Arlene M. Butz

Medications Used by Children With Asthma Living in the Inner City

Objective. The purpose of the study was to examine medication use reported by families participating in an urban school-based community intervention program and to relate this use to other social and medical variables. Design. The design of the study was a cross-sectional questionnaire survey. Setting. Patients and their families recruited from elementary schools in a community setting were interviewed between December 1991 and January 1992. Participants. A total of 508 children with asthma were identified by school health records and teacher surveys. Their families confirmed the diagnosis and agreed to enter the study. Questionnaires were completed by 392 families. Intervention. The 392 families participated in a controlled trial of asthma education after providing the data that are the basis of this report. Results. More than half of the children took two or more medications for asthma. Thirty-one percent took theophylline alone or in combination with an adrenergic agent; 11% took some form of daily antiinflammatory medication, either cromolyn (8%) or inhaled steroids (3%). The pattern of medication use related to measures of severity and to regular visits to physicians or nurses. In general, however, children were undermedicated. A total of 78 children (20%) reported no medication or over-the-counter medication use, although 37% reported asthma severe enough to be associated with ≥20 days of school missed per month, and 37% had had an emergency room visit for asthma in the past 6 months. More than half of children ≥9 years old supervised their own medication. Conclusions. We concluded that undermedication is common in poor children with asthma living in urban areas. Antiinflammatory medications are used less commonly than in the general population, and theophylline is used more often. School children may be likely to supervise their own medication.

Home environmental intervention in inner-city asthma: a randomized controlled clinical trial

BACKGROUND Airborne pollutants and indoor allergens increase asthma morbidity in inner-city children; therefore, reducing exposure, if feasible, should improve asthma morbidity. OBJECTIVE To conduct a randomized controlled trial of methods to reduce environmental pollutant and allergen exposure in the homes of asthmatic children living in the inner city. METHODS After the completion of questionnaires, spirometry and allergen skin tests, home inspection, and measurement of home air pollutant and allergen levels, 100 asthmatic children aged 6 to 12 years were randomized to the treatment group (home-based education, cockroach and rodent extermination, mattress and pillow encasings, and high-efficiency particulate air cleaner) or to the control group (treated at the end of the 1-year trial). Outcomes were evaluated by home evaluations at 6 and 12 months, clinic evaluation at 12 months, and multiple telephone interviews. RESULTS In the treatment group, 84% received cockroach extermination and 75% used the air cleaner. Levels of particulate matter 10 microm or smaller declined by up to 39% in the treatment group but increased in the control group (P < .001). Cockroach allergen levels decreased by 51% in the treatment group. Daytime symptoms increased in the control group and decreased in the treatment group (P = .04). Other measures of morbidity, such as spirometry findings, nighttime symptoms, and emergency department use, were not significantly changed. CONCLUSIONS A tailored, multifaceted environmental treatment reduced airborne particulate matter and indoor allergen levels in inner-city homes, which, in turn, had a modest effect on morbidity.

Improving the management of family psychosocial problems at low-income children's well-child care visits: the WE CARE Project.

OBJECTIVE. Our goal was to evaluate the feasibility and impact of an intervention on the management of family psychosocial topics at well-child care visits at a medical home for low-income children. PATIENTS AND METHODS. A randomized, controlled trial of a 10-item self-report psychosocial screening instrument was conducted at an urban hospital-based pediatric clinic. Pediatric residents and parents were randomly assigned to either the intervention or control group. During a 12-week period, parents of children aged 2 months to 10 years presenting for a well-child care visit were enrolled. The intervention components included provider training, administration of the family psychosocial screening tool to parents before the visit, and provider access to a resource book that contained community resources. Parent outcomes were obtained from postvisit and 1-month interviews, and from medical chart review. Provider outcomes were obtained from a self-administered questionnaire collected after the study. RESULTS. Two hundred parents and 45 residents were enrolled. Compared with the control group, parents in the intervention group discussed a significantly greater number of family psychosocial topics (2.9 vs 1.8) with their resident provider and had fewer unmet desires for discussion (0.46 vs 1.41). More parents in the intervention group received at least 1 referral (51.0% vs 11.6%), most often for employment (21.9%), graduate equivalent degree programs (15.3%), and smoking-cessation classes (14.6%). After controlling for child age, Medicaid status, race, educational status, and food stamps, intervention parents at 1 month had greater odds of having contacted a community resource. The majority of residents in the intervention group reported that the survey instrument did not slow the visit; 54% reported that it added <2 minutes to the visit. CONCLUSIONS. Brief family psychosocial screening is feasible in pediatric practice. Screening and provider training may lead to greater discussion of topics and contact of community family support resources by parents.

Adherence Feedback to Improve Asthma Outcomes Among Inner-City Children: A Randomized Trial

OBJECTIVE: We evaluated the longitudinal effects of home-based asthma education combined with medication adherence feedback (adherence monitoring with feedback [AMF]) and asthma education alone (asthma basic care [ABC]) on asthma outcomes, relative to a usual-care (UC) control group. METHODS: A total of 250 inner-city children with asthma (mean age: 7 years; 62% male; 98% black) were recruited from a pediatric emergency department (ED). Health-outcome measures included caregiver-frequency of asthma symptoms, ED visits, hospitalizations, and courses of oral corticosteroids at baseline and 6-, 12-, and 18-month assessments. Adherence measures included caregiver-reported adherence to inhaled corticosteroid (ICS) therapy and pharmacy records of ICS refills. Multilevel modeling was used to examine the differential effects of AMF and ABC compared with UC. RESULTS: ED visits decreased more rapidly for the AMF group than for the UC group, but no difference was found between the ABC and UC groups. The AMF intervention led to short-term improvements in ICS adherence during the active-intervention phase relative to UC, but this improvement decreased over time. Asthma symptoms and courses of corticosteroids decreased more rapidly for the ABC group than for the UC group. Hospitalization rates did not differ between either intervention group and the UC group. No differences were found between the ABC and AMF groups on any outcome. CONCLUSIONS: Asthma education led to improved adherence and decreased morbidity compared with UC. Home-based educational interventions may lead to modest short-term improvements in asthma outcomes among inner-city children. Adherence feedback did not improve outcomes over education alone.

A Randomized Trial of Air Cleaners and a Health Coach to Improve Indoor Air Quality for Inner-City Children With Asthma and Secondhand Smoke Exposure

OBJECTIVE To test an air cleaner and health coach intervention to reduce secondhand smoke exposure compared with air cleaners alone or no air cleaners in reducing particulate matter (PM), air nicotine, and urine cotinine concentrations and increasing symptom-free days in children with asthma residing with a smoker. DESIGN Randomized controlled trial, with randomization embedded in study database. SETTINGS The Johns Hopkins Hospital Childrens Center and homes of children. PARTICIPANTS Children with asthma, residing with a smoker, randomly assigned to interventions consisting of air cleaners only (n = 41), air cleaners plus a health coach (n = 41), or delayed air cleaner (control) (n = 44). MAIN OUTCOME MEASURES Changes in PM, air nicotine, and urine cotinine concentrations and symptom-free days during the 6-month study. RESULTS The overall follow-up rate was high (91.3%). Changes in mean fine and coarse PM (PM(2.5) and PM(2.5-10)) concentrations (baseline to 6 months) were significantly lower in both air cleaner groups compared with the control group (mean differences for PM(2.5) concentrations: control, 3.5 μg/m(3); air cleaner only, -19.9 μg/m(3); and air cleaner plus health coach, -16.1 μg/m(3); P = .003; and PM(2.5-10) concentrations: control, 2.4 μg/m(3); air cleaner only, -8.7 μg/m(3); and air cleaner plus health coach, -10.6 μg/m(3); P = .02). No differences were noted in air nicotine or urine cotinine concentrations. The health coach provided no additional reduction in PM concentrations. Symptom-free days were significantly increased [corrected] in both air cleaner groups compared with the control group (P = .03). CONCLUSION Although the use of air cleaners can result in a significant reduction in indoor PM concentrations and a significant increase in symptom-free days, it is not enough to prevent exposure to secondhand smoke.

Interventions to Modify Health Care Provider Adherence to Asthma Guidelines: A Systematic Review

BACKGROUND AND OBJECTIVE: Health care provider adherence to asthma guidelines is poor. The objective of this study was to assess the effect of interventions to improve health care providers’ adherence to asthma guidelines on health care process and clinical outcomes. METHODS: Data sources included Medline, Embase, Cochrane CENTRAL Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, PsycINFO, and Research and Development Resource Base in Continuing Medical Education up to July 2012. Paired investigators independently assessed study eligibility. Investigators abstracted data sequentially and independently graded the evidence. RESULTS: Sixty-eight eligible studies were classified by intervention: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement/pay-for-performance, multicomponent, and information only. Half were randomized trials (n = 35). There was moderate evidence for increased prescriptions of controller medications for decision support, feedback and audit, and clinical pharmacy support and low-grade evidence for organizational change and multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans. Moderate evidence supports use of decision support tools to reduce emergency department visits, and low-grade evidence suggests there is no benefit for this outcome with organizational change, education only, and quality improvement/pay-for-performance. CONCLUSIONS: Decision support tools, feedback and audit, and clinical pharmacy support were most likely to improve provider adherence to asthma guidelines, as measured through health care process outcomes. There is a need to evaluate health care provider-targeted interventions with standardized outcomes.

Attitudes about stimulant medication for attention-deficit/hyperactivity disorder among African American families in an inner city community

Limited information exists on views among African American families living in low-income, inner-city communities regarding the treatment of children with attention-deficit/hyperactivity disorder (ADHD). Parents of children treated for ADHD in an urban primary care setting were recruited to complete a survey to assess attitudes toward stimulant medications. Although most (71%) were initially hesitant to use stimulants based on what they heard in the lay press, 63% would recommend stimulant medication to a relative/friend whose child had ADHD. Approximately 17% believed stimulants led to drug abuse, 21% preferred counseling over medication, 21% felt medications had bad side effects, and 23% believed that too many children were medicated for ADHD. Most (90%) felt the medication was safe if a physician recommended it. Views did not differ between participants whose child had or had not received counseling. Additional studies are needed to clarify whether such views impact treatment choices and health outcomes.

Prenatal care and drug use in pregnant women

This case-control study tested the hypothesis that pregnant inner-city women with low utilization of prenatal care are likely to be frequent drug users. Cases registered consecutively for prenatal care at > or = 28 weeks gestation or had < 4 prenatal visits. Controls were matched to cases by date of delivery. 24/81 (30%) cases and 16/128 (12%) controls were frequent drug users (adjusted odds ratio = 2.5; 95% CI, 1.2-5.4). Drug use (P = 0.01) and socioeconomic status (P = 0.001) were significantly correlated with prenatal care utilization. Self-report alone failed to note as many drug users as toxicology screen alone. Both substance use history and toxicology screen are advisable in women with low utilization of prenatal care.

Self-Efficacy for Smoking Cessation Counseling Parents in Primary Care: An Office-Based Intervention for Pediatricians and Family Physicians

Few pediatricians or family physicians routinely counsel parental smokers to quit smoking. Poor self-efficacy in smoking cessation counseling skills may be one barrier to counseling. Analysis of self-efficacy scores of physicians participating in the Clean Air for Healthy Children program demonstrates that pediatricians had higher self-efficacy scores for explaining the health risks of environmental tobacco smoke on children (P < .05); family physicians had higher self-efficacy scores for smoking cessation counseling knowledge (P < .05). Posttraining, both pediatricians and family physicians who participated in an office-based smoking cessation counseling program had significantly higher scores in all 4 self-efficacy domains (P < .01).

Intelligence and school readiness in preschool children with prenatal drug exposure.

This prospective, longitudinal study examined factors affecting intelligence and school readiness in children 4-5 years of age with prenatal cocaine/opiate exposure. Intelligence and school readiness scores were not significantly different for the drug-exposed group (N=104) than for unexposed, demographically matched controls (N=35), although both groups scored slightly below average. Caregivers of drug-exposed children scored significantly lower in intelligence and reading achievement than caregivers of controls; both were below average. Caregiver reading scores accounted for the largest variance in both child intelligence and school readiness; for school readiness, birth weight also contributed but was less important in the model. Neither prenatal drug exposure nor continuing caregiver drug use was significant in the regression analyses. The relationship between child scores and caregiver reading achievement is consistent with studies showing the importance of a stimulating, supportive home environment, and suggests interventions to foster caregiver literacy skills and facilitate caregiver-child cognitive interactions such as reading to the child.