A childhood asthma severity scale: symptoms, medications, and health care visits.

BACKGROUND: Although there are current measures to evaluate childhood asthma severity for clinical diagnosis and treatment, there is no standard valid measure to evaluate childhood asthma severity for large-scale epidemiologic studies. OBJECTIVES: To develop and test a childhood asthma severity scale (CHAS) for clinimetric validity and to determine differences in symptoms, medication use, and health care visits by participant characteristics. METHODS: Eight hundred ninety-seven actively asthmatic children under the age of 12 years were selected from a general population of children. Children were selected from a screening questionnaire administered at six Connecticut hospitals that serve large minority populations in Bridgeport, New Haven, Hartford, and Danbury and one hospital serving south central Massachusetts. Twelve-month baseline data for a prospective cohort study of childhood asthma severity were collected on a monthly basis through home interviews. Home interviews addressed questions on daily symptoms, medication use, and health care visits. A severity scale was constructed using three dimensions: symptoms, medication use, and health care visits. RESULTS: CHAS has sufficient preliminary content, construct, and predictive validity. Despite similarities in symptoms, there were health care utilization and medication differentials according to race and ethnicity, insurance status, family income, and maternal education. CONCLUSIONS: CHAS is a potentially useful measure of asthma severity for large-scale epidemiologic studies. It seems that CHAS has sufficient clinimetric properties.     

Treating allergic rhinitis in patients with comorbid asthma: the risk of asthma-related hospitalizations and emergency department visits.

BACKGROUND: Although asthma and allergic rhinitis commonly occur together, the nature of the association has yet to be determined. Treatments for one condition could potentially alleviate the coexisting condition. OBJECTIVE: Patients with both allergic rhinitis and asthma were studied to test the hypothesis that treating allergic rhinitis reduces health care utilization for co-morbid asthma. METHODS: A retrospective cohort study was carried out with 1994-1995 MarketScan claims data. The cohort was limited to patients with both allergic rhinitis and asthma, aged 12 to 60 years, who were continuously enrolled and had no evidence of chronic obstructive pulmonary disease. Allergic rhinitis treatment and asthma-related events (hospitalizations and emergency department visits) were identified. An incidence density ratio (IDR) associated with exposure to allergic rhinitis treatment was calculated. A multivariate Poisson regression was estimated, and the parameter estimates were transformed into IDRs for each explanatory variable. An allergic rhinitis treatment indicator was included in all regressions. RESULTS: The study sample population consisted of 4944 patients with allergic asthma, approximately 73% of whom were treated for their allergic rhinitis. Asthma-related events occurred more often for the untreated group compared with the treated group, 6.6% compared with 1.3%. An IDR of 0.49 for the treatment group (P =.001) indicates that the risk of an asthma-related event for the treated group was about half that for the untreated group. CONCLUSION: In summary, those who were treated for allergic rhinitis have a significantly lower risk of subsequent asthma-related events (emergency department visits or hospitalizations) than those who were not treated.     

GP frequent attendance in Liverpool and Granada: the impact of depressive symptoms.

BACKGROUND: Frequent attendance in general practice increases workload and affects doctor-patient relationships. It is a complex phenomenon, but patients' psychological problems appear to be important. AIM: To assess whether frequent attendance is more likely to be associated with depressive symptoms than with physical health problems. METHOD: The study was carried out in two general practices: one in Liverpool and one in Granada. Subjects comprised 127 frequent attenders (FAs) plus 175 matched controls, stratified by age and sex. Measures included demographic factors, Beck Depression Inventory (BDI), self-reported health, and current health problems classified by ICHPPC-2 criteria. RESULTS: Seventy-five (59%) FAs had a BDI score > or = 13, compared with 9 (5%) controls (odds ratio [OR] = 26.6, 95% confidence interval [CI] = 12.4 to 56.8, P < 0.001). A total of 136 (78%) controls reported their health to be good or excellent, compared with 40 (31%) FAs (OR = 7.6, 95% CI = 4.5 to 12.7, P < 0.001). Respiratory problems were present in 50 (39%) FAs and 47 (27%) controls (chi 2 = 6.992, P < 0.03). Depression rates were similar in Liverpool and Granada, although Liverpool subjects were less likely to report good health. On logistic regression, BDI status was the major predictor of frequent attendance (OR = 17.18, 95% CI = 7.54 to 39.01). Self-reported ill health (OR = 2.67, 95% CI = 1.40 to 5.10) and respiratory problems (OR = 2.20, 95% CI = 1.11 to 4.37) were also associated with frequent attendance. CONCLUSION: Depressive symptoms were the major predictor of frequent attendance in this study. Clinical and research activity should therefore concentrate on the identification and management of psychological problems among FAs in general practice.     

Outcomes of emergency room visits for asthma. I. Patient determinants

To learn how differences among individual patients influence the outcomes of their emergency room (ER) visits for asthma, we matched the results of 1209 sequential ER visits with the records of the 464 children and young adults who visited during a 37-week interval. Most patients visited the ER only once and were unlikely to be admitted. Those patients admitted once were unlikely to be admitted a second time. Only 119 patients (25.6%) made 54.7% of all ER visits and were responsible for 68.5% of admissions; they also accounted for all but eight of 92 relapses. Patients were accordingly stratified into group F, frequent visitors, and group I, infrequent visitors. A separate high-risk category (group HR) was composed of 50 other patients who received especially conservative treatment in the ER owing to prior episodes of severe asthma. HR patients included both frequent and infrequent visitors and had a very high probability of being admitted on any given visit. The patients of group F, each of whom visited the ER at least four times during the 37 weeks initially studied, were also consistently frequent visitors for comparable periods before and after the initial period. Their rate of ER relapses for exceeded their visiting rate, at least in part because some patients tended to relapse on repeated occasions. Patterns of ER use allow differentiation among groups of patients with distinctly different prognoses. These groups are similar to prognostic categories reported by previous authors. Such differences among individual patients must be taken into account when management systems are evaluated or clinical strategies are organized.     

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.     

Multicenter study of emergency department visits for food allergies

BACKGROUND: Relatively little is known about the characteristics of patients who visit the emergency department (ED) for an acute allergic reaction. Although anaphylaxis guidelines suggest treatment with epinephrine, teaching about self-injectable epinephrine, and referral to an allergist, current ED management remains uncertain. OBJECTIVE: The objective of this study was to describe the management of food-related acute allergic reactions. METHODS: The Multicenter Airway Research Collaboration performed a chart review study in 21 North American EDs. Investigators reviewed a random sample of 678 charts of patients who presented with food allergy (International Classification of Diseases-ninth revision codes 693.1, 995.0, 995.3, and 995.60-995.69). RESULTS: Patients had an average age of 29 years; the cohort was 57% female and 40% white. A variety of foods provoked the allergic reaction, including nuts (21%), crustaceans (19%), fruit (12%), and fish (10%). Although exposure to these foods can be life threatening, only 18% of patients came to the ED by ambulance. In the ED, 72% of patients received antihistamines, 48% received systemic corticosteroids, and 16% received epinephrine; 33% received respiratory treatments such as inhaled albuterol. Among patients with severe reactions (55% of total), 24% received epinephrine. Overall, 97% of patients were discharged to home. At ED discharge, 16% of patients were prescribed self-injectable epinephrine, and 12% were referred to an allergist. CONCLUSIONS: Although guidelines suggest specific approaches for the management of acute allergic reactions, ED concordance for food allergy appears low. These findings support a new collaboration between professional organizations in allergy and emergency medicine and the development of educational programs and materials for ED patients and staff.     

Risk factors for the persistence of respiratory symptoms in childhood asthma.

OBJECTIVE: To evaluate the parameters which could predict the persistence of respiratory symptoms in asthmatic children who have been treated with a considerably uniform therapy. METHODS: A retrospective review was performed on the records of 279 children with asthma. An end of study visit, results of spirometry and prick tests completed the data. The mean age at referral and at final visit was 6.2 +/- 3.7 years and 8.9 +/- 4.1 years, respectively; and the children were followed up for a mean of 3 +/- 1.2 years. RESULTS: Eighty-five of the 279 patients (30%) experienced no respiratory symptoms in the previous 12 months. There was no significant difference between those with and without current respiratory symptoms with respect to age, sex, age at onset of symptoms, duration of followup, age at referral, therapeutic choice, severity of asthma and duration of symptoms at referral. For subjects with current respiratory symptoms the initial serum total IgE level, and the percentage of RAST/prick test positivity was significantly higher than those without current respiratory symptoms (P = 0.0027, P = 0.011, respectively). Although the initial FEF 25%-75%, FEV1, and FEV1/FVC was significantly lower in those with current respiratory symptoms (P = 0.003; P = 0.005; and P = 0.04, respectively), there was no statistically significant difference between lung functions of the two groups at the end of followup. The persistence of respiratory symptoms was significantly predicted by initial FEF25%-75% and sensitivity to allergens (P = 0.03 and P = 0.04, respectively). CONCLUSIONS: We concluded that the risk factors for the persistence of respiratory symptoms in our patient population have been low FEF25%-75% value and sensitivity to allergens at referral.     

Psychological triggers and hyperventilation symptoms in asthma.

BACKGROUND: Anecdotal accounts have identified hyperventilation as one route through which psychological factors can trigger bronchoconstriction. However, little is known about the empirical association between psychological and other trigger factors and hyperventilation in asthma exacerbations. OBJECTIVE: To study the cross-sectional association between perceived triggers and hyperventilation symptoms in 1 British and 1 German sample of patients with asthma who were recruited from the community and from primary care clinics. METHOD: Patients completed relevant language versions of the Asthma Trigger Inventory and the Asthma Symptom Checklist. RESULTS: After controlling for demographics and asthma severity, perceived asthma triggers measured by subscales of the Asthma Trigger Inventory explained 12.5% to 37.3% of the variance in Asthma Symptom Checklist hyperventilation-hypocapnia symptoms. Psychological triggers accounted for 10.6% to 26.7% of the variance alone and 4.3% to 11.0% of the variance over and above other trigger factors. In contrast, perceived animal and pollen allergen triggers did not contribute unique variance to the hyperventilation symptom report. Psychological triggers did not explain variance in classic airway obstruction symptoms, thus arguing against a general bias toward inflated symptom reports in patients with psychologically induced asthma. CONCLUSION: Differences in perceived asthma triggers are substantially associated with hyperventilation symptoms, and patients with more frequent psychological triggers also tend to report that they experience more hyperventilation symptoms during their asthma symptom episodes.     

Outcomes of emergency room visits for asthma. II. Relationship to admission criteria

To learn how the outcomes of emergency room (ER) care relate to the decision-making process, criteria for the disposition of asthma in the ER were incorporated into a formal protocol in the form of an algorithm for use by pediatric resident physicians. We compared the application of those criteria with the consequences of 199 decisions to admit patients to the hospital for asthma and of 293 decisions to discharge patients from the ER. For most patients the chance of relapse was significantly raised if they were discharged from the ER when the protocol had specified admission. This was not true, however, for a group of "frequent visitors" (12.7% of all patients) who accounted for 66.3% of all relapses. This finding offers an explanation for previous difficulties in identifying characteristics of visits destined to be followed by relapse. Patients were placed in jeopardy by inappropriate ER discharges only if they were high-risk patients who had experienced prior episodes of respiratory failure. Nearly all admissions involving severe episodes of asthma were also limited to high-risk patients. A variety of criteria supported such admissions. At the other extreme, "avoidable" admissions, in which obstruction resolved within a few hours of admission, occurred equally among all patient strata, and no particular admission criterion could be held at fault for admission of such rapidly remitting cases. The results support the use of explicit, quantitative criteria for guiding ER disposition of asthma, especially specific arrangements for management of ER visits by high-risk patients.(ABSTRACT TRUNCATED AT 250 WORDS)