Adult Physicians Research Articles

Quality of care in inflammatory bowel disease in Asia: the results of a multinational web-based survey in the 2(nd) Asian Organization of Crohn's and Colitis (AOCC) meeting in Seoul.

Background/AimsThe quality of care in inflammatory bowel disease (IBD) has not been systematically estimated. The aim of this study was to investigate the current status of quality of IBD care in Asian countries.MethodsA questionnaire-based survey was conducted between March 2014 and May 2014. The questionnaire was adopted from "An adult inflammatory bowel disease physician performance measure set" developed by the American Gastroenterological Association. If the respondent executed the performance measure in more than 70% of patients, the measure was regarded as well performed.ResultsA total of 353 medical doctors from Asia completed the survey (116 from Korea, 114 from China, 88 from Japan, 17 from Taiwan, 8 from Hong-Kong, 4 from India, 3 from Singapore, and 1 each from the Philippines, Malaysia and Indonesia). The delivery of performance measures, however, varied among countries. The documentation of IBD and tuberculosis screening before anti-tumor necrosis factor therapy were consistently performed well, while pneumococcal immunization and prophylaxis of venous thromboembolisms in hospitalized patients were performed less frequently in all countries. Physician awareness was positively associated with the delivery of performance measures. Variations were also noted in reasons for non-performance or low performance of quality measures, and the two primary reasons cited were consideration of the measure to be unimportant and lack of time.ConclusionsThe delivery of performance measures varies among physicians in Asian countries, and reflects variations in the quality of care among the countries. This variation should be recognized to improve the quality of care in Asian countries.

Results of the first survey for the current status of inflammatory bowel disease management in Asian countries.

Results of the first survey for the current status of inflammatory bowel disease management in Asian countries.

Hyperammonemia due to Adult-Onset N-Acetylglutamate Synthase Deficiency.

A 59-year-old woman, with a medical history of intellectual disability after perinatal asphyxia, was admitted because of coma due to hyperammonemia after she was treated for a fracture of the pelvis. The ammonia level was 280μM. Acquired disorders as explanation for the hyperammonemia were excluded. Metabolic investigations showed an elevated glutamine and alanine and low citrulline, suspect for a urea cycle defect (UCD). Orotic acid could not be demonstrated in urine. DNA investigations were negative for mutations or deletions in the OTC and CPS1 gene, but revealed a homozygous c.603G>C mutation in exon 2 of the N-acetylglutamate synthase (NAGS) gene (NM_153006.2:c.603G>C), which mandates p.Lys201Asn. This is a novel mutation in the NAGS gene.After the diagnosis of NAGS deficiency was made carbamylglutamate was started in a low dose. In combination with mild protein restriction the ammonia level decreased to 26μM.This is one of the first patients in literature in whom the diagnosis of a UCD is made at such an advanced age. It is important for the adult physician to consider a metabolic disorder at every age.

Bridging Paediatric Liver Diseases to Adult Care: What Does the Gastroenterologist Need to Know?

Advances in medical and surgical therapy mean that significant numbers of children with previously fatal liver disease are surviving into adult life. In particular, 80% of transplant recipients now survive for over 20 years. Gastroenterologists and hepatologists who treat adult patients need to be aware of the clinical management and complications of diseases originating in infancy, such as biliary atresia, progressive familial intrahepatic cholestasis, Alagille syndrome, and metabolic diseases such as hereditary tyrosinemia type 1. They need to be familiar with the long-term consequences of liver transplantation in childhood, e.g. renal failure, recurrent disease, osteoporosis, and post-transplant malignancies, especially post-transplant lymphoproliferative disease, which differs in presentation and evolution from adult transplant recipients. Survivors of childhood illness require a different approach to that for young adults presenting after 18 years of age. Adult physicians need to consider the emotional, social, and sexual health of these young people, and be aware of the high rate of non-adherence, both for clinic appointments and medication, as well as the implications for graft loss, particularly after transition to adult services. Developing adequate transitional care for these young people is based on effective collaboration at the paediatric–adult interface and is a major challenge for paediatric and adult providers alike in the 21st century.

Book Review: Oxford Respiratory Medicine Library: Cystic Fibrosis

Book review: Cystic Fibrosis by A. Horsley et al. http://ow.ly/UpIzP

The Role of Obesity Training in Medical School and Residency on Bariatric Surgery Knowledge in Primary Care Physicians.

Objective. US primary care physicians are inadequately educated on how to provide obesity treatment. We sought to assess physician training in obesity and to characterize the perceptions, beliefs, knowledge, and treatment patterns of primary care physicians. Methods. We administered a cross-sectional web-based survey from July to October 2014 to adult primary care physicians in practices affiliated with the Massachusetts General Hospital (MGH). We evaluated survey respondent demographics, personal health habits, obesity training, knowledge of bariatric surgery care, perceptions, attitudes, and beliefs regarding the etiology of obesity and treatment strategies. Results. Younger primary care physicians (age 20–39) were more likely to have received some obesity training than those aged 40–49 (OR: 0.08, 95% CI: 0.008–0.822) or those 50+ (OR: 0.03, 95% CI: 0.004–0.321). Physicians who were young, had obesity, or received obesity education in medical school or postgraduate training were more likely to answer bariatric surgery knowledge questions correctly. Conclusions. There is a need for educational programs to improve physician knowledge and competency in treating patients with obesity. Obesity is a complex chronic disease, and it is important for clinicians to be equipped with the knowledge of the multiple treatment modalities that may be considered to help their patients achieve a healthy weight.

Infection control in the Intensive Care Unit

“Infection Control In The Intensive Care Unit” by HK Saene, L Silvestri, MADe la Cal, and A Gullo, SpringerVerlag, 3 Edition, 2012, ISBN 9788847016002. «Infection Control In The Intensive Care Unit (ICU)», third edition, is a comprehensive book regarding the clinical microbiology of critically ill patients. It includes thirty chapters gathered under the same five different thematic networks as in the previous edition. As mentioned in the preface by the editors: “All statements are justified by the best available evidence. All authors have made efforts to avoid unsubstantiated expert opinion.” The first section entitled «essentials in clinical microbiology» addresses different basic topics such as distinction between carriage, colonization and infection. It also provides a classification of ICU infections as well as of the different microorganisms according to their pathogenicity. The second part is on «antimicrobials», providing an excellent overview of systemic antibiotics, antifungals, and compounds which are used enterally. The third section on «infection control in the ICU» discusses devices, antibiotic policies to be used in the ICU as well as infection outbreaks. The issue of selective digestive decontamination is also well addressed. The fourth section of this book presents the different types of infections, which may be encountered by practitioners, according to their specific localization (blood stream infections, pneumonia, peritonitis, mediastinitis, urinary tract infections and wounds). There are interesting chapters on infections occurring in the neonatal and pediatric intensive care unit, and those following organ transplantation. Finally, the fifth section encompasses several «special topics» including: the role of gut as the motor of systemic inflammation and multiple organ dysfunction syndrome, non antibiotic measures to control ventilator associated pneumonia, the impact of gut mucosal protection and nutritional route on the occurrence of infections. Finally, antimicrobial resistance and ICU-acquired infections are specifically addressed. In summary, «Infection Control In The Intensive Care Unit», discusses all important aspects of infectious diseases relevant to the practice. This book will certainly be helpful to adult and pediatric critical care physicians, surgeons, and pharmacists, as well as clinical researchers performing in the intensive care unit.

Polycystic ovarian syndrome in adolescent girls

Polycystic ovary syndrome is a spectrum of disorders consisting of chronic oligo-anovulation, androgen excess, obesity, insulin resistance and polycystic ovaries. The diagnosis carries life-long implications with increased risk for infertility, endometrial hyperplasia/carcinoma, metabolic syndrome, type 2 diabetes and cardiovascular disease. Lack of well-defined diagnostic criteria makes identification of this common condition challenging. Because of the varying clinical presentation and manifestation of PCOS, adolescent and young adult woman can present to a variety of healthcare professionals including general practitioners, general paediatricians, adult physicians, gynaecologists, dermatologists or endocrinologists (paediatric and adult). Treatment of adolescent girls with PCOS includes weight reduction if associated with obesity, exercise and various pharmacological interventions. As many women with PCOS have the onset of symptoms during adolescence, it is important for paediatricians to be familiar with the disorder and be able to facilitate a management plan and consider treatments to ameliorate symptoms and reduce the risk of long-term sequelae. This review will focus on the diagnosis and current management of PCOS in adolescent girls.

Adolescent and young adult medicine in Australia and New Zealand: towards specialist accreditation.

In Australia and New Zealand, a critical mass of academic and clinical leadership in Adolescent Medicine has helped advance models of clinical services, drive investments in teaching and training, and strengthen research capacity over the past 30 years. There is growing recognition of the importance of influencing the training of adult physicians as well as paediatricians. The Royal Australasian College of Physicians (RACP) is responsible for overseeing all aspects of specialist physician training across the two countries. Following advocacy from adolescent physicians, the RACP is advancing a three-tier strategy to build greater specialist capacity and sustain leadership in adolescent and young adult medicine (AYAM). The first tier of the strategy supports universal training in adolescent and young adult health and medicine for all basic trainees in paediatric and adult medicine through an online training resource. The second and third tiers support advanced training in AYAM for specialist practice, based on an advanced training curriculum that has been approved by the RACP. The second tier is dual training; advanced trainees can undertake 2 years training in AYAM and 2 years training in another area of specialist practice. The third tier consists of 3 years of advanced training in AYAM. The RACP is currently seeking formal recognition from the Australian Government to have AYAM accredited, a process that will be subsequently undertaken in New Zealand. The RACP is expectant that the accreditation of specialist AYAM physicians will promote sustained academic and clinical leadership in AYAM to the benefit of future generations of young Australasians.

Volume responsiveness assessment by transthoracic echocardiography and the application in pediatric intensive care unit

Fluid resuscitation is the primary step in the management of acute circulation failure, aims to make a significant increase in cardiac output, and then providing adequate blood perfusion for peripheral tissues.According to Frank-Starling curve, the positive outcome only occurs in patients within a certain range of cardiac function, while in other conditions fluid overload would immediately increase the mortality.Distinguish-ing volume responders form non-responders effectively is still a serious problem common to adult and pediatric physicians at intensive care unit.Volume responsiveness assessment using transthoracic echocardiography has become a research hotspot during the past few years, this review aims to make a summary of those findings as well as the present situation in pediatric field. Key words: Volume responsiveness; Transthoracic echocardiography; Intensive care unit; Children

292 Cystic fibrosis and transition to adult care in Northern Ireland

Background Transition from paediatric to adult care for patients with chronic disease is challenging. Transition should be holistic, patient centred, coordinated, gradual, involve parents and promote autonomy. Adolescents in the paediatric CF unit are reviewed at joint transition clinics with one of our adult CF physicians. In their 18 th year they attend a final transfer clinic (attended by both paediatric and adult multidisciplinary teams). Objective and Methods A questionnaire was distributed to patients aged 18–25 years in the adult CF centre in the Belfast City Hospital to evaluate patients' experience of transition. Results Eighty-five patients were identified with 40 respondents (24 female, 16 male). The average age was 21 years. Twenty-five percent found transition difficult. All valued being seen by the paediatric and adult teams together. All of the males felt ready to take responsibility for their own health, rather than relying on parents, however 38% admitted that they found this difficult in practice. The majority of females (79%) also felt ready to self-care, but 50% acknowledged difficulty in practice. 33% of respondents reported that parents struggled with transition (85% of these found self-care difficult). The majority of patients settled in to the adult service quickly, but 43% took months-years; these were patients who found it difficult to take ownership of their own care. Conclusion Our model facilitates gradual transition through close cooperation with paediatrics. Based on the above results we plan to introduce a patient information pack to improve the service further, which will address the psychosocial and educational needs of adolescents.

Transition: changing old habits.

Transitioning patients from pediatric to adult care is an issue of increasing concern, especially when it involves children with chronic conditions that are congenital or complex.1 Care of these children often requires the special expertise of pediatric subspecialists in addition to ongoing primary care. Pediatric specialists and generalists anticipate that patients will age out of their care, yet many adult medicine practitioners do not feel comfortable assuming responsibility for young adults chronically ill with pediatric disorders. A growing array of strategies and interventions are being designed to facilitate this transition, yet they all may not be necessary. The conclusion that a transition to adult care is indicated is generally based on traditional age cutoffs rather than science. Although it would be a significant change, pediatric subspecialists could reframe their services as condition-specific rather than age-specific care and continue to provide care to their aging patients over the life course in conjunction with adult primary care physicians. There is no consensus on the appropriate upper age of pediatricians’ patients or when youths become adults. Adulthood is more a social construct than a developmental stage. It has no readily identifiable markers such as those that define puberty, the beginning of adolescence. As a socially defined stage of life, there exists great variability about who is considered legally an adult. Even the assumption of “adult” responsibilities, that is, responsibility for meeting one’s own basic needs, does not consistently signify adulthood, although perhaps success at that endeavor would count as being an adult. Imaging studies of the brain demonstrate that adult brain size, especially that of the frontal cortex, is attained between the … Address correspondence to Edward L. Schor, MD, The Lucile Packard Foundation for Children’s Health, 400 Hamilton Avenue, Suite 340, Palo Alto, CA 94301. E-mail: edward.schor{at}lpfch.org

G585(P) Transition from children’s to adult diabetes clinic -patient’s views

Context The best method of providing transition of young people with diabetes is a complex and much debated subject. Problem There is a dearth of empirical evidence on the best approach to the transition process. Involving patients is an integral part of designing and delivering this service Intervention To obtain input from young people with diabetes regarding the current transition service in the Hospital and also invite suggestions for improvement. Study design Young people over 16 years and adults up to age of 25 years were included. We distributed survey questionnaires via the paediatrics diabetic clinics, and also posted them to patients who were in an adult service. Measurement of improvement Responses from the patients. Effects of changes Results There were 200 patients between the age of 16 yrs and 25 yrs available, with 68 responses. The current system (one joint appointment with the paediatrician and the adult physician, then straight to a young adult clinic) was popular (46.3%). Most (44.1%) would like to stay for 1 year in the clinic but few longer than that. A significant number (71.2%) want the adult doctor to be present in the clinic. Interestingly few (3%) were interested in a psychologist being present. This may reflect a lack of understanding of the difficulties in the transition process by the patients. It may also reflect the lack of knowledge of how a psychologist can support them. The best time to hold the clinic seems to be at routine clinic times. Most would like the appointment to last between 20–30 min. A diabetic nurse run clinic was preferred by 48.4% (51.6% did not want it). The best age to be transferred was between 16–19 yrs. Lessons learnt Patient input and experience can give useful insight when designing a model for transition for young people with diabetes. Message for others Patient views are imperative to bring about a change in the service made for them.

G68(P) A retrospective review of epilepsy related admissions to the paediatric department at a district general nhs trust, england

Aims Child and Maternal Health (ChiMat) Observatory Data indicate our institution has higher Paediatric Emergency Epilepsy admissions and length of stay, compared to other PCTs in England. This report has been referred to by Commissioning Groups when reviewing and commissioning services. The information produced by ChiMat is based on data from the hospital’s coding department, who determine the admission reason from discharge letters completed by junior doctors. We carried out a retrospective audit to review: The accuracy of coding Medical management of Paediatric Emergency Epilepsy admissions. Methods We reviewed the medical notes of all patients coded as having a Paediatric Emergency Epilepsy admission during 2011. There were 78 patients during this period, and information was collected using a standardised proforma. Inappropriately coded patients were excluded from analysis in the second part of the audit. Results 10 of the 78 patients (12.8%) were exclusively under the care of the adult physicians, with age range 16–19 years. Of the other 68 patients, 15 were incorrectly coded (22%). Review of the medical management in the remaining 53 admissions, showed areas for improvement in medication adherence, patient education and awareness, and community management plans. Conclusions This study has shown the importance of accurate data coding, as this is used to review the service we provide, highlighting exceptional practice as well as areas which require improvement. Variation in practice and value in healthcare are the current quality indicators which are used, to compare hospitals and clinicians, and to continue the quality improvement cycle. It is therefore in the interest of all to engage with clinical coding to ensure accurate, robust data is being used. Our audit has led to more streamlined management of patients with epilepsy, including the consideration of more community-based management plans and proposal for a Paediatric Epilepsy Specialist Nurse. There has also been quality improvement effects, including introduction of a weekly epilepsy-related admissions report which is reviewed for accuracy, monthly epilepsy peer-review meeting to review all admissions and challenging cases, importance of accurate coding on discharge letters being emphasised to junior doctors at induction, and introduction of a checklist for management of patients with epilepsy.

G395(P) Experiences of patients on long term ventilation transferring to adult services

Aims Medical advances mean that more children with serious illnesses are surviving into adulthood. Recent legislation and guidelines stress the importance of delivering improved joined-up services for children undergoing transition to adult services. 1,2 A qualitative study was performed to explore the experiences of patients receiving long-term ventilation (LTV). Methods Questionnaire-based telephone interviews were conducted with 21 patients (14 males, median age 26 years, range 14–57) on LTV or their carers. All had previously been within children’s services and were now under adult respiratory care at a UK teaching hospital. The underlying causes for LTV included: Duchenne muscular dystrophy (9), other muscular dystrophies (6), congenital central hypoventilation syndrome (4) and other (2). Results Thematic analysis of the data identified 3 main themes: Variability : the age at which transition occurred varied (17–25), as did the option to attend combined clinics, which was only given to 3 of the 21 patients. There were discrepancies in the provision of community services, which was described as being “post-code dependent”. Unfamiliarity : patients expressed concerns about the unfamiliarity of adult doctors with their background and condition, which was often interpreted as insensitivity or lack of knowledge. They expressed frustration at having to repeat their story to numerous health care professionals. Separation of services : care under children’s services was reported as being more holistic when compared with the single organ approach in adult services. However, the thoroughness of adult physicians in patient management was appreciated. Conclusion Our study highlights the gap that needs to be bridged between children and adult services for patients on LTV. Early transition planning should occur to alleviate the unfamiliarity commonly experienced. This should include information about adult care and the differences in service provision. The utilisation of health care passports can do much to avoid physician unfamiliarity with the patient’s situation. These changes need to be uniformly adopted in order to improve patient satisfaction, care and long term outcome. References Care Act 2014 Care Quality Commission. From the pond into the sea: Children’s transition to adult healthcare services. June 2014

Bronquiectasias diseminada en un adulto con inmunodeficiencia común variable

Las inmunodeficiencias primarias (IDP) son patologías que tradicionalmente se consideran de la niñez sin embargo los adultos representan el 35% del total de pacientes con IDP. Las deficiencias de anticuerpos, en especial la Inmunodeficiencia Común Variable (IDCV) tienen su pico de incidencia en la edad adulta, requiere un alto índice de sospecha y si bien su frecuencia estimada no es alta (1:25,000), es muy posible que el subregistro y subdiagnóstico si lo sean. El retraso en el diagnóstico aumenta la morbi-mortalidad razón por la cual los médicos de adultos deben estar en capacidad de sospechar, identificar e iniciar el manejo de las personas con IPD. Presentamos el caso de un hombre de 37 años de edad atendido en la sala de urgencias con disnea, fiebre y tos, desarrolla falla respiratoria requiriendo ventilación mecánica. Refería neumonías a repetición desde los 18 años de edad asociadas con bronquiectasias generalizadas. La cuantificación de inmunoglobulinas séricas evidenció hipogammaglobulinemia severa (IgG total <140 mg/dL, IgA total 2.9 mg/dL, IgM total <5 mg/dL), se inició inmunoglobulina humana endovenosa (IGIV) al 10%, y recibió tratamiento antibiótico por 14 días para neumonía severa, su evolución clínica ha sido favorable hasta ahora (un año de seguimiento), se estableció el diagnostico de Inmunodeficiencia Común Variable (IDCV).

Direct Versus Remote Clinical Observation: Assessing Learners' Milestones While Addressing Adolescent Patients' Needs.

Direct clinical observation is an essential component of medical trainee assessment, particularly in the era of milestone-based competencies. However, the adolescent patient's perspective on this practice is missing from the literature. Quality health care is patient centered, yet we did not know if our educational practices align with this clinical goal. We sought to better understand our adolescent/young adult patients' perspectives of the direct observation of our medical trainees in the outpatient clinical setting. As a quality improvement initiative, we surveyed adolescent/young adult patients, medical trainees, and physician observers in our outpatient clinical practice regarding their experience following a direct observation encounter. We performed descriptive analyses of the data. During a 1-year period, responses were received from 23 adolescent/young adult patients, 8 family members, 14 trainees, and 6 faculty observers. Nearly all adolescent/young adult patients (n=22) and all surveyed family members (n=8) expressed comfort with direct observation, and all respondents felt the care they received was the same or better. All patient/family respondents preferred direct observation to the idea of remote observation, and most, but not all, trainees and faculty observers expressed similar opinions. Adolescent/young adult patients and their family members found direct observation of their trainee providers to be comfortable and beneficial. Despite adolescent and young adults' facility and comfort with modern technologies, there was an expressed preference for direct versus remote observation.

BSACI guideline for the management of chronic urticaria and angioedema

This guidance for the management of patients with chronic urticaria and angioedema has been prepared by the Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is aimed at both adult physicians and paediatricians practising in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a Web-based system. Their comments and suggestions were carefully considered by the Standards of Care Committee. Where evidence was lacking, a consensus was reached by the experts on the committee. Included in this management guideline are clinical classification, aetiology, diagnosis, investigations, treatment guidance with special sections on children with urticaria and the use of antihistamines in women who are pregnant or breastfeeding. Finally, we have made recommendations for potential areas of future research.

The Frequencies of Different Inborn Errors of Metabolism in Adult Metabolic Centres: Report from the SSIEM Adult Metabolic Physicians Group.

There are few centres which specialise in the care of adults with inborn errors of metabolism (IEM). To anticipate facilities and staffing needed at these centres, it is of interest to know the distribution of the different disorders. A survey was distributed through the list-serve of the SSIEM Adult Metabolic Physicians group asking clinicians for number of patients with confirmed diagnoses, types of diagnoses and age at diagnosis. Twenty-four adult centres responded to our survey with information on 6,692 patients. Of those 6,692 patients, 510 were excluded for diagnoses not within the IEM spectrum (e.g. bone dysplasias, hemochromatosis) or for age less than 16 years, leaving 6,182 patients for final analysis. The most common diseases followed by the adult centres were phenylketonuria (20.6%), mitochondrial disorders (14%) and lysosomal storage disorders (Fabry disease (8.8%), Gaucher disease (4.2%)). Amongst the disorders that can present with acute metabolic decompensation, the urea cycle disorders, specifically ornithine transcarbamylase deficiency, were most common (2.2%), followed by glycogen storage disease type I (1.5%) and maple syrup urine disease (1.1%). Patients were frequently diagnosed as adults, particularly those with mitochondrial disease and lysosomal storage disorders. A wide spectrum of IEM are followed at adult centres. Specific knowledge of these disorders is needed to provide optimal care including up-to-date knowledge of treatments and ability to manage acute decompensation.

Establishing the relationship of inhaler satisfaction, treatment adherence, and patient outcomes: a prospective, real-world, cross-sectional survey of US adult asthma patients and physicians

Background Inhaled asthma medications are the mainstay of treatment for chronic asthma. However, nonadherence rates for long-term inhaler therapy among adults are estimated to exceed 50 %. Nonadherence is associated with unfavorable clinical outcomes and diminished quality of life. Research suggests that adherence is associated with patients’ satisfaction with their treatment regimen and other factors, such as concomitant allergic rhinitis and tobacco use.Methods This prospective, cross-sectional survey of physicians and their patients evaluated the relationship between patient satisfaction with attributes of inhaler devices, treatment adherence, and clinical outcomes. Primary care and specialist physicians completed a physician-reported patient record form for patients with a confirmed asthma diagnosis. Patients for whom a physician-reported form was completed were invited to complete a patient-reported form. Both surveys collected information about demographics, symptoms, exacerbation history, treatment, smoking status, comorbidities, type of inhaler device, and treatment adherence. Patients also indicated the degree to which they were satisfied with attributes of their currently prescribed inhaler device(s). Partial least squares path modeling quantified relationships between latent variables and clinical outcomes.Results A total of 243 patients were included in our analysis and 41 % had poorly controlled asthma. More favorable clinical outcomes were significantly associated with greater patient satisfaction with drug delivery (P = 0.002), higher medication adherence (P = 0.049), no history of tobacco use (P < 0.001), and absence of comorbid allergic rhinitis (P = 0.005). Attributes associated with device satisfaction included patient perceptions of consistency in the amount of drug delivery to the lungs, ease of use, and feedback about the number of remaining doses.Conclusions Higher patient satisfaction with their asthma drug delivery inhaler device is a significant predictor of more favorable clinical outcomes while allergic rhinitis and smoking history were negatively associated with optimal control of asthma. These findings provide clinicians with opportunities to improve patients’ clinical outcomes by tailoring choice of inhaler device therapy and providing education about the correct way to use the device to ensure optimal outcomes. Patients will likely benefit from medical therapy to manage comorbid allergic rhinitis and smoking cessation interventions. Patients unable to stop smoking may require alternative medical therapies to improve their clinical outcomes.