Asthma Management Program Research Articles

Pilot study of a randomized trial to evaluate a Web-based intervention targeting adolescents presenting to the emergency department with acute asthma

BackgroundLow-income African-American adolescents use preventive medical services less frequently than their White counterparts, indicating a need for effective interventions targeting this group. Puff City is a Web-based, asthma management program for urban adolescents that has been evaluated in high school settings with promising results. The objective of this pilot was to assess the feasibility of initiating Puff City (treatment) in an emergency department setting, thereby informing the conduct of an individual randomized trial to evaluate its effectiveness compared to a generic, Web-based program (control) in preventing subsequent emergency department (ED) visits.MethodsTeens aged 13–19 years presenting with acute asthma to two urban EDs within the study period were eligible. Subsequent ED visits were collected using the electronic medical record. A priori indication of a potential intervention effect was p < 0.20.ResultsOf the 121 teens randomized (65 treatment, 56 control), 86.0% were African-American and 44.6% male, with the mean age = 15.4 years. Computer ownership was reported by 76.8% of teens. Overall, 64.5% of teens completed >3 of 4 sessions and 90% completed the 12-month survey. At 12 months, the treatment group showed a trend toward fewer ED visits than controls (33.8 versus 46.4%), p = 0.15.ConclusionsResults indicate the feasibility of enrolling at-risk adolescents in ED settings and set the stage for a large, pragmatic trial using a technology-based intervention to reduce the burden of pediatric asthma.Trial registrationClinicalTrials.gov, NCT01695031

A pharmacy management service for adults with asthma: a cluster randomised controlled trial.

Although clinical guidelines are available for the management of asthma, this health condition is still poorly managed in many countries. To assess the effects of a Pharmacy Management Service (PharMS) on asthma control of adult patients. This study comprised of a cluster randomised controlled trial (RCT) that was conducted from April 2014 to July 2015 at four government health clinics. The control participants received usual pharmacy service, while the intervention participants were recruited into the PharMS. Each participant was monitored for 6 months, and the outcome measures included asthma control using the Asthma Control Test (ACT), inhaler technique using a checklist and medication adherence using the Malaysian Medication Adherence Scale. A total of 157 participants were recruited: 77 in the control and 80 in the intervention group. At the end of the study, 90% of the intervention participants achieved well-controlled asthma compared to 28.6% in the control group (P < 0.001). The differences in the proportion of participants with correct inhaler technique was also significant, with an adjusted effect size of 0.953 (P < 0.001). In addition, the intervention participants showed significantly higher medication adherence than the control group (92.5% versus 45.5%, P < 0.001). The Generalised Estimated Equation analysis further confirmed that the PharMS (P < 0.001) was significantly related to an improvement in the ACT scores. A community-based asthma management program, the PharMS, that provided asthma education and skill training by a trained pharmacist, resulted in positive and significant improvements in clinical and management outcomes of adult asthma patients.

School absence and productivity outcomes associated with childhood asthma in the USA

ABSTRACTBackground: Previous studies have examined the association between childhood asthma and lost productivity; however, more data are needed to understand its impact. Methods: This was a retrospective analysis of cross-sectional data in the nationally representative 2007–2013 Medical Expenditure Panel Survey (MEPS). School-aged children (SAC), children (age 6–11), and adolescents (age 12–17) with asthma were compared to those without asthma to examine annual missed school days. Adult parents/caregivers of SAC with asthma were compared to those of SAC without asthma to examine missed work days. The cost of premature asthma mortality for SAC was also estimated. Negative binomial regression was used for missed school days, and a two-part model structure was used for missed work days. All analyses controlled for sociodemographics and other covariates. Results: There were 44,320 SAC of whom 5,890 had asthma. There were 43,496 employed adults with at least one child. SAC (6–17) with asthma missed 1.54 times the number of school days compared to SAC without asthma. Caregivers of SAC (6–17) with asthma missed 1.16 times the number of work days to care for others compared to caregivers of SAC without asthma. SAC in the USA missed an additional 7 million school days associated with asthma (3.7 million children and 3.3 million adolescent). There were 130 asthma deaths resulting in an annual cost of $211 million ($US 2015). Conclusions: Childhood asthma is associated with a significant school absence and productivity loss in the USA. Better treatment and asthma management programs are needed to alleviate this burden.

Building school health partnerships to improve pediatric asthma care: the School-based Asthma Management Program.

Children with asthma require care that is seamlessly coordinated so that asthma symptoms are recognized and managed at home and at school. The purpose of this review is to discuss recent consensus recommendations in school-based asthma care. The School-based Asthma Management Program (SAMPRO) provides a widely endorsed framework to coordinate care with schools and consists of four components: establishing a circle of support around the child with asthma; facilitating bidirectional communication between clinicians and schools; comprehensive asthma education for schools; and assessment and remediation of environmental asthma triggers at school. SAMPRO standardizes recommendations for school-based asthma care coordination and provides a toolkit with websites and resources useful for the care of children with asthma in the school setting. The review will discuss the need for coordinated school asthma partnerships, the inception and development of SAMPRO, and its vision to improve pediatric asthma care coordination within the circle of support, comprising clinicians, school nurses, families, and communities.

Physical activity, restrictions in activity, and body mass index among urban children with persistent asthma

BackgroundAsthma and obesity are public health problems that disproportionately affect underserved children. Urban children with asthma may be limited in their participation in physical activity, further increasing their risk for overweight. ObjectiveTo determine the prevalence of overweight and obesity among high-risk children with persistent asthma, to assess physical activity and activity restrictions by level of asthma control, and to evaluate whether activity is associated with weight status. MethodsWe analyzed baseline data from 324 urban children with poorly controlled asthma (3–10 years old) enrolled in the School-Based Telemedicine Enhanced Asthma Management program in Rochester, New York. Caregivers reported their child's asthma symptoms, physical activity, and activity limitation, and height and weight were measured. ResultsMost children were black (59%), and 69% had Medicaid. Almost half (47%) of children had symptoms that indicated poorly controlled asthma, 15% were overweight, and 31% were obese. Few children (39%) participated in 1 or more hour of physical activity per day. In addition, most (85%) did not walk to and from school, 38% did not have any recess in school, and 35% reported no safe place to exercise. More children with very poorly controlled asthma symptoms, compared with children with more mild symptoms, reported limitation in gym class (58% vs 43%, P = .01) and even in mild activities (28% vs 14%, P = .004). Children with activity limitation were at significantly greater odds of being overweight or obese (odds ratio, 2.1; 95% confidence interval, 1.2–3.8). ConclusionMany children with persistent asthma are overweight or obese, have limited opportunity for activity, and experience activity limitations. Efforts are needed to optimize asthma control and provide opportunity for increased physical activity in and outside school. Trial RegistrationClinicalTrials.gov Identifier: NCT01650844.

Genome-wide interaction study of dust mite allergen on lung function in children with asthma

Childhood asthma is likely the result of gene-by-environment (G×E) interactions. Dust mite is a known risk factor for asthma morbidity. Yet, there have been no genome-wide G×E studies of dust mite allergen on asthma-related phenotypes. We sought to identify genetic variants whose effects on lung function in children with asthma are modified by the level of dust mite allergen exposure. A genome-wide interaction analysis of dust mite allergen level and lung function was performed in a cohort of Puerto Rican children with asthma (Puerto Rico Genetics of Asthma and Lifestyle [PRGOAL]). Replication was attempted in 2 independent cohorts, the Childhood Asthma Management Program (CAMP) and the Genetics of Asthma in Costa Rica Study. Single nucleotide polymorphism (SNP) rs117902240 showed a significant interaction effect on FEV1 with dust mite allergen level in PRGOAL (interaction P=3.1×10-8), and replicated in the same direction in CAMP white children and CAMP Hispanic children (combined interaction P=.0065 for replication cohorts and 7.4×10-9 for all cohorts). Rs117902240 was positively associated with FEV1 in children exposed to low dust mite allergen levels, but negatively associated with FEV1 in children exposed to high levels. This SNP is on chromosome 8q24, adjacent to a binding site for CCAAT/enhancer-binding protein beta, a transcription factor that forms part of the IL-17 signaling pathway. None of the SNPs identified for FEV1/forced vital capacity replicated in the independent cohorts. Dust mite allergen exposure modifies the estimated effect of rs117902240 on FEV1 in children with asthma. Analysis of existing data suggests that this SNP may have transcription factor regulatory functions.

High-dimensional adaptive function-on-scalar regression

Applications of functional data with large numbers of predictors have grown precipitously in recent years, driven, in part, by rapid advances in genotyping technologies. Given the large numbers of genetic mutations encountered in genetic association studies, statistical methods which more fully exploit the underlying structure of the data are imperative for maximizing statistical power. However, there is currently very limited work in functional data with large numbers of predictors. Tools are presented for simultaneous variable selection and parameter estimation in a functional linear model with a functional outcome and a large number of scalar predictors; the technique is called AFSL for Adaptive Function-on-Scalar Lasso. It is demonstrated how techniques from convex analysis over Hilbert spaces can be used to establish a functional version of the oracle property for AFSL over any real separable Hilbert space, even when the number of predictors, I, is exponentially large compared to the sample size, N. AFSL is illustrated via a simulation study and data from the Childhood Asthma Management Program, CAMP, selecting those genetic mutations which are important for lung growth.

Examining Profiles of Family Functioning in Pediatric Asthma: Longitudinal Associations With Child Adjustment and Asthma Severity.

Identify profiles of functioning in families of children with asthma and examine whether profile membership predicts subsequent child mental and physical well-being. Primary caregivers and children ( N = 1,030) from the Childhood Asthma Management Program completed questionnaires assessing family functioning and child adaptation at five time points. Asthma severity was also assessed via spirometry. Latent profile analyses identified a four-profile solution as best fitting the data: cohesive, permissive, controlling/disengaged, and controlling/enmeshed families. Distal outcome analyses using Bolck-Croon-Hagenaars techniques suggested that children from families that were more cohesive had fewer internalizing and externalizing symptoms. These associations remained stable across time. Family profiles did not differ with regards to child asthma severity. Results highlight the importance of looking beyond the effects of distinct components of family functioning and instead using pattern-based approaches. Recommendations for incorporating screenings and services for families in pediatric care settings are provided.

Low risk of adverse obstetrical and perinatal outcome in pregnancies complicated by asthma: A case control study

BackgroundAsthma in pregnancy have been associated with an increased risk of pregnancy complications. Our aim was to estimate incidence and describe risk factors for adverse obstetrical and perinatal outcomes in pregnant women with asthma. MethodsWomen enrolled in the Management of Asthma during Pregnancy (MAP) program were each matched with three controls (i.e. consecutive women giving birth at our obstetrical service). Asthma severity was classified according to treatment step. Data on obstetrical and perinatal outcomes were obtained from medical records. Logistic regression analysis was applied, and findings expressed as odds ratios (OR) unadjusted and adjusted (adj) for BMI, age, parity, smoking, ethnicity and marital status. ResultsNine-hundred-thirty-nine pregnancies in women with asthma (i.e. cases) were compared to 2.782 controls. Overall, the incidence of complications was low, although women with asthma had a statistically significant higher risk of pre-eclampsia (5% vs. 3%, ORadj 1.60, 95% CI 1.07–2.38; p = 0.02) and small for gestational age neonates (SGA) (ORadj 1.30, 95% CI 1.10–1.54; p < 0.01) compared to controls. Compared to mild asthma, more severe asthma was associated with a higher risk of SGA (60% vs 53%, ORadj. 1.30, 95% CI 1.10–1.54; p < 0.01). Women with asthma exacerbation during pregnancy tended to have a higher risk of severe pre-eclampsia (ORadj 3.33 95% CI 0.96–11.65, p = 0.06) compared to pregnancies without any exacerbations. ConclusionThe overall risk of adverse obstetrical and perinatal outcomes in pregnancies complicated by asthma is low compared to non-asthmatic women. Our observations suggest that enrollment into an asthma management program has a positive impact on overall pregnancy outcome.

Creation and implementation of SAMPRO™: A school-based asthma management program

Clinicians who care for children with asthma have an obligation to coordinate asthma care with the schools. Aside from routine clinical care of asthmatic children, providers must educate the family and child about the need for an asthma treatment plan in school and support the school nurse meeting the needs of the student requiring school-based asthma care. The following article was developed by multiple stakeholders to address this need. It describes the 4 components of the School-based Asthma Management Program (SAMPRO™). SAMPRO™ details elements necessary for the education of children, families, clinicians, and school-based personnel based on a “circle of support” that would enhance multidirectional communication and promote better care for children with asthma within the school setting.

Circulating MicroRNAs: Association with Lung Function in Asthma.

BackgroundMicroRNAs are key transcriptional and network regulators previously associated with asthma susceptibility. However, their role in relation to asthma severity has not been delineated.ObjectiveWe hypothesized that circulating microRNAs could serve as biomarkers of changes in lung function in asthma patients.MethodsWe isolated microRNAs from serum samples obtained at randomization for 160 participants of the Childhood Asthma Management Program. Using a TaqMan microRNA array containing 754 microRNA primers, we tested for the presence of known asthma microRNAs, and assessed the association of the individual microRNAs with lung function as measured by FEV1/FVC, FEV1% and FVC%. We further tested the subset of FEV1/FVC microRNAs for sex-specific and lung developmental associations.ResultsOf the 108 well-detected circulating microRNAs, 74 (68.5%) had previously been linked to asthma susceptibility. We found 22 (20.3%), 4 (3.7%) and 8 (7.4%) microRNAs to be associated with FEV1/FVC, FEV1% and FVC%, respectively. 8 (of 22) FEV1/FVC, 3 (of 4) FEV1% and 1 (of 8) FVC% microRNAs had functionally validated target genes that have been linked via genome wide association studies to asthma and FEV1 change. Among the 22 FEV1/FVC microRNAs, 9 (40.9%) remain associated with FEV1/FVC in boys alone in a sex-stratified analysis (compared with 3 FEV1/FVC microRNAs in girls alone), 7 (31.8%) were associated with fetal lung development, and 3 (13.6%) in both. Ontology analyses revealed enrichment for pathways integral to asthma, including PPAR signaling, G-protein coupled signaling, actin and myosin binding, and respiratory system development.ConclusionsCirculating microRNAs reflect asthma biology and are associated with lung function differences in asthmatics. They may represent biomarkers of asthma severity.

Enrolment in an Asthma Management Program during Pregnancy and Adherence with Inhaled Corticosteroids: The ‘Management of Asthma during Pregnancy' Program

Background: Poor adherence with inhaled corticosteroids (ICS) is a major problem in asthma and according to previous studies not least during pregnancy. Objective: Our aim was to assess if enrolment in an asthma management program, and by that close monitoring, can improve self-reported and documented adherence with ICS in pregnant women with asthma. Methods: Pregnant women with doctor-diagnosed asthma, currently being prescribed ICS, referred during a 12-month period to the outpatient respiratory clinic, were consecutively included in the study. They had follow-up visits every 4 weeks during pregnancy. Asthma control was assessed according to GINA guidelines. Self-reported adherence was compared to documented adherence, defined as medical possession rate (MPR), calculated on the basis of filled prescriptions (data from each individuals' medication profile at www.fmk-online.dk). Results: A total of 130 women fulfilled the inclusion criteria, but at the initial visit, 16 women reported no current use of ICS, and the analyses are therefore based on 114 patients. Self-reported adherence to ICS was significantly higher during pregnancy than before pregnancy (73 and 52%, respectively, reporting good adherence; p < 0.001). The actual adherence, i.e. MPR, was also higher during pregnancy than before (46 vs. 28%, p < 0.0001). In keeping with this, an overall improvement was also observed in asthma control. Of the women with a low pre-pregnancy MPR, 71% had moderate or good adherence (MPR) during pregnancy. Self-reported adherence was significantly correlated with MPR during pregnancy (p = 0.004) but not before pregnancy (p = 0.46). At the 3-month postpartum visit, adherence was close to the pre-pregnancy level. Conclusion: Enrolment in an asthma management program during pregnancy seems to improve adherence with controller medication, but self-reported adherence is not a valid measure for actual adherence in patients with asthma.

Asthma management programs for primary care providers: increasing adherence to asthma guidelines.

This article reviews new approaches, facilitators, barriers, and opportunities to increasing guideline-adherent care for children with asthma by primary care clinicians. Primary care clinicians are challenged by the volume of guidelines and want transparent guidelines that are easy to use and that can be used in complex patients with multiple comorbidities. Programs that use decision support tools and electronic technologies and provide support from individuals new to the medical home such as panel management assistants, community health workers, patient advocates, practice facilitators, school nurses, and pharmacists may enhance use of guidelines by primary care clinicians and reduce asthma morbidity. Primary care clinician burnout and difficulty incorporating electronic asthma decision tools into current workflow are recently recognized barriers to guideline integration and improved asthma outcomes. In addition, many of these interventions are labor intensive, costly and may not be capable of being widely disseminated. Programs that simplify guidelines, provide decision support tools and use electronic technologies and an expanded medical team may improve the quality of asthma care provided by the primary care community to children and their families with asthma.

A Comprehensive Pediatric Asthma Management Program Reduces Emergency Department Visits and Hospitalizations

We evaluated the impact of a comprehensive pediatric asthma management program (the Children's Asthma Wellness Program, CAWP) on the frequency of emergency department (ED) visits and hospital admissions. The CAWP generally consisted of 4 clinic sessions over a 1-year period, but some patients attended fewer clinic sessions, and some required additional clinic sessions due to incomplete asthma control. Patients were evaluated and treated by pediatric pulmonologists, nurse asthma care coordinator/educator, and social worker. We retrospectively reviewed program results over an 8-year period (2005–2013). We compared ED visits and hospital admissions before and after participation in the CAWP. There were 254 children referred to the CAWP; 172 children were enrolled. Fifty-four children (31%) received >6 sessions due to incomplete asthma control. On average, children requiring additional clinic sessions were older and more likely to be African American, hold Medicaid insurance, and have severe asthma. We obtain...

Stratified patient appointment scheduling for mobile community-based chronic disease management programs

ABSTRACTDisease management programs have emerged as a cost-effective approach to treat chronic diseases. Appointment adherence is critical to the success of such programs; missed appointments are costly, resulting in reduced resource utilization and worsening of patients’ health states. The time of an appointment is one of the factors that impacts adherence. We investigate the benefits, in terms of improved adherence, of incorporating patients’ time-of-day preferences during appointment schedule creation and, thus, ultimately, on population health outcomes. Through an extensive computational study, we demonstrate, more generally, the usefulness of patient stratification in appointment scheduling in the environment that motivates our research, a mobile asthma management program. We find that capturing patient characteristics in appointment scheduling, especially their time preferences, leads to substantial improvements in community health outcomes. We also identify settings in which simple, easy-to-use policies can produce schedules that are comparable in quality to those obtained with an optimization-based approach.

A genetic factor associated with low final bone mineral density in children after a long-term glucocorticoids treatment.

Treatment with glucocorticoids is associated with lower bone mineral density (BMD). We performed a genome-wide association study to analyze interactive effects between genotypes and cumulative dose of prednisone (PD) over 4.3 years of follow-up period on the final BMD Z-scores in 461 white children from the Childhood Asthma Management Program. No variants met the conventional criteria for genome-wide significance, and thus we looked for evidence of replication. The top 100-ranked single-nucleotide polymorphisms (SNPs) were then carried forward replication in 59 children with acute lymphoblastic leukemia (ALL) exposed to large fixed doses of PD as part of their chemotherapeutic regimen. Among them, rs6461639 (interaction P=1.88 × 10-5 in the CAMP population) showed a significant association with the final BMD Z-scores in the ALL population (P=0.016). The association of the ALL population was only present after correction for the anti-metabolite treatment arm (high vs low dose). We have identified a novel SNP, rs6461639, showing a significant effect on the final BMD Z-scores in two independent pediatric populations after long-term high-dose PD treatment.

Applying the Social Ecological Model to Creating Asthma-Friendly Schools in Louisiana.

In 2010, the Louisiana Asthma Management and Prevention Program (LAMP) implemented the Asthma-Friendly Schools Initiative in high-risk Louisiana populations. The social ecological model (SEM) was used as a framework for an asthma program implemented in 70 state K-12 public schools over 2 years. Activities included a needs assessment, identification of students with asthma, individualized asthma action plans (AAP), staff trainings, environmental quality improvement, and school system policy changes to address the asthma burden. There were 522 new or existing asthma cases recognized. Asthma knowledge/awareness was measurably improved among school personnel. School indoor air quality was improved across all locations. School-level policies were adopted that improved AAP collection, compliance to bus-idling restrictions, and asthma medication self-carry. The SEM framework can be used for school-based programs to address successfully and improve asthma-related issues from the individual through policy levels.

Gene expression profiling of asthma phenotypes demonstrates molecular signatures of atopy and asthma control

Recent studies have used cluster analysis to identify phenotypic clusters of asthma with differences in clinical traits, as well as differences in response to therapy with anti-inflammatory medications. However, the correspondence between different phenotypic clusters and differences in the underlying molecular mechanisms of asthma pathogenesis remains unclear. We sought to determine whether clinical differences among children with asthma in different phenotypic clusters corresponded to differences in levels of gene expression. We explored differences in gene expression profiles of CD4(+) lymphocytes isolated from the peripheral blood of 299 young adult participants in the Childhood Asthma Management Program study. We obtained gene expression profiles from study subjects between 9 and 14years of age after they participated in a randomized, controlled longitudinal study examining the effects of inhaled anti-inflammatory medications over a 48-month study period, and we evaluated the correspondence between our earlier phenotypic cluster analysis and subsequent follow-up clinical and molecular profiles. We found that differences in clinical characteristics observed between subjects assigned to different phenotypic clusters persisted into young adulthood and that these clinical differences were associated with differences in gene expression patterns between subjects in different clusters. We identified a subset of genes associated with atopic status, validated the presence of an atopic signature among these genes in an independent cohort of asthmatic subjects, and identified the presence of common transcription factor binding sites corresponding to glucocorticoid receptor binding. These findings suggest that phenotypic clusters are associated with differences in the underlying pathobiology of asthma. Further experiments are necessary to confirm these findings.

Estimating Variance Components in Functional Linear Models With Applications to Genetic Heritability

Quantifying heritability is the first step in understanding the contribution of genetic variation to the risk architecture of complex human diseases and traits. Heritability can be estimated for univariate phenotypes from nonfamily data using linear mixed effects models. There is, however, no fully developed methodology for defining or estimating heritability from longitudinal studies. By examining longitudinal studies, researchers have the opportunity to better understand the genetic influence on the temporal development of diseases, which can be vital for populations with rapidly changing phenotypes such as children or the elderly. To define and estimate heritability for longitudinally measured phenotypes, we present a framework based on functional data analysis, FDA. While our procedures have important genetic consequences, they also represent a substantial development for FDA. In particular, we present a very general methodology for constructing optimal, unbiased estimates of variance components in functional linear models. Such a problem is challenging as likelihoods and densities do not readily generalize to infinite-dimensional settings. Our procedure can be viewed as a functional generalization of the minimum norm quadratic unbiased estimation procedure, MINQUE, presented by C. R. Rao, and is equivalent to residual maximum likelihood, REML, in univariate settings. We apply our methodology to the Childhood Asthma Management Program, CAMP, a 4-year longitudinal study examining the long term effects of daily asthma medications on children.

Initiating an online asthma management program in urban emergency departments: the recruitment experience

BackgroundThe emergency department could represent a means of identifying patients with asthma who could benefit from asthma interventions. ObjectiveTo assess the initiation of a Web-based tailored asthma intervention in the emergency department of 2 urban tertiary care hospitals. MethodsIn addition to awareness strategies for emergency department staff (eg, attending nursing huddles, division meetings, etc), recruitment experiences are described for 2 strategies: (1) recruitment during an emergency department visit for acute asthma and (2) recruitment from patient listings (mail or telephone). Patient enrollment was defined as baseline completion, randomization, and completion of the first of 4 online sessions. ResultsOf 499 eligible patients 13 to 19 years old visiting the emergency department for asthma during the study period, 313 (63%) were contacted in the emergency department (n = 65) or by mail or telephone (n = 350). Of these, 121 (38.6%) were randomized. Mean age of the study sample was 15.4 years and 88.4% were African American. Refusal rates for emergency department recruitment and mail or telephone were 18.5% (12 of 65) and 16.6% (58 of 350), respectively. On average, emergency department enrollment took 44 to 67 minutes, including downtime. When surveyed, emergency department providers were more positive about awareness activities and emergency department recruitment than were research staff. ConclusionEmergency department recruitment was feasible but labor intensive. Refusal rates were similar for the 2 strategies. Targeting patients with acute asthma in the emergency department is one way of connecting with youth at risk of future acute events.