The National Academy of Medicine Social Care Framework and COVID-19 Care Innovations

Despite social care interventions gaining traction in the US healthcare sector in recent years, the scaling of healthcare practices to address social adversity and coordinate care across sectors has been modest. Against this backdrop, the coronavirus pandemic arrived, which re-emphasized the interdependence of the health and social care sectors and motivated health systems to scale tools for identifying and addressing social needs. A framework on integrating social care into health care delivery developed by the National Academies of Science, Engineering, and Medicine provides a useful organizing tool to understand the social care integration innovations spurred by COVID-19, including novel approaches to social risk screening and social care interventions. As the effects of the pandemic are likely to exacerbate socioeconomic barriers to health, it is an appropriate time to apply lessons learned during the recent months to re-evaluate efforts to strengthen, scale, and sustain the health care sector’s social care activities.

In recent years, social care interventions in the US health care sector have gained traction, driven by compelling research, payment reforms, and new technology.¹ Despite this momentum, the scaling of new health care practices to address social adversity has been modest, and examples of sustainable alignment or coordination of care across sectors are scarce.² Against that backdrop, the new coronavirus arrived in the USA. In response, numerous academic, trade, and lay press publications highlighted how vulnerable populations disproportionately shoulder the growing pandemic’s burdens.^3–9 By re-emphasizing the interdependence of the health and social care sectors, the COVID-19 experience also has led health systems to develop, deploy, and scale tools for identifying and addressing patients’ social needs with new urgency.¹⁰Yet feasible and effective roles for health care systems in attending to patients’ social and economic needs remain elusive. A 2019 framework from the National Academies of Sciences, Engineering, and Medicine (NAM) described five strategies health care organizations can leverage to strengthen social care: awareness, assistance, adjustment, alignment, and advocacy.¹¹ (See Table ​Table1.)1.) We use the NAM framework to highlight promising social care integration innovations spurred by the COVID-19 pandemic and to recommend opportunities for strengthening and sustaining those efforts in the context of the virus’ long-term economic sequelae.Table 1Social Care Categories, Practice Examples from COVID-19 Pandemic, and Opportunities for Scaling

Behavioral Problems in Children and Adolescents with Difficult-To-Treat Asthma

Background. The aim of this study was to quantify behavioral problems in clinically treated children and adolescents with asthma and to examine the association of these problems and quality of life with difficult-to-treat asthma. Methods. Clinical patients with difficult-to-treat asthma (n = 31) and patients with asthma who were not classified as difficult-to-treat asthma (n = 52) completed the Pediatric Asthma Quality of Life Questionnaire [PAQLQ(S)]. Their parents completed the Child Behavior Checklist (CBCL) to assess behavioral problems. Behavioral problem scores were compared to norms of population reference groups and both behavioral problems and quality of life were compared between children and adolescents with and without difficult-to-treat asthma. Results. Especially internalizing behavioral problems such as being withdrawn/depressed and somatic complaints were more severe in the asthmatic groups compared to the healthy reference groups. The behavioral problems ‘somatic complaints’ and ‘thought problems’ as well as a lower quality of life were more severe in children and adolescents with difficult-to-treat asthma than in asthma patients who did not fulfill the criteria of difficult-to-treat asthma. Conclusions. Behavioral problems and a lower quality of life are suggested to be more pronounced in clinically treated children and adolescents with difficult-to-treat asthma than in asthma patients who are not classified as difficult-to-treat asthma. With respect to practical implications, our data suggest that health-care professionals should – especially in children and adolescents with difficult-to-treat asthma – assess and, if necessary, treat behavioral problems.     

Acute Asthma in Children and Adolescents

Children and adolescents experiencing acute exacerbations of asthma benefit from the use of β₂-adrenoceptor agonists (β₂-agonists) and systemic corticosteroids. However, there have been conflicting reports regarding the efficacy of inhaled anticholinergic agents.This article summarizes the evidence provided by randomized controlled trials studying the efficacy of adding inhaled anticholinergic agents to β₂-agonists in nonhospitalized children and adolescents with acute exacerbations of asthma. This systematic review of randomized controlled trials suggests that the addition of inhaled anticholinergic agents to β₂-agonists is beneficial in children and adolescents, particularly those with severe exacerbations of asthma. When given in repeated doses, the addition of inhaled anticholinergic agents to β₂-agonists improves lung function and reduces the risk of hospital admission by 25%. Several treatment regimens, namely ipratropium bromide (250 or 500μg per dose) every 20–60 minutes for two to three doses have been tested with similar beneficial effects. The addition of a single dose of an inhaled anticholinergic agent to β₂-agonists improves lung function but does not prevent hospital admission. The review did not identify any beneficial effects of anticholinergic agents in children with nonsevere asthma. Use of anticholinergic agents was not associated with increase in the incidence of nausea, vomiting or tremor.In conclusion, the addition of repeated doses of an inhaled anticholinergic agent to inhaled β₂-agonist is indicated in the emergency room management of children and adolescents with acute asthma, particularly those with severe exacerbations.     

Asthma and Wheezy Bronchitis in Adolescents: Biosocial Correlates

This study examined the epidemiological aspects of asthma and wheezy bronchitis at 16 years of age in children of a large British National cohort previously studied at the time of birth and when they were 7 and 11. It confirmed, for age 16, the steady decline in numbers of children suffering from asthma or wheezy bronchitis previously seen between ages 7 and 11. Significantly more boys than girls continued to report having these ailments. At age 16, children with asthma were more likely than those without to suffer from such allergy-related conditions as eczema and to come from homes where the principal wage-earner has a nonmanual job and where both mother and child smoke.     

Patterns of Asthma Control Perception in Adolescents: Associations with Psychosocial Functioning

Objective. The purpose was to identify and describe the patterns of asthma control perception in relation to actual symptom reports in adolescents and to compare the group with accurate control perception with those of inaccurate perception in relationship to sociodemographic characteristics, illness-related factors, and psychosocial factors. Methods. A sample of 126 adolescents from 13 through 20 years of age participated in the study. Patterns of control perception were constructed based on participants' rating of their perception of asthma control and self-reported asthma symptoms using Latent Class Analysis. Analyses of variance (ANOVAs) and multinomial logistic regressions were computed for group comparisons. Results. Participants were classified into four groups according to the patterns of control perception. Accurate groups were divided into either the well-controlled (62%) or the poorly-controlled group (7%), and inaccurate groups were manifested inaccuracy either with nighttime symptoms (25%) or daytime symptoms (6%). Minority participants (p < 0.001) or those with low socioeconomic status (p < 0.001) were more likely to be represented in the inaccurate group than their counterparts. The well-controlled accurate group consistently reported higher asthma-related knowledge (p = 0.02), more positive attitude toward asthma (p < 0.001), fewer barriers to self-management (p = 0.04), and higher quality of life (p < 0.001) than the inaccurate group. Conclusion. This study demonstrated that accuracy of asthma control perception can be classified into four criteria based on patterns of various asthma symptoms. Adolescents' tendency toward underperception was evident. The inaccurate groups are at greater risk for psychosocial impairments. This study underscores the importance of an intervention that improves the accuracy of asthma control perception in adolescents while promoting psychosocial well-being among adolescents with inaccurate perception.     

Adherence-Related Behavior in Adolescents with Asthma: Results from Focus Group Interviews

Focus group interviews were conducted with 14 adolescents with asthma to explore self-management behavior, in particular with regard to adherence behavior. In addition, the adolescents discussed their feelings about having asthma, gave insight into how they evaluate the provided health care, and made recommendations for healthcare providers and for the development of patient education materials. The majority of participants did not take their prophylactic asthma medication regularly, and were rather late in starting to use their bronchodilator. They were sometimes fed up with having asthma. Moreover, the majority of participants were not always frank in telling their pediatrician how they managed their asthma. Finally, they found it essential that information about asthma should be given personally and not by means of leaflets, and recommended that healthcare providers should use audio-visual aids to illustrate what they are explaining. The results of the focus group interviews have been used for the development of an intervention program which aims at enhancing adherence in adolescents with asthma.     

Health-Related Quality of Life in Children and Adolescents with Asthma: Results from the ESTAR Study

Our aim was to assess the psychosocial well-being of asthmatic children and adolescents, the influencing factors, and to determine the effect of inpatient rehabilitation on their quality of life; 226 asthmatic children and adolescents participated in the inpatient rehabilitation (IG). The comparison group (CG) included 92 asthmatic children and adolescents receiving standard medical treatments. Patients were aged between 8 and 16 years and were predominantly male. The health-related quality of life was measured with the German version of the “Paediatric Asthma Quality of Life Questionnaire.” Interviews were carried out for IG 2 weeks before the commencement of their inpatient stay and 1 year after their stay ended. The same time schedule was carried out for CG. All patients reported a mild to moderate impairment of their quality of life. Girls described a slightly lower quality of life than boys. With increasing asthma severity, quality of life decreased. Inpatients described a lower quality of life than CG at enrollment. Inpatient rehabilitation resulted in a greater improvement of quality of life over time for IG than for CG. Gender and severity status had no effect on this time course. The only modestly affected quality of life may reflect the good adaptation to the disease and medical treatment. Children and adolescents in the IG recorded improvements in their quality of life. Differences in quality of life based on gender and disease severity were not shown to influence the improvements. In summary, inpatient rehabilitation results in an improvement of health-related quality of life. Further research concerning the psychosocial situation of children and adolescents in this setting is needed.     

A Self-Efficacy Scale for Children and Adolescents with Asthma: Construction and Validation

A self-efficacy scale for children and adolescents with asthma between 10 and 18 years of age is described. A scale of 38 items was constructed and administered to 60 children and adolescents. A factor analysis of the results yielded a scale consisting of 22 items which can be divided into three subscales: factor one (24.8% of variance) measured efficacy expectations concerning medical treatment, factor two (10.3% of variance) measured efficacy expectations concerning the environment, and factor three (6.7% of variance) measured efficacy concerning problem-solving skills. Confirmation of several predicted conceptual relationships between the self-efficacy measures and other measures (Personality Questionnaire, Coping, Anxiety, Knowledge, Optimism, and Shame) provided preliminary evidence of construct validity. Further research and clincial applications are discussed.     

Clearing Clinical Barriers: Enhancing Social Support Using a Patient Navigator for Asthma Care

Background. Patients with moderate or severe asthma, particularly those who are minority or poor, often encounter significant personal, clinical practice, and health system barriers to accessing care. Objective. To explore the ideas of patients and providers for potentially feasible, individualized, cost-effective ways to reduce obstacles to care by providing social support using a patient advocate or navigator. Methods. The authors conducted four focus groups of adults with moderate or severe asthma. Participants were recruited from clinics serving low-income and minority urban neighborhoods. Data from these patient focus groups were shared with two additional focus groups, one of nurses and one of physicians. Researchers independently coded and agreed upon themes from all focus groups, which were categorized by types of social support: instrumental (physical aid), informational (educational), emotional (empathizing), validation (comparisons to others). Results. Patients and providers agreed that a patient navigator could help patients manage asthma by giving social support. Both groups found instrumental and informational support most important. However, patients desired more instrumental help whereas providers focused on informational support. Physicians stressed review of medical information whereas patients wanted information to complete administrative tasks. Providers and patients agreed that the patient navigator's role in asthma would need to address both short-term care of exacerbations and enhance long-term chronic self-management by working with practice personnel. Conclusions. Along with medical information, there is a need for providers to connect patients to instrumental support relevant to acute and long-term asthma-self-management.     

Asthma and Obesity in Adolescents: Is There an Association?

To determine if obesity is more prevalent in adolescents with asthma compared with nonasthmatic adolescents and to determine if obesity is associated with more severe asthma, we studied 265 adolescent asthmatics 12-21 years of age and 482 nonasthmatic adolescents. The prevalence of obesity in the asthmatic group was 20% compared to 17% in the control group. The prevalence of being at risk of overweight was similar for asthmatics (16%) and controls (15%). The prevalence of obesity in moderate to severe asthmatics (21%) was not different from prevalence of obesity in mild asthmatics (19%) or controls (17%). In this study of primarily African-American urban adolescents, obesity was not associated with asthma or more severe asthma.     

Complementary and Alternative Medicine Behaviors and Beliefs in Urban Adolescents with Asthma

Background/purpose. Up to 80% of adolescents with asthma have used complementary and alternative medicine (CAM) for symptom management. However, little is known about patient characteristics associated with CAM factors other than use. Previous studies recommend provider–patient discussion of CAM use, although few adolescents with asthma disclose their CAM use to their providers. To inform clinical interactions, this study examined prevalence and predictors of CAM use, consideration of use, disclosure of use, and perceived efficacy of use, in urban adolescents with asthma. Methods. Adolescents with asthma (N = 151) recruited from a children's hospital completed questionnaires addressing demographic and clinical variables and 10 CAM modalities. Response frequencies to four questions assessing CAM use, consideration of use, disclosure, and perceived efficacy were calculated for each modality. Multivariable logistic regression analyses examined characteristics associated with responses to each question for the two most commonly used CAM modalities. Results. Participants' mean age was 15.8 (SD = 1.8), 60% were female and 85% were African-American. Seventy-one percent reported using CAM for symptom management in the past month. Relaxation (64%) and prayer (61%) were the most frequently reported modalities and were perceived to be the most efficacious. Adolescents most commonly reported considering using relaxation (85%) and prayer (80%) for future symptom management. Participants were most likely to disclose their use of yoga (59%) and diet (57%), and least likely to disclose prayer (33%) and guided imagery (36%) to providers. In multivariable analyses, older adolescents (OR = 1.27, p < .05) and African-Americans (OR = 2.76, p < .05) were more likely to use relaxation. Adolescents with more frequent asthma symptoms (OR = 0.98, p < .05) were more likely to use prayer. African-Americans were more likely to report using prayer (OR = 3.47, p < .05) and consider using prayer (OR = 7.98, p < .01) in the future for symptom management. Conclusions. Many urban adolescents used and would consider using CAM, specifically relaxation and prayer, for asthma symptom management. African-Americans, older adolescents, and those with more frequent symptoms were more likely to use and/or consider using CAM. Providers caring for urban adolescents with asthma should discuss CAM with patients, particularly those identified as likely to use CAM. Future studies should examine relationships between CAM use and health outcomes.     

Nocturnal Reflux in Children and Adolescents with Persistent Asthma and Gastroesophageal Reflux

Background. A higher frequency of nocturnal gastroesophageal reflux (GER) in adult patients with respiratory symptoms has been demonstrated. The aim of this study was to determine the prevalence of nocturnal GER by using prolonged intraesophageal pH monitoring and compare it with spirometry results in children with persistent asthma. Methods. Thirty-eight patients with persistent asthma for at least 2 years were studied. Gastrointestinal symptoms suggestive of GER were considered as regurgitation, heartburn, and abdominal pain. All patients underwent prolonged intraesophageal pH study and spirometry. GER was considered positive when a reflux index (RI) was higher than 5%. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), forced mid-expiratory flow rate (FEF_{25 ? 75%}), and FEV₁/FVC ratio were measured. Results. Median age was 10 years of age (range 5 to 15) and 58% were male; GER prevalence was 47.3%. Median (range) of reflux index during supine and upright periods from GER patients were, respectively, 8.7% (3.2 to 23.6) and 10.5% (5.2 to 15.0) (p = 0.913), and only FEF_{25 ? 75%} was below the predicted value: 54.5% (39.4 to 96.9). Reflux index was not significantly correlated with FVC, FEV₁ and FEF_{25 ? 75%}. Conclusions. A high prevalence of GER was found in children and adolescents with persistent asthma, equally distributed in the supine (nocturnal) and upright positions. There was no correlation with pulmonary function test.     

Managed Care and the Treatment of Asthma

Few diagnoses offer managed care more return for the investment than asthma. Physicians are beset by mandates to use more anti-inflammatory therapy, peak flow meters, spacer devices, and written step care plans. The managed care system offers the organization and resources to meet this challenge to support physicians on the front line. Economies of scale and computer data bases now make asthma care outcome measures available for evaluation and revision. The current review focuses on five areas for development of successful asthma intervention: (1) physician education, (2) the comanagement concept, (3) patient education, (4) cost-effectiveness, and (5) implementation.     

Severe Asthma in Primary Care: Identification and Management

Most patients with asthma are managed by primary care providers. Severe asthma is associated with substantial morbidity and health care resource use, and long-term sequelae of severe asthma include airway remodeling and a greater risk of developing chronic obstructive pulmonary disease. These consequences highlight the importance of early identification and improved management of patients with severe asthma. Although treatment guidelines can be confusing and it can be difficult to keep abreast of updates, routine assessments of lung function, frequency and severity of exacerbations, symptom control, and medication adherence in the primary care setting provide the necessary information for identifying severe asthma and determining appropriate management strategies. An increased understanding of asthma pathophysiology and its relationship to disease activity has identified therapeutic targets and associated biomarkers. Biologic therapies directed at these targets offer individualized targeted treatment of severe asthma. We review evidence-based guidelines for identification and management of severe asthma, clarify the relationship of asthma control and asthma severity, and provide an overview of new biologic therapies offering additional treatment options for patients with severe asthma.     

Effects of Coping-Skills Training in Low-Income Urban African-American Adolescents with Asthma

Background. Minority teens with asthma are at particular risk for this life-threatening disease due to increased morbidity and mortality rates in addition to the normal challenges of adolescence. Objective. The purpose of this randomized controlled trial (n = 137) was to determine the effects of a coping-skills training program (intervention) compared with standard asthma education (attention control) in African-American teens with asthma. Methods. Adolescents were recruited from five African-American dominant high schools serving low-income areas of Chicago. Data were collected at baseline, 2 months (immediately following the intervention), 6 months, and 12 months. Results. Both groups improved over time, with significant increases in asthma-related quality of life, asthma knowledge, and asthma self-efficacy, accompanied by decreases in symptom days and asthma-related school absences. Conclusions. Findings suggest that coping-skills training as implemented in this study provided no additional benefit beyond that experienced in the control group. However, group-based interventions delivered in the school setting may be beneficial for low-income, minority teens with asthma.