Telemedicine use for pediatric asthma care: a mixed methods study.

OBJECTIVES: To identify factors associated with telemedicine use for asthma care among children and young adults, and to describe the parent and patient experience of asthma care over telemedicine. METHODS: Our mixed methods study consisted of an electronic health record analysis and a qualitative focus group analysis. We analyzed records for all patients aged 2-24 seen at UC Davis Health between March 19, 2020 and September 30, 2020 for a primary diagnosis of asthma. We performed multivariable logistic regression to quantify the relationships between patient characteristics and telemedicine use. We also conducted focus groups with parents and patients who received asthma care during the study period and used qualitative content analysis to identify themes from the transcripts. RESULTS: 502 patients met the inclusion criteria. Telemedicine use was significantly lower among patients with a primary language other than English (OR = 0.12, 95% CI: 0.025-0.54, p = 0.006), school-aged children (OR = 0.43, 95% CI: 0.24-0.77, p = 0.005), and patients who received asthma care from a primary care provider instead of a specialist (OR = 0.55, 95% CI: 0.34-0.91, p = 0.020). Six thematic categories emerged from focus groups: engaging with the patient, improving access to care, experience of visit, measurements, scheduling, and the future of telemedicine in asthma care. CONCLUSIONS: Alternating telemedicine with in-person visits for asthma care may result in improved access to care and reduced burdens on patients and families. Providers and researchers should work to understand the specific reasons for low telemedicine use among non-English speaking patients so that these patients receive equitable access to care.

School-Based Telemedicine Interventions for Asthma: A Systematic Review.

BACKGROUND: School health systems are increasingly investing in telemedicine platforms to address acute and chronic illnesses. Asthma, the most common chronic illness in childhood, is of particular interest given its high burden on school absenteeism. OBJECTIVE: Conduct a systematic review evaluating impact of school-based telemedicine programs on improving asthma-related outcomes. DATA SOURCES: PubMed, Cochrane CENTRAL, CINAHL, ERIC, PsycINFO, Embase, and Google Scholar. STUDY ELIGIBILITY CRITERIA: Original research, including quasi-experimental studies, without restriction on the type of telemedicine. PARTICIPANTS: School-aged pediatric patients with asthma and their families. INTERVENTIONS: School-based telemedicine. STUDY APPRAISAL AND SYNTHESIS METHODS: Two authors independently screened each abstract, conducted full-text review, assessed study quality, and extracted information. A third author resolved disagreements. RESULTS: Of 371 articles identified, 7 were included for the review. Outcomes of interest were asthma symptom-free days, asthma symptom frequency, quality of life, health care utilization, school absences, and spirometry. Four of 7 studies reported significant increases in symptom-free days and/or decrease in symptom frequency. Five of 6 reported increases in at least one quality-of-life metric, 2 of 7 reported a decrease in at least 1 health care utilization metric, 1 of 3 showed reductions in school absences, and 1 of 2 reported improvements in spirometry measures. LIMITATIONS: Variability in intervention designs and outcome measures make comparisons and quantitative analyses across studies difficult. Only 2 of 7 studies were randomized controlled trials. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: High-quality evidence supporting the use of school-based telemedicine programs to improve patient outcomes is limited. While available evidence suggests benefit, only 2 comparative trials were identified, and the contribution of telemedicine to these studies' results is unclear.

Excessive Absenteeism Due to Asthma in California Elementary Schoolchildren.

OBJECTIVE: Previous studies of asthma-related school absenteeism have reported absenteeism dichotomously (ie, any school days missed vs none). However, schools use higher thresholds to identify and intervene for students at risk of chronic absenteeism (18 days or ≥10% schoolyear missed), which is associated with negative health and educational outcomes. We sought to identify factors associated with excessive absenteeism (EA) due to asthma (≥9 days missed), a threshold based on a convention defined by Attendance Works for absenteeism risk, and is linked to decreased academic performance and increased risk of chronic absenteeism. METHODS: We examined responses for asthma-related absenteeism from the 2011 to 2014 California Health Interview Survey for children ages 5-11. Multivariate logistic regression modeled odds ratios of EA for demographic, healthcare utilization, and asthma-related factors. Sensitivity analysis was performed modeling a ≥1 threshold (any absenteeism). RESULTS: 715 respondents represent an estimated 314,200 California schoolchildren with asthma. 50.3% of students missed ≥1 day, and 11.7% missed ≥9 days of school due to asthma. Odds of EA were significantly higher for younger children, lower-income families, and rural students, but not significant for any absenteeism. Indicators of greater asthma severity and poorer control were significantly associated with both EA and any absenteeism. CONCLUSIONS: This study identified factors significantly associated with EA that were not significant for lower absence thresholds. This may help direct school-based asthma interventions for which limited resources must target students at higher risk of chronic absenteeism.

A population-based study of the association of prenatal diagnosis with survival rate for infants with congenital heart defects.

Prenatal diagnosis has been shown to improve preoperative morbidity in newborns with congenital heart defects (CHDs), but there are conflicting data as to the association with mortality. We performed a population-based, retrospective, cohort study of infants with prenatally versus postnatally diagnosed CHDs from 1994 to 2005 as ascertained by the Metropolitan Atlanta Congenital Defects Program. Among infants with isolated CHDs, we estimated 1-year Kaplan-Meier survival probabilities for prenatal versus postnatal diagnosis and estimated Cox proportional hazard ratios adjusted for critical CHD status, gestational age, and maternal race/ethnicity. Of 539,519 live births, 4,348 infants had CHDs (411 prenatally diagnosed). Compared with those with noncritical defects, those with critical defects were more likely to be prenatally diagnosed (58% vs 20%, respectively, p <0.001). Of the 3,146 infants with isolated CHDs, 1-year survival rate was 77% for those prenatally diagnosed (n = 207) versus 96% for those postnatally diagnosed (n = 2,939, p <0.001). Comparing 1-year survival rate among those with noncritical CHDs alone (n = 2,455) showed no difference between prenatal and postnatal diagnoses (96% vs 98%, respectively, p = 0.26), whereas among those with critical CHDs (n = 691), prenatally diagnosed infants had significantly lower survival rate (71% vs 86%, respectively, p <0.001). Among infants with critical CHDs, the adjusted hazard ratio for 1-year mortality rate for those prenatally versus postnatally (reference) diagnosed was 2.51 (95% confidence interval 1.72 to 3.66). In conclusion, prenatal diagnosis is associated with lower 1-year survival rate for infants with isolated critical CHDs but shows no change for those with isolated noncritical CHDs. More severe disease among the critical CHD subtypes diagnosed prenatally might explain these findings.

Instinctive Clinical Teaching: Erasing the Mental Boundary Between Clinical Education and Patient Care to Promote Natural Learning.

Effective clinical teaching is essential in physician education, yet faculty members rarely receive formal training in clinical teaching. Formal models for training clinical educators are often tedious and require significant time and effort. Instinctive clinical teaching allows clinicians to seamlessly integrate and promote effective teaching into their clinical practice. The approach is guided by similarities between the components of Kolb's experiential learning cycle-concrete experience, reflective observation, abstract conceptualization, and active experimentation-and the elements of the patient care process-history and physical, initial assessment, differential, hypothesis, final diagnosis, management, and follow-up. Externalization of these clinical thought processes allows for inclusion of learners and promotes effective clinical teaching.