions of Japanese patients with chronic rhinosinusitis who underwent endoscopic sinus surgery

BACKGROUND

Chronic rhinosinusitis (CRS), which is clinically classified into CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP), shows considerable geographic differences and heterogeneity. Eosinophilic (E) CRS with nasal polyps (ECRSwNP) has a higher degree of disease severity and higher frequency of comorbid asthma. Epidemiologic studies in different ethnic populations have improved understanding of the pathophysiology of the disease. Here we report the clinical characteristics of Japanese patients with medically refractory CRS undergoing endoscopic sinus surgery (ESS).

METHODS

We recruited a total of 210 CRS patients and assessed them by nasal endoscopy, the Lund-Mackay score using computed tomography (CT), peripheral eosinophilia and smoking status. We also examined the comorbidity of asthma, effects of age and lung functions in the patients.

RESULTS

In this study, 13% of CRSwNP patients and 20% of CRSwNP patients with peripheral blood eosinophilia exhibited obstructive lung dysfunction (FEV1/FVC <70%) despite the absence of an asthma diagnosis. Among elderly nonsmoker patients (≥ 60 years) who had never been diagnosed with asthma, 50% of CRSwNP patients with peripheral blood eosinophilia showed decreased FEV1/FVC <70%.

CONCLUSIONS

Our findings suggest that asthma is under-diagnosed in CRS patients who undergo ESS, especially the elderly. Although the association between CRS and asthma has been recognized, increased attention to the comorbidity of obstructive airway diseases such as asthma is still needed for management of medically refractory CRS.

Evidence of high rates of undiagnosed asthma in central Ohio elementary schoolchildren

BACKGROUND

In Ohio, 14.5% of 5- to 9-year-olds and 17.3% of 10- to 17-year-olds have asthma. Moreover, there is concern that these numbers may underestimate the true disease burden. We sought to evaluate variability in asthma rates and respiratory symptoms among central Ohio fourth graders as a means to assess potential undiagnosed and undertreated asthma and its determinants.

METHODS

We recruited 13 central Ohio elementary schools representing a broad range of nonurban settings and surveyed fourth graders to estimate school-level physician-diagnosed asthma (PDA), respiratory morbidity, and home exposures to smoking and pets. We used generalized linear mixed models with random intercept for school to examine relationships among exposures, respiratory symptoms, and PDA.

RESULTS

Across the 13 schools, 94% of students participated in the survey, and the estimated asthma prevalence rate was 10.2% (N = 101 of 987). An additional 41% reported not having PDA but then went on to report symptoms consistent with asthma potentially suggestive of undiagnosed asthma. Of students with PDA, 21% reported symptoms suggestive of poorly controlled asthma. High levels of secondhand smoke (SHS) exposure were associated both with PDA (p = .05) and with respiratory symptoms (p < .0001). Students who owned a cat or a bird were more likely to report respiratory symptoms (p = .02 and p = .04, respectively).

CONCLUSIONS

We provide evidence that the already high childhood asthma public health burden in central Ohio may be underreported. Schools may be an ideal location to conduct screenings and implement environmental interventions oriented toward SHS and household pets that will yield respiratory morbidity benefits.

Challenges of asthma management for school nurses in districts with high asthma hospitalization rates

BACKGROUND

School nurses play a central role in assisting elementary school children in managing their asthma, especially those in higher-risk school districts that are at increased risk of uncontrolled asthma. Study purposes are to (1) identify barriers to asthma management by school nurses in higher-risk school districts; and (2) assess the extent to which National Asthma Education and Prevention Program (NAEPP) recommendations are followed in these districts.

METHODS

School districts containing at least one zipcode with high asthma hospitalization rates among children (0-14 years) in a New York State county were identified. Nurses in 44 elementary schools were surveyed about asthma management during 2008. Both quantitative and qualitative data were collected.

RESULTS

Study nurses learned of children with asthma mainly through school records and when students presented with symptoms rather than through parents. The major obstacles to asthma management were communication with parents and parental support. Reluctance of some physicians to diagnose asthma in these children presented a barrier and contributed to the nurses' ability to gain parental cooperation. Adherence to the NAEPP school recommendations was inconsistent.

CONCLUSIONS

Improvement in the communication among parents, school nurses, and providers is critical to the improvement of asthma management for children in high-risk school districts.

Perceptual accuracy of upper airway compromise in children: Clinical relevance and future directions for research

Approximately 80% of children with asthma have coexisting allergic rhinitis. The accurate recognition and assessment of asthma and rhinitis symptoms is an integral component of guideline-based treatment for both conditions. This article describes the development and preliminary evaluation of a novel paradigm for testing the accuracy of children's assessment of their upper airway (rhinitis) symptoms. This work is guided by our previous research showing the clinical efficacy of tools to evaluate children's perceptual accuracy of asthma symptoms and linking accurate asthma symptom perception to decreased asthma morbidity (Fritz G, et al., Ethnic differences in perception of lung function: A factor in pediatric asthma disparities? Am J Respir Crit Care Med 182:12-18, 2010; Klein RB, et al., The Asthma Risk Grid: Clinical interpretation of symptom perception, Allergy Asthma Proc 251-256, 2004). The pilot study tests a paradigm that allows for the examination of the correspondence of children's assessment of their upper airway functioning with actual values of upper airway flow through the use of a portable, handheld nasal peak flowmeter. Nine children with persistent asthma were evaluated over a 4-week period. The article describes the rhinitis perceptual accuracy paradigm and reviews the results of a pilot study, showing a large proportion of inaccurate rhinitis symptoms "guesses" by the sample of children with persistent asthma. Patterns of inaccuracy, rhinitis control, and asthma morbidity are also described. Directions for future work are reviewed. The development of clinical tools to evaluate children's accuracy of rhinitis symptoms are needed, given the central role of the self-assessment of symptoms in guideline-based care. Accurate perception of the severity of rhinitis symptoms may enhance rhinitis control, lessen the burden of asthma, and prevent unnecessary emergency use among this high-risk group of children.

The home environment and family asthma management among ethnically diverse urban youth with asthma

Although the pediatric psychology literature underscores the importance of illness-related aspects of the home environment for optimal family asthma management, little is known about the contribution of more global aspects of the home environment (e.g., family routines/schedule, quality of stimulation provided to child) to asthma management in ethnic minority and urban families. The goals of this study were to (a) explore ethnic/racial group differences in global and specific dimensions of home environment quality among Latino, non-Latino White (NLW), and African American urban children with asthma; and (b) examine associations between the quality and quantity of support and stimulation within the home environment, as measured by the HOME Inventory, and family asthma management. Urban, low-income children (N = 131) between the ages of 6 and 13 with asthma and a primary caregiver participated in a multimodal assessment, including an in-home observation and semistructured interviews to assess aspects of home environment quality and family asthma management practices. While controlling for poverty, no ethnic group differences were found in the global home environment; however, there were significant differences in specific dimensions (e.g., Family Participation in Developmentally Stimulating Experiences, and Aspects of the Physical Environment) of home environment quality. Across the whole sample, home environment quality predicted family asthma management. When examining this association for specific ethnic groups, this finding did not hold for the Latino subsample. The results highlight the need to consider ethnic group differences in non-illness-specific aspects of the home environment when addressing families' asthma management strategies.

The relationship of blood lead with immunoglobulin E, eosinophils, and asthma among children: NHANES 2005-2006

Early life lead exposure may alter immune function and predispose a child to develop asthma. In an initial exploration of this hypothesis, we examined the association between blood lead, and serum immunoglobulin E (IgE), eosinophils, and asthma prevalence in a cross-sectional study of 1788 children from the National Health and Nutrition Examination Survey 2005-2006. Geometric mean blood lead, serum IgE, and percent eosinophils were 1.13 μg/dL (95% confidence interval (CI): 1.04, 1.22), 46.3 kU/L (95% CI: 40.3, 53.1), and 2.82 percent (95% CI 2.67, 2.98), respectively. Prevalence of asthma, atopic asthma, and atopy were 11.8% (95% CI: 9.5, 14.2), 8.1% (6.2, 9.9), and 44.4% (40.1, 48.7), respectively. Regression models controlled for season, age, sex, race/ethnicity, education, passive smoke exposure, and body mass index. Based on these models, there was an 11.1% (95% CI: 5.6, 16.9) increase in IgE and a 4.9% (95% CI: 2.3, 7.6) increase in eosinophils per 1 μg/dL increase in blood lead. In independent stratified analyses, lead was found to increase IgE and eosinophils among non-Hispanic whites, but not other children; and stronger associations were observed among children who lived with a smoker vs. not. Lead was not associated with asthma, atopic asthma, or general atopy. This study provides additional evidence of a cross-sectional association between lead with IgE and new evidence for eosinophils. This may be a mechanism for development of downstream allergic disease. The mechanisms that determine ultimate development of allergic disease are currently unknown, but are the focus of ongoing studies.

The course of asthma activity: a population study

BACKGROUND

Unlike most chronic diseases, which tend to progress over time, asthma is known to persist, possibly resolve, and/or present with any combination of remissions and relapses. As a result, its course has been difficult to characterize and its prognosis difficult to predict.

OBJECTIVE

To quantify the proportion of individuals with asthma who have active disease and, of those, the proportion who experience significant gaps in their asthma activity; and to determine factors associated with asthma activity.

METHODS

Universal population health administrative databases were used to identify all individuals with asthma living in Ontario, Canada, in 1993 and follow them for 15 years. Active asthma was indicated by 1 or more physician claims for asthma.

RESULTS

Of 613,394 individuals with asthma in 1993, 504,851 (82.3%) had active disease in subsequent years. Of those who had complete follow-up, 74.6% experienced a gap of 2 or more years in their asthma activity. Previous asthma claims, older and younger age, and a codiagnosis of chronic obstructive pulmonary disease correlated with greater asthma activity.

CONCLUSION

Over 15 years, most individuals with asthma in Ontario, Canada, had active disease that was interspersed by periods of inactivity when they did not require medical attention and were likely in remission. These analyses offer insight into the natural course of asthma activity that may help improve the ability to predict an individual's course of disease.

Socio-demographic disparities of childhood asthma

Childhood asthma is particularly prevalent among disadvantaged children and is associated with greater functional consequences. This study described factors associated with childhood asthma in a sample of Latino and non-Latino children. Data were from baseline measures of 791 parent and child dyads involved in a childhood obesity prevention study. Parents completed a self-administered survey assessing childhood factors, demographics, acculturation and child asthma diagnosis. Multivariate mixed effects logistic regression analyses tested for correlates of child asthma and ethnicity interactions. Children were 4-10 years old, half were female, 86.0 percent were US-born and 45.7 percent were overweight or obese. The prevalence of childhood asthma was 11.5 percent. In multivariate analyses, the odds of childhood asthma were greater among children of non-Latino descent (OR = 4.1, CI: 1.8, 9.2), who had health insurance (OR = 11.1, CI: 2.7, 46.4), were male (OR = 1.8; CI: 1.1, 3.1) and born pre-term (OR = 3.0, CI: 1.4, 6.3). This study supports socio-demographic disparities in childhood asthma and evidence of their independent effects.

Coping patterns in Latino families of children with asthma

INTRODUCTION

Using the Coping Health Inventory for Parents (CHIP), this study examined coping behaviors in 26 Latino parents of children with asthma.

METHODS

Correlations and t tests were used to look at variables related to the parents' coping patterns and to compare their frequency of usage of these patterns.

RESULTS

The parents in this study were most likely to cope with their child's asthma by making active attempts to understand this condition, doing activities with family members, and maintaining an optimistic perspective. Child and family variables were not significantly associated with parents' usage of coping patterns.

DISCUSSION

These results shed light on coping in Latino families of children with asthma and contribute to a growing framework of research and practice regarding health problems in this population. The aforementioned results can enhance health care professionals' understanding of the experiences of these families and help develop and expand culturally sensitive interventions to positively affect their health and psychological needs.

The association of health insurance and disease impairment with reported asthma prevalence in U.S. children

OBJECTIVE

To test the hypotheses that reported asthma prevalence is higher among insured than uninsured children and that insurance-based differences in asthma diagnosis, treatment, and health care utilization are associated with disease severity.

DATA SOURCES

National Health and Nutrition Examination Survey, 2003-2008.

STUDY DESIGN

We used multivariate logistic regression to examine the relationship between insurance and asthma symptom severity with asthma diagnosis, treatment, and acute care utilization.

PRINCIPAL FINDINGS

In multivariate analysis, insured children had greater odds of reporting a current diagnosis of asthma than uninsured children (odds ratio [OR] = 2.08, 95% confidence interval [CI]: 1.47-2.94). When interactions between insurance and asthma impairment were included, insurance was associated with greater odds of diagnosis among children with intermittent (OR = 4.08, 95% CI: 1.57-10.61), but not persistent, symptoms. Among children with intermittent symptoms, insurance was associated with inhaled corticosteroid use (OR = 4.51, 95% CI: 1.18-17.24) and asthma-related acute care utilization (OR = 5.21, 95% CI: 1.21-23.53); these associations were nonsignificant among children with persistent symptoms.

CONCLUSION

Being insured increases only the likelihood that a child with intermittent, not persistent, asthma symptoms will receive an asthma diagnosis and control medication, and it may not reduce acute care utilization. Although universal insurance may increase detection and management of undiagnosed childhood asthma, theorized cost savings from reduced acute care utilization might not materialize.

Pulmonary function testing in the diagnosis of asthma: a population study

BACKGROUND

Asthma is a common chronic respiratory condition, the diagnosis of which depends on symptoms and objective evidence of variable airflow obstruction or airway hyperresponsiveness. The proportion of people who have had objective pulmonary function testing around the time of diagnosis and factors associated with receiving testing are not well understood.

METHODS

A retrospective cohort study was conducted using the health administrative data of all individuals aged 7 years and older with newly physician-diagnosed asthma living in Ontario, Canada between 1996 and 2007. Receipt of pulmonary function testing in the peridiagnostic period was determined and examined across patient sociodemographic and clinical factors.

RESULTS

Only 42.7% (95% CI, 42.6%-42.9%) of the 465,866 Ontarians newly diagnosed with asthma received pulmonary function testing between 1 year prior and 2.5 years following the time of diagnosis. In adjusted analyses, individuals 7 to 9 years old and those 70 years or older were less likely to receive testing than younger adults, individuals in the lowest neighborhood income quintile were less likely to receive testing than those in the highest, and individuals seeing a medical specialist were more likely to receive testing than those seeing only a general practitioner.

CONCLUSIONS

Less than one-half of patients with new physician-diagnosed asthma in Ontario, Canada received objective pulmonary function testing around the time of diagnosis. Further study is needed to determine why more pulmonary function testing is not being used to diagnose asthma and how barriers to its appropriate use can be overcome.

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.

Knowledge and use of ethnomedical treatments for asthma among Puerto Ricans in an urban community

PURPOSE

Puerto Ricans have higher lifetime and current asthma prevalence than other racial and ethnic groups in the United States. A great many Hispanics use ethnomedical therapies for asthma. This study elicited participant knowledge of ethnomedical therapies, developed a typology of the therapies, and considered whether some types are used or deemed efficacious based, in part, on information source.

METHODS

Eligible participants were randomly selected from the medical records of an inner-city primary care clinic serving a predominantly Hispanic community in Buffalo, New York. Thirty adult Puerto Ricans who had asthma or were care-givers of children with asthma were interviewed in person using a semistructured instrument. Qualitative data analysis followed a content-driven immersion-crystallization approach. Outcome measures were ethnomedical treatments for asthma known to participants, whether these treatments were used or perceived effective, and the participant's information source about the treatment.

RESULTS

Participants identified 75 ethnomedical treatments for asthma. Behavioral strategies were significantly more likely to be used or perceived effective compared with ingested and topical remedies (P <.001). Among information sources for ingested and topical remedies, those recommended by community members were significantly less likely to be used or perceived effective (P <.001) compared with other sources.

CONCLUSIONS

This sample of Puerto Ricans with a regular source of medical care was significantly more likely to use or perceive as effective behavioral strategies compared with ingested and topical remedies. Allopathic clinicians should ask Puerto Rican patients about their use of ethnomedical therapies for asthma to better understand their health beliefs and to integrate ethnomedical therapies with allopathic medicine.

Improving pediatric asthma control among minority children participating in medicaid: providing practice redesign support to deliver a chronic care model

BACKGROUND

Asthma, a leading chronic disease of children, currently affects about 6.2 million (8.5%) children in the United States. Despite advances in asthma research and availability of increasingly effective therapy, many children do not receive appropriate medications to control the disease, have over-reliance on reliever medication, and lack systematic follow-up care. The situation is even worse for poor inner-city and minority children who have significantly worse asthma rates, severity, and outcomes. National Asthma Education and Prevention Program Guidelines recommend a multimodal, chronic care approach.

OBJECTIVE

The authors assessed the effectiveness of practice redesign and computerized provider feedback in improving both practitioner adherence to National Asthma Education and Prevention Program Guidelines (NAEPP), and patient outcomes in 295 poor minority children across four Federally Qualified Health Centers (FQHC).

METHODS

In a nonrandomized, two-group (intervention versus comparison), two-phase trial, all sites were provided redesign support to provide quarterly well-asthma visits using structured visit forms, community health workers for outreach and follow-up, a Web-based disease registry for tracking and scheduling, and a provider education package. Intervention sites were given an additional Web-based, computerized patient-specific provider feedback system that produced a guideline-driven medication assessment prompt.

RESULTS

Logistic regression results showed that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to our feedback system during the Phase I enrollment period than providers at comparison sites (exp(B) = 2.351, confidence interval [CI] = 1.315-4.204). In Phase II (the post-enrollment visit period), hierarchical linear models (HLMs) and latent growth curves were used to show that asthma control improved significantly by .19 (SE = .05) on average for each of the remaining four visits (about 11% of a standard deviation), and improved even more for patients at intervention sites. These results show that implementation of practice redesign support guided by a pediatric chronic care model can improve provider adherence to treatment guidelines as well as patients' asthma control.

CONCLUSIONS

The addition of patient-specific feedback for providers results in quicker adoption of guideline recommendations and potentially greater improvements in asthma control compared to the basic practice redesign support alone.

Disparities between asthma management and insurance type among children

Asthma is a chronic illness among children. Minority children may be vulnerable to asthma complications since more than half are from households that are poor or near poor, and some have no health insurance. Asthma management plans are important for the long-term treatment of asthma and beneficial for self-management. This study analyzed insurance type and the relationship between having an asthma management plan among children across all races with asthma. This study utilized the 2002 and 2003 National Health Interview Survey. Findings showed that whites were significantly more likely than Non-Hispanic blacks and Hispanics to have an asthma management plan (OR, 1.66; p = .0031). In this study, children who reported Children's Health insurance Program (CHIP) coverage were twice as likely to have an asthma management plan (OR, 2.67; p = .0004). Mandating all insurers to provide an asthma management plan to children with asthma may reduce the race-based inequities and differences in asthma management plan status.

The impact of school building conditions on student absenteeism in Upstate New York

OBJECTIVES

We investigated Upstate New York school building conditions and examined the associations between school absenteeism and building condition problems.

METHODS

We merged data from the 2005 Building Condition Survey of Upstate New York schools with 2005 New York State Education Department student absenteeism data at the individual school level and evaluated associations between building conditions and absenteeism at or above the 90th percentile.

RESULTS

After adjustment for confounders, student absenteeism was associated with visible mold (odds ratio [OR]=2.22; 95% confidence interval [CI]=1.34, 3.68), humidity (OR=3.07; 95% CI=1.37, 6.89), poor ventilation (OR=3.10; 95% CI=1.79, 5.37), vermin (OR=2.23; 95% CI=1.32, 3.76), 6 or more individual building condition problems (OR=2.97; 95% CI=1.84, 4.79), and building system or structural problems related to these conditions. Schools in lower socioeconomic districts and schools attended by younger students showed the strongest associations between poor building conditions and absenteeism.

CONCLUSIONS

We found associations between student absenteeism and adverse school building conditions. Future studies should confirm these findings and prioritize strategies for school condition improvements.

Stress and the city: housing stressors are associated with respiratory health among low socioeconomic status Chicago children

Asthma disproportionately affects non-whites in urban areas and those of low socioeconomic status, yet asthma's social patterning is not well-explained by known risk factors. We hypothesized that disadvantaged urban populations experience acute and chronic housing stressors which produce psychological stress and impact health through biological and behavioral pathways. We examined eight outcomes: six child respiratory outcomes as well as parent and child general health, using data from 682 low-income, Chicago parents of diagnosed and undiagnosed asthmatic children. We created a continuous exposure, representing material, social and emotional dimensions of housing stressors, weighted by their parent-reported difficulty. We compared the 75th to the 25th quartile of exposure in adjusted binomial and negative binomial regression models. Higher risks and rates of poor health were associated with higher housing stressors for six of eight outcomes. The risk difference (RD) for poor/fair general health was larger for children [RD = 6.28 (95% CI 1.22, 11.35)] than for parents [RD = 3.88 (95% CI -1.87, 9.63)]. The incidence rate difference (IRD) for exercise intolerance was nearly one extra day per 2 weeks for the higher exposure group [IRD = 0.88 (95% CI 0.41, 1.35)]; nearly one-third extra day per 2 weeks for waking at night [IRD = 0.32 (95% CI 0.01, 0.63)]; and nearly one-third extra day per 6 months for unplanned medical visits [IRD = 0.30 (95% CI 0.059, 0.54)]. Results contribute to the conceptualization of urban stress as a "social pollutant" and to the hypothesized role of stress in health disparities. Interventions to improve asthma outcomes must address individuals' reactions to stress while we seek structural solutions to residential stressors and health inequities.

Factors related to undiagnosed asthma in urban adolescents: a multilevel approach

PURPOSE

We report the results of a school-based asthma case-identification survey to determine the prevalence and predictors of possible undiagnosed asthma in a population of urban adolescents.

METHODS

During school years 2006-2008, middle school students in Oakland, California, completed a brief survey adapted from the International Study of Asthma and Allergy in Children. Students were classified into one of three categories: no asthma, current asthma, or possible undiagnosed asthma. Students reported demographic information and residential address, which was geocoded and matched tract-level data from the US Census 2000, Oakland land use designations, public and assisted housing locations, and distance from closed-access roadways. Logistic regression was used to examine factors associated with possible undiagnosed asthma.

RESULTS

Of the 4,017 students who completed the survey, 4.8% (95% confidence interval [CI]: 4.1, 5.5) were classified as possible undiagnosed asthma. Female students (odds ratio: 1.53, 95% CI: 1.07, 2.19) and students who resided in an urban residential area (odds ratio: 2.05, 95% CI: 1.05, 4.05) had significantly increased odds of classification as "possible undiagnosed asthma" compared to current asthma. Percentage of noncitizen recent immigrants in a census tract was related to increased odds of possible undiagnosed asthma. Residence in a census tract with older residential units was significantly associated with decreased odds of undiagnosed asthma.

CONCLUSIONS

In urban settings, school-based asthma surveillance can aid in the identification of children with possible undiagnosed asthma. Implementation of a geographic information systems framework can enhance the identification of demographic and physical environmental factors associated with possible undiagnosed asthma.

A comparison of asthma prevalence and morbidity between rural and urban schoolchildren in Arkansas

BACKGROUND

Asthma disproportionately affects minority and low-income children. Investigations that focus on high-risk pediatric populations outside the inner city are limited.

OBJECTIVE

To compare asthma prevalence and morbidity in urban and rural children in Arkansas.

METHODS

We administered a validated survey to parents of children enrolled in urban and rural school districts in Arkansas. Rates of asthma diagnosis, asthma symptoms, medication use, and health care utilization were compared between urban and rural groups.

RESULTS

Age and sex distributions were similar; however, 85% of rural and 67% of urban children were black and 78% of rural and 37% of urban children had state-issued medical insurance (P < .001 for both). Provider-diagnosed asthma was similar in the rural vs urban groups (19% vs 20%); however, rural children were more commonly diagnosed as having chronic bronchitis (7% vs. 2%, P < .001). Rural children had more asthma morbidity compared with urban children, including recurrent trouble breathing (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.5-2.2), recurrent cough (OR, 2.2; 95% CI, 1.9-2.6), recurrent chest tightness (OR, 1.8; 95% CI, 1.5-2.2), and repeated episodes of bronchitis (OR, 2.2; 95% CI, 1.7-2.8) during the preceding 2 years. Rural children were more likely to report symptoms consistent with moderate to severe asthma compared with urban children (46% vs. 35%, P < .001). There were no differences in health care utilization between groups.

CONCLUSION

Asthma prevalence was similar between representative rural and urban groups in Arkansas, but asthma morbidity was significantly higher in the rural group.

Parent perceptions of neighborhood stressors are associated with general health and child respiratory health among low-income, urban families

BACKGROUND

This cross-sectional study examines parents' perceptions of their neighborhoods and general and respiratory health among low-income Chicago families. Asthma disproportionately affects nonwhite, urban, and low socioeconomic status (SES) populations, but Chicago's burden, and the national epidemic, are not well explained by known risk factors. Urban dwellers experience acute and chronic stressors that produce psychological distress and are hypothesized to impact health through biological and behavioral pathways. Identifying factors that covary with lower SES and minority-group status-e.g., stress-is important for understanding asthma's social patterning.

METHODS

We used survey data from 319 parents of children 5-13 years with asthma/respiratory problems and principal components analysis to create exposure variables representing parents' perceptions of two aspects of neighborhoods: collective efficacy ("CE") and physical/social order ("order"). Adjusted binomial regression models estimated risk differences (RDs) and 95% confidence intervals (CIs) for eight binary outcomes.

RESULTS

Magnitude was generally as expected, i.e., RD for low- versus high- (most favorable) exposure groups (RD(low v. high)) was larger than for the middle versus high contrast (RD(mid v. high)). "Parent general health" was strongly associated with "CE" (RD(low v. high) = 20.8 [95% CI: 7.8, 33.9]) and "order" (RD(mid v. high) = 11.4 [95% CI: 2.1, 20.7]), unlike "child general health," which had nearly null associations. Among respiratory outcomes, only "waking at night" was strongly associated with "CE" (RD(low v. high) = 16.7 [95% CI: 2.8, 30.6]) and "order" (RD(low v. high) = 22.2 [95% CI: 8.6, 35.8]). "Exercise intolerance" (RD(low v. high) = 15.8 [95% CI: 2.1, 29.5]) and "controllability" (RD(mid v. high) = 12.0 [95% CI: 1.8, 22.3]) were moderately associated with "order" but not with "CE," whereas "school absences," "rescue medication use," and "unplanned visits" had nearly null associations with both exposures.

CONCLUSIONS

More negative perceptions tended to be associated with higher risk of undesirable outcomes, adding to evidence that the social environment contributes to health and supporting research on stress' health impact among disadvantaged populations. Interventions must address not only traditional "environmental" factors, but also individuals' reactions to stress and attempt to mitigate effects of stressors while structural solutions to health inequities are sought.

Technical report--racial and ethnic disparities in the health and health care of children

OBJECTIVE

This technical report reviews and synthesizes the published literature on racial/ethnic disparities in children's health and health care.

METHODS

A systematic review of the literature was conducted for articles published between 1950 and March 2007. Inclusion criteria were peer-reviewed, original research articles in English on racial/ethnic disparities in the health and health care of US children. Search terms used included "child," "disparities," and the Index Medicus terms for each racial/ethnic minority group.

RESULTS

Of 781 articles initially reviewed, 111 met inclusion criteria and constituted the final database. Review of the literature revealed that racial/ethnic disparities in children's health and health care are quite extensive, pervasive, and persistent. Disparities were noted across the spectrum of health and health care, including in mortality rates, access to care and use of services, prevention and population health, health status, adolescent health, chronic diseases, special health care needs, quality of care, and organ transplantation. Mortality-rate disparities were noted for children in all 4 major US racial/ethnic minority groups, including substantially greater risks than white children of all-cause mortality; death from drowning, from acute lymphoblastic leukemia, and after congenital heart defect surgery; and an earlier median age at death for those with Down syndrome and congenital heart defects. Certain methodologic flaws were commonly observed among excluded studies, including failure to evaluate children separately from adults (22%), combining all nonwhite children into 1 group (9%), and failure to provide a white comparison group (8%). Among studies in the final database, 22% did not perform multivariable or stratified analyses to ensure that disparities persisted after adjustment for potential confounders.

CONCLUSIONS

Racial/ethnic disparities in children's health and health care are extensive, pervasive, and persistent, and occur across the spectrum of health and health care. Methodologic flaws were identified in how such disparities are sometimes documented and analyzed. Optimal health and health care for all children will require recognition of disparities as pervasive problems, methodologically sound disparities studies, and rigorous evaluation of disparities interventions.

School variation in asthma: compositional or contextual?

Background

Childhood asthma prevalence and morbidity have been shown to vary by neighborhood. Less is known about between-school variation in asthma prevalence and whether it exists beyond what one might expect due to students at higher risk of asthma clustering within different schools. Our objective was to determine whether between-school variation in asthma prevalence exists and if so, if it is related to the differential distribution of individual risk factors for and correlates of asthma or to contextual influences of schools.

Methods

Cross-sectional analysis of 16,640 teens in grades 7–12 in Wave 1 (data collected in 1994–5) of the National Longitudinal Study of Adolescent Health. Outcome was current diagnosis of asthma as reported by respondents' parents. Two-level random effects models were used to assess the contribution of schools to the variance in asthma prevalence before and after controlling for individual attributes.

Results

The highest quartile schools had mean asthma prevalence of 21.9% compared to the lowest quartile schools with mean asthma prevalence of 7.1%. In our null model, the school contributed significantly to the variance in asthma ( = 0.27, CI: 0.20, 0.35). Controlling for individual, school and neighborhood attributes reduced the between-school variance modestly ( = 0.19 CI: 0.13–0.29).

Conclusion

Significant between-school variation in current asthma prevalence exists even after controlling for the individual, school and neighborhood factors. This provides evidence for school level contextual influences on asthma. Further research is needed to determine potential mechanisms through which schools may influence asthma outcomes.

Asthma morbidity among children evaluated by asthma case detection

OBJECTIVE

Population-based asthma detection is a potential strategy to reduce asthma morbidity in children; however, the burden of respiratory symptoms and health care use among children identified by case detection is not well known.

METHODS

Data come from a school-based asthma case detection validation study of 3539 children. Respiratory symptoms, emergency department (ED) visits, and hospitalizations were assessed by questionnaire for children whose case detection result and physician study diagnosis agreed.

RESULTS

Physician evaluation of 530 case detection results yielded 420 cases of agreement (168 children with previously diagnosed asthma, 39 with undiagnosed asthma, and 213 without asthma). Children with previously diagnosed asthma were more likely to be male (P < .0001). No differences in severity were observed in children with previously and undiagnosed asthma (P = .31). Children with undiagnosed asthma reported less frequent daytime and nighttime symptoms than children with previously diagnosed asthma but more than those without asthma (P < .0001). The proportion of children with at least 1 respiratory-related ED visit in the past year was 32%, 3%, and 3% for those with previously diagnosed, undiagnosed, and no asthma, respectively (P < .0001). The proportion with at least 1 respiratory-related hospitalization was 8%, 0%, and 0%, respectively (P < .0001). There were no differences in nonrespiratory ED visits (P = .93).

CONCLUSIONS

Despite similar physician-rated severity, children with undiagnosed asthma reported significantly less frequent respiratory symptoms and health care use than children with previously diagnosed asthma. These findings suggest that the potential health gains from case detection may be smaller than expected.

Changes in the health burden of a national sample of children with asthma

This paper focused on the extent to which factors that are modifiable by health policies or provider recommendations influenced the level and changes in the burden of childhood asthma. Demographic factors, access to health care services, and asthma control activities were posited to potentially influence the level and changes in health burden of children with asthma. The Medical Expenditure Panel Survey data from 1996-1999 on 3-11 year old U.S. children with asthma (N=784) were used. The findings of multilevel models of perceived burden indicated unfavorable trajectories among those families who had public health insurance. Asthma control activities were associated with favorable trajectories of both perceived and objectively measured burden. These findings emphasized the significance of asthma control and access to high quality and stable health care services as health policy targets.

Social and environmental stressors in the home and childhood asthma

BACKGROUND

Both physical environmental factors and chronic stress may independently increase susceptibility to asthma; however, little is known on how these different risks may interact. The authors examined the relationship between maternal intimate partner violence (IPV), housing quality and asthma among children in the Fragile Families and Child Wellbeing Study (N=2013).

METHODS

Maternal reports of IPV were obtained after the child's birth and at 12 and 36 months. At the 36-month assessment, interviewers rated indoor housing conditions, regarding housing deterioration (ie, peeling paint, holes in floor, broken windows) and housing disarray (ie, dark, cluttered, crowded or noisy house). At the same time, mothers reported on housing hardships (ie, moving repeatedly, and hardships in keeping house warm). Maternal-report of physician-diagnosed asthma by age 36 months which was active in the past year was the outcome.

RESULTS

Asthma was diagnosed in 10% of the children. In an adjusted analysis, an increased odds of asthma was observed in children of mothers experiencing IPV chronically (OR 1.8, 95% CI 1.0 to 3.5) and in children experiencing housing disarray (OR 1.5, 95% CI 1.1 to 2.0) compared with those not exposed to these risks. In stratified analyses, a greater effect of IPV on asthma was noted among children living in disarrayed or deteriorated housing or among children whose mothers were experiencing housing hardship.

CONCLUSIONS

IPV and housing disarray are associated with increased early childhood asthma. Exposure to cumulative or multiple stressors (ie, IPV and poor housing quality) may increase children's risk of developing asthma more than a single stressor.

School-based asthma programs

Asthma is prevalent in school-age children and contributes to school absenteeism and limitation of activity. There is a sizable literature on school-based interventions for asthma that attempt to identify children with asthma and improve outcomes. The purpose of this review is to describe and discuss limitations of screening tools and school-based asthma interventions. Identification of children with asthma may be appropriate in schools located in districts with a high prevalence of children experiencing significant morbidity and a high prevalence of undiagnosed asthma, provided there is access to high-quality asthma care. We review strategies for improving access to care, for teaching self-management skills in schools, and for improving school personnel management skills. Although studies indicate that school-based programs have the potential to improve outcomes, competing priorities in the educational system present challenges to their implementation and emphasize the need for practical, targeted, and cost-effective strategies.

A new focus on assessing and treating asthma control in the African-American community: a call to action

Asthma continues to be a highly prevalent disease characterized by significant morbidity, unnecessary mortality, and substantial cost to the health care system. After decades of increasing prevalence, the number of current asthmatics in recent years has plateaued at approximately 22 million people in the United States. An additional 10 million Americans have a past history of asthma that is not active. The burden of asthma is higher among African Americans than in any other racial or ethnic group in America. The African-American community continues to experience a disproportional increase in asthma prevalence, morbidity, and mortality. The educational initiatives stemming from the newly revised National Heart Lung and Blood Institute (NHLBI) guidelines provide the opportunity to address the increased burden of asthma in the African American community. These new guidelines, released in August 2007, focus on asthma control as the primary goal of therapy, routine monitoring of asthma control, and use of asthma control assessments to direct treatment. The present review discusses the following: I. The impact of health disparities on outcomes of African Americans with asthma, II. The barriers that prevent asthmatic patients from achieving optimal control, III. The unique factors that challenge practitioners and patients in achieving optimal asthma control in the African American Community, IV. The impact of good asthma control and the need for patients and clinicians to assess asthma control in with a standardized assessment tool, and V. Strategic initiatives and the role of the End The Attacks NOW program in improving outcomes for African American patients with asthma.

Underdiagnosed and uncontrolled asthma: findings in rural schoolchildren from the Delta region of Arkansas

BACKGROUND

Studies of asthma in school-aged rural children in the United States are limited, and there are no studies of high-risk pediatric populations in rural environments.

OBJECTIVES

To examine the prevalence of asthma and to evaluate markers of morbidity in 2 rural school districts in the Arkansas Delta region.

METHODS

Children at risk for asthma were identified by using a cross-sectional asthma case-finding survey. Surveys were distributed to students enrolled in the Marvell and Eudora school districts during the 2005-2006 school year.

RESULTS

The response rate was 81% (964 of 1,190). The mean age of the 964 children who completed the survey was 10.3 years (age range, 4-17 years); 85% were African American, and 78% had state-issued insurance. Twenty-eight percent (268 of 964) of the children were categorized as being at risk for asthma by previous physician diagnosis (33%), algorithm diagnosis (16%), or both (51%). Of the 268 at-risk children, 79% reported persistent symptoms and 21% reported intermittent or no current symptoms. In the previous 4 weeks, 59% of the children experienced daytime and nocturnal symptoms and 62% used rescue medications. Activity limitation and treatment in the emergency department or hospitalization for asthma in the previous 2 years were reported by 82% and 49% of the children, respectively.

CONCLUSIONS

Active asthma symptoms are prevalent in this predominantly minority, low-income, rural population. High rates of undiagnosed and uncontrolled asthma are suggested by frequent asthma symptoms, activity limitation, rescue medication use, and emergency health care utilization. Future studies of pediatric asthma should focus on high-risk populations in rural locales.

The experience of being an Asthma Amigo in a program to decrease asthma episodes in Hispanic children

Asthma is the most common chronic illness among Latino children in urban areas. It is especially problematic for schools serving low-income and minority populations. The purpose of this study was to describe the experience of being an Asthma Amigo, a community-based educator who delivered asthma education to a Hispanic community in a train-the-trainer educational model. Focus group process evaluation was used to assess participant experiences and program strengths and weaknesses. Findings suggested that being an Asthma Amigo helped in gaining entrée into the community and in spreading the message of asthma triggers and prevention.

Normative values for exhaled breath condensate pH and its relationship to exhaled nitric oxide in healthy African Americans

BACKGROUND

Exhaled breath condensate (EBC) pH and exhaled nitric oxide (FeNO) have been proposed as markers of asthma severity. EBC pH values below 6.5 have been associated with asthma exacerbations. Protonation of airway nitrite occurs at low pH and may contribute to FeNO.

OBJECTIVE

To establish normative EBC pH values and to determine the contribution of EBC pH to FeNO in healthy African Americans.

METHODS

Two hundred seventy healthy African American subjects without asthma between 18 and 40 years old were evaluated. Subjects had simultaneous measurement of EBC pH, EBC nitrite, nitrate, and FeNO.

RESULTS

The median EBC pH was 8.14 (interquartile range, 7.83-8.28). Of subjects, 11.9% had an EBC pH < or = 6.5. In subjects with EBC pH values below 6.5, there was an inverse correlation between EBC pH and FeNO (r(2) = 0.158; P = .0245; n = 32). In the entire cohort, there was a direct correlation between EBC pH and EBC nitrite (r(2) = 0.163; P < .0001), but there was no correlation between EBC nitrite and FeNO. In multivariate analyses, EBC pH and nitrite did not contribute significantly to FeNO variation while controlling for other confounders of FeNO.

CONCLUSION

There was an increased prevalence (11.9%) of low EBC pH (less than 6.5) in healthy African American subjects compared with white subjects (<5%). EBC pH and nitrite were directly correlated, but there was no correlation between EBC nitrite and FeNO. FeNO correlated with EBC pH at pH values less than 6.5 in univariate but not multivariate analyses. This suggests that EBC pH and nitrite are not significant determinants of FeNO in healthy subjects.