Medical Nonadherence Research Articles

Transition of care from pediatric to adult nephrology post-renal transplant: a review.

Pediatric renal transplant recipients (RTRs) face heightened risks when they transition from a childhood nephrologist to an adult-centered one. The transition of care usually occurs when an individual is between ages 18 and 21 years, although some change providers earlier or later depending on varying circumstances. Turbulence during this shift can significantly impact daily life and, in severe cases, lead to graft loss. Several modern studies have explored the transition from pediatric to adult-centered nephrology care post-renal transplant. In this review, we first provide an overview of the differences between pediatric and adult renal transplant, highlighting unique challenges faced by pediatric patients such as donor-recipient size disparity, growth impairment, and need for additional immunizations. We then emphasize the criticality of a well-planned transition process, identifying factors that can hinder a smooth transition-such as medical and medication nonadherence, lack of health literacy, patient psychosocial challenges, and systemic shortcomings in coordination between care teams. Furthermore, this review outlines existing protocols and risk assessment tools, in addition to highlighting recent advancements aimed at facilitating smoother transitions such as the RISE protocol, readiness assessment, and the use of multidisciplinary teams. Proper implementation of coordinated, evidence-based transition protocols can improve patient outcomes, promote medication and appointment adherence, and reduce graft rejection rates. Efforts from multidisciplinary teams utilizing technology, risk stratification tools, and open communication between providers and patients are key to optimizing the transition process for pediatric RTRs as they transfer to adult-centered care.

Cognitive-behavioral Therapy for Medical Non-adherence: A Topical Review and Clinical Recommendations

Cognitive-behavioral Therapy for Medical Non-adherence: A Topical Review and Clinical Recommendations

P60 Cost-Related Medical Care Use Reduction and Mediation Nonadherence in US Adults with Multiple Chronic Conditions: A Comparison of High Deductible Health Plans and Traditional Insurance Enrollees

To examine cost-related forgone and delayed medical care and medication nonadherence in privately insured high deductible health plan (HDHP) vs. traditional insurance plan enrollees with multiple chronic conditions (MCC) in the US.

Effects of Experienced Discrimination in Pediatric Sickle Cell Disease: Caregiver and Provider Perspectives.

For Black children with sicklecell disease (SCD) and their families, high disease stigmatization and pervasive racism increase susceptibility to discrimination in healthcare settings. Childhood experiences of discrimination can result in medical nonadherence, mistrust of healthcare providers, and poorer health outcomes across the lifespan. Caregivers and medical providers are essential to childhood SCD management and are therefore well-positioned to provide insight into discrimination in the context of pediatric SCD. This mixed-methods study sought caregivers' and providers' perspectives on processes underlying discrimination and potential solutions to mitigate the negative effects of perceived discrimination among children with SCD. Caregivers (N = 27) of children with SCD (≤ 12years old) and providers from their hematology clinics (N = 11) participated in individual semi-structured interviews exploring experiences of discrimination and daily SCD management and completed a quantitative measure of discrimination. Qualitative data were collected until themes reached saturation and subsequently transcribed verbatim, coded, and analyzed using applied thematic analysis. Quantitative and qualitative data converged to suggest the pervasiveness of discrimination in healthcare settings. Three qualitative themes emerged: (1) healthcare system factors underlie discrimination, (2) families' challenging interactions with providers lead to perceptions of discrimination, and (3) experiences of discrimination impact caregiver-provider interactions. Both caregivers and providers highlighted building trusting patient-provider relationships and encouraging patients' self-advocacy as means to reduce experiences and impacts of discrimination. These findings offer potential approaches to tangibly mitigate occurrences of discrimination in pediatric healthcare settings by trust building, accountability keeping, and fostering rapport to improve quality of care and pediatric SCD health outcomes.

The Role of Access and Cost-Effectiveness in Managing Asthma: A Systematic Review

BackgroundInconsistent and unequal access to medical care is an issue that predates the COVID19 pandemic, which only worsened the problem. Limited access to care from asthma specialists and other specialists treating comorbid diseases may adversely affect asthma.ObjectiveThe purpose of this review is to identify health disparities associated with access to care for asthma, and cost-effectiveness of therapies and interventions addressing this health disparity.MethodsA narrative systematic review was undertaken using MeSH searches of English language articles published in CINAHL, Scopus, or PubMed.ResultsA total of 725 articles were identified. Barriers recognized from the literature included access to diagnostic spirometry, access to specialists, medication formulary restrictions, and issues leading to medical nonadherence. Telemedicine, school-based health care interventions, digital applications, and non–office-based digital spirometry could be used to address these gaps in access to asthma care while potentially being cost-effective.ConclusionWith the widespread adoption of telemedicine because of the pandemic, and adoption of other mobile services, we now have potential tools that can increase access to asthma care, which can help address this health care inequity. Evidence is limited, but favorable, that some of these tools may be cost-effective.

Abstract 12761: Association of Medical Non-Adherence to Health Status Outcomes in the ISCHEMIA Trial

Introduction: In the ISCHEMIA trial, participants managed invasively (INV; guideline-directed medical therapy [GDMT] + angiography ± revascularization) had better health status outcomes than those managed conservatively (CON; GDMT alone). It is unknown whether adherence to prescribed medications affects health status outcomes in chronic coronary disease (CCD). Hypothesis: Patient-reported medication non-adherence more adversely impacts health status outcomes in those treated with a CON, but not an INV, strategy. Methods: Self-reported adherence was assessed at randomization with a modified Morisky-Green-Levine medication adherence measure and patients were dichotomized into adherent (never skipping meds) and non-adherent (occasionally skipping meds). Twelve-month health status outcomes were assessed with the 7-item Seattle Angina Questionnaire (SAQ) Summary Score (SS; range 0-100, higher = better) using adjusted mixed effects cumulative probability models within a Bayesian framework to estimate differences between adherent and non-adherent patients, stratified by study arm. Results: Among 4480 randomized patients in the SAQ cohort, 1245 (27.8%) reported non-adherence at baseline. These patients had worse SAQ scores at baseline (CON: 72.9 ± 19.3 vs. 75.6 ± 18.4; INV: 71.0 ± 19.8 vs. 74.2 ± 18.7) and follow-up (CON: 81.2 ± 18.3 vs. 85.4 ± 15.0; INV: 84.3 ± 17.4 vs. 88.2 ± 13.9). The Figure shows similar posterior distributions of better SAQ scores with adherence in both arms (Mean difference = 1.63 (95% CrI 0.33, 2.89) in CON; 1.93 (95% CrI 0.80, 3.06) in INV). Conclusions: Medication non-adherence—as was reported in over 1 in 4 patients—was associated with worse 12-month health status, an effect that was similar in CON and INV strategies. While causation cannot be established, improving adherence may improve health status outcomes in CCD, regardless of treatment strategy.

Disparities in health care affordability among childhood cancer survivors persist following the Affordable Care Act.

The Affordable Care Act (ACA) included many provisions that may have improved access to care for childhood cancer survivors (CCS). In this study, we sought to compare health insurance coverage and the affordability of health care among adult childhood CCS before and after the implementation of the ACA. Using data from the National Health Interview Survey (NHIS), two cohorts of CCS age 21-65years old and matched (1:3) controls without a history of cancer were identified. A difference-in-differences analysis was used to compare insurance coverage and health care affordability pre- (2011-2013) and post-ACA (2015-2017). There were 309 CCS identified in the pre-ACA cohort and 324 in the post-ACA cohort. The two cohorts were similar in demographic composition. Prior to the ACA, CCS were 39% more likely to be uninsured than their peers (p = .046). Post, there was no difference in the odds of being uninsured between CCS and their peers. Following implementation of the ACA, the proportion of CCS who reported having difficulty with the affordability of health care decreased (p = .013) as did the proportion reporting skipping needed care due to cost (p<.001). However, 13% of CCS still reported being uninsured, 36% reported difficulty paying for health care, and 13% reported foregoing needed care due to cost. Relative to their peers, CCS saw improvement in foregoing needed care due to cost, but disparities still remain. Although improvements were observed, health care affordability, and medical nonadherence remains a problem for CCS. Additional efforts are needed to improve health care affordability among CCS.

Association Between the Modalities of Complementary and Alternative Medicine Use and Cost-Related Nonadherence to Medical Care Among Older Americans: A Cohort Study.

Introduction: Complementary and alternative medicine (CAM) use has been increasingly prevalent among Americans, whereas its relationship with medical nonadherence is unknown. Methods: Using the National Health Interview Survey, we evaluated the use of CAM modalities and their association with cost-related nonadherence to medical care (CRN) among older Americans by gender strata. Results: Men and women were, in general, in the same pattern of higher likelihood of reporting CRN if they utilized herbal supplements, meditation, and chiropractic or osteopathic manipulations (p < 0.05, respectively). Conclusion: Both men and women are more likely to report financial distress while using various CAM modalities.

A Behavior-Analytic Approach to Antivaccination Practices.

In recent years, there has been an increase in outbreaks of diseases that are preventable by vaccination. As vaccination involves behavior, behavior analysts are uniquely positioned to contribute solutions to this socially significant problem. The present article explores a behavior-analytic approach to understanding the function of the behavior of both people who have their children vaccinated and those who do not have their children vaccinated, and potential interventions to increase vaccination rates. An introduction to the problem is followed by a brief history of the antivaccination movement. In our analysis, a failure to vaccinate is conceptualized as a noncompliance response (i.e., medical nonadherence), and conditions giving rise to that noncompliance are evaluated. In this process, the roles of avoidance, the functional-altering impact of rule-governed behavior, relational frames, and countercontrol are considered. Potential solutions informed by applied behavior-analytic literature, including contingency management and behavioral safety, are discussed.

Invasive Approaches in the Management of Cocaine-Associated Non-ST-Segment Elevation Myocardial Infarction.

The aim of this study was to determine the impact of invasive approaches and revascularization in patients with cocaine-associated non-ST-segment elevation myocardial infarction (NSTEMI). The role of invasive approaches in cocaine-associated NSTEMI is uncertain. This retrospective cohort study identified 3,735 patients with NSTEMI and history of cocaine use from the Nationwide Readmissions Database from 2016 to 2017. Invasive approaches were defined as coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Revascularization was defined as PCI and CABG. The primary efficacy outcome was major adverse cardiac events (MACE), and the primary safety outcome was emergent revascularization. Nonadherence was identified using appropriate International Classification of Diseases-Tenth Revision codes. Two propensity-matched cohorts were generated (noninvasive vs. invasive and noninvasive vs. revascularization) through multivariate logistic regression. In the propensity score-matched cohorts, an invasive approach (hazard ratio [HR]: 0.72; 95% confidence interval [CI]: 0.56 to 0.92; p=0.008) and revascularization (HR: 0.54; 95%CI: 0.40 to 0.73; p<0.001) (compared with a noninvasive approach) were associated with a lower rate of MACE, without an increase in emergent revascularization. On stratification, PCI and CABG individually were associated with a lower rate of MACE. Emergent revascularization was increased with PCI (HR: 1.78; 95%CI: 1.12 to 2.81; p=0.014) but not with CABG. Nonadherent patients after PCI and CABG did not have significant difference in rate of MACE. PCI in nonadherent patients was associated with an increase in emergent revascularization (HR: 4.45; 95%CI: 2.07 to 9.57; p<0.001). Invasive approaches and revascularization for cocaine-associated NSTEMI are associated with lower morbidity. A history of medical nonadherence was not associated with a difference in morbidity but was associated with an increased risk for emergent revascularization with PCI.

TRANSITION of Pediatric Liver Transplant Patients to Adult Care: a Review.

Many pediatric liver transplant patients are surviving to adulthood, and providers have come to recognize the importance of effectively transitioning these patients to an adult hepatologist. The review aims to analyze the most recent literature regarding patient outcomes after transition, barriers to successful transition, recommendations from clinicians and medical societies regarding transition programs, and to provide personal insights from our experience in transitioning liver transplant recipients. While results were variable between studies, many recent reports show significant morbidity and mortality in patients following transition to adult care. Medical non-adherence is frequently seen in adolescents and young adults both prior to and after transition, and is consistently associated with higher rates of rejection, graft loss, and death. In general, transplant programs with a formal transition process had better patient outcomes though recent findings are mostly-single center and direct comparison between programs is difficult. Societal recommendations for how to create a transition program contain a number of common themes that we have categorized for easier understanding. Successful transition is vital to the continued health of pediatric liver transplant patients. While an effective transition program includes a number of key components, it should be individualized to best function within a given transplant center. Here, we have reviewed a number of recent single-center retrospective studies on transition, but multi-site retrospective or prospective data is lacking, and is a fertile area for future research.

A model exploring the relationship between betrayal trauma and health: The roles of mental health, attachment, trust in healthcare systems, and nonadherence to treatment.

Prior research suggests that there is a relationship between traumatic experiences and poor health. When considered through the lens of betrayal trauma (i.e., the perpetrator and the victim have a close interpersonal relationship), traumatic experiences predict greater posttraumatic difficulty and higher levels of depression. Betrayal trauma has been associated with poorer interpersonal relationships and less trust in individuals and systems that may be important for a person's wellbeing, such as health care systems. In turn, trauma survivors are less likely to adhere to medical treatment, which may ultimately affect their overall health. The current study examined the complex relationship between experiences of betrayal trauma and poor health, while accounting for demographics, mental health symptoms, trust in physicians and the medical system, attachment style, and nonadherence to medical treatment. A demographically representative sample of 312 Canadian participants was surveyed online. Participants completed measures that assessed symptoms of mental health (PTSD, depression), trauma, attachment style, trust, and nonadherence to medical treatment. Hierarchical regression models were used to examine the relationship between betrayal trauma and health. Betrayal trauma significantly predicted nonadherence to treatment, while trust in physicians was explained by trauma, attachment style, and mental health symptoms. All of these factors significantly explained poor health status. Results suggest the importance of implementing trauma-informed care in health care systems. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Living environment, social support, and informal caregiving are associated with healthcare seeking behaviour and adherence to medication treatment: A cross-sectional population study.

Despite the well‐known associations between local environment and health, few studies have focused on environment and healthcare utilisation, for instance healthcare seeking behaviour or adherence. This study was aimed at analysing housing type, behaviour based on perceived local outdoor safety, social support, informal caregiving, demographics, socioeconomics, and long‐term illness, and associations with health‐seeking and adherence behaviours at a population level. This study used data from the Swedish National Public Health Survey 2004–2014, an annually repeated, large sample, cross‐sectional, population‐based survey study. In all, questionnaires from 100,433 individuals were returned by post, making the response rate 52.9% (100,433/190,000). Descriptive statistics and multiple logistic regressions were used to investigate associations between explanatory variables and the outcomes of refraining from seeking care and non‐adherence behaviour. Living in rented apartment, lodger, a dorm or other was associated with reporting refraining from seeking care (adjusted OR 1.16, 95% CI 1.00–1.22), and non‐adherence (adjusted OR 1.22; 95% CI 1.13–1.31). Refraining from going out due to a perceived unsafe neighbourhood was associated with refraining from seeking care (adjusted OR 1.59, 95% CI 1.51–1.67) and non‐adherence (adjusted OR 1.26, 95% CI 1.17–1.36). Social support and status as an informal caregiver was associated with higher odds of refraining from seeking medical care and non‐adherence. This study suggests that living in rental housing, refraining from going out due to neighbourhood safety concerns, lack of social support or informal caregiver status are associated with lower health‐seeking behaviour and non‐adherence to prescribed medication.

Do-it-Yourself Medicine? The Impact of Light Cannabis Liberalization on Prescription Drugs

Governments worldwide are increasingly concerned about the booming CBD (cannabidiol) products. However, little is known about the impact of their liberalization. We study a unique case of unintended liberalization of a CBD-based product (light cannabis) that occurred in Italy in 2017. Using unique and high-frequency data on prescription drug sales and by exploiting the staggered local availability of the new product in each Italian province, we document a significant substitution effect between light cannabis and anxiolytics, sedatives, opioids, anti-depressants, and antipsychotics. Such medical non-adherence is consistent with a self-medication interpretation. Results are informative for regulators and suggest that policies contrasting this green oil boom risk to disregard the effective need of patients to seek effective reliefs of their symptoms.

Beliefs about medicines in dialysis patients and after renal transplantation.

Patients with end-stage renal disease are burdened by a complex medication regimen, but little is known about the belief about medicine among dialysis- and renal transplant (RTX) patients. Patients' beliefs about medicines may influence drug adherence and thereby affect morbidity and mortality. The aim of the present study was to assess the beliefs about medicine in dialysis as well as after RTX. In a prospective study, 301 dialysis patients were followed for up to 5.5 years during which time 142 had been transplanted. Out of the transplanted patients, 110 were eligible for inclusion. The Beliefs about Medicine Questionnaire (BMQ) was used to assess the beliefs in dialysis and after transplantation. BMQ in dialysis was also compared to that of the general Norwegian population (n = 426). Multiple linear regression analyses were performed with BMQ subscales as dependent variables and sociodemographic and clinical data as independent variables. Median age in dialysis was 62 (IQR 50-73) years, 66.1% were male and 80.7% were treated with hemodialysis. When in dialysis, 98.2% strongly believed their medications were necessary, while 34.4% reported strong concerns. Furthermore, 17.3% believed their medications to be harmful and 38.6% believed that doctors overprescribed medicines. The Necessity-concern differential had a positive score in 92.6% of the patients. Follow-up time was 55 (IQR 50-59) months. After transplantation, there was an increase in the patient-reported necessity of medication (21.9 ± 2.7 vs. 23.8 ± 1.9, P < 0.001) compared to while in dialysis. Correlations were found between patient beliefs and education, age, and depression. Although positive beliefs about medicines increase after transplantation, concerns are high in both dialysis and after RTX. Implementing the BMQ routinely in the clinical evaluation of dialysis- and RTX patients may help to identify patients with increased risk for medical nonadherence.

Therapeutic Approaches to Secondary Fracture Prevention in High Risk Populations: Current Recommendations and Advances

Background: Osteoporotic fragility fracture is a burgeoning health epidemic that is associated with high rates of disability, morbidity, and mortality. Based on NHANES data, approximately 10 million Americans are affected by this disease. Areas of Uncertainty: Successful secondary fracture prevention measures are often limited by the under-diagnosis of osteoporosis after fragility fractures because of lack of patient and physician awareness of the disease, lack of follow-up, and medical nonadherence. Therapeutic Advances: Current guidelines recommend the use of Bisphosphonate as the first-line therapy for secondary fracture prevention. Compared with placebo, randomized controlled trials have demonstrated a significant reduction in vertebral and nonvertebral fractures using Alendronate, Risedronate, Ibandronate, and Zoledronic acid. All but Ibandronate showed a significant reduction in hip fractures as well (all trials with P &lt; 0.05). Denosumab is an option in patients with impaired renal function or who are unresponsive to other therapies. It significantly decreases the risk of new vertebral fracture [hazard ratio (HR) = 0.32, 95% confidence interval (CI), 0.26–0.41], hip fracture (HR = 0.60, 95% CI, 0.37–0.97) and nonvertebral fracture (HR = 0.80; 95% CI, 0.67–0.95) without an increased in adverse events. Hormonal therapy has been shown to be effective but should be used in the lowest effective dose to minimize the risk of coronary heart disease, stroke, and venous thromboembolism. Selective estrogen replacement modulators, calcitonin, and parathyroid hormone analog are other alternatives described in this article. In addition to current therapies, emerging therapies under investigation such as Abaloparatide, a parathyroid receptor ligand, and Romosozumab, a monoclonal anti-sclerotin antibody both showed a reduction in new morphometric vertebral fractures compared with placebo (0.58% vs. 4.22%, relative risk = 0.14, 95% CI, 0.05–0.39 and 0.5 vs. 1.8%, relative risk = 0.27, 95% CI, 0.16–0.47, respectively). In this article, we summarize advances in current therapeutic agents used for secondary fracture prevention and provide insight into potential therapies that hold promise in the future of osteoporosis. Conclusion: Secondary prevention of fragility fractures through care coordination and initiation of various pharmacologic agents is crucial in the elderly population. Careful risk assessment and stratification should be performed before the initiation of pharmacologic treatment to optimize disease management.

The relationship between risk factors and medication adherence among breast cancer survivors: What explanatory role might depression play?

Despite the efficacy of clinical treatments (eg, adjuvant hormonal therapy) for breast cancer survivors (BCS), nonadherence rates remain high, increasing the risk of recurrence and mortality. The current study tested a theoretical model of medical nonadherence that proposes depression to be the most proximal predictor of medical nonadherence among BCS. Breast cancer survivors were recruited from radiation clinics in Missouri. Survey data were collected 12months after the end of primary treatment. The sample size included 133 BCS. Findings show substantial support for the model, demonstrating that depression mediated the relation between physical symptoms, cognitive symptoms, social support, and adherence to medication. This finding was replicated with a measure of mood disturbance. These findings support the prediction that medication nonadherence among BCS multiply determined process and have compelling implications for healthcare providers and interventions designed to increase medication adherence among BCS.

Does Message-Based Communication Through Mobile Phones for Medication and Treatment Adherence Improve Health Outcomes? A Systematic Review

Medical non-adherence has been a pervasive issue in healthcare for far too long and consequences of medical non-adherence are far reaching. With the proliferation of mobile technology globally, there have been concerted efforts to improve adherence using mHealth both in developed and developing countries. The objective of this study was to evaluate through previous studies whether mobile phone innovations improve health outcomes through adherence messages to patients and how many of the studies mention and actually consider the content going out to patients as contributing to positive or negative health outcome. A systematic review was conducted using four search engines: PubMed, Mendley, Advanced Google, and Google Scholar. The publications were randomized clinical trials, cross-sectional studies, and pre and post interventional studies. The publications reviewed were considered to be eligible if they were based on use of mobile technology or smart phone applications in improving health outcomes through sending adherence messages. Forty one potential articles were retrieved based on the first search criteria and review of abstracts. Full text was not obtainable for 11 articles due to fees to access the document and/or a registration requirement for the websites making the full text inaccessible. Nine articles were published before the year 2009, 7 were systematic reviews, 1 was an SMS based study but was used by community health workers and did not necessarily address adherence, 3 were protocols for a study to be done, 10 articles met all the inclusion criteria. Mobile health technology has been proven to contribute towards improving adherence to treatment, medication and appointments. However it is crucial to consider the content and its development processes just as much as the technology in use as this might elevate the health outcomes even higher.

Stringent Response Factors PPX1 and PPK2 Play an Important Role in Mycobacterium tuberculosis Metabolism, Biofilm Formation, and Sensitivity to Isoniazid In Vivo.

Mycobacterium tuberculosis remains a global health threat largely due to the lengthy duration of curative antibiotic treatment, contributing to medical nonadherence and the emergence of drug resistance. This prolonged therapy is likely due to the presence of M. tuberculosis persisters, which exhibit antibiotic tolerance. Inorganic polyphosphate [poly(P)] is a key regulatory molecule in the M. tuberculosis stringent response mediating antibiotic tolerance. The polyphosphate kinase PPK1 is responsible for poly(P) synthesis in M. tuberculosis, while the exopolyphosphatases PPX1 and PPX2 and the GTP synthase PPK2 are responsible for poly(P) hydrolysis. In the present study, we show by liquid chromatography-tandem mass spectrometry that poly(P)-accumulating M. tuberculosis mutant strains deficient in ppx1 or ppk2 had significantly lower intracellular levels of glycerol-3-phosphate (G3P) and 1-deoxy-xylulose-5-phosphate. Real-time PCR revealed decreased expression of genes in the G3P synthesis pathway in each mutant. The ppx1-deficient mutant also showed a significant accumulation of metabolites in the tricarboxylic acid cycle, as well as altered arginine and NADH metabolism. Each poly(P)-accumulating strain showed defective biofilm formation, while deficiency of ppk2 was associated with increased sensitivity to plumbagin and meropenem and deficiency of ppx1 led to enhanced susceptibility to clofazimine. A DNA vaccine expressing ppx1 and ppk2, together with two other members of the M. tuberculosis stringent response, M. tuberculosis rel and sigE, did not show protective activity against aerosol challenge with M. tuberculosis, but vaccine-induced immunity enhanced the killing activity of isoniazid in a murine model of chronic tuberculosis. In summary, poly(P)-regulating factors of the M. tuberculosis stringent response play an important role in M. tuberculosis metabolism, biofilm formation, and antibiotic sensitivity in vivo.

Acute severe asthma (status asthmaticus).

Acute severe asthma, formerly known as status asthmaticus, is defined as severe asthma unresponsive to repeated courses of beta-agonist therapy. It is a medical emergency that requires immediate recognition and treatment. Albuterol in combination with ipratropium bromide in the emergency department (ED) has been shown to decrease the time spent in the ED and the hospitalization rates. The benefits of ipratropium are not sustained after admission to the hospital. Oral or parenteral corticosteroids should be administered to all patients with acute severe asthma as early as possible because clinical benefits may not occur for a minimum of 6 to 12 hours. Viral respiratory infections are a common trigger for acute asthma; other causes include medical nonadherence, allergen exposure (especially pets and mold [e.g., Alternaria species]) in individuals who are severely atopic, nonsteroidal anti-inflammatory exposure in patients with aspirin allergy, irritant inhalation (e.g., smoke, paint), exercise, and insufficient use of inhaled or oral corticosteroids. The patient's history should focus on the acute assessment of asthma control and morbidity, including current use of oral or inhaled corticosteroids; the number of hospitalizations, ED visits, intensive care unit admissions, and intubations; the frequency of albuterol use; the presence of nighttime symptoms; activity intolerance; current medications; exposure to allergens; and other significant medical conditions. Severe airflow obstruction may be predicted by accessory muscle use, difficulty speaking, refusal to recline < 30°, a pulse of >120 beats/min, and decreased breath sounds. More objective measures of airway obstruction via peak flow or forced expiratory volume in 1 second and pulse oximetry before oxygen administration usually are helpful. Pulse oximetry values of >90% are reassuring, although CO₂ retention and a low partial pressure of oxygen may be missed.