A Comparison of Patient Attitudes Toward Asthma Self-Management Among Acute and Preventive Care Settings

This study characterizes the attitudes regarding asthma and asthma care of low-income, African-American adults who receive care from acute care settings. As a point of reference, their attitudes and knowledge were compared with those of a group of patients receiving asthma care from a private setting that stresses preventive asthma self-management. Patients were assessed regarding attitudes toward (1) routine asthma self-care and decisions as to when to self-treat versus seek asthma care, (2) administration of asthma medications, (3) satisfaction with acute-care services, and (4) the desire for asthma education. Asthma morbidity, sociodemographic characteristics, awareness of environmental triggers, and daily stressors were also assessed. Responses of adults receiving most of their asthma care from acute care settings suggest the same pattern of failure to treat asthma regularly and delay in seeking care as implicated in asthma deaths among children. Emphasis on self-treatment of asthma symptoms, not preventive selfmanagement, was apparent among the attitudes of the acute care patients. Lack of regular care, delay of treatment, and reliance on self-treatment via over-the-counter medications was noted. Implications of these findings for the development of asthma education programs are addressed.     

Articulation of Asthma and Its Care Among Low-Income Emergency Care Recipients

Low-income minority patients from East St. Louis, Illinois, a depressed midwestern urban city, who had visited acute care settings with asthma symptoms, participated in a focus group. Questions were constructed around the Health Belief Model to characterize participants' experiences in receiving asthma care, their confidence in long-term asthma self-management, barriers they perceived to managing their asthma, and recommendations they would make for improving asthma care in their community. Analysis of comments suggests an appreciable understanding of asthma triggers, limited coping behaviors for asthma symptoms, very limited practice of active asthma management, perception of the health care system as frequently insensitive to their needs or their knowledge of their own care, exchange of well-articulated information regarding how to deal with the system, and an apparent lack of awareness of any potential contribution of patient education or support system.     

Benefit from the inclusion of self-treatment guidelines to a self-management programme for adults with asthma.

This study assessed the long-term efficacy of adding self-treatment guidelines to a self-management programme for adults with asthma. In this prospective randomized controlled trial, 245 patients with stable, moderate to severe asthma were included. They were randomized into a self-treatment group (group S) and a control group (group C). Both groups received self-management education. Additionally, group S received self-treatment guidelines based on peak expiratory flow (PEF) and symptoms. Outcome parameters included: asthma symptoms, quality of life, pulmonary function, and exacerbation rate. The 2-yr study was completed by 174 patients. Both groups showed an improvement in the quality of life of 7%. PEF variability decreased by 32% and 29%, and the number of outpatient visits by 25% and 18% in groups S and C, respectively. No significant differences in these parameters were found between the two groups. After 1 yr, patients in both groups perceived better control of asthma and had more self-confidence regarding their asthma. The latter improvements were significantly greater in group S as compared to group C. There were no other differences in outcome parameters between the groups. Individual self-treatment guidelines for exacerbations on top of a general self-management programme does not seem to be of additional benefit in terms of improvements in the clinical outcome of asthma. However, patients in the self-treatment group had better scores in subjective outcome measures such as perceived control of asthma and self-confidence than patients in the control group.     

Perceptions and attitudes of adolescents with asthma.

BACKGROUND: Psychosocial factors can limit one's ability to effectively manage asthma. This can result in asthma morbidity that limits quality of life. While self-perceptions of asthmatic children and parents have been studied, less is known about self-perceptions of inner-city adolescents with asthma. OBJECTIVE: To examine perceptions and attitudes to treatment among inner-city adolescents with asthma. DESIGN/METHODS: We conducted a multistaged stratified sample survey at a high school located in the Bronx, NY. First, an asthma-screening survey was administered to 3800 registered students. Then, we identified a subset of 200 children with the most positive screening results for asthma. Next, a 32-item self-completion questionnaire was administered to this cohort. Students were surveyed regarding severity of asthma, perceptions and attitudes, and demographic information. Differences in proportions were tested by Chi-square analyses. Pearson rank-order correlation and multiple logistic regression were used to assess the relationship between perceptions and attitudes to self-treatment. RESULTS: A total of 160 (80%) students participated. Mean age was 15.7 years. Of the respondents, 63% were female. 68% were Hispanic, 26% were African American. 33% had weekly symptoms, and 14% had daily symptoms. Additionally, 41% did not know the name of their asthma medicine. Only 38% reported bringing an "asthma pump" when leaving the house. While 70% reported feeling in control over their asthma symptoms, 63% reported feelings of anxiety and 39% could remember a time when they felt like they were going to die from asthma. Subjects who reported feeling in control over their asthma were more likely to take an asthma pump with them when leaving the house (r = 72, p = 0.004). Only 39% had disclosed their asthma to their friends, and 29% felt embarrassed about having an asthma attack in front of their friends. Subjects who felt embarrassed about their asthma were significantly less likely to take their asthma pumps with them (r = 0.98, p < 0.001) and less likely to use their medications in front of their friends (r = .87, p < 0.001). CONCLUSIONS: Adolescents in this study reported feelings of anxiety, fear, and embarrassment about their asthma. Feelings of control over asthma symptoms were associated with positive attitudes toward self-treatment, while embarrassment was correlated with negative attitudes. These findings have implications for counseling adolescents with asthma about self-management strategies.     

Nebulized beta2-agonist use in high-risk inner-city adults with asthma.

Nebulizer use has been linked to worse asthma outcomes, but the precise reason(s) for this relationship is not known. We assessed the frequency of nebulized beta2-agonist use in high-risk inner-city adults with asthma and compared asthma self-management practices according to nebulizer use in this population. This was a cross-sectional study conducted over 6 weeks from July to August 2000. A convenience sample (N=50) was recruited from an inner-city emergency department (ED). Adults (age > or = 18 years) were eligible if they had a physician diagnosis of acute asthma exacerbation. Data regarding asthma symptoms, acute care utilization, use of nebulized beta2-agonist for symptom relief, and indicators of asthma self-management (physician for asthma care, use of controller medications, current cigarette smoking, and substance use) were collected by an interviewer-administered survey. Nebulized beta2-agonist use was reported by 54.0% of patients during the 30 days before their ED visit. Nebulizer users reported more severe asthma symptoms (96.3% vs. 73.9% with moderate or severe persistent asthma, p=0.02) than nonusers. Nebulizer users were more likely to have a physician for asthma care (85.2% vs. 56.5%, p=0.02), have more frequent care from their physicians in the past 12 months (e.g., >3 visits: 59.3% vs. 30.4%, p=0.02), and notify their physician during their asthma exacerbation (39.1% vs. 7.7%, p=0.04). Compared with nonusers, nebulizer users reported better care across other indicators of care, though differences between groups were not significant. After accounting for symptom severity, results were largely unchanged. If these findings are confirmed in other studies with larger numbers of patients, we conclude that the relationship between nebulizer use and higher asthma morbidity largely represents preferential use of nebulizers by patients with more symptomatic disease.     

Patient safety perceptions: a survey of Iowa physicians, pharmacists, and nurses

BACKGROUND: Patient safety is of concern to consumers, health professionals, policymakers, insurers, and researchers. OBJECTIVE: Assess the perceptions of health care providers regarding the impact of parts of the health care system on patient safety, barriers to patient safety, and strategies to improve patient safety. METHODS: Statewide survey mailed in May 2001. Participants rated the impact of 10 parts of the health care system on patient safety, selected barriers to patient safety that they thought should be priorities, and selected the best strategies for improving patient safety. RESULTS: Of random samples of 1310 physicians, 1310 pharmacists, and 2620 nurses licensed by the state of Iowa, 5075 providers were eligible and 2388 responded (47%). Provider education, norms and values, patient and family characteristics, and continuity of care were rated as having a major impact on patient safety by at least 70% of each provider group. A general lack of consensus exists among providers about which barriers to patient safety should be priorities and which strategies would best improve the system. However, a majority of providers agreed that educating patients about their role in health care and sharing information between providers and across settings of care are important strategies for improving patient safety. CONCLUSION: In areas in which providers agree on the best strategies, broader, system-wide interventions that include physicians, pharmacists, and nurses in multiple settings may be implemented to improve patient safety. Health care organizations and providers must get patients more involved in their care by asking them to help define roles, design educational materials, and develop useful methods of sharing information across settings.     

Reasons for Delay in Seeking Treatment for Acute Asthma: The Patient's Perspective

Increased morbidity and mortality due to asthma suggested the need to investigate whether persons with asthma report delay in seeking medical care during acute asthma exacerbations and the reasons they gave for delay. We interviewed 95 asthmatic adults, 36 men and 59 women, using a critical incident technique to discover how patients responded to acute asthma symptom episodes. Subjects were interviewed once per month for a total of three interviews. All subjects had physician-diagnosed asthma for a mean of 16.8 ± 14.5 years. Eighty-six percent of the sample (n = 82) reported delay in seeking medical care for severe asthma symptoms. Seven reasons for delay were identified: uncertainty, disruption, minimization, fear of systemic corticosteroid, previous bad experiences in emergency departments, the need to “tough it out” alone, and economic reasons. Seventy-one subjects (86.5%) reported three or more reasons for delay. Thirteen subjects (16%) identified pivotal episodes in which they realized they could die from asthma and as a result, no longer delayed. People with asthma often delay seeking urgent care for acute episodes for a variety of reasons. Some of these reasons are modifiable. Clear directions from health professionals to guide patients in responding to acute asthma episodes are needed. Asthma action plans written by the primary physician may be a positive agent of change for those who delay.     

Exposure to environmental tobacco smoke among children presenting to the emergency department with acute asthma: a multicenter study

Environmental tobacco smoke (ETS) exposure has been associated with increased use of the emergency department (ED) for acute asthma care. The purpose of this study was to determine the prevalence of ETS exposure among children presenting to the ED for acute asthma care and whether ETS exposure affects acute asthma severity or response to therapy. We conducted a multi-center study of children 2-11 years with physician-diagnosed acute asthma presenting to 44 EDs in 18 states. Chi-square test, Student's t-test, Wilcoxon rank sum test, and logistic regression were used for the analyses. The study population included 954 children. Thirty-six percent (95% CI, 33-39%) of caregivers reported that their child was exposed to ETS. Among exposed children, 35% were exposed 1-6 days/week, and 65% were exposed daily. Compared to unexposed children, ETS-exposed children were older at asthma diagnosis, older at ED presentation, and were less likely to be Hispanic. Indicators of chronic asthma severity were higher among unexposed children (i.e., total number of medications, use of controller medications, use of beta(2) agonists, number of urgent clinic visits, and lifetime hospitalizations). There was a weak association between ETS and acute asthma severity. Response to therapy (including ED disposition) did not differ between groups. On multivariate analysis, ETS-exposed children were more likely to be older, female, non-Hispanic, have lower household income, not use controller medications, and have a pet at home (all P < 0.05). Our study showed that the prevalence of ETS exposure among children presenting to the ED with acute asthma differs across demographic factors. There were no significant differences in acute asthma symptoms or response to ED therapy between ETS-exposed and unexposed children. Lower use of controller medications and less frequent urgent clinic visits among ETS-exposed children suggest inadequate asthma care or milder disease. The weak association between ETS exposure and acute asthma severity might reflect confounding by psychological factors and/or chronic asthma severity. The frequency of ETS exposure suggests that the ED may be an appropriate venue to engage caregivers of children with asthma in asthma education and smoking cessation efforts.     

Effectiveness of Acute Asthma Care Among Inner-city Adults

BACKGROUND: Acute asthma often requires expensive emergency department visits and hospitalizations, especially among economically disadvantaged inner-city adults. However, few studies have examined approaches for improving acute asthma care in this population. METHODS: We conducted a cohort study involving patients who were discharged from a public hospital emergency department following acute asthma care between March 31, 1997, and August 5, 1999, to identify processes of care effective for improving peak expiratory flow rate at a 2- to 3-week follow-up. Adult patients who met the predetermined criteria for asthma, who underwent a baseline peak expiratory flow rate reading, and who did not have concurrent acute sinusitis or pneumonia were eligible (N = 448). Of the 365 patients enrolled in the study, 309 (84.7%) completed it. We used a multiple linear regression analysis adjusted for patient risk to assess the association between acute asthma care processes derived from the National Asthma Education Prevention Program guidelines (inhaled beta2-agonists, inhaled corticosteroids, systemic corticosteroids, asthma care follow-up, and patient asthma education) and percentage peak expiratory flow rate change at follow-up. RESULTS: Systemic corticosteroids had a significant effect for increasing percentage peak expiratory flow rate change at the 2- to 3-week follow-up for all asthma exacerbation severity levels (beta = 26.1; 95% confidence interval, 1.8-50.5; P =.04) and severity levels specified by the National Asthma Education Prevention Program guidelines (beta = 31.6; 95% confidence interval, 8.1-55.1; P =.01). CONCLUSION: Outpatient systemic corticosteroids were effective for improving lung function 2 to 3 weeks after acute asthma care, and their use should reduce asthma-related morbidity, especially among economically disadvantaged inner-city adults.     

Nebulized β2-Agonist Use in High-Risk Inner-City Adults with Asthma

Nebulizer use has been linked to worse asthma outcomes, but the precise reason(s) for this relationship is not known. We assessed the frequency of nebulized β₂-agonist use in high-risk inner-city adults with asthma and compared asthma self-management practices according to nebulizer use in this population. This was a cross-sectional study conducted over 6 weeks from 07 to 08 2000. A convenience sample (N = 50) was recruited from an inner-city emergency department (ED). Adults (age ≥18 years) were eligible if they had a physician diagnosis of acute asthma exacerbation. Data regarding asthma symptoms, acute care utilization, use of nebulized β₂-agonist for symptom relief, and indicators of asthma self-management (physician for asthma care, use of controller medications, current cigarette smoking, and substance use) were collected by an interviewer-administered survey. Nebulized β₂-agonist use was reported by 54.0% of patients during the 30 days before their ED visit. Nebulizer users reported more severe asthma symptoms (96.3% vs. 73.9% with moderate or severe persistent asthma, p = 0.02) than nonusers. Nebulizer users were more likely to have a physician for asthma care (85.2% vs. 56.5%, p = 0.02), have more frequent care from their physicians in the past 12 months (e.g., >3 visits: 59.3% vs. 30.4%, p = 0.02), and notify their physician during their asthma exacerbation (39.1% vs. 7.7%, p = 0.04). Compared with nonusers, nebulizer users reported better care across other indicators of care, though differences between groups were not significant. After accounting for symptom severity, results were largely unchanged. If these findings are confirmed in other studies with larger numbers of patients, we conclude that the relationship between nebulizer use and higher asthma morbidity largely represents preferential use of nebulizers by patients with more symptomatic disease.     

A National Survey of Asthma Knowledge and Practices Among Specialists and Primary Care Physicians

Asthma is a chronic disorder that causes significant morbidity and mortality and requires ongoing chronic care. Approximately two-thirds of people with asthma are receiving care from a primary care clinician, such as an internist, family practitioner, nurse practitioner, or pediatrician. The other one-third of patients are obtaining treatment and ongoing care from specialists, including allergists or pulmonologists. The outcomes of asthma care are a subject of intense investigation. Many studies focus on pharmacotherapy, allergen control, and asthma education as interventions to reduce the morbidity and costs associated with asthma. Fewer studies have explored the differences in outcomes between asthmatic patients cared for by specialists compared with generalists. Even fewer have explored the practice differences between generalists and specialists that may relate to outcomes of care. With the advent of national asthma guidelines and the high prevalence of asthma seen in primary care settings, it is important to investigate the knowledge, attitudes, and practices of primary care physicians with regard to asthma.     

A national survey of asthma knowledge and practices among specialists and primary care physicians.

Asthma is a chronic disorder that causes significant morbidity and mortality and requires ongoing chronic care. Approximately two-thirds of people with asthma are receiving care from a primary care clinician, such as an internist, family practitioner, nurse practitioner, or pediatrician. The other one-third of patients are obtaining treatment and ongoing care from specialists, including allergists or pulmonologists. The outcomes of asthma care are a subject of intense investigation. Many studies focus on pharmacotherapy, allergen control, and asthma education as interventions to reduce the morbidity and costs associated with asthma. Fewer studies have explored the differences in outcomes between asthmatic patients cared for by specialists compared with generalists. Even fewer have explored the practice differences between generalists and specialists that may relate to outcomes of care. With the advent of national asthma guidelines and the high prevalence of asthma seen in primary care settings, it is important to investigate the knowledge, attitudes, and practices of primary care physicians with regard to asthma.     

Knowledge, attitudes, and self-efficacy and compliance with medical regimen, number of emergency department visits, and hospitalizations in adults with asthma.

PURPOSE: The purpose of this study was to examine the relationship between knowledge, attitudes, and self-efficacy and compliance with prescribed medical regimen, number of emergency department (ED) visits, and hospitalizations in adults with asthma. METHOD: The sample consisted of 29 adults with a diagnosis of asthma. The relationship among knowledge, attitudes, self-efficacy, and compliance with medical regimen was explored through use of a survey design. The Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire and the Asthma Management Questionnaire that measured compliance were mailed to subjects' homes. Once completed, questionnaires were returned, and demographic data and number of ED visits and hospitalizations were obtained through a retrospective chart review. RESULTS: There was a significant correlation between knowledge and attitudes and knowledge and self-efficacy. The more positive persons' attitudes toward their asthma, the higher their knowledge and self-efficacy scores. There were significant correlations between select demographic variables and knowledge, attitude, and self-efficacy. Women scored higher on attitudes, persons with a college education scored higher on knowledge and attitudes, and persons with mild asthma scored highest on the self-efficacy scale. Compliance with use of peak-flow meters correlated with higher scores on the attitude and self-efficacy scales. The higher total compliance score group had significantly higher self-efficacy scores. In addition, higher self-efficacy scores correlated with lower numbers of hospitalizations. CONCLUSION: Attitudes and self-efficacy rather than knowledge had the most significant impact on compliance and number of ED visits and hospitalizations. The Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire provides a means for nurses to assess patients' knowledge, attitudes, and self-efficacy regarding their asthma. Patients with low scores could be channeled into programs that would help them improve their ability to manage their asthma.     

A National Survey of Asthma Knowledge and Practices Among Specialists and Primary Care Physicians

Asthma is a chronic disorder that causes significant morbidity and mortality and requires ongoing chronic care. Approximately two‐thirds of people with asthma are receiving care from a primary care clinician, such as an internist, family practitioner, nurse practitioner, or pediatrician. The other one‐third of patients are obtaining treatment and ongoing care from specialists, including allergists or pulmonologists. The outcomes of asthma care are a subject of intense investigation. Many studies focus on pharmacotherapy, allergen control, and asthma education as interventions to reduce the morbidity and costs associated with asthma. Fewer studies have explored the differences in outcomes between asthmatic patients cared for by specialists compared with generalists. Even fewer have explored the practice differences between generalists and specialists that may relate to outcomes of care. With the advent of national asthma guidelines and the high prevalence of asthma seen in primary care settings, it is important to investigate the knowledge, attitudes, and practices of primary care physicians with regard to asthma.     

Understanding of asthma management: Medicaid parents' perspectives

OBJECTIVE: This article explores parental caregiver perspectives on barriers to asthma care in the Medicaid system. METHODS: Focus groups were held for parents of children with persistent asthma to identify barriers to asthma care for children insured by Medicaid in the Ypsilanti, MI area. Semistructured questions regarding health goals, asthma care, and access were used. Themes were defined as distinct categories or concepts regarding aspects of asthma care and coded. RESULTS: Thirty-six adults participated in four focus groups, 89% were the biological mother, and 64% were African American. Major themes identified included caregiver emotions, caregiver/patient knowledge, environmental issues, school/daycare support, Medicaid health-care system issues, the role of medical providers, and emerging adolescence. Parents demonstrated asthma awareness but were not confident in their role as the child's disease manager. A specific gap was seen in the caregiver's level of self-efficacy to control exposure to asthma triggers, monitor the child's symptoms, and modify medications based on asthma symptoms. CONCLUSION: Medicaid-insured families face unique barriers related to income and insurance limitations as well as issues common to others with asthma. Caregivers demonstrated a high level of asthma knowledge, but like other caregivers gaps between knowledge and behavior existed. Barriers to asthma care that may be specific to Medicaid-insured patients included difficulty maintaining continuity of care due to physician participation in Medicaid programs, and concerns about possible differences in asthma care from health-care providers due to their Medicaid insurance status.     

The influence of age on acute myocardial infarction symptoms and patient delay in seeking treatment

A secondary analysis was conducted from data gathered from 239 patients with acute myocardial infarction presenting to the emergency departments of three hospitals to explore the influence of age on delay time, experienced symptoms, and factors predicting a delay of >1 hour. During hospitalization, a structured interview about the patients' experience before hospital admission was completed and their medical records were reviewed. The median delay before seeking treatment was not significantly different between older (2.5 hours) and younger patients (2.1 hours). Older patients were significantly less likely to report classic pain in the center of the chest and other associated symptoms such as sweating and nausea; they also used fewer words to describe their discomfort compared with younger patients. Independent predictors of longer delay were: contacted physician, lacked similarity between experienced and expected symptoms, did not use 911 (older adults), lived alone, and contacted physician (younger adults). Primary care providers need to be aware that elderly persons are more likely to have mild or ambiguous acute myocardial infarction symptoms and education is needed for elderly persons regarding not only acute myocardial infarction symptoms but also rapid, action-centered decisions to attribute symptoms to heart problems and initiate ambulance use.     

Living with idiopathic pulmonary fibrosis: an in-depth qualitative survey of European patients

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, and fatal lung disease of unknown origin. Despite recent advancements, the diagnosis and management of IPF remains a distinct clinical challenge; as a result, patients often experience considerable delays in receiving an accurate diagnosis and confusion regarding prognosis and the availability of treatment options. In order to gain further insights regarding patients' perspectives on the diagnostic process, disease education, emotional well-being, and quality of life, we conducted a qualitative in-depth survey among IPF patients in Europe. Patients with a physician-confirmed IPF diagnosis were recruited to participate in an in-depth interview conducted by a trained facilitator who used a qualitative topic guide. A total of 45 patients from 5 European countries participated in the survey. The median reported time from initial presentation to confirmed diagnosis of IPF was 1.5 years (range <1 week to 12 years); in 58% of cases there was a delay of >1 year between initial presentation and a confirmed diagnosis of IPF. Additionally, 55% of patients reported consulting ≥3 physicians before receiving an IPF diagnosis. Patient satisfaction with medical care and disease education appeared to be higher among patients who were receiving care at a recognized center of excellence. Patients generally had reasonable expectations regarding the goals of therapy, with most recognizing the irreversibility of the disease and the limited prospects for achieving a cure. The most common unmet needs cited by participants were disease education resources, access to centers of excellence, and familial support programs. Our findings suggest that patients with IPF commonly experience protracted delays in receiving an accurate diagnosis and generally perceive the level of medical care as suboptimal, despite expressing reasonable expectations regarding the goals of therapy. These results support the need for further improvement in the areas of diagnosis, disease management, and patient education.