Minal R. Patel

An Examination of Adverse Asthma Outcomes in U.S. Adults with Multiple Morbidities

RATIONALE More Americans are managing multiple chronic conditions. Little is known regarding combinations of multiple chronic conditions with asthma. OBJECTIVES To examine the prevalence and demographic distribution of five common chronic conditions (arthritis, heart disease, cancer, diabetes, and hypertension) in adults with and without asthma and the adverse asthma outcomes associated with multiple chronic conditions. METHODS Cross-sectional interview data from the National Health and Nutrition Examination Survey were analyzed (n = 22,172) between 2003 and 2010. Bivariate analysis methods and multivariate generalized linear regression were used to examine associations. MEASUREMENTS AND MAIN RESULTS Of the 10% of subjects with asthma, 54% had one or more coexisting health condition(s). The prevalence of two or three or more other chronic conditions was greater among those with asthma compared with those without (P < 0.001). Common comorbidities with asthma were hypertension (34%) and arthritis (31%). For every additional comorbid chronic condition, there was an increase in the prevalence of reported asthma symptom episodes (prevalence ratio [PR], 1.06; 95% confidence interval [CI], 1.00-1.13), frequent activity limitation (PR, 1.14; 95% CI, 1.04-1.25), sleep disturbances (PR, 1.22; 95% CI, 1.04-1.43), and emergency department visit for asthma (PR, 1.45; 95% CI, 1.19-1.76) when adjusted for socioeconomic and demographic factors and body mass index. The population-attributable risk for emergency department visits for asthma among individuals with asthma who have other chronic comorbidities was 19.5%. CONCLUSIONS Half of the adult population with asthma in the United States suffers from comorbid conditions, which are associated with adverse asthma-related outcomes and account for up to 20% of emergency room visits for asthma.

Asthma Action Plans and Patient Satisfaction Among Women With Asthma

BACKGROUND Asthma action plans (AAPs) are a priority recommendation of the National Asthma Education and Prevention Program and have been shown to positively affect health outcomes. Patient satisfaction is an important clinical outcome, yet little is known about its association with receiving an AAP. This study examined the association between having an AAP and behaviors to keep asthma in control and patient satisfaction with care. METHODS The study design was a cross-sectional analysis of baseline data from a randomized trial evaluating a self-management program among 808 women with asthma. Participants reported demographic information, interactions with clinicians, whether they had an AAP and owned a peak flow meter, self-management behaviors, and symptoms. RESULTS The mean age of the participants was 48 ±13.6 years, 84% (n= 670) were satisfied with their asthma care, and 48% (n= 383) had a written AAP from their physician. Women not having an AAP were less likely to take asthma medication as prescribed [ x 2 (1) = 13.68, P , .001], to initiate a discussion about asthma with their physicians [ x 2 (1) = 26.35, P < .001], and to own a peak fl ow meter [ x 2 (1) =77.84, P < .001]. Adjusting for asthma control, income, and medical specialty,women who did not have an AAP were more likely to report dissatisfaction with their asthma care (OR, 2.07; 95% CI, 1.35-3.17; P < .001). CONCLUSIONS Women without an AAP were less likely to initiate discussions with their physicians,take medications as prescribed, and own a peak fl ow meter to monitor asthma, all considered important self-management behaviors. They were also less satisfied with their care. Not having an AAP may affect interactions between patient and physician and clinical outcomes.

Physician Communication Regarding Cost When Prescribing Asthma Medication to Children

Children with asthma require multiple medications, and cost may be a barrier to care. The purpose of this study was to determine how often physicians ask about cost when prescribing new asthma medication and to identify factors influencing queries. We surveyed pediatricians and family physicians and asked whether they asked about cost when prescribing new asthma medication and if cost was a barrier to prescribing. One third of physicians (35%) reported that concern for cost to the family was a barrier to prescribing. Half reported not asking their patients about drug costs. Pediatricians were less likely to ask about cost (odds ratio [OR] = 0.43; 95% confidence interval [CI] = 0.20-0.92) when compared with family physicians. For every 10% increase in the number of privately insured patients, a physician was less likely to ask about cost (OR = 0.83; 95% CI = 0.74-0.94). Communication about medication costs should be included in childhood asthma management.

Asthma outcomes in children and adolescents with multiple morbidities: Findings from the National Health Interview Survey.

BACKGROUND More Americans are managing multiple chronic conditions (MCCs), and trends are particularly alarming in youth. OBJECTIVE The purpose of this study was to examine the prevalence and distribution of 9 chronic conditions in children and adolescents with and without asthma, and adverse asthma outcomes associated with having MCCs. METHODS Cross-sectional interview data from the National Health Interview Survey were analyzed (N = 66,790) between 2007 and 2012 in youth 0 to 17 years of age. Bivariate analysis methods and multivariate generalized linear regression were used to examine associations. RESULTS Five percent of children with asthma had 1 or more coexisting health conditions. The prevalence of 1 or more comorbidities was greater among those with asthma than those without (5.07% [95% CI: 4.5-5.6] vs. 2.73% [95% CI: 2.6-2.9]). Those with asthma were twice as likely to have co-occurring hypertension (prevalence ratio [PR] = 2.2 [95% CI: 1.5-3.2]) and arthritis (PR = 2.7 [95% CI: 1.8-4.0]) compared with those without asthma. Every additional chronic condition with asthma was associated with a greater likelihood of an asthma attack (PR = 1.1 [95% CI: 1.0-1.2]), all-cause emergency department visits (PR = 1.3 [95% CI: 1.1-1.5]), and missed school days (PR = 2.3 [95% CI: 1.7-3.2]). CONCLUSIONS Children and adolescents with asthma in the US who suffer from MCCs have increased asthma symptoms, missed school days, and all-cause emergency department visits. Further research on optimal management strategies for this group is needed.

Physician–Patient Communication on Cost and Affordability in Asthma Care. Who Wants to Talk about It and Who Is Actually Doing It

RATIONALE Patient perceptions of financial burden and rates of cost-related nonadherence are high among individuals with asthma across the socioeconomic spectrum. Little is known about preferences and frequency of physician-patient discussions about cost/affordability among individuals managing respiratory conditions. OBJECTIVES To examine who has a preference to discuss the cost of their asthma care with their physician, how often physician-patient communication about cost/affordability actually is occurring, and what clinical and demographic characteristics of patients are predictive of communication. METHODS Data came from 422 African American adult women with asthma who were asked about communication preferences and practices around cost and affordability with their physician. Data were analyzed using descriptive statistics and multiple variable logistic regression models. MEASUREMENTS AND MAIN RESULTS Fifty-two percent (n = 219) of this sample perceived financial burden. Seventy-two percent (n = 300) reported a preference to discuss cost with their health-care provider. Thirty-nine percent (n = 163) reported actually having a conversation with their physician about cost. Among the 61% who reported no discussion, 40% (n = 103) reported financial burden, and 55% (n = 140) reported a preference for discussion. Lower household income (P < 0.001), perception of financial burden (P < 0.001), and higher out-of-pocket expenses for medicines (P < 0.05) were significantly predictive of greater preference to communicate about cost/affordability with the doctor when adjusted for clinical and demographic characteristics. Perception of financial burden (P < 0.001), preference to discuss affordability (P < 0.001), and greater number of chronic conditions (P < 0.001) were significantly predictive of greater likelihood of communication about cost/affordability with the doctor when adjusted for clinical and demographic characteristics. Bivariate analyses revealed that patients who reported a discussion of cost were more likely to report worse asthma control and lower asthma-related quality of life. CONCLUSIONS An imbalance is evident between patients who would like to discuss cost with their doctor and those who actually do. Patients are interested in low-cost options and a venue for addressing their concerns with a care provider; therefore, a greater understanding is needed in how to effectively and efficiently integrate these conversations and viable solutions into the delivery of health care. Additional research is necessary to determine whether communication about the cost of therapy is associated with health outcomes.

What About Your Friends? Exploring Asthma-Related Peer Interactions

Purpose. School-based asthma interventions have been shown to be effective, but many may not be sensitive to the influence of peer interactions in shaping asthma-related emotional experiences. This exploratory study describes associations between peer interactions and asthma-related emotional experiences, asthma control, and outcomes among elementary-aged children with asthma. Methods. Data come from the baseline assessment of a randomized trial evaluating the effect of a school-based asthma intervention. Univariate and multivariate statistics were completed to examine associations between peer interactions and asthma-related variables of interest. Results. Eight hundred and thirty-five caregiver and child interviews were used in the analysis. Both males and females were enrolled in this study, 31% had not well controlled or poorly controlled asthma and 44% reported taking asthma medications. Overall, 26% of children talked to friends about asthma. Females were significantly more likely to talk to friends about asthma (p < .05) and more likely to report that they were worried, concerned, or troubled about asthma (p < .01). Significant differences in emotional quality of life between males and females were also found. Children who reported talking to friends about asthma were more likely to report teasing about asthma (OR = 2.47; 95% CI 1.57, 3.89) and to report that friends help with their asthma (OR = 1.79; 95% CI 1.07, 3.01). Conclusions. School-based asthma interventions should be sensitive to emotional-related outcomes associated with asthma and the influence of asthma-related peer interactions. Providing children with communication strategies for disclosure of asthma status to peers that result in more supportive interactions may be needed.

Special challenges in treatment and self-management of older women with asthma

Asthma is one of the most common chronic conditions in the United States, and prevalence is currently at historically high levels. The most recent figures from the Centers for Disease Control and Prevention (CDC) reveal that approximately 13% of adults have ever been told they have asthma, and 8% still have asthma.1 Asthma is marked by significant health disparities, with certain population subgroups exhibiting increased prevalence and worse health outcomes. One such group is older asthmatic women, in whom the highest asthma mortality rate is seen. While the prevalence of asthma in the elderly is no different than the general population, the morbidity and mortality figures are strikingly worse. For example, the death rate among those above 65 is by far the highest, nearly four times higher than the overall average.2 Moreover, physician office visits per 100 persons with asthma are highest in those over 65.3 Although the rate of emergency department visits is no higher than other age groups, hospitalizations are again disproportionately higher among older adults (Figure 1). This suggests that older adults with asthma who visit the emergency room are more likely to require hospitalization, and are more likely to have a fatal asthma event, than other age groups. Figure 1 Asthma hospitalization rates by detailed age group: United States, average annual rate 2007 – 2009. Data presented as mean +/− SE mean. Vital Health Stat 3(35). 2012. Gender discrepancies in asthma prevalence and outcomes are evident. Among all adults, women are significantly more likely to report asthma than men (9.9 vs. 6.2%). In those over 65, 9.1% of older women and 5.7% of older men noted current asthma in 2011.4 Among the elderly, it is women who suffer most from asthma. From 2007 – 2009, the asthma mortality rate was by far the highest in women over age 65, and this rate was 30% higher than men over age 65.2 The asthma death rate among older women is approximately four times higher than the overall total. Women over age 65 are also nearly twice as likely as men over age 65 to visit the emergency department for asthma. When considering asthma hospitalization rates by age and gender, older women had the highest rate of any sub-group.3 Therefore, understanding and improving asthma outcomes for older women is desperately needed in order to decrease health care costs, improve outcomes, and reduce health disparities. Until recently, little research has focused on the unique asthma challenges of women or the elderly. The purpose of this paper is to examine factors that may contribute to the unequal burden of asthma among older women, and to present practical solutions to improve care in this population.

Social Determinants of Health, Cost-related Nonadherence, and Cost-reducing Behaviors Among Adults With Diabetes: Findings From the National Health Interview Survey.

Background:Cost-related nonadherence (CRN) is prevalent among individuals with diabetes and can have significant negative health consequences. We examined health-related and non–health-related pressures and the use of cost-reducing strategies among the US adult population with and without diabetes that may impact CRN. Methods:Data from the 2013 wave of National Health Interview Survey (n=34,557) were used to identify the independent impact of perceived financial stress, financial insecurity with health care, food insecurity, and cost-reducing strategies on CRN. Results:Overall, 11% (n=4158) of adults reported diabetes; 14% with diabetes reported CRN, compared with 7% without diabetes. Greater perceived financial stress [prevalence ratio (PR)=1.07; 95% confidence interval (CI), 1.05–1.09], financial insecurity with health care (PR=1.6; 95% CI, 1.5–1.67), and food insecurity (PR=1.30; 95% CI, 1.2–1.4) were all associated with a greater likelihood of CRN. Asking the doctor for a lower cost medication was associated with a lower likelihood of CRN (PR=0.2; 95% CI, 0.2–0.3), and 27% with CRN reported this. Other cost-reducing behavioral strategies (using alternative therapies, buying prescriptions overseas) were associated with a greater likelihood of CRN. Conclusions:Half of the adults with diabetes perceived financial stress, and one fifth reported financial insecurity with health care and food insecurity. Talking to a health care provider about low-cost options may be protective against CRN in some situations. Improving screening and communication to identify CRN and increase transparency of low-cost options patients are pursuing may help safeguard from the health consequences of cutting back on treatment.

Translation of an evidence-based asthma intervention: Physician Asthma Care Education (PACE) in the United States and Australia

BACKGROUND Physician Asthma Care Education (PACE) is a programme developed in the USA to improve paediatric asthma outcomes. AIMS To examine translation of PACE to Australia. METHODS The RE-AIM framework was used to assess translation. Demographic characteristics and findings regarding clinical asthma outcomes from PACE randomised clinical trials in both countries were examined. Qualitative content analysis was used to examine fidelity to intervention components. RESULTS Both iterations of PACE reached similar target audiences (general practice physicians and paediatric patients with asthma); however, in the USA, more children with persistent disease were enrolled. In both countries, participation comprised approximately 10% of eligible physicians and 25% of patients. In both countries, PACE deployed well-known local physicians and behavioural scientists as facilitators. Sponsorship of the programme was provided by professional associations and government agencies. Fidelity to essential programme elements was observed, but PACE Australia workshops included additional components. Similar outcomes included improvements in clinician confidence in developing short-term and long-term care plans, prescribing inhaled corticosteroids, and providing written management instructions to patients. No additional time was spent in the patient visit compared with controls. US PACE realised reductions in symptoms and healthcare use, results that could not be confirmed in Australia because of limitations in follow-up time and sample sizes. US PACE is maintained through a National Heart, Lung, and Blood Institute website. Development of maintenance strategies for PACE Australia is underway. CONCLUSIONS Based on criteria of the RE-AIM framework, the US version of PACE has been successfully translated for use in Australia.

Beyond co-pays and out-of-pocket costs: perceptions of health-related financial burden in managing asthma among African American women

Abstract Objective: The purpose of this study was to define perceptions of health-related financial burden based on the views of individuals who report these perceptions through qualitative approaches. Methods: Four focus groups were conducted in Southeast Michigan with 26 African American women with asthma, recruited based on maximum variation sampling procedures. A semi-structured interview was employed by facilitators. Coded transcripts were analyzed for themes regarding dimensions of the meaning of financial burden. Results: Major domains of financial burden identified included (1) high out-of-pocket expenses; (2) lost wages from exacerbations, inability to maintain a stable job and stress from making decisions about taking a sick day or coming to work; (3) transport costs; (4) both costs and stress of managing insurance eligibility and correcting erroneous bills. Conclusion: Greater awareness of factors that add to perceptions of financial burden might better equip researchers to develop interventions to help care teams manage such concerns with their patients.