Asthma is one of the most common chronic diseases affecting children. Despite publicized expert panels on asthma management and the availability of high-potency inhaled corticosteroids, asthma continues to pose an enormous burden on quality of life for children. Research into the genetic and molecular origins of asthma are starting to show how distinct disease entities exist within the syndrome of “asthma”. Biomarkers can be used to diagnose underlying molecular mechanisms that can predict the natural course of disease or likely response to drug treatment. The progress of personalized medicine in the care of children with asthma is still in its infancy. We are not yet able to apply stratified asthma treatments based on molecular phenotypes, although that time may be fast approaching. This review discusses some of the recent advances in asthma genetics and the use of current biomarkers that can help guide improved treatment. For example, the fraction of expired nitric oxide and serum Immunoglobulin E (IgE) (including allergen-specific IgE), when evaluated in the context of recurrent asthma symptoms, are general predictors of allergic airway inflammation. Biomarker assays for secondhand tobacco smoke exposure and cysteinyl leukotrienes are both promising areas of study that can help personalize management, not just for pharmacologic management, but also education and prevention efforts.
asthma; biomarkers; children; management
Allergic diseases such as bronchial asthma and atopic dermatitis develop by a combination of genetic and environmental factors. Several candidate causative genes of asthma and atopy have been reported as the genetic factors. The clinical features of patients and causes of diseases vary. Therefore, personalized medicine (tailor-made medicine) is necessary for the improvement of quality of life (QOL) and for asthma cure. Pharmacogenetics is very important for personalized medicine. Here, we present the genetics and pharmacogenetics of asthma in children. Finally, we show the guideline for personalized medicine for asthma, particularly in childhood, including the pharmacogenetics of anti-asthmatic drugs, preliminarily produced by the authors.
Pharmacogenetics; asthma; individualized medicine
There is evidence that both personality traits and personal beliefs about medications affect adherence behavior. However, limited research exists on how personality and beliefs about asthma medication interact in influencing adherence behavior in people with asthma. To extend our knowledge in this area of adherence research, we aimed to determine the mediating effects of beliefs about asthma medication between personality traits and adherence behavior.
Asthmatics (n=516) selected from a population-based study called West Sweden Asthma Study completed the Neuroticism, Extraversion and Openness to Experience Five-Factor Inventory, the Medication Adherence Report Scale, and the Beliefs about Medicines Questionnaire. Data were analyzed using confirmatory factor analysis and structural equation modeling.
Three of the five investigated personality traits – agreeableness, conscientiousness, and neuroticism – were associated with both concerns about asthma medication and adherence behavior. Concerns functioned as a partial mediator for the influencing effects of agreeableness, conscientiousness, and neuroticism on adherence behavior.
The findings suggest that personality traits could be used to identify individuals with asthma who need support with their adherence behavior. Additionally, targeting concerns about asthma medication in asthmatics with low levels of agreeableness or conscientiousness or high levels of neuroticism could have a favorable effect on their adherence behavior.
adherence; individual differences; medication concerns; health behavior
Health literacy (HL) affects adult asthma management, yet less is known about how parent HL affects child asthma care.
To examine associations between parent HL and measures related to child asthma.
Parents of 499 school-age urban children with persistent asthma in Rochester, New York completed home interviews. Measures: The Rapid Estimate of Adult Literacy in Medicine for parent HL; NHLBI criteria for asthma severity, and validated measures of asthma knowledge, beliefs, and experiences. Analyses: Bivariate and multivariate analyses of associations between parent HL measures related to child asthma.
Response rate: 72%, mean child age: 7.0 years. Thirty-two percent had a Hispanic parent; 88% had public insurance. Thirty-three percent had a parent with limited HL. Low parent HL was independently associated with greater parent worry parent perception of greater asthma burden, and lower parent-reported quality of life. Measures of health care use (e.g., emergency care, preventive medicines) were not associated with parent HL.
Parents with limited HL worried more and perceived greater overall burden from the child’s asthma, even though reported health care use did not vary.
Improved parent understanding and provider-parent communication about child asthma could reduce parent-perceived asthma burden, alleviate parent worry, and improve parent quality of life.
Health Literacy; asthma; asthma care; child health; child asthma; health behavior; health beliefs; provider-patient communication; pediatric care; medical care; REALM; poverty; low-income; PACQOL; asthma burden; urban children
Many studies have shown the effectiveness of self-management for patients with asthma. In particular, possession and use of a written asthma action plan provided by a doctor has shown to significantly improve patients’ asthma control. Yet, uptake of a written asthma action plan and preventative asthma management is low in the community, especially amongst adults.
A Web-based personally controlled health management system (PCHMS) called Healthy.me will be evaluated in a 2010 CONSORT-compliant 2-group (static websites verse PCHMS) parallel randomized controlled trial (RCT) (allocation ratio 1:1).
The PCHMS integrates an untethered personal health record with consumer care pathways and social forums. After eligibility assessment, a sample of 300 adult patients with moderate persistent asthma will be randomly assigned to one of these arms. After 12 months of using either Healthy.me or information websites (usual care arm), a post-study assessment will be conducted.
The primary outcome measure is possession of or revision of an asthma action plan during the study. Secondary outcome measures include: (1) adherence to the asthma action plan, (2) rate of planned and unplanned visits to healthcare providers for asthma issues, (3) usage patterns of Healthy.me and attrition rates, (4) asthma control and asthma exacerbation scores, and (5) impact of asthma on life and competing demands, and days lost from work.
This RCT will provide insights into whether access to an online PCHMS will improve uptake of a written asthma action plan and preventative asthma actions.
Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12612000716864; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362714 (Archived by WebCite at http://www.webcitation.org/6IYBJGRnW).
asthma management; Internet intervention; personalized health record; personally controlled health management system; eHealth; asthma action plan
Epidemiologic studies have suggested the association between environmental exposure to volatile organic compounds (VOCs) and polycyclic aromatic hydrocarbons (PAHs) and the increased risk of incurring asthma. Yet there is little data regarding the relationship between personal exposure to air pollution and the incidence of asthma in children. This study was designed to evaluate the effect of exposure to air pollution on children with asthma by using exposure biomarkers. We assessed the exposure level to VOCs by measuring urinary concentrations of hippuric acid and muconic acid, and PAHs by 1-OH pyrene and 2-naphthol in 30 children with asthma and 30 children without asthma (control). The mean level of hippuric acid was 0.158 ± 0.169 µmol/mol creatinine in the asthma group and 0.148 ± 0.249 µmol/mol creatinine in the control group, with no statistical significance noted (p=0.30). The mean concentration of muconic acid was higher in the asthma group than in the control group (7.630 ± 8.915 µmol/mol creatinine vs. 3.390 ± 4.526 µmol/mol creatinine p=0.01). The mean level of urinary 1-OHP was higher in the asthma group (0.430 ± 0.343 µmol/mol creatinine) than the control group (0.239 ± 0.175 µmol/mol creatinine), which was statistically significant (p=0.03). There was no difference in the mean concentration of 2-NAP between the two groups (9.864 ± 10.037 µmol/mol in the asthma group vs. 9.157 ± 9.640 µmol/mol in the control group, p=0.96). In conclusion, this study suggests that VOCs and PAHs have some role in asthma.
VOCs; PAHs; asthma
In the management of asthma, features of care important to patients may not be fully appreciated. This study quantifies the importance of different features of asthma management from the patient perspective. This may assist in the development of personalised management strategies.
We used the technique of discrete choice experiment (DCE). Patients over 18 years of age with asthma, prescribed and taking medicine at step 3 of the UK guidelines were recruited from 15 general (family) practices in three areas of the UK. 147 evaluable questionnaires were returned from a total of 348 sent out. The outcome measures were the relative importance to patients of features of asthma management and the impact of changes in asthma management, as measured by utility shift between the features tested.
The largest shift in mean utility values was recorded in "number of inhalers" and "use of inhaled steroid". Use of a personal asthma action plan was ranked next highest.
This study suggests that adults with moderate or severe asthma would trade some improvements in symptom relief in favour of, for example, simpler treatment regimens that use as few inhalers as possible and a lower dose of inhaled steroid.
The knowledge of most plants used in the treatment of asthma, the plant part which is effective in treatment is confined to very few persons
who are engaged in folklore medicine. However, this form of medicine is not very popular. Therefore, it is of considerable interest to ethno-botanical
community to understand the plants and the parts used for treatment. Here, we describe AsthmaPlantBase, a database containing information of medicinal
plants for treatment of asthma.
asthmaplants; medicinal; database; phytochemical; active principles
Many international and national asthma guidelines are now available in large parts of the world, but they are not yet implemented appropriately. There is a gap between scientific evidence-based medicine and real clinical practice. Implementation of guidelines is highly complex. Special strategies are needed to encourage guideline-based, high-quality care. It is important to understand the contents, the format, and the learning strategies which physicians prefer for the dissemination of guidelines. Physicians prefer more concise and immediately available guidelines that are practical to use. Thus, asthma guidelines should be disseminated as convenient and easily accessible tools. Various education programs and decision-support tools have been designed and applied to the clinical management of asthma to solve these challenging problems. Many of them have been shown to be effective at increasing physicians' knowledge and adherence to asthma guidelines and improving patients' clinical outcomes. These educational and decision-support tools are expected to contribute to a narrowing of the gap between asthma guidelines and practice/implementation of the guidelines.
Asthma; Guideline; Education; Decision-support; Implementation
Asthma is a significant disease among children, and its prevalence has increased notably during the last 2 decades. A traditional Korean medicine, So-Cheong-Ryong-Tang (SCRT), has been used for the treatment of asthma in Asia for centuries, but its mechanism for reducing bronchopulmonary inflammation in asthma has yet to be elucidated.
To investigate whether the herbal extract SCRT inhibits inflammation in a mouse model of cockroach allergen–induced asthma.
A house dust extract containing endotoxin and cockroach allergens was used for immunization and 2 additional pulmonary challenges in BALB/c mice. Mice were treated with SCRT or vehicle 1 hour before each pulmonary challenge. Respiratory parameters were evaluated by whole-body plethysmography and forced oscillation methods 24 hours after the last challenge. Bronchoalveolar lavage (BAL) fluid was collected, and histologic sections of lung were prepared either 4 or 24 hours after the last house dust extract challenge.
SCRT treatment significantly reduced the hyperreactivity of the airways as measured by whole-body plethysmography and direct measurement of airway resistance. Inflammation was significantly inhibited by SCRT treatment as demonstrated by reduced plasma IgE levels and improved pulmonary histologic characteristics. SCRT significantly reduced the number of neutrophils in the BAL fluid and also significantly reduced the BAL levels of CXC chemokines, providing a potential mechanism for the reduced inflammation. In a similar fashion, SCRT reduced eosinophil recruitment and BAL levels of eotaxin and RANTES.
These data indicate that SCRT treatment alleviates asthma-like pulmonary inflammation via suppression of specific chemokines.
Current data overwhelmingly document the existence of a worldwide asthma epidemic, although individual studies remain controversial. The epidemic is thought to involve primarily persons with allergic asthma, and many diverse theories, based on an immunopathologic understanding of disease, have recently emerged to explain this involvement. In the context of recent insights into the immune basis of experimental asthma, we discuss in this review the leading asthma epidemic theories, including a new theory based on inhaled environmental proteases. Although no single theory may yet be fully embraced, there exists substantial hope that a unifying mechanism for the epidemic will be revealed through additional research.
Rationale: Urban African-American youth, aged 15–19 years, have asthma fatality rates that are higher than in whites and younger children, yet few programs target this population. Traditionally, urban youth are believed to be difficult to engage in health-related programs, both in terms of connecting and convincing.
Objectives: Develop and evaluate a multimedia, web-based asthma management program to specifically target urban high school students. The program uses “tailoring,” in conjunction with theory-based models, to alter behavior through individualized health messages based on the user's beliefs, attitudes, and personal barriers to change.
Methods: High school students reporting asthma symptoms were randomized to receive the tailored program (treatment) or to access generic asthma websites (control). The program was made available on school computers.
Measurements and Main Results: Functional status and medical care use were measured at study initiation and 12 months postbaseline, as were selected management behaviors. The intervention period was 180 days (calculated from baseline). A total of 314 students were randomized (98% African American, 49% Medicaid enrollees; mean age, 15.2 yr). At 12 months, treatment students reported fewer symptom-days, symptom-nights, school days missed, restricted-activity days, and hospitalizations for asthma when compared with control students; adjusted relative risk and 95% confidence intervals were as follows: 0.5 (0.4–0.8), p = 0.003; 0.4 (0.2–0.8), p = 0.009; 0.3 (0.1–0.7), p = 0.006; 0.5 (0.3–0.8), p = 0.02; and 0.2 (0.2–0.9), p = 0.01, respectively. Positive behaviors were more frequently noted among treatment students compared with control students. Cost estimates for program delivery were $6.66 per participating treatment group student.
Conclusions: A web-based, tailored approach to changing negative asthma management behaviors is economical, feasible, and effective in improving asthma outcomes in a traditionally hard-to-reach population.
asthma; urban; adolescents; school-based; web-based
Urban African-American youth, aged 15–19 years, have asthma fatality rates that are higher than in whites and younger children, yet few programs target this population. Traditionally, urban youth are believed to be difficult to engage in health-related programs, both in terms of connecting and convincing.
Develop and evaluate a multimedia, web-based asthma management program to specifically target urban high school students. The program uses “tailoring,” in conjunction with theory-based models, to alter behavior through individualized health messages based on the user’s beliefs, attitudes, and personal barriers to change.
High school students reporting asthma symptoms were randomized to receive the tailored program (treatment) or to access generic asthma websites (control). The program was made available on school computers.
Measurements and Main Results
Functional status and medical care use were measured at study initiation and 12 months postbaseline, as were selected management behaviors. The intervention period was 180 days (calculated from baseline). A total of 314 students were randomized (98% African American, 49% Medicaid enrollees; mean age, 15.2 yr). At 12 months, treatment students reported fewer symptom-days, symptom-nights, school days missed, restricted-activity days, and hospitalizations for asthma when compared with control students; adjusted relative risk and 95% confidence intervals were as follows: 0.5 (0.4–0.8), p = 0.003; 0.4 (0.2–0.8), p = 0.009; 0.3 (0.1–0.7), p = 0.006; 0.5 (0.3–0.8), p = 0.02; and 0.2 (0.2–0.9), p = 0.01, respectively. Positive behaviors were more frequently noted among treatment students compared with control students. Cost estimates for program delivery were $6.66 per participating treatment group student.
A web-based, tailored approach to changing negative asthma management behaviors is economical, feasible, and effective in improving asthma outcomes in a traditionally hard-to-reach population.
asthma; urban; adolescents; school-based; web-based
Asthma is believed to increase the risk for several proinflammatory diseases, yet epidemiologic studies on asthma in relation to risk of developing type 2 diabetes are sparse and have reported inconsistent results. In the present study, we investigated the hypothesis that asthma is associated with an increased risk of incident type 2 diabetes in Chinese adults.
We used data from the Singapore Chinese Health Study, including Chinese men and women aged 45–74 years, free of cancer, heart disease, stroke, and diabetes at baseline (1993–1998) and followed through 2004 for incident physician-diagnosed diabetes. Cox regression models were used to examine the associations between self-reported history of physician-diagnosed asthma and risk of diabetes.
During an average follow-up of 5.7 years per person, 2,234 of the 42,842 participants included in the current analyses reported diagnoses of type 2 diabetes. After adjustment for potential confounders, not including body mass index (BMI), asthma was associated with a 31% increased risk of incident diabetes (HR = 1.31; 95% CI: 1.00–1.72). The association was attenuated after adjustment for adult BMI (HR = 1.25 95% CI: 0.95–1.64). The asthma-diabetes association appeared stronger for adult- versus child-diagnosed asthma cases, and for participants who were obese compared to non-obese.
In Singaporean Chinese adults we observed a positive association between self-reported, physician-diagnosed asthma and risk of developing type 2 diabetes that was modestly attenuated upon adjustment for BMI.
Asthma; Type 2 diabetes; Obesity
To assess the effects of depressive symptoms on asthma patients' reports of functional status and health-related quality of life.
Primary care internal medicine practice at a tertiary care center in New York City.
We studied 230 outpatients between the ages of 18 and 62 years with moderate asthma.
MEASUREMENTS AND MAIN RESULTS
Patients were interviewed in person in English or Spanish with two health-related quality-of-life measures, the disease-specific Asthma Quality of Life Questionnaire (AQLQ) (possible score range, 1 to 7; higher scores reflect better function) and the generic Medical Outcomes Study SF-36 (general population mean is 50 for both the Physical Component Summary [PCS] score and Mental Component Summary [MCS] score). Patients also completed a screen for depressive symptoms, the Geriatric Depression Scale (GDS), and a global question regarding current disease activity. Stepwise multivariate analyses were conducted with the AQLQ and SF-36 scores as the dependent variables and depressive symptoms, comorbidity, asthma, and demographic characteristics as independent variables. The mean age of patients was 41 ±SD 11 years and 83% were women. The mean GDS score was 11 ±SD 8 (possible range, 0 to 30; higher scores reflect more depressive symptoms), and a large percentage of patients, 45%, scored above the threshold considered positive for depression screening. Compared with patients with a negative screen for depressive symptoms, patients with a positive screen had worse composite AQLQ scores (3.9 ±SD 1.3 vs 2.8 ±SD 0.8, P < .0001) and worse PCS scores (40 ±SD 11 vs 34 ±SD 8, P < .0001) and worse MCS scores (48 ±SD 11 vs 32 ±SD 10, P < .0001) scores. In stepwise analyses, current asthma activity and GDS scores had the greatest effects on patient-reported health-related quality of life, accounting for 36% and 11% of the variance, respectively, for the composite AQLQ, and 11% and 38% of the variance, respectively, for the MCS in multivariate analyses.
Nearly half of asthma patients in this study had a positive screen for depressive symptoms. Asthma patients with more depressive symptoms reported worse health-related quality of life than asthma patients with similar disease activity but fewer depressive symptoms. Given the new emphasis on functional status and health-related quality of life measured by disease-specific and general health scales, we conclude that psychological status indicators should also be considered when patient-derived measures are used to assess outcomes in asthma.
asthma; depressive symptoms; quality of life; global measure
Tylophora indica (Burm.f) Merr. (ASCLEPIDACEAE) is an important Indian medicinal plant. It is called “ASTHMA KODI” OR “NANJARUPPAN” IN Tamil in the Siddha system of medicine. Tamil medical literature reveal that it is an ideal plant medicine for respiratory problems and is also a cardiac tonic. For medicinal purposes it is collected only from the wild. It has not yet been brought under cultivation. Its taxonomy, morphology, ecology and medicinal uses were studied. Since, tissue-culture is a costly technology and requiring a high-tech laboratory a low-cost mass- multiplication technique has been invented through water-culture experiments, in order to make its saplings available to the interested herbal farmers in a larger scale. The results are reported in this paper, which will be of immense help and use to the herbal farmers.
To evaluate documentation of compliance with the National Asthma Education and Prevention Program publication Guidelines for the Diagnosis and Management of Asthma.
A retrospective review of 114 charts coded as asthma. Fourteen chart evaluation questions were developed based on the 4 management components in the guidelines: assessment and monitoring of asthma, control of asthma factors, pharmacotherapy, and patient education.
A hospital-based asthma clinic, a private pulmonary group, and a general internal medicine group in Dallas, Texas.
Nearly all physicians documented inquiries about daytime asthma symptoms, but only 64% of pulmonary group and 58% of internal medicine physicians documented inquiries about nighttime symptoms. In addition, in 14% of pulmonary group charts and 74% of internal medicine charts, no spirometry or peak flow data were documented. Most asthma clinic and pulmonary group charts (98% and 78%, respectively) included a history of triggers, but the pulmonary group and internal medicine group were more likely to document administration of the influenza vaccine than the asthma clinic (25% and 26% vs 13%). Of 38 patients with ≥1 recorded forced expiratory volume in 1 second <60%, all but 1 were on inhaled steroids. However, many charts lacked adequate documentation to match drug selection to asthma severity. The asthma clinic group documented the 4 educational interventions 65% to 83% of the time, compared with the pulmonary group, at 17% to 50%, and the internal medicine group, at 5% to 18%.
Results showed significant variation with the recommendations. Areas in particular need of improvement were objective diagnosis and assessment, control of asthma-associated factors, and patient education. Furthermore, the study demonstrated significant variation between specialists and primary care physicians, with the more specialized clinics demonstrating better guideline compliance.
Many risk factors for asthma have been investigated, one of which is the workplace. Work related asthma is a frequently reported occupational respiratory disease yet the characteristics which distinguish it from non‐work related asthma are not well understood. The purpose of this study was to examine differences between work related and non‐work related asthma with respect to healthcare use and asthma control characteristics.
Data from the Massachusetts Behavioral Risk Factor Surveillance System for 2001 and 2002 were used for this analysis. Work related status of asthma was determined by self‐report of ever having been told by a physician that asthma was work related. Healthcare measures evaluated were emergency room visits and physician visits for worsening asthma and for routine care. Characteristics of asthma control evaluated were frequency of asthma symptoms, asthma attacks, difficulty sleeping, and asthma medication usage in the last 30 days and limited activity in the past 12 months.
The prevalence of lifetime and current asthma in Massachusetts were 13.0% and 9.2%, respectively. Approximately 6.0% (95% CI 4.8 to 7.3) of lifetime and 6.2% (95% CI 4.7 to 7.8) of current asthma cases were work related. In the past 12 months, individuals with work related current asthma were 4.8 times (95% CI 2.0 to 11.6) as likely to report having an asthma attack, 4.8 times (95% CI 1.8 to 13.1) as likely to visit the emergency room at least once, and 2.5 times (95% CI 1.1 to 6.0) as likely to visit the doctor at least once for worsening asthma compared to individuals with non‐work related asthma.
Work related asthma is associated with increased frequency of asthma attacks and use of healthcare services. A better understanding of factors that contribute to differences in healthcare use and asthma control is needed to improve prevention and control strategies for individuals suffering from the disease.
Whilst global asthma mortality seems to be decreasing, childhood asthma incidence is rising, and early warnings from Australia show an increase in asthma-related deaths in under-15s; this article considers whether we should view the future impact of asthma with trepidation. Age-adjusted mortality statistics for asthma have been reevaluated to provide an international standard. Comparisons across regions and time are complex, yet over the last two decades asthma mortality has clearly decreased, coinciding with a significant change in asthma management. The majority of remaining asthma deaths are preventable.
Nonetheless, ongoing vigilance is required. Asthma remains under-diagnosed and under-treated. Childhood asthma has become more common; it is a matter of debate whether it is also more severe. Rather than being encouraged by the fall in numbers of asthma deaths, we should focus on the surging numbers of children suffering from the disease - and the worrying increase in asthma death rates in Australian children - and work to avert future issues.
Asthma mortality; Asthma incidence; Asthma clinical trials
Information about personalized medicine abounds, yet it is difficult to comprehensively search for information on this topic due to the broadness of the term “personalized medicine, ” the variety of terms that are used to describe this concept, the vast amount of pertinent journal articles and Web sites, and the fast pace of developments in this field, A selected list of Web sites is provided as a starting place for information about concepts, terminology, projects, databases, tools, and stakeholders related to personalized medicine.
personalized medicine; personalized health care; pharmacogenomics; genomics; Human Genome Project; Web site; internet
In commemorate the 9th Asia Pacific Congress of Allergy, Asthma, and Clinical Immunology (APCAACI) in Taipei, Taiwan in November this year, some of the seminar works and contributions by the researchers from Taiwan to the advance in the field of allergy and clinical immunology, such as DNA vaccine, traditional Chinese medicine, anti-IgE antibody, and personalized medicine for severe drug allergic reaction, are summarized in this special review.
Allergy; Taiwan; Anti-IgE antibody; Severe drug reaction
This article reports on the development of a personalized, Web-based asthma-education program for parents whose 4- to 12-year-old children have moderate to severe asthma. Personalization includes computer-based tailored messages and a human coach to build asthma self-management skills. Computerized features include the Asthma Manager, My Calendar/Reminder, My Goals, and a tailored home page. These are integrated with monthly asthma-education phone calls from an asthmanurse case manager. The authors discuss the development process and issues and describe the current randomized evaluation study to test whether the yearlong integrated intervention can improve adherence to a daily asthma controller medication, asthma control, and parent quality of life to reduce asthma-related healthcare utilization. Implications for health education for chronic disease management are raised.
asthma case management; medication adherence-pediatric asthma; pediatric asthma; program development-pediatric asthma; nurse case management; chronic disease selfmanagement; eHealth; interactive health communication
To compare the medical costs and prevalence of health conditions of family members of persons with an alcohol or drug dependence (AODD) diagnosis to family members of persons with diabetes and asthma.
Kaiser Permanente of Northern California (KPNC)
Family members of persons diagnosed with AODD between 2002 and 2005, and matched samples of family members of persons diagnosed with diabetes and asthma.
Logistic regression was used to determine whether the family members of persons with AODD were more likely to be diagnosed with medical conditions than family members of persons with diabetes or asthma. Multivariate models were used to compare health services cost and utilization of AODD family members and diabetes and asthma family members. Analyses were for the year before, and two years after, initial diagnosis of the index person.
In the year before initial diagnosis of the index person, AODD family members were more likely to be diagnosed with substance use disorders, depression and trauma than diabetes or asthma family members. AODD family members had higher total health care costs than diabetes family members in the year after, and the second year after, the index date ($217 and $293, respectively). AODD family members had higher total health care costs than asthma family members in the year before, and second year after, the index date ($104 and $269, respectively).
AODD family members have unique patterns of health conditions compared to the diabetes and asthma family members, and have similar, or higher, health care cost and utilization.
alcohol; drug; dependence; costs; family; diabetes; asthma
Assessing asthma control at each patient encounter is an essential task to determine pharmacologic requirements. Rules of Two (Ro2) was created from the original 1991 National Asthma Education Program guidelines to determine the need for controller therapy. This study determined the degree of agreement between Ro2 and the Expert Panel Report (EPR-3) definition of “in control” asthma and compared that value with the Asthma Control Test (ACT) in a group of asthmatics for the purpose of validating this tool. Patients with documented asthma were randomized to complete Ro2 or ACT prior to being assessed for asthma control by certified asthma educators using an EPR-3 template. Assessments occurred in either a specialty asthma clinic or at a local health fair. Patients were also queried for their personal assessment of asthma control. The primary statistical methodology employed was the degree of agreement (kappa) between each survey tool and the EPR-3 template. Of 150 patients, 72% did not have their asthma in control, based on the EPR-3 template. Ro2 identified 58% of patients not in control of their asthma, whereas ACT identified 36%, with kappa scores of 0.41 for Ro2 and 0.37 for ACT compared with the EPR-3 template. These were not significantly different. Of the 150 patients, 75% considered their asthma in control based on self-assessments, with a kappa of 0.23. In 14 of 73 ACT questionnaires, scores were not added or were misadded. Eliminating evaluation of static lung function significantly improved both kappa scores of Ro2 and ACT. In conclusion, Ro2 identifies patients with uncontrolled asthma as well as ACT and may be useful to the primary assessing clinician in determining asthma control.
Respect is frequently invoked as an integral aspect of ethics and professionalism in medicine, yet it is often unclear what respect means in this setting. While we recognize that there are many reasonable ways to think about and use the term ‘respect’, in this paper, we develop a conception of respect that imposes a distinct moral duty on physicians. We are concerned mainly with the idea of respect for persons, or more specifically, respect for patients as persons. We develop an account of respect as recognition of the unconditional value of patients as persons. Such respect involves respecting the autonomy of patients, but we challenge the idea that respect for autonomy is a complete or self-sufficient expression of respect for persons. Furthermore, we suggest that the type of respect that physicians owe to patients is independent of a patient’s personal characteristics, and therefore, ought to be accorded equally to all. Finally, the respect that we promote has both a cognitive dimension (believing that patients have value) and a behavioral dimension (acting in accordance with this belief).
ethics; respect for persons; respect for autonomy; professionalism