Obesity and Asthma Morbidity in a Community-Based Adult Cohort in a Large Urban Area: The Chicago Initiative to Raise Asthma Health Equity (CHIRAH)

Background. Urban minority populations experience increased rates of obesity and increased asthma prevalence and severity. Objective. The authors sought to determine whether obesity, as measured by body mass index (BMI), was associated with asthma quality of life or asthma-related emergency department (ED)/urgent care utilization in an urban, community-based sample of adults. Methods. This is a cross-sectional analysis of 352 adult subjects (age 30.9 ± 6.1, 77.8% females, forced expiratory volume in one second (FEV₁)% predicted = 87.0% ± 18.5%) with physician-diagnosed asthma from a community-based Chicago cohort. Outcome variables included the Juniper Asthma Quality of Life Questionnaire (AQLQ) scores and health care utilization in the previous 12 months. Bivariate tests were used as appropriate to assess the relationship between BMI or obesity status and asthma outcome variables. Multivariate regression analyses were performed to predict asthma outcomes, controlling for demographics, income, depression score, and β-agonist use. Results. One hundred ninety-one (54.3%) adults were obese (BMI > 30 kg/m²). Participants with a higher BMI were older (p = .008), African American (p < .001), female (p = .002), or from lower income households (p = .002). BMI was inversely related to overall AQLQ scores (r = ?.174, p = .001) as well as to individual domains. In multivariate models, BMI remained an independent predictor of AQLQ. Obese participants were more likely to have received ED/urgent care for asthma than nonobese subjects (odds ratio [OR] = 1.8, p = .036). Conclusions. In a community-based sample of urban asthmatic adults, obesity was related to worse asthma-specific quality of life and increased ED/urgent care utilization. However, compared to other variables measured such as depression, the contribution of obesity to lower AQLQ scores was relatively modest.     

Using Global Initiative for Asthma guidelines to assess asthma severity in populations.

The classification of asthmatics into severity categories is a crucial issue for assessing the asthma burden within a community, in which a proportion of patients is currently treated. There is no epidemiological method currently available. The Global Initiative for Asthma (GINA) was used to classify 4,362 patients aged 16-45 yrs (49% males, 42% taking inhaled corticosteroids), enrolled by 545 chest specialists in France with short standardized questionnaires including forced expiratory volume in one second (FEV1) measurements. Two independent GINA classifications were combined, one based only on symptoms and FEVI, and the other based only on current medication, to construct a final "symptom-FEV1 medication" classification. Almost 40% of the patients classed as step 1, 30% of those classed as step 2 and 13% of those classed as step 3 in the initial symptom-FEV1-classification, were allocated to categories of higher severity in the final classification. The approach was validated by showing that the proportions of: 1) patients considered by the physicians as having severe or moderately severe asthma; 2) patients with a history of hospital admission for asthma; and 3) patients with a history of emergency department visits for asthma, increased with severity steps in the final classification, for each step of the two initial independent classifications. The treatment manage plan in the Global Initiative for Asthma was not developed for assessing severity of asthma but rather to describe the recommended therapy for asthma with different severity. This is the first attempt to assess the severity of asthma in a large population of asthmatics mostly taking treatment, based on the Global Initiative for Asthma guidelines. The authors propose this simple and pragmatic procedure for a potential classification which should be put to the test in other studies.     

Night of the Sirens: Analysis of Carbon Monoxide-Detector Experience in Suburban Chicago

Study Objective: To determine the pattern and environmental causes of carbon monoxide (CO)–detector alarms. Methods: Data including time, location, detector manufacturer, CO measurements in the home, reported illness, cause, and actions taken were collected between July 15, 1994, and January 26, 1995, on all calls to 17 suburban Chicago fire departments for CO-detector alarms. We used univariate time-series analysis involving joint estimation of model parameters and outlier effects to analyze data and compared data on ambient CO levels from the Illinois Environmental Protection Agency to the number of calls per day. Results: During the study period, 777 calls for sounding CO detectors were made to the fire departments in question. The median number of calls per day was three. Our univariate time series identified 3 days with a significant excess of calls (December 12, 29 calls; December 21, 69; December 22, 128; P<.001). The average ambient CO readings on these days were 0.99, 3.25, and 3.89 ppm, respectively, compared with an overall mean of 0.8 ppm. In-home CO levels among all 828 measurements taken from the 777 domestic calls ranged from 0 to 425 ppm, 0 in 249 (30%), 1 to 10 in 340 (41%), 11 to 50 in 149 (18%), 51 to 100 in 22 (9%), and more than 100 in 11 (1.3%). No measurement was taken in six cases. Cause of alarm was listed as furnace in 25 cases, auto exhaust in 24, stove/oven in 22, poor location of detector in 14, water heater in 11, outside sources in 7, and multiple sources in 7. Other sources accounted for fewer than 1% each. The participating fire departments considered 242 cases (31%) to be false alarms. Cause was not determined in 400 calls (51%). In 37 calls (4.8%), people reported illness. Conclusion: Above-average ambient CO levels coincided with a significant increase in the number of calls and may have contributed to the triggering of CO alarms. [Bizovi KE, Leikin JB, Hryhorczuk DO, Frateschi LJ: Night of the sirens: Analysis of carbon monoxide–detector experience in suburban Chicago. Ann Emerg Med June 1998;31:737-740.]     

Asthma nurse practice--a resource-effective approach in asthma management.

The objective of this study was to evaluate the efficacy of an Asthma Nurse Practice (ANP) in primary health care. A 12-month (September 1994-August 1995) open, prospective intervention study with pre- and post-test comparisons was performed on patients with asthma treated at a primary care centre in Sweden. Sixty-three patients with mild or moderate asthma participated and medication, structured follow-up and education in self-management at an ANP were assessed over a 12-month period. The main outcome measures assessed were pulmonary function, eosinophil cationic protein (ECP) in serum, respiratory symptoms, patient knowledge of asthma and emergency visits. ANP in primary health care increased patient knowledge of asthma and medication. The number of patients with nocturnal symptoms decreased significantly. Pulmonary function was improved: vital capacity (VC) 98-106, forced expiratory volume in 1 sec (FEV1) 93-100 and peak expiratory flow (PEF) 98-115% of predicted (P < 0.001). Variation in PEF fell from 21 to 12% (P < 0.001). ECP was significantly reduced. Visits to the emergency room were 60% fewer during the year of intervention (P < 0.01). In conclusion, patients attending an Asthma Nurse Practice, comprising a structured programme for asthma management, improve their knowledge and asthma control.     

Asthma management and control in the United States: results of the 2009 Asthma Insight and Management survey

Past asthma surveys have shown suboptimal management and control of asthma in the United States. No major survey of asthma management has been conducted since the Third Expert Panel Report for the National Asthma Education and Prevention Program (NAEPP) guidelines on diagnosis and treatment of asthma (August 2007). This study was designed to report asthma management and control results from the Asthma Insight and Management survey of U.S. patients and physicians. A telephone-based survey was conducted during 2009 in 2500 patients with asthma, aged ≥12 years, and 309 physicians (104 allergists, 54 pulmonologists, 101 family practitioners, and 50 internists). Patients' asthma control perceptions (71% "completely controlled" or "well controlled") were inconsistent with their NAEPP control level as determined by self-reported symptoms (29% well controlled). Patients and physicians had low expectations for effective asthma management; patients considered asthma well managed if rescue medication was used three times per week (46%), urgent care visits occurred twice per year (67%), or emergency department visits occurred once per year (60%). Asthma-related syncope, seizure, intensive care unit admission, and intubation were associated with uncontrolled asthma based on NAEPP guidelines. Respiratory specialists (allergists/pulmonologists) implemented asthma management recommendations more than other physicians surveyed. However, only 22% of patients visited a specialist for usual asthma care and 48% had never visited a specialist. Despite detailed NAEPP guidance, asthma management and control in U.S. patients is unsatisfactory. Improved asthma control assessment (impairment and risk) and implementation of NAEPP management recommendations are needed to improve asthma control and outcomes.     

Rationale for the use of immunomodulatory therapies in the Global Initiative for Asthma (GINA) step V asthma other than oral glucocorticosteroids

Asthma is a major problem worldwide, which is estimated to affect 300 million individuals. The global prevalence ranges from 1% to 18% of the population. The incidence, morbidity and mortality of the condition have increased over the last 50 years despite the development of new anti‐asthmatic drugs. Fewer than 1% of the asthmatic population are steroid‐dependent, but these patients consume most of the resources and time at asthma units. The consensus documents published by professional societies all support a stepwise therapeutic approach for asthma. However, patients who require frequent or continuous oral corticosteroid administration have received little attention. Due to the severe side‐effects of oral corticosteroids when administered over long periods or at high doses, many drugs have been assessed in the search for a possible corticosteroid‐sparing agent. Recently, the update of the Global Initiative for Asthma (GINA) introduced a new drug – omalizumab – as an alternative to oral corticosteroids in patients included in step V. Other alternatives include immunosuppressive drugs, among which methotrexate has been found to offer the best benefit/risk ratio. This paper will review, comment and criticize the evidence of the effectiveness of immunomodulatory drugs, as an alternative to oral glucocorticosteroid treatment in GINA step V asthma patients. The experience of the authors combined with the information of the literature will lead to the conclusion that methotrexate and omalizumab are the only advisable drugs and will clarify when and how these drugs should be used.     

Towards Excellence in Asthma Management: Final report of an eight-year program aimed at reducing care gaps in asthma management in Quebec

BACKGROUND AND OBJECTIVES:

Asthma care in Canada and around the world persistently falls short of optimal treatment. To optimize care, a systematic approach to identifying such shortfalls or ‘care gaps’, in which all stakeholders of the health care system (including patients) are involved, was proposed.

METHODS:

Several projects of a multipartner, multidisciplinary disease management program, developed to optimize asthma care in Quebec, was conducted in a period of eight years. First, two population maps were produced to identify regional variations in asthma-related morbidity and to prioritize interventions for improving treatment. Second, current care was evaluated in a physician-patient cohort, confirming the many care gaps in asthma management. Third, two series of peer-reviewed outcome studies, targeting high-risk populations and specific asthma care gaps, were conducted. Finally, a process to integrate the best interventions into the health care system and an agenda for further research on optimal asthma management were proposed.

RESULTS:

Key observations from these studies included the identification of specific patterns of noncompliance in using inhaled corticosteroids, the failure of increased access to spirometry in asthma education centres to increase the number of education referrals, the transient improvement in educational abilities of nurses involved with an asthma hotline telephone service, and the beneficial effects of practice tools aimed at facilitating the assessment of asthma control and treatment needs by general practitioners.

CONCLUSIONS:

Disease management programs such as Towards Excellence in Asthma Management can provide valuable information on optimal strategies for improving treatment of asthma and other chronic diseases by identifying care gaps, improving guidelines implementation and optimizing care.     

Recruitment of Participants in the Childhood Asthma Management Program (CAMP). I. Description of Methods

The Childhood Asthma Management Program (CAMP), a multicenter clinical trial sponsored by the Division of Lung Diseases of the National Heart, Lung, and Blood Institute (NHLBI), is the largest outcome study of mild to moderate asthma in children to be undertaken, with eight clinical centers in the United States and Canada participating. The initial recruitment goal was 960 children within an 18-month recruitment period. Recruitment was extended to 23 months, with 1041 children randomized from late December, 1993, to early September, 1995. In this time interval each of the eight centers met the recruitment goal of 120 using a variety of self-selected recruitment strategies. The goal for minority recruiting was 33%, or 320 of the planned 960 children to be recruited. CAMP achieved the overall goal for the number of minorities, with 330 patients. Three centers recruited at or above the expected rate from the beginning. The other five centers had significant delays in recruitment. Examination of the recruitment experiences of the centers with and without delays did not indicate any single recruitment strategy that was certain to be successful. The most commonly cited factors for success were a cohesive staff, endorsement of participation by the child's primary care provider, and ability of the staff to be flexible and honest in assessing progress and the value of recruiting methods being used.     

The Regional Asthma Disease Management Program (RADMP) for low income underserved children in rural western North Carolina: a National Asthma Control Initiative Demonstration Project

Background: A substantial proportion of low-income children with asthma living in rural western North Carolina have suboptimal asthma management. To address the needs of these underserved children, we developed and implemented the Regional Asthma Disease Management Program (RADMP); RADMP was selected as one of 13 demonstration projects for the National Asthma Control Initiative (NACI). Methods: This observational intervention was conducted from 2009 to 2011 in 20 rural counties and the Eastern Band Cherokee Indian Reservation in western North Carolina. Community and individual intervention components included asthma education in-services and environmental assessments/remediation. The individual intervention also included clinical assessment and management. Results: Environmental remediation was conducted in 13 childcare facilities and 50 homes; over 259 administrative staff received asthma education. Fifty children with mild to severe persistent asthma were followed for up to 2 years; 76% were enrolled in Medicaid. From 12-month pre-intervention to 12-month post-intervention, the total number of asthma-related emergency department (ED) visits decreased from 158 to 4 and hospital admissions from 62 to 1 (p?<?0.0001). From baseline to intervention completion, lung function FVC, FEV1, FEF 25–75 increased by 7.2%, 13.2% and 21.1%, respectively (all p?<?0.001), and average school absences dropped from 17 to 8.8 days. Healthcare cost avoided 12 months post-intervention were approximately $882?021. Conclusion: The RADMP program resulted in decreased ED visits, hospitalizations, school absences and improved lung function and eNO. This was the first NACI demonstration project to show substantial improvements in healthcare utilization and clinical outcomes among rural asthmatic children.     

Asthma on the job: work-related factors in new-onset asthma and in exacerbations of pre-existing asthma

Occupational asthma (OA) can be defined as variable airways narrowing causally related to exposure in the working environment to airborne dusts, gases, vapours or fumes. There are many agents in the work-place that can induce asthma or cause substantial deterioration in pre-existing asthma. It has been estimated that 5-15% of adult-onset asthma can be attributed to occupational exposures. Hence adult patients, especially those with new-onset asthma, must be investigated with regard to occupational risk factors for disease. The prognosis for OA is improved if the causal exposure is controlled either by controlling the exposure at the workplace or by moving the patient out of the workplace.