Relationship of medical home quality with school engagement and after-school participation among children with asthma

Objectives: To examine the relationship between medical home quality and measures of daily life experiences among children with asthma. Methods: A nationally representative sample of children from the 2007 National Survey of Children's Health (NSCH), aged 6–17 years (n = 6357), who have asthma was used to assess the relationship of a quality medical home and its features with their daily life experiences. Five medical home features – access, continuity, comprehensiveness, family-centered care, and coordination of care – were examined individually and in total in relation to measures of school engagement (missed school days, parents contacted about problems with the child, repeating a grade since kindergarten) and after-school activity participation (physical activity, sports participation, and community service or volunteer work). Results: Before and after adjustment for personal characteristics, health insurance status, family environment, neighborhood variables, and asthma severity, total medical home score was associated with more days exercised [beta (B) = 0.10, p < .05] and a greater likelihood of having performed community service or volunteer work [odds ratio (OR) = 1.16, CI: 1.02–1.31]. Additionally, the medical home features of access, comprehensiveness, and family-centered care remained favorably associated with three of the six measures of school engagement and after-school activity participation, even after adjustment. Conclusion: Medical home quality – particularly the features of access, comprehensiveness, and family-centered care – is positively associated with the daily life experiences of children with asthma. Working to enhance these aspects of primary care might be one place to start in improving the management of children's chronic conditions and their quality of life.     

Effects of regular exercise on asthma control in young adults

Background: According to our systematic literature review, no previous study has assessed potential effects of regular exercise on asthma control among young adults. We hypothesized that regular exercise improves asthma control among young adults. Methods: We studied 162 subjects with current asthma recruited from a population-based cohort study of 1,623 young adults 20–27 years of age. Asthma control was assessed by the occurrence of asthma-related symptoms, including wheezing, shortness of breath, cough, and phlegm production, during the past 12 months. Asthma symptom score was calculated based on reported frequencies of these symptoms (range: 0–12). Exercise was assessed as hours/week. Results: In Poisson regression, adjusting for gender, age, smoking, environmental tobacco smoke exposure, and education, the asthma symptom score reduced by 0.09 points per 1 hour of exercise/week (95% CI: 0.00 to 0.17). Applying the “Low exercise” quartile as the reference, “Medium exercise” reduced the asthma symptom score by 0.66 (?0.39 to 1.72), and “High exercise” reduced it significantly by 1.13 (0.03 to 2.22). The effect was strongest among overweight subjects. Conclusions: Our results provide new evidence that regular exercising among young adults improves their asthma control. Thus, advising about exercise should be included as an important part of asthma self-management in clinical practice.     

Risk factors for repeat attendance at hospital emergency departments among adults and children with asthma

Background: Acute asthma attacks are frequent causes of attendance at hospital Emergency Departments (EDs) and a subgroup of these patients repeatedly present for such treatment.
Aims: This study sought to characterise patients who were repeat attenders at EDs, to assist the targetting of appropriate future interventions aimed at reducing avoidable presentation.
Methods: A cross-sectional survey was undertaken of patients presenting with an asthma attack to the EDs of six teaching hospitals in Adelaide, South Australia between 14 May and 30 June 1994. Patients were interviewed within six weeks of their attendance about aspects of their asthma history, severity, medications, self-management, attitudes and environment. Repeat attenders, defined as two or more visits over the course of the preceding year, were compared with those who reportedly attended on one occasion only, using logistic regression analyses.
Results: Sixty-two per cent of 272 patients aged under 15 years and 40% of 165 patients aged 15 years or more reported having attended two or more times over the course of the preceding year. Among adults, the variables independently associated with repeat attendance principally related to asthma severity. Among children, repeat attendance was associated with parental attitudinal variables relating to appraisal of their child's asthma severity, management of asthma attacks and parental worry.
Conclusions: The factors underlying repeated presentations at EDs differ between adults and children and interventions to minimise avoidable presentation will require different emphasis for these patient subgroups.     

Management of osteonecrosis in children and young adults with acute lymphoblastic leukaemia

Osteonecrosis is a disabling complication in children and young adults with acute lymphoblastic leukaemia. It can affect any or multiple joints but the hip and knee are most frequently involved and a cause of long-term disability. The problem is almost exclusively that of older children and young adults of whom over 70% have asymptomatic changes on screening magnetic resonance imaging and 15-20% have resulting symptoms. Dexamethasone is associated with a higher risk than prednisolone in US but not European or UK trials and alternate week scheduling of dexamethasone in the intensification course is associated with a lower risk than a continuous 3-week schedule in US trials. Genetic factors and obesity contribute to the risk, as do metabolic abnormalities caused by drugs, such as asparaginase, which increase tissue exposure to steroids. Management is primarily supportive but a minority of patients require surgical intervention including replacement of the affected joint. A variety of surgical techniques and, latterly, bisphophonates, have been tried to prevent progression but their efficacy remains uncertain. Whether patients should continue to receive steroids after diagnosis of osteonecrosis is uncertain but most trial investigators recommend stopping them after completion of the intensification phase of treatment.     

Association between pediatric home management plan of care compliance and asthma readmission

Objectives: In 2007, The Joint Commission implemented three children's asthma care (CAC) measures to help improve the quality of care for patients admitted with asthma. Due to lack of consistent evidence showing a relationship between home management plan of care (HMPC) compliance and readmission rates, CAC-3 was retired in 2016. We aimed to understand the relationship between HMPC compliance and revisits to the hospital, and investigate which components of the HMPC, if any, were driving the effect. Methods: This was a retrospective cohort study at a quaternary care freestanding children's hospital, including patients between 2 and 17 years of age admitted with a primary diagnosis of asthma between January 1, 2006, and July 1, 2013. Bivariate and multiple logistic regression analyses examined effects of HMPC provider compliance on hospital readmission and emergency department utilization for asthma within 180 days of initial discharge, controlling for admission to the intensive care unit, age, gender, ethnicity, insurance type, and whether inhaled corticosteroids were prescribed. Results: A total of 1,176 patients were included. Those discharged with an HMPC (n = 756, of which 84% were fully compliant) were found to have significantly lower readmission rates (7 vs. 11.9%; aOR = 0.63; 95% CI, 0.41–0.95) and ED revisit rates (aOR = 0.73; 95% CI, 0.56–0.96) within 180 days of discharge. Conclusions: Providing an HMPC upon discharge was found to be associated with decreased asthma readmission and ED utilization rates. This suggests that although HMPC is no longer a required measure, there may still be utility in continuing this practice.     

Associations of patient-centered medical home with quality of care,patient experience,and health expenditures: A STROBE-compliant cross-sectional study

In efforts to improve the delivery of quality primary care, patient-centered medical home (PCMH) model has been promoted. However, evidence on its association with health outcomes has been mixed. The aim of this study was to assess the performance of PCMH model on quality of care, patient experience, health expenditures.This was a cross-sectional study of the 2015–2016 Medical Expenditure Panel Survey-Medical Organization Survey linked data, including 5748 patient-provider pairs. We examined twenty-four quality of care measures (18 high-value and 6 low-value care services), health service utilization, patient experience (patient-provider communication, satisfaction), and health expenditure.Of 5748 patients, representing a weighted population of 56.2 million American adults aged 18 years and older, 44.2% were cared for by PCMH certified providers. 9.3% of those with PCMHs had at least one inpatient stay in the past year, which was comparable to the 11.4% among those with non-PCMHs. Similarly, 17.4% of respondents cared for by PCMH and 18.5% cared for by non-PCMH had at least one ED visit. Overall, we found no significant differences in quality of care measures (neither high-nor low-value of care) between the two groups. The overall satisfaction, the experience of access to care, and communication with providers were also comparable. Patients who were cared for by PCMHs had less total health expenditure (difference $217) and out-of-pocket spending (difference $91) than those cared for by non-PCMHs; however, none of these differences reached the statistical significance (adjusted P > 0.05 for all).This study found no meaningful difference in quality of care, patient experience, health care utilization, or health care expenditures between respondents cared for by PCMH and non-PCMH. Our findings suggest that the PCMH model is not superior in the quality of care delivered to non-PCMH providers.     

Perception of asthma as a factor in career choice among young adults with asthma

BACKGROUND/AIM:

Asthma is a common chronic condition that can be aggravated by workplace exposures. Young adults with asthma should know how their future occupation might affect their asthma, and potentially, their quality of life. The aim of the present study was to assess the awareness of young adults to occupational risks for asthma and high-risk occupations, as well as their perception of the role of asthma in career choice.

METHODS:

Young adults 16 to 22 years of age with reported physician-diagnosed asthma were recruited to complete a questionnaire eliciting information regarding asthma control, career choice and awareness of occupational exposure risks.

RESULTS:

A small majority of the study cohort (56.4%) could identify occupations that cause or exacerbate asthma, and 34.7% indicated that asthma was an important factor in their career plans. Family physicians were most responsible for asthma management (80.2%), but young adults were more likely to discuss asthma and career plans with their parents (43.6%) or friends (29.7%) than with their family physician (13.9%; P<0.001).

CONCLUSION:

Young adults with asthma have suboptimal awareness of potential work-related asthma risks. Family physicians most commonly provide asthma care to these young adults. However, few young adults are talking to their family physicians about career choices and asthma. This observation represents an area of asthma care that needs to be explored in young adults with asthma.     

The Program for the Prevention of Childhood Asthma: a specialized care program for children with wheezing or asthma in Brazil

Objective

: To present the Programa Infantil de Prevenção de Asma (PIPA, Program for the Prevention of Childhood Asthma) and the characteristics of the patients followed in this program.

Methods

: Implemented in the city of Uruguaiana, Brazil, PIPA has as its target population children and adolescents (< 18 years of age) with asthma or suspected asthma. Patients either enroll in PIPA spontaneously or are referred by pediatricians or primary care physicians. In this retrospective study, we use a standardized protocol to assess PIPA patients.

Results

: By the end of the study period, 646 patients were being followed. Of those, 298 (46.1%) were ≤ 3 years of age. In this group of patients, recurrent wheezing was identified in 60.7%, and the first episode of wheezing occurred in the first six months of life in 86.0%. Severe wheezing was identified in 29.5% and 45.4% in the children ≤ 3 and > 3 years of age, respectively. Physician-diagnosed asthma was reported in 26.5% and 82.2%, respectively. In the sample as a whole, the prevalence of passive smoking was high (> 36%), occurring during pregnancy in > 15%; > 40% of the patients had been born by cesarean section; and 30% had a mother who had had < 8 years of schooling.

Conclusions

: A prevention program for children with asthma is an effective strategy for controlling the disease. Knowledge of local epidemiological and environmental characteristics is essential to reducing the prevalence of the severe forms of asthma, to improving the use of health resources, and to preventing pulmonary changes that could lead to COPD in adulthood.     

Comfort of General Internists and General Pediatricians in Providing Care for Young Adults with Chronic Illnesses of Childhood

Background  As an increasing number of patients with chronic conditions of childhood survive to adulthood, experts recommend that young adults with chronic conditions transfer from child-focused to adult-focused primary care. Little, however, is known about how comfortable physicians are caring for this population. Objectives  To assess the comfort of general internists and general pediatricians in treating young adult patients with chronic illnesses originating in childhood as well as the factors associated with comfort. Participants   In a random sample, 1288 of 2434 eligible US general internists and pediatricians completed a mailed survey (response rate = 53%). Methods  We measured respondents’ comfort level in providing primary care for a patient with sickle cell disease (SCD) or cystic fibrosis (CF). We also measured levels of disease familiarity, training and subspecialty support, as well as individual physician characteristics. Results  Fifteen percent of general internists reported being comfortable as the primary care provider for adults with CF and 32% reported being comfortable providing primary care for adults with SCD, compared with 38% of pediatricians for CF (p < .001) and 35% for SCD (p > 0.05). Less than half of general internists felt that their specialty should take primary care responsibility for adult patients with CF and SCD. Conclusions  A majority of general internists and pediatricians are not comfortable providing primary care for young adults with chronic illnesses of childhood origin, such as CF and SCD. Efforts to increase treatment comfort among providers may help with the transition to adult-focused care for the growing numbers of young adults with complex chronic conditions. This work was funded by the Robert Wood Johnson Clinical Scholars Program and the UCSF Division of Pediatrics. Dr. Heisler is a VA Health Services Research and Development Career Development Awardee.     

Continuous ratings of breathlessness during exercise by children and young adults with asthma and healthy controls

Although it is recommended and common practise for adults with respiratory disease to rate symptoms (e.g., dyspnea and/or leg discomfort) during exercise testing, there are no reports on whether children can rate their perception of breathlessness during exercise. Our aims were to evaluate the ability of children and young adults with asthma to continuously rate breathlessness on the 0-10 category-ratio (CR-10) scale with a computerized system during cycle ergometry, and to compare their results with those of healthy subjects. At an initial visit, subjects were familiarized with equipment and exercise protocol, and practised rating breathlessness while cycling. At a follow-up visit (2-4 days later), subjects performed incremental exercise and rated breathlessness using a computer system, mouse, and monitor. Changing the position of the mouse caused movement of a vertical bar located adjacent to the CR-10 scale to indicate the severity of breathlessness. Baseline characteristics of the 14 subjects with asthma (age, 15 +/- 3 years) and 33 healthy subjects (age, 16 +/- 2 years) were similar. The two groups had comparable levels of fitness as measured by peak oxygen consumption (VO(2)). Correlations between exercise physiologic variables (power production, VO(2), and minute ventilation) and breathlessness ratings were >0.90. Subjects reported progressively more ratings of breathlessness with increasing exercise intensities. There were no differences between groups for slopes, x-intercepts, and absolute thresholds relating physiologic variables and breathlessness. In conclusion, children and young adults with asthma as well as healthy individuals of comparable age successfully used the computerized system to rate breathlessness continuously during cycle ergometry. Both groups reported more ratings of breathlessness with this technique as exercise progressed.