Black Emerging Adults With Uncontrolled Asthma: A Qualitative Study.

RATIONALE: Asthma morbidity and mortality are disproportionately high in the Black population, especially among Black emerging adults (BEAs) (age 18-30 years). Few studies have been done to identify unique challenges to asthma care in BEAs. OBJECTIVE: To assess the challenges and barriers to asthma care BEAs experience. METHODS: We conducted virtual focus groups consisting of BEAs (n = 16) with a physician diagnosis of asthma. Discussion questions regarding asthma triggers, management, and challenges were used. Focus group discussions were recorded and transcribed verbatim. The transcripts were then coded by 3 coders using a thematic saturation approach. RESULTS: Seven major domains were identified: heightened anxiety around asthma management; asthma symptoms interfering with school and/or work; asthma in social group setting; transitioning to adulthood leading to increased autonomy and financial independence; use of technology in asthma management; concerns regarding coronavirus disease 2019; and perceived discrimination and biases. These domains create complex barriers to optimal asthma management and overlapping elements were identified. Technology was described as a potential method to address these challenges. CONCLUSIONS: BEAs with asthma have unique challenges due to age and race. Physicians should address these challenges through innovative means such as technology-based interventions.

Hereditary angioedema in older adults: Understanding the patient perspective.

BACKGROUND: Hereditary angioedema (HAE) is a rare condition characterized by potentially fatal, recurrent episodes of painful swelling. Whereas there are limited studies evaluating the quality of life of individuals with HAE, none have evaluated the impact of HAE on older adults. OBJECTIVE: To evaluate the effect of HAE on older adults through qualitative methodology. METHODS: A group of 3 physicians with extensive research and clinical experience in HAE developed a focus group guidebook highlighting issues of importance to older adults. A total of 17 patients with HAE (type I or II) aged 60 years and older participated in focus groups. Three independent reviewers coded each focus group transcript using a thematic saturation approach. RESULTS: Reviewers identified 7 core themes from the focus groups. The themes identified encompassed the following: (1) challenges with securing medications and insurance concerns; (2) the experience of living with HAE before the advent of newer and more effective therapeutic options; (3) a worsening of HAE attack frequency and severity with aging; (4) the effects of comorbid conditions such as arthritis, memory loss, and irritable bowel syndrome; (5) changes in HAE with menopause; and (6) changing perspective on HAE with age, the effect of HAE on interpersonal relationships including the decision to have children, and goals for future care and research including support groups and a desire to be included in clinical trials. CONCLUSION: Older adults with HAE have specific challenges and concerns that may be unique compared with younger populations. Health care providers should address these to provide optimal care.

Consequences of Insurance Coverage Delays and Denials for Patients With Hereditary Angioedema.

BACKGROUND: Hereditary angioedema (HAE) is a rare and potentially fatal genetic disease associated with recurrent and unpredictable episodes of angioedema. Although modern therapies have dramatically increased quality of life, insurance changes, delays, and denials are becoming more common. OBJECTIVE: To examine the impact of insurance delays and denials on patient health and well-being. METHODS: A total of 20 patients with HAE (type 1 and 2) who recently experienced insurance delays or denials completed an online survey, and 19 participated in a follow-up focus group. The survey and focus group addressed the impact of insurance challenges on the use of health care services, work/school attendance, and anxiety. Three independent reviewers coded each focus group transcript using a thematic saturation approach. RESULTS: A total of 70% of participants reported an increased frequency of angioedema attacks resulting from insurance delays or denials. More than 50% missed work/school days because of increased attacks, and 90% reported greater anxiety. Twenty-five percent of respondents reported more urgent care or emergency department visits. In focus groups, participants identified specific ways that losing access to medication had a negative impact on their health, family, and work/school life. Insufficient notification of health insurance policy changes and the time and effort required to regain access to medications compounded patients' frustration and anxiety. CONCLUSION: Insurance delays and denials have significant impacts on individuals with HAE including (1) increased urgent care and emergency department visits, (2) missed work/school days, (3) higher levels of anxiety, and (4) a negative impact on family life.

Asthma care during COVID-19: differences in attitudes and expectations between physicians and patients.

OBJECTIVE: The aim of this study was to explore differences in attitudes, behaviors and expectations related to COVID-19 between physicians and patients with asthma. METHODS: An anonymous survey was distributed through email and social media to adult patients with asthma during a three-week period in April-May 2020. A separate survey was sent to physicians. The surveys asked about demographic information, specific challenges and concerns due to COVID-19, and attitudes/behaviors during this time. RESULTS: A total of 1171 patients and 225 physicians completed the surveys. Overall, patients with asthma and physicians had large differences in expectations related to COVID-19. Patients were more likely than physicians to believe that individuals with asthma are at a higher risk to get COVID-19 (37.5% vs. 12.0%, p < 0.001), have increased anxiety due to COVID-19 (79.6% vs 70.0%, p = 0.002), and should not go to work (62.7% vs 11.9%, p < 0.001). Neither patients nor physicians felt confident they could distinguish COVID-19 symptoms from asthma (61.2% and 74.5% did not feel confident, respectively). Patients with severe asthma were significantly more impacted by the pandemic (e.g., became unemployed [OR 2.15], had difficulty getting asthma medications [OR 2.37]) compared to those with nonsevere asthma. CONCLUSION: Patients with asthma and their physicians have markedly different attitudes and opinions regarding care during the COVID-19 pandemic. Such differences have important implications when providing patient-centered care.Supplemental data for this article can be accessed at publisher's website.

Breathing exercises in older adults with asthma: a blinded, randomized, placebo-controlled trial.

OBJECTIVE: Breathing exercises have been found to benefit patients with some respiratory disorders, but can take a significant amount of time to complete. The effects of a breathing exercise program are unknown. The aim of this study was to evaluate the effectiveness of a short multi-component exercise program for older adults with asthma. METHODS: To be included, subjects were age 65 years or older with persistent asthma. 90 subjects with predominantly moderate to severe asthma were randomized, 45 each, into either the exercise or control groups. After in person training at the initial visit, those in the exercise group performed a short three-part exercise program twice per day at home for one month. Those in the control group performed 2 breaths with the incentive spirometer twice per day. At the initial visit patients completed baseline questionnaires assessing demographic information, asthma control (Asthma Control Test - ACT) and quality of life (mini-Asthma Quality of Life Questionnaire - mini-AQLQ) as well as spirometry. After the one-month period at the follow-up visit the ACT, mini-AQLQ, and spirometry were repeated. RESULTS: Subjects in the intervention felt that breathing exercises were helpful, and 87% would recommend them to a friend. Although both groups had improvement in ACT and mini-AQLQ, there were no differences between groups. FEV1 was lower in both groups. CONCLUSION: Although a short breathing exercise program was acceptable for older adults with asthma, it did not produce meaningful improvements in asthma outcomes. A longer program may be necessary.

Asthma Disparities During the COVID-19 Pandemic: A Survey of Patients and Physicians.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has demonstrated significantly worse outcomes for minority (black and Hispanic) individuals. Understanding the reasons for COVID-19-related disparities among patients with asthma has important public health implications. OBJECTIVE: To determine factors contributing to health disparities in those with asthma during the COVID-19 pandemic. METHODS: An anonymous survey was sent through social media to adult patients with asthma, and a separate survey was sent to physicians who provide asthma care. The patient survey addressed demographic information including socioeconomic status, asthma control, and attitudes/health behaviors during COVID-19. RESULTS: A total of 1171 patients (10.1% minority individuals) and 225 physicians completed the survey. Minority patients were more likely to have been affected by COVID-19 (eg, became unemployed, lived in a community with high COVID-19 cases). They had worse asthma control (increased emergency visits for asthma, lower Asthma Control Test score), were more likely to live in urban areas, and had a lower household income. Initial differences in attitudes and health behaviors disappeared after controlling for baseline demographic features. Institutional racism was demonstrated by findings that minority individuals were less likely to have a primary care physician, had more trouble affording asthma medications due to COVID-19, and were more likely to have lost health insurance because of COVID-19, and that 25% of physicians found it more challenging to care for black individuals with asthma during COVID-19. CONCLUSIONS: Differences in socioeconomic status and the effects of institutional racism, but not health behaviors, sources of information, or attitudes, are playing a role in disparities seen for patients with asthma during COVID-19.

A behavioral intervention can decrease asthma exacerbations in older adults.

BACKGROUND: Older adults have higher rates of asthma morbidity and mortality compared with younger age groups. Few interventions are tailored to this population. OBJECTIVE: To evaluate a self-management asthma intervention in older adults. METHODS: Adults age 55 and older with persistent asthma were enrolled into blinded, randomized controlled trial of a 6-session asthma self-management intervention. This educational intervention was conducted in group sessions and through individual telephone calls. Outcomes including asthma exacerbations (defined as unscheduled office visits, emergency department visits, or hospitalizations for asthma), spirometric values, FeNO, asthma control, asthma quality of life, and asthma self-management were assessed at 3, 6, and 12 months. RESULTS: One hundred eighty-nine subjects were enrolled, 172 were randomized and received at least 1 treatment dose, and 145 (84%) were analyzed at 12 months. On a modified intent-to-treat analysis, those in the intervention group were less likely to have an asthma exacerbation (26.9% vs 47.1%, P = .01), had a lower asthma exacerbation rate (0.8 vs 1.9, P = .02), had better asthma control (19.9 vs 18.6, P = .08), and had a higher asthma self-management score (8.9 vs 8.4, P = .03). After a mixed-model analysis to control for confounding factors, a decrease in asthma exacerbations (P = .02), as well as a decreased asthma exacerbation rate (P = .04), remained statistically significant, whereas asthma control and self-management did not. No other significant outcome differences were found. CONCLUSION: A 6-session asthma self-management intervention can successfully decrease asthma exacerbations among older adults.

The impact of patient autonomy on older adults with asthma.

BACKGROUND: Understanding patient preferences and desire for involvement in making medical decisions is important when managing chronic conditions. Previous studies have used the Autonomy Preference Index (API) in younger patients with asthma to evaluate these preferences. OBJECTIVE: To identify factors associated with autonomy and to determine whether autonomy is related to asthma outcomes among older adults. METHODS: A total of 189 older adults (>55 years old) with persistent asthma were included. Preferences for autonomy were assessed using the API, with a higher score indicating higher desire for autonomy. Scores were separated into 2 domains of information-seeking and decision-making preferences. The separated scores were correlated with asthma outcomes and demographic variables. To control for confounding factors, a linear regression analysis was performed. RESULTS: Higher decision-making preference scores correlated with female sex (P = .007), higher educational level (P = .01), and lower depression scores (P = .04). Regarding outcomes, decision-making scores positively correlated with Mini Asthma Quality of Life Questionnaire (Mini-AQLQ) scores (P = .01). On linear regression analysis, the Mini-AQLQ score remained significantly associated with decision-making preference scores (P = .03). There was no association with asthma control test scores, spirometry values, and health care use. Information-seeking preference scores correlated with educational level (P = .03), but there was no correlation with asthma outcomes. CONCLUSION: Older adults with asthma and a greater desire for involvement in decision making have better asthma-related quality of life. Future studies with the intention to increase patient autonomy may help establish a causal relationship.

Risk factors and clinical outcomes associated with fixed airflow obstruction in older adults with asthma.

BACKGROUND: Asthma in older adults is associated with increased morbidity and mortality compared with asthma in younger patients. Fixed airflow obstruction (FAO) is associated with decreased survival in younger patients, but its significance remains unclear in older adults with asthma. OBJECTIVE: To identify risk factors and outcomes related to FAO in older adults with asthma. METHODS: Subjects older than 55 years with a physician diagnosis of persistent asthma were evaluated. Collected data included participant demographic information, medications, asthma exacerbations, Asthma Control Test (ACT) score, Asthma Quality of Life (AQLQ) score, comorbidities, spirometry, atopic status, and fractional exhaled nitric oxide. Clinical characteristics and outcomes associated with FAO (defined as post-bronchodilator ratio of forced expiratory volume in 1 second to forced vital capacity ≤70%) were assessed. RESULTS: A total of 186 participants were analyzed (48 men and 138 women, mean age 66 years). FAO was demonstrated in 30% of participants. Using regression analysis, predictors of FAO included advanced age, African American race, male sex, and longer duration of asthma. In outcomes analysis, FAO was associated with worsened ACT and AQLQ scores; however, after controlling for confounding factors, logistic regression showed no association. No significant association was found between FAO and exacerbations, fractional exhaled nitric oxide, atopy, rhinitis, education level, depression, smoking, or body mass index. CONCLUSION: Risk factors associated with FAO in older adults with asthma include advanced age, African American race, increased asthma duration, and male sex. Unlike younger patients, FAO is not independently associated with worsened asthma control, quality of life, or exacerbations in older patients with asthma. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01979055.

Distinct Asthma Phenotypes Among Older Adults with Asthma.

BACKGROUND: Older adults have high rates of asthma morbidity and mortality. Asthma is now recognized as a heterogeneous disease, yet the distinct phenotypes among older adults are unknown. OBJECTIVE: The objective of this study was to identify asthma phenotypes in a diverse population of elderly patients with asthma. METHODS: Using cluster analysis, 180 older adults with persistent asthma were analyzed. Subjects completed detailed questionnaires, skin prick testing, and spirometry with reversibility. Twenty-four core variables were analyzed. RESULTS: Four groups were identified. Subjects in cluster 1 (n = 69) typically had asthma diagnosed after the age of 40 and the shortest duration of asthma. Cluster 2 (n = 40) had the mildest asthma defined by spirometry, Asthma Control test (ACT), and Asthma Quality of Life Questionnaire (AQLQ). They also had the lowest body mass index (BMI), lowest depression score, and least number of comorbidities. Cluster 3 (n = 46) had the longest duration of asthma (56 years) and the highest atopic skin test sensitization (74%). Cluster 4 (n = 25) had the most severe asthma, with extremely low FEV1% predicted (37.8%), lowest ACT, and lowest AQLQ scores. They were more likely to be black and had the highest comorbidities. Using BMI, posttreatment FEV1% predicted, and duration of asthma, 95.6% of subjects were able to be correctly classified. CONCLUSIONS: In older adults with asthma, distinct phenotypes vary on key features that are more pronounced among the elderly, including comorbidities, fixed airway obstruction, and duration of asthma ≥40 years. Further work is required to determine the clinical and therapeutic implications for different asthma phenotypes in older adults.

Sustaining school-based asthma interventions through policy and practice change.

BACKGROUND: Schools are an ideal setting for implementation of asthma interventions for children; however, sustaining school-based programs can be challenging. This study illustrates policy and practice changes brought about through the Childhood Asthma Linkages in Missouri (CALM) program to sustain such programs. METHODS: Researchers analyzed caregiver-reported quantitative data regarding asthma-related outcomes in preintervention and postintervention surveys and qualitative data regarding sustainability efforts in schools reported by CALM grantees. A grounded theory approach was used to identify key concepts and themes that emerged. RESULTS: In 330 children, significant improvements were seen in asthma symptoms, rescue inhaler use, health care utilization, school absenteeism, and activity limitations. Overall, 27 school-based policy and practice changes supporting program sustainability were reported, with policy changes most often concerning the assessment and/or monitoring of children with asthma in the school setting, and practice changes most often regarding institution of regular asthma education programs for students and school personnel. CONCLUSIONS: Sustaining school-based asthma programs is challenging, but can be realized through the participation of diverse partners in enacting policy and practice changes that support the institutionalization of programs into the day-to-day processes of the schools.