Cost-effectiveness of a primary care depression intervention

OBJECTIVE: To determine the incremental cost-effectiveness of a quality improvement depression intervention (enhanced care) in primary care settings relative to usual care. DESIGN: Following stratification, we randomized 12 primary care practices to enhanced or usual care conditions and followed patients for 12 months. SETTING: Primary care practices located in 10 states across the United States. PATIENTS/PARTICIPANTS: Two hundred eleven patients beginning a new treatment episode for major depression. INTERVENTIONS: Training the primary care team to assess, educate, and monitor depressed patients during the acute and continuation stages of their depression treatment episode over 1 year. MEASUREMENTS AND MAIN RESULTS: Cost-effectiveness was measured by calculating incremental (enhanced minus usual care) costs and quality-adjusted life years (QALYs) derived from SF-36 data. The mean incremental cost-effectiveness ratio in the main analysis was US dollars 15463 per QALY. The mean incremental cost-effectiveness ratios for the sensitivity analyses ranged from US dollars 11341 (using geographic block variables to control for pre-intervention service utilization) to US dollars 19976 (increasing the cost estimates by 50%) per QALY. CONCLUSIONS: This quality improvement depression intervention was cost-effective relative to usual care compared to cost-effectiveness ratios for common primary care interventions and commonly cited cost-effectiveness ratio thresholds for intervention implementation.     

Characteristics of fibromyalgia in Muslim Bedouin women in a primary care clinic

BACKGROUND: Fibromyalgia (FM) has been described and studied in various sociocultural settings in both developed and developing countries. OBJECTIVES: To study the clinical manifestations of FM and to describe its effect on quality of life in the unique setting of Muslim Bedouin women in the southern Israel Negev desert area. METHODS: One hundred two Bedouin women were recruited from a primary health care clinic in the Negev area. All patients fulfilled American College of Rheumatology criteria for the diagnosis of FM. Tenderness was assessed by manual dolorimetry and the fibromyalgia impact questionnaire was utilized to estimate the severity of FM symptoms. Anxiety and depression were assessed by the Arthritis Impact Measurement Scales subscales and quality of life was evaluated by the SF-36 questionnaire. RESULTS: The study population was characterized by a low educational level, a high rate of consanguinity, a high number of children per mother, and a high rate of polygamy. There was a high frequency of classic FM symptoms such as pain and fatigue, as well as anxiety and depression. The overall impact of FM on quality of life was exceedingly high (8.9 on a scale of 0 to 10). CONCLUSIONS: FM is relatively common in the unique setting of Muslim Bedouin women and has a very significant impact on their quality of life as well as on their dependents. Physicians involved in the primary care of this population should be attentive to the manifestations of FM and related disorders.     

Persistent differences in asthma self-efficacy by race,ethnicity, and income in adults with asthma

Abstract

Objective: The objective of this population-based study was to determine if and to what extent there are differences in asthma self-efficacy by race/ethnicity and income, and whether health status, levels of acculturation, and health care factors may explain these differences. Methods: We conducted a secondary data analysis of asthma self-efficacy using the 2009 and 2011–2012 California Health Interview Survey, in adults with asthma (n?=?7874). In order to examine if and how the effect of race/ethnicity and income on asthma self-efficacy may have been altered by health status, acculturation, and health care factors, we used staged multivariable logistic regression models. We conducted mediation analyses to evaluate which of these factors might mediate disparities in self-efficacy by race/ethnicity and income. Results: 69.8% of adults reported having high asthma self-efficacy. Latinos (OR 0.66; 95% CI 0.51–0.86), African-Americans (OR 0.50; 95% CI 0.29–0.83), American Indian/Alaskan Natives (OR 0.55; 95% CI 0.31–0.98) and Asian/Pacific Islanders (OR 0.34; 95% CI 0.23–0.52) were less likely to report high self-efficacy compared to Whites. Individuals with income below the federal poverty level (OR 0.56; 95% CI 0.40–0.78) were less likely to report high self-efficacy compared to higher income individuals. The relationship between income and self-efficacy was no longer significant after further adjustment for health care factors; however, the differences in race and ethnicity persisted. Receiving an asthma management plan mediated the relationship in certain subgroups. Conclusions: Addressing modifiable health care factors may play an important role in reducing disparities in asthma self-efficacy.     

The quality of life of Brazilian adolescents with asthma: associated clinical and sociodemographic factors

Objective: Asthma is the most common chronic disease among adolescents. This study assessed the quality of life (QOL) related to health in adolescents with asthma and its determining factors (demographic, socioeconomic, and clinical). We also separately evaluated each of the parameters that comprised the asthma control classification. Methods: This was an observational, cross-sectional study of 114 adolescents who had doctor-diagnosed asthma. QOL was assessed using a version of the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) that was adapted and validated for Brazil, and higher scores indicated a better QOL. The level of asthma control was assessed using the rating system proposed by the Global Initiative for Asthma, and sociodemographic factors were evaluated. Results: When the averages of the PAQLQ domains and overall scores were compared to the potentially explanatory variables, significantly lower average PAQLQ scores were obtained for individuals with an inadequate level of asthma control (p?Conclusions: The level of asthma control was related to QOL, but this association manifested mainly in the subjective control domains, such as nighttime and daytime symptoms and physical activity limitations. The objective domain for control classification, represented by pulmonary function, was not an independent predictor or determinant of the QOL of adolescent asthma patients.     

Pediatric asthma hospitalizations among urban minority children and the continuity of primary care

Objective: To examine the effect of ambulatory health care processes on asthma hospitalizations. Methods: A retrospective cohort study using electronic health records was completed. Patients aged 2–18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations. Results: 5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09–1.78). Conclusions: In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.     

Regular clinic attendance in two large San Francisco HIV primary care settings

Although poor clinic attendance is associated with increased morbidity and mortality among HIV-infected individuals, less is known about predictors of retention and the acceptability of targeted interventions to increase regular clinic attendance. To better understand which patients are at risk for irregular clinic attendance and to explore interventions to aid in retention to care, we surveyed patients attending two outpatient HIV clinics affiliated with the University of California, San Francisco. A total of 606 participants were surveyed, and the analysis was restricted to the 523 male respondents. Of this group, 45% (N = 299) reported missing at least one visit a year. Missing a clinic visit was associated with being African American (aOR = 1.99; 95%CI 1.12–3.52), being a man who has sex with both men and women (aOR=2.72; 95%CI 1.16–6.37), and reporting at least weekly methamphetamine use (aOR=5.79; 95%CI 2.47–13.57). Participants who reported a monthly income greater than $2000 were less likely to miss an appointment (aOR = 0.56; 95%CI 0.34–0.93). Regarding possible retention interventions, most patients preferred phone calls over other forms of support. These findings support the need for ongoing engagement support with particular attention to at-risk sub-groups.     

Smokers who have children with asthma: Perceptions about child secondhand smoke exposure and tobacco use initiation and parental willingness to participate in child-focused tobacco interventions

Objective: This study examined, among parents who smoke and have children with asthma, perceptions about child secondhand smoke exposure (SHSe), child tobacco use (TU) initiation, and parent willingness to participate in child-focused tobacco interventions. Methods: Participants were 300 caregivers who smoked and had a child with asthma (aged 10–14). Parents completed an online survey and self-reported perceptions about child SHSe elimination, child TU prevention, and willingness to participate in three types of interventions with and without their child (SHSe reduction intervention, tobacco prevention intervention, and the combination of the two). Correlates of perceptions and willingness were examined. Results: Parents who were ready to quit smoking and who reported home smoking bans (HSBs) were more motivated to eliminate SHSe (p < 0.05). Being white, younger, ready to quit, and having HSBs were associated with greater confidence to eliminate SHSe (p < 0.05). Parents with HSBs reported higher perceived importance about preventing child TU (p < 0.05). Parents were less confident about preventing male children from using tobacco (p = 0.001). Parents were highly willing to participate in all the described intervention approaches, with or without their child. Conclusions: Parents were willing to participate in child-focused tobacco interventions, with or without their child with asthma, including interventions that address both child SHSe and TU prevention. This research demonstrates the acceptability of child-focused tobacco interventions among a high-risk population and may be a foundational step for intervention development.     

Examining health literacy among urban African-American adolescents with asthma

Objective: This exploratory study assessed health literacy among urban African-American high school students to improve understanding of the association between adolescent health literacy and asthma. Methods: We conducted a secondary data analysis of the control group (n = 181) of the Puff City randomized controlled trial (2006–2010), a web-based intervention to promote asthma management among students, grades 9 through 12. A validated self-report 3-item health literacy screening instrument was completed at final online follow-up survey. Logistic regression was used to explore the association between health literacy, demographic characteristics, quality of life, asthma management, and health care utilization. Results: Multivariate analysis revealed that an overall inadequate health literacy score was associated with students who were more likely to be younger (OR 0.61; 95% CI 0.44–0.84), not on Medicaid (OR 0.36; 95% CI 0.17–0.76), have at least one hospitalization (OR 1.29; 95% CI 1.07–1.56); and a lower overall quality of life (OR 0.75; 95% CI 0.59–0.95). Those lacking confidence in filling out medical forms, needing help reading hospital materials, and having difficulty understanding written information were more likely to not have a rescue inhaler (OR 0.49; 95% CI 0.25–0.94), have one or more emergency visits (OR 1.21 95% CI 1.02–1.43), and one or more hospitalizations (OR 1.19; 95% CI 1.01–1.41), respectively. Conclusions: The findings indicate a significant association between inadequate health literary and suboptimal asthma management. It is important to advance understanding of adolescent health literacy, especially those at-risk, as they assume asthma self-management tasks and move toward independent adult self-care.     

The relationship between asthma and depression in a community-based sample

Objective: Asthma is an increasingly prevalent disease that is associated with substantial physical and financial burdens. Additionally, asthma is linked to psychiatric disorders. This study examines the relationship between asthma diagnosis, current depressive symptoms, and lifetime psychiatric disorder history in a large, community-based sample. Methods: We analyzed data from 2168 participants in the Dallas Heart Study, a large, diverse, community-based sample of people designed to be representative of the Dallas County population. Logistic regressions analyzing the relationship between asthma diagnosis and history of a psychiatric disorder, as well as between asthma diagnosis and the Quick Inventory of Depressive Symptomatology (QIDS) scores were performed, controlling for demographic data. Results: 13.4% of the sample had an asthma diagnosis. Asthma diagnosis was significantly associated with a history of nervous, emotional, or mental health disorder diagnosis [OR 1.810 (95% CI 1.280–2.559) p = 0.001], and with QIDS scores consistent with moderate or greater current depressive symptom severity [OR 1.586 (95%CI 1.106–2.274) p = 0.012]. The relationships were not moderated by age, gender, race, smoking status, or Body Mass Index. Conclusions: A diagnosis of asthma may be associated with current clinically significant levels of depressive symptoms and a lifetime psychiatric disorder. The current report adds to the existing literature in this area by assessing both current and lifetime symptoms and by using a large and diverse population. The findings highlight the clinical importance of considering the possibility of psychiatric illness in asthma patients and suggest further research in this area is needed.     

Improved quality-of-life of caregivers of children with asthma through guideline-based management

Objective: The quality of life (QOL) of caregivers of children with asthma may be related to children's responses to asthma management. Aim: To evaluate change in QOL over time of caregivers of children with asthma through guideline-based management. Design: This was a 3-year prospective cohort study of children with asthma referred to our pediatric asthma center. Families completed Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ), the Asthma Control Test? (ACT), and reported the number of days/month of albuterol use and wheezing at each clinic visit. Results: We enrolled 143 children, ages 7–17 years (mean = 10.6 ± 2.9), 56.6% male, 70.6% Caucasian. Patients were managed by the same MD (n = 65,45.5%) or APN (n = 78,54.5%) over time. The mean total PACQLQ significantly increased over the 3-year period (F = 67.418, p < .001). Total scores at the first visit were 4.8 ± 1.6, which improved to 6.1 ± 1 at the 3-month follow-up visit. This improvement was sustained at the 1, 2, and 3-year clinic visits. PACQLQ emotional function (F = 60.798, p < .001) and activity limitation (F = 41.517, p < .001) domains significantly improved as well. PACQLQ scores were significantly associated with improved ACT scores (r = .37 to .47, p < .05), fewer days/month of albuterol use (r = ?.25 to ?.36., p < .05), and wheezing (r = ?.28 to ?.33, p < .05). There were no significant differences in PACQLQ, or asthma clinical outcome measures between MD and APN providers. Conclusion: Use of National Asthma Education and Prevention Program (NAEPP) guidelines significantly improved QOL of caregivers of children with asthma and in asthma-related symptoms. Improvements over time were independent of type of providers.     

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.     

Combining pharmacy expertise with asthma educator certification: assessing the impact on inner-city asthma patients

Objective: Asthma is one of the major causes of hospital readmissions in the South Bronx. The goal of this study was to assess the impact of asthma education provided by registered pharmacists with asthma educator certification (AE-C), on medication adherence and hospitalizations/Emergency Department (ED) visits. Methods: This was a retrospective chart review of patients seen in the pulmonary clinic from October 2014 to August 2015 for asthma education by AE-C pharmacists. Medical records were reviewed over an 18-month period – 9?months before and after the initial asthma education session. Data obtained included adherence to asthma controller inhalers based on pharmacy refill claims, asthma control using asthma control test (ACT) scores and asthma-related hospitalizations or ED visits within 30?days of asthma education. Pre-education data served as the pre-intervention group data and post-education data served as the post-intervention group data, allowing each patient to serve as their own control. Results: We found a statistically significant improvement in average medication adherence, i.e. asthma controller inhaler fills at pharmacy (46.3% vs 67.9%, p-value <0.001) and asthma control (15.71% vs 56.38%, p-value <0.001) between the pre-intervention and the post-intervention groups. Additionally, a lower hospitalization/ED utilization rate (31.2% vs 6.38%, p-value <0.001) was observed in the post-intervention group within 30?days of education. Conclusions: Asthma education provided by AE-C pharmacists had a positive impact on asthma care in our inner-city community. Improving medication adherence and asthma control as well as decreasing hospital utilization could potentially decrease health care costs in addition to improving quality of life.     

The effect of early child care attendance on childhood asthma and wheezing: A meta-analysis

Objective: Research evidence offers mixed results regarding the relationship between early child care attendance and childhood asthma and wheezing. A meta-analysis was conducted to synthesize the current research evidence of the association between early child care attendance and the risk of childhood asthma and wheezing. Method: Peer reviewed studies published from 1964–January 2017 were identified in MEDLINE, CINAL, and EMBASE using MeSH headings relevant to child care and asthma. Two investigators independently reviewed the selected articles from this search. All relevant articles that met our inclusion criteria were selected for further analysis. Data were extracted from studies that had sufficient data to analyze the odds of asthma or wheezing among children who attended child care. Results: The meta-analysis of 32 studies found that (1) early child care attendance is protective against asthma in children 3–5 years of age but not for children with asthma 6 years of age or older. (2) Early child care attendance increases the risk of wheezing among children 2 years of age or younger, but not the risk of wheezing for children over 2 years of age. Conclusions: This meta-analysis shows that early child care attendance is not significantly associated with the risk of asthma or wheeze in children 6 years of age or older.     

A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic

Objectives: The aim of this study was to evaluate inhaler technique and symptom control in patients with poorly controlled asthma at baseline and at follow-up in a dedicated asthma clinic in a tertiary hospital. We also investigated the impact of asthma on these patients’ quality of life. Methods: Patients referred to a newly established asthma clinic in Cork University Hospital were prospectively recruited over a 6-month period. Their inhaler technique was assessed by a pulmonary nurse specialist using a validated scoring system. They received instruction on inhaler usage when scores were suboptimal. Patients completed a validated asthma control questionnaire (ACQ) and asthma quality of life questionnaire (AQLQ). At follow-up 3–4 months later, the inhaler technique was reassessed and the ACQ questionnaire repeated. Results: Forty-six patients were recruited (female?=?74%), and 40/46 were followed up. Mean [SD] FEV1 % predicted at baseline?=?76.5% [21.5]. About 63% of the patients were classified as incorrectly using their inhaler at their initial assessment. This decreased to 20% at follow-up, indicating an overall significant improvement in inhaler usage post-training (p?=?0.003). ACQ scores improved significantly from median [interquartile range] 2.70 [1.66] to 2.00 [1.90] (p?=?0.002). Baseline measurement indicated that patients’ quality of life was moderately affected by asthma, with a median AQLQ score of 4.75 [1.97]. Conclusion: This study demonstrates the importance of educating and formally assessing inhaler technique in patients with asthma as a part of their ongoing clinical review.     

Improving preventive care in high risk children with asthma: lessons learned

Objectives: Rates of preventive asthma care after an asthma emergency department (ED) visit are low among inner-city children. The objective of this study was to test the efficacy of a clinician and caregiver feedback intervention (INT) on improving preventive asthma care following an asthma ED visit compared to an attention control group (CON). Methods: Children with persistent asthma and recent asthma ED visits (N?=?300) were enrolled and randomized into a feedback intervention or an attention control group and followed for 12 months. All children received nurse visits. Data were obtained from interviews, child salivary cotinine levels and pharmacy records. Standard t-test, chi-square and multiple logistic regression tests were used to test for differences between the groups for reporting greater than or equal to two primary care provider (PCP) preventive care visits for asthma over 12 months. Results: Children were primarily male, young (3–5 years), African American and Medicaid insured. Mean ED visits over 12 months was high (2.29 visits). No difference by group was noted for attending two or more PCP visits/12 months or having an asthma action plan (AAP). Children having an AAP at baseline were almost twice as likely to attend two or more PCP visits over 12 months while controlling for asthma control, group status, child age and number of asthma ED visits. Conclusions: A clinician and caregiver feedback intervention was unsuccessful in increasing asthma preventive care compared to an attention control group. Further research is needed to develop interventions to effectively prevent morbidity in high risk inner-city children with frequent ED utilization.