Preventive Asthma Care Research Articles

Cost-Benefit Analysis of Childhood Asthma Management Through School-Based Clinic Programs

Asthma is a leading chronic illness among American children. School-based health clinics (SBHCs) reduced expensive ER visits and hospitalizations through better healthcare access and monitoring in select case studies. The purpose of this study was to examine the cost-benefit of SBHC programs in managing childhood asthma nationwide for reduction in medical costs of ER, hospital and outpatient physician care and savings in opportunity social costs of lowing absenteeism and work loss and of future earnings due to premature deaths. Eight public data sources were used to compare costs of delivering primary and preventive care for childhood asthma in the US via SBHC programs, including direct medical and indirect opportunity costs for children and their parents. The costs of nurse staffing for a nationwide SBHC program were estimated at $4.55 billion compared to the estimated medical savings of $1.69 billion, including ER, hospital, and outpatient care. In contrast, estimated total savings for opportunity costs of work loss and premature death were $23.13 billion. Medical savings alone would not offset the expense of implementing a SBHC program for prevention and monitoring childhood asthma. However, even modest estimates of reducing opportunity costs of parents' work loss would be far greater than the expense of this program. Although SBHC programs would not be expected to affect the increasing prevalence of childhood asthma, these programs would be designed to reduce the severity of asthma condition with ongoing monitoring, disease prevention and patient compliance.

Parental Knowledge and Use of Preventive Asthma Care Measures in Two Pediatric Emergency Departments

Objectives: Parents of children who visit the pediatric emergency department (PED) for asthma exacerbations may have inadequate knowledge of preventive asthma care. The primary objective of this study was to assess knowledge and use of preventive asthma care measures among parents of children with asthma who present to the PED with asthma exacerbations. The secondary objective was to identify variables that predict adherence to four key preventive care measures. Methods: The authors administered a 38-item questionnaire to 229 parents of children ages 2 to 18 years with asthma exacerbations who presented to two urban PEDs, one in the southeast and one in the northwest United States. Descriptive statistics were calculated to assess parental knowledge of preventive care. Multivariable logistic regression was used to identify variables associated with the use of four key preventive care measures. Results: Thirty-two percent of the children had an action plan, and 52% received the influenza vaccine within the preceding year. Sixty-six percent of the children had persistent asthma by National Institutes of Health (NIH) criteria. Of these, 51% received daily inhaled corticosteroids (ICSs). When parents were asked how an ICS medicine worked, 29% (64/221) responded “immediately opens the airway,” and 24% (53/221) responded “I do not know.” Daily use of ICS in these children was significantly associated with parent education level beyond high school (odds ratio [OR] = 2.81; 95% confidence interval [CI]: 1.26, 6.24; p = .011). Non-African Americans were more likely to have received an action plan than African Americans (OR = 2.18; 95% CI: 1.17, 4.06; p = .014). A secondary analysis of the parent's perception of his/her ability to provide care during an asthma exacerbation was significantly associated with receipt of an action plan in a multivariable proportional odds model (OR = 3.63; 95% CI: 1.99, 6.62; p <.001). Conclusions: Parents of children with persistent asthma presenting to urban tertiary care PEDs with asthma exacerbations frequently have inadequate understanding of appropriate ICS use. Parents with less than a high school education, in particular, may benefit from focused educational interventions that address the importance of daily ICS use in asthma control. Parents who receive a written action plan are more confident in their ability to provide care for their child during an asthma exacerbation.

The Breathmobile ® Program: Effective Preventive Asthma Care for Underserved Children, At What Cost?

The Breathmobile ® Program: Effective Preventive Asthma Care for Underserved Children, At What Cost?

Improved Preventive Care for Asthma: A Randomized Trial of Clinician Prompting in Pediatric Offices

Halterman JS, Fisher S, Conn KM, et al. Arch Pediatr Adolesc Med. 2006;160:1018–1025 PURPOSE OF THE STUDY. To determine if clinician prompting regarding asthma severity and guideline recommendations at the time of an office visit improves the delivery of preventive asthma care. STUDY POPULATION. Children aged 2 to 12 years (N = 226) with persistent asthma from 2 inner-city pediatric practices in Rochester, New York. Children were at the clinic for a well-child check, asthma care, or non–asthma-related illness care and were randomly assigned to 1 of 2 groups: clinician-prompting group (CPG) or standard-care group (SCG). METHODS. A baseline survey was conducted to obtain information regarding household demographics, medication use, and environmental tobacco-smoke exposure. Parents of the children who were randomly assigned to the CPG were instructed to give a prompt sheet to their clinician along with a blank asthma action plan form. Parents of the children who were assigned to the SCG also completed baseline assessment interviews but were not given a prompt sheet, and no information regarding the interview was shared with the clinician. Follow-up information was collected within 60 days through telephone interviews. RESULTS. The children in the CPG were more likely to have any preventive action related to asthma taken at the visit compared with children in the SCG (86.6% vs 69.3%). Children in the CPG were also more likely to have received an asthma action plan (50.0% vs 23.7%), recommendation for a specific asthma follow-up visit (53.6% vs 36.8%), discussion regarding asthma (75.0% vs 63.2%), and smoke-reduction counseling (57.5% vs 35.4%) compared with those in the SCG. There were no statistical differences in referrals for specialty care, treatment of comorbid conditions, or changes in preventive medications between the 2 groups. CONCLUSIONS. Clinician prompting regarding asthma severity and care guidelines at the time of an office visit increased the likelihood of delivering preventive asthma care. REVIEWER COMMENTS. Several studies have demonstrated that health care providers often underestimate asthma severity and have demonstrated poor adherence to National Asthma Education and Prevention Program guidelines. Successful management of asthma requires both accurate determination of asthma severity and proper treatment. This study demonstrates a method that may increase the likelihood of delivering preventive asthma care at non–asthma-related office visits by prompting clinicians. However, as the authors pointed out, although prompting improved the delivery of preventive asthma care, a large percentage of patients in the CPG did not have follow-up–visit recommendations (46.4%), received no asthma action plan (50%), and received no discussion related to asthma (25%). This study demonstrates that a better system needs to be implemented to increase the rate of delivering appropriate preventive care for patients with asthma.

Patterns of inhaled antiinflammatory medication use in young underserved children with asthma.

Asthma guidelines advocate inhaled corticosteroids as the cornerstone treatment of persistent asthma, yet several studies report underuse of inhaled corticosteroids in children with persistent asthma. Moreover, few studies use objective pharmacy data as a measure of drug availability of asthma medications. We examined factors associated with the use of inhaled corticosteroids in young underserved children with persistent asthma using pharmacy records as their source of asthma medications. This was a cross-sectional analysis of questionnaire and pharmacy record data over a 12-month period from participants enrolled in a randomized clinical trial of a nebulizer educational intervention. Although exposure to > or = 1 inhaled corticosteroids refill was high at 72%, 1 of 5 children with persistent asthma had either no medication or only short-acting beta agonist fills for 12 months. Only 20% of children obtained > or = 6 inhaled corticosteroids fills over 12 months. Obtaining > or = 3 inhaled corticosteroids fills over 12 months was significantly associated with an increase in short-acting beta agonist fills and receiving specialty care in the regression models while controlling for child age, asthma severity, number of emergency department visits, having an asthma action plan, and seeking preventive care for the child's asthma. Overreliance on short-acting beta agonist and underuse of inhaled corticosteroid medications was common in this group of young children with persistent asthma. Only one fifth of children obtained sufficient controller medication fills.

Improved Preventive Care for Asthma

To determine whether clinician prompting regarding a child's symptom severity and guideline recommendations at the time of an office visit improves the delivery of preventive asthma care. Randomized controlled trial. Two inner-city pediatric practices in Rochester, NY. Two hundred twenty-six children with persistent asthma (aged 2-12 years) presenting to the clinics for well-child care, asthma care, or non-asthma-related illness care. Intervention We assigned children randomly to a clinician-prompting group (single-page prompt including the child's symptoms and guideline recommendations given to the clinician at the time of the visit) or a standard-care group (no prompt given). Interviewers called parents after the visit to inquire about preventive measures taken, and medical charts were reviewed. Any preventive action related to asthma taken at the visit. Children in the clinician-prompting group were more likely to have had any preventive measures taken at the visit compared with children in the standard-care group (87% vs 69%). Specifically, visits for children in the clinician-prompting group were more likely to include delivery of an action plan (50% vs 24%), discussions regarding asthma (87% vs 76%), and recommendations for an asthma follow-up visit (54% vs 37%). In a regression model, children in the clinician-prompting group had 3-fold greater odds of receiving any preventive action compared with the standard-care group. Clinician prompting regarding asthma severity and care guidelines at the time of an office visit significantly improved the delivery of preventive asthma care.

Quantifying Preventive Asthma Care Delivered at Office Visits: The Preventive Asthma Care–Composite Index (PAC-CI)

Our objective was to develop a composite index to measure and quantify preventive asthma care delivered in the primary care office. We documented preventive actions used for children with asthma at the time of an office visit and weighted actions based on their intensity to create a composite index. The usefulness of the index was supported by significant correlations with several measures of symptom severity. The composite index also varied by visit type, with the highest scores noted for asthma-related visits, compared to well-child and other illness visits. This composite index has potential use for research and quality improvement efforts.

Impact of depressive symptoms on adult asthma outcomes

Psychological disorders, including depression, are common in adults with asthma. Although depression is treatable, its impact on longitudinal asthma outcomes is not clear. To elucidate the impact of depressive symptoms on patient-centered outcomes and emergency health care use in adults with asthma. We conducted a prospective cohort study of 743 adults with asthma who were recruited after hospitalization for asthma. Depressive symptoms were defined as having a score of 16 or more on the Center for Epidemiologic Studies Depression Scale. We examined the impact of depressive symptoms on patient-centered outcomes (validated severity-of-asthma score, Marks Asthma Quality of Life Questionnaire, and 12-Item Short-Form Health Survey physical component summary score) and on future emergency health care use for asthma ascertained from computerized databases. The prevalence of depressive symptoms was 18% (95% confidence interval [CI], 15%-21%) among adults with asthma. Depressive symptoms were associated with greater severity-of-asthma scores after controlling for age, sex, race/ ethnicity, educational attainment, and cigarette smoking (mean score increment, 2.6 points; 95% CI, 1.8-3.4 points). Furthermore, depressive symptoms were associated with poorer asthma-specific quality of life (mean score increment, 19.9 points; 95% CI, 17.7-22.1 points) and poorer physical health status (mean score decrement, 3.7 points; 95% CI, 1.5-5.8 points). Depressive symptoms were associated with a greater longitudinal risk of hospitalization for asthma (hazard ratio, 1.34; 95% CI, 0.98-1.84). After controlling for differences in preventive care for asthma, the relationship was stronger (hazard ratio, 1.45; 95% CI, 1.05-2.0). Depressive symptoms are common in adults with asthma and are associated with poorer health outcomes, including greater asthma severity and risk of hospitalization for asthma.

Factors Associated with Preventive Asthma Care in Inner-City Children

The goal of this cross-sectional study was to determine if the caregiver's quality of life was associated with the child receiving appropriate preventive asthma care (2 or more preventive asthma care visits per year) in a sample of inner-city children with moderate to severe persistent asthma. Our findings confirm that children with moderate to severe persistent asthma are not receiving adequate preventive asthma care despite experiencing frequent asthma symptoms. Having a recent emergency department (ED) visit and increased number of school absences due to asthma were the strongest factors associated with these children receiving guideline-based preventive asthma care. However, for a subgroup of children without recent ED care, we found that low caregiver education level, increased school absences, and decreased caregiver's quality of life, albeit a trend, were associated with the child's receiving adequate preventive asthma care. This suggests that in a subgroup of children receiving adequate preventive care, other issues beyond basic asthma management may need to be addressed.

Acute severe asthma: Outcome and Medicaid insurance.

OBJECTIVE: Economically disadvantaged children receive less preventive asthma care and more inpatient care. Studies have not evaluated the association of insurance status on children with severe exacerbations. We evaluated differences in severity of illness, resource use, and outcome associated with Medicaid insurance among children receiving intensive care for asthma. DESIGN: Retrospective cohort study. SETTING: Fourteen American pediatric intensive care units participating in the Pediatric Intensive Care Evaluations database. Methods: Patients with a primary diagnosis of asthma treated from May 1995 to February 2000 were identified. Demographic information and clinical data were evaluated to determine whether there was an association between Medicaid insurance, severity of illness, and length of stay. RESULTS: Twenty-six percent of the children had Medicaid insurance; 22% of children with Medicaid insurance received mechanical ventilation compared with 15% of those with commercial insurance and 16% in a health maintenance organization. After adjustment for severity of illness (Pediatric Risk of Mortality III and use of invasive therapies), Medicaid insurance was significantly associated with increased length of stay in the intensive care unit and hospital. Among children who received mechanical ventilation, patients with Medicaid also received ventilator support significantly longer. CONCLUSIONS: Asthmatic children receiving Medicaid had longer pediatric intensive care unit and hospital stays and an increased risk of mechanical ventilation compared with asthmatic children with commercial or health maintenance organization insurance. Further studies are needed to evaluate differences in outcome and resource utilization for economically disadvantaged asthmatic children.

Head Start: A Setting for Asthma Outreach and Prevention

Hospitalization for asthma occurs most often in children under 5 years of age, and children from low-income, minority families have higher morbidity and mortality rates from asthma than their more advantaged peers. This study measured the prevalence of asthma, asthma symptoms, and health care utilization among urban, predominantly minority, children enrolled in Head Start, an early education program for low-income children under 5 years of age. Parents of nonasthmatic children were asked about the presence of asthma symptoms in their children using the International Study on Asthma and Allergy in Children (ISAAC) questionnaire. Surveys asking about the history of asthma and allergy, health care access, and insurance coverage were administered to parents of children attending Head Start in southeastern Virginia. Questionnaires were completed by 671 (52%) parents of Head Start enrolled children. All children were 3 to 4 years of age. Among asthmatic children, 10 (9%) were hospitalized for asthma and 51 (46%) had been seen in the emergency department (ED) for asthma in the previous year. Asthmatic children saw their primary care physician more often (p < 0.001) than nonasthmatic children, however, an ED was the primary source of asthma medications for 13 (11%) children. The majority of asthmatic children (75%) were using a quick relief medication, but only 18% were using a long-term, controller medication. Parents of asthmatic children reported access barriers to care: 35 (30%) reported transportation problems; 27 (23%), problems with physician access; 18 (16%), financial or insurance problems; and 59 (50%), at least one barrier to preventive asthma care for their child. The study found that Head Start provides an important, and previously overlooked, setting for identifying preschool children at high risk for asthma and an opportunity for implementing asthma outreach and prevention programs.

Improving Care for Minority Children With Asthma: Professional Education in Public Health Clinics

Recent studies have shown that lack of continuing primary care for asthma is associated with increased levels of morbidity in low-income minority children. Although effective preventive therapy is available, many African-American and Latino children receive episodic treatment for asthma that does not follow current guidelines for care. To see if access, continuity, and quality of care could be improved in pediatric clinics serving low-income children in New York City, we trained staff in New York City Bureau of Child Health clinics to provide continuing, preventive care for asthma. We evaluated the impact of the intervention over a 2-year period in a controlled study of 22 clinics. Training for intervention clinic staff was based on National Asthma Education and Prevention Program guidelines for the diagnosis and management of asthma, and included screening to identify new cases and health education to improve family management. The intervention included strong administrative support by the Bureau of Child Health to promote staff behavior change. We hypothesized that after the intervention, clinics that received the intervention would, compared with control clinics, have increased numbers of children with asthma receiving continuing care in the clinics and increased staff use of new pharmacologic and educational treatment methods. In both the first and second follow-up years, the intervention clinics had greater positive changes than control clinics on measures of access, continuity, and quality of care. For second year follow-up data these include: for access, greater rate of new asthma patients (40/1000 vs 16/1000; P < .01); for continuity, greater percentage of asthma patients returning for treatment 2 years in a row (42% vs 12%; P < .001) and greater annual frequency of scheduled visits for asthma per patient (1.85 vs .88; P < .001); and for quality, greater percentage of patients receiving inhaled beta agonists (52% vs 15%; P < .001) and inhaled antiinflammatory drugs (25% vs 2%; P < .001), and greater percentages of parents who reported receiving patient education on 12 topics from Bureau of Child Health physicians (71% vs 58%; P < .01) and nurses (61% vs 44%; P < .05). We conclude that the intervention substantially increased the Bureau of Child Health staff's ability to identify children with asthma, involve them in continuing care, and provide them with state-of-the-art care for asthma.