Sande O. Okelo

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.

Does higher body mass index contribute to worse asthma control in an urban population

BACKGROUND Epidemiologic findings support a positive association between asthma and obesity. OBJECTIVE Determine whether obesity or increasing level of body mass index (BMI) are associated with worse asthma control in an ethnically diverse urban population. METHODS Cross-sectional assessment of asthma control was performed in patients with asthma recruited from primary care offices by using 4 different validated asthma control questionnaires: the Asthma Control and Communication Instrument (ACCI), the Asthma Control Test (ACT), the Asthma Control Questionnaire (ACQ), and the Asthma Therapy Assessment Questionnaire (ATAQ). Multiple linear regression analysis was performed to evaluate the association between obesity and increasing BMI level and asthma control. RESULTS Of 292 subjects with a mean age of 47 years, the majority were women (82%) and African American (67%). There was a high prevalence of obesity with 63%, with only 15% normal weight. The mean score from all 4 questionnaires showed an average suboptimal asthma control (mean score/maximum possible score): ACCI (8.3/19), ACT (15.4/25), ACQ (2.1/6), and ATAQ (1.3/4). Regression analysis showed no association between obesity or increasing BMI level and asthma control using all 4 questionnaires. This finding persisted even after adjusting for FEV(1), smoking status, race, sex, selected comorbid illnesses, and long-term asthma controller use. CONCLUSION Using 4 validated asthma control questionnaires, we failed to find an association between obesity and asthma control in an urban population with asthma. Weight loss may not be an appropriate strategy to improve asthma control in this population.

Are Physician Estimates of Asthma Severity Less Accurate in Black than in White Patients

BackgroundRacial differences in asthma care are not fully explained by socioeconomic status, care access, and insurance status. Appropriate care requires accurate physician estimates of severity. It is unknown if accuracy of physician estimates differs between black and white patients, and how this relates to asthma care disparities.ObjectiveWe hypothesized that: 1) physician underestimation of asthma severity is more frequent among black patients; 2) among black patients, physician underestimation of severity is associated with poorer quality asthma care.Design, Setting and PatientsWe conducted a cross-sectional survey among adult patients with asthma cared for in 15 managed care organizations in the United States. We collected physicians’ estimates of their patients’ asthma severity. Physicians’ estimates of patients’ asthma as being less severe than patient-reported symptoms were classified as underestimates of severity.MeasurementsFrequency of underestimation, asthma care, and communication.ResultsThree thousand four hundred and ninety-four patients participated (13% were black). Blacks were significantly more likely than white patients to have their asthma severity underestimated (OR = 1.39, 95% CI 1.08–1.79). Among black patients, underestimation was associated with less use of daily inhaled corticosteroids (13% vs 20%, p < .05), less physician instruction on management of asthma flare-ups (33% vs 41%, p < .0001), and lower ratings of asthma care (p = .01) and physician communication (p = .04).ConclusionsBiased estimates of asthma severity may contribute to racially disparate asthma care. Interventions to improve physicians’ assessments of asthma severity and patient–physician communication may minimize racial disparities in asthma care.

Patient Factors Used by Pediatricians to Assign Asthma Treatment

OBJECTIVE. Although asthma is often inappropriately treated in children, little is known about what information pediatricians use to adjust asthma therapy. The purpose of this work was to assess the importance of various dimensions of patient asthma status as the basis of pediatrician treatment decisions. PATIENTS AND METHODS. We conducted a cross-sectional, random-sample survey, between November 2005 and May 2006, of 500 members of the American Academy of Pediatrics using standardized case vignettes. Vignettes varied in regard to (1) acute health care use (hospitalized 6 months ago), (2) bother (parent bothered by the childs asthma status), (3) control (frequency of symptoms and albuterol use), (4) direction (qualitative change in symptoms), and (5) wheezing during physical examination. Our primary outcome was the proportion of pediatricians who would adjust treatment in the presence or absence of these 5 factors. RESULTS. Physicians used multiple dimensions of asthma status other than symptoms to determine treatment. Pediatricians were significantly more likely to increase treatment for a recently hospitalized patient (45% vs 18%), a bothered parent (67% vs 18%), poorly controlled symptoms (4–5 times per week; 100% vs 18%), or if there was wheezing on examination (45% vs 18%) compared with patients who only had well-controlled symptoms. Pediatricians were significantly less likely to decrease treatment for a child with well-controlled symptoms and recent hospitalization (28%), parents who reported being bothered (43%), or a child whose symptoms had worsened since the last doctor visit (10%) compared with children with well-controlled symptoms alone. CONCLUSIONS. Pediatricians treat asthma on the basis of multiple dimensions of asthma status, including hospitalization, bother, symptom frequency, direction, and wheezing but use these factors differently to increase and decrease treatment. Tools that systematically assess multiple dimensions of asthma may be useful to help further improve pediatric asthma care.

Intimate partner violence exposure, salivary cortisol, and childhood asthma

OBJECTIVES Neuroendocrine alterations may help explain health differences between intimate partner violence (IPV) exposed children and non-exposed children. We sought to determine the feasibility of having families, recruited at a child asthma visit, collect at home and return via mail child salivary samples, and whether socio-demographic variables were associated with sample return. For those returning samples, we examined whether past-year IPV exposure was associated with total cortisol output (AUC) and the magnitude of the cortisol awakening response (CAR), and whether these cortisol values were associated with asthma control. METHODS Fifty-five families with an asthmatic child of any age were recruited from 2 pediatric asthma clinics. At the time of the visit, parents completed a survey packet which included a modified version of the Conflict Tactics Scale to assess IPV. Parents were given supplies to collect 3 child salivary cortisol samples (awakening, 30-min after awakening, bedtime) at home on a typical day, and return them via mail. Medical records also were abstracted. RESULTS Fifty-three percent (n=29) returned child salivary samples. Families who returned samples typically returned them within 2 weeks, most commonly before we made a reminder call. Parental male sex was associated (p=.06) with increased rate of return at the trend level. In multivariable models, a 1-unit increase in IPV was significantly associated with a .93 SD increase in root-transformed total cortisol output (AUC) (un-standardized beta=2.5; SE .59; p=.001). The odds of uncontrolled asthma were marginally higher for every nmol/l increase in CAR (OR 1.04; 95% CI 1.0, 1.1; p=.06). CONCLUSIONS This study provides support for the feasibility of obtaining a moderate return of salivary specimens from a convenience sample. Findings that IPV was associated with elevated total cortisol output and uncontrolled asthma was marginally associated with cortisol awakening response suggest that future studies should investigate whether cortisol mediates the IPV-child asthma relationship.

Asthma identification and medication administration forms in New York City schools

Asthma is a chronic respiratory disease affecting nearly 9.6% of United States children.1 Asthma disproportionately burdens children from poor and minority backgrounds.2 Children with asthma have high rates of school absenteeism.3 With children spending nearly half of their day at school, appropriate school asthma management can help optimize care for students with asthma. Successful school asthma management involves individual case identification and provision of medications to students when needed.4 New York City (NYC) schools require caregiver submission of a Medication Administration Form (MAF; a physician-completed order form that must be renewed every school year) to confirm asthma diagnoses and allow school nurses to administer medication for asthma exacerbations.5 Without an MAF, due to systems-based regulations, the nurse cannot administer medication, even if a student is having an asthma attack. Many NYC schools struggle with individual asthma case identification6 and have difficulty obtaining MAFs for students, making acute asthma management challenging. Therefore, the objectives of this study were to 1) compare asthma prevalence in four NYC schools based on caregiver and school report; and 2) identify asthma morbidity factors associated with MAF submission. We conducted a cross-sectional survey of caregivers of children attending 2nd-4th grades in four Bronx, New York (NY) elementary schools as the first step in preparation for a school-based intervention study. The NYC Department of Education and the universitys Institutional Review Board (IRB) approved this study. We developed a 6-item self-administered English-Spanish asthma survey based on prior surveys7,8 and NYC DOE guidelines for MAF.5 The survey was field-tested with 10 caregivers of children with and without asthma at routine office visits to ensure questions were clear and easy to comprehend. The survey is available in an online supplement. Surveys and return envelopes were sent home with students during the fall of 2012. Caregivers were instructed to return completed surveys to the classroom teachers in the sealed envelopes. We then collected envelopes from the teachers. Children received a small gift (e.g. stickers, tattoos) for reminding caregivers to return the surveys. Schools were asked to report the number of students with asthma in the same grades. Schools use several Board of Education forms, such as health examination forms and MAFs sent to all students, to identify asthma cases. We performed descriptive statistics for all variables. Differences in proportions were tested by Chi-square. A two-sided α<0.05 was considered statistically significant. We used SPSS V20.0 software (Statistical Product and Service Solutions 20.0, SPSS Inc., Chicago, IL). The survey was distributed to 1,270 students and 769 (61%) were returned. Overall, 192 (25%) children had physician-diagnosed asthma. Of these, 150 (80%) were prescribed asthma medication and 106 (55%) had ≥1 urgent asthma visits in the past year. Half (51%) of caregivers reported that their child had symptoms with exercise and 18 (9%) listed asthma as a condition limiting their childs sports participation. Only 52 (27%) had an MAF at school, and 28 (15%) of caregivers were unaware the MAF existed. (Figure 1) Children were more likely to have an MAF on file at school if they were prescribed asthma medication (32.6% vs 10.5%, p=.007) or had ≥1 urgent asthma visit in the past 12 months (38.7% vs 14.1%, p<.001). Schools identified only 50 students with asthma in the same grades using their usual screening methods. Figure 1 Survey Results on Asthma Identification and Medication Administration Forms in NYC schools. These results show a high prevalence of asthma in this population of inner-city elementary school-age children. According to caregiver report, 1/4 of children had physician-diagnosed asthma. This is consistent with an earlier study that reported a 20% asthma prevalence in several Bronx elementary schools.9 Similarly, the 2009 Child Community Health Survey reported a 16.7% (95% CI (14.4 - 19.4)) asthma prevalence in Bronx children 6-12 years of age.10 Our survey identified many more cases of asthma compared to the prevalence reported by schools. This suggests that methods used by schools to identify children substantially underestimate asthma cases. Further, while children with a medication prescription and those with more urgent visits in the past year were more likely to have an MAF submitted, overall less than 1/3 of caregivers submitted MAF and, even among those with urgent visits, MAFs were frequently unavailable. This makes prompt and appropriate school management of acute asthma challenging and may contribute to avoidable visits to the physicians office or emergency department. Future research should focus on the reasons for low MAF submission by caregivers and the impact system-based regulations may have on students’ school asthma management. Our study had some limitations. The study was conducted in NYC elementary schools. Thus, the conclusions may not be generalizable to other schools in different communities. Our response rate, while comparable to other urban school-based asthma prevalence studies,4 was only 61%. While subject self-selection might have biased estimates of asthma prevalence, an earlier school-based study in the Bronx found similar prevalence rates.9 Differences in the definition of asthma used, methods to identify cases and timing of data collection may have accounted for some discrepancy between asthma cases identified by our survey and those identified by schools. Further, due to privacy rules, we were unable to link individual survey and school data; thus, we do not know if students identified by the school were the same students whose caregivers reported having MAF on file at the school. However these limitations are unlikely to account for the large discrepancy in asthma prevalence found. In conclusion, our study is the first to compare asthma prevalence as reported by caregiver with school report, and to assess factors associated with MAF submission in NYC public schools. We found that a short, take-home, self-administered caregiver survey identified 74% more cases of asthma than schools, and that MAFs are markedly lacking. Instituting a streamlined method of school asthma case identification and communicating to caregivers the importance of MAF may improve school asthma management. Further, this process may serve as the first step toward establishing interventions to improve outcomes of inner-city children with asthma.

Day Care Increases the Risk of Respiratory Morbidity in Chronic Lung Disease of Prematurity

OBJECTIVES: Infants and children with chronic lung disease of prematurity (CLDP) are at increased risk for morbidity and mortality from respiratory viral infections. Exposure to respiratory viruses may be increased in the day care environment. The risk of respiratory morbidity from day care attendance in the CLDP population is unknown. We therefore sought to determine if day care attendance is a significant risk factor for increased respiratory morbidity and symptoms in infants and children with CLDP. METHODS: Between January 2008 and October 2009, parents of infants and children with CLDP were surveyed. Information on perinatal history, sociodemographic information, day care attendance, and indicators of respiratory morbidity, including emergency department (ED) visits, hospitalizations, systemic corticosteroid use, antibiotic use, and respiratory symptoms, was collected on children <3 years of age. Logistic regression models were constructed to examine associations between exposure to day care and respiratory morbidities. RESULTS: Data were collected from 111 patients with CLDP. The average gestational age was 26.2 ± 2.0 weeks. Day care attendance was associated with significantly higher adjusted odds for ED visits (odds ratio [OR]: 3.74 [95% confidence interval (CI): 1.41–9.91]; P < .008), systemic corticosteroid use (OR: 2.22 [CI: 1.10–4.49]; P < .026), antibiotic use (OR: 2.40 [CI: 1.08–5.30]; P < .031), and days with trouble breathing (OR: 2.72 [CI: 1.30–5.69]; P < .008). Although there was an increased OR for hospitalization (OR: 3.22 [CI: 0.97–10.72]; P < .057), this did not reach statistical significance. CONCLUSIONS: We found that day care attendance is associated with increased respiratory morbidities in young children with CLDP. Physicians should consider screening for and educating caregivers about the risks of day care attendance by young children with CLDP.

Socio-economic factors and outcomes in chronic lung disease of prematurity.

Infants and children with chronic lung disease of prematurity (CLDP) are at increased risk for respiratory morbidities. We sought to determine (1) whether socio‐economic status, race/ethnicity, and/or sex are risk factors for respiratory morbidities and (2) whether disparities in care existed for major therapy decisions such as home supplemental oxygen and gastrostomy tubes as well as initial length of stay in the neonatal intensive care unit.

The Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) improves physician assessment of asthma morbidity in pediatric emergency department patients

Abstract Objectives: To determine whether the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED), a 12-item questionnaire, can help ED attendings accurately assess a patient’s asthma control and morbidity. Methods: This was a randomized-controlled trial performed at an urban pediatric ED of children aged 1–17 years presenting with an asthma exacerbation. Parents answered PACCI-ED questions about their children’s asthma. Attendings were randomized to view responses to the PACCI-ED (intervention group) or to be blinded to the completed PACCI-ED (control group). The two groups were compared on their empirical clinical assessment of: (1) chronic asthma control categories, (2) asthma trajectory (stable, worsening or improving), (3) patient adherence to controller medications, and (4) burden of disease for the patient’s family. The validated PACCI algorithm was used as the criterion standard for these four outcomes. Accuracy of clinical assessment was compared between intervention and control groups using chi-squared tests and an intention-to-treat approach. Results: Seventeen ED attendings were enrolled in the study and 77 children visits were included in the analysis. There were no significant differences between the intervention and the control groups for child’s gender, age, race, and asthma characteristics. Intervention group attendings were more accurate than control group attendings in assessing the category of chronic asthma control (43% versus 19%; p = 0.03), disease trajectory (72% versus 45%; p = 0.02), and the disease burden for families (74% versus 35%; p = 0.001) over the past 12 months. There was a trend towards more accuracy of intervention versus control attendings for estimating patient adherence to controller medications (72% versus 48%; p = 0.06). Conclusions: The PACCI-ED improves the assessment of asthma control, trajectory, and burden by ED attendings, and may help assessment of asthma medication adherence and prior asthma exacerbations. The PACCI-ED can be used to improve provider assessment of asthma morbidity during pediatric ED visits for asthma exacerbations, and to identify children who may benefit from interventions to reduce asthma morbidity.

Differences in spirometry values between US children 6–11 years and adolescents 12–19 years with current asthma, 2007–2010

National Asthma Education and Prevention Program (NAEPP) guidelines recommend that periodic spirometry be performed in youth with asthma. NAEPP uses different spirometry criteria to define uncontrolled asthma for children (6–11 years) and adolescents (12+ years).