Factors associated with emergency department use in asthma: acute care interventions improving chronic disease outcomes.

OBJECTIVE: To provide a literature review of the factors associated with childhood asthma-related emergency department (ED) visits and to identify elements of effective ED interventions that reduce the frequency of childhood ED visits while increasing primary health care utilization. DATA SOURCE: English Medline articles from 1990 that cross-referenced with the terms asthma, emergency, intervention, pediatric, and/or acute care. Experts in the field of allergy and asthma were also consulted. STUDY SELECTION: Childhood asthma interventions in the ED. RESULTS: Factors associated with childhood asthma-related ED visits include being impoverished, being exposed to allergens, receiving Medicaid or lacking insurance, being noncompliant with self-management skills, and having an African-American heritage. Other minorities may also be at risk, but further investigation is required to determine the extent. Attempts to link the patient to primary health care by the ED staff resulted in increased adherence to followup care. CONCLUSIONS: The ED provides an opportunity to help patients and families deal with asthma to improve their quality of life. Further, current studies demonstrate that the ED is an appropriate setting for an intervention that links the patient back to the primary health care provider. More research is needed on the appropriate educational messages to be delivered in ED. Also, barriers to followup care and regular use of a primary health care provider need to be identified so that future intervention designs can address these issues.     

Do self-management plans reduce morbidity in patients with asthma?

BACKGROUND: Self-management plans may help patients with asthma intervene when symptoms deteriorate, thus preventing asthma attacks. AIM: A study set out to test whether a self-management plan tailored to the circumstances of the individual reduces morbidity from asthma. METHOD: General practitioners who had participated in a national audit of asthma attacks were randomized into intervention and control groups. Six months after the intervention group had issued self-management plans to patients with asthma, both groups of practitioners completed morbidity questionnaires on patients. Morbidity outcomes were compared for the 6-month periods before and after the issue of the plans. RESULTS: In the 6 months before the study, the 376 patients enrolled by the intervention group experienced higher levels of morbidity than the 530 patients for whom details were recorded by the control group. In the 6 months after the issue of the plans, control group patients showed little change in levels of morbidity, but intervention group patients showed significant reductions in hospital admissions, consultations for asthma symptoms, asthma review consultations, courses of oral steroids and use of emergency nebulized bronchodilators. CONCLUSION: General practitioners appeared to operate enthusiast bias' and issued more self-management plans to patients with uncontrolled asthma. The reduction in morbidity in this group is probably a result of the use of the plans, but the verdict on whether plans reduce morbidity must be deemed 'not proven'.     

Adherence issues in the medical management of asthma

Asthma is a common chronic illness of childhood that requires coordinated efforts by children, families, and health care professionals for proper medical management. The medical management of pediatric asthma involves pharmacological and behavioral recommendations to both prevent and control asthma attacks. However, management of these attacks is hindered by failure to adhere to the prescribed recommendations. While the literature on adherence in pediatric asthma has grown over the past 10 years, few definitive statements can be made about causes and treatment. Various issues related to adherence and pediatric asthma are reviewed in this paper, including assessment methods, factors influencing adherence, and treatment strategies. Recommendations for future research are provided, starting with more controlled randomized studies.     

Adapting a self-management education program for asthma for use in an outpatient clinic

A self-management patient education program for children with asthma which incorporates a slide tape program, pamphlets, nurse discussion, and physician discussion has been adapted from an emergency room site to an outpatient clinic for use during routine asthma clinic visits. Pre-interviews and post-interviews with and medical record review of 12 patients, aged 4 to 12 years, demonstrated that the children had statistically significant increases in knowledge of self-management skills (recognition of asthma triggers and early warning signs and appropriate behaviors to manage acute episodes) and a significant increase in the sense of personal control (Health Locus of Control). Parents reported less disruption of family activities due to asthma and that the children had increased their use of asthma self-management techniques, resulting in improved management of asthma at home. Nurse and physician response to the program was enthusiastic and demonstrated the feasibility of integrating patient education into the outpatient clinic medical care routine.     

Health literacy and asthma

The report "Healthy people" from the US Department of Health and Human Services defines health literacy (HL) as follows: "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions." The same report identifies asthma as a public health problem of high priority. Unfortunately, impaired HL is prevalent in our society, and patients with low HL and asthma face multiple challenges as they attempt to manage their disease. Indeed, the National Asthma Education and Prevention Program's current guidelines require patients to have considerable HL and self-management skills. Numerous studies have linked inadequate literacy with poor health outcomes. Unlike many sociodemographic variables, HL can potentially be addressed in the health care setting. The purpose of this review is to raise awareness of the problem, summarize the current evidence linking HL and asthma, and offer strategies to strengthen the communication between patients and health care providers to decrease asthma health disparities. In addition, we discuss potential future directions for research in this field.     

Computer-assisted instructions for patients with bronchial asthma

We produced computer-assisted instruction (CAI) software for bronchial asthma patients (asthma educational system with computer-assisted instruction; ASTCAI) to assist in self-management and avoid asthmatic attacks and death. ASTCAI is a question-and-answer program operating in a multimedia environment, and was evaluated from questionnaires which 33 patients were asked. Thirty-two patients could perform ASTCAI without any assistance. The responses of 31 patients (94%) indicated that they had no difficulty with manipulation, and 29 patients (88%) stated that the program was beneficial to control of their asthma. Elderly patients (over 65) required more time than younger adults. Emergency visits or admissions of at least 1 year after the first CAI trial decreased in eight out of 26 patients, while only two patients deteriorated compared to the previous year. Our results show that CAI is feasible for most patients, and through active self-learning CAI can improve motivation for self-management as well as supplement the physician's instructions.     

Enhancing the design and utilization of asthma action plans through community-based participatory research in an urban African American community

BackgroundAcross the U.S., large inequities in asthma prevalence and outcomes persist, disproportionately affecting low-income, minoritized children. West Louisville is particularly impacted by these inequities due to a complex interplay of socioeconomic, historical, and industrial processes. Additionally, low health literacy and mistrust in healthcare exacerbate poor asthma self-management.ObjectiveTo engage community members and health professionals to address childhood asthma management in a marginalized community experiencing significant health inequities.Patient InvolvementAlthough prior asthma knowledge was not required, the majority of our community advisory council (CAC) members either had asthma or cared for children/grandchildren with asthma. Through facilitated decision-making using the Boot Camp Translation approach, the CAC chose to focus on improving asthma self-management in their community through enhancing the design and utilization of asthma action plans (AAPs).MethodsUpon adding inhaler images to a user-friendly AAP, the CAC developed and implemented a provider incentive program and a health communication campaign to promote the Tool’s utilization. Evaluation of the intervention consisted of a short questionnaire measuring relevant patient demographics and campaign knowledge, and phone interviews with providers to gather feedback on the incentive and Tool design.ResultsOver the short two-month intervention, a total of 8 practices with 28 providers used 153 Tools to provide asthma self-management counseling. The majority of providers preferred the enhanced Tool to other AAPs they had used. Inhaler images facilitating improved communication regarding asthma medications.DiscussionUsing a participatory approach, a community preferred intervention targeting barriers to effective asthma control increased provider utilization and community awareness of AAPs and bridged a communication gap between patients and providers.Practical ValueLeveraging community members’ (including patients/caregivers) and health professionals’ expertise led to the development of an enhanced patient-education tool and an effective provider incentive program with the potential to improve childhood asthma management in marginalized populations.     

Watch, Discover, Think, and Act: a model for patient education program development

In this report we describe the development of the Watch, Discover, Think and Act asthma self-management computer program for inner-city children with asthma. The intervention focused on teaching two categories of behaviors--asthma specific behaviors such as taking preventive medication and self-regulatory processes such as monitoring symptoms and solving asthma problems. These asthma self-management behaviors were then linked with empirical and theoretical determinants such as skills and self-efficacy. We then further used behavioral science theory to develop methods such as role modeling and skill training linked to the determinants. We matched these theoretical methods to practical strategies within the computer simulation and created a culturally competent program for inner-city minority youth. Finally, we planned a program evaluation that linked program impact and outcomes to the theoretical assumptions on which the intervention was based.     

Qualitative study of young people''s and parents'' beliefs about childhood asthma.

BACKGROUND: Asthma continues to be a common childhood chronic illness managed principally in primary care. Self-management requires co-ordinated efforts of young people, carers and health professionals. Non-compliance occurs even when parents are supervising care, suggesting that decisions are made on the basis of beliefs that contrast with professional advice. Health professionals therefore need to understand the views of parents (or other carers) and patients to promote good self-management. Little attention has been given to carers' and young people's perspectives on asthma. AIM: To gain insights into the beliefs of a group of 25 young people aged nine to 16 years old and their carers about asthma and its management. DESIGN OF STUDY: Qualitative study using conversational-style interviews. SETTING: Generally deprived urban areas of Greater Manchester. METHOD: Interviews were conducted with 25 young people with asthma and separately with their carers. The interviews were analysed using the principles and procedures of grounded theory. RESULTS: Carers reported assessing asthma symptoms through observed effects on the child and other family members, including emotions and behaviours that disrupted family life. Young people emphasised the effect of asthma on their everyday lives and in particular the extent to which they appeared different to their peers. Some young people reported continuing symptoms and restrictions of activity that differed widely from the reports of their carers. CONCLUSION: Differences between young people's and carers' criteria for assessment suggest explanations for some 'non-compliant' behaviour. Carers' assessment of asthma severity through the absence of acute attacks is consistent with managing asthma as intermittent acute episodes. Professionals should take account of differences between young people's, carers' and professionals' perceptions of asthma.     

Asthma education programme in Russia: educating patients

To address the recent rise in asthma morbidity and mortality in Russia, an intervention study was conducted to improve asthma diagnosis, treatment and prevention. US recommendations for asthma management were adapted for use in educating Moscow families with children with asthma. Two hundred and fifty-two children with asthma aged 4–14 years receiving health care in eight Moscow public health clinics together with their parents were enrolled in the study to see whether US teaching manuals for asthma management would be acceptable and effective in Russia. Children at four of the clinics with recent asthma attacks were randomly assigned to either the education or control group to test if patient education and guided asthma care would improve outcomes for patients. Modern medications were made available to both groups to see if training in the US guidelines was necessary to get physicians to use the medications. Children with recent asthma attacks at the other four clinics were defined as comparison group 1 to control for the possible effect of medication availability. All children at the eight clinics who had no asthma attacks composed comparison group 2 to see if the outcomes for these children would change over time. One-year follow-up results showed significant improvement in asthma self-management skills of children and parents, in terms of asthma treatment, only among those in the education group. Significant increases were observed in the subgroup of children in the education group using anti-inflammatory drugs for asthma control. Children in the education group had markedly increased peak flow rates and reduced daily peak flow variability as compared to control and comparison groups. There was a significantly greater reduction in doctor visits by the education group of children compared to control. Presumably, changes in parents' and children's behaviour in terms of asthma treatment and prevention skills, proper treatment of the disease and access to medications could be responsible for reducing asthma morbidity in children.     

Self-management training for children with chronic bronchial asthma.

We have described examples of behaviors that occur antecedent to, concurrent with, or as a consequence of childhood asthma. Ways these patterns can be altered have also been described. Three points should be emphasized: first, social learning techniques can contribute to a child acquiring self-monitoring and self-management skills over his or her affliction. Thus, youngsters with asthma can learn self-responsibility over their affliction. Second, while we do have follow-up data indicating that youngsters continue to perform similar behaviors once they leave the Center and return to their families, such generalization does not automatically occur. For this reason, we have initiated several programs for working with a child's family. Finally, what about the youngster who is never admitted to an asthma facility such as the national Asthma Center? It is here where we are beginning to focus most of our efforts. By teaching a child and his or her family ways that the youngster can learn to manage asthma means that the disease will become less of a disruptive influence within the home, that costs of the affliction can be contained, and that the youngster can remain within the mainstream of both his or her family and community. Future reports from the Center will describe efforts we are making in this direction.     

Paediatric and adolescent asthma: A narrative review of telemedicine and emerging technologies for the post-COVID-19 era

Children and young people with asthma need regular monitoring to maintain good asthma control, prevent asthma attacks and manage comorbidities. The COVID-19 pandemic has resulted in healthcare professionals making fundamental changes to the way healthcare is delivered and for patients and families adapting to these changes. Comprehensive remotely delivered, technology-based healthcare, closer to the patients home (reducing hospital footfall and possibly reducing carbon footprint) is likely to be one of the important collateral effects of the pandemic. Telemedicine is anticipated to impact everyone involved in healthcare - providers and patients alike. It is going to bring changes to organization, work areas and work culture in healthcare. Healthcare providers, policymakers and those accessing healthcare services will experience the impact of technology-based healthcare delivery. Telemedicine can play an exciting role in the management of childhood asthma by delivering high-quality care closer to the child's home. However, unlike adults, children still need to be accompanied by their carers for virtual care. Policymakers will need to take into account potential additional costs as well as the legal, ethical and cultural implications of large scale use of telemedicine. In this narrative review, we review evidence regarding the role of telemedicine and related emerging technologies in paediatric and adolescent asthma. Although there are gaps in the current knowledge, there is evidence demonstrating the important role of telemedicine in management of childhood and adolescent asthma. However, there is an urgent need for healthcare researchers and policymakers to focus on improving the technologies and address the disparities in accessing novel technology-based management strategies to improve asthma care.     

The behavioral management of asthma and asthma-related problems in children: A critical review of the literature

This review focuses upon the behavioral approach to childhood asthma. Asthma is defined as intermittent, variable, and reversible airways obstruction with a complex multidimensional etiology. The major measures of asthma include physiological, symptomatic, and collateral measures. The behavioral management of childhood asthma has been restricted to relaxation training, systematic desensitization, assertive training, biofeedback, and deconditioning of exercise induced asthma. The efficacy of such intervention strategies for asthmatic children is in doubt, although the management of asthma-related problems in children appears to be a more promising area of research. The author suggests that the power of intervention programs for asthmatic children may be strengthened by the development of multifaceted treatment programs contingent upon the antecedents and consequences of the individual case. Also, behavior therapy may be of assistance to mild asthmatic children.     

Asthma education: the adolescent experience

Recent studies show that prevalence of asthma is higher among adolescents than children. Adolescents have poor asthma self-management skills resulting in a significant increase in the severity of asthma exacerbations and a reduction in their quality of life. Despite this, few self-management programs have been developed for adolescents. Adolescents experience developmental transitions that both hinder and facilitate asthma self-management. In this paper we discuss developmental transitions in cognition, knowledge, autonomy, identity development, and peer relations in terms of their influence on adolescents' management of asthma. Next, we describe the Asthma Self-Management for Adolescents (ASMA) program that incorporates developmental characteristics into an age-appropriate school-based asthma education program. Preliminary data is presented indicating that the program is successful in enrolling and engaging the interest of adolescents with persistent asthma.     

Efficacy of a self-management program for childhood asthma–: A prospective controlled study

Asthma training programs for parents and children have been developed to increase both the self-management skills of asthmatic children and compliance with medical regimes. In order to evaluate two training programs for asthmatic children aged 7–14, 81 patients were randomly assigned to three groups. Group 1 consisted of 27 patients and their parents who participated in a five-day standardized family-oriented clinical asthma training program. They had monthly follow-up meetings with the training team for a period of six months. Group 2 (n=29) had the same clinical training without follow-up interventions; a control group (n=25) received regular medical treatment according to the international guidelines at the asthma clinics without a training program and served as control group. Questionnaires regarding self-management aspects, coping and anxiety were filled out by patients, parents, family doctors and the training team prior to as well as twelve months after the training. The results indicate that Training group 1 benefitted most with respect to active asthma self-management, Training group 2 to some degree while the control group showed no significant effects. The differences after one year between the three groups regarding physical parameters such as lung-function and days missed in school did not reach the level of significance. Our results indicate that the long-term efficacy of self management courses for asthmatic children is enhanced by regular follow-up training sessions.     

The effect of health beliefs and feelings of self efficacy on self management behavior of children with a chronic disease

This study is among the first to examine the value of chronically ill children's health beliefs, self-efficacy beliefs, experiences of hospitalization, and participation in a health education program in predicting self-management behavior. Data were collected from a random sample of 214 children with asthma being served by any of four NYC hospitals. As measured, perceived self-efficacy, prior hospitalization and participation in a health education program had modest predictive value for self-management while measures of perceived severity of asthma attacks and beliefs in the benefits of self-management techniques in controlling the disease failed to predict subsequent use of self-management techniques. We conclude that (1) the Health Belief Model may not be useful in predicting the behavior of children because of their developmental status, or (2) the measures used in the present study did not adequately tap the health belief constructs.     

Behavioral treatment of symptoms of childhood illness

Behavioral treatment of somatic symptoms is gaining increasing acceptance in pediatric medicine. In this article, behavioral treatment will be referred to in the broadest sense to include behavior therapy procedures, biofeedback training, and relaxation techniques. In a number of disorders common to childhood, behavioral treatment of the symptoms is considered a primary intervention following medical diagnosis. Migraine, recurrent abdominal pain, and urinary and fecal incontinence are disorders in which this is most likely to be the case (Varni, 1983; Masek, Russo, & Varni, 1984).Behavioral treatment procedures are also finding wide application as an adjunct to medical management of symptoms of disease. Chronic pain associated with hemophilia, juvenile rheumatoid arthritis and sickle cell disease has been responsive to behavioral treatment in a limited number of patients and further evaluation is warranted (Varni, 1983). Juvenile primary hypertension is another disorder in which behavioral treatment is considered as a potential adjunctive therapeutic (Croates & Masek, 1982). With chronic illness such as cystic fibrosis, asthma, and some types of childhood cancer, symptoms can arise from the stress of coping with the cardinal manifestations of the illness and the threat to life. In turn, these symptoms (e.g., hypcrventilation, gastrointestinal distress, lowered pain tolerance, sleep disturbance, and anxiety) can interfere with medical management and even exacerbate the illness. Behavioral treatment of secondary symptoms is aimed at reducing arousal and developing more effective coping strategies.The distinction between primary and adjunctive roles for behavioral treatment of symptoms of illness is an important one in terms of the points of interaction with medicine. There are also practical differences in the provision of treatment under these two conditions and the degree to which empirical evaluation of the effects of treatment is possible. To illustrate this distinction in clinical practice, behavioral treatment as a primary intervention for symptoms of asthma and cystic fibrosis are discussed. Medical aspects of these illnesses and relevant behavioral research are reviewed. Emphasis is placed on the process of implementing behavioral treatment procedures that are effective and complimentary to medical care.     

Adult asthma prevalence, morbidity and mortality and their relationships with environmental and medical care factors in Singapore

We have conducted a series of studies on adult asthma in Singapore that describe the prevalence, morbidity and mortality and their relationships with environmental and medical care factors. There was no evidence of a temporal increase of mortality from 1976 to 1995 for adults. The prevalence rate of asthma is 2.4% in men and 2.0% in women. There is considerable morbidity among asthmatics, corticosteroids are under-used, and patients' knowledge and self-management skills is poor. Increased morbidity is significantly associated with current keeping of pets, current smoking, and the patients' knowledge and self-management skills. Occupational exposure contributes up to a third of asthma morbidity. Malays and Indians have higher rates of asthma mortality and morbidity than Chinese. They have greater exposures to airborne allergens from keeping rugs or carpets, and pets. Malays experience the most morbidity from asthma, but make less use of health services, and receive less medical attention, than Indians or Chinese.     

Self-management and behaviour modification in COPD

There is new evidence from recent studies that disease-specific self-management improves health status and reduces hospital admissions in COPD patients. It is critical to implement health education programs in the continuum of care aimed at behaviour modification. Studies in COPD have shown that self-management increases knowledge and skills the patients require to treat their own illness. It is also essential to be more effective in improving patients' confidence in their ability to follow a self-care regimen, for example, by augmenting self-efficacy. Self-efficacy plays a part in determining which activities or situations an individual will perform or avoid. Results from a recent qualitative study suggested that a continuum self-management program helps COPD patients to perform given self-health behaviours. COPD patients have perceived barriers and factors (disease-related skills), which will hinder or facilitate lifestyle modification. To be successful, self-management does require a multifaceted approach that incorporates not only teaching various disease contents but also implementing strategies to change behaviour in patients. Further research is needed to develop strategies on how to intervene and facilitate behaviour modification in chronic disease and as such the relevance for the implementation of self-management programs in COPD.     

Mobile applications to enhance self-management of gout

BackgroundGout is an arthritic condition that is characterised by extremely painful, debilitating acute attacks and eventual joint and organ damage if not controlled. Despite the availability of very effective therapies that, if adhered to, will prevent acute attacks and long-term damage, the disorder is increasingly prevalent. There is an urgent need to improve self-management of gout.ObjectivesMobile health (mHealth) applications (‘apps’), designed to facilitate management of chronic conditions, present novel opportunities for supporting patient self-management of gout. The aim of this review was to assess features of available gout management apps designed to assist consumers in managing their gout and their consistency with guidelines for gout management.MethodsEnglish-language, smart-device apps designed to assist self-management of gout were identified using search term “gout” and downloaded from Apple and Google Play app stores. To be included in the review, apps had to allow users to monitor their gout disease (e.g. serum uric acid (sUA) tracking, record acute attacks) and/or educate patients about gout. Investigators derived patient-focused recommendations for gout management from contemporary guidelines. Features of reviewed apps were independently assessed by two reviewers for their facilitation of these recommendations.ResultsThe search identified 57 apps possibly relevant to gout management, of which six met the inclusion criteria. One app incorporated all recommendations for patient-focused gout management from guidelines including monitoring sUA, recording attacks and lifestyle advice. However, the majority of these elements were not functional within the app, and instead required users to manually complete printouts.ConclusionsCurrently, only one app exists that includes all recommendations to facilitate patient self-management of gout, however some features can only be actioned manually. Given the lack of progress in achieving better patient outcomes and the promise of mHealth interventions to deliver significant gains, new or updated gout management apps are required to promote successful self-management of this chronic disease.