Passive Smoking Among Children with Chronic Respiratory Disease

The purpose of this study was to determine the prevalence and source of passive smoke exposure among children with chronic respiratory diseases and compare these to both a well child and nonrespiratory chronic illness child population. Rates and source of passive smoke exposure were compared among four child groups: asthma, cystic fibrosis, rheumatoid arthritis, and well children using a questionnaire mailed to the parents of the selected children. Twenty percent of respondents reported current smoking with a significantly higher rate among the cystic fibrosis and rheumatoid arthritis groups. One-third of all children surveyed were exposed to passive smoke at home and/or day care on a daily basis. Over 80% of the asthma and cystic fibrosis respondents reported a change in smoking behavior (i.e., smoking outside the home or smoking fewer cigarettes) after the diagnosis of their child's illness as compared with only 40% of the nonrespiratory groups. Health care providers need to inquire about potential sources of passive smoke exposure in their patients, particularly children with chronic respiratory disease.     

The impact of managed care on health care utilization among adults with asthma.

STUDY OBJECTIVES: To compare kinds and amounts of health care used by adults with asthma in managed care and fee-for-service settings. DESIGN: Cross-sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist-immunologists, family practitioners, and from a random sample of the non-institutionalized population. MEASUREMENTS: Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. RESULTS: Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee-for-service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta-agonists, home nebulized beta-agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI -5.4, -0.1), principally because those in MC had many fewer visits to allergist-immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = -16.5, 95% CI -27.8, -5.3). The two groups did not differ significantly in the proportion with asthma-related or nonasthma hospital admissions. CONCLUSIONS: Persons with asthma in fee-for-service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist-immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in nonasthma care.     

Socio-economic disadvantage, quality of medical care and admission for acute severe asthma

Background: In asthma, socio-economic and health care factors may operate by a number of mechanisms to influence asthma morbidity and mortality.
Aim: To determine the quality of medical care including the patient perception of the doctor-patient relationship, and the level of socio-economic disadvantage in patients admitted to hospital with acute severe asthma.
Methods: One hundred and thirty-eight patients (15–50 years) admitted to hospital (general ward or intensive care unit) with acute asthma were prospectively assessed using a number of previously validated instruments.
Results: The initial subjects had severe asthma on admission (pH=7.3±0.2, PaCO2=7.1 ±5.0 kPa, n =90) but short hospital stay (3.7±2.6 days). Although having high morbidity (40% had hospital admission in the last year and 60% had moderate/severe interference with sleep and/or ability to exercise), they had indicators of good ongoing medical care (96% had a regular GP, 80% were prescribed inhaled steroids, 84% had a peak flow meter, GP measured peak flow routinely in 80%, 52% had a written crisis plan and 44% had a supply of steroids at home). However, they were severely economically disadvantaged (53% had experienced financial difficulties in the last year, and for 35% of households the only income was a social security benefit). In the last year 39% had delayed or put off GP visit because of cost. Management of the index attack was compromised by concern about medical costs in 16% and time off work in 20%.
Conclusion: Patients admitted to hospital with acute asthma have evidence of good quality on-going medical care, but are economically disadvantaged. If issues such as financial barriers to health care are not acknowledged and addressed, the health care services for asthmatics will not be effectively utilised and the current reductions in morbidity and mortality may not be maintained.     

Underuse of inhaled steroid therapy in elderly patients with asthma

STUDY OBJECTIVES: Despite their proven efficacy, inhaled steroids may be underused in the elderly asthmatic population. The objectives of this study were to determine if inhaled steroids are underused in the elderly asthmatic population, who are at a high risk for rehospitalization and mortality, and to identify certain risk factors that predict lower use of inhaled steroids in this group of patients. DESIGN: Population-based, retrospective, cohort study using linked data from hospital discharge and outpatient drug databases. PARTICIPANTS: All people > or = 65 years old in Ontario, Canada, who survived an acute exacerbation of asthma between April 1992 and March 1997. MEASUREMENTS AND RESULTS: Of the 6,254 patients, 2,495 patients (40%) did not receive inhaled steroid therapy within 90 days of discharge from their initial hospitalization for asthma. Patients > 80 years old were at a greater risk of not receiving inhaled steroid therapy, compared to those 65 to 70 years of age (adjusted odds ratio [OR], 1.23; 95% confidence interval [CI], 1.05 to 1.47). Patients with a Charlson comorbidity index of > or = 3 were also at an increased risk of not receiving inhaled steroid therapy, compared to those having no comorbidities (adjusted OR, 3.45; 95% CI, 1.56 to 7.69). Moreover, receipt of care from a primary-care physician was independently associated with an elevated risk of not receiving inhaled steroid therapy, compared to receipt of care from respirologists/allergists (adjusted OR, 1.35; 95% CI, 1.10 to 1.61). INTERPRETATION: Forty percent of Ontario patients > or = 65 years old who experienced a recent acute exacerbation of asthma did not receive inhaled steroid therapy near discharge from their initial hospitalization for asthma. Nonreceipt of inhaled steroid therapy was particularly prominent in the older patients with multiple comorbidities. Moreover, those who received care from primary-care physicians were also less likely to receive inhaled steroid therapy, compared to those who received care from specialists.     

Latino children with asthma: rates and risks for medical care utilization.

Latino families have been reported to underutilize health care services compared with families from other ethnic backgrounds. As part of a community trial in a low income Latino population designed to decrease environmental tobacco smoke (ETS) exposure in children with asthma in San Diego, we examined unscheduled medical care for asthma. Latino families (N = 193) reported information about medical care use for their children during the past 12 months. About 23% were hospitalized, 45% used the emergency department, and 60% used urgent care services. About 8.5% of families had two or more hospitalizations in 12 months. Most families were insured by Medicaid or had no insurance. Significant risk factors for a child's hospitalization were age (under age six), failure to use a controller medication, and a parental report of the child's health status as being poor. Risk factors for emergency department use were age (under age six) and male gender. These findings indicate that low-income Latino families with young children with asthma lack the medical resources necessary for good asthma control. Quality and monitored health care with optimization of asthma management could reduce costly acute care services.     

Latino Children with Asthma: Rates and Risks for Medical Care Utilization

Latino families have been reported to underutilize health care services compared with families from other ethnic backgrounds. As part of a community trial in a low income Latino population designed to decrease environmental tobacco smoke (ETS) exposure in children with asthma in San Diego, we examined unscheduled medical care for asthma. Latino families (N = 193) reported information about medical care use for their children during the past 12 months. About 23% were hospitalized, 45% used the emergency department, and 60% used urgent care services. About 8.5% of families had two or more hospitalizations in 12 months. Most families were insured by Medicaid or had no insurance. Significant risk factors for a child's hospitalization were age (under age six), failure to use a controller medication, and a parental report of the child's health status as being poor. Risk factors for emergency department use were age (under age six) and male gender. These findings indicate that low-income Latino families with young children with asthma lack the medical resources necessary for good asthma control. Quality and monitored health care with optimization of asthma management could reduce costly acute care services.     

Insurance and quality of care for adults with acute asthma

OBJECTIVE: The relationship between health care insurance and quality of medical care remains incompletely studied. We sought to determine whether type of patient insurance is related to quality of care and subsequent outcomes for patients who arrive in the emergency department (ED) for acute asthma. DESIGN: Using prospectively collected data from the Multicenter Airway Research Collaboration, we compared measures of quality of pre-ED care, acute severity, and short-term outcomes across 4 insurance categories: managed care, indemnity, Medicaid, and uninsured. SETTING AND PARTICIPANTS: Emergency departments at 57 academic medical centers enrolled 1,019 adults with acute asthma. RESULTS: Patients with managed care ranked first and uninsured patients ranked last on all 7 unadjusted quality measures. After controlling for covariates, uninsured patients had significantly lower quality of care than indemnity patients for 5 of 7 measures and had lower initial peak expiratory flow rates than indemnity insured patients. Patients with managed care insurance were more likely than indemnity-insured patients to identify a primary care physician and report using inhaled steroids in the month prior to arrival in the ED. Patients with Medicaid insurance were more likely than indemnity-insured patients to use the ED as their usual source of care for problems with asthma. We found no differences in patient outcomes among the insurance categories we studied. CONCLUSIONS: Uninsured patients had consistently poorer quality of care and than insured patients. Despite differences in indicators of quality of care between types of insurance, we found no differences in short-term patient outcomes by type of insurance.     

The Impact of Managed Care on Health Care Utilization Among Adults with Asthma

Study Objectives. To compare kinds and amounts of health care used by adults with asthma in managed care and fee-for-service settings. Design. Cross-sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist-immunologists, family practitioners, and from a random sample of the non-institutionalized population. Measurements. Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. Results. Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee-for-service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta-agonists, home nebulized beta-agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI - 5.4, - 0.1), principally because those in MC had many fewer visits to allergist-immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = - 16.5, 95% CI - 27.8-5.3). The two groups did not differ significantly in the proportion with asthma-related or non asthma hospital admissions. Conclusions. Persons with asthma in fee-for-service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist-immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in non asthma care.     

Obstructive airways diseases, smoking and use of inhaled corticosteroids in southern Sweden in 1992 and 2000.

OBJECTIVE: To examine the prevalence of obstructive pulmonary diseases, respiratory symptoms, smoking habits and pulmonary medication in an adult population, and to compare the results with a study performed in the same geographical area in 1992. DESIGN: In 2000, a postal questionnaire was sent to a randomly selected population of 5179 subjects aged 20-59 years living in southern Sweden. RESULTS: The participation rate was 71.3%. Self-reported asthma was reported by 8.5% of all respondents (vs. 5.5% in 1992, P < 0.001) and 14.5% of females aged 20-29 years. Self-reported chronic bronchitis and/or emphysema and/or chronic obstructive pulmonary disease (CBE/COPD) was reported by 3.6% (vs. 4.6% in 1992, non-significant) with the highest prevalence (5.7%) in the 50-59 year cohort. Smoking decreased from 33.3% in 1992 to 28.4% in 2000 (P < 0.05). About 46% of asthmatics reported nocturnal respiratory symptoms, and 69% reported having had asthma symptoms in the last 12 months. Use of inhaled steroids increased in subjects with asthma and CBE/COPD from 19.4% to 36.5% (P < 0.05) and from 8.6% to 30.0% (P < 0.05), respectively. CONCLUSIONS: Self-reported asthma increased significantly between 1992 and 2000, but the prevalence of CBE/COPD was unchanged. The high proportion of reported symptoms in asthmatics despite an increased use of steroids suggests that further efforts are needed to improve asthma treatment.     

Asthma, current wheezing, and tobacco use among adolescents and young adults in Costa Rica.

OBJECTIVES: To examine the prevalence of asthma and the relation between tobacco use and asthma among university students in Costa Rica. METHODS: Cross-sectional study of 1279 adolescents and young adults enrolled in careers in the health sciences in public and private universities in Costa Rica. RESULTS: Of the 1279 study participants, 105 (8.2%) had current asthma, and 136 (10.6%) reported wheezing in the previous 12 months (current wheezing). Among individuals with either current wheezing or current asthma, none was using anti-inflammatory medications for asthma (e.g., inhaled corticosteroids). Approximately one third of the study participants reported any cigarette smoking. Young adults who had current wheezing were 5.8 times more likely to smoke at least 10 cigarettes per day than those who had no current wheezing [95% confidence interval (CI) for odds ratio (OR) = 3.3-10.2, p < 0.001]. Similar results were observed when an alternative definition of asthma (current asthma) was used in the analysis (OR for smoking at least 10 cigarettes per day = 4.4, 95% CI = 2.3-8.5, p < 0.001). CONCLUSIONS: Adequate public health measures are needed to prevent tobacco use in Costa Rican adolescents and to promote smoking cessation among young adults. Young adults with asthma living in Latin American countries with high asthma prevalence, such as Costa Rica, should be better educated with regard to asthma and the risks of tobacco use.     

Asthma management practices at home in young inner-city children.

Information on parental asthma management practices for young children is sparse. The objective of this article is to determine if specific caregiver asthma management practices for children were associated with children's asthma morbidity. Caregivers of 100 inner-city children diagnosed with persistent asthma and participating in an ongoing asthma intervention study were enrolled and interviewed to ascertain measures of asthma morbidity, medication use, health care use (acute and primary care), and asthma management practices. Overall, asthma morbidity was high with almost two thirds of caregivers reporting their child having one or more emergency department visits within the last 6 months and 63% receiving specialty care for their asthma. Appropriate medication use was reported predominantly as albuterol and inhaled steroids (78%). However, only 42% of caregivers reported administering asthma medicines when their child starts to cough and less than half (39%) reported having an asthma action plan. There were no significant differences by asthma severity level for any asthma management practice. In conclusion, caregivers lack knowledge regarding cough as an early asthma symptom. Caregivers should be encouraged to review asthma action plans with health care providers at each medical encounter.     

The Impact of Managed Care on Health Care Utilization Among Adults with Asthma

Study Objectives. To compare kinds and amounts of health care used by adults with asthma in managed care and fee‐for‐service settings. Design. Cross‐sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist‐immunologists, family practitioners, and from a random sample of the non‐institutionalized population. Measurements. Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. Results. Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee‐for‐service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta‐agonists, home nebulized beta‐agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI ? 5.4, ? 0.1), principally because those in MC had many fewer visits to allergist‐immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = ? 16.5, 95% CI ? 27.8–5.3). The two groups did not differ significantly in the proportion with asthma‐related or non asthma hospital admissions. Conclusions. Persons with asthma in fee‐for‐service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist‐immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in non asthma care.     

Asthma Management Practices at Home in Young Inner-City Children

Information on parental asthma management practices for young children is sparse. The objective of this article is to determine if specific caregiver asthma management practices for children were associated with children's asthma morbidity. Caregivers of 100 inner-city children diagnosed with persistent asthma and participating in an ongoing asthma intervention study were enrolled and interviewed to ascertain measures of asthma morbidity, medication use, health care use (acute and primary care), and asthma management practices. Overall, asthma morbidity was high with almost two thirds of caregivers reporting their child having one or more emergency department visits within the last 6 months and 63% receiving specialty care for their asthma. Appropriate medication use was reported predominantly as albuterol and inhaled steroids (78%). However, only 42% of caregivers reported administering asthma medicines when their child starts to cough and less than half (39%) reported having an asthma action plan. There were no significant differences by asthma severity level for any asthma management practice. In conclusion, caregivers lack knowledge regarding cough as an early asthma symptom. Caregivers should be encouraged to review asthma action plans with health care providers at each medical encounter.     

Asthma Management Practices at Home in Young Inner‐City Children

Information on parental asthma management practices for young children is sparse. The objective of this article is to determine if specific caregiver asthma management practices for children were associated with children's asthma morbidity. Caregivers of 100 inner‐city children diagnosed with persistent asthma and participating in an ongoing asthma intervention study were enrolled and interviewed to ascertain measures of asthma morbidity, medication use, health care use (acute and primary care), and asthma management practices. Overall, asthma morbidity was high with almost two thirds of caregivers reporting their child having one or more emergency department visits within the last 6 months and 63% receiving specialty care for their asthma. Appropriate medication use was reported predominantly as albuterol and inhaled steroids (78%). However, only 42% of caregivers reported administering asthma medicines when their child starts to cough and less than half (39%) reported having an asthma action plan. There were no significant differences by asthma severity level for any asthma management practice. In conclusion, caregivers lack knowledge regarding cough as an early asthma symptom. Caregivers should be encouraged to review asthma action plans with health care providers at each medical encounter.     

Symptomatic asthma: attendance and prescribing in general practice

Under-prescribing and low attendance continue to be cited as reasons for ongoing asthma symptoms in primary care despite marked increases in prescribing and structured care for asthma over the past 10 years. The objective of this study was to determine the relationship between continuing asthma morbidity and the attendance of and prescribing for symptomatic asthmatic patients in primary care. A random sample of 402 subjects from 801 who reported at least one of six symptoms in the previous month on most or every day were identified from responses to a validated morbidity questionnaire. An analysis of their care over a 2-year period (1 year before and 1 year after the questionnaire) was carried out from their general practice case-notes. Data on 308 patients was available for analysis. Ninety-four per cent of these symptomatic asthma patients attended over the 2-year period, with 77% attending for an asthma related consultation. Most patients were managed exclusively in primary care. Inhaled steroids were prescribed for 78% of patients and high dose inhaled steroids (> or = 800 mcg of beclomethasone or equivalent per day) were prescribed for 38%. Patients with most symptoms were more likely to be prescribed inhaled steroids. Rescue courses of oral steroids were prescribed for 29% of patients. Changes in asthma medications were recorded for 31% during the study period. Metered dose inhalers (MDI) were prescribed for 86% with more than half prescribed MDIs combined with some other delivery device. Elements of structured care were more frequently recorded in patients who reported most symptoms. In conclusion the asthma management of the majority of patients in this study was active with high levels of steroid prescribing. There appeared to be room to increase prescribing and to improve the structure of care.While patients who were 'symptomatic on steroids' should have had their medications, delivery devices and structured care reviewed regularly many were already on maximal treatment and were therefore likely to remain symptomatic. It is unclear how practitioners could improve morbidity in many of these patients as under-treatment and low attendance seem unlikely to be the principal causes of continuing symptoms.     

Gaps in asthma care of the oldest adults

OBJECTIVES: To assess the adequacy of asthma care reported by a group of older adults who were subsequently hospitalized for their asthma. DESIGN: Prospective cohort study. SETTING: Fifteen managed care organizations in the United States. PARTICIPANTS: Adults with asthma, enrolled in managed care. MEASUREMENTS: Patient survey of demographics, asthma symptoms, health status, comorbid conditions, asthma treatment, asthma knowledge, and asthma self-management at baseline and 1 year later. RESULTS: Of 254 older adults, 38 (15.0%) reported being hospitalized for asthma at 1-year follow-up. Of these, 22.9% owned a peak flow meter (PFM). Of those with allergies, only about half (56.0%) had been told how to avoid allergens and had been referred for formal allergy testing. Adrenergic drug use was high in some patients. Nearly all (94.6%) used beta-agonist metered-dose inhalers (MDIs); 60.0% reported theophylline; 17.1% reported beta-agonist MDI overuse (>8 puffs per day); 10.5% reported beta-agonist MDI over-use and theophylline; and 13.2% reported both beta-agonist MDI over-use and oral beta-agonist use. Only 18.4% of respondents rated their overall asthma attack knowledge as excellent. Compared with nonhospitalized older adults, the hospitalized group reported care that was more consistent with guidelines, but also higher rates of potentially toxic combinations of adrenergic drugs. Compared with younger hospitalized adults, older hospitalized adults had clear deficiencies, including lower use of PFMs (55.3% vs 22.9%) and worse asthma self-management knowledge. CONCLUSIONS: There are many opportunities to improve both the pharmacologic and non-pharmacologic care of older adults with asthma. Overuse of and potentially toxic combinations of inhaled and oral sympathomimetics should probably be avoided. Older asthmatics may also benefit from increased specialty referral, PFM use, allergy testing, and asthma teaching.     

A qualitative study of compliance with medication and lifestyle modification in Chronic Obstructive Pulmonary Disease (COPD).

Aim: The aim of this study is to examine patients' perceptions of factors that influence their compliance with inhaled therapy for COPD, and their compliance with health related behaviours related to smoking cessation, exercise and diet. Methods: Five focus groups of 29 diagnosed COPD patients who had not attended pulmonary rehabilitation were recruited from secondary and primary care. The severity of their illness ranged from mild to severe. For each group, the moderator asked patients what they had been told and what they actually did with regard to medication, smoking, exercise and diet. Results: All patients except one reported good compliance with medication but some patients expressed concerns about technique. All patients reported being told to stop smoking, but patients varied as to whether they believed that smoking was harmful or not. Some had stopped smoking, some had tried to cut down, and others continued as normal. Patients had not been offered constructive help to quit smoking. Patients had been told to exercise but were given inadequate information as to why this was helpful. Patients were unsure how much they should exercise, and were unsure whether breathlessness during exercise was harmful. Patients had been given minimal advice about diet. Conclusions: Patients with COPD have low levels of intentional non-compliance with medication in COPD, probably because, unlike asthmatics, these patients are chronically symptomatic. Fear of dyspnoea and feelings of vulnerability also appear to contribute to good compliance. Information given by health professionals about lifestyle modification was poor. COPD patients require better education to manage their disease effectively.