Assessing the Family Asthma Management System

The importance of “self-management” has been increasingly recognized in the treatment of asthma. In the case of childhood asthma, such management must be accomplished by the family system, including the caregivers, the asthmatic child, and the alternate caregivers in collaboration with the health care providers. This paper presents an assessment tool, the Family Asthma Management System Scale (FAMSS), for evaluating the effectiveness of the family asthma management system. The scale is internally consistent and has excellent inter-rater reliability. The FAMSS score, together with an asthma severity measure, jointly accounted for a significant portion of the variance when predicting the functional severity of asthma experienced by this group of children.     

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.     

The Anatomy of Asthma Care Visits in Community Family Practice

Background: We know little about the activities that occur during asthma-related visits with primary care physicians. A better understanding of how time is spent during visits for asthma may facilitate the design of programs to enhance asthma disease management.

Objective: To describe the content of asthma visits made to family physicians.

Methods: Research nurses directly observed consecutive outpatient visits during two separate days in the offices of 138 community family physicians. Time was classified into 20 different behavioral categories using the Davis Observation Code, and compared for visits for asthma, visits for other chronic conditions, and visits for non-asthma-related acute illnesses during 3035 visits by patients of all ages. Results: Visits for asthma shared several characteristics with visits for other chronic conditions but were longer than visits for other chronic illnesses or for acute illness. Asthma visits were distinguished from both acute care and other chronic care visits by a greater percentage of time spent discussing patient compliance, evaluating patient knowledge, and providing smoking assessment and cessation advice. Conclusions: Visits for asthma are structured differently than acute care visits and specifically address issues important to asthma self-management. Future quality improvement initiatives should recognize, affirm, and enhance many current behaviors by family physicians, while working to expand specific areas of care that still fall short of asthma care guidelines.     

Management of Asthma Among Community-Based Primary Care Physicians

Background. Despite significant improvements in asthma treatment and the dissemination of national and international guidelines for asthma management, there are ongoing concerns that suboptimal care is being provided for patients with asthma. Objective. To determine the current practice patterns of asthma care among primary care physicians. Design. A cross-sectional study. Setting. Province of Alberta, Canada (population: 3 million people). Participants. Patients, 5 years of age or older, who had a physician's diagnosis of asthma, and had at least two visits for asthma between 1996 and 2001. Measurement and Results. Charts of 3072 distinct patients (from 45 unique primary care physicians) were reviewed. Previous emergency department visits or hospitalizations were experienced by 20% of the sample. A total of 25% of patients had documented evidence that they had performed spirometry. More than half of the patients had no documented evidence that they had received any form of asthma education; only 2% of the charts indicated that patients received a written action plan. Two thirds of the patients were prescribed an inhaled steroid within 6 months of the last clinic visit. Conclusions. Our study indicates a gap in the provision of asthma education, written action plans, and spirometric testing for patients diagnosed with asthma among primary care physicians.     

Patients' Perceptions of Asthma Control and Impact on Attitudes and Self-Management

The objective of this work was to describe the incidence of chronic breathing problems, particularly asthma-related breathing problems, in a cross-section of the United States population and to assess the perceived impact of these problems on daily living. An initial screening survey was used in a nationwide panel of 30,000 households; an in-depth follow-up questionnaire was sent to a random sample of respondents who reported a breathing problem. A sample (n = 2685) of respondents who reported persistent cough, shortness of breath, or wheezing within the previous 2 years were sent a newly developed questionnaire. A subsample (n = 723) of respondents reported a primary diagnosis of asthma and of these, 59.4% were female and 90.2% were white. Their mean age was 37.4 years. Respondents (n = 723) characterized their level of perceived asthma control as completely controlled, well controlled, somewhat controlled, or poorly/not controlled. At least 31% of those with a perception of some control and 59% of those with a perception of poor/no control reported their breathing problems had increased in the last year. Those who perceived their asthma-related breathing problems as poorly controlled reported significantly greater symptom frequency, activity restriction, fears and concerns about their breathing difficulties, less helpful coping strategies, and less confidence in their doctor's ability to care for them. Responses to many of the questions indicated that the worst levels of disease control were associated with poorer quality of life and a more negative perception of the disease and its effects on daily living. A significant portion of the U.S. population appears to suffer from chronic breathing problems; this requires confirmation and further exploration to reduce the potential mortality and morbidity due to asthma in the United States.     

Implementing Continuing Education Strategies for Family Physicians to Enhance Asthma Patients' Quality of Life

The goal of the study was to provide asthma-related continuing medical education (CME) to family physicians with the objective of improving patient outcomes. Using a quasi-experimental design in a single community, the intervention included academic detailing, a case-based workshop, newsletters, medical grand rounds, and patient-centered education materials. Outcome measures included physician participation in CME; patient self-reported quality of life, asthma knowledge, asthma self-management, medication use, and health service utilization before and after the intervention; and physician feedback. Our results indicated that 78% of family physicians participated in one or more of the CME activities. The majority of physicians provided positive feedback on the use of the intervention both from their own and their patients' perspectives. Academic detailing increased the involvement of physicians in CME. We concluded that there was a statistically significant improvement in patients' quality of life, whereas changes in patients' knowledge, behavior, and health service use were positive but not statistically significant. Methodological factors are identified that could improve the effectiveness of future studies.     

The Allocation of Family Responsibility for Asthma Management Tasks in African-American Adolescents

The allocation of responsibilities for asthma management within African-American families was examined in 60 adolescents and their primary caretakers. Separate structured interviews were conducted with adolescents and primary caretakers, and perceptions of family management, adherence to asthma treatment regimen, and functional morbidity were assessed. Support for the primary hypothesis that higher levels of nonadherence and functional morbidity would be observed in families where caretakers overestimated the level of adolescent involvement in asthma self-care was found. Implications for family-based asthma management in ethnic minority adolescents are discussed.     

The Allocation of Family Responsibility for Asthma Management Tasks in African-American Adolescents

The allocation of responsibilities for asthma management within African-American families was examined in 60 adolescents and their primary caretakers. Separate structured interviews were conducted with adolescents and primary caretakers, and perceptions of family management, adherence to asthma treatment regimen, and functional morbidity were assessed. Support for the primary hypothesis that higher levels of nonadherence and functional morbidity would be observed in families where caretakers overestimated the level of adolescent involvement in asthma self-care was found. Implications for family-based asthma management in ethnic minority adolescents are discussed.     

Two-Year Results from the Asthma Self-Management Program: Long-Term Impact on Health Care Services, Costs, Functional Status, and Productivity

Participants in a variety of health plans, clinics and employer groups were invited to participate in the Asthma Self-Management Program (ASMP), an education program designed to improve self-management skills and daily functioning in individuals with asthma. The ASMP is an 8-week classroom program that provides information on the respiratory system, trigger avoidance, use of monitoring techniques and asthma medications. After program completion, graduates were contacted at scheduled intervals to reinforce performance of behaviors that are important to asthma self-management and to collect outcomes data. This paper reports the results of 2 years of follow-up with these individuals.     

Association Between Outpatient Follow-Up and Pediatric Emergency Department Asthma Visits

Background.?The National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend that patients receive a follow-up outpatient asthma visit after being discharged from an emergency department (ED) for asthma. Objective.?To measure the frequency of follow-up outpatient asthma visits and its association with repeat ED asthma visit. Design.?We conducted a retrospective cohort study of children with asthma using claims data from a university-based managed care organization from 01 1998 to 10 2000. We performed a multivariate survival analysis using Cox proportional hazards model to determine the effect of follow-up outpatient asthma visits on the likelihood of a repeat ED asthma visit, after controlling for severity of illness, patient age, gender, insurance, and the specialty of the primary care provider. Results:?A total of 561 children had 780 ED asthma visits. Of these, 103 (17%) had a repeat ED asthma visit within 1 year. Almost two-thirds of children (66%) did not receive outpatient follow-up for asthma within 30 days of an ED asthma visit. Outpatient asthma visits within 30 days of an ED asthma visit are associated with an increased likelihood (relative risk = 1.80; 95% confidence interval 1.19, 2.72) for repeat ED asthma visits within 1 year. Conclusions.?Most patients do not have outpatient follow-up after an ED asthma visit. However, those patients that present for outpatient follow-up have an increased likelihood for repeat ED asthma visits. For the primary care provider, these outpatient follow-up visits signal an increased risk that a patient will return to the ED for asthma and are a key opportunity to prevent future ED asthma visits.     

Association Between Outpatient Follow-Up and Pediatric Emergency Department Asthma Visits

Background. The National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend that patients receive a follow-up outpatient asthma visit after being discharged from an emergency department (ED) for asthma. Objective. To measure the frequency of follow-up outpatient asthma visits and its association with repeat ED asthma visit. Design. We conducted a retrospective cohort study of children with asthma using claims data from a university-based managed care organization from 01 1998 to 10 2000. We performed a multivariate survival analysis using Cox proportional hazards model to determine the effect of follow-up outpatient asthma visits on the likelihood of a repeat ED asthma visit, after controlling for severity of illness, patient age, gender, insurance, and the specialty of the primary care provider. Results: A total of 561 children had 780 ED asthma visits. Of these, 103 (17%) had a repeat ED asthma visit within 1 year. Almost two-thirds of children (66%) did not receive outpatient follow-up for asthma within 30 days of an ED asthma visit. Outpatient asthma visits within 30 days of an ED asthma visit are associated with an increased likelihood (relative risk = 1.80; 95% confidence interval 1.19, 2.72) for repeat ED asthma visits within 1 year. Conclusions. Most patients do not have outpatient follow-up after an ED asthma visit. However, those patients that present for outpatient follow-up have an increased likelihood for repeat ED asthma visits. For the primary care provider, these outpatient follow-up visits signal an increased risk that a patient will return to the ED for asthma and are a key opportunity to prevent future ED asthma visits.     

Two-Year Results from the Asthma Self-Management Program: Long-Term Impact on Health Care Services,Costs, Functional Status,and Productivity

Participants in a variety of health plans, clinics and employer groups were invited to participate in the Asthma Self-Management Program (ASMP), an education program designed to improve self-management skills and daily functioning in individuals with asthma. The ASMP is an 8-week classroom program that provides information on the respiratory system, trigger avoidance, use of monitoring techniques and asthma medications. After program completion, graduates were contacted at scheduled intervals to reinforce performance of behaviors that are important to asthma self-management and to collect outcomes data. This paper reports the results of 2 years of follow-up with these individuals.     

What Nurses in Primary Care Practices Know About Asthma Care: Results from a National Survey

Objectives: The purpose of this study was to characterize what nurses working in primary care settings know about asthma care. Current views on the care of persons with asthma suggest the need for sound knowledge of guideline-based care and a health care team that includes both physicians, nurses, and other providers. While there are reports of physician-related asthma care practices in the United States, there are few, if any, reports of nursing knowledge, attitudes, or beliefs about asthma care.

Methods: A national, randomly selected, representative sample of nurses working in ambulatory primary care settings was interviewed by telephone using a structured interview format.

Results: Of a sample of 80 nurses, less than 10% identified inflammation of the airways as the underlying condition that causes asthma symptoms. Fifty-one percent believed the underlying condition could be treated, while 44% believed only the symptoms could be treated, and 5% didn't know. Only 35% said they were aware of the National Heart, Lung, and Blood (NHLBI) asthma guidelines.

Conclusions: Nurses working in ambulatory primary care settings may lack sufficient knowledge to effectively teach and participate in asthma care.     

What Nurses in Primary Care Practices Know About Asthma Care: Results from a National Survey

Objectives: The purpose of this study was to characterize what nurses working in primary care settings know about asthma care. Current views on the care of persons with asthma suggest the need for sound knowledge of guideline-based care and a health care team that includes both physicians, nurses, and other providers. While there are reports of physician-related asthma care practices in the United States, there are few, if any, reports of nursing knowledge, attitudes, or beliefs about asthma care.

Methods: A national, randomly selected, representative sample of nurses working in ambulatory primary care settings was interviewed by telephone using a structured interview format.

Results: Of a sample of 80 nurses, less than 10% identified inflammation of the airways as the underlying condition that causes asthma symptoms. Fifty-one percent believed the underlying condition could be treated, while 44% believed only the symptoms could be treated, and 5% didn't know. Only 35% said they were aware of the National Heart, Lung, and Blood (NHLBI) asthma guidelines.

Conclusions: Nurses working in ambulatory primary care settings may lack sufficient knowledge to effectively teach and participate in asthma care.     

The Asthma Outreach Project: A Promising Approach to Comprehensive Asthma Management

We describe a pilot system of coordinated asthma care emphasizing home visits by a community-based lay worker collaborating with a pediatrician, pharmacist, and public health nurse. Study participants included 23 low-income children with moderate to severe asthma and their families at an inner-city pediatric clinic. This system was successfully implemented, and client satisfaction was extremely high. Utilization review showed a reduction in hospitalizations, emergency department visits, and unscheduled clinic visits, and an increase in follow-up clinic visits. This model of care may reduce unscheduled service use and deserves further study as an alternative for asthma management among similar patient populations.     

The Asthma Outreach Project: A Promising Approach to Comprehensive Asthma Management

We describe a pilot system of coordinated asthma care emphasizing home visits by a community-based lay worker collaborating with a pediatrician, pharmacist, and public health nurse. Study participants included 23 low-income children with moderate to severe asthma and their families at an inner-city pediatric clinic. This system was successfully implemented, and client satisfaction was extremely high. Utilization review showed a reduction in hospitalizations, emergency department visits, and unscheduled clinic visits, and an increase in follow-up clinic visits. This model of care may reduce unscheduled service use and deserves further study as an alternative for asthma management among similar patient populations.     

Bridging the Gap Between Doctors' and Patients' Expectations of Asthma Management

Objectives. To assess the prevalence of asthma symptoms, their impact on daily activities, and perceptions of disease severity among people with asthma. Methods. A telephone survey of 699 people with asthma was conducted in 1999 in metropolitan and nonmetropolitan New South Wales, Victoria, and Queensland, Australia. Results. Forty-two percent of adults and 26% of children reported experiencing asthma symptoms at least every 2-3 days. Thirty-seven percent of adults and 26% of children reported using a reliever more than four times in the previous week. Of those for whom preventer therapy had been prescribed (61% of respondents), 30% of children and 45% of adults did not use their preventer as instructed. A high proportion of respondents reported avoiding physical and social activities because of their asthma, while 75% said asthma generally made them feel tired. Many respondents attributed frustration (61%), irritability (57%), fear (38%), and worry (43%) to their asthma. Only 50% of respondents had been reviewed by a general practitioner for asthma in the past year. Respondents generally underestimated the severity of their asthma, compared with symptom frequencies reported. Conclusions. The Living with Asthma Survey suggests that national asthma management goals are not being achieved in a high proportion of patients, with evidence for both underprescribing and underusage of preventer medication. Achieving closer alignment between medical and patient perspectives is an important goal of asthma education and management in order to help bridge the gap between current concepts of best practice and the reality of persistently poor asthma outcomes.     

Primary School Nurses' Knowledge/Competence Pertaining to Childhood Asthma and Its Management Prior to and Following a National Asthma Education Program in Taiwan

The main purpose of the National Asthma Education Program was to provide asthma education to school nurses in Taiwan. It was also designed to enhance the knowledge and competence of school nurses in managing the asthmatic problems that children experience while in school. In addition to providing instruction about current asthma management skills, tools, and other relevant information, the program demonstrated the use of the peak flow meter for asthmatic children. A single, 4‐hr session conducted in each county and city in Taiwan, the National Asthma Education Program began on August 1, 1999, and ended December 31, 2000. A total of 829 school nurses joined the program, with an overall attendance rate of 74%. Significant effects of this program on nurses' asthma care knowledge and competence and case management efficacy were noted. The participating school nurses' demographics, however, were found to be irrelevant to these effects. Expecting the training activities to help relieve the anxieties of managing asthmatic cases in the school environment, participants reported that the training was of much benefit to them. Development of a teaching program to elevate school nurses' capabilities in asthmatic student care in the school environment and the implications of such a program within Taiwanese schools were also discussed.