Effects of pediatric asthma care coordination in underserved communities on parent perceptions of care and asthma-management confidence

Objective: Disparities by race and socioeconomic status persist in pediatric asthma morbidity, mortality, and treatment. Improving parent/provider communication and parents' asthma-management confidence may result in better asthma control in vulnerable populations. The Merck Childhood Asthma Network, Inc. funded an initiative to implement medical-social care coordination to improve asthma outcomes at sites in four low-income, urban communities (Los Angeles, CA; Philadelphia, PA; Chicago, IL; and San Juan, PR.) As part of a cross-site evaluation of this effort, pre- post-program changes in parents' reports of asthma care and management were assessed. Methods: Across sites, 805 parents or other caregivers responded to a baseline survey that was repeated one year later following their child's participation in care coordination. Parents' asthma-management confidence, as well as their perceptions of provider access, trust, and communication, were measured with Likert scales. Linear mixed models were used to assess improvement in these variables, across and within sites, adjusting for sociodemographics. Results: Pooled across sites, the adjusted mean estimate for all outcomes showed a significant improvement (p <.05) from baseline to follow-up. Knowledge and Between-Provider Communication improved significantly (p <.05) within all four sites; Access improved significantly in Chicago, Philadelphia, and Puerto Rico; Trust improved significantly in Chicago, Los Angeles, and Philadelphia; and Patient-Provider Communication improved significantly in Philadelphia only. Conclusion: Pediatric asthma care coordination, as implemented variously in diverse settings, was associated with improvement in parents' perceptions of asthma care and self-reported asthma-management knowledge and confidence. This positive impact on parents may help sustain care coordination's impact on children.     

The Role of Caregivers' Depressive Symptoms and Asthma Beliefs on Asthma Outcomes Among Low-income Puerto Rican Children

Objective. To examine the relationship between depressive symptoms and asthma beliefs (self-efficacy and empowerment), child asthma outcomes, and caregiver's quality of life among Puerto Rican caregivers of children with asthma. Methods. The caregivers of 221 children with persistent bronchial asthma were stratified into those with no/low or high levels of depressive symptoms. Differences between the groups in caregiver self-efficacy, family empowerment, child asthma outcomes, and quality of life were examined. Results. Caregivers with more depressive symptoms reported lower self-efficacy, less empowerment, less symptom-free days and nights for their children, and a lower quality of life compared to caregivers with no or fewer depressive symptoms. Conclusions. Depressive symptoms among Puerto Rican caregivers were associated with asthma beliefs, children's asthma symptoms, and caregiver quality of life. Our findings reinforce the importance of physician screening skills in recognizing caregiver depression in parents of asthma patients.     

School‐Based Asthma Disease Management

Background. Asthma is the most common chronic childhood illness and the leading cause of missed school days. School is a potential location for establishing an asthma education program for children and their parents/caregivers designed to improve disease management. Objective. To determine whether a comprehensive, school‐based asthma management program, in addition to a conventional disease management program, can reduce measures of asthma control, student absenteeism, and caregiver lost workdays. Methods. School nurses recruited parents/caregivers of students with asthma from three urban elementary and middle schools. Children were identified as having asthma by a previous diagnosis from their personal physician. Parents were invited to attend educational sessions about the program. Students received peak flow meters and training in their use and had access to an interactive asthma diary to record symptoms, peak flow, and medicine usage. They received monthly asthma education at school and had access to an online asthma education program and additional handouts. Parents received several educational calls regarding asthma and had a 24‐hour, 7‐days‐a‐week emergency number to call if problems arose. Results. At 6 months, missed school days and unscheduled doctor visits were reduced by two thirds (n = 41; p < 0.01 for each). Caregivers' perception of children's activity level increased by 11% (n = 26; p = 0.037). Daytime and nighttime frequency of symptoms dropped by 62% and 34%, respectively (n = 32; p < 0.007 and p < 0.03 for each). These trends continued at 12 months, although only reduction in frequency of symptoms attained statistical significance. Conclusions. A comprehensive, school‐based asthma management program can successfully improve asthma control and reduce absenteeism in elementary and middle school students and caregiver lost workdays.     

Relationship Among Coping Strategies,Quality of Life,and Anxiety and Depressive Disorders in Hemodialysis Patients

Patients with hemodialysis face many physical and emotional stressors; yet little is known regarding coping strategies and their effects on patients' quality of life (QOL) and anxiety and depressive disorders. A total of 117 patients were enrolled in this cross‐sectional study between October 2016 and April 2017. This study assessed QOL (Medical outcome short form 36—MOS 36), coping (Assessment Scale for Coping Attitudes—COPE) and psychiatric comorbidities in hemodialysis patients. Beck Depression Scale and Beck Anxiety Scale were also applied. Differences between groups were evaluated using Student's t‐tests and anova . Correlations among parameters were performed. Patients with any depressive disorder (22.2%, n = 26) and patients with any anxiety disorder (19.6%, n = 23) reported more impaired QOL. The most frequently used coping strategy in all patients was religious coping. Use of instrumental social support, humor, and positive reinterpretation scores were lower in patients with any depressive disorder (P = 0.009, P = 0.034, P = 0.047).The total score of emotion‐focused coping strategies was lower with patients with any depressive disorder (P = 0.021) and emotion‐focused coping strategies were positively correlated with QOL scores. Younger age and longer duration of hemodialysis have significant negative correlation with emotion‐focused coping strategies' total score (P = 0.01, P = 0.02). Patients with hemodialysis use variety of coping strategies. The use of emotion‐focused coping was associated with better QOL and reducing the risk of depressive disorder. Interventions to facilitate the use of adaptive coping strategies may improve patients' QOL and mood.     

Primary juvenile fibromyalgia. Psychological adjustment,family functioning,coping, and functional disability

Objectives. 1) To determine the importance of psychological adjustment and family functioning in primary juvenile fibromyalgia by assessing these factors in children with fibromyalgia and in their parents, compared with children with juvenile rheumatoid arthritis (JRA) and with pain-free control children and their parents. 2) To examine which of these factors predict functional disability. Methods. Fifteen children in each of the 3 study groups, and their parents, completed self-report questionnaires and pain diaries. A medical evaluation of each child was performed, including assessment of tender points by palpation and by dolorimetry. Results. All children in the fibromyalgia group met the Yunus and Masi criteria for fibromyalgia, and 11 met the American College of Rheumatology criteria. There were almost no significant group differences in the children's or parents' psychological adjustment, ratings of family functioning, or coping strategies. Significant group differences in functional disability, pain, fatigue, tender point threshold, and control point tolerance were found. A number of the psychological adjustment, pain, fatigue, and coping variables were significantly associated with functional disability. Conclusion. The notion that fibromyalgia is a psychogenic condition is not supported by these results. Fibromyalgia is associated with disability of a magnitude comparable to that of other chronic pain conditions. Disability among children with fibromyalgia or JRA is a function of the children's psychological adjustment and physical state, and of the parents' physical state and method of coping with pain.     

Urban Minority Children with Asthma: Substantial Morbidity,Compromised Quality and Access to Specialists,and the Importance of Poverty and Specialty Care

Background. Asthma disproportionately affects minorities, but not enough is known about morbidity and specialist access in asthmatic minority children. Objective. To examine asthma morbidity and access to specialty care in urban minority children. Methods. A consecutive series was recruited in 2004–2007 of urban minority children 2 to 18 years old seen for asthma in four emergency departments (EDs) or admitted to a children's hospital. Outcomes assessed included asthma symptom and attack frequency; missed school and parental work; asthma ED visits and hospitalizations; severity of illness; and asthma specialty care. Results. Of 648 children assessed, 220 were eligible. The mean age was 7 years; 68% were poor, 83% had Medicaid, 84% were African-American, and 16% were Latino. Sixty-eight percent of children were not in excellent/very good health, 73% had persistent asthma (moderate/severe = 52%), and only 44% had asthma care plans. The mean number of asthma attacks in the past year was 12, and of monthly daytime and nighttime asthma symptoms, is 12 and 12, respectively. The mean annual number of asthma doctor visits was 6; of ED asthma visits, 3; hospitalizations, 1; missed school days, 7; and missed parent work days, 6. Eighty-three percent of children have no asthma specialist, and 62% use EDs as the usual asthma care source. Poor children were less likely than the non-poor to have asthma specialists (13 vs. 26%; p < 0.03). African-Americans were more likely than Latinos to use EDs for usual asthma care (68% vs. 44%; p < 0.01). In multivariable analyses, poverty was associated with greater odds and having an asthma care plan with lower odds of an asthma attack in the past year; poverty also was associated with half the odds of having an asthma specialist. African-American children were significantly more likely to report the ED as the usual source of asthma care, and having an asthma specialist and male gender were associated with greater odds of having an asthma care plan. Conclusions. Urban minority children with asthma average 1 asthma symptom daily, 1 exacerbation monthly, and 7 missed school days, 6 missed parental work days, 3 ED visits, and 1 hospitalization yearly; most receive their usual asthma care in EDs and have no asthma care plan or asthma specialist. Urban minority asthmatic children need interventions to reduce morbidity and improve access to specialists and asthma care plans, especially among the poor and African-Americans.     

The Yes We Can Urban Asthma Partnership: A Medical/Social Model for Childhood Asthma Management

Pediatric asthma programs have struggled to integrate children's medical and social needs. We developed and piloted an integrated team model for asthma care for low-income children through the Yes We Can Urban Asthma Partnership. Program evaluation demonstrated increases in prescribing controller medications (p <0.05), use of action plans (p<0.001), and the use of mattress covers (p<0.001); and decrease in asthma symptoms (p<0.01). Additional changes occurred within the local system of asthma care to support ongoing efforts to improve asthma management. We conclude that pediatric asthma programs can effectively target the social and medical needs of children in a sustainable manner.     

Evidence-based pediatric asthma interventions and outcome measures in a healthy homes program: An integrative review

Objective: Asthma disproportionately impacts and has poorer outcomes in low-income, minority, and inner-city children. The home environment has a profound impact on a child's asthma. Home-based asthma visits have the potential to positively impact a child's asthma, especially in targeted populations. The purpose of this integrative review is 1.) to explore the effectiveness of home-based education and environmental measures and 2.) to explore specific indicators and tools to measure pediatric asthma control and program effectiveness. Data Sources: Medline, CINHAL, and Ovid databases were searched from 2010 to 2017 utilizing the keywords healthy homes AND asthma and home based interventions AND asthma. Study Selections: A total of 71 articles were retrieved of which 27 articles met the inclusion criteria of English language, human subjects, and the inclusion of pediatric populations. Three additional articles were hand-searched from previous references. In total, 30 articles were reviewed. A quality appraisal was conducted utilizing standardized appraisal tools. Results: Home-based asthma education and environmental interventions have proven to be effective. The programs reviewed varied in types of interventions, intensity and duration, the type of provider, length of follow-up, and outcome measures. Successful programs were patient-centered, included a home assessment and individualized education and interventions, and were collaborative. Multiple outcome indicators such as health care utilization, asthma control, missed days of school or productivity, asthma symptoms, and verification of environmental remediation have been utilized. Conclusion: Home-based asthma programs can be beneficial to children with poorly controlled asthma and have the potential to be cost-effective.     

Prevalence,Demographics, and Health Outcomes of Comorbid Asthma and Overweight in Urban Children

Background. Asthma and overweight are epidemic in urban children but the relationship between these conditions is not fully understood. This study presents demographic and risk profiles of comorbidity for overweight asthmatic children, characterizes morbidity by comparing health outcomes among overweight asthmatics and healthy weight asthmatics, and examines socioeconomic factors associated with comorbidity. Objective. To construct a demographic profile of overweight asthmatic children in an urban setting and identify factors that contribute to prevalence. Method. Cross-sectional study of 5250 children in New York City public elementary schools using a parent-report questionnaire on body mass index, socioeconomic status, asthma, and asthma-related outcomes. Results. Prevalence of overweight (body mass index ≥ 85th percentile for age and gender) was 50.9%. The prevalence of overweight and ever being diagnosed with asthma was 10.9%. The prevalence of overweight with current asthma was 6.2%. Overweight current asthmatics had more night symptoms, missed school days, and asthma medication use than healthy weight asthmatics. Almost 50% of overweight current asthmatic children reported emergency department visits for asthma compared with 30% of healthy weight asthmatics. Comorbidity was most prevalent among males, Latinos, and children in low-income households, with the highest prevalence among Puerto Ricans. In multivariate analysis stratified by gender, the most significant factors associated with comorbidity among girls were low income and minority race/ethnicity, while among boys significant factors were parental education and parental history of asthma. Interestingly, there were few underweight children (7.8%) but they had high prevalence of asthma (13.8%). Conclusions. The comorbidity of overweight and asthma has a large impact on urban populations, causing greater disease burden than asthma alone. Overweight asthmatics show more uncontrolled asthma, evidenced by emergency department visits, quick-relief medication use, and days with asthma symptoms. The relationship between socioeconomic factors and the asthma–obesity comorbidity may vary by gender and requires further study to identify successful interventions to reduce disease in children.     

Peak Flow Measurements in Children with Asthma: What Happens at School?

Background. Self-monitoring of symptoms or peak flow monitoring (PFM) is recommended for all asthma patients and is commonly included in asthma management plans. Limited data are available documenting PFM outcomes in school settings. Method. Three hundred twenty-three urban children with persistent asthma were enrolled in a school-based study that implemented an internet-based asthma monitoring and data collection system. The mean age of the children was 10.0 (SD 2.1) years; 57% were male and 91% were African American. Children logged in daily to an internet-based program to record their asthma symptoms and PFM reading. Teachers logged in daily to confirm the PFM readings. School staff responsible for student health reported actions taken for low PFM readings. Results. A total of 12,245 child reports were completed; 98% (n = 11,974) had corresponding teacher reports, confirming the peak flow meter readings reported by the children. The prevalence of reported asthma symptoms varied across PFM readings; the highest prevalence occurred in the setting of red zone readings, with intermediate prevalence in the setting of yellow zone readings, and lowest prevalence in the setting of green zone readings. The actions reported in response to children's symptoms and peak flow results similarly varied; however, instances of no action were reported in the setting of yellow and red zone readings. When comparing the “worst days” of children who had ever had a red or yellow PFM reading with those of children who only had exhibited green, there was a nonsignificant trend toward fewer symptoms in the green-only group. Additionally, there was a nonsignificant trend toward a greater likelihood of being sent to the office or school nurse with greater symptoms in the setting of a yellow or red zone reading. Conclusions. On the whole, peak flow readings tended to correspond to asthma disease activity. However, the data indicate that school staff may be more inclined to take action based on their own perceptions of a child's asthma or respond to children's subjective reports of asthma symptoms rather than using a more objective measure of disease activity provided by a peak flow meter.     

Psychological, Academic, and Work Functioning in College Students with Childhood-Onset Asthma

This study investigated differences in psychological, academic, and work functioning between college students with and without asthma and identified predictors of functioning. Both participants with asthma (n = 121) and age-and gender-matched healthy control subjects (n = 121) completed measures of psychological distress, provided information on missed school and work days, and consented to have their grade point averages released from the registrar. College students with asthma also completed measures of illness uncertainty and illness intrusiveness. Participants with asthma reported greater anxiety, general psychological distress, and more missed school and work days compared to healthy control subjects. Within the asthma group, both illness uncertainty and illness intrusiveness independently predicted anxious and depressive symptoms and general psychological distress; illness intrusiveness also predicted missed school days. Although enrollment in college implies resilient functioning, college students with asthma remain at risk for problems with psychological and academic functioning.     

Enrolling Adolescents in Asthma Research: Adolescent,Parent, and Physician Influence in the Decision-making Process

Background. The factors influencing family decisions to participate in adolescent asthma research are not well understood. Legal and ethical imperatives require adolescent research participation to be voluntary. While parents and adolescents often agree about research decisions, disagreements may also occur with relative frequency. Physician recommendations are also known to influence research participation decisions. Little attention has been given to how these dynamics may affect adolescents' involvement in decisions to participate in research. Objective. To examine the influence of family and physician-investigator relationships and recommendations on adolescent asthma clinical research participation decisions. Methods. A statewide community sample of 111 adolescents 11 to 17 years of age, with a diagnosis of asthma, and their parents participated in this study. Adolescents received a medical evaluation from an asthma specialist and then the family was offered participation in a hypothetical asthma clinical trial. By random assignment, the research study was presented by either the same or an unknown asthma specialist, and half the families in each group also received affirmative recommendations from the asthma specialist to participate in the hypothetical asthma clinical trial. Parents and adolescents made initial private decisions about participating in the trial. Then, following a family discussion of the clinical trial, a final research participation decision was made. Results. Thirty-three percent of parents and adolescents initially disagreed about the research participation decision. When disagreements occurred, final decisions followed the parents' initial views except when the physician-investigator was known and a recommendation was made. Families with initial disagreement about participating were less likely to enroll when the investigator was unknown or when no recommendation was made. Adolescents who initially disagreed with parents' views were less likely to concur with the final research participation decision, felt less comfortable, and were less likely to feel they influenced the decision. Conclusions. Parents' views on research decisions take precedence over adolescents' views in most circumstances. Physician-investigator relationships may reduce parental resistance to participation and enhance adolescent decision-making autonomy when research participation is desired by the adolescent.     

The national burden of poorly controlled asthma,school absence and parental work loss among school-aged children in the United States

Objective: The degree of poorly controlled asthma and its association with missed school days and parental missed work days is not well understood. Methods: This was a retrospective analysis of missed school days and missed work days for school-aged children (SAC; aged 6–17) and their caregivers in the nationally representative 2007–2013 Medical Expenditure Panel Survey (MEPS). Indicators of poor asthma control included: exacerbation in previous 12 months; use of >3 canisters of short-acting beta agonist (SABA) in 3 months; and annual asthma-specific (AS) Emergency Department (ED) or inpatient (IP) visits. Negative binomial regression was used for missed school days, and a Heckman two-step selection model was used for missed work days. All analyses controlled for sociodemographics and other covariates. Results: There were 44,320 SAC in MEPS, of whom 5,890 had asthma. SAC with asthma and an indicator of poor control missed more school days than SAC without asthma: exacerbation (1.8 times more; p < 0.001); >3 canisters SABA (2.7 times more; p < 0.001) and ED/IP visit (3.8 times more; p < 0.001). The parents/caregivers of SAC with asthma and an exacerbation missed 1.2 times more work days (p < 0.05), while those with SAC with asthma and an ED/IP visit missed 1.8 times more work days (p < 0.01) than the parents of SAC without asthma. Conclusions: This study provides evidence of the significant national burden of poorly controlled asthma due to missed school and work days in the United States. More effective and creative asthma management strategies, with collaboration across clinical, community and school-based outreach, may help address this burden.     

Assessing health outcomes,quality of life,and healthcare use among school-age children with asthma

Objective: Asthma affects six million children in the United States. Most people can control their asthma symptoms with effective care, management, and appropriate medical treatment. Information on the relationship between asthma control and quality of life indicators and health care use among school-age children is limited. Methods: Using the 2006–2010 combined Behavior Risk Factor Surveillance System Asthma Call-back Survey child data, we examined asthma control and asthma attack status among school-age (aged 5–17 years) children with asthma from 35 states and the District of Columbia. Multivariable logistic regression models were used to assess if having uncontrolled asthma and having ≥1 asthma attacks affect quality of life (activity limitation and missed school days) and healthcare use (emergency department [ED] visits and hospitalizations). Results: About one-third (36.5%) of the 8,484 respondents with current asthma had uncontrolled asthma and 56.8% reported ≥1 asthma attack in the past year. Having uncontrolled asthma and having ≥1 asthma attack were significantly associated with activity limitation (aPR = 1.43 and 1.74, respectively), missed school (1.45 and 1.68), ED visits (2.05 and 4.78), and hospitalizations (2.38 and 3.64). Long-term control (LTC) medication use was higher among respondents with uncontrolled asthma (61.3%) than respondents with well-controlled asthma (33.5%). Conclusions: Having uncontrolled asthma is associated with reduced quality of life and increased health care use. However, only 61.3% of respondents with uncontrolled asthma use LTC medications. Increasing use of LTC medications among children with uncontrolled asthma could help improve quality of life and reduce health care use.     

In-school asthma management and physical activity: children’s perspectives

Objective: Regular physical activity (PA) is an important component of pediatric asthma management. No studies have examined how in-school asthma management influences PA from children’s perspectives. The aim of this study was to explore children’s perceptions of the impact of in-school asthma management on PA. Methods: Qualitative interviews with 23 inner-city minority children with asthma (aged 8–10 yrs; 12 girls, 11 boys) were conducted in 10 Bronx, New York elementary schools. Sampling continued until saturation was reached. Interviews were recorded, transcribed and independently coded for common themes. Results: Interviews produced five themes representing students’ perceptions about (1) asthma symptoms during in-school PA; (2) methods to control asthma episodes during school PA; (3) methods to prevent asthma episodes during school; (4) limited accessibility of asthma medications; and (5) negative feelings about asthma and medication use. The majority of students experienced asthma symptoms while performing PA during school. Primary methods of managing asthma symptoms were sitting out during activity, drinking water, and visiting the nurse. Students lacked awareness or adherence to action plans to prevent or control asthma. Students reported limited access to medication during school and feelings of embarrassment and/or concerns of teasing when medicating in front of others. Conclusions: Our results indicate inappropriate in-school management of asthma symptoms, poor asthma control, lack of accessible medication, and stigma around publicly using asthma medication. Thus, students often missed or were withheld from PA. Interventions to improve in-school asthma care must consider ways to address these issues.     

Factors associated with depressive symptoms in uncontrolled asthmatics

Rationale: Recent epidemiological data indicate that approximately 6.7% of US adults suffer from depression in any given year. The purpose of the study is to identify factors associated with depressive symptoms in a large diverse group of patients with poorly controlled asthma. The factors include quality of life (QOL), lung function, asthma knowledge, attitudes, self-efficacy, symptoms and control of disease. Methods: Baseline characteristics of a cohort of 599 subjects with asthma recruited from twenty Asthma Clinical Research Centers across the United States were examined. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to stratify subjects into those with depressive symptoms (CES-D score ≥ 16) and those without depressive symptoms (CES-D < 16). Bivariate statistics were used to compare the two groups; additionally, logistic regression was used to determine factors that have the greatest association with depressive symptoms. Results: Subjects with depressive symptoms had significantly lower QOL scores and less knowledge about their disease than subjects with no depression; however, lung function (FEV1%) and asthma control were not significantly associated with depressive symptoms in the logistic regression analysis. Subjects who were non-white had lower household income, high school diploma or less, and those who were unemployed or disabled had significantly higher scores for depressive symptoms. Conclusion: Subjects with depressive symptoms have significantly less knowledge of their disease and poorer QOL compared to those without depressive symptoms. Evaluating depressive symptoms in subjects with asthma will provide a more complete picture of their overall condition. The role of asthma education on depressive symptoms in this population needs to be further investigated. The effect of QOL on treating depression in asthma patients also needs to be studied.     

Elevated Asthma and Indoor Environmental Exposures Among Puerto Rican Children of East Harlem

Objective. East Harlem in New York City, a community with a large Puerto Rican population, has among the highest rates of asthma hospitalizations and mortality in the United States, but it is not known if the high rates are related to the ethnic composition, environmental or community factors, or if the higher rates reflect differentials in access to appropriate asthma care. A survey was conducted to: (a) estimate the prevalence of current asthma by ethnicity among school-age children, (b) assess indoor environmental risk factors for childhood asthma, and (c) assess health care utilization and school absences associated with childhood asthma. Design.?A cross-sectional survey of parents of elementary school children, using a self-administered questionnaire with a 12-month recall on asthma symptoms based on the International Study of Asthma and Allergies in Childhood. Setting.?Two public elementary schools in East Harlem (n = 1615 students 5–12 years of age). Results.?Among the 1319 respondents (response rate 82%), the prevalence for current asthma (doctor or nurse diagnosis at any time plus wheezing in the past 12 months) was 23%. Puerto Rican children had a prevalence of 35%. Puerto Rican children reported both higher symptomatic frequencies and higher rates of physician diagnosis. Living in a home where cockroaches, rats, or mice had been seen in the past month and with a dust-enhancing heating system also was associated with having asthma, regardless of ethnicity. Compared with other children with asthma, Puerto Rican children with asthma were more likely to live in homes where rats or mice had been seen in the past month. Regardless of ethnicity, children with more frequent, more severe asthma symptoms and incomplete asthma action plans were more likely to have visited the emergency department in the past year. Puerto Rican children were more likely to have missed school because of their asthma in the past year. Conclusion.?The prevalence of current asthma was significantly higher among Puerto Ricans, who had higher symptomatic frequency and greater diagnosis rates. Although all children with asthma in the East Harlem study appear to be sensitive to selected indoor environmental risk factors, only Puerto Rican children with asthma appear to be sensitive to the presence of rodents in their buildings. However, their higher school absence rate suggests problems with routine asthma management that could be addressed by improved medical management, programs to help parents manage their children's asthma, or school staff assistance with medications.     

Depressive symptomatology,quality of life and disease control among individuals with well-characterized severe asthma

Abstract

Objectives: A thorough examination of the relationship of asthma severity and control with symptoms of depression is needed to identify groups of asthmatics at high risk for poor disease control outcomes. This study examines the relationship of symptoms of depression with severity and control in a well-characterized cohort of asthmatics and healthy controls. Methods: Depressive symptoms and quality of life were assessed using the Beck Depression Inventory. Disease control was measured by a composite index incorporating symptoms, activity limitation and rescue medication use. Results: Individuals with asthma (n?=?91) reported more symptoms of depression than controls (n?=?36; p?<?0.001). Those with severe asthma (n?=?49) reported more symptoms of depression (p?=?0.002) and poorer asthma control (p?<?0.0001) than those with not severe asthma. Worse asthma control was associated with more depressive symptoms in severe (r?=?0.46, p?=?0.002) but not in not severe (r?=?0.13, p?=?0.40) asthmatics. The relationship of symptoms of depression among severe asthmatics was attenuated by disease control. Exploratory analyses identified specific disease symptom characteristics, as opposed to exacerbations, as associated with symptoms of depression. Conclusions: Among individuals with severe asthma, increased symptom burden is positively associated with risk for co-morbid depression. These findings point to a need for regular mood disorder screenings and treatment referrals among this group. Further research is warranted to examine whether treatment of comorbid depression improves treatment adherence and asthma-related quality of life.     

A missed primary care appointment correlates with a subsequent emergency department visit among children with asthma

Objective: Since the Affordable Care Act's implementation, emergency department (ED) visits have increased. Poor asthma control increases the risk of acute exacerbations and preventable ED visits. The Centers for Medicare and Medicaid Services support the reduction of preventable ED visits to reduce healthcare spending. Implementation of interventions to avoid preventable ED visits has become a priority for many healthcare systems yet little data exist examining children's missed asthma management primary care (PC) appointments and subsequent ED visits. Methods: Longitudinal, retrospective review at a children's hospital was conducted for children with diagnosed asthma (ICD-9 493.xx), ages 2–18 years, scheduled for a PC visit between January 1, 2010, and June 30, 2012 (N = 3895). Records were cross-referenced with all asthma-related ED visits from January 1, 2010 to December 31, 2012. Logistic regression with maximum likelihood estimation was conducted. Results: None of the children who completed a PC appointment experienced an ED visit in the subsequent 6 months whereas 2.7% of those with missed PC appointments had an ED visit (χ² = 64.28, p <.0001). Males were significantly more likely to have an ED visit following a missed PC appointment than females (χ² = 34.37, p <.0001). There was a statistically significant interaction of sex × age. Younger children (<12 years) made more visits than older children. Conclusions: The importance of adherence to PC appointments for children with asthma as one mechanism for preventing ED visits was demonstrated. Interventions targeting missed visits could decrease asthma-related morbidity, preventable ED visits, and healthcare costs.     

Attention Deficit and Hyperactivity Symptoms in Children with Asthma

Background. Asthma that is chronic may influence children's behavioral health and quality of life (QoL) negatively. Objective. To evaluate the frequency of attention deficit and hyperactivity symptoms in children with asthma and to determine if these symptoms are associated with a deterioration of QoL. Methods. Mothers of 62 children with moderate asthma and those of 38 healthy children aged between 7–12 years were included in the study. Conners' Parent Rating Scale-48 (CPRS), a 48-item multiple-choice questionnaire, was completed by the mothers to identify attention deficit and hyperactivity symptoms in children. The Pediatric Asthma Quality of Life Questionnaire (PAQLQ) was filled in by children to measure QoL. Results. Mean age was 9.2 ± 1.5 years for asthmatic children (37 male, 25 female) and 10.1 ± 1.3 years for control group (20 male, 18 female). The two groups were similar regarding age and sex. Attention deficit score in the asthma group was significantly higher than that in the control group (p = 0.01). The frequency of hyperactivity was higher in the asthmatic group but the difference between the groups was not significant (p = 0.36). Attention deficit and hyperactivity scores of Conners-P were not correlated with PAQLQ scores (regarding total, activity, emotional and symptom domains). Conclusion. Increased rates of attention deficit symptoms in children with asthma, as reported by mothers, might reflect the negative impact of asthma on neurobehavioral health. Asthmatic children, especially the ones who display attention deficit symptoms, must be considered for further evaluation regarding attention deficit hyperactivity disorder.