The impact of inadequately controlled asthma in urban children on quality of life and productivity.

BACKGROUND: The burden of inadequately controlled pediatric asthma on education and other daily activities is not well described. OBJECTIVE: To evaluate asthma-related activity limitations and productivity losses among children and caregivers. METHODS: Surveys were mailed to caregivers of children with asthma. Caregivers provided demographics, health-related quality of life (HRQL), workplace productivity, and asthma-related costs. Adolescents (aged 12-18 years) provided HRQL, asthma control, and school-based productivity, and young children (aged 4-11 years) completed an asthma control questionnaire with help from a caregiver. RESULTS: Among the 239 respondents, the mean age was 10.1 years; 49% were girls. More than half were inadequately controlled as measured using the Asthma Control Test. Both HRQL and productivity were significantly lower in patients with inadequately controlled asthma compared with those with controlled asthma. In the previous year, caregivers reported missing 1.4 days of work due to their child's asthma, with the child missing an average of 4.1 school days. Fewer adolescents with controlled asthma reported missing 1 or more school days in the previous week compared with adolescents with inadequately controlled asthma (3.5% vs 34.0%; P < .001). There were similar differences in caregiver workdays missed and health care resource use: both were significantly higher in children with inadequately controlled asthma. CONCLUSIONS: Inadequately controlled asthma has a significant impact on asthma-specific HRQL, school productivity and attendance, and work productivity of children and their caregivers.     

Home-based asthma education of young low-income children and their families

OBJECTIVE: To conduct a controlled trial of a home-based education program for low-income caregivers of young children with asthma. METHODS: Participants were randomized to treatment-eight weekly asthma education sessions adapted from the Wee Wheezers program (n = 49)-or usual care (n = 46). Baseline and 3- and 12-month follow-up data were gathered from caregivers and from children's medical records. RESULTS: Treatment was associated with less bother from asthma symptoms, more symptom-free days, and better caregiver quality of life at follow-up for children 1-3, but not those 4-6, years of age. Treatment and control groups did not differ in caregiver asthma management behavior or children's acute care utilization. CONCLUSIONS: This home-based asthma education program was most effective with younger children; perhaps their caregivers were more motivated to learn about asthma management. Targeting psychosocial factors associated with asthma morbidity might also enhance the efficacy of asthma education for these families.     

Prevalence of asthma and health service utilization of asthmatic children in an inner city

To determine the prevalence of asthma and to examine the pattern of health service utilization of asthmatic children in Baltimore, we sent questionnaires randomly to 4096 first and sixth graders attending Baltimore City public schools; 2898 completed the questionnaire. Asthma was defined as “a condition which causes difficulty in breathing, with wheezing noises in the chest.” On the basis of this definition, we found that the cumulative prevalence of asthma was 10.5% and the 12 mo period prevalence was 7.2%. The prevalence was significantly higher for boys (male: female = 1.6:1) and for blacks (black:white = 1.5:1). Nearly 50% of the children with active asthma missed 6 days or more out of the school year because of illnesses due to asthma. Almost half the asthmatic children obtained their care of asthma in the emergency room, and twice as many blacks as whites used the emergency room as their primary source of care. Moreover, emergency room users had a higher school absentee rate than non-emergency room users.     

Relationship of body mass index with asthma indicators in head start children.

OBJECTIVE: To examine the relationship of body mass index (BMI) and asthma indicators on children with asthma in a Head Start (HS) program. METHODS: In this cross-sectional study (November 18, 2000, to December 12, 2003) of children aged 3 to 5 years with asthma, we compared the BMI data of HS asthmatic patients (n = 213) with the data of peer control subjects from a sample (n = 816) of the National Health and Nutrition Examination Survey aged 3 to 5 years and with children in prekindergarten in Arkansas public schools (n = 1,024). Parental reports of asthma symptoms, health care use, medication use, school days missed, and quality of life were used as indicators of asthma morbidity. Categorical analysis and chi2 tests were performed to examine the relationship between BMI and asthma morbidity. RESULTS: The prevalence of overweight (> or =95th percentile) was significantly higher in HS children with asthma compared with the National Health and Nutrition Examination Survey children (P < .001) and Arkansas prekindergarten children (P = .05). Compared with HS asthmatic children with a BMI less than the 85th percentile, HS asthmatic patients with a BMI of the 85th percentile or greater reported significantly more school days missed (P = .02), lifetime hospitalizations (P = .04), emergency department visits (P = .02), and activity limitations (P = .03) and fewer oral corticosteroid bursts (P = .04). There was also a trend for more daytime symptoms (P = .05) and lower quality of life (P = .06). No differences were observed in rescue (P = .28) or controller (P = .47) medications, environmental tobacco smoke exposure (P = .47), positive allergy test results (P = .85), and nighttime symptoms (P > .99). CONCLUSIONS: Having an increased BMI was associated with more asthma morbidity in this group of HS asthmatic patients. Despite the lack of a clear explanation for the link between asthma and BMI, our data suggest that an increased BMI significantly affects the well-being of young asthmatic patients and should be further addressed.     

Association between asthma control in children and loss of workdays by caregivers.

BACKGROUND: Although the economic burden of pediatric asthma is a significant public health issue, the loss of workdays by caregivers because of their children's asthma remains scarcely investigated. OBJECTIVES: To evaluate asthma-related loss of workdays incurred by caregivers of asthmatic children and its association with the level of asthma control. METHODS: A retrospective observational study was conducted based on a French computerized general practitioners' database and a survey questionnaire. Children aged 6 to 16 years with persistent asthma (Global Initiative for Asthma grade > or = 2) were included in the study. Level of children's asthma control was evaluated from recent asthma symptoms. Caregivers reported the number of workdays lost because of their child's asthma during the 12-month study. RESULTS: Nearly 30% of caregivers lost workdays during the study because of their children's asthma. More than 13% of caregivers lost more than 5 days. Caregiver absenteeism significantly correlated with all components of asthma control (use of relievers, nocturnal symptoms, impairment of activities, and asthma crises). A significant 8-fold risk of losing more than 5 workdays by caregivers was observed when the child's asthma was poorly controlled (odds ratio, 8.6; 95% confidence interval, 2.4-30.5); caregivers' absenteeism also increased significantly with the number of episodes of oral corticosteroid use during the study. CONCLUSIONS: Caregivers' loss of workdays owing to their children's asthma is substantial and is highly correlated with the level of asthma control. These findings highlight the necessity of educational programs for children with poor asthma control and their caregivers to prevent severe asthma attacks that lead to caregiver absenteeism.     

Health-related quality-of-life measures for children with asthma: reliability and validity of the Children's Health Survey for Asthma and the Pediatric Quality of Life Inventory 3.0 Asthma Module.

BACKGROUND: Economically disadvantaged African American youth are especially vulnerable to the effects of pediatric asthma and are at increased risk for difficulties in daily functioning. Measures of health-related quality of life (HRQoL) yield important information regarding the impact of pediatric chronic illness on daily functioning. It is essential to develop and validate measures of HRQoL to detect the impact of asthma on this vulnerable population. OBJECTIVE: To examine the psychometric properties of 2 asthma-specific measures of pediatric HRQoL in a sample of economically disadvantaged African American children diagnosed as having asthma. METHODS: One hundred twenty-seven caregivers completed questionnaires regarding their child's HRQoL, asthma symptoms, health care utilization, and school absences and regarding caregiver emotional distress. The severity of the child's asthma was measured via spirometry. RESULTS: The Children's Health Survey for Asthma and the Pediatric Quality of Life Inventory 3.0 Asthma Module demonstrated adequate internal consistency reliability and validity for the present sample. Lower HRQoL was associated with poorer adherence and more health care utilization, asthma symptom days, school absences, and caregiver distress. Only the Children's Health Survey for Asthma was significantly associated with severity, when defined as airway obstruction. CONCLUSIONS: This study supports the psychometric equivalence of 2 condition-specific measures of HRQoL in a population at high risk for asthma and asthma-related problems. The utility of each measure will depend on the needs of the researcher or physician. Both measures can inform the treatment course, help identify and address barriers to treatment adherence, and inform treatment interventions.     

Community asthma education program for parents of urban asthmatic children

OBJECTIVES: To demonstrate the effectiveness of community asthma education provided by peers in the urban community. METHOD: A convenience sample of 267 self-referred, primarily African-American parents or primary caregivers of asthmatic children aged 18 months to 16 years completed a five-session education program. Program efficacy was evaluated at baseline, immediately postinstruction, and at three-, six-, and 12 months retention. Outcomes included three questionnaires measuring asthma self-management knowledge, control and quality of life. RESULTS: Immediately following program completion, participants demonstrated improvements in asthma knowledge (13% increased proportion correct, p < 0.01), ability to control their child's asthma 16% increased score, p < 0.01), and asthma quality of life (7% increased score, p < 0.01). Retention of knowledge with steady improvement of control and quality of life was observed up to one year postinstruction, as compared with immediate postprogram scores (p = 0.09 and 0.05, respectively). CONCLUSIONS: A community-based asthma educational program for caregivers should be an important component of childhood asthma management. The complexities of asthma management are best taught in educational programs that are easily accessible, provide a comfortable environment for participants, and are taught by peers.     

Environmental tobacco smoke exposure and nocturnal symptoms among inner-city children with asthma

BACKGROUND: Environmental tobacco smoke (ETS) is a frequent exposure and is linked to asthma among inner-city children. OBJECTIVE: We sought to examine the relationship among ETS exposure, select asthma symptoms, and consequences among inner-city children with asthma. METHODS: Data from interviews with primary caregivers of inner-city elementary school children with asthma were evaluated (n = 590). Caregiver reports of child asthma symptoms, exercise limitations, asthma management, health care use, and ETS exposure were examined. RESULTS: Smoking in the home was reported by 29.4% of primary caregivers. ETS exposure (yes/no) was not related to frequency of child nocturnal symptoms or other select asthma morbidity markers. However, among children exposed to ETS, the frequency and severity of child nocturnal symptoms were highest among children exposed to moderate-to-heavy levels of ETS. After controlling for child age, anti-inflammatory medication use, asthma primary care, and caregiver's education, exposure to higher levels of ETS was associated with nearly a 3-fold increase in nocturnal symptoms in children (odds ratio, 2.83; 95% CI, 1.22-6.55). CONCLUSION: Among elementary school inner-city children with asthma, exposure to higher levels of ETS was associated with increased frequency of nocturnal symptoms. Reducing the exposure of children with asthma to ETS should be a clear priority in developing effective asthma management plans for inner-city families.     

Identification of preschool children with asthma from low-income families in Los Angeles, CA.

BACKGROUND: Few studies have addressed asthma screening in the preschool age group. Early asthma recognition and intervention in preschool children may reduce costs related to unscheduled medical care and missed school and work. OBJECTIVE: To facilitate an early recognition and referral process for asthma in a preschool education program in Los Angeles, CA. METHODS: We administered a 7-question survey to parents and guardians of children aged 12 months to 6 years in the prekindergarten program of a large school district in Southern California. English and Spanish survey questions addressed health care use, school absenteeism, and asthma symptoms. Postsurvey reports to parents recommended clinical evaluation of children who had probable asthma. RESULTS: Of the 609 surveys returned from 8 centers (> or = 80% survey return rate), 12% were positive for probable asthma and only 5.4% of these cases had been previously diagnosed. Of the 12% found to have a high probability of asthma, 3 independent factors were associated with a lower likelihood of prior asthma diagnosis: Hispanic descent; Spanish speaking; and medicine use 2 or more times per week for symptoms such as cough, chest tightness, trouble breathing, or wheezing. Symptoms at play, during the day, and at night were noted in 35% to 44% of the preschoolers. Cough was the most frequently reported symptom (71.9%, n = 424). CONCLUSIONS: A school-based screening process in an early education program can help identify preschool children with a high probability of asthma and offer a basis for early recognition and intervention.     

Screening for poor short-term outcome in acute pediatric asthma.

BACKGROUND: Despite good initial treatment response, many children with acute asthma exacerbations have poor short-term outcomes. OBJECTIVE: To develop and validate a risk score to screen for poor short-term outcome at the time of emergency department (ED) treatment. Methods: Prospective cohort study of children treated for acute asthma at 2 pediatric EDs. Poor 14-day outcome was defined as any of the following: asthma symptoms still above baseline at 14 days, child missed 5 or more days of school or day care, caretaker missed 5 or more days of school or work, or unscheduled care or admission after the ED visit for worsening symptoms. RESULTS: A total of 1,221 children were enrolled: 852 at the derivation site and 369 at the validation site. Five variables independently associated with poor outcome by logistic regression were used to create a simple linear score: wheezing 2 or more days before the visit, 3 or more acute outpatient asthma visits in the previous 12 months, home use of albuterol, history of severe persistent asthma, and fever at the ED visit. Area under the receiver operating characteristic curve values were 0.66/0.67 for the derivation/validation samples. Two or more features categorized high risk. The test characteristics for the derivation/validation samples are as follows: sensitivity, 0.67/0.62; specificity, 0.61/0.68; likelihood ratio, 1.7/1.9; pretest probability, 33%/47%; and posttest probability, 50%/62%. CONCLUSIONS: Information available at the ED visit was used to develop a simple risk score that identifies patients at high risk for poor outcome. The score would be useful in evaluating interventions to improve outcomes by allowing interventions to be targeted to a subgroup most likely to benefit.     

Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys

BACKGROUND: In 1995, the Global Initiative for Asthma (GINA) guidelines recommended goals for the management of asthma, which were updated in 2002. However, there are no recent international surveys on the real management of asthma. OBJECTIVE: The Asthma Insights and Reality surveys are the first large-scale surveys aimed at determining international variations in the severity, control, and management of asthma in children and adults. METHODS: A cross-section of households in 29 countries in North America, Europe, and Asia were surveyed to identify from the general population asthmatic patients with symptoms within the last year or who were taking current asthma medication. A standard questionnaire was administered to 7786 adults, and, through a proxy, to 3153 children with asthma. Objective and subjective patient perception of asthma control and severity were assessed, including access to medical care, health care use, missed work-school, and medication use. RESULTS: Despite variations at a country level, a substantial effect of asthma on patients' lives was observed, with considerable loss of schooldays and workdays. The current level of asthma control worldwide falls far short of the goals for long-term management in international guidelines. A significant proportion of patients continue to have symptoms and lifestyle restrictions and to require emergency care. The proportion of adult asthmatic patients who were current smokers was also high. However, the use of anti-inflammatory preventative medication, even in patients with severe persistent asthma, was low, ranging from 26% in Western Europe to 9% in Japan, as was the use of objective lung function testing. The correlation between self-perceived severity of asthma and objective assessment of severity on the basis of GINA criteria was consistently poor in all areas. CONCLUSION: We conclude that there is direct evidence for suboptimal asthma control in many patients worldwide, despite the availability of effective therapies, with long-term management falling far short of the goals set in the GINA guidelines.     

Effect of allergic rhinitis on the use and cost of health services by children with asthma

PURPOSE: Allergic rhinitis (AR) is common among children with asthma and exacerbates asthma symptoms. To assess the incremental utilization and cost of asthma-related health services due to concomitant AR among asthmatic children. MATERIALS AND METHODS: Asthma-related claims were extracted from the Korean National Health Insurance (NHI) claims database, which covers 97% of the population. Per-capita utilization and costs of asthma-related services were determined from the societal perspective. RESULTS: Of 319,714 children (1-14 years old) with chronic asthma in 2003, 195,026 had concomitant AR (prevalence 610 per 1,000 asthmatic children). Children with AR had 1.14 times more outpatient visits, 1.30 times more emergency department (ED) visits, and 1.49 times more hospitalizations than children without AR. More children with AR used general hospitals (7.17%) than children without AR (3.23%). The ratios of unit pharmaceutical costs per outpatient visit, ED visit, and admission between children with and without AR were 1.27, 1.20, and 1.14. Total annual expenditure combining direct health care, transportation, and caregivers' costs, were $273 and $217 for children with and without AR, respectively. CONCLUSION: Health service utilization and costs for asthma were greater for asthmatic children with AR. More frequent ED visits and admissions among asthmatic children with AR suggest poorer control and more frequent exacerbations. Higher unit cost of pharmaceuticals during visits, tendency to receive asthma care from a higher-level facility, and greater risk of ED visit or admission all contributed to the additional economic burden of AR.     

Asthma management and perceptions in rural South Africa.

BACKGROUND: Many First World countries have endeavored to measure the impact of asthma on individuals with asthma and, in addition to this quality of life evaluation, have attempted to define the quality of care for this common chronic illness. OBJECTIVE: The primary objective of this research probe was to assist the National Asthma Program in South Africa with the formulation and delivery of its outreach program to rural asthmatic patients. METHODS: A discussion/questionnaire document was compiled by Partners in Research from established literature. All interviews were conducted in either the clinics, hospitals, or respondents' homes. Both adult asthmatic patients and parents of pediatric asthmatic patients were interviewed. Interviewing took place at seven rural health clinics across South Africa. Each interview included extensive demographic details, questions on asthma definition, symptoms and symptom triggers, family history, age at diagnosis, frequency of symptoms, and treatment. RESULTS: Thirty-five adult asthmatic patients and 27 parents of pediatric asthmatic patients were interviewed. Of the adults, 40% reported wheezing at least once a week (despite diagnosis and treatment) and 19% of children reported similar symptom exacerbations. Fifty-one percent of adults and 56% of children were awakened at least once a week by cough or wheeze. Quality of life measurement reflected that, on average, 37% of responders were frightened during an acute asthma attack, and 68% of parents reported fearing the death of their asthmatic children. Fifty-one percent of adults and 33% of children had been hospitalized at least once for asthma. Although respondents claimed regular training in use of inhaler device, only 43% of adults completed each step correctly. CONCLUSIONS: There is a great deal of fear and ignorance surrounding asthma and, therefore, there is a real need for a greater level of patient education even in the rural areas of South Africa. In rural South Africa, attention should be paid to nurses, because they play a greater role than doctors in management and education of asthma.     

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.     

Predictors of repeat visits to the emergency room by asthmatic children in primary care

BACKGROUND: Subsets of asthmatic children, particularly in the Caribbean, burden the health system through repeated emergency room (ER) visits. We examined children to determine predictors of repeated ER visits in Trinidad. METHODS: Caregivers of 300 asthmatic children in primary healthcare in Trinidad reported on perceived factors of exacerbated wheeze requiring ER services. RESULTS: Prevalence of ER utilization in the past 12 months was 59.7% and 40.3% for repeated visits. Average age of wheezing onset was 2.8 (SD = 2.5) years. From the logistic regression analyses, independent predictors of repeat ER visits were mothers with a history of asthma (OR = 2.0, 95%Cl = 1.0-4.0), exposure to perfumes/odors (OR = 2.4, 95% Cl = 1.4-4.2), using inhaled corticosteroids (ICS) (OR = 2.2, 95% Cl = 1.2-4.0), and young age group (1-5 vs. 13-16 years) (OR = 2.7, 95% Cl = 1.1-6.4). More 1-5 year-olds (63.8%) and 6-12-year-olds (60.2%) wheezed in the dry and wet seasons, respectively (p = 0.04). Follow-up was poor (32.3%), and disease management did not include educational interventions. CONCLUSIONS: Repeated ER use in pediatric asthma underscores a pressing need for health providers and caregivers to develop an asthma management plan noting the identified predictors to assist in reducing Trinidad's asthma burden.     

A comprehensive inner-city asthma program reduces hospital and emergency room utilization.

OBJECTIVE: To evaluate the efficacy of a comprehensive asthma program on emergency department (ED) visits and hospital admission rates in an inner-city pediatric population. DESIGN: A12-month prospective randomized trial. METHODS: Three hundred asthma patients, ages 2 to 17 years, were recruited and randomized in an inner-city pediatric ED, to obtain asthma care in a specialty clinic or to continue receiving care by other health resources. The specialty clinic provided intensive medical and environmental control, education, close monitoring, and 24-hour availability. For the prospective study, monthly questionnaires were sent to the caregivers of these children to evaluate use of hospital facilities for asthma care. For the retrospective study, use of hospital resources by the study participants was analyzed using a hospital database. RESULTS: One hundred twenty-nine patients (60 in the treatment group and 69 in the control group) were included in the final analysis. Asthma severity index was significantly higher for the patients in the treatment versus the control group (35% versus 16.2%, P = .05). Fewer patients in the treatment group visited the ED at least once during the first study year, 32 versus 46, (P = .11), and they made fewer visits, 73 versus 269. The mean number of ED visits of the patients who used the ED was 0.1 versus 0.326 for the control group (P = .01). There were also fewer admissions in the treatment group, 22 versus 29 (P < .59). The 53 patients remaining in the treatment group in the second study year made fewer visits to the ED versus the control group (P < .03). In comparison to the first year, fewer patients in the treatment group visited the ED or were hospitalized in the second year (P = .007 and P = .04, respectively). CONCLUSIONS: A comprehensive asthma care program is efficacious in reducing hospital utilization.     

A modified pulmonary index score with predictive value for pediatric asthma exacerbations.

BACKGROUND: Several clinical asthma scores have been derived from combinations of physical findings in pediatric asthmatic patients. OBJECTIVE: To test the reproducibility and validity of one such score, the Modified Pulmonary Index Score (MPIS), and to evaluate its predictive value in children hospitalized for asthma. METHODS: In the MPIS, 6 categories are evaluated: oxygen saturation, accessory muscle use, inspiratory to expiratory flow ratio, degree of wheezing, heart rate, and respiratory rate. For each of these 6 measurements or observations, a score of 0 to 3 is assigned. To evaluate the reproducibility of the MPIS, inpatients with status asthmaticus were examined by an attending physician, nurse, and respiratory therapist who were blinded to the other observers' scores. To evaluate the validity of the MPIS as a scale of severity of illness in asthmatic patients, the score at admission was compared with selected outcomes in the same patients. RESULTS: A total of 30 patients participated in this study (mean +/- SD age, 7.6 +/- 5.5 years). Our finding revealed that the MPIS is highly reproducible with a high degree of interrater reliability across caregiver groups (physician to nurse: r = 0.98; 95% confidence interval [CI], >0.96; physician to respiratory therapist: r = 0.95; 95% CI, >0.92; nurse to respiratory therapist: r = 0.94; 95% CI, >0.90). The admission MPIS positively correlated with intensive care unit admission (P < .001), days of continuous albuterol therapy (P = .002), days of supplemental oxygen (P = .002), and length of hospital stay (P = .004). CONCLUSIONS: The MPIS is a highly reproducible and valid indicator of severity of illness in children with asthma. To our knowledge, this is the first pediatric clinical asthma score demonstrated to be reproducible across groups of health care professionals who treat pediatric patients with asthma.     

Symptom monitoring in childhood asthma: a randomized clinical trial comparing peak expiratory flow rate with symptom monitoring.

BACKGROUND: Accurate symptom evaluation is a critical component of asthma management. Limited data are available about the accuracy of symptom evaluation by children with asthma and their parents, or the impact of various symptom-monitoring strategies on asthma morbidity outcomes. OBJECTIVE: The purpose of this randomized clinical trial was to evaluate the effect of three different intensities of symptom monitoring on asthma morbidity outcomes. METHODS: One hundred sixty-eight children (ages 6 to 19) of diverse racial, geographic, and socioeconomic backgrounds were randomized to 1 of 3 treatment groups (subjective symptom evaluation, symptom-time peak expiratory flow rate (PEFR) monitoring, daily PEFR monitoring) in this longitudinal, clinical trial. Outcome measures included a summary asthma severity score, forced expiratory volume in 1 second, symptom days, and health care utilization. RESULTS: Children who used PEFR meters (PFMs) when symptomatic had a lower asthma severity score, fewer symptom days, and less health care utilization than children in the other two treatment groups. Minority and poor children had the greatest amount of improvement using PFMs when symptomatic. Results were much less striking in white families. Thirty percent of families in the PFM treatment groups discontinued use entirely by 1 year postexit, whereas the majority of families who continued use (94%) used them only when symptomatic to inform symptom interpretation and management decisions. CONCLUSIONS: Not every child with asthma needs a PFM. Children and families facing extra challenges as a result of illness severity, sociodemographic, or health care system characteristics clearly benefited most from PFM use.