Usual Asthma Care Research Articles

Asthma Care and Management Before an Emergency Department Visit in Children in Western Michigan: How Well Does Care Adhere to Guidelines?

Asthma is one of the more common reasons for children's visits to the emergency departments (EDs). Many studies show that the level of asthma care and self-management in children before an ED visit for asthma is often inadequate; however, most of these studies have been conducted in the inner cities of large urban areas. Our objectives were to describe asthma care and management in children treated for asthma in 3 EDs located in an urban, suburban, or rural setting. We studied a prospective patient cohort consisting of children aged 2 to 17 years who presented with an acute asthma exacerbation at 3 EDs in western Michigan. An in-person questionnaire was administered to the parent or guardian during the ED visit. Information was collected on demographics; asthma history; usual asthma care; frequency of symptoms during the last 4 weeks; current asthma treatment, management, and control; and past emergency asthma care. A telephone interview conducted 2 weeks after the ED visit obtained follow-up information. The 8 quality indicators of asthma care and management were defined based on recommendations from national guidelines. Of 197 children, 70% were enrolled at the urban site, 18% at the suburban site, and 12% at the rural site. The average age was 7.9 years; 60% were male, and 33% were black. At presentation, nearly half (46%) of the children had mild intermittent asthma, 20% had mild persistent asthma, 15% had moderate persistent asthma, and 19% had severe persistent asthma. One quarter of the children had been hospitalized for asthma, and two thirds had at least 1 previous ED visit in the past year. At least 94% had health insurance coverage and 95% reported having a primary care provider. Less than half of the children had attended at least 2 scheduled asthma appointments with their regular asthma care provider in the past year. Although only 5% of the subjects reported that the ED was their only source of asthma care, at least 30% reported that they always went directly to the ED when they needed urgent asthma care. Only 3 in 5 children possessed either a spacer or a peak-flow meter, whereas approximately 2 in 5 reported having a written asthma action plan. Among those with persistent asthma, there was considerable evidence of undertreatment, with 36% not on either an inhaled corticosteroid or a suitable long-term control medication. Only 20% completed a visit with their regular asthma care provider within 1 week of their ED visit. Despite very high levels of health care coverage and access to primary care, the overall quality of asthma care and management fell well short of that recommended by national guidelines.

Cost‐effectiveness of early intervention with once‐daily budesonide in children with mild persistent asthma: results from the START study

The inhaled Steroid Treatment As Regular Therapy in early asthma (START) study has shown that early intervention with inhaled budesonide in mild persistent asthma improves clinical outcomes in both adults and children. The aim of this study was to estimate the incremental cost-effectiveness of early treatment with budesonide Turbuhaler in children aged 5-10 yr who participated in START. Direct and indirect costs associated with asthma were determined for 1974 children participating in the double-blind, 3-year part of the study. Randomization was to placebo or to budesonide 200 microg once daily in each case in addition to usual asthma care. Cost-effectiveness ratios were calculated from the healthcare payer's and societal perspectives (using US prices). The addition of once-daily budesonide therapy to usual asthma care was associated with 16 additional symptom-free days (SFDs) per child over the 3-yr period (p < 0.001), with a substantial reduction (50%) in the mean number of days spent in hospital, and with reduced frequency of emergency room visits and missed school and caregiver work days. From the healthcare payer's perspective (direct costs), the increase in mean direct cost over 3 yr with budesonide was 169 dollars, which translated into an incremental cost of early intervention with budesonide in children of 10.50 dollars (95% CI 1.20-33.30 dollars) per SFD gained. From the societal perspective, there was a cost reduction over 3 yr of 192 dollars with budesonide relative to placebo. From a societal perspective, budesonide was therefore dominant. In conclusion, early intervention with once-daily budesonide added to usual asthma care in children with mild persistent asthma is cost-saving from a societal perspective and is acceptably cost-effective when viewed from a healthcare payer perspective.

The Salmeterol Multicenter Asthma Research Trial: A Comparison of Usual Pharmacotherapy for Asthma or Usual Pharmacotherapy Plus Salmeterol

To compare the safety of salmeterol xinafoate or placebo added to usual asthma care. A 28-week, randomized, double-blind, placebo-controlled, observational study. Study subjects were seen once in the study physician's office for screening and were provided all blinded study medication for the entire study period. Follow-up by telephone was scheduled every 4 weeks. Subjects (> 12 years old) with asthma as judged by the study physician were eligible. Individuals with a history of long-acting beta2-agonist use were excluded. Salmeterol, 42 mug bid via metered-dose inhaler (MDI), and placebo bid via MDI. Following an interim analysis in 26,355 subjects, the study was terminated due to findings in African Americans and difficulties in enrollment. The occurrence of the primary outcome, respiratory-related deaths, or life-threatening experiences was low and not significantly different for salmeterol vs placebo (50 vs 36; relative risk [RR] = 1.40; 95% confidence interval [CI], 0.91 to 2.14). There was a small, significant increase in respiratory-related deaths (24 vs 11; RR, 2.16; 95% CI, 1.06 to 4.41) and asthma-related deaths (13 vs 3; RR, 4.37; 95% CI, 1.25 to 15.34), and in combined asthma-related deaths or life-threatening experiences (37 vs 22; RR, 1.71; 95% CI, 1.01 to 2.89) in subjects receiving salmeterol vs placebo. The imbalance occurred largely in the African-American subpopulation: respiratory-related deaths or life-threatening experiences (20 vs 5; RR, 4.10; 95% CI, 1.54 to 10.90) and combined asthma-related deaths or life-threatening experiences (19 vs 4; RR, 4.92; 95% CI, 1.68 to 14.45) in subjects receiving salmeterol vs placebo. For the primary end point in the total population, there were no significant differences between treatments. There were small, but statistically significant increases in respiratory-related and asthma-related deaths and combined asthma-related deaths or life-threatening experiences in the total population receiving salmeterol. Subgroup analyses suggest the risk may be greater in African Americans compared with Caucasian subjects. Whether this risk is due to factors including but not limited to a physiologic treatment effect, genetic factors, or patient behaviors leading to poor outcomes remains unknown.

Effects of 24 Weeks of Lansoprazole Therapy on Asthma Symptoms, Exacerbations, Quality of Life, and Pulmonary Function in Adult Asthmatic Patients With Acid Reflux Symptoms

Difficult-to-control asthma has been associated with gastroesophageal acid reflux. Acid-suppressive treatment has been inconsistent in improving asthma control. To determine whether a proton-pump inhibitor improves asthma control in adult asthmatic patients with acid reflux symptoms. Multicenter, double-blind, randomized, placebo-controlled trial. Twenty-nine private practices and 3 academic practices in the United States. Two hundred seven patients receiving usual asthma care including an inhaled corticosteroid (ICS). Patients had acid reflux symptoms and moderate-to-severe persistent asthma. Lansoprazole, 30 mg bid, or placebo, bid, for 24 weeks. The primary outcome measure was daily asthma symptoms by diary. Secondary asthma outcomes included rescue albuterol use, daily morning and evening peak expiratory flow, FEV1, FVC, asthma quality of life with standardized activities (AQLQS) questionnaire score, investigator-assessed symptoms, exacerbations, and oral corticosteroid-treated exacerbations. Daily asthma symptoms, albuterol use, peak expiratory flow, FEV1, FVC, and investigator-assessed asthma symptoms at 24 weeks did not improve significantly with lansoprazole treatment compared to placebo. The AQLQS emotional function domain improved at 24 weeks (p = 0.025) with lansoprazole therapy. Fewer patients receiving lansoprazole (8.1% vs 20.4%, respectively; p = 0.017) had exacerbations and oral corticosteroid-treated (ie, moderate-to-severe) exacerbations (4% vs 13.9%, respectively; p = 0.016) of asthma. A post hoc subgroup analysis revealed that fewer patients receiving one or more long-term asthma-control medications in addition to an ICS experienced exacerbations (6.5% vs 24.6%, respectively; p = 0.016) and moderate-to-severe exacerbations (2.2% vs 17.5%, respectively; p = 0.021) with lansoprazole therapy. In adult patients with moderate-to-severe persistent asthma and symptoms of acid reflux, treatment with 30 mg of lansoprazole bid for 24 weeks did not improve asthma symptoms or pulmonary function, or reduce albuterol use. However, this dose significantly reduced asthma exacerbations and improved asthma quality of life, particularly in those patients receiving more than one asthma-control medication.

Is it cost-effective to prompt Australian parents to bring their children with asthma to the general practitioner for proactive review under the asthma 3+ visit plan?

The aim of this project was to perform an economic evaluation of the implementation of the Asthma 3+ visit Plan in Australia, in parallel with a randomised controlled trial. The trial involved 24 GPs and 174 children aged 5-11 years with moderate to severe asthma, cluster-randomised into two groups by medical practice. The control group received usual asthma care, while the intervention group were reminded to attend by the researchers prompting practices to recall patients according to the recommended schedule.The evaluation focused on the marginal costs of promoting the Asthma 3+ Visit Plan to GPs and patients, and compared the costs with the economic consequences of the plan on attendance rates, use of other health services and use of medication. Analysis was done of the difference in costs of asthma care between the two groups over a twelve-month period. A societal perspective was taken, with both direct and indirect costs being considered as they impacted on general practitioners, other health providers, patients and their families.While there was a statistically significant increase in the number of asthma-related GP visits by those in the intervention group, there was no statistically significant difference in the total number of visits, nor in the associated travel and time costs for parents of the children. The number and cost of referrals to specialists and allied health professionals were lower for the intervention group, while the use and cost of diagnostic tests was higher, but neither were statistically significant. The proportion of patients incurring any medication costs was lower in the intervention group, with a reduced cost per patient. The costs to implement the plan averaged approximately $400 per GP, with the prompts to practices costing $100 per GP. This study suggests that the 3+ plan is cost-effective when implemented with children with asthma.

Emergency department visits by urban African American children with asthma

Background: Asthma morbidity among African American children has been identified as a significant national health concern. High emergency department use is one index of this morbidity and may reflect disease severity, disease management, and social factors. Objective: This study examined the prevalence and correlates of emergency department use and other indices of asthma morbidity among a sample of urban, low-income, African American children. Methods: Parents of 392 elementary school children with asthma who had consented to participate in an asthma education program were interviewed by phone according to a standardized protocol. Results: Children had a mean of 6.2 days of restricted activity (SD 8.1) and 7.9 symptomatic nights (SD 8.1). The mean number of school days missed because of asthma was 9.7 (SD 13.5). Among children with asthma symptoms in the past 12 months, 73.2% could identify a specific physician or nurse who provided asthma care. For those families without an identified asthma primary care provider, 39.3% received their usual asthma care from the emergency department. A total of 43.6% of the children had been to the emergency department for asthma care without hospitalization in the previous 6 months. Close to 80% of children reported using one or more prescribed asthma medication, and of these only 12% reported using inhaled anti-inflammatory medications. Families of children who had used the emergency department in the prior 6 months reported more asthma symptoms, lower social support, problems paying for health care, and the absence of a hypoallergenic mattress cover and that they had seen a physician for regular asthma care in the past 6 months. Conclusions: We conclude that asthma management for children in the inner city relies on episodic care and emergency care, that asthma medication management does not conform to current guidelines, and that asthma symptoms resulting in school absences and workdays lost are prevalent. (J Allergy Clin Immunol 2000;105:83-90.)

Parental Perceptions of Access to Care and Quality of Care forInner-City Children with Asthma

Dinkevich EI, Cunningham SJ, Crain EFJ Asthma.3519986371To describe perceptions of asthma care, morbidity, and health service utilization by parents of children with asthma presenting to an inner-city emergency department (ED).Parents of children (n = 466) receiving asthma treatment in an urban pediatric ED during a consecutive 6-week period in late fall 1995.Parents completed a 30-item survey including sociodemographic data, source of primary medical care and asthma care for their child, selected measures of access to care, and medications used by their child in the week before the ED visit. Perceived quality of asthma care was measured by six items reported to have been performed by the child's asthma doctor: discussion of home peak flow monitoring, triggers, dogs/cats, smoke, postexacerbation calling instructions, and provision of a written asthma management plan. Functional morbidity was measured by nights of poor sleep, days of cough, and school days missed because of asthma in the previous month.Of the patients surveyed, 325 had previously been diagnosed with asthma. Three hundred eight (97%) reported a source of primary medical care. The primary care provider (PCP) was identified as the child's usual source of asthma care (PCP users) in 126 respondents, while 158 identified the ED as the usual source of asthma care (ED users). The groups did not differ by insurance status, ethnicity, or mean age of the child. Thirty-nine percent of PCP users compared with 15% of ED users had used inhaled steroids or cromolyn in the week before the ED visit (P < .0001). PCP users had a higher mean quality score than ED users (3.7 vs 2.8; P< .0001), but there was no relationship between source of asthma care and functional morbidity.The ED remains the usual source of asthma care for many inner-city children. Among parents surveyed in the ED, there was a significant relationship between source of usual asthma care and quality of care, but a relationship between usual source of asthma care and functional morbidity could not be identified.High ED utilizers don't get the message: asthma is a chronic disease requiring 1) daily preventive management including trigger avoidance measures and antiinflammatory therapy, and 2) regular follow-up asthma care at least with the PCP, if not with an asthma specialist. How can we get this message through?

Parental Perceptions of Access to Care and Quality of Care for Inner-City Children with Asthma

The objective of this study was to describe perceptions of asthma care, morbidity, and health service utilization by parents of children with asthma presenting to an inner-city emergency department (ED). A cross-sectional survey was conducted in an urban pediatric ED, with a convenience sample of 466 parents of children receiving asthma treatment during a consecutive 6-week period in late fall 1995. Parents completed a 30-item survey including sociodemographic data, source of primary medical care and asthma care for their child, selected measures of access to care, and medications used by their child in the week prior to the ED visit. Perceived quality of asthma care was measured by six items (summary score = 0-6) reported to have been performed by the child's asthma doctor: discussion of home peak flow monitoring, child-specific triggers, dogs/cats, smoke, postexacerbation calling instructions, and provision of a written asthma management plan. Functional morbidity was measured by nights of poor sleep, days of cough, and school days missed due to asthma in the previous month. Among 325 patients with previously diagnosed asthma, 308 (97%) were reported to have a source of primary medical care. Of these, 126 respondents identified their primary care provider as the child's usual source of asthma care, while 158 identified the ED as the usual source. The groups did not differ by insurance status, ethnicity, or mean age of the child. Thirty-nine percent of children with the same provider for primary and asthma care compared with 15% of children reported to receive their asthma care predominantly in the ED had used inhaled steroids or cromolyn in the week prior to the ED visit (p < .0001). Children with the same provider for primary and asthma care had a higher mean quality score than children receiving asthma care in the ED (3.7 vs. 2.8, p < 0.0001), but there was no relationship between source of asthma care and functional morbidity. The ED remains the usual source of asthma care for many inner-city children. Among parents surveyed in the ED, there was a significant relationship between source of usual asthma care and quality of care, but a relationship between usual source of asthma care and functional morbidity could not be identified.