Does cross-cultural communication training for physicians improve pediatric asthma outcomes? A randomized trial.

OBJECTIVE: Adverse cross-cultural interactions are a persistent problem within medicine impacting minority patients' use of services and health outcomes. To test whether 1) enhancing the evidence-based Physician Asthma Care Education (PACE), a continuing medical education program, with cross cultural communication training (PACE Plus) would improve the asthma outcomes of African American and Latino/Hispanic children; and 2) whether PACE is effective in diverse groups of children. METHODS: A three-arm randomized control trial was used to compare PACE Plus, PACE, and usual care. Participants were primary care physicians (n = 112) and their African American or Latino/Hispanic pediatric patients with persistent asthma (n = 867). The primary outcome of interest included changes in emergency department visits for asthma overtime, measured at baseline, and 9 and 21 months following the intervention. Other outcomes included hospitalizations, asthma symptom experience, caregiver asthma-related quality of life, and patient-provider communication measures. RESULTS: Over the long term, PACE Plus physicians reported significant improvements in confidence and use of patient-centered communication and counseling techniques (p < 0.01) compared to PACE physicians. No other significant benefit in primary and secondary outcomes was observed in this trial. CONCLUSION: PACE Plus did not show significant benefit in asthma-specific clinical outcomes. More trials and multi-component strategies continue to be needed to address complex risk factors and reduce disparities in asthma care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01251523 December 1, 2010.

Impact of Goal Setting and Goal Attainment Methods on Asthma Outcomes.

Optimal use of goal-setting strategies in self-management efforts with high-risk individuals with asthma is not well understood. This study aimed to describe factors associated with goal attainment in an asthma self-management intervention for African American women with asthma and determine whether goal attainment methods proved beneficial to goal achievement and improved asthma outcomes. Data came from 212 African American women in the intervention arm of a randomized clinical trial evaluating a telephone-based asthma self-management program. Telephone interview data were collected to assess goals and goal attainment methods identified, asthma symptoms, asthma control, and asthma-related quality of life at baseline and 2-year follow-up. Generalized estimating equations were used to assess the long-term impact of goal setting and goal attainment methods on outcomes. The average age of the sample was 42.1 years ( SD = 14.8). Factors associated with goal attainment included higher education ( p < .01) and fewer depressive symptoms ( p < .01). Using a goal attainment method also resulted in more goals being achieved over the course of the intervention (Estimate [ SE] = 1.25 [0.18]; p < .001) when adjusted for clinical and demographic factors. Use of and types of goal attainment methods and goals were not found to significantly affect asthma control, quality of life, or frequency of nighttime asthma symptoms at follow-up. Using a method to achieve goals led to greater goal attainment. Goal attainment alone did not translate into improved asthma outcomes in our study sample. Further studies are warranted to assess the challenges of self-management in chronic disease patients with complex health needs and how goal setting and goal attainment methods can be strategically integrated into self-management efforts to improve health endpoints.

A randomized clinical trial of a culturally responsive intervention for African American women with asthma.

BACKGROUND: Few interventions have focused on the difficulties that African American women face when managing asthma. OBJECTIVE: To evaluate a telephone-based self-regulation intervention that emphasized African American women's management of asthma in a series of 6 sessions. METHODS: A total of 422 African American women with persistent asthma were randomly assigned to either an intervention or control group receiving usual care. Behavioral factors, symptoms and asthma control, asthma-related quality of life, and health care use at baseline and 2 years after baseline were assessed. Generalized estimating equations were used to assess the long-term effect of the intervention on outcomes. RESULTS: Compared with the control group, those who completed the full intervention (6 sessions) had significant gains in self-regulation of their asthma (B estimate, 0.73; 95% CI, 0.17-1.30; P < .01), noticing changes to their asthma during their menstrual cycle (B estimate, 1.42; 95% CI, 0.69-2.15; P < .001), and when having premenstrual syndrome (B estimate, 1.70; 95% CI, 0.67-2.72; P < .001). They also had significant reductions in daytime symptoms (B estimate, -0.15; 95% CI, -0.27 to -0.03; P < .01), asthma-related hospitalization (B estimate, 0.51; 95% CI, 0.00-1.02; P < .05), and improved asthma control (B estimate, 1.34; 95% CI, 0.57-2.12; P < .001). However, neither grouped changed over time in outcomes. CONCLUSION: Despite high comorbidity, African American women who completed a culturally responsive self-management program had improvements in asthma outcomes compared with the control group. Future work should address significant comorbidities and psychosocial issues alongside asthma management to improve asthma outcomes in the long term. TRIAL REGISTRATION: clinicaltrials.gov Identifier NCT01117805.

Study protocol for improving asthma outcomes through cross-cultural communication training for physicians: a randomized trial of physician training.

BACKGROUND: Massive resources are expended every year on cross-cultural communication training for physicians. Such training is a focus of continuing medical education nationwide and is part of the curriculum of virtually every medical school in America. There is a pressing need for evidence regarding the effects on patients of cross-cultural communication training for physicians. There is a need to understand the added benefit of such training compared to more general communication. We know of no rigorous study that has assessed whether cross-cultural communication training for physicians results in better health outcomes for their patients. The current study aims to answer this question by enhancing the Physician Asthma Care Education (PACE) program to cross cultural communication (PACE Plus), and comparing the effect of the enhanced program to PACE on the health outcomes of African American and Latino/Hispanic children with asthma. METHODS/DESIGN: A three-arm randomized control trial is used to compare PACE Plus, PACE, and usual care. Both PACE and PACE Plus are delivered in two, two-hour sessions over a period of two weeks to 5-10 primary care physicians who treat African American and Latino/Hispanic children with asthma. One hundred twelve physicians and 1060 of their pediatric patients were recruited who self-identify as African American or Latino/Hispanic and experience persistent asthma. Physicians were randomized into receiving either the PACE Plus or PACE intervention or into the control group. The comparative effectiveness of PACE and PACE Plus on clinician's therapeutic and communication practices with the family/patient, children's urgent care use for asthma, asthma control, and quality of life, and parent/caretaker satisfaction with physician performance will be assessed. Data are collected via telephone survey and medical record review at baseline, 9 months following the intervention, and 21 months following the intervention. DISCUSSION: This study aims to reduce disparities in asthma outcomes among African American and Latino/Hispanic children through cross-cultural communication training of their physicians and assessing the added value of this training compared to general communication. The results of this study will provide important information about the value of cross-cultural training in helping to address persistent racial disparities in outcomes. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01251523 December 1, 2010.

Long-term effects of negotiated treatment plans on self-management behaviors and satisfaction with care among women with asthma.

OBJECTIVE: To examine characteristics of women with negotiated treatment plans, factors that contribute to newly forming a treatment plan, and the impact of plans on asthma management, and their satisfaction with care over 2 years. METHODS: Data came from telephone interviews with 324 women with asthma at baseline, 12 and 24 months. The effect of having a negotiated treatment plan on medication adherence, asking the physician questions about asthma, asthma management self-efficacy, and satisfaction with care was assessed over 24 months. Data were analyzed using mixed models. Analyses controlled for patient characteristics. RESULTS: Thirty-eight percent of participants reported having a negotiated treatment plan at three time points. Seeing an asthma specialist (χ(2)(1) = 24.07, p < .001), was associated with having a plan. Women who did not have a negotiated treatment plan at baseline, but acquired one at 12 or 24 months, were more likely to report greater urgent office visits for asthma (odds ratio (OR) = 1.37, 95% confidence interval (CI) = 1.07-1.61). No associations were observed between having a plan and urgent healthcare use or symptom frequency. When adjusting for household income, level of asthma control, and specialty of the caregiving provider, women who did not have a negotiated treatment plan (OR = 0.28, 95% CI = 0.09-0.79) and those with a plan at fewer than three time points (OR = 0.30, 95% CI = 0.11-0.83) were less likely to report medication adherence and satisfaction with their care (regression coefficient (standard error) = -0.65 (0.17), p < .001). No differences in asthma management self-efficacy or asking the doctor questions about asthma were observed. CONCLUSION: Women with asthma who had a negotiated treatment plan were more likely to see an asthma specialist. In the long-term, not having a treatment plan that is developed in partnership with a clinician may have an adverse impact on medication use and patient views of clinical services.

Asthma action plans and patient satisfaction among women with asthma.

BACKGROUND: Asthma action plans (AAPs) are a priority recommendation of the National Asthma Education and Prevention Program and have been shown to positively affect health outcomes. Patient satisfaction is an important clinical outcome, yet little is known about its association with receiving an AAP. This study examined the association between having an AAP and behaviors to keep asthma in control and patient satisfaction with care. METHODS: The study design was a cross-sectional analysis of baseline data from a randomized trial evaluating a self-management program among 808 women with asthma. Participants reported demographic information, interactions with clinicians, whether they had an AAP and owned a peak flow meter, self-management behaviors, and symptoms. RESULTS: The mean age of the participants was 48 ±13.6 years, 84% (n= 670) were satisfied with their asthma care, and 48% (n= 383) had a written AAP from their physician. Women not having an AAP were less likely to take asthma medication as prescribed [ x 2 (1) = 13.68, P , .001], to initiate a discussion about asthma with their physicians [ x 2 (1) = 26.35, P < .001], and to own a peak fl ow meter [ x 2 (1) =77.84, P < .001]. Adjusting for asthma control, income, and medical specialty,women who did not have an AAP were more likely to report dissatisfaction with their asthma care (OR, 2.07; 95% CI, 1.35-3.17; P < .001). CONCLUSIONS: Women without an AAP were less likely to initiate discussions with their physicians,take medications as prescribed, and own a peak fl ow meter to monitor asthma, all considered important self-management behaviors. They were also less satisfied with their care. Not having an AAP may affect interactions between patient and physician and clinical outcomes.

Study protocol for Women of Color and Asthma Control: a randomized controlled trial of an asthma-management intervention for African American women.

BACKGROUND: Among adults in the United States, asthma prevalence is disproportionately high among African American women; this group also experiences the highest levels of asthma-linked mortality and asthma-related health care utilization. Factors linked to biological sex (e.g., hormonal fluctuations), gender roles (e.g., exposure to certain triggers) and race (e.g., inadequate access to care) all contribute to the excess asthma burden in this group, and also shape the context within which African American women manage their condition. No prior interventions for improving asthma self-management have specifically targeted this vulnerable group of asthma patients. The current study aims to evaluate the efficacy of a culturally- and gender-relevant asthma-management intervention among African American women. METHODS/DESIGN: A randomized controlled trial will be used to compare a five-session asthma-management intervention with usual care. This intervention is delivered over the telephone by a trained health educator. Intervention content is informed by the principles of self-regulation for disease management, and all program activities and materials are designed to be responsive to the specific needs of African American women. We will recruit 420 female participants who self-identify as African American, and who have seen a clinician for persistent asthma in the last year. Half of these will receive the intervention. The primary outcomes, upon which the target sample size is based, are number of asthma-related emergency department visits and overnight hospitalizations in the last 12 months. We will also assess the effect of the intervention on asthma symptoms and asthma-related quality of life. Data will be collected via telephone survey and medical record review at baseline, and 12 and 24 months from baseline. DISCUSSION: We seek to decrease asthma-related health care utilization and improve asthma-related quality of life in African American women with asthma, by offering them a culturally- and gender-relevant program to enhance asthma management. The results of this study will provide important information about the feasibility and value of this program in helping to address persistent racial and gender disparities in asthma outcomes. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01117805.

Asthma in 10- to 13-year-olds: challenges at a time of transition.

In 10- to 13-year-old children with asthma, we know less than is desirable about the nature of the disease management tasks they face as youngsters approaching adolescence. This article reviews aspects of asthma management in youngsters at a time of significant transition. They experience puberty and growth spurts. Their cognitive abilities enable more abstract thinking. They seek individuation from their parents and socialization with peers. These factors influence asthma outcomes, including symptom control, health care use, and school attendance and performance. Furthermore, significant sex- and gender-related differences in outcome exist. Those with asthma who are 10 to 13 years of age contend not only with the particular management demands their chronic condition imposes on them but also the challenges associated with maturation. Most asthma management interventions do not account for the challenges faced at this transitional phase, and developmentally appropriate programs are needed.

An evaluation of asthma interventions for preteen students.

BACKGROUND: Asthma is a serious problem for low-income preteens living in disadvantaged communities. Among the chronic diseases of childhood and adolescence, asthma has the highest prevalence and related health care use. School-based asthma interventions have proven successful for older and younger students, but results have not been demonstrated for those in middle school. METHODS: This randomized controlled study screened students 10-13 years of age in 19 middle schools in low-income communities in Detroit, Michigan. Of the 6,872 students who were screened, 1,292 students were identified with asthma. Schools were matched and randomly assigned to Program 1 or 2 or control. Baseline, 12, and 24 months data were collected by telephone (parents), at school (students) and from school system records. Measures were the students' asthma symptoms, quality of life, academic performance, self-regulation, and asthma management practices. Data were analyzed using multiple imputation with sequential regression analysis. Mixed models and Poisson regressions were used to develop final models. RESULTS: Neither program produced significant change in asthma symptoms or quality of life. One produced improved school grades (p = .02). The other enhanced self-regulation (p = .01) at 24 months. Both slowed the decline in self-regulation in undiagnosed preteens at 12 months and increased self-regulation at 24 months (p = .04; p = .003). CONCLUSION: Programs had effects on academic performance and self-regulation capacities of students. More developmentally focused interventions may be needed for students at this transitional stage. Disruptive factors in the schools may have reduced both program impact and the potential for outcome assessment.

A current picture of asthma diagnosis, severity, and control in a low-income minority preteen population.

BACKGROUND: Asthma severity, control, type of medical regimen provided, and compliance with it are not well understood in minority patients at the transition stage from childhood to adolescence. OBJECTIVE: Describe the level of asthma severity and control and the clinical regimens provided to a large population of low-income, African American children at this developmentally significant period. METHODS: Parents of 1292 children with asthma among 6827 preteens in 19 middle schools in predominantly African American (94%), low-income neighborhoods in Detroit, Michigan, were enrolled in the study. Data were collected through self-administered survey and telephone interviews and were useable for 936 participants. Study queries related to demographics, asthma symptoms, and medication use. Mixed effects models with a random intercept for school were used to determine severity and control and the association of medical regimens to these. RESULTS: Sixty-seven percent of children with probable asthma had received a physician's diagnosis. Being female was associated with being undiagnosed (p = .02). Forty-seven with no diagnosis had persistent asthma and 10% of these were classified as severe. Sixty-eight percent with a diagnosis and asthma medicine prescriptions were not controlled. Compliant use of controller medicine was associated with poorer asthma control compared to noncompliant controller users (p = .04) and reliever-only users (p < .001). Thirty-nine percent of children had controller medicine; of those 40% were not compliant with controller use; 9% nebulized their controller medicine. CONCLUSIONS: Care provided low-income minority children at an important stage in their development was not consistent with guidelines for asthma control. Therapy choices for treatment did not account for the actual level of their symptoms. Lack of an asthma diagnosis was significant in the population. Adolescent girls were at risk for not receiving a diagnosis. Patient compliance with asthma regimens was limited. Both clinician and patient education regarding effective asthma management appears needed regarding preteens in low-income minority communities.