National Asthma Education Research Articles

Success of a Comprehensive School-Based Asthma Intervention on Clinical Markers and Resource Utilization for Inner-City Children with Asthma in Chicago: The Mobile C.A.R.E. Foundation's Asthma Management Program

Children with asthma in low-income households in Chicago were participants in a school-based mobile van clinic, Mobile C.A.R.E. Our objective was to investigate whether long-term follow-up changed clinical markers and resource utilization. Children were evaluated by a pediatrician in a mobile allergy clinic and classified and treated based on National Asthma Education and Prevention Program (NAEPP) guidelines. Intervention consisted of assessment of allergic environment with avoidance recommendations, institution of appropriate controller therapy and inhaler technique, education on asthma and asthma management, and expectations for asthma control. Over 20,000 children were screened, 2041 were examined at least once, and 677 children had four follow-up visits. With follow-up, there was a decrease in hospitalizations and emergency room visits. Symptomatic markers (daytime and nighttime cough, wheezing, and dyspnea symptoms), frequency of rescue inhaler use, and a quality-of-life score improved from baseline. These findings suggest that ongoing school interventions may reduce resource utilization and improve clinical symptoms. Primary care physicians may be able to deliver specialized care to large numbers of inner-city children with asthma.

Addressing issues of asthma in inner-city children

For children living in the inner city, asthma tends to be more frequent and severe. Although the causes for this heightened severity of asthma are not clearly established, environmental allergens likely play a major role. To characterize, understand, and treat children with asthma living in the inner city better, the National Institutes of Allergy and Infectious Diseases of the National Institutes of Health established an Inner City Asthma Program in 1991. Over the past 15 years, 3 separate inner-city asthma research networks have been formed and funded by this institute. The work from these programs has led to important observations including evidence that environmental allergens, particularly cockroach, are important for sensitization and severity of asthma of the affected children. Furthermore, reductions in the allergen load can lead to improved asthma control. The most recent program, the Inner City Asthma Consortium, was formed in 2002 with a goal to develop immune-based therapy for children with asthma in the inner city and to determine mechanisms of these therapies as well as immunopathogenesis of asthma in these high-risk children. This article reviews these programs and how they have begun the effort to understand and treat children with asthma who live in inner cities better and what their findings mean in relationship to unique features of asthma in inner city children.

Initiation of Maintenance Antiinflammatory Medication in Asthmatic Children in a Pediatric Emergency Department

Despite National Asthma Education and Prevention Program guidelines recommending the use of daily controller medication in patients with persistent asthma, less than half of children requiring emergency department treatment for asthma exacerbations are receiving antiinflammatory therapy. The purpose of this study was to evaluate a pediatric emergency department-based intervention designed to affect the prescribing practices of primary care physicians to better comply with national asthma guidelines. The intervention involved initiating maintenance antiinflammatory therapy in children with an asthma exacerbation who met guidelines for persistent disease but were not on antiinflammatory medications. Guardians of children 2 to 18 years of age presenting to the pediatric emergency department with an asthma exacerbation were asked to complete an asthma survey. Patients were classified into severity categories. Those with persistent disease not on antiinflammatory medications were given a 2-week supply of medication and were instructed to follow-up with their primary care physicians to obtain a prescription for the antiinflammatory medication. Patient adherence information was obtained through telephone calls, pharmacy claims data, and physician office records. Forty-seven of 142 patients met criteria and were enrolled in the intervention. Seven patients were lost to follow-up. Of the remaining 40 patients, 28 followed-up with their primary care physician. Of these patients, 75% were continued on an antiinflammatory medication. Primary care physicians were significantly more likely to continue an antiinflammatory prescription in patients with severe persistent asthma (88.9% vs 68.4% of mild- or moderate-persistent asthmatics). Of the 28 patients who followed-up with their primary care physician, 13 had a prescription written, dispensed, and reported using the medication at the time of follow-up. Pediatric emergency department physicians can successfully partner with primary care physicians to implement national guidelines for children requiring maintenance antiinflammatory asthma therapy. Patient nonadherence continues to be a significant barrier for asthma management.

From asthma severity to asthma control: identification of new guidelines.

Managed care pharmacists utilize clinical guidelines to assist them in identifying acceptable treatment and management of chronic diseases. For the past several months, an expert panel representing the National Asthma Education and Prevention Program (NAEPP) has discussed updated asthma guidelines, which could change future medication management of patients with asthma. To identify new guidelines for asthma control. Taking control of asthma is a foremost objective in managed care, as new guidelines are debated, and asthma disease management programs identify more effective models of asthma disease management. Within an effective asthma disease management program, managed care practitioners, including but not limited to physicians and pharmacists, must have a thorough understanding of the most recent clinical guidelines as well as current knowledge of the current consensus among opinion leaders regarding asthma treatment and management. This ongoing education is critical in order to allow managed care practitioners to perform their role and function within their organizations. With the advent of changing asthma practice guidelines and processes, managed care practitioners need current information to recognize and apply guidelines-based asthma control. Appropriate asthma treatment requires adherence to current management guidelines. Approximately one third of asthmatics will not respond to standard asthma treatment and may even worsen while on therapy. Monitoring, close tracking, and regular evaluation of asthma patients at every health care provider visit is a strategy that can be utilized to generate improved asthma control.

IS IT BEING USED THE RIGHT WAY? HOME NEBULIZER USE AMONG CHILDREN AND YOUNG ADULTS DYING FROM ASTHMA, MICHIGAN, 2002-2004

PURPOSE: Widespread prescription and use of home nebulizers in asthma may have the unintended consequence of contributing to over-reliance on bronchodilators and inadequate use of inhaled steroids with subsequent delay in seeking medical care during an acute exacerbation and poor management of chronic asthma. This may lead to poor outcome and even death. National Asthma Education and Prevention Program (NAEPP) guidelines include the use of a daily peak flow monitor and asthma action plan in individuals over five years of age who are prescribed a nebulizer. We retrospectively analyzed the use of home nebulizers in individuals dying from asthma.

Continuous Noninvasive Measurement of Pulsus Paradoxus Complements Medical Decision Making in Assessment of Acute Asthma Severity

Pulsus paradoxus (PP) is a pathophysiologic parameter that is indicative of asthma severity. The ability of PP to categorize acutely asthmatic patients in accordance with the earlier National Asthma Education and Prevention Program (NAEPP) expert panel report 1 guidelines was determined. An arterial tonometric BP monitor, which was interfaced to an analog-digital converter, executed a periodic amplitude analysis algorithm, which computed PP in real time. The PP measurement was compared to the criterion standard of emergency physicians in determining the hospital admission vs hospital discharge disposition following the NAEPP standardized treatment. Receiver operating characteristics (ROCs) were calculated, and the PP threshold, which maximized sensitivity and specificity, was identified. In a separate laboratory investigation, PP was induced in a healthy volunteer by inspiration through a fixed resistance. Plethysmographic waveform changes, induced by PP, were measured by a second analog-to-digital converter that was connected to a pulse oximeter. A total of 79 patients were enrolled in the study, of whom 63 met a priori inclusion criteria and had uninterrupted data acquisition. The mean PP for patients who were appropriately discharged from the hospital was 9.1 mm Hg (95% confidence interval [CI], 7.3 to 10.9 mm Hg) and differed from the PP of 17.6 mm Hg (95% CI, 13.5 to 21.8; p < 0.001) for patients admitted to the hospital/relapsed. The sensitivity and specificity for physician disposition were 0.83 and 0.89, respectively, and for PP values were 0.78 and 0.78, respectively. The Wilcoxon area under the ROC curve was 0.82 (95% CI, 0.64 to 0.99) following treatment. The risk ratio was 5.32 for hospital admission among patients with a PP of > 11.3 mm Hg. Changes in the photoplethysmography peak height were correlated to PP from the BP monitor by a regression line with a slope of 0.01 V/mm Hg. Continuous PP can aid in determining disposition among emergency department (ED) patients with acute asthma. ED physicians equipped with a PP monitor would be able to objectify the work of breathing and would more closely adhere to NAEPP guidelines. The possibility that a PP detection algorithm could reside in a pulse oximeter warrants further investigation.

The Influence of Variation in Type and Pattern of Symptoms on Assessment in Pediatric Asthma

We conducted a national, population-based survey to examine the asthma-related health burden of US children. A telephone-based survey was conducted in 2004 of children 4 to 18 years of age with current asthma in the United States. In 41,433 households screened, 1089 children reported current asthma; 801 interviews were completed by parents of children aged 4 to 15 years and by children themselves aged 16 to 18 years. The survey included questions about symptoms, perceived level of control, activity limitations, health care use, medicines, disease management, and knowledge. Global asthma symptom burden, derived from the National Asthma Education and Prevention Program guidelines, was composed of 3 components: short-term symptom burden (4-week recall), long-term symptom burden (past year), and functional impact (activity limitation). The majority of children were classified with mild intermittent disease on the basis of recent daytime symptoms alone (80%); yet, when report of nighttime symptoms was included, the proportion of children classified as having mild intermittent symptoms decreased (74%). When asthma burden was assessed on the basis of the global symptom burden construct, only a minority (13%) of individuals was classified as having an asthma symptom burden consistent with mild intermittent disease; the majority (62%) was classified as having moderate/severe disease. In addition, the impact of asthma on the daily activities is substantial; avoiding exertion (47%) and staying inside (34%) are common approaches to improve control of asthma symptoms. The goals of therapy for asthma, based on the National Asthma Education and Prevention Program guidelines, have not been achieved for the majority of children. In addition, parents and children overestimate the child's asthma control and commonly restrict activities to control asthma symptoms. Deficiencies in the control of asthma may be related to the underestimation of the burden of disease.

Classification of Asthma Severity in Children

Despite increasing awareness of the National Asthma Education and Prevention Program guidelines, the relative contribution of symptom frequency or pulmonary function to the recommended asthma severity levels remains poorly understood. To determine whether adding lung function measurements to clinical history substantially changes the asthma severity classification, thereby influencing treatment decisions. Baseline data were studied from children enrolled in 2 multicenter studies: phase 1 of the National Cooperative Inner-City Asthma Study (1992-1994) (cohort 1) and the Inner-City Asthma Study (1998-2001) (cohort 2). Fifteen (8 for cohort 1 and 7 for cohort 2) major metropolitan inner-city areas in the United States. Inner-city children aged 8 through 11 years with asthma. Proportion of children reclassified from less severe asthma categories based on symptom frequency into more severe categories because of lung function. Of children with symptoms of mild intermittent asthma, 22.8% in cohort 1 and 27.7% in cohort 2 would be reclassified as having either moderate or severe persistent asthma. Of children with symptoms of mild persistent asthma, 31.2% in cohort 1 and 33.3% in cohort 2 would be similarly reclassified. In 2 different studies of inner-city children with asthma, approximately one third of the participants were reclassified into higher National Asthma Education and Prevention Program asthma severity categories when pulmonary function was considered in addition to symptom frequency. This may have direct implications for the undertreatment of asthma.

Use of Asthma Guidelines by Primary Care Providers to Reduce Hospitalizations and Emergency Department Visits in Poor, Minority, Urban Children

Purpose of the Study. To determine if a standardized citywide asthma management program delivered by primary care providers (PCPs) would increase adherence with the National Asthma Education and Prevention Program guidelines and whether this would improve medical service utilization. Study Population. Children between 6 months and 18 years of age (n = 8324) who presented for care at any of 6 primary care clinics in Hartford, Connecticut, between 1998 and 2002 and had enrolled in either Medicaid or the State Children’s Health Insurance Plan (SCHIP). Methods. Enrollment in the Easy Breathing asthma management program for PCPs included completing a survey regarding the child’s clinical history, provider assessment of asthma severity, and a written asthma treatment plan for the caregiver. Providers underwent training in the Easy Breathing curriculum. Data regarding demographics for enrolled patients were obtained from the survey and compared with all resident children in Hartford. Claims data were obtained. Utilization of medical services and prescriptions was examined. Children were continuously enrolled in the program during the 4-year analysis period. Relative rates of utilization (in event/child-months) were compared for the same children before and after enrollment. Results. Of the 1799 children with persistent asthma, only 38% were treated with antiinflammatory therapy before Easy Breathing; after enrollment, this improved to 96%, with 85% of those treated specifically with an inhaled corticosteroid. After enrollment in Easy Breathing, the rate of hospitalization for all children with asthma decreased 35% (P &amp;lt; .006), and the decrease was sustained over 3 years. There was a 27% overall decrease in emergency department (ED) visits for asthma (P &amp;lt; .01) and less seasonal variation in hospitalizations. Adjusted relative rates for total and asthma-specific ED and hospital visits decreased significantly for children with persistent asthma. Decreases in adjusted rates of outpatient visits after enrollment were also found for children overall (19%; P &amp;lt; .0001). This was true for children with intermittent asthma (22%; P &amp;lt; .001) and persistent asthma (18%; P &amp;lt; .001). Conclusions. Adherence to National Asthma Education and Prevention Program guidelines by PCPs managing asthma for low-income minority children decreased their total number of hospitalizations and asthma-specific ED visits and outpatient visits. The authors believe that contributors to the success of the program include the standardized approach to therapy, including inhaled corticosteroids when indicated, as well as the development of a written, individualized asthma treatment plan. The benefits of the program continued through the 3 years. Reviewer Comments. Despite a few limitations (nonrandomized, use of claims data), this study strongly reinforces the idea that improving asthma management relies not only on patient adherence but also physician review and faithful implementation of the current guidelines. PCPs managing asthma in low-income, urban, minority children would benefit the community by participating in such standardized programs that are focused on diagnosis and treatment. This not only decreases the morbidity related to asthma in these children but also alleviates the financial burden involved in excessive utilization of medical services.

The Influence of Pulmonary Function Testing on the Management of Asthma in Children

Purpose of the Study. Seventy-five percent of the asthma care in the United States is provided by primary care generalists. The National Asthma Education and Prevention Program guidelines recommend spirometry to assess management once the peak flow has stabilized. The purpose of this study was to assess how pulmonary-function tests (PFTs) performed during a patient encounter influence management decisions beyond the history and physical examination alone. Study Population. A total of 367 asthmatic patients were enrolled during their visit to a pediatric pulmonary clinic. The patients were 4 to 18 years old (mean: 10.4 years), and 60% were male. Patients were excluded if PFTs could not be performed on them, if they had a pulmonary diagnosis other than asthma, or if they had used albuterol within 4 hours. Methods. History of asthma symptoms was obtained, and a physical examination was performed. Spirometry was performed before the provider assessment. Peak expiratory flow rate (PEF) was also obtained. The results of the PFTs were not known to the provider at the time of the assessment and initial decision-making. The provider then reviewed the spirometry results and revised the initial recommendations if necessary. Changes in management were analyzed with respect to demographic data and spirometry. The diagnostic accuracy of PEF to detect abnormal lung function was determined. Results. Eight percent of the patients had mild intermittent asthma, 21% mild persistent asthma, 57% moderate persistent asthma, and 14% severe persistent asthma. Spirometry results were normal in 55% of the visits. Abnormal spirometry occurred equally in boys and girls. Sixty percent of the abnormal results were new compared with previous baseline measurements. The likelihood of an abnormal PFT increased with increasing severity classification. Ten percent of those in the group with mild intermittent asthma had abnormal PFTs, compared with 74% of those with severe persistent asthma. PFT results changed management in 15% of the visits. When spirometry did not change the treatment, the providers were more likely to have already decided to maintain therapy (58%). When spirometry did change treatment, providers were more likely to increase medications (75%). PEF was moderately inaccurate in detecting abnormal spirometry. Conclusions. In a clinical setting, even asthma care experts tended to overestimate the degree of asthma control as measured by airway obstruction. Spirometry results in this study were just as likely to be abnormal in patients with a normal history and physical examination. Reviewer Comments. The next logical question is: Does decision-making enhanced by spirometry result in better outcomes such as decreased symptoms, improved functioning and sleep, fewer exacerbations requiring steroid rescue, and less use of urgent asthma care services? When assessing asthma control, one should always consider comorbidities and adherence issues before stepping up therapy.

Adult Asthma Severity in Individuals With a History of Childhood Asthma

Purpose of the Study. Childhood asthma has a range of outcomes in adulthood. This study sought to identify clinical features and exposures associated with persistence and severity of childhood asthma in adulthood. Study Population. Subjects had been previously enrolled in the Childhood Asthma Study, a double-blind, randomized, placebo-controlled trial designed to study the role of immunotherapy as an adjunct treatment. The 121 original study members, aged 5 to 12 years at the time of randomization, had moderate-to-severe asthma and had been followed for at least 1 year before enrollment. Evaluations performed during the original study included daily medication-symptom diaries, home allergen analysis, allergy skin testing, and methacholine challenges. The cohort had varied socioeconomic status, genders, and ethnicities. For this study an attempt was made to enroll all original participants. Methods. Eighty-five of the original subjects participated in the adult evaluation, underwent spirometry and inhalant allergy skin testing, and completed questionnaires regarding their interim medical history, asthma symptoms, and medications. Asthma severity was classified by using a modified version of the 1997 National Asthma Education and Prevention Program algorithm. Postbronchodilator spirometry was used for severity categorization. Subjects were categorized in the most severe category for which they qualified. Results. Thirteen (15.3%) of these young adults, aged 17 to 30 years, were in remission. Another 19 (22%) had only mild intermittent asthma. There were 12 (14%) with mild persistent asthma, 25 (29%) with moderate persistent asthma, and 16 (19%) with severe persistent disease. Subjects in remission, compared with subjects with mild intermittent or persistent asthma, had lower serum immunoglobulin E in childhood (412 vs 1136 vs 968 ng/mL, respectively) and fewer positive allergy skin tests (7 vs 9 vs 10, respectively, from a panel of 18 allergens). Subjects in remission also had milder childhood asthma, indicated by lower average daily medication usage scores and lower percentage of days on inhaled corticosteroids (13.7% vs 24.7% vs 40.9%). There was no association found between current asthma severity and childhood immunotherapy. Conclusions. The prognosis of childhood allergic asthma in adulthood is largely determined early in life. The degree of atopy seems to be a critical determinant of asthma persistence. Reviewer Comments. The authors point out that numerous studies of the natural history of asthma have suggested associations between childhood atopy and disease severity with risk of asthma persistence and severity in later childhood and adulthood. It remains to be seen whether there is any sort of intervention at a very early phase in the disease that will more favorably alter the course of asthma. Thus far, there are no compelling candidates.

A Multisite Randomized Trial of the Effects of Physician Education and Organizational Change in Chronic Asthma Care: Cost-effectiveness Analysis of the Pediatric Asthma Care Patient Outcomes Research Team II (PAC-PORT II)

Purpose of the Study. To estimate the cost-effectiveness of 2 different asthma care interventions: a peer leader–based physician behavior-change intervention (PLE) and a practice-based redesign called the planned asthma care intervention (PACI). Study Population. Participants were 638 children (aged 3–17 years) with mild-to-moderate asthma. More than half of the subjects were on maintenance medication. Methods. This was a 3-arm cluster-randomized trial conducted in 42 primary care practices. These practices were randomly assigned to PLE (n = 226), PACI (n = 213), or usual care (n = 199). The PLE strategy involved training a pediatrician at each of the practice sites as an asthma expert and champion. This leader provided support, education, and feedback to the other members of the practice with regard to asthma management. The PACI strategy included all the components of the PLE arm and also included scheduled asthma care visits with an asthma nurse, who provided standardized assessments, care planning, coordination with the primary care physician, and self-management tools. Practices in the usual-care arm received copies of the National Asthma Education and Prevention Program Expert Panel Report 2 and patient-information handouts 12 months into the study. The subjects were followed for 2 years. The primary outcome was symptom-free days (SFDs). Costs included asthma-related health care utilization and intervention. Results. Patients in the usual-care arm of the study had in increase in SFDs of 14.8 per year. Patients in the PLE and PACI arms had an additional gain of 6.5 and 13.3 SFDs per year, respectively, compared with the usual-care arm. When the costs of development were excluded, the cost for SFDs gained compared with usual care was $18 for PLE and $68 for PACI. Conclusions. It is possible to increase SFDs in children and to move organizations toward guideline recommendations for asthma management. However, the improvements were associated with an increase in the costs associated with asthma care. Reviewer Comments. This trial was designed to provide cost analyses to both health care providers and health maintenance organizations. It is difficult, however, to establish a threshold for cost-effectiveness. The authors cite other trials to provide a context for this question. For example, the cost-effectiveness of inhaled corticosteroids in the treatment of children ranges from $7 to $12 per SFD gained. A social worker–based intervention had a cost-effectiveness ratio of $9 per SFD gained. What is it worth to patients, their families, and their health care providers to have an extra SFD?

The Breathmobile™: A Novel Comprehensive School-Based Mobile Asthma Care Clinic for Urban Underprivileged Children

Urban minority children have higher rates of asthma morbidity due to multiple factors. Many school-based programs have been funded to improve asthma management, especially for these "high-risk" inner-city children with asthma. Here we report the outcomes of the Children's Hospital of Orange County Breathmobile program, which is a school-based asthma program that combines the use of a mobile clinic and a pediatric asthma specialist. Baseline evaluations included a detailed history and physical, skin prick test to common allergens, spirometry measurements, and asthma severity classification based on the current National Asthma Education and Prevention Program guidelines. From April 2002 to September 2005, a total of 1321 children were evaluated for asthma. Analysis of the 1112 (84%) children diagnosed with asthma showed a population mean age of 7.8 years, 81% Latino ethnicity, and 73% with persistent disease. At baseline, only 24% of children with persistent asthma were on daily anti-inflammatory medications, which increased to 78% by the first follow-up visit. In the year prior to entry into the program, 64% had school absenteeism related to asthma (38% >10 days), 45% had emergency room (ER) visits (28% >1), and 19% had hospitalizations (9% >1). There was a significant reduction (p < .001) in the annual rates of ER visits, hospitalizations, and school absenteeism when comparing pre- and postentry into the program. These data suggest that a mobile asthma van clinic at the school site with an asthma specialist could be an effective model in reducing morbidity in the underserved child with asthma. Further studies are necessary to determine whether this model is applicable to other inner-city settings.

Forced Expiratory Volume in 1 Second Percentage Improves the Classification of Severity Among Children With Asthma

Spirometry is an important component of the National Asthma Education and Prevention Program guidelines for asthma, yet published data show variable associations between forced expiratory volume in 1 second percentage (FEV1%) predicted, symptoms and health care utilization. The objective of this analysis was to examine the association between FEV1% and future risk of exacerbations among a well-characterized population of children with asthma. Using data that are available from the Childhood Asthma Management Program, we examined the relationship between prebronchodilator FEV1% and important clinical outcomes. Multiple observations of FEV1 were available for each patient; multivariate regression analysis, using a general estimating equation approach, was used to control for the correlation between repeated measurements among individuals and potential confounders. FEV1% was categorized into 4 levels and as a continuous variable. Outcomes of interest included mean symptom score (0-3), episode-free days, and asthma-related events (oral steroid use, emergency department visits, and hospitalizations) during the ensuing 4-month period. Our analysis was limited to the placebo group (N = 417). We observed a clear relationship between prebronchodilator FEV1% and important clinical outcomes. In multivariable models that simultaneously controlled for covariates of interest, age at baseline, time, previous event history, and nocturnal awakenings, a significant relationship between FEV1% and asthma symptoms and serious asthma exacerbations (oral steroids, emergency department visits, and hospitalizations) was observed. Compared with children with an FEV1% > or = 100%, children with FEV1% 80% to 99%, 60% to 79%, and < 60% were 1.3, 1.8, and 4.8, respectively, more likely to have a serious asthma exacerbation during the ensuing 4 months. CONCLUSIONS. In children with mild to moderate asthma, FEV1% predicted is independently associated with future asthma symptoms and health care utilization. Previous asthma-related hospitalizations and nocturnal symptoms also were independently associated with risk for future adverse events. FEV1 is an important component of asthma health status and asthma severity classification.

Modifications to HEDIS and CSTE algorithms improve case recognition of pediatric asthma

Our objective was to validate the Council of State and Territorial Epidemiologists (CSTE) definition of "probable" asthma and the Health Plan Employer Data and Information Set (HEDIS) definition of persistent asthma for diagnosis of pediatric asthma, and examine modifications that improve case recognition. CSTE and HEDIS criteria were applied to a cross-sectional study of 3,905 Medicaid children with physician-confirmed diagnosis of asthma/no asthma using a validated survey instrument based upon National Asthma Education and Prevention Program (NAEPP) Guidelines. Modified criteria were applied to another group of 1,458 non-Medicaid children from a managed care organization (MCO). Of 1,852 Medicaid children with physician-confirmed asthma, 906 had persistent asthma. CSTE identified 61% of children with "probable" asthma; HEDIS identified 44% of children with persistent asthma. Correct identification increased with greater disease severity. A modified CSTE increased sensitivity from 0.61 to 0.90, while maintaining high specificity. Three new HEDIS algorithms increased sensitivity from 0.44 to >0.84, with specificity >0.89. When applied prospectively to MCO children, these new algorithms demonstrated improved sensitivity. In conclusion, studies using current CSTE or HEDIS algorithms for case recognition underestimate asthma prevalence and overestimate asthma severity in children. Modified algorithms improve the identification of "probable" and persistent asthma.

Side Effects With Inhaled Corticosteroids: The Physician's Perception

The National Asthma Education and Prevention Program 1997 guidelines and 2002 update provide an overview of potential local and systemic side effects associated with inhaled corticosteroids (ICS) and suggest ways of minimizing the risk of these side effects occurring. Despite the guidelines and extensive clinical experience of the safe use of ICS, a significant number of physicians retain concerns regarding side effects. Local side effects may lead to patients discontinuing therapy, with or without the knowledge of their physicians. In particular, concerns regarding systemic side effects, such as growth retardation in children and osteoporosis, remain relatively widespread. Pharmacokinetic studies reveal that different ICS compounds and formulations result in different degrees of systemic bioavailability, indicating possible differences in their potential to cause systemic side effects. However, clinical studies that can be used to differentiate between ICS formulations are generally lacking. Consequently, there is a need to continue to further our understanding of side effects with ICS, with the aim of identifying formulations, devices, and doses with an optimal risk/benefit ratio. The introduction of new agents with potentially improved safety profiles may reassure physicians and patients as to the relative benefits of ICS therapy in asthma.

Classifying Asthma

The most widely known method of asthma classification is the severity classification recommended in the National Asthma Education and Prevention Program 1997 guidelines, which also formed the basis of the Global Initiative for Asthma guidelines. This method was developed to direct a hierarchy of asthma therapy based on the patient's severity of disease. However, this severity classification has not been validated and has a number of limitations; in particular, it is challenging for physicians to apply reliably. Moreover, it does not allow asthma control to be assessed after the initiation of treatment, even though symptom control is a key objective of the treatment guidelines. A number of tools have been evaluated to provide longitudinal information on asthma control, and some of these have been validated. Clinically relevant measures of inflammation, such as eosinophilic airway inflammation, may also be helpful in classifying asthma and in guiding the use of antiinflammatory therapy. This may be a particularly useful approach in patients who are asymptomatic but have poor lung function, by permitting physicians to determine whether inflammatory processes are active, thus requiring ICS therapy. In the clinical setting, easy-to-use tools are needed to enable longitudinal assessments of symptom control and (ideally) disease progression.

Long-acting Inhaledβ2Agonists (LABAs) in Children and the New "Black Box" Warning

Pediatric Asthma, Allergy & ImmunologyVol. 19, No. 2 Pharmacotherapy UpdateLong-acting Inhaledβ 2 Agonists (LABAs) in Children and the New "Black Box" WarningH. William KellyH. William KellySearch for more papers by this authorPublished Online:6 Jun 2006https://doi.org/10.1089/pai.2006.19.126AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byThe U.S. Food and Drug Administration (FDA) and the Safety of Salmeterol in Children H.W. Kelly12 September 2008 | Pediatric Asthma, Allergy & Immunology, Vol. 21, No. 2The New National Asthma Education and Prevention Program's Guidelines on the Diagnosis and Management of Asthma and Childhood Asthma Treatment H. William Kelly28 January 2008 | Pediatric Asthma, Allergy & Immunology, Vol. 20, No. 4Budesonide/Formoterol Fumarate (Symbicort®) H. William Kelly28 December 2006 | Pediatric Asthma, Allergy & Immunology, Vol. 19, No. 4LiteratureWatch25 September 2006 | Pediatric Asthma, Allergy & Immunology, Vol. 19, No. 3 Volume 19Issue 2Jun 2006 InformationCopyright 2006, Mary Ann Liebert, Inc.To cite this article:H. William Kelly.Long-acting Inhaledβ 2 Agonists (LABAs) in Children and the New "Black Box" Warning.Pediatric Asthma, Allergy & Immunology.Jun 2006.126-131.http://doi.org/10.1089/pai.2006.19.126Published in Volume: 19 Issue 2: June 6, 2006PDF download

Education and Cultural Development of the Health Care Work Force Part I. The Health Professions

HomeRadiologyVol. 239, No. 3 PreviousNext Reviews and CommentaryPerspectivesEducation and Cultural Development of the Health Care Work Force Part I. The Health ProfessionsJames H. ThrallJames H. ThrallAuthor Affiliations1From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Founders House 216, 55 Fruit St, Boston, MA 02114. Received February 15, 2006; final version accepted February 20.Address correspondence to the author (e-mail: [email protected]).James H. ThrallPublished Online:Jun 1 2006https://doi.org/10.1148/radiol.2393060291MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1 Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000. Google Scholar2 Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001. Google Scholar3 Institute of Medicine. Preparing the workforce. In: Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001; 207–223. Google Scholar4 Greiner AC, Knebel E, eds. Health professions education: a bridge to quality. Washington, DC: National Academy Press, 2003. Google Scholar5 Introduction. In: Greiner AC, Knebel E, eds. Health professions education: a bridge to quality. Washington, DC: National Academy Press, 2003, 19–27. Google Scholar6 Allied Health Careers. American Medical Association Web site. http://www.ama-assn.org/ama/pub/category/14598.html. Accessed December 18, 2005. Google Scholar7 The core competencies needed for health care professionals. In: Greiner AC, Knebel E, eds. Health professions education: a bridge to quality. Washington, DC: National Academy Press, 2003; 45–73. Google Scholar8 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635–2645. Crossref, Medline, Google Scholar9 Thrall JH. Quality and safety revolution in health care. Radiology 2004;233:3–6. Link, Google Scholar10 Institute of Medicine. Improving the 21st century care system. In: Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001; 39–60. Google Scholar11 National asthma education and prevention program. National Heart, Lung, and Blood Institute Web site. http://www.nhlbi.nih.gov/about/naepp/naep_pd.htm. Accessed July 20, 2004. Google Scholar12 General Competencies. Accreditation Council for Graduate Medical Education Outcomes Project Web site. http://www.acgme.org/outcome/comp/compMin.asp. Accessed December 17, 2005. Google ScholarArticle HistoryPublished in print: June 2006 FiguresReferencesRelatedDetailsCited ByHumanities and Social Sciences Communications, Vol. 9, No. 1Academic Radiology, Vol. 23, No. 5Stepping Out Further from the Shadows: Disclosure of Harmful Radiologic Errors to PatientsStephen D. Brown, , Constance D. Lehman, , Robert D. Truog, , David M. Browning, , and Thomas H. Gallagher, 1 February 2012 | Radiology, Vol. 262, No. 2Education and Cultural Development of the Health Care Workforce Part II. Opportunities for Nonprofessional Workers1James H. Thrall, 1 August 2006 | Radiology, Vol. 240, No. 2Recommended Articles Fostering a Healthy AI Ecosystem for Radiology: Conclusions of the 2018 RSNA Summit on AI in RadiologyRadiology: Artificial Intelligence2019Volume: 1Issue: 2Peer Feedback, Learning, and Improvement: Answering the Call of the Institute of Medicine Report on Diagnostic ErrorRadiology2016Volume: 283Issue: 1pp. 231-241The Road to Wellness: Engagement Strategies to Help Radiologists Achieve Joy at WorkRadioGraphics2018Volume: 38Issue: 6pp. 1651-1664Adapting Scientific Conferences to the Realities Imposed by COVID-19Radiology: Imaging Cancer2020Volume: 2Issue: 4Continuous Learning AI in Radiology: Implementation Principles and Early ApplicationsRadiology2020Volume: 297Issue: 1pp. 6-14See More RSNA Education Exhibits Incorporating Peer Learning Into Your Breast Imaging PracticeDigital Posters2020Quantitative Ultrasound: A Primer for RadiologistsDigital Posters2018Neural Networks in Deep Learning: A Simplified Explanation for RadiologistsDigital Posters2019 RSNA Case Collection IgG4-Related Disease RSNA Case Collection2021Patella FractureRSNA Case Collection2020Right dorsal triquetral fracture with hook of hamate fractureRSNA Case Collection2020 Vol. 239, No. 3 Metrics Altmetric Score PDF download

Symptom reporting in childhood asthma: a comparison of assessment methods

Background: One barrier to receiving adequate asthma care is inaccurate estimations of symptom severity. Aims: To interview parents of children with asthma in order to: (1) describe the range of...