A Qualitative Understanding of Midlife Sources of Stress and Support in African-American Women.

African-American women suffer from disproportionate adverse health outcomes compared to women of other ethnicities living in the United States. It is suggested in the literature that chron- ic stress can be an antecedent to health disparity. The purpose of this study was to evaluate changes in perceived stress from late pre-menopause to post-menopause and to identify significant life stressors perceived by a cohort of African-American women. Retrospective and current data were used to evaluate perceived stress over time, sources of stress, and resources in a cohort of 15 African-American women. Mixed methodologies were utilized. Perceived stress scores were consistent over time. Six themes were identified in responses about stress: finances, caringforfamily members, relationships, personal health and aging, race and discrimination, and raising children. Understanding the role that unique life stressors play in the lives of African-American women is essential in anticipating the need for assistance and in implementing preventive strategies.

Omalizumab adherence in an observational study of patients with moderate to severe allergic asthma.

BACKGROUND: Adherence to omalizumab is not well characterized and its association with asthma control has not been well established. OBJECTIVE: To evaluate adherence in patients initiating omalizumab in the Epidemiologic Study of Xolair (omalizumab): Evaluating Clinical Effectiveness and Long-term Safety in Patients with Moderate to Severe Asthma (EXCELS) observational study. METHODS: Adherence was assessed over 5 years using the proportion of patients who missed any dose, rates of doses missed, and proportions of patients with good (<10% doses missed) or poor (≥30% doses missed) adherence. Multivariable analyses identified independent predictors of good adherence. Associations between adherence and asthma control were assessed using the minimum important difference for the Asthma Control Test at various time points. RESULTS: A total of 289 patients newly initiated on omalizumab completed 5 years of EXCELS. Of these, 83.0% on the 2-week dosing regimen (n = 152) and 65.0% on the 4-week dosing regimen (n = 137) missed at least 1 dose. More frequent dosing was associated with a larger number of missed doses. Older age (odds ratio per year 1.02, 95% confidence interval 1.01-1.03) and lower prebronchodilator percentage of predicted forced expiratory volume in 1 second (<76; odds ratio 1.88, 95% confidence interval 1.09-3.24) were independent predictors of good adherence. CONCLUSION: Adherence to omalizumab is characterized by distinct factors. Patients receiving the 4-week dosing regimen achieved better adherence than those treated every 2 weeks. Improved adherence could be associated with better asthma control. Age and lung function could interact with dosing frequency to affect patient adherence, thus warranting prospective planning at the time of prescribing to support long-term adherence.

Veteran Affairs Centers of Excellence in Primary Care Education: transforming nurse practitioner education.

To integrate health care professional learners into patient-centered primary care delivery models, the Department of Veterans Affairs has funded five Centers of Excellence in Primary Care Education (CoEPCEs). The main goal of the CoEPCEs is to develop and test innovative structural and curricular models that foster transformation of health care training from profession-specific "silos" to interprofessional, team-based educational and care delivery models in patient-centered primary care settings. CoEPCE implementation emphasizes four core curricular domains: shared decision making, sustained relationships, interprofessional collaboration, and performance improvement. The structural models allow interprofessional learners to have longitudinal learning experiences and sustained and continuous relationships with patients, faculty mentors, and peer learners. This article presents an overview of the innovative curricular models developed at each site, focusing on nurse practitioner (NP) education. Insights on transforming NP education in the practice setting and its impact on traditional NP educational models are offered. Preliminary outcomes and sustainment examples are also provided.

Effect of culturally tailored diabetes education in ethnic minorities with type 2 diabetes: a meta-analysis.

BACKGROUND: Diabetes is a major cause of cardiovascular morbidity and mortality. Ethnic minorities experience a disproportionate burden of diabetes; however, few studies have critically analyzed the effectiveness of a culturally tailored diabetes intervention for these minorities. OBJECTIVE: The aim of this study was to evaluate the effectiveness of a culturally tailored diabetes educational intervention (CTDEI) on glycemic control in ethnic minorities with type 2 diabetes. METHOD: We searched databases within PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), PsycINFO, and ProQuest for randomized controlled trials (RCTs). We performed a meta-analysis for the effect of diabetes educational intervention on glycemic control using glycosylated hemoglobin (HbA(1c)) value in ethnic minority groups with type 2 diabetes. We calculated the effect size (ES) with HbA(1c) change from baseline to follow-up between control and treatment groups. RESULTS: The 12 studies yielded 1495 participants with a mean age of 63.6 years and a mean of 68% female participants. Most studies (84%) used either group education sessions or a combination of group sessions and individual patient counseling. The duration of interventions ranged from 1 session to 12 months. The pooled ES of glycemic control in RCTs with CTDEI was -0.29 (95% confidence interval, -0.46 to -0.13) at last follow-up, indicating that ethnic minorities benefit more from CTDEI when compared with the usual care. The effect of intervention was greatest and significant when HbA(1c) level was measured at 6 months (ES, -0.41; 95% confidence interval, -0.61 to -0.21). The ES also differed by each participant's baseline HbA1c level, with lower baseline levels associated with higher ESs. CONCLUSIONS: Based on this meta-analysis, CTDEI is effective for improving glycemic control among ethnic minorities. The magnitude of effect varies based on the settings of intervention, baseline HbA1c level, and time of HbA1c measurement. More rigorous RCTs that examine tailored diabetes education, ethnically matched educators, and more diverse ethnic minority groups are needed to reduce health disparities in diabetes care.

Determinants of frequency, duration, and continuity of home walking in patients with COPD.

The purpose of this study was to identify determinants of frequency (days per week), duration (minutes per session), and continuity (persistence over 1 year) of home walking in 103 patients with chronic obstructive pulmonary disease (COPD) who participated in a dyspnea self-management program. Dimensions of home walking exercise were measured by logs and reports of biweekly telephone calls with the intervention nurse. The selection of personal, cognitive, and environmental determinants of home walking was guided by social cognitive theory. Participants walked more frequently if they were exercising before they entered the study, had less depressive symptoms, and were living with friends or family. Duration of walks was influenced by supervised exercise training; living with spouse, friends, or family; and physical conditioning. Participants who walked most consistently over the course of the year had more supervised exercise sessions as part of the dyspnea self-management program, exercised regularly before entering the program, and perceived a gain in social support over the year. These findings can be used to tailor exercise interventions to the specific needs of patients and improve the likelihood of consistent exercise participation.

Barriers to patient-clinician collaboration in asthma management: the patient experience.

OBJECTIVE: To describe what adult patients with asthma report about their experiences with their own self-management behavior and working with their clinicians to control asthma. METHODS: The study sample consisted of 104 patients with persistent asthma participating in a clinical trial on asthma monitoring. All subjects were seen by primary care clinicians of a large, academic medical center. This qualitative post hoc analysis examined the views of adults with asthma about their asthma-related health care. Patients attended monthly visits as part of their study participation, during which data were derived from semistructured interviews. All patients included in this analysis participated in the study for 1 year. At the end of study participation, patients were asked to complete an evaluation of their clinician's communication behavior. All study clinicians were also asked to complete a self-evaluation of their own communication behavior. RESULTS: Five major themes of barriers to successful self-management were identified, including personal constraints, social constraints, communication failures, medication issues, and health care system barriers to collaboration with their clinicians. Patients most frequently reported lack of communication surrounding issues relating to day-to-day management of asthma (31%) and home management of asthma (24%). Clinicians generally rated themselves well for consistency in showing nonverbal attentiveness (89%) and maintaining interactive conversations (93%). However, only 30% of clinicians reported consistency in helping patients make decisions about asthma management and only 33% of clinicians reported consistency in tailoring medication schedules to the patient's routines. CONCLUSION: These findings emphasize the difficulties of establishing and maintaining a therapeutic partnership between patients and clinicians. The results underscore the need for system-wide interventions that promote the success of a therapeutic patient-clinician relationship in order to achieve long-term success in chronic disease management.

Individualized asthma self-management improves medication adherence and markers of asthma control.

BACKGROUND: Adherence to inhaled anti-inflammatory therapy and self-management skills are essential parts of the asthma treatment plan to improve asthma control and prevent exacerbations. Whether self-management education improves long-term medication adherence is less clear. OBJECTIVE: A 24-week prospective, randomized controlled trial was performed to study the effect of self-management education on long-term adherence to inhaled corticosteroid (ICS) therapy and markers of asthma control. METHODS: After stabilization on ICS medication during a run-in phase, 95 adults with moderate-to-severe asthma were recruited from a large metropolitan community, and 84 were randomized to individualized self-management education, including self-monitoring of symptoms and peak flow or usual care with self-monitoring alone. The key components of the 30-minute intervention were asthma information, assessment, and correction of inhaler technique; an individualized action plan based on self-monitoring data; and environmental control strategies for relevant allergen and irritant exposures. The intervention was personalized based on pulmonary function, allergen skin test reactivity, and inhaler technique and reinforced at 2-week intervals. RESULTS: Participants randomized to the self-management intervention maintained consistently higher ICS adherence levels and showed a 9-fold greater odds of more than 60% adherence to the prescribed dose compared with control subjects at the end of the intervention (P = .02) and maintained a 3-fold greater odds of higher than 60% adherence at the end of the study. Perceived control of asthma improved (P = .006), nighttime awakenings decreased (P = .03), and inhaled beta-agonist use decreased (P = .01) in intervention participants compared with control subjects. CONCLUSION: Our results show that individualized asthma self-management education attenuates the usual decrease in medication adherence and improves clinical markers of asthma control.

Meeting a primary care challenge in the United States: chronic illness care.

Leading health care experts in the United States have stated that the greatest primary care challenge today is meeting the complex needs of patients with chronic illness/long-term conditions or impairment.To address this challenge, there is a need for health care system redesign that requires a multidisciplinary team approach, including active participation from professional nurses. In particular, it is essential for advanced practice nurses to provide leadership in health systems design for which they are specifically trained and experienced. In this article, the primary care challenge related to chronic illness care management is addressed. Future implications for community-based, chronic illness care delivery and the education of future health care providers with a focus on advanced practice nurses will also be discussed.

Leukocyte Telomere Length in Postmenopausal Women.

OBJECTIVE: To compare leukocyte telomere length (LTL) by race and describe demographic, health, and psychosocial factors associated with LTL in postmenopausal women. DESIGN: Descriptive study with comparative analyses and correlations. SETTING: Data were collected at the University of California-San Francisco, San Francisco Clinical and Translational Science Institute. PARTICIPANTS: Thirty-nine African American and White postmenopausal women between 58 and 65 years of age (mean age = 61.3 ± 1.83 years). METHODS: Measures included demographics, blood pressure, anthropometrics, scores on the Perceived Stress Scale and the Center for Epidemiologic Studies-Depression, and blood samples for LTL. RESULTS: African American women (n = 14) had greater PSS-10 and CES-D scores, greater blood pressure, and greater body mass index than White women (n = 25; p < .05), but LTL did not significantly differ between the two groups. Age was inversely related to LTL (r = -.355, p < .05). After age and race were controlled, fewer children (p = .005) and greater perceived stress (p = .036) were related to shorter LTL. CONCLUSION: Findings from this small sample support the association between age and LTL. The association between perceived stress, number of children, and shorter LTL in postmenopausal women requires further research and replication of findings in a larger, more diverse sample.

Symptom Clusters Change Over Time in Women Receiving Adjuvant Chemotherapy for Breast Cancer.

CONTEXT: Patients with breast cancer receiving chemotherapy (CTX) experience multiple concurrent symptoms, but little is known about how symptoms change during and after treatment. Knowledge of the identity and trajectory of symptom clusters (SCs) would enhance measurement and management. OBJECTIVES: We aimed to identify SCs and their change over time from baseline to completion of breast cancer CTX. METHODS: SCs were identified and assessed for change in 219 women from Nebraska at four times: baseline, during cycles #3 and #4 of CTX, and one month after finishing CTX. Ten symptoms were measured: two using the Hospital Anxiety and Depression Scale and eight using the Symptom Experience Scale. Exploratory factor analysis was conducted at each time point, then changes in SCs were evaluated at different times. RESULTS: Two SCs were identified before and after initiating CTX: gastrointestinal and treatment-related. The number and type of symptoms in each cluster differed over time. Clusters were dynamic during CTX with changes in the number and type of symptoms. Only one treatment-related SC, which consisted of fatigue, pain, and sleep disturbance, was identified after CTX completion. CONCLUSION: SCs during CTX appear to be dynamic, changing over time from before until after CTX completion. Repeated assessments of SCs reveal symptoms that are present and when patients are most burdened and in need of additional support.

Effects of treatment on two types of self-efficacy in people with chronic obstructive pulmonary disease.

Self-management is crucial in people with chronic diseases, and self-efficacy has been shown to impact patients' self-management. The purposes of this study were to 1) determine the effect of intervention on self-efficacy and 2) determine the relationship between domain-specific self-efficacy, walking performance, and symptom severity in patients with chronic obstructive pulmonary disease (COPD). Subjects (n=102, forced expiratory volume in 1 second % predicted 44.8+/-14) received one of three self-management interventions. Self-efficacy for walking and managing shortness of breath, walking performance, and shortness of breath severity were measured at baseline and after intervention. Self-efficacy increased after intervention (P<0.01). Self-efficacy for walking was positively related to walking performance (P<0.05). Self-efficacy for managing shortness of breath was positively related to symptom severity (P<0.05). This study examined two types of disease-specific self-efficacy in patients with COPD and demonstrated that improving self-efficacy is an important outcome of self-management interventions. Studies in other domains of self-efficacy are needed.

Perception of Risk for Developing Diabetes Among Foreign-Born Spanish-Speaking US Latinos.

PURPOSE: The purpose of the study was to describe perception of risk for developing diabetes among foreign-born Spanish-speaking US Latinos. METHODS: Participants (N = 146), recruited at food-pantry distribution events and free clinics, were surveyed using the Risk Perception Survey for Developing Diabetes in Spanish. Type 2 diabetes risk factors measured included body mass index, physical activity, and A1C. RESULTS: Sample characteristics were mean (SD) age of 39.5 (9.9) years, 58% with less than a high school graduate-level education, and 65% with a family income less than $15,000/year. Prevalence of risk factors was 81% overweight or obese, 47% less than 150 minutes/week moderate/vigorous-intensity physical activity, and 12% A1C consistent with prediabetes. Of the 135 participants with complete data, 31% perceived a high/moderate risk for developing diabetes. In univariate logistic regression analyses, 9 of 18 potential variables were significant (P < .05) predictors of perception of risk. When these 9 variables were entered into a multiple logistic regression model, 5 were significant predictors of perception of risk: history of gestational diabetes, high school graduate or above, optimistic bias, worry, and perceived personal disease risk. CONCLUSIONS: Use of the Spanish-language translation of the Risk Perception Survey for Developing Diabetes revealed factors influencing perception of risk for developing diabetes. Results can be used to promote culturally acceptable type 2 diabetes primary prevention strategies and provide a useful comparison to other populations.

A Spanish-Language Risk Perception Survey for Developing Diabetes: Translation Process and Assessment of Psychometric Properties.

BACKGROUND AND PURPOSE: Create a Spanish-language version of the Risk Perception Survey for Developing Diabetes (RPS-DD) and assess psychometric properties. RESEARCH DESIGN AND METHODS: The Spanish-language version was created through translation, harmonization, and presentation to the tool's original author. It was field tested in a foreignborn Latino sample and properties evaluated in principal components analysis. RESULTS: Personal Control, Optimistic Bias, and Worry multi-item Likert subscale responses did not cluster together. A clean solution was obtained after removing two Personal Control subscale items. Neither the Personal Disease Risk scale nor the Environmental Health Risk scale responses loaded onto single factors. Reliabilities ranged from .54 to .88. Test of knowledge performance varied by item. CONCLUSIONS: This study contributes to evidence of validation of a Spanish-language RPS-DD in foreign-born Latinos.

Impact of exogenous glucocorticoid use on salivary cortisol measurements among adults with asthma and rhinitis.

The diurnal rhythm of cortisol secretion in chronic disease can reflect the interactions between exogenous and endogenous factors. Exogenous glucocorticoid use may impact salivary cortisol measurements, but this has not been well-studied in ambulatory settings. In this report salivary cortisol levels were used to evaluate aspects of the diurnal rhythm of cortisol secretion within an ambulatory population of patients with asthma and allergic rhinitis. 183 persons with asthma with or without concomitant rhinitis and 34 persons with rhinitis alone were asked to collect at home, two saliva samples, 30 min after awakening and 12h later. The salivary cortisol levels were quantified by enzyme immunoassay. The recent use of glucocorticoids in the study group was determined by interview and direct examination of medications. We report that the median salivary cortisol levels 30 min post-awakening significantly differed by exogenous steroid status: no glucocorticoid use (n = 91), 10.1 nmol/l; nasal gluco-corticoid use alone (n = 25), 11.4 nmol/l; inhaled glucocorticoids (with or without concomitant nasal glucocorticoids; n = 76), 9.0 nmol/l; systemic glucocorticoids (n = 17), 4.0 nmol/l; (P = 0.02). 12-h post-awakening salivary cortisol values among the groups were similar (P = 0.85). The median 30-min post-awakening cortisol differed significantly by type and amount of inhaled steroid used: non-fluticasone users (n = 21), 11.5 nmol/l; lower dose fluticasone (<800 microg per day, n = 35); 9.2 nmol/l; and higher dose fluticasone (> or =800 microg, n=20), 5 nmol/l; (P=0.01). We conclude that in an ambulatory setting, exogenous glucocorticoid use can decrease the 30 min post-awakening but not the 12-h post-awakening salivary cortisol levels, an effect that should be taken into account in assessing the effects of other potential determinants on cortisol secretion.

A pilot study to evaluate the magnitude of association of the use of electronic personal health records with patient activation and empowerment in HIV-infected veterans.

The HITECH Act signed into law in 2009 requires hospitals to provide patients with electronic access to their health information through an electronic personal health record (ePHR) in order to receive Medicare/Medicaid incentive payments. Little is known about who uses these systems or the impact these systems will have on patient outcomes in HIV care. The health care empowerment model provides rationale for the hypothesis that knowledge from an electronic personal health record can lead to greater patient empowerment resulting in improved outcomes. The objective was to determine the patient characteristics and patient activation, empowerment, satisfaction, knowledge of their CD4, Viral Loads, and antiretroviral medication, and medication adherence outcomes associated with electronic personal health record use in Veterans living with HIV at the San Francisco VA Medical Center. The participants included HIV-Infected Veterans receiving care in a low volume HIV-clinic at the San Francisco VA Medical Center, divided into two groups of users and non-users of electronic personal health records. The research was conducted using in-person surveys either online or on paper and data abstraction from medical records for current anti-retroviral therapy (ART), CD4 count, and plasma HIV-1 viral load. The measures included the Patient Activation Measure, Health Care Empowerment Inventory, ART adherence, provider satisfaction, current CD4 count, current plasma viral load, knowledge of current ART, knowledge of CD4 counts, and knowledge of viral load. In all, 40 participants were recruited. The use of electronic personal health records was associated with significantly higher levels of patient activation and levels of patient satisfaction for getting timely appointments, care, and information. ePHR was also associated with greater proportions of undetectable plasma HIV-1 viral loads, of knowledge of current CD4 count, and of knowledge of current viral load. The two groups differed by race and computer access. There was no difference in the current CD4, provider satisfaction, Health Care Empowerment Inventory score, satisfaction with provider-patient communication, satisfaction with courteous and helpful staff, knowledge of ART, or ART adherence. The use of electronic personal health records is associated with positive clinical and behavioral characteristics. The use of these systems may play a role in improving the health of people with HIV. Larger studies are needed to further evaluate these associations.

Effects of individual self-management education on clinical, biological, and adherence outcomes in asthma.

BACKGROUND: Asthma guidelines urge teaching patients the knowledge and skills required for self-management, based on the assumption that education will lead to improved skills and better asthma control. METHODS: In a prospective, randomized controlled trial of 65 adults with mild-to-moderate asthma, we examined whether an educational self-management intervention would improve adherence to inhaled corticosteroid therapy, decrease markers of airway inflammation, and improve clinical control. Peak flow, symptoms, and adherence were monitored for 7 weeks. After a 1-week run-in, subjects were assigned randomly to either the educational intervention or control group. The 30-minute intervention was delivered and reinforced at biweekly intervals. RESULTS: Compared with the control group, the intervention group had improvements in adherence to inhaled corticosteroid therapy (by 30% vs. -5%, P = 0.01), self-reported control of asthma (by 14% vs. 5%, P = 0.04), and perhaps quality of life (by 37% vs. 21%, P = 0.06). The direction of change for all other clinical outcomes was more favorable in the intervention group, but not significantly so. Markers of inflammation in sputum decreased more in the intervention group, with sputum eosinophils declining significantly (P = 0.02). CONCLUSION: In asthmatic patients treated with inhaled corticosteroids, education and training in self-management improves adherence with inhaled therapy, perceived control of asthma, and sputum eosinophilia.

Asthma management across the life span: applications for the adult and older adult.

Asthma is one of the most common and chronic diseases of adults and creates substantial health problems. The disease must be diagnosed appropriately, its severity assessed, and treatment prescribed that matches the level of severity. Patient education in self-management techniques and attention to the problems of adherence are essential for long-term management. Comorbid conditions should be suspected and treated when asthma becomes difficult to control. Asthma in the elderly is a challenging but frequent problem that requires particular attention to controlling the causes of excessive morbidity and mortality. All health care professionals have an important role in controlling this common disease.

Barriers to diabetes management: patient and provider factors.

Despite significant advances in diagnosis and treatment, the persistence of inadequate metabolic control continues. Poor glycemic control may be reflected by both the failure of diabetes self-management by patients as well as inadequate intervention strategies by clinicians. The purpose of this systematic review is to summarize existing knowledge regarding various barriers of diabetes management from the perspectives of both patients and clinicians. A search of PubMed, CINAHL, ERIC, and PsycINFO identified 1454 articles in English published between 1990 and 2009, addressing type 2 diabetes, patient's barriers, clinician's barriers, and self-management. Patients' adherence, attitude, beliefs, and knowledge about diabetes may affect diabetes self-management. Culture and language capabilities influence the patient's health beliefs, attitudes, health literacy, thereby affecting diabetes self-management. Other influential factors include the patient's financial resources, co-morbidities, and social support. Clinician's attitude, beliefs and knowledge about diabetes also influence diabetes management. Clinicians may further influence the patient's perception through effective communication skills and by having a well-integrated health care system. Identifying barriers to diabetes management is necessary to improve the quality of diabetes care, including the improvement of metabolic control, and diabetes self-management. Further research that considers these barriers is necessary for developing interventions for individuals with type 2 diabetes.

Factors associated with psychological insulin resistance in individuals with type 2 diabetes.

OBJECTIVE: To describe the predictive relationships of selected sociodemographic, biomedical, and psychosocial variables to reluctance to use insulin among patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 178 patients with type 2 diabetes participated in this cross-sectional, observational study. Data were obtained by patient interview using validated measures of diabetes attitude, knowledge, self-efficacy, care communication, and perceived barriers to treatment, as well as sociodemographic and biomedical data. RESULTS: Women and ethnic minorities with type 2 diabetes have more psychological barriers to insulin treatment (P < 0.05). The final regression model showed that individuals who believed in the value of tight glucose control, had strong self-efficacy, and had better interpersonal processes with their healthcare providers were less reluctant to use insulin treatment (R(2) = 0.403; P < 0.0001). CONCLUSIONS: Diabetes self-efficacy and better interaction with clinicians were important in decreasing patients' reluctance to use insulin, known as psychological insulin resistance.

Objective airway monitoring improves asthma control in the cold and flu season: a cluster randomized trial.

BACKGROUND: The goals of asthma care are reductions in risk and impairment, but achieving these goals requires collaborative work between patients and their clinicians. The purpose of this study was to improve inhaled corticosteroid (ICS) adherence and asthma control by cueing therapeutic communication between patients with asthma and their primary care clinicians. METHODS: We conducted a prospective, cluster-randomized, controlled effectiveness trial to assess the effect of providing visually standardized, interpreted peak flow graphs (CUE intervention) to patients and their clinicians on ICS adherence and asthma control. Asthma control outcomes were analyzed by season to account for seasonal variations in exacerbation frequency. RESULTS: Although mean log-transformed ICS adherence was not significantly different between the two groups, there was a trend toward preserved adherence in the intervention group over time (P = .16). Intervention patients required fewer courses of oral steroids during winter (9% vs 23%, P < .001) and spring (3% and 17%, P < .001) compared with control subjects. Intervention patients also had fewer periods of worsening symptoms (65% vs 89%, P < .001) and fewer urgent care visits (10% vs 23%, P < .001) during winter compared with control subjects. Post hoc analysis showed significant improvement in the intervention group with respect to ICS adherence during winter months (P < .05), the likely explanation for the reduction in prednisone use and symptoms. Day-to-day peak flow variability in the intervention group fell consistently throughout the study from an average of 32% at baseline to 23% at final measurement (P < .001), indicating less airway reactivity over time. CONCLUSIONS: Our findings provide evidence of the value of peak flow monitoring for patients with asthma during seasons of greatest vulnerability, the cold/flu season. The peak flow information apparently led to improvements in ICS adherence resulting in less need for prednisone rescue and fewer episodes of worsening symptoms.