Concordance of Provider Chart Notation and Guideline-Based Classification of Asthma Severity.

Objective: To evaluate concordance of asthma severity classification via physician chart notation compared with guideline-based criteria in adolescents with diagnosed asthma.Design/Methods: Of 284 urban primary care and subspecialty clinic patients aged 13-18 years approached through convenience sampling, 203 surveys were completed (RR = 71.5%). We assessed concordance with sensitivity, specificity, and positive predictive values; overall agreement was evaluated with weighted kappa coefficients and McNemar's test.Results: When considering prescribed treatment according to NAEPP guidelines as a gold standard, the sensitivity for chart notation was very good for intermittent (95%) and less for non-intermittent severity ratings (51%, 58%, and 67% for moderate, severe, and mild persistent asthma, respectively). Overall agreement between chart notation and guideline-based asthma criteria ranged from fair-to-good for mild- (k = 0.36), moderate- (k = 0.44), and severe-persistent severity (k = 0.66). Although the agreement for intermittent severity was highest (k = 0.88), it did not significantly differ by between the two classifications (p > 0.05).Conclusions: Concordance for all non-intermittent asthma severity classifications varied between physician and medication-driven 2007 NAEPP guideline classifications in an ethnically diverse urban adolescent patient sample. Physicians should remain aware of the potential for this discordance and refer to the guidelines to classify and treat adolescents with asthma.

SARS-CoV-2 pandemic effect on pediatric asthma health care utilization in an urban hospital.

Background: The "September epidemic" is a well-described phenomenon of increased pediatric asthma-related health care utilization from August to September each year. The coronavirus disease 2019 (COVID-19) pandemic has brought about significant changes in health care utilization, warranting an investigation into its impact on the September epidemic. Objective: Our aim was to identify the impact of COVID-19 in asthma-related health care utilization, specifically in the September epidemic. Methods: Our study involved a retrospective analysis of data from a Children's Hospital in New York City. We compared the change in asthma-related health care utilization during August and September 2020 with the average change in utilization during the same period in 2017-2019 and 2021-2022. Stratified analyses based on age and sex were conducted by using chi-square tests to determine variations in health care utilization. Results: During September 2020, there was a marked reduction in emergency department (ED) visits related to asthma, with only a 6% rise from the preceding month. This stands in contrast to the observed increases from 89% to 193% in the other years studied (P < .05 for all). This pattern was seen in both sexes and in children under 13 years old (P < .05). No significant variation was found for those older than 13 years (P > .05). Conclusions: Despite an overall reduction in health care utilization over the first year of the COVID-19 pandemic, the decline in ED visits related to asthma during the September epidemic was significantly more pronounced. These results suggest that there may be remediable risk factors contributing to the September epidemic that can be used to guide future interventions for managing pediatric asthma.

ASTHMAXcel PRO patient satisfaction and usability field testing.

Background: ASTHMAXcel PRO, an enhanced version of the ASTHMAXcel mobile application, has been developed to deliver comprehensive, guideline-based asthma education while also facilitating the collection of patient-reported outcomes (PROs) and enhancing user experience.Objective: To perform field testing and conduct formative and summative evaluation of the ASTHMAXcel PRO application to assess its impact on patient satisfaction, usability, and usage.Methods: Twenty-eight adult patients completed a baseline visit during which ASTHMAXcel PRO was introduced, health literacy was assessed, and demographic data were collected. They were instructed to use the app for 4 weeks. The Questionnaire for User Interface Satisfaction (QUIS) and the Unified Theory of Acceptance and Use of Technology (UTAUT) questionnaire were administered at baseline and 4 weeks to assess user satisfaction and technology acceptance, respectively. Semi-structured interviews were conducted to gather feedback regarding the application from patients.Results: The baseline total scores were high for both UTAUT and QUIS (mean (SD): 64.2 (10.1), 6.8 (2.2) respectively) indicating that user satisfaction and acceptance began at high levels. UTAUT total score, as well as all domain scores, improved significantly from baseline to 4 weeks (p < 0.02). QUIS total score along with several domain scores (screen, system capabilities, usability) also increased from baseline to 4-weeks (p = 0.03, 0.01, 0.03, 0.01, respectively). These improvements remained significant when adjusting for age, gender, education, and health literacy. Patients reported that the application was helpful, informative, and easy to understand and use.Conclusion: The significant increases in satisfaction and technology adoption observed among ASTHMAXcel PRO users demonstrate that the application is viable and has the potential to improve upon usability challenges faced by existing mobile health applications.

Unmet Social Needs and Pediatric Asthma Severity in an Urban Primary Care Setting.

OBJECTIVE: Community-level social determinants of health impact asthma outcomes among children; however, individual patient's priorities are not often included in designing social care interventions. Identifying connections between patient-prioritized unmet social needs and asthma severity status may allow for improved patient-centered approaches to asthma management. In this analysis, we examined the association between unmet social needs and asthma severity in an urban population of children. We hypothesized that those with a greater number of unmet social needs would report a more severe asthma status. METHODS: We conducted a secondary analysis of 4887 patients screened for unmet social needs and asthma severity status. Bivariate associations and adjusted logistic regression modeling were used to assess the association between unmet social needs and asthma severity. RESULTS: Persistent asthma severity status was associated with several unmet social needs, including housing quality and stability, lack of money for food, transportation, and healthcare costs. In the multivariable analysis, having 3 or more unmet social needs was associated with a 59% greater odds of persistent asthma status (CI, 1.18-2.14; P = .002), and having 2 unmet social needs was associated with a 33% greater odds of persistent asthma status (CI, 1.00-1.78; P = .05). CONCLUSIONS: Unmet social needs were associated with asthma severity status, with a greater number of unmet social needs associated with greater odds of severe asthma status. Additional studies are warranted to further evaluate the temporal relationship between unmet social needs and how they may compound one another in their relationship with asthma severity.

Measurement of adherence to inhaled corticosteroids by self-report and electronic medication monitoring.

OBJECTIVE: Poor adherence to daily inhaled corticosteroids (ICS) is an important factor contributing to asthma morbidity. Assessing adherence in clinical settings using self-reported adherence often overestimates actual adherence. Electronic monitoring devices (EMDs) are objective means of assessing adherence, but are not routinely used in practice. Here, we aimed to establish adherence rates to ICS using EMDs in an inner-city, minority population in the Bronx, NY, and to compare two methods of self-reported adherence with EMD-measured adherence. METHODS: Patients with physician-confirmed persistent asthma and daily ICS prescription were recruited. Self-reported adherence to ICS was measured by parental report for children and self-report for adults and the Medication Adherence Report Scale for Asthma (MARS-A). Two weeks after enrollment, EMD data were accessed for analysis. Daily adherence was calculated based on the number of puffs actuated per day as captured by EMD divided by the prescribed number of puffs. RESULTS: 41 children and 40 adults participated. Median EMD-measured ICS adherence was 41% (children) and 43% (adults). This was significantly lower than the median self-reported adherence (100% for children, p < 0.001; 100% for adults, p < 0.001). MARS-A score in children did not correlate with EMD adherence data (p = 0.18), while in adults, this correlation tended to be more consistent (p = 0.07). CONCLUSIONS: Adherence to daily ICS as measured using EMD is low in this population. In both adults and children, self-reported adherence was a poor indicator of true adherence. Further efforts using objective measures of medication adherence for patients with high asthma morbidity may be warranted to guide therapeutic decisions.

Going mobile with primary care: smartphone-telemedicine for asthma management in young urban adults (TEAMS).

BACKGROUND: The majority of adults with persistent asthma have chronically uncontrolled disease and interventions to improve outcomes are needed. We evaluated the efficacy, feasibility, and acceptability of a multi-component smartphone-telemedicine program (TEAMS) to deliver asthma care remotely, support provider adherence to asthma management guidelines, and improve patient outcomes. METHODS: TEAMS utilized: (1) remote symptom monitoring, (2) nurse-led smartphone-telemedicine with self-management training for patients, and (3) Electronic medical record-based clinical decision support software. Adults aged 18-44 (N = 33) and primary care providers (N = 4) were recruited from a safety-net practice in Upstate New York. Asthma control, quality of life, and FEV1 were measured at 0, 3 and 6 months. Acceptability was assessed via survey and end-of-study interviews. Paired t-test and mixed effects modeling were used to evaluate the effect of the intervention on asthma outcomes. RESULTS: At baseline, 80% of participants had uncontrolled asthma. By 6-months, 80% classified as well-controlled. Improvements in control and quality of life were large (d = 1.955, d = 1.579). FEV%pred increased 4.2% (d = 1.687) with the greatest gain in males, smokers, and lower educational status. Provider adherence to national guidelines increased from 43.3% to 86.7% (CI = 22.11-64.55) and patient adherence to medication increased from 45.58% to 85.29% (CI = 14.79-64.62). Acceptability was 95.7%; In follow up interviews, 29/30 patients and all providers indicated TEAMS worked better than usual care, supported effective self-management, and reduced symptoms over time, which led to greater self-efficacy and motivation to manage asthma. DISCUSSION: Based on these findings, we conclude that smartphone telemedicine could substantially improve clinical asthma management, adherence to guidelines, and patient outcomes.

A randomized controlled trial of a community health worker delivered home-based asthma intervention to improve pediatric asthma outcomes.

OBJECTIVE: The objective of this study was to evaluate the effects of using Community Health Workers (CHWs) to deliver the home-based Wee Wheezers asthma education program on asthma symptoms among children with persistent asthma. METHODS: In this randomized controlled trial of 151 children aged 2-9 years with persistent asthma, we assigned 75 to the intervention and 76 to the control. The primary outcome was caregiver-reported asthma symptom days. Secondary outcomes included asthma-related healthcare utilization, caregivers' asthma knowledge, illness perception and management behaviors, MDI-spacer administration technique, and home environmental triggers. Outcomes were collected at baseline, 3, 6, 9 and 12 months. A repeated measurements analytic approach with generalized estimating equations was used. To account for missing data, multiple imputation methods were employed. RESULTS: At 3 and 6 months, improvement in symptom days was not significantly different between groups. However, at 9 and 12 months, the reduction in asthma symptom days was 2.15 and 2.31 days more respectively for those in the intervention group compared to the control. Improvements in MDI-spacer technique, knowledge and attitudes were significant throughout follow-up. Improvement in habits regarding MDI use was significant at 3 and 6 months, and asthma routines were improved at 3 months. However, there was no change in asthma-related healthcare utilization or home environmental triggers. CONCLUSION: Using CHWs to deliver a home-based asthma education program to caregivers of children with persistent asthma led to improvements in symptom days and several secondary outcomes. Expanding the use of CHWs to provide home-based interventions can help reduce disparities in children's health outcomes.

Severe asthma in adult, inner-city predominantly African-American and latinx population: demographic, clinical and phenotypic characteristics.

INTRODUCTION: The burden of asthma morbidity with co-existing atopy among the racial/ethnic minorities in the socio-economically disadvantaged NYC borough of the Bronx is unusually high. The multidisciplinary Montefiore Asthma Center (MAC) provides guideline-based treatment to this high-risk population through the joint efforts of Allergists/Immunologists, Pulmonologists, and on-site health educators. METHODS: The objective of this prospective, observational study was to define the demographic and clinical characteristics of severe asthma, evaluate improvement in asthma severity and lung function through the course of treatment at the MAC, and describe the asthma phenotypes of the patients managed at the MAC. Adults with severe asthma receiving treatment at the MAC were followed from their first to their last visit at the MAC. Patient demographics, along with asthma severity and co-existing allergies, were assessed. Possible phenotypes were defined (based on presence or absence of atopy, age at asthma onset, and blood eosinophil counts). RESULTS: 227 patients were included in the final analysis, of which 55.5% were Hispanic and 33.9% identified as non-Hispanic Black. Ninety-one percent (91%) of our cohort was found to be atopic and allergic rhinoconjunctivitis (ARC) was the most commonly identified co-existing allergic condition (86.3%). Mean Asthma Control Test (ACT) scores improved from 11.1 (± 4.9) at the initial visit to 14.8 (± 6.1) at the last visit. The spirometric values did not improve despite treatment at MAC. CONCLUSION: A multidisciplinary severe asthma center is an ideal setting to phenotype patients and offer personalized guideline-based management and education to adults with severe asthma.

A randomized trial of a one-time pest intervention: impact on childhood asthma outcomes.

Objectives: To evaluate the effects of a one-time, apartment-level Integrated Pest Management (IPM) intervention on healthcare utilization and asthma symptoms among children with persistent asthma living in households with a pest infestation.Study design: In a randomized controlled trial of 384 children aged 5-12 years with persistent asthma, we assigned 183 to receive IPM and 197 to usual care (UC). The primary outcome was healthcare utilization from hospital and Medicaid claims records. Secondary outcomes included caregiver-reported asthma symptoms, pest infestation levels, missed days of school due to asthma, and rescue medication use.Results: The entire cohort improved over the study period, with significant but equivalent declines in mean healthcare utilization in both groups. IPM group had fewer days with reduced activity due to asthma (p = 0.04) and larger declines that fell short of statistical significance in asthma symptom days (p = 0.22), severe symptoms (p = 0.16), missed school (p = 0.27) and rescue medication use (p = 0.27). Both roach (p = 0.001) and mice (p = 0.11) infestations decreased much more in the IPM group than the UC group.Conclusions: After a one-time, apartment-level IPM intervention, we found no difference in health care utilization, but fewer days of reduced activity and consistent suggestive evidence of clinically meaningful improvements relative to usual care across other secondary outcomes. Coupled with the established effectiveness of IPM in reducing allergens and scientific consensus on pest-related allergens as asthma triggers, these findings support adding home pest control to traditional medical management of children with severe asthma.

Development and preliminary results of an Electronic Medical Record (EMR)-integrated smartphone telemedicine program to deliver asthma care remotely.

INTRODUCTION: Technology-based interventions that can function within real-world practice and improve outcomes without increasing provider burden are needed, yet few successfully cross the research-to-practice divide. This paper describes the process of developing a clinically integrated smartphone-telemedicine program for adults with asthma and results from proof-of-concept testing. METHODS: We used a contextually grounded intervention development approach and May's implementation theory to design the intervention, with emphasis on systems capabilities and stakeholder needs. The intervention incorporated symptom monitoring by smartphone, smartphone telemedicine visits and self-management training with a nurse, and clinical decision-support software, which provided automated calculations of asthma severity, control and step-wise therapy. Seven adults (aged 18-40 y) engaged in a 3-month beta-test. Asthma outcomes (control, quality of life, FEV1) and healthcare utilisation patterns were measured at baseline and end-of-study. RESULTS: Each participant averaged four telemedicine visits (94% patient satisfaction). All participants had uncontrolled asthma at baseline; end-of-study 5/7 classified as well-controlled. Mean asthma control improved 1.55 points (CI = 0.59-2.51); quality of life improved 1.91 points (CI = 0.50-3.31), FEV1 percent predicted increased 14.86% (CI = -3.09-32.80): effect sizes of d = 1.16, 1.09, and 0.96, respectively. Preventive healthcare utilisation increased significantly (1.86 visits/year vs. 0.28/year prior, CI 0.67-2.47) as did prescriptions for controller medications (9.29 prescriptions/year vs. 1.57 prescriptions/year, CI 4.85-10.58). DISCUSSION: Smartphone telemedicine may be an effective means to improve outcomes and deliver asthma care remotely. However, careful attention to systems capabilities and stakeholder acceptability is needed to ensure successful integration with practice.Clinical Trials registration #: NCT03648203.

A mixed-methods analysis of younger adults' perceptions of asthma, self-management, and preventive care: "This isn't helping me none".

BACKGROUND: Young adults (ages 18-44) have increased emergency department use for asthma and poor adherence to medications. The objective of this mixed-methods study was to understand experiences with and approaches to managing asthma, of which little is known in this age group. METHODS: Surveys (Asthma Control Questionnaire, Asthma Quality of Life Questionnaire) and 1:1 semi-structured interviews were used to explore experiences with asthma, symptoms, self-management behaviours, and relationship to asthma control and quality of life. Qualitative data were analysed using content analysis techniques. Descriptive statistics and bivariate correlations were used to examine distributive characteristics and associations between variables. RESULTS: Forty urban adults participated (mean age 32.7 ± 6.2, 1σ). Coughing was reported nearly 46% more often than wheezing, with 42.5% (17/40) coughing until the point of vomiting most days. Most participants delayed using medication for symptoms due to misperceptions about inhalers. Higher symptom frequency and worse asthma control were associated with greater use of non-pharmacologic symptom management strategies (r = 0.645, P < .001; r = 0.360, P = .022, respectively). Five themes were identified regarding young adults experiences with asthma: (1) having asthma means being limited and missing out on life; (2) health care for asthma is burdensome, and other things are more important; (3) there is not enough personal benefit in medical interactions to make preventive care worthwhile; (4) there are insufficient support and education about asthma for adults; and (5) people normalize chronic symptoms over time and find ways of coping that fit with their lifestyle. CONCLUSIONS AND CLINICAL RELEVANCE: Young adults may tolerate symptoms without using quick-relief medication or seeking preventive care. Increasing engagement with preventive services will require decreasing perceived burdens and increasing the personal benefits of care. Evaluating for non-pharmacologic approaches to managing symptoms and asthma-related coughing may identify uncontrolled asthma. Enhanced training for clinicians in patient-centric asthma care may be needed.

Developing and evaluating ASTHMAXcel adventures: A novel gamified mobile application for pediatric patients with asthma.

BACKGROUND: The ASTHMAXcel mobile application has been linked to favorable outcomes among adult patients with asthma. OBJECTIVE: To assess the impact of ASTHMAXcel Adventures, a gamified, guideline-based, pediatric version on asthma control, knowledge, health care utilization, and patient satisfaction. METHODS: Pediatric patients with asthma received the ASTHMAXcel Adventures mobile intervention on-site only at baseline (visit 1), 4 months (visit 2), and 6 months (visit 3). The asthma control test, asthma illness representation scale-self-administered, pediatric asthma impact survey, and Client Satisfaction Questionnaire-8 were used to assess asthma control, knowledge, and patient satisfaction. Patients reported the number of asthma-related emergency department (ED) visits, hospitalizations, and oral prednisone use. RESULTS: A total of 39 patients completed the study. The proportion of controlled asthma increased from visit 1 to visits 2 and 3 (30.8% vs 53.9%, P = .04; 30.8% vs 59.0%, P = .02), and largely seen in boys. The mean asthma illness representation scale-self-administered scores increased from baseline pre- to postintervention, with sustained improvements at visits 2 and 3 (3.55 vs 3.76, P < .001; 3.55 vs 3.80, P = .001; 3.55 vs 3.99, P < .001). The pediatric asthma impact survey scores improved from baseline to visits 2 and 3 (43.33 vs 34.08, P < .001; 43.33 vs 31.74, P < .001). ED visits and prednisone use significantly decreased from baseline to visits 2 and 3 (ED: 0.46 vs 0.13, P = .03; 0.46 vs 0.02, P = .02; prednisone use, 0.49 vs 0.13, P = .02; 0.49 vs 0.03, P = .003. Satisfaction was high with mean client satisfaction questionnaire score of approximately 30 (out of 32) at all visits. CONCLUSION: ASTHMAXcel Adventures improved asthma control, knowledge, and quality of life, and reduced ED visits and prednisone use with high satisfaction scores.

Improving teacher comfort and self-efficacy in asthma management.

Background: Asthma is common among urban school-age children. Though teachers should be prepared to assist children during an asthma attack, studies show they lack self-efficacy in managing asthma.Objective: To assess feasibility of implementing an asthma workshop for elementary school teachers, describe themes of questions raised, and determine workshop's impact on teachers' comfort and self-efficacy in asthma management.Methods: We developed and implemented an asthma workshop for teachers from four Bronx elementary schools (2012-2014). Teachers completed a questionnaire evaluating their comfort and self-efficacy in asthma management before and after the workshop. Questions asked during the sessions were recorded and analyzed for themes. Paired t-test and McNemar tests compared before/after scores.Results: 65 out of 70 teachers (92.9%) participated in the educational sessions. Teachers asked questions about school policy for inhalers, medication administration guidelines, and physical activity and asthma. 64/65 (98.5%) teachers completed pre/post surveys (mean age 39.7 years; mean years at the school 8.0). Post-intervention, more teachers reported knowing how to manage an asthma attack (93.8% vs. 64.1%, p < .0001); and felt comfortable assessing (50.8% vs. 30.8%, p = 0.019) and handling an asthma attack (52.3% vs. 33.8%, p = .023). The overall mean self-efficacy score increased post-intervention (43.0 vs. 38.1, p < .0001), as did 8/12 individual self-efficacy items. Post-workshop, 95.3% of teachers agreed that teacher in-service asthma education should be done annually.Conclusions: An asthma workshop was successfully implemented in the school setting and improved teacher comfort and self-efficacy in managing asthma. Annual training may improve teachers' confidence in assisting students with asthma.

Longitudinal trends in asthma emergency department visits, pollutant and pollen levels, and weather variables in the Bronx from 2001-2008.

Objective: To evaluate how asthma-related emergency department visits (AREDV), air pollutant levels, pollen counts, and weather variables changed from 2001 to 2008 in the Bronx, NY. Methods: 42,065 daily AREDV values (1 January 2001 to 31 December 2008) were collected using our institution's Clinical Looking Glass software. Daily values of sulfur dioxide (SO2), carbon monoxide (CO), ozone (O3), nitrogen dioxide (NO2), temperature, and humidity were obtained from the National Climatic Data Center's Bronx station. Daily tree pollen counts were obtained from the Armonk counting station near the Bronx. Median values for each variable were analyzed using the Mann-Whitney test to compare 2001-2004 and 2005-2008 values. Simple linear regression examined associations between AREDV and individual pollutants. Due to seasonal variations of the variables, each season was considered separately. Results: There were significant decreases for AREDV, SO2, CO, and humidity for all seasons, and for NO2 in the spring and winter. Significant increases occurred for O3 in the spring, fall, and winter; for temperature in the summer and winter; and for tree pollen in the spring. Significant positive associations were found between AREDV and SO2, CO, NO2, and humidity, respectively, while significant negative associations were found between AREDV and O3 and temperature, respectively. Conclusions: From 2001 to 2008, significant: a) decreases in AREDV, SO2, CO, and humidity for all seasons, and decreases in NO2 for the spring and winter; and b) increases in O3, temperature, and spring tree pollen were observed. By tracking and anticipating environmental and pollutant changes, efforts can be made to minimize AREDV.

Do Urban Minority Parents and Children Agree on Asthma Symptoms with Exercise, Worries, and Confidence in Disease Management?

OBJECTIVE: Providers commonly rely on parent reports of a child's asthma symptoms; however, children as young as 7 years can report on their own health. Our study compared parent and child reports of asthma symptoms with exercise, worries about developing an asthma attack, and confidence in disease management. METHODS: We recruited children ages 7 to 10 years with asthma from 4 Bronx, NY, schools, as well as their parents. The parents and children completed interview surveys with parallel questions regarding perceived asthma symptoms, asthma-related worries, and confidence in disease management. We used McNemar tests for paired data to compare parent and child responses. RESULTS: We analyzed data for 105 parent-child pairs. Mean child age was 8.5 years (standard deviation, 0.99); 53% were male, and 82% were Hispanic. Children were more likely than their parents to report ever having an exercise-induced asthma attack (85% vs 48%; P < .001) and that they "worry a lot" about developing an asthma attack during exercise (63% vs 45%; P = .01). Children felt more confident about using an inhaler correctly (76% of the children were "very sure" vs 60% of the parents; P = .009) and were more likely to report having an inhaler available in case of an attack (38% of the children were "very sure" vs 20% of the parents; P = .003). CONCLUSIONS: In this school-based sample of urban children with asthma, we found disagreement between parent and child reports of symptoms with exercise, worry about developing an attack, and confidence in medication use. These findings suggest that including child reports during history taking could help providers identify children in need of enhanced asthma management.

Asthma management in New York City schools: A physical education teacher perspective.

OBJECTIVE: Physical education (PE) teachers may be the first to assist students with asthma attacks during PE class. This study explores the PE teachers' perspectives on in-school asthma management and barriers to physical activity (PA) in children with asthma attending urban elementary schools. METHODS: We conducted qualitative semi-structured interviews with 16 PE teachers from 10 Bronx, NY elementary schools. Interviews were recorded, transcribed, and independently coded. Content analysis was used to identify 10 major themes common across interviews which were then categorized into 3 domains. RESULTS: Three domains were identified: 1) school procedures and policies for asthma management; 2) role of PE teachers in asthma management; and 3) barriers to PA for students. Most PE teachers were unaware of written procedures for acute asthma management and did not receive asthma-specific training. Many PE teachers expressed confidence regarding asthma management. PE teachers identified students with asthma most commonly through communication with students. The PE teachers utilized various methods to manage asthma but all relied on the nurse to handle acute asthma symptoms. Several barriers to PA were determined, including PE teachers' unawareness of NYS PE requirements, lack of gym facilities, inclement weather, inconsistent PE class time, asthma diagnosis, and having no asthma inhalers at the nurse's office. CONCLUSIONS: PE teachers' perspectives on asthma management may influence the way asthma is handled at school. The results from this study highlight several barriers that can be targeted in future interventions to improve asthma management.

Asthma symptoms, interactive physical play and behavioral and academic outcomes in urban children with persistent asthma.

OBJECTIVES: Asthma may lead to reduced participation in interactive physical play (IPP). Urban youth with asthma are also at risk for behavioral and academic difficulties. Exploring associations between asthma, IPP and socio-emotional and academic outcomes in children with asthma is important. Study objectives are to: (1) describe IPP participation among school children with persistent asthma; (2) determine if IPP varies with asthma severity (3) determine independent associations of both asthma severity and IPP with socio-emotional and academic outcomes. METHODS: We analyzed data from children with persistent asthma enrolled in the SB-TEAM trial (Rochester, NY). Caregiver surveys assessed asthma severity, IPP participation (gym ≥3 days/week, running at recess, sports team participation), socio-emotional and academic outcomes. Bivariate and regression analyses assessed relationships between variables. RESULTS: Of 324 children in the study (59% Black, 31% Hispanic, mean age 7.9), 53% participated in any IPP at school. Compared to those with mild persistent asthma, fewer children with moderate-severe asthma had no limitation in gym (44% vs. 58%, p < .01), and fewer ran at recess (29% vs. 42%, p < .01) or engaged in any IPP (48% vs. 58%, p = .046). Asthma severity was not associated with socio-emotional or academic outcomes. However, children participating in IPP had better positive peer social and task orientation skills, were less shy/anxious, and more likely to meet academic standards (all p < .05). Results were consistent in multivariable analyses. CONCLUSIONS: Urban children with moderate-severe asthma partake in less IPP, which is associated with socio-emotional and academic outcomes. Further efforts are needed to optimize asthmatic children's participation in IPP.

School-based supervised therapy programs to improve asthma outcomes: current perspectives.

BACKGROUND: Asthma is one of the most common chronic diseases of childhood affecting 6.2 million (8.4%) children (<18 years old) in the USA. Asthma is also a leading cause of school absenteeism. Daily administration of preventive asthma medications improves asthma control. However, poor medication adherence is one of the barriers in achieving improved asthma outcomes. School-based supervised asthma therapy programs have been implemented to address this barrier. OBJECTIVES: To conduct a review of the literature on school-based supervised asthma therapy interventions and the effect on outcomes in children with persistent asthma. METHODS: We conducted a literature search using electronic search engines (ie, PubMed and Cochrane) and combinations of different search terms "school-based asthma," "school-based asthma therapy," and "school-based supervised asthma therapy." Inclusion criteria were school-based interventions with supervised asthma medication administration conducted in the USA, measuring asthma outcomes. From 443 titles and abstracts, 9 studies met the inclusion criteria. RESULTS: School-based interventions with supervised asthma medication administration revealed improvement in asthma outcomes, including improved medication adherence, increased symptom-free days, decreased daytime and nighttime symptoms, decreased use of rescue medication, decreased asthma-related health care utilization, fewer exacerbations requiring treatment with prednisone, decreased school absenteeism due to asthma, fewer days of activity limitation, improved quality of life, and improvement in both pulmonary inflammatory markers and peak flow readings. CONCLUSION: Our literature review demonstrated that school-based supervised asthma therapy improves asthma outcomes in urban children with persistent asthma. Schools are an ideal setting for implementation of asthma interventions for children and adolescents.

The Impact of a Clinical Asthma Pathway on Resident Education.

Clinical pathways for asthma management decrease hospital cost and length of stay; however little is known about the educational impact of pathways on residents. Pediatric residents at a children's hospital (N = 114) were invited to complete a 22-item computerized, anonymous survey 6 months before and 6 months after asthma pathway implementation. The survey assessed pathway use and residents (1) pathway knowledge, (2) attitudes and experiences with managing asthma, and (3) perceived educational benefits. Mean pathway knowledge score increased from the case before to the case after implementation [1.5 ± 1.0 versus 2.6 ± 1.3, p < 0.001], as did high preparedness to manage asthma [61% versus 91%, p < 0.001] and electronic order set use [28% versus 80%, p < 0.001]. The top three educational benefits of the pathway endorsed by residents were application of evidence-based medicine (57%), ability to assess exacerbations (52%), and skill at communicating respiratory status (47%). After implementation, residents' knowledge and preparedness to manage asthma improved as well as many endorsed educational benefits.

Parental Perspectives of Barriers to Physical Activity in Urban Schoolchildren With Asthma.

OBJECTIVE: Physical activity (PA) levels are low in today's youth and may even be lower in those with asthma. Barriers to PA have not been well studied in inner-city minority children with asthma. We conducted a qualitative study to characterize parental perceptions of barriers to PA and ways to improve PA levels in children with asthma. METHODS: We used the socioecologic model to inform development of our interview guide. Questions fell into 2 socioecologic model domains: interpersonal (parent, family) barriers and community (neighborhood, school) barriers. Qualitative semistructured interviews were conducted with 23 parents (21 mothers, 2 fathers) of inner-city children with asthma (aged 8-10 years) from 10 Bronx, New York, elementary schools. Sampling continued until thematic saturation was reached. Interviews were recorded, transcribed, and independently coded for common themes. Emerging themes were discussed and agreed on by investigators. RESULTS: Three themes surrounding interpersonal barriers to PA emerged: 1) parental fear of exercise-induced asthma due to lack of child symptom awareness, 2) nonadherence and refusal to take medications, and 3) challenges with asthma management. Four themes around community barriers to PA emerged: 1) lack of trust in school management of asthma, 2) lack of school PA facilities, 3) unsafe neighborhoods, and 4) financial burden of PA. CONCLUSIONS: A complex, multilevel set of barriers to PA exist in children with asthma. Addressing these barriers by involving stakeholders at the family, school, and community levels may improve PA levels in children with asthma.