Tricia Morphew

Predictive Value of a Cross-Cultural Asthma Case-Detection Tool in an Elementary School Population

Objective. Bronchial asthma, which affects ∼5 million US children, is vastly underdiagnosed and treated, particularly among minorities and those of low socioeconomic status. Because current methods of detecting those at greatest risk of asthma in a multicultural setting appear inadequate, we assessed the validity and reliability of a new asthma questionnaire across 3 dominant cultures in Orange County, California (white, Hispanic, and Vietnamese). Methods. Children in grades 1, 3, and 5 and their families, in 3 different schools representative of these major ethnic groups, were randomly selected to participate in the validation process. Two schools with low socioeconomic status and dominant Hispanic or Vietnamese minorities were designated inner-city schools, whereas the third school was a suburban school with predominately white students. Participants completed a 7-question, 11-element questionnaire in their primary language, followed by an asthma evaluation (history, physical examination, and spirometry) by an asthma specialist (who was blinded with respect to the results of the questionnaire), at their respective schools. The physician then made a determination regarding the presence and severity (according to National Institutes of Health guidelines) of asthma. Several weeks later, the entire student body was asked to complete the questionnaire at home and return it to school for analysis. Validation of each item was evaluated for sensitivity, specificity, and positive and negative predictive values, and application of univariate analyses provided an estimated probability of an asthma diagnosis by the asthma specialist. A “best-fit” algorithm was determined with all 11 elements, if possible, and an abbreviated algorithm that selected the fewest-question combination that yielded the best asthma predictability was established. Reliability was established with the percent agreement between the 2 questionnaires and the κ statistic. Results. Of the 401 children/families who participated in the validation analysis, 45% were Hispanic, 22% white, 19% Vietnamese, and 15% other. The overall prevalence of asthma specialist-diagnosed asthma was 28%, with 65% of cases being graded as intermittent and 35% as persistent. Sixty-two percent of the children had not been previously diagnosed with asthma. There were no significant differences among cultures in sensitivity or specificity for any of the individual questions or the complete or abbreviated algorithms. The abbreviated algorithm with 3 questions, ie, question 1 (asthma in the past 2 years), question 4 (cough, chest tightness, trouble breathing, or wheezing with exercise), and question 6 (same symptoms in the morning or day in the past 4 weeks) yielded comparable sensitivity and specificity for the complete algorithm in all groups. The abbreviated algorithm had >86% predictability in detecting children with persistent asthma and 56% predictability in detecting children with intermittent asthma. Reliability was also excellent, with percent agreement usually > 80% and κ values of >.70. Conclusions. This asthma detection tool has been shown to be suitable for detecting persistent asthma in a multicultural inner-city population, as well as in a suburban setting. An abbreviated algorithm with 3 questions and >80% predictability in detecting persistent asthma seems ideal for evaluating large numbers of school-aged children. The school setting is an excellent site for identifying children with asthma. Although there is concern that subjects detected in the school setting might not have access to ongoing medical care, case detection is an important first step that could lead to earlier diagnosis and treatment. Reducing the barriers to good care in inner-city environments is the next step.

Current Asthma Guidelines May Not Identify Young Children Who Have Experienced Significant Morbidity

BACKGROUND. The current guideline for classifying asthma severity, the National Asthma Education Prevention Program (NAEPP) 2002, is not evidence-based. We had the opportunity to validate this guideline in an untreated inner-city population, both in those ≤5 and those >5 years of age. The basis for this retrospective validation model was to determine how well the NAEPP severity classification based on symptom-frequency criteria alone identified patients in those age groups demonstrating significant morbidity the previous year and thus the potential need for controller therapy. METHODS. Using a mobile asthma van (Breathmobile) at the school site, children not receiving controller medication were evaluated by an asthma specialist for severity according to NAEPP guideline clinical criteria. Validation was determined by the relationship of guideline severity to ≥2 emergency department (ED) visits, any hospitalization, health care utilization (any ED visit, hospitalization), number of exacerbations, and school absenteeism resulting from asthma the prior year. RESULTS. Eight hundred twenty-six asthmatic children were evaluated; 89 (10.8%) were ≤2 years, 222 (26.9%) were 3 to 5 years, and 515 (62.3%) were >5 years of age; 60.5% were male, and 80.9% were Hispanic. Classification of asthma severity included 34.4% with mild intermittent, 10.2% with mild persistent, 31.5% with moderate persistent, and 24.0% with severe persistent asthma categories. There were significantly more Hispanic children and children ≤5 years classified as having mild intermittant asthma. Morbidity was clearly related to severity in the overall population. However, although the health care utilization was significantly related to severity, it was borderline in those 3 to 5 years and nonsignificant in children ≤2 years. CONCLUSIONS. The NAEPP guidelines 2002, based on symptom-frequency criteria as assessed in this study, seem to offer a valid basis for classifying asthma severity in those >5 years of age but may underclassify younger children. Our data suggest that morbidity experienced in the prior year may provide a useful additional criterion for classifying asthma severity, particularly in those children ≤5 years of age.

The Relationship of the Bronchodilator Response Phenotype to Poor Asthma Control in Children with Normal Spirometry

OBJECTIVE To determine the relationship of poor asthma control to bronchodilator response (BDR) phenotypes in children with normal spirometry. STUDY DESIGN Children with asthma were assessed for clinical indexes of poorly controlled asthma. Pre- and post-bronchodilator spirometry were performed, and the percent BDR was determined. Multivariate logistic regression assessed the relationship of the clinical indices to BDR at ≥ 8%, ≥ 10%, and ≥ 12% BDR thresholds. RESULTS There were 510 controller naïve children and 169 on controller medication. In the controller naïve population the mean age (± 1 SD) was 9.5 (3.4); 57.1% were male, 85.7% Hispanic. Demographics were similar in both populations. In the adjusted profile, significant clinical relationships were found particularly to positive BDR phenotypes ≥ 10% and ≥ 12% versus negative responses including younger age, (OR 2.0, 2.5; P < .05), atopy (OR 1.9, 2.6; P < .01), nocturnal symptoms in females (OR 3.4, 3.8; P < .01); β₂ agonist use (OR 1.7, 2.8; P < .01); and exercise limitation (OR 2.2, 2.5; P < .01) only in the controller naïve population. CONCLUSIONS The BDR phenotype ≥ 10% is significantly related to poor asthma control, providing a potentially useful objective tool in controller naïve children even when the pre-bronchodilator spirometry result is normal.

Ability to control persistent asthma in obese versus non-obese children enrolled in an asthma-specific disease management program (breathmobile).

To determine if asthma control was more difficult to achieve in obese versus non-obese asthmatic children, retrospective analysis was performed on obese and non-obese Los Angeles inner-city children (2 to 18 years of age) with persistent asthma. No difference in time required to achieve control of asthma, ability to maintain control of asthma, baseline pulmonary functions, and number of controllers prescribed was found between the two groups. We conclude that in a Los Angeles inner-city pediatric population, obesity is not a factor in the ability to control asthma.

Asthma control and future asthma-related morbidity in inner-city asthmatic children

BACKGROUND Asthma guidelines recommend routine evaluation of asthma control, which includes measurements of impairment and risk. It is unclear whether rigorous asthma control changes risk of asthma morbidity. OBJECTIVE To examine whether the degree of asthma control in inner-city asthmatic children results in differential risk reduction of future asthma-related morbidity. METHODS This retrospective observational study examines 960 inner-city children with asthma who were highly engaged in an asthma-specific disease management program for a minimum of 2 years. Degree of asthma control was determined during the first year of enrollment and was categorized as well controlled (> or = 80% of visits in control), moderately controlled (50%-79% of visits in control), or difficult to control (< 50% of visits in control). Risk and probability of asthma-related morbidity at each visit were determined during the second year of enrollment and included self-reported asthma exacerbations requiring systemic corticosteroid rescue and emergency department visits or hospitalizations. RESULTS Increasing the degree of asthma control measured during the first year of enrollment led to statistically significant incremental reductions in risk of acute asthma exacerbations and emergency department visits or hospitalizations during the second year of enrollment. CONCLUSIONS Achieving and maintaining asthma control in inner-city children with asthma results in significant reductions in asthma-related morbidity. Systematic assessments of asthma control may be useful for predicting future risk in children with asthma.

School Asthma Screening and Case Management: Attendance and Learning Outcomes.

Asthma is related to school absenteeism and underperformance in elementary students. This pilot study assessed whether school nurse case management (CM) in children identified with asthma impacts academic performance and school absenteeism in one school. A validated questionnaire was used to identify children at risk for asthma and CM was provided to link these students to medical care and assure asthma action plans at school. In the 40 children with confirmed diagnosis who received CM, academic performance on standardized testing postintervention was similar to the 76 children who were low risk for asthma. Average days absent due to illness in the CM group were reduced from 5.8 to 3.7 days in the postintervention school year. School nurse screening, CM, and collaboration with a medical provider resulted in early identification, referral, and subsequent treatment of students at risk for asthma and may have contributed to reduced illness absences.

The Breathmobile program: a good investment for underserved children with asthma

BACKGROUND The Breathmobile, a specialty-based mobile asthma clinic, provides free care to underserved children. The cost of symptom-free day (SFD) improvement in this population has not been previously reported. OBJECTIVE To examine the clinical impact and cost-effectiveness of the Baltimore Breathmobile. METHODS Existing computerized data were analyzed for Breathmobile patient visits between 2002 and 2007. All SFDs were calculated, and direct medical cost savings attributable to decreased emergency department visits and hospitalizations (after program utilization vs the previous year) were compared with annual operating costs. Incremental cost-effectiveness ratios were determined by calculating the incremental costs of Breathmobile care per additional SFD gained per child per year. RESULTS The analysis included 255 patients enrolled in the program for at least 1 year. Most participants were black (93.3%), and 54.9% were male. At baseline, patients reported a mean (SD) of 199 (118) SFDs in the year before enrollment. After 1 year in the program, patients had a mean (SD) improvement of 44 (9) SFDs. The program resulted in overall cost savings of

Validation of a single survey that can be used for case identification and assessment of asthma control: the Breathmobile Program.

79.43 per SFD gained, with greater cost savings for children aged 5 to 11 years (-

Mobile health care operations and return on investment in predominantly underserved children with asthma: the breathmobile program.

116.84 per SFD gained) and those with intermittent asthma (-

Identification of preschool children with asthma from low-income families in Los Angeles, CA

126.71 per SFD gained). CONCLUSIONS The Baltimore Breathmobile program has demonstrated significant improvement in SFDs, with direct medical cost savings of the program outweighing the operational costs. These data support the need to continue to sustain and expand Breathmobile programs for children at high risk for asthma exacerbations and to conduct a randomized clinical trial to estimate the cost-effectiveness of the Breathmobile.