Cynthia M. Rand

Noncompliance and treatment failure in children with asthma.

BACKGROUND Accurate and reliable information about childrens use of inhaled medications is needed because of the growing reliance on these drugs in the treatment of asthma and the excessive morbidity and mortality attributable to this disease. OBJECTIVE This study was designed to evaluate the adherence of children with asthma to regimens of inhaled corticosteroids and beta-agonists. METHODS Data collected electronically by metered-dose inhaler monitors were compared with data recorded by patients on traditional diary cards. A volunteer sample of 24 children, between 8 and 12 years old, who had asthma for which they were receiving both inhaled corticosteroids and beta-agonists, participated over a 13-week period. Each child was accompanied by a parent to all study visits. The main outcome measures were the use of medication as reported by diary card entries and recorded by electronic monitoring and disease exacerbation, as indicated by requirement for oral corticosteroids. RESULTS The median use of inhaled corticosteroids reported by patients on their diaries was 95.4%, whereas the median actual use was 58.4%. More than 90% of patients exaggerated their use of inhaled steroids, and diary entries of even the least compliant subjects reflected a high level of adherence. The children who experienced exacerbation of disease sufficient to require a burst of oral corticosteroids differed markedly from the others in their adherence to prescribed therapy as recorded by the electronic monitors. The median compliance with inhaled corticosteroids was 13.7% for those who experienced exacerbations and 68.2% for those who did not. CONCLUSIONS Electronic monitoring demonstrated much lower adherence to prescribed therapy than was reported by patients on diary cards. Low rates of compliance with prescribed inhaled corticosteroids were associated with exacerbation of disease. Poor control of asthma should alert the physician to the possibility of noncompliance.

Medication non-adherence and asthma treatment cost.

Purpose of reviewThe purpose of this review is to describe the impact of asthma treatment non-adherence on patients and the healthcare system, and to outline areas of responsibility towards improved adherence. Recent findingsThe average cost of healthcare expenses for each person in the United States in 2002 was US

Modifiable Risk Factors for Suboptimal Control and Controller Medication Underuse Among Children With Asthma

5440. In that year, there were 800 million medical encounters. However, adherence research suggests that a significant portion of the healthcare advice and prescriptions dispensed in these encounters was wasted. The annual cost to the healthcare system caused by non-adherence has been estimated at US

Delivering Adolescent Vaccinations in the Medical Home: A New Era?

300 billion dollars. The responsibility for improving adherence has usually been placed on the patient and healthcare provider. However, if non-adherence is to be more effectively addressed, other components of the healthcare and pharmaceutical industries must also take responsibility. SummaryTreatment non-adherence compromises treatment effectiveness and drives up the healthcare costs related to asthma and other chronic conditions. Collaborative efforts to improve adherence to treatments for chronic illness, recently promoted by the World Health Organization, must include multiple components of the healthcare system, must recognize that the costs of adherence promotion are outweighed by cost savings after improved adherence, and must support research to develop new and better strategies for improving adherence.

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

OBJECTIVES. Our aims were (1) to describe rates of suboptimal control and controller medication underuse in a diverse population of children with asthma and (2) to identify potentially modifiable parental behaviors and beliefs associated with these outcomes. METHODS. We conducted telephone interviews with parents of 2- to 12-year-old children with persistent asthma, in a Medicaid plan and a large provider group. Suboptimal control was defined as ≥4 symptom days, ≥1 symptom night, or ≥4 albuterol use days in the previous 2 weeks. Controller medication underuse was defined as suboptimal control and parent report of <6 days/week of inhaled steroid use. Multivariate analyses identified factors that were independently associated with suboptimal control and controller medication underuse. RESULTS. Of the 754 study children, 280 (37%) had suboptimal asthma control; this problem was more common in Hispanic children (51%) than in black (37%) or white (32%) children. Controller medication underuse was present for 133 children (48% of those with suboptimal asthma control and 18% overall). Controller medication underuse was more common among Hispanic (44%) and black (34%) children than white (22%) children. In multivariate analyses, suboptimal control was associated with potentially modifiable factors including low parental expectations for symptom control and high levels of worry about competing household priorities. Controller medication underuse was associated with potentially modifiable factors including parental estimation of asthma control that was discordant with national guidelines and no set time to administer asthma medications. CONCLUSIONS. Deficiencies in asthma control and controller medication use are associated with potentially modifiable parental beliefs, which seem to mediate racial/ethnic and socioeconomic disparities in suboptimal control and controller medication underuse.

Additional Health Care Visits Needed Among Adolescents for Human Papillomavirus Vaccine Delivery Within Medical Homes: A National Study

BACKGROUND. Medical homes are health care settings that offer continuous, comprehensive, accessible primary care; these settings generally involve pediatric and family physician practices or community health centers but can also involve gynecologists or internists. OBJECTIVES. In this article, we review available evidence on the role of the medical home in optimizing adolescent immunization delivery, particularly with respect to health care utilization patterns and barriers to vaccinations in medical homes, and solutions. METHODS. We conducted a systematic review of the existing immunization and adolescent literature and used a Delphi process to solicit opinions from content experts across the United States. RESULTS. Most adolescents across the United States do have a medical home, and many pay a health care visit to their medical home within any given year. Barriers exist in regards to the receipt of adolescent immunizations, and they are related to the adolescent/family, health care provider, and health care system. Although few studies have evaluated adolescent vaccination delivery, many strategies recommended for childhood or adult vaccinations should be effective for adolescent vaccination delivery as well. These strategies include education of health care providers and adolescents/parents; having appropriate health insurance coverage; tracking and reminder/recall of adolescents who need vaccination; practice-level interventions to ensure that needed vaccinations are provided to eligible adolescents at the time of any health care visit; practice-level audits to measure vaccination coverage; and linkages across health care sites to exchange information about needed vaccinations. Medical homes should perform a quality improvement project to improve their delivery of adolescent vaccinations. Because many adolescents use a variety of health care sites, it is critical to effectively transfer vaccination information across health care settings to identify adolescents who are eligible for vaccinations and to encourage receipt of comprehensive preventive. CONCLUSIONS. Medical homes are integral to both the delivery of adolescent immunizations and comprehensive adolescent preventive health care. Many strategies recommended for childhood and adult vaccinations should work for adolescent vaccinations and should be evaluated and implemented if they are successful. By incorporating evidence-based strategies and coordinating effectively with other health care sites used by adolescents, medical homes will be the pivotal settings for the delivery of adolescent vaccinations.

A Randomized Trial of the Effect of Centralized Reminder/Recall on Immunizations and Preventive Care Visits for Adolescents

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.

Additional Visit Burden for Universal Influenza Vaccination of US School-Aged Children and Adolescents

OBJECTIVE. We estimated the additional number of primary care visits needed to deliver 3 doses of human papillomavirus vaccine to all US adolescents in medical homes. We determined adolescent and family factors associated with needing the greatest number of additional visits for full human papillomavirus vaccination. METHODS. We performed a cross-sectional analysis of adolescents 11 to 21 years of age included in the 2002 and 2003 Medical Expenditure Panel Surveys (n = 2900) to measure existing primary care visits to pediatricians, family physicians, obstetrician/gynecologists, and internists. We then estimated additional visits needed for human papillomavirus vaccination. We determined the number of additional visits needed within a 6-, 12-, 18-, or 24-month vaccination window. RESULTS. Within a 12-month period, 72% of female adolescents would need 3 visits for human papillomavirus vaccination if the vaccine was introduced at a preventive visit; 9% and 16% would need 1 and 2 more visits, respectively. Similarly, 79% of male patients would need 3 visits; 7% and 12% would need 1 and 2 more visits, respectively. If all opportunities to vaccinate were used, then 41% of female patients and 52% of male patients would need 3 additional visits within 12 months. With expansion of the window to 24 months and vaccination at every possible visit, 23% of female patients and 37% of male patients would need 3 additional visits. Factors that predicted needing more visits (2 or 3 vs 0 or 1 in 24 months) included being older, male, black, Hispanic, uninsured, and near-poor. CONCLUSIONS. Most adolescents would require 2 or 3 additional primary care visits to receive 3 vaccines for human papillomavirus in the medical home. Strategies to minimize additional visits include vaccinating patients at all primary care visits and encouraging annual preventive visits.

Patient—Provider Communication and Human Papillomavirus Vaccine Acceptance

OBJECTIVE To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents. METHODS We conducted a randomized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11-17 years to one of three groups: mailed letter, telephone reminders, or control. Publicly insured youths (n = 4115) were identified in 37 participating primary care practices. The main outcome measures were immunization rates for routine vaccines (meningococcus, pertussis, HPV) and preventive visit rates at study end. RESULTS Intervention and control groups were similar at baseline for demographics, immunization rates, and preventive visits. Among adolescents who were behind at the start, immunization rates at study end increased by 21% for mailed (P < .01 vs control), 17% for telephone (P < .05), and 13% for control groups. The proportion of adolescents with a preventive visit (within 12 months) was: mailed (65%; P < .01), telephone (63%; P < .05), and controls (59%). The number needed to treat for an additional fully vaccinated adolescent was 14 for mailed and 25 for telephone reminders; for an additional preventive visit, it was 17 and 29. The intervention cost

Effectiveness of Centralized Text Message Reminders on Human Papillomavirus Immunization Coverage for Publicly Insured Adolescents

18.78 (mailed) or