Bronchial thermoplasty (BT) can provide relief for patients with severe, uncontrolled asthma despite maximal medical therapy. However, it is unclear whether BT is safe in patients with very severe airflow obstruction.
We performed BT in eight patients with severe asthma as defined by Expert Panel Report 3 (EPR-3) guidelines who were poorly controlled despite step 5 therapy. Data were available on each subject for 1 year prior to and 15–72 weeks following BT.
The mean (±SEM) pre-bronchodilator forced expiratory volume in one second (FEV1) prior to BT was 51.8 ± 8.6% of predicted, and the mean (±SEM) number of hospitalizations for asthma in the year prior to BT was 2.9 ± 1.2. No subject had an unexpected severe adverse event due to BT. Among the eight patients with follow-up of at least 15 weeks, there was no significant decline in FEV1 (p = .4).
We suggest that BT may be safe for asthma patients with severe airflow obstruction and higher hospitalization rates than previously reported.
airway smooth muscle; persistent airflow obstruction; poorly controlled asthma; radiofrequency ablation; refractory asthma
Bronchial thermoplasty (BT) is an emerging therapy for patients with severe persistent asthma who remain poorly controlled despite standard maximal medical therapy. Thermoplasty elicits asthma control over time by applying thermal radiofrequency energy to airways to ablate underlying smooth muscle. While this therapy is suggested to eliminate such smooth muscle permanently, no human studies have examined the possibility of treatment failure.
We present a 62-year-old female with severe, refractory asthma symptoms who underwent BT without apparent complications. However, severe symptoms including multiple clinical exacerbations persisted despite BT treatment. Repeat endobronchial biopsy done six months after BT treatment demonstrated persistent smooth muscle hyperplasia in multiple airways that previously had been treated. The patient continued to have uncontrolled, refractory asthma despite multiple therapies.
This case is the first to describe a failure of BT to reduce or eliminate airway smooth muscle in a patient with severe persistent asthma. It suggests the potential for treatment failure in the management of these patients after BT and highlights the need for further study of potential BT-refractory patients.
Bronchial thermoplasty; severe asthma
Parents of children who visit the pediatric emergency department (PED) for asthma exacerbations may not receive adequate instruction in preventive asthma care. Our primary objective was to assess knowledge and use of preventive asthma care measures among parents of children with asthma who present to the PED with asthma exacerbations. Our secondary objective was to identify variables that predict adherence to four key preventive care measures.
We administered a 38-item questionnaire to 229 parents of children ages 2 to 18 years with asthma exacerbations who presented to two, urban PEDs, one in the southeast and one in the northwest U.S. Descriptive statistics were calculated to assess parental knowledge of preventive care. Multivariable logistic regression was used to identify variables associated with the use of four key preventive care measures.
Thirty-two percent of the children had an action plan, 29% of children ≥ 5 years of age had a peak flow meter, and 52% received the influenza vaccine within the preceding year. Sixty-six percent of the children had persistent asthma by NIH criteria. Of these, 51% received daily inhaled corticosteroids (ICS). When parents were asked how an ICS medicine worked, 29% (64/221) responded “immediately opens the airway”, and 24% (53/221) responded “I do not know.” Daily use of ICS in these children was significantly associated with parent education level beyond high school (OR=2.81; 95% CI: 1.26, 6.24; P=0.01). Non-African Americans were more likely to have received an action plan than African Americans (OR=2.18; 95% CI:1.17, 4.06; P=0.01). A secondary analysis of the parent’s perception of his/her ability to provide care during an asthma exacerbation was significantly associated with receipt of an action plan in a multivariable proportional odds model (OR=3.63; 95% CI: 1.99, 6.62; P<0.001).
Parents of children with persistent asthma presenting to urban tertiary care PEDs with asthma exacerbations frequently have inadequate understanding of appropriate ICS use. Parents with less than a high school education, in particular, may benefit from focused educational interventions which address the importance of daily ICS use in asthma control. Parents who receive a written action plan are more confident in their ability to provide care for their child during an asthma exacerbation.
pediatric asthma; prevention; self-management; parental knowledge; racial disparity
Previous studies have reported that the prevalence of exercise-induced bronchoconstriction (EIB) in athletes is higher than that of the general population. There is increasing evidence that athletes fail to recognize and report symptoms of EIB. As a result, there has been debate whether athletes should be screened for EIB, particularly in high-risk sports.
We prospectively studied 144 athletes from six different varsity sports at a large National Collegiate Athletic Association Division I collegiate athletic program. Baseline demographics and medical history were obtained and the presence of asthma symptoms during exercise was documented. Each athlete subsequently underwent a eucapnic voluntary hyperventilation (EVH) test to document the presence of EIB. Exhaled nitric oxide (eNO) quantification was performed immediately before EVH testing. EIB was defined as a ≥10% decline in forced expiratory volume in 1 second compared with baseline.
Only 4 of 144 (2.7%) athletes were EIB-positive after EVH testing. The presence of symptoms was not predictive of EIB as only 2 of the 64 symptomatic athletes (3%) were EIB-positive based on EVH testing. Two of the four athletes who were found to be EIB-positive denied such symptoms. The mean baseline eNO in the four EIB-positive athletes was 13.25 parts per billion (ppb) and 24.5 ppb in the EIB-negative athletes.
Our data argue that screening for EIB is not recommended given the surprisingly low prevalence of EIB in the population we studied. In addition, the presence or absence of symptoms was not predictive of EIB and eNO testing was not effective in predicting EIB.
asthma; athletes; bronchoconstriction; exercise; screening
Obesity is more prevalent in asthmatics. Short sleep duration is a novel risk factor for obesity in general populations.
We tested the association of sleep duration and asthma characteristics with obesity.
Adults at tertiary clinics were surveyed on asthma symptoms and habitual sleep duration. Medical records were used to assess asthma severity step (1-4), extract height and weight, current medications and diagnosed comorbid conditions. BMI≥30 kg/m2 defined obesity. Habitual sleep was categorized as <6 (very short), 6 to <7h (short), 7-8h (normal), >8 to ≤9h (long) and >9h (very long). Inhaled corticosteroid doses were categorized as low, moderate and high.
Among 611 participants (mean BMI 30±8), 249 (41%) were obese. After adjustment for covariates, obesity was associated with short and very long sleep: as compared to normal sleepers, the odds of being obese were on average 66% higher ([95% Confidence Interval: 1.07-2.57], p=0.02) among short and 124% higher ([1.08-1.65], p=0.03) among very long sleepers, and the association with very short sleep approached significance (1.74 [0.96-3.14], p=0.06). Obesity was also significantly related to highest asthma step (1.87 [1.09-3.21], p=0.02) and psychopathology (1.64 [1.08-2.48], p=0.02), and a trend was seen with high dose inhaled corticosteroids (1.82 [0.93-3.56], p=0.08).
Obesity in asthmatics is associated with shorter and very long sleep duration, worse asthma severity, psychopathology, and high dose inhaled corticosteroids. Although this cross-sectional study cannot prove causality, we speculate that further investigation of sleep may provide new opportunities to reduce the rising prevalence of obesity among asthmatics.
asthma; sleep duration; obesity
There is limited information on performance rates for tests of lung function and inflammation in pediatric patients with acute asthma exacerbations. We sought to examine how frequently pediatric patients with acute asthma exacerbations could perform non-invasive lung function and exhaled nitric oxide testing and participant characteristics associated with successful performance.
We studied a prospective convenience sample aged 5–17 years with acute asthma exacerbations in a pediatric emergency department. Participants attempted spirometry for percent predicted forced expiratory volume in 1-second (%FEV1), airway resistance (Rint) and exhaled nitric oxide (FENO) testing before treatment. We examined overall performance rates and the associations of age, gender, race, and baseline acute asthma severity score with successful test performance.
Among 573 participants, age was (median [IQR]) 8.8 [6.8, 11.5] years, male 60%, African-American 57%, and Medicaid insurance 58%. Tests were performed successfully by [n (%)]: full ATS/ERS-criteria spirometry, 331 (58%); Rint, 561 (98%); and FENO, 354 (70% of 505 attempting test). Sixty-percent with mild-moderate exacerbations performed spirometry compared to 17% with severe exacerbations (P=0.0001). Participants ages 8–12 years (67%) were more likely to perform spirometry than those 5–7 years (48%) (OR=2.23, 95% CI: 1.45–3.11) or 13–17 years (58%) (OR=1.61, 95%CI: 1.00–2.59).
There is clinically important variability in performance of these tests during acute asthma exacerbations. The proportion of patients with severe exacerbations able to perform spirometry (17%) limits its utility. Almost all children with acute asthma can perform airway resistance testing, and further development and validation of this technology is warranted.
Asthma; asthma exacerbation; spirometry; airway resistance; respiratory function testing
Rates of preventive follow-up asthma care after an acute emergency department (ED) visit are low among inner-city children. We implemented a novel behavioral asthma intervention, Pediatric Asthma Alert (PAAL) intervention, to improve outpatient follow-up and preventive care for urban children with a recent ED visit for asthma.
The objective of this article is to describe the PAAL intervention and examine factors associated with intervention completers and noncompleters.
Children with persistent asthma and recurrent ED visits (N = 300) were enrolled in a randomized controlled trial of the PAAL intervention that included two home visits and a facilitated follow-up visit with the child’s primary care provider (PCP). Children were categorized as intervention completers, that is, completed home and PCP visits compared with noncompleters, who completed at least one home visit but did not complete the PCP visit. Using chi-square test of independence, analysis of variance, and multiple logistic regression, the intervention completion status was examined by several sociodemographic, health, and caregiver psychological variables.
Children were African-American (95%), Medicaid insured (91%), and young (aged 3–5 years, 56%). Overall, 71% of children randomized to the intervention successfully completed all home and PCP visits (completers). Factors significantly associated with completing the intervention included younger age (age 3–5 years: completers, 65.4%; noncompleters, 34.1%; p < .001) and having an asthma action plan in the home at baseline (completers: 40%; noncompleters: 21%; p = .02). In a logistic regression model, younger child age, having an asthma action plan, and lower caregiver daily asthma stress were significantly associated with successful completion of the intervention.
The majority of caregivers of high-risk children with asthma were successfully engaged in this home and PCP-based intervention. Caregivers of older children with asthma and those with high stress may need additional support for program completion. Further, the lack of an asthma action plan may be a marker of preexisting barriers to preventive care.
asthma; children; controller medications; inner city; preventive care
To examine time-dependent changes of spirometry (percent-predicted FEV1[%FEV1])and the Pediatric Respiratory Assessment Measure (PRAM)during treatment of acute asthma exacerbations.
We conducted a prospective study of participants ages 5–17 years with acute asthma exacerbations managed in a Pediatric Emergency Department. %FEV1 and the PRAM were recorded pretreatment and at 2 and 4 hours. We examined responses at 2 and 4 hours following treatment and assessed whether changes of %FEV1 and of the PRAM differed during the first and second 2-hour treatment periods.
Amongst 503 participants, median [IQR] age was 8.8 [6.9, 11.4], 61% were male and 63% African-American. There was significant mean change of %FEV1 during the first (+15.4%; 95%, CI 13.7, 17.1; P<0.0001) but not during the second 2 hour period (+1.5%; 95% CI −0.8, 3.8; P=0.21), and of the PRAM during the first (−2.1 points; 95% CI −2.3, −1.9; P < 0.0001) and second (−1.0 point; 95% CI −1.3, −0.7; P < 0.0001) 2 hour periods.
Most improvement of lung function and clinical severity occur in the first two hours of treatment. Amongst pediatric patients with acute asthma exacerbationsthe PRAM detects significant and clinically meaningful change of severity during the second 2-hours of treatment, whereas spirometry does not. This suggests that spirometry and clinical severity scores do not have similar trajectories and that clinical severity scores may be more sensitive to clinical change of acute asthma severity than spirometry.
Asthma; spirometry; pulmonary function tests; pediatrics; PRAM score
To characterize two groups of asthmatics who had achieved remission and those who had not achieved remission of asthma.
The study was a retrospective cohort study based on 117 asthmatic children who participated in a previous study. We categorized the children into two groups: asthmatics with remission versus asthmatics without remission. We defined remission of asthma as lack of symptoms/signs of asthma or asthma-related medications or health care services for at least three consecutive years. Long-term remission was defined by no relapse of asthma after achieving remission. We characterized these groups.
Of the 117 subjects, 70 (60%) were male, 91 (78%) were Caucasians, and the mean age at index date of asthma was 8.1 years. A total of 59 asthmatic children (50%) achieved remission and 28 asthmatics (24%) achieved long-term remission. Asthmatics with remission were more likely to be Caucasian (87%) compared to those without (69%) (p = .039) There were no differences in the frequency of visits for viral (0.3 vs. 0.4 per person-years, p = .29) or bacterial infections (0.7 vs. 0.5 per person-years, p = .49) between asthmatics with and without remission. Gender, socioeconomic status, smoking exposure, family history of asthma or atopy, breastfeeding history, peak flow meter availability, asthma action plan, and influenza vaccinations were not associated with remission.
Only half of asthmatic children accomplished remission of asthma ever and 24% of asthmatic children had long-term remission. Ethnicity may affect remission of asthma but microbial infections may not influence the likelihood of remission of asthma and vice versa.
asthma; childhood; epidemiology; microbial infection; remission; risk
To describe and categorize contextual information relevant to patients’ medical care unexpectedly volunteered to research personnel as part of a patient advocate intervention to facilitate access health care, communication with medical personnel, and self-management of a chronic disease like asthma.
We adapted a patient navigator intervention, to overcome barriers to access and communication for adults with moderate or severe asthma. Informed by focus groups of patients and providers, our Patient Advocates facilitated preparation for a visit with an asthma provider, attended the visit, confirmed understanding, and assisted with post-visit activities. During meetings with researchers, either for PA activities or data collection, participants frequently volunteered personal and medical information relevant for achieving successful self-management that was not routinely shared with medical personnel. For this project, researchers journaled information not captured by the structured questionnaires and protocol. Using a qualitative analysis, we describe 1) researchers’ journals of these unique communications, 2) their relevance for accomplishing self-management, 3) Patient Advocates’ formal activities including teach-back, advocacy, and facilitating appointment-making, and 4) observations of patients’ interactions with the clinical practices.
In 83 journals, patients’ social support (83%), health (68%), and deportment (69%) were described. Patient Advocate assistance with navigating the medical system (59%), teach-back (46%), and observed interactions with patient and medical staff (76%) were also journaled. Implicit were ways patients and practices could overcome barriers to access and communication.
These journals describe the importance of seeking contextual and medically relevant information from all patients and especially those with significant morbidities, prompting patients for barriers to accessing care, and confirming understanding of medical information.
patient advocate; patient navigator; asthma; health communication; health literacy; health access
Understanding triggers is important for managing asthma particularly for patients who seek emergency department (ED) care for exacerbations. The objectives of this analysis were to delineate self-reported triggers in ED patients and to assess associations between triggers and asthma knowledge, severity, and quality of life.
At the time of an ED visit, 296 patients were asked what were their usual asthma triggers based on a checklist of 25 potential items, and what they thought specifically precipitated their current ED visit. Using standardized scales, patients also were asked about asthma knowledge, severity and quality of life.
Mean age was 44 years and 72% were women. Patients cited a mean of 12 triggers; most patients had diverse triggers spanning respiratory infections, environmental irritants, emotions, allergens, weather, and exercise. Patients with more triggers were more likely to be women (OR 2.0, CI 1.3, 3.2, p=.002), obese (OR 1.7, CI 1.1, 2.5, p=.01), and to not have a smoking history (OR 1.9, CI 1.3, 2.9, p=.001). There were no associations between number of triggers and current age, age at diagnosis, education, socioeconomic status or race/ethnicity. Patients who cited more triggers had more frequent flares (OR 1.1, CI 1.1, 1.2, p<.0001), worse quality of life scores (OR 1.6, CI 1.1, 2.4, p=.02), and were more likely to have been previously hospitalized for asthma (OR 1.9, CI 1.3, 2.9, p=.003) and to have previously required oral corticosteroids (OR 2.9, CI 1.6, 5.1, p=.003). There was little clustering of specific triggers according to the variables we considered except for more frequent animal allergy in patients diagnosed at a younger age (OR 2.8, CI 1.7, 4.5, p<.0001) and worse quality of life in patients citing emotional stress as a trigger (OR 2.5, CI 1.5, 4.0, p=.0002). Patients attributed their current ED visit to multiple precipitants, particularly respiratory infections and weather, and these were concordant with what they reported were known triggers.
Patients presenting to the ED for asthma reported multiple triggers spanning diverse classes of precipitants and having more triggers was associated with worse clinical status. ED patients should be instructed that although it may not be possible to eliminate all triggers, mitigating even some triggers can be helpful. (ClinicalTrials.gov NCT00110409)
flares; exacerbations; precipitants; irritants; emotional stress
Frequent use of healthcare services associated with pediatric asthma places substantial economic burden on families and society. The purpose of this study is to examine the cost saving effects of a peer-led program through reduction in healthcare utilization in comparison to an adult-led program.
Randomly assigned adolescents (13-17 years) participated in either peer-led (n=59) or adult-led (n=53) asthma self-management program. Healthcare utilization data were collected at baseline and at 3-, 6- and 9-months post-intervention. Negative binomial regression models were conducted to examine the effects of the peer-led program on healthcare utilization. Net cost savings were estimated based on differences in program costs and healthcare utilization costs between groups.
Significant group differences were found in acute office visits and school clinic visits after controlling for race and socioeconomic status. The incidence rate of acute office visits was 80-82% less for the peer-led group during follow-ups. The peer-led group was 4 to 5 times more likely to use school clinics due to asthma than the adult-led group during follow-ups. The non-research cost of peer-led program per participant was lower than the adult-led program, $64 vs. $99 respectively. The net cost saving from the reduction in acute office visits and the lower program costs of the peer-led program was estimated $51.8 per person for a 3-month period.
An asthma self-management program using peer leaders can potentially yield healthcare cost savings through the reduction in acute office visits in comparison to a traditional program led by healthcare professionals.
Adolescents; Peer leaders; Camp; Healthcare utilization; Cost savings
A possible association between long-acting beta-agonists (LABA) and severe asthma exacerbations including death remains controversial. We examined whether LABA in the setting of combination therapy with inhaled corticosteroids (ICS) increases the risk of near-fatal asthma in children using a case-control study design.
Medical records from admissions for asthma exacerbations in children 4 to 18 years of age during the 2005 calendar year at Children’s Hospital of Pittsburgh of UPMC were reviewed. Cases and controls were determined by pediatric intensive care (PICU) and floor admission, respectively. Exposure was defined by LABA use in combination with ICS versus ICS alone.
Records from 156 PICU and 207 pediatric floor admissions were reviewed. Records were excluded for non-asthma admissions, complicated pneumonias, debilitating comorbid disorders and multiple admissions leaving 85 PICU and 96 floor admissions. LABA use in combination with ICS did not increase the risk of PICU admission (OR 1.07, 95% CI 0.46–2.52), compared to ICS only without LABA. After adjusting for demographics, asthma severity, history of PICU admissions and concurrent infection, LABA/ICS use still did not increase the risk of PICU admission (aOR 0.84, 95% CI 0.26–2.76), compared to ICS alone. There were no deaths and five intubations within the study period.
The combination of LABA and ICS did not appear to increase the risk of near-fatal asthma in children.
Asthma; Long-acting Beta-agonist; Inhaled Corticosteroids; Drug Safety
We previously conducted the School Based Asthma Therapy trial to improve adherence to national asthma guidelines for urban children through directly observed administration of preventive asthma medications in school. The trial successfully improved outcomes among these children; however several factors limit its potential for dissemination. To enhance sustainability, we subsequently developed a new model of care using web-based guides for efficient communications and integration within school and community systems. This paper describes the development of the School-Based Preventive Asthma Care Technology (SB-PACT) trial.
We developed the SB-PACT web-based system based on stakeholder feedback, and conducted a pilot randomized trial with 100 children to establish its feasibility in facilitating preventive asthma care for high-risk children. The SB-PACT system represents a new model of care using web-based guides for asthma symptom screening, follow-up control assessments, and electronic communications with providers.
We enrolled and successfully screened all children using the web-based system. Most providers used the electronic communication system without difficulty, and the majority of children in the intervention group received preventive medications through school as planned and dose adjustments as needed. Several challenges to implementation also were encountered.
This program is designed to promote sustainability of school-based asthma care, reduce program costs, and to ultimately succeed in a real-world setting. With further refinements, it has the potential to be implemented nationally in schools.
asthma; school-based; technology; sustainability; preventive care
Obstructive sleep apnea (OSA) worsens nocturnal asthma, but its potential impact on daytime asthma remains largely unassessed. We investigated whether the sleep disorder is associated with daytime, in addition to nighttime asthma symptoms.
Asthma patients at tertiary-care centers completed the Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ), and an asthma control questionnaire. SA-SDQ scores ≥36 for men and ≥32 for females defined high OSA risk. Medical records were reviewed for established diagnosis of OSA and continuous positive airway pressure (CPAP) use.
Among 752 asthma patients, high OSA risk was associated similarly with persistent daytime and nighttime asthma symptoms (p<0.0001 for each). A diagnosis of OSA was robustly associated with persistent daytime (p<0.0001), in addition to nighttime (p=0.0008) asthma symptoms. In regression models that included obesity and other known asthma aggravators, high OSA risk retained associations with persistent daytime (odds ratio =1.96 [95% confidence interval 1.31–2.94]) and nighttime asthma symptoms (1.97 [1.32–2.94]). Diagnosed OSA retained an association with persistent daytime (2.08 [1.13–3.82]) but not with nighttime (1.48 [0.82–2.69]) asthma symptoms. CPAP use was associated with lower likelihood of persistent daytime symptoms (0.46 [0.23–0.94]).
Questionnaire-defined OSA risk and historical diagnosis were each associated with persistent daytime asthma symptoms, to an extent that matched or exceeded associations with nighttime asthma symptoms. Unrecognized OSA may be a reason for persistent asthma symptoms during the day as well as the night.
asthma; asthma control; sleep; obstructive sleep apnea; obstructive sleep apnea risk
Understanding events preceding emergency department (ED) asthma visits can guide patient education regarding managing exacerbations and seeking timely care. The objectives of this analysis were to assess time to seeking ED care, self-management of asthma exacerbations, and clinical status on presentation.
296 patients were grouped according to time to seeking ED care: ≤ 1 day (22%), 2-5 days (44%), and > 5 days (34%) and were compared for clinical and psychosocial characteristics. Asthma severity at presentation was obtained from patient report with the Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ) and from physicians’ ratings using decision to hospitalize as an indicator of worse status.
Mean age was 44 years, 72% were women, 10% had been in the ED in the prior week, and 28% came to the ED by ambulance. Patients who waited longer were more likely to be older, have more depressive symptoms, and to have been in the ED in the prior week. They also were more likely to have taken more medications, but they were not more likely to have visited or consulted their outpatient physicians. Patients who waited longer reported worse ACQ (p<.0001) and AQLQ (p=.0002) scores, and were more likely to be hospitalized for the current exacerbation (odds ratio 1.9, 95% confidence interval 1.1, 3.2, p=.03).
Patients who waited longer to come to the ED had worse asthma on presentation, more functional limitations, and were more likely to be hospitalized. Ability to gauge severity of exacerbations and use the ED in a timely manner are important but often overlooked self-management skills that patients should be taught. (ClinicalTrials.gov NCT00110409)
triggers; ambulance; exacerbation; depressive symptoms; delay
The purpose of this research was to calibrate an item bank for a computerized adaptive test (CAT) of asthma impact on health-related quality of life (HRQOL), test CAT versions of varying lengths, conduct preliminary validity testing, and evaluate item bank readability.
Asthma Impact Survey (AIS) bank items that passed focus group, cognitive testing, and clinical and psychometric reviews were administered to adults with varied levels of asthma control. Adults self-reporting asthma (N=1106) completed an Internet survey including 88 AIS items, the Asthma Control Test (ACT), and other HRQOL outcome measures. Data were analyzed using classical and modern psychometric methods, real-data CAT simulations, and known groups validity testing.
A bi-factor model with a general factor (asthma impact) and several group factors (cognitive function, fatigue, mental health, physical function, role function, sexual function, self-consciousness/stigma, sleep, and social function) was tested. Loadings on the general factor were above 0.5 and were substantially larger than group factor loadings, and fit statistics were acceptable. Item functioning for most items and fit to the model was acceptable. CAT simulations demonstrated several options for administration and stopping rules. AIS distinguished between respondents with differing levels of asthma control.
The new 50-item AIS item bank demonstrated favorable psychometric characteristics, preliminary evidence of validity, and accessibility at moderate reading levels. Developing item banks for CAT can improve the precise, efficient, and comprehensive monitoring of asthma outcomes, and may facilitate patient-centered care.
asthma control; Asthma Impact Survey; item response theory; patient-reported outcome; health-related quality of life
Racial/ethnic disparities have been well documented in asthma. While socioeconomic status (SES) has been repeatedly implicated as a root cause, the role of limited health literacy has not been extensively studied. The purpose of this study was to examine the independent contributions of SES and health literacy in explaining asthma disparities.
A cohort study was conducted in a Chicago-based sample of 353 adults aged 18–40 years with persistent asthma from 2004 to 2007. Health literacy, SES, and asthma outcomes including disease control, quality of life, emergency department visits, and hospitalizations were assessed in person at baseline, and asthma outcomes were measured every 3 months for 2 years by phone. Multivariate models were used to assess racial/ethnic disparities in asthma outcomes and the effect of health literacy and SES on these estimates.
Compared with White participants, African American adults fared significantly worse in all asthma outcomes (p < .05) and Latino participants had lower quality of life (β = −0.47; 95% confidence interval [CI]= −0.79, −0.14; p = .01) and worse asthma control (risk ratio [RR] = 0.63; 95% CI = 0.41, 0.98; p = .04). Differences in SES partially explained these disparities. Health literacy explained an additional 20.2% of differences in quality of life between Latinos and Whites, but differences in hospitalization rates between African American and White adults remained (RR = 2.97; 95% CI = 1.09, 8.12, p = .03).
Health literacy appears to be an overlooked factor explaining racial and ethnic disparities in asthma. Evidence-based low literacy strategies for patient education and counseling should be included in comprehensive interventions.
control; hospitalization; quality of life; race/ethnicity
The prevalence of written “action plans” (APs) among emergency department (ED) patients with acute asthma is unknown.
To determine the prevalence of APs among ED patients, to describe the demographic and clinical profile of patients with and without APs, and to examine the appropriateness of response to an asthma exacerbation scenario.
Using a standard protocol, 49 North American EDs performed a prospective cohort study involving interviews of 1,756 patients, ages 2–54, with acute asthma. Among children only, a random sample was contacted two years after the index ED visit to assess current AP status and parents’ self-management knowledge.
The overall prevalence of APs was 32% (95% confidence interval [CI], 30%–34%), and was higher among children than adults (34% vs. 26%, respectively; p = 0.001). Patients with APs had worse measures of chronic asthma severity (p < 0.05) and were more likely to be hospitalized (multivariate odds ratio, 1.5; 95%CI, 1.1–2.1). After 2 years, most children with an AP at the index ED visit still had one but only 20% of those without an AP had obtained one; moreover, many of the APs appeared inadequate. Parents of children with a current AP performed slightly better on the asthma scenario, but both groups overestimated their asthma knowledge.
The prevalence of APs among ED patients with acute asthma is unacceptably low, and many of these APs appear inadequate. “Confounding by severity” will complicate any non-randomized analysis of the potential impact of APs on asthma outcomes in ED patients.
asthma; action plans; emergency medicine; education; self-management
The purpose of this study was to examine: (a) the extent to which caregivers and children asked asthma management questions during pediatric asthma visits, (b) the extent to which providers engaged in shared decision-making with these caregivers and children, and (c) the factors associated with question-asking and shared decision-making.
Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at five pediatric practices in non-urban areas of North Carolina. All of the medical visits were audio-tape recorded. Generalized estimating equations were used to analyze the data.
Only 13% of children and 33% of caregivers asked one or more questions about asthma management. Caregivers were most likely to ask questions about their child’s medications. Providers obtained child input into their asthma management treatment plan during only 6% of encounters and caregiver input into their child’s asthma management treatment plan during 10% of visits.
Given the importance of involving patients during health care visits, providers need to consider asking for and including child and caregiver input into asthma management treatment plans so that shared decision-making can occur more frequently.
Urban minority populations experience increased rates of obesity and increased asthma prevalence and severity.
We sought to determine whether obesity, as measured by body mass index (BMI), was associated with asthma quality of life or asthma-related emergency department (ED)/urgent care utilization in an urban, community-based sample of adults.
This is a cross-sectional analysis of 352 adult subjects (age 30.9±6.1, 77.8% females, FEV1%pred=87.0%±18.5) with physician diagnosed asthma from a community-based Chicago cohort. Outcome variables included the Juniper Asthma Quality of Life Questionnaire (AQLQ) scores and health care utilization in the previous 12 months. Bivariate tests were used as appropriate to assess the relationship between BMI or obesity status and asthma outcome variables. Multivariate regression analyses were performed to predict asthma outcomes, controlling for demographics, income, depression score, and beta-agonist use.
191 (54.3%) adults were obese (BMI>30 kg/m2). Participants with a higher BMI were older (p=0.008), African American (p<0.001), female (p=0.002), or from lower income households (p=0.002). BMI was inversely related to overall AQLQ scores (r =−0.174, p=0.001) as well as to individual domains. In multivariate models, BMI remained an independent predictor of AQLQ. Obese participants were more likely to have received ED/urgent care for asthma than non-obese subjects (OR=1.8, p=0.036).
In a community-based sample of urban asthmatic adults, obesity was related to worse asthma-specific quality of life and increased ED/urgent care utilization. However, compared to other variables measured such as depression, the contribution of obesity to lower AQLQ scores was relatively modest.
Asthma; obesity; urban; healthcare disparities; health outcomes
This cross-sectional study examines parents’ perceptions of their neighborhoods and general and respiratory health among low-income Chicago families. Asthma disproportionately affects non-white, 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.
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 (RD) and 95% confidence intervals (CI) for eight binary outcomes.
Magnitude was generally as expected, i.e., RD for low versus high (most favorable) exposure groups (RDlow v. high) was larger than for the middle vs. high contrast (RDmid v. high). “Parent general health” was strongly associated with “CE” [RDlow v. high=20.8 (95% CI: 7.8, 33.9)] and “order” [RDmid 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” [RDlow v. high=16.7 (95% CI: 2.8, 30.6)] and “order” [RDlow v. high=22.2 (95% CI: 8.6, 35.8)]. “Exercise intolerance” [RDlow v. high=15.8 (95% CI: 2.1, 29.5)] and “controllability” [RDmid v. high=12.0 (95% CI: 1.8, 22.3)] were moderately associated with “order” but not with “CE,” while “school absences,” “rescue medication use,” and “unplanned visits” had nearly null associations with both exposures.
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 individuals’ reactions to stress and attempt to mitigate effects of stressors while structural solutions to health inequities are sought.
To evaluate the effect of the timeliness of asthma diagnosis on chest X-ray (CXR) and antibiotic utilization in children.
Patients and methods
This was a retrospective cohort study of 276 asthmatic children aged 5–12 years from Rochester, Minnesota. From the time when children met our predetermined asthma criteria, the frequency of CXR and antibiotic utilizations for respiratory illnesses were collected from medical records until age 18 years. Using a Poisson regression model, the frequency of CXR and antibiotic utilizations were compared in children with timely, delayed, or no clinician diagnosis of asthma.
Of the 276 asthmatic patients, 97 (35%) had a timely diagnosis, 122 (44%) had a delayed diagnosis, while 57 patients (21%) had no clinician diagnosis of asthma. There was no significant difference in CXR or antibiotic utilization for respiratory illness between these groups. In addition, this was true for the comparison between the timely diagnosed group and the delayed diagnosed group combining both the group with a delay in asthma diagnosis and the group who never had asthma diagnosis.
A delay in the diagnosis of asthma in children is common and overall it may not influence antibiotic and CXR utilization for respiratory symptoms by clinicians. However, its impact on access to asthma-related therapies and other healthcare utilizations could be possible and was not assessed in this study. Given the limitations of our study, a larger prospective study needs to be considered.
adolescent; antibacterial agents; child; health services; radiography; therapeutics; thoracic
To evaluate the cross-sectional relationship between asthma and pre-gravid body mass index (BMI); and to assess the risk of adult weight change among women with history asthma diagnosed in childhood or adulthood, respectively.
Study participants were 3,737 pregnant women enrolled in a cohort study. Information on history of asthma, pre-gravid BMI, adult weight change (difference between BMI at age 18 and pre-gravid BMI) and other socio demographic characteristics was collected using interviewer-administered questionnaires. Pre-gravid BMI was categorized into lean (BMI <18.5 kg/m2), overweight (BMI 25–24.9 kg/m2) and obese (BMI ≥30 kg/m2). Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI).
Approximately 13.1% of study participants reported history of asthma. Compared with the reference group (BMI 18.5–24.9 kg/m2), the odds of asthma was higher among overweight (OR=1.51; 95%CI 1.18–1.93) and obese (OR=1.47; 95% CI 1.06–2.03) women while it was lower among lean women (OR=0.42; 95% CI 0.21–0.84) (trend p-value <0.001). Women who gained ≥20 kg, compared with those who maintained their weight (±2.5 kg) had a 2.7-fold increased odds of asthma (95% CI 1.02–7.00).
Overweight and obese women were more likely to have history of asthma. Adult weight gain was positively associated with asthma diagnosis. Longitudinal studies designed to prospectively assess patterns of adult weight change in relation to asthma are warranted.
Asthma; Pediatric Asthma; Body Mass Index; Obesity; Adult Weight Change