Effects of pediatric asthma care coordination in underserved communities on parent perceptions of care and asthma-management confidence.

OBJECTIVE: Disparities by race and socioeconomic status persist in pediatric asthma morbidity, mortality, and treatment. Improving parent/provider communication and parents' asthma-management confidence may result in better asthma control in vulnerable populations. The Merck Childhood Asthma Network, Inc. funded an initiative to implement medical-social care coordination to improve asthma outcomes at sites in four low-income, urban communities (Los Angeles, CA; Philadelphia, PA; Chicago, IL; and San Juan, PR.) As part of a cross-site evaluation of this effort, pre- post-program changes in parents' reports of asthma care and management were assessed. METHODS: Across sites, 805 parents or other caregivers responded to a baseline survey that was repeated one year later following their child's participation in care coordination. Parents' asthma-management confidence, as well as their perceptions of provider access, trust, and communication, were measured with Likert scales. Linear mixed models were used to assess improvement in these variables, across and within sites, adjusting for sociodemographics. RESULTS: Pooled across sites, the adjusted mean estimate for all outcomes showed a significant improvement (p <.05) from baseline to follow-up. Knowledge and Between-Provider Communication improved significantly (p <.05) within all four sites; Access improved significantly in Chicago, Philadelphia, and Puerto Rico; Trust improved significantly in Chicago, Los Angeles, and Philadelphia; and Patient-Provider Communication improved significantly in Philadelphia only. CONCLUSION: Pediatric asthma care coordination, as implemented variously in diverse settings, was associated with improvement in parents' perceptions of asthma care and self-reported asthma-management knowledge and confidence. This positive impact on parents may help sustain care coordination's impact on children.

Pediatric Asthma Care Coordination in Underserved Communities: A Quasiexperimental Study.

OBJECTIVES: To assess the effect of care coordination on asthma outcomes among children in underserved urban communities. METHODS: We enrolled children, most of whom had very poorly or not well-controlled asthma, in medical-social care coordination programs in Los Angeles, California; Chicago, Illinois; Philadelphia, Pennsylvania; and San Juan, Puerto Rico in 2011 to 2014. Participants (n = 805; mean age = 7 years) were 60% male, 50% African American, and 42% Latino. We assessed asthma symptoms and health care utilization via parent interview at baseline and 12 months. To prevent overestimation of intervention effects, we constructed a comparison group using bootstrap resampling of matched control cases from previous pediatric asthma trials. RESULTS: At follow-up, intervention participants had 2.2 fewer symptom days per month (SD = 0.3; P < .01) and 1.9 fewer symptom nights per month (SD = 0.35; P < .01) than did the comparison group. The relative risk in the past year associated with the intervention was 0.63 (95% confidence interval [CI] = 0.45, 0.89) for an emergency department visit and 0.69 (95% CI = 0.47, 1.01) for hospitalization. CONCLUSIONS: Care coordination may improve pediatric asthma symptom control and reduce emergency department visits. POLICY IMPLICATIONS: Expanding third-party reimbursement for care coordination services may help reduce pediatric asthma disparities.

The "Retrofitting" Approach to Adapting Evidence-Based Interventions: A Case Study of Pediatric Asthma Care Coordination, United States, 2010-2014.

Adaptation of evidence-based interventions upon implementation into new practice settings is universal, yet poorly understood. During a cross-site evaluation of the implementation of a proven intervention for pediatric asthma care coordination into 4 resource-challenged settings, we conducted in-depth interviews with site representatives, who reported how and why they modified intervention components. Interview notes were coded for themes. We focused on a single theme from a respondent who described the adaptation process as "backing" the intervention into ongoing services; we found evidence of a similar process at other sites. We labeled this process "retrofitting" to signify adaptation that consists of altering existing services to align with intervention components, rather than modifying the intervention to fit a new setting. Advantages of retrofitting may include allowing organizations to keep what works, capitalizing on existing support for program activities, elevating the role of local knowledge, and potentially promoting the sustainability of effective innovations.

Association between Health Care Utilization with Asthma Control Levels among a Sample of Adult Patients in Puerto Rico.

OBJECTIVE: Asthma is an important and serious public health problem in Puerto Rico; however, very few studies measuring the association between health care utilization and asthma control levels in adult asthma patients in Puerto Rico have been done. METHODS: This study is secondary analysis of an observational and cross-sectional database generated by the Latin American Asthma Insights and Management (LA AIM) survey. Our sub-sample consisted of adults 18 years or older living with asthma, representing a total of 343 individuals. This study determined the numbers of ambulatory physician visits, emergency visits to a physician or an emergency room, and hospitalizations that took place the 12 months prior to the survey. Patients were characterized as having well-controlled, partly controlled, or uncontrolled asthma. Descriptive and inferential statistics were performed to detect differences in the mean and number of events for physician visits, emergency visits, and hospitalizations by asthma control groups. RESULTS: After adjusting for age, sex, and chronic health conditions (other than asthma), adult asthma patients with controlled asthma had 92.0% fewer physician visits, 82.5% fewer emergency visits, and 92.2% fewer hospitalizations than did those with uncontrolled asthma. CONCLUSION: Interventions geared toward controlling asthma symptoms and clinical manifestations in adults asthma patients-which interventions might include strategies for controlling environmental risk factors, increasing patient and family education with regard to asthma management, and boosting the use of appropriate and effective medications-may have significant potential in terms of reducing the direct and indirect costs of asthma, costs that have a critical impact on the whole health care system.

A Mixed-Method Application of the Program Sustainability Assessment Tool to Evaluate the Sustainability of 4 Pediatric Asthma Care Coordination Programs.

INTRODUCTION: As part of a cross-site evaluation of the implementation of an evidence-based intervention for pediatric asthma care coordination into low-income communities, we sought to understand the factors that influenced the programs' expected sustainability of the programs after external funding ended. METHODS: We administered the Center for Public Health Systems Science's Program Sustainability Assessment Tool, a 40-item instrument assessing 8 domains of sustainability capacity, to 12 key informants across 4 program sites. We developed open-ended probes for each domain. We examined patterns in site-specific and overall domain scores, and coded qualitative data to identify challenges and strategies in each domain. RESULTS: Across sites, the domains of program evaluation (cross-site mean, 5.4 on a scale of 1-7) and program adaptation (mean, 5.2) had the highest ratings (indicating a strong finding during program evaluation) and funding stability had the lowest rating (mean, 2.7). Scores varied most across sites in the domains of strategic planning (SD, 0.9) and funding stability (SD, 0.9). Qualitative data revealed key challenges, including how implementation difficulties and externally led implementation can impede planning for sustainability. Program leaders discussed multiple strategies for enhancing capacity within each domain, including capitalizing on the interconnectedness of all domains, such as using evaluation and communication strategies to bolster internal political support throughout the implementation process. CONCLUSION: Findings indicating weak and strong domains were consistent with previous findings of studies that used the Program Sustainability Assessment Tool. The addition of qualitative probes yielded detailed data describing capacity strengths, weaknesses, and strategies to increase the likelihood that programs are sustained.

The Influence of Setting on Care Coordination for Childhood Asthma.

Asthma affects 7.1 million children in the United States, disproportionately burdening African American and Latino children. Barriers to asthma control include insufficient patient education and fragmented care. Care coordination represents a compelling approach to improve quality of care and address disparities in asthma. The sites of The Merck Childhood Asthma Network Care Coordination Programs implemented different models of care coordination to suit specific settings-school district, clinic or health care system, and community-and organizational structures. A variety of qualitative data sources were analyzed to determine the role setting played in the manifestation of care coordination at each site. There were inherent strengths and challenges of implementing care coordination in each of the settings, and each site used unique strategies to deliver their programs. The relationship between the lead implementing unit and entities that provided (1) access to the priority population and (2) clinical services to program participants played a critical role in the structure of the programs. The level of support and infrastructure provided by these entities to the lead implementing unit influenced how participants were identified and how asthma care coordinators were integrated into the clinical care team.

Allergen sensitivity (mites, insects, and pets) in a Puerto Rican population.

OBJECTIVE: The people of Puerto Rico have one of the highest asthma prevalence and morbidity rates in the U.S.A. Limited information is available on the most common allergy sensitivities among island residents. The aims of the study were to determine the most common inhalant allergen sensitivities among a convenience sample in Puerto Rico and determine as well their relationship to an asthma or a rhinitis diagnosis. METHODS: In August of 2008, we evaluated a cohort of subjects visiting ambulatory clinics offering health screening; the clinics were located in two of the island's biggest cities: Guaynabo in the north and Ponce in the south. Subjects over three years of age (or their parents) visiting the clinics answered a survey on asthma and rhinitis and were skin tested for reactivity to common aeroallergens. RESULTS: The survey included 395 subjects with a mean age of 29 years. Thirty-six percent reported a history of asthma, of whom 83% (30% of the total participants) reported still having asthma, and 76% reported having rhinitis. Sixty-five percent of the subjects were sensitive to at least one antigen. Subjects sensitive to mites were 53% more likely to have suffered from asthma than were non-mite-sensitized subjects (OR = 1.53, p < 0.05) sensitivity to mosquitoes (OR = 2.25, p < 0.02), mites (OR = 2.53, p < 0.00001), feathers (OR = 2.72, p < 0.03), dogs (OR = 3.02, p < 0.01), or cats (OR = 3.42, p < 0.001) increased an individual's likelihood of suffering from rhinitis. CONCLUSION: The most common sensitivities identified were to mites and insects. Mite sensitivity was associated with rhinitis and asthma. Sensitivity to animal dander as well as to mosquitoes was associated to with rhinitis. Further studies are warranted to explore the relevance of allergen sensitivity in terms of asthma and rhinitis prevalence and morbidity among residents of Puerto Rico.

Allergist role in asthma care in Puerto Rico.

INTRODUCTION: Puerto Ricans have one of the highest asthma prevalence and morbidity rates. However, limited information is available on asthma care and attitudes toward asthma treatment among Puerto Ricans living in the island. METHODS: We evaluated a cohort of subjects attending Ambulatory Health Screen Clinic in the two main cities in the north and south of the island during August of 2008. Subjects attending the clinic answered a survey about asthma care and attitudes toward asthma treatment. Approval was obtained from the Medical Sciences IRB and written informed consent obtained from all research subjects before enrollment. RESULTS: According to subject report, asthma care is primarily conducted by primary care physicians including pediatricians (35.8%), general practitioners (31.4%), and family physicians (4.3%). Pulmonary physicians conducted 23.3% of asthma care and allergists conduct 3.6%. Only 65.5 % reported using prescribed asthma medications. Fear of medication side effects (37.7%), lacks of health insurance coverage (26.4%), and medication cost (15.1%) were the most common causes reported for poor compliance. Subjects considered that physicians were one of the best sources (68.1%) for information on asthma, followed by the TV (23.7%) and the web (15.4%). CONCLUSIONS: Most asthma care in Puerto Rico is conducted by primary care providers. Subspecialists have a limited role and particularly allergists. Efforts to increased public and physician awareness of the role of allergists in asthma care in Puerto Rico are warranted.

Newborn screening for hermansky-pudlak syndrome type 3 in Puerto Rico.

BACKGROUND: Hermansky-Pudlak syndrome (HPS) is an autosomal recessive disorder characterized by albinism, mucocutaneous bleeding, and storage of ceroid material in macrophages. Patients who are not easily identified by physical characteristics (mostly HPS-3 patients) may have hemorrhagic complications with trauma or surgery. OBJECTIVE: To determine the prevalence of HPS-3 in Puerto Rican newborns using DNA pooling technique. DESIGN/METHODS: Twelve percent of annual Puerto Rican births were tested randomly by polymerase chain reaction for the HPS-3 mutation, using pooled DNA extracted from dried blood samples. RESULTS: HPS-3 mutation was detected in 75 samples. Two newborns were found to be homozygous. Carrier frequency was 1:85 (1.18%). CONCLUSIONS: The HPS-3 carrier frequency found (1.18%) justifies universal newborn screening in Puerto Rico. DNA pooling reduces time and labor in newborn screening thus facilitating early diagnosis and treatment of children with HPS-3 and the provision of genetic counseling to parents and relatives.

Breast Cancer in a Caribbean Population in Transition: Design and Implementation of the Atabey Population-Based Case-Control Study of Women in the San Juan Metropolitan Area in Puerto Rico.

Global breast cancer incidence varies considerably, particularly in comparisons of low- and high-income countries; rates may vary even within regions. Breast cancer rates for Caribbean countries are generally lower than for North America and Europe. Rates in Puerto Rico are in the middle of the range between the highest and the lowest Caribbean countries. Populations in transition, with greater variability in risk factor exposures, provide an important opportunity to better understand breast cancer etiology and as potential sources of variation in rates. Understanding of exposures across the life span can potentially contribute to understanding regional differences in rates. We describe here the design and implementation of a population-based, case-control study in the San Juan Metropolitan Area (SJMA) of Puerto Rico, the Atabey Epidemiology of Breast Cancer Study. We describe steps taken to ensure that the study was culturally appropriate, leveraging the Atabey researchers' understanding of the culture, local health system, and other required resources to effectively recruit participants. A standardized, in-person interview was developed, with attention to life course events customized to the study population. In order to understand variation in global breast cancer rates, studies customized to the populations outside of North America and Europe are required.

Cesarean delivery as a barrier for breastfeeding initiation: the Puerto Rican experience.

The study's objective was to examine the relationship between cesarean section delivery and the initiation of breastfeeding in a representative sample of 1695 Puerto Rican women aged 15 to 49 years, who delivered their last healthy singleton child in Puerto Rico between 1990 and 1996. Secondary analysis of data collected in the population-based cross-sectional study Puerto Rico Reproductive Health Survey was performed. Bivariate and multivariate logistic regression analyses were used to examine the crude and covariate adjusted association between type of childbirth and initiation of breastfeeding. Overall, 36% of all births were performed by cesarean section, while initiation of breastfeeding was achieved by 61.5% of the women. Cesarean section was negatively related to breastfeeding initiation in multivariable logistic regression models (odds ratio=.64; 95% CI=0.51-0.81) after controlling for confounding variables. Intervention programs that aim to promote breastfeeding and that provide special assistance to women undergoing this procedure should be developed.

Reducing quality-of-care disparities in childhood asthma: La Red de Asma Infantil intervention in San Juan, Puerto Rico.

BACKGROUND AND OBJECTIVE: Although children living in Puerto Rico have the highest asthma prevalence of all US children, little is known regarding the quality-of-care disparities they experience nor the adaptability of existing asthma evidence-based interventions to reduce these disparities. The objective of this study was to describe our experience in reducing quality-of-care disparities among Puerto Rican children with asthma by adapting 2 existing evidence-based asthma interventions. METHODS: We describe our experience in adapting and implementing 2 previously tested asthma evidence-based interventions: the Yes We Can program and the Inner-City Asthma Study intervention. We assessed the feasibility of combining key components of the 2 interventions to reduce asthma symptoms and estimated the potential cost savings associated with reductions in asthma-related hospitalizations and emergency department visits. A total of 117 children with moderate and severe asthma participated in the 12-month intervention in 2 housing projects in San Juan, Puerto Rico. A community-academic team with the necessary technical and cultural competences adapted and implemented the intervention. RESULTS: Our case study revealed the feasibility of implementing the combined intervention, henceforth referred to as La Red intervention, in the selected Puerto Rican communities experiencing a disproportionately high level of asthma burden. After 1-year follow-up, La Red intervention significantly reduced asthma symptoms and exceeded reductions of the original interventions. Asthma-related hospitalizations and emergency department use, and their associated high costs, were also significantly reduced. CONCLUSIONS: Asthma evidence-based interventions can be adapted to improve quality of care for children with asthma in a different cultural community setting.

Natural history and incidence of premature thelarche in Puerto Rican girls aged 6 months to 8 years diagnosed between 1990 and 1995

OBJECTIVE: To describe the natural history and estimate the incidence of premature thelarche in girls aged 6 months to 8 years living in Puerto Rico and diagnosed between 1990 and 1995. BACKGROUND: In the 1970s and 1980s, several pediatric endocrinologists, based on their clinical experience, acknowledged a dramatic increase in the number of cases of precocious sexual development in Puerto Rico. In 1987, the Puerto Rico Health Department developed the Registry of Premature Thelarche and Precocious Sexual Development, which began to operate in 1989. Data regarding the long-term outcomes of girls diagnosed with premature thelarche are insufficient. Knowledge about the natural history of this condition is relevant for predicting the long-term prognosis and therapeutic management of the affected population. METHODS: Of 2,716 cases of precocious sexual development reported to the Premature Thelarche and Precocious Sexual Development Registry, 1,916 (70.5) were premature thelarche. The clinical characteristics and evolution during follow-up of premature thelarche cases were described and compared by age group at diagnosis. RESULTS: Incidences were 6.2 and 1.62 per 1,000 live births for girls aged < 2 years and 2 to 8 years, respectively. These estimates were 10 and 15 times higher than those reported in Olmsted, MN. When the average change in mammary tissue diameter during follow-up was evaluated, a slight reduction in girls aged < 2 years was observed; however, it remained constant for girls aged 2 to 8 years. CONCLUSIONS: The results of this study underscore the need to continue an active search of premature thelarche cases and to perform analytical investigations of precocious sexual development to expand the understanding of the etiology of this important public health problem.

Prevalence of alcohol and drug use in a Medical Sciences Campus Freshman Class

Una encuesta del uso de alcohol y drogas en la clase de primer año de 1989-90 del Recinto de Ciencias Médicas de la U.P.R. fue llevada a cabo mediante un cuestionario de 55 artículos. El instrumento fue completado por 73%de los matriculados en primer año (403 respuestas). Los datos reflejaron que 64%de los sujetos encuestados usan alcohol; 47.4%fueron clasificados como bebedores ocasionales, 9.9%como bebedores moderados y 6.7%como bebedores fuertes. El consumo de alcohol por sexo fue de 87.1%en varones y 58.3%en mujeres. Uso de drogas fue informado por 14.6%de todos los sujetos. No se encontró diferencias por sexo en la distribución de usuarios de drogas. Los resultados fueron clasificados y analizados por facultad. Se exploró la motivación para el consumo de alcohol y drogas encontrando que aproximadamente 50%de las respuestas no caían bajo categorias tradicionales tales como "para reducir tensión" y "aprobación social". Se enfatiza la deseabilidad de fortalecer aún más los esfuerzos preventivos y educativos de la institución relacionado al riesgo de mal uso de alcohol y dorgas