The Child Opportunity Index 2.0 and exacerbation-prone asthma in a cohort of urban children.

RATIONALE: Social determinants of health underlie disparities in asthma. However, the effects of individual determinants likely interact, so a summary metric may better capture their impact. The Child Opportunity Index 2.0 (COI) is one such tool, yet its association with exacerbation-prone (EP) asthma is unknown. OBJECTIVE: To investigate the association between the COI and EP asthma and clinical measures of asthma severity in children. METHODS: We analyzed data from two prospective observational pediatric asthma cohorts (n = 193). Children were classified as EP (≥1 exacerbation in the past 12 months) or exacerbation-null (no exacerbations in the past 5 years). Spirometry, exhaled nitric oxide, IgE, and Composite Asthma Severity Index (CASI) were obtained. The association between COI and EP status was assessed with logistic regression. We fit linear and logistic regression models to test the association between COI and each clinical measure. RESULTS: A 20-point COI decrease conferred 40% higher odds of EP asthma (OR 1.4; 95%CI 1.1-1.76). The effect was similar when adjusted for age and sex (OR 1.38, 95%CI 1.1-1.75) but was attenuated with additional adjustment for race and ethnicity (OR 1.19, 95%CI 0.92-1.54). A similar effect was seen for the Social/Economic and Education COI domains but not the Health/Environment Domain. A 20-point COI decrease was associated with an increase in CASI of 0.34. COI was not associated with other clinical measures. CONCLUSIONS: Lower COI was associated with greater odds of EP asthma. This highlights the potential use of the COI to understand neighborhood-level risk and identify community targets to reduce asthma disparities.

Comprehensive In-Patient Education Consult for Asthma Exacerbations.

BACKGROUND: Asthma is the most common chronic disease leading to hospital admissions and readmissions in childhood. Bedside nurses and respiratory therapists are the primary asthma educators, but they may lack time or knowledge to provide comprehensive asthma education and identify barriers to care. Patients and their parent(s) may benefit from comprehensive education and assessment of barriers from a certified asthma educator. METHODS: A team of certified asthma educators used a quality improvement method to create an in-patient asthma education consulting service. The in-patient pulmonary consult and medical teams referred subjects ≥ 1 y in age with a new or existing diagnosis of asthma who had been admitted to the ICU or identified as having concerns for poor medication adherence to the asthma consult. The asthma consult provided face-to-face education with the subject and parent(s), addressed barriers to the plan of care, and helped facilitate appointments to an asthma specialist after discharge. RESULTS: There were 126 subjects eligible for the asthma consult pilot implemented October 1, 2018-April 30, 2020. The asthma consult saw 52 subjects. Subjects who received consults had a higher rate of previous health care utilization and existing specialist for asthma. After the in-patient stay, the odds of returning to the emergency department/urgent care (UC) or hospital within the following 12 months did not differ between asthma consult and control group. However, after adjusting for covariates of age, race, ethnicity, previous health care utilization, and existing specialist, there was a significant difference in the odds of readmission and revisits (adjusted odds ratio 0.39 [95% CI 0.16-0.98], P = .04) for the asthma consult group compared to the control group. CONCLUSIONS: Providing comprehensive, face-to-face asthma education and working with subjects and their parent(s) to address barriers to medication adherence and facilitate specialty follow-up post discharge decreased health care utilization.

Association between early childhood lower respiratory tract infections and subsequent asthma.

OBJECTIVE: We examined the relationship between recurrent lower respiratory tract infections (LRTI) in young children and subsequent childhood asthma outcomes. METHODS: Retrospective cohort study using 2009-2017 Colorado All Payer Claims Database to assess 0- to 2-year-old children with visits due to LRTI and acute gastroenteritis (AGE). The primary exposure was number of LRTI visits prior to 2 years of age. Children with AGE served as the no LRTI comparator group. The primary outcome was incident asthma, defined by ICD-9 (490.XX) or ICD-10 (J45.9XX) codes, in the same children between 3 and 9 years of age. Multivariable accelerated failure time (AFT) models were used to estimate the effect of LRTI visits on median time to asthma diagnosis. Sensitivity analyses were performed using more conservative asthma diagnostic criteria and with hospitalized children only. RESULTS: Of 38,441 eligible subjects, 32,729 had ≥1 LRTI and 5,712 had AGE (no LRTI) between 0 and 2 years of age. Children with ≥3 LRTI visits had an 80% decrease in median time to asthma diagnosis relative to those with AGE visits only (time ratio [TR] 0.2; 95% CI 0.16, 0.24). Children with ≥3 LRTI hospitalizations had a 98% reduction in median time to asthma diagnosis relative to those with AGE hospitalizations only (TR 0.02; 95% CI 0.01, 0.07). History of atopy, wheezing, and family history of asthma documented prior to 2 years of age were also associated with earlier asthma diagnosis. CONCLUSIONS: Recurrent LRTIs, especially LRTI hospitalizations, before 2 years of age are associated with earlier diagnosis of pediatric asthma.

Exacerbation-Prone Asthma: A Biological Phenotype or a Social Construct.

Asthma is a complex syndrome with multiple phenotypes and endotypes. Asthma exacerbations are not only the clearest indictor of the morbidity of asthma and of the risk for mortality due to asthma, but also comprise a significant amount of the cost to care for poorly controlled asthma. There continues to be significant disparity in the prevalence, mortality, and morbidity due to asthma. Patients with asthma who suffer recurrent exacerbations are considered to have exacerbation-prone asthma (EPA). Efforts to characterize patients with frequent exacerbations show that the etiology is likely multifactorial. Research to determine the intrinsic risk factors for EPA include studies of both genetic and inflammatory biomarkers. External factors contributing to exacerbations have been extensively reviewed and include viral infection, environmental exposures, air pollution, and psychosocial and economic barriers to optimizing health. It is likely that EPA occurs when patients who have an increased underlying intrinsic/biological risk are placed in a given exposome (environments with a variety of exposures and triggers including allergens, pollution, stress, barriers, and occupational exposures). It is the social construct combined with underlying biology that frequently drives an EPA phenotype.

The Impact of Social Determinants of Health on Children with Asthma.

SzAsthma is the most common chronic disease of childhood. Disparities in asthma outcomes have led to international attention on the biologic, social, economic, and other factors that impact the health of children with asthma. Studies indicate that social determinants of health such as housing, neighborhood safety, and access to care significantly impact the health of children with asthma. However, screening for socioeconomic and environmental factors that impact asthma can be difficult to integrate into clinical practice. In addition, it is not yet clear which interventions to address these factors are most effective. This article will review recent studies of determinants and social determinants of health and propose a framework for identifying and addressing them in the care of children with asthma in a clinical setting.

They just don't take their medicines: Reframing medication adherence in asthma from frustration to opportunity.

Assessing and addressing suboptimal adherence to asthma medications is a key component in the treatment of all children with asthma, particularly those with difficult-to-treat asthma. However, parents often overreport adherence to asthma medications. Increased medication adherence could lead to improved outcomes in the form of better asthma control and decreased asthma exacerbations, as well as decreased healthcare utilization costs. Yet there are many complex factors that affect medication adherence, and barriers are often different in each family. Social determinants of health, complex healthcare relationships, and patient-related factors may all affect medication adherence. Multicomponent patient-centered strategies, as well as strategies that utilize technology and habit formation strategies may be helpful in improving medication adherence. Further study is needed to reliably and sustainably improve medication adherence in children with asthma across the broader population; in some populations, alternate diagnoses, adjusting therapy, and other intervention may be required to improve asthma control and health.

Steroid variability in pediatric inpatient asthmatics: survey on provider preferences of dexamethasone versus prednisone.

Objective: Our hospital's pediatric Emergency Department (ED) began using dexamethasone for treating asthma exacerbations after ED studies showed non-inferiority of dexamethasone compared to prednisone. However, providers have not reached consensus on optimal inpatient steroid regimen. This study evaluates provider preference for inpatient steroid treatment.Methods: A survey was distributed to providers who care for inpatient pediatric asthmatics. Respondents answered questions about steroid choice and timing. Data were summarized as percentages; bivariate comparisons were analyzed with Pearson's chi-squared test.Results: Ninety-two providers completed the survey (60% response rate). When patients received dexamethasone in the ED, subsequent inpatient management was variable: 44% continued dexamethasone, 14% switched to prednisone, 2% said no additional steroids, and 40% said it depended on the scenario. Hospitalists were more likely to continue dexamethasone than pulmonologists (61% and 15%, respectively; p < .001). Factors that influenced providers to switch to prednisone in the inpatient setting included severity of exacerbation (73%) and asthma history (47%). Fifty-one percent felt uncomfortable using dexamethasone because of "minimal data to support [its] use inpatient." In case-based questions, 28% selected dexamethasone dosing intervals outside the recommended range. Thirteen percent reported experiencing errors in clinical practice.Conclusions: Use of dexamethasone in the ED for asthma exacerbations has led to uncertainty in inpatient steroid prescribing practices. Providers often revert to prednisone, especially in severe asthma exacerbations, possibly due to experience with prednisone and limited research on dexamethasone in the inpatient setting. Further research comparing the effectiveness of dexamethasone to prednisone in inpatient asthmatic children with various severities of illness is needed.

Applying a biopsychosocial model to inner city asthma: Recent approaches to address pediatric asthma health disparities.

Pediatric asthma in inner cities is often severe and children living in these urban locations with socioeconomic disadvantage experience greater asthma morbidity. There are many interconnected risk factors that individually, and in combination, enhance asthma morbidity. These include biologic factors innate to the child, such as genetics and allergen susceptibility, as well as factors related to the family and neighborhood context. The biopsychosocial model can be used to frame these risk factors and develop interventions specific to the inner city. Successful inner city asthma interventions exist and key characteristics include multi-tiered components that operate within the community to coordinate disease management resources between patients, families and health care systems.

Medical home characteristics and asthma control: a prospective, observational cohort study protocol.

BACKGROUND: This paper describes the methods for an observational comparative effectiveness research study designed to test the association between practice-level medical home characteristics and asthma control in children and adults receiving care in safety-net primary care practices. METHODS: This is a prospective, longitudinal cohort study, utilizing survey methodologies and secondary analysis of existing structured clinical, administrative, and claims data. The Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) is a safety net-oriented, primary care practice-based research network, with federated databases containing electronic health record (EHR) and Medicaid claims data. Data from approximately 20,000 patients from 50 practices in four healthcare organizations will be included. Practice-level medical home characteristics will be correlated with patient-level asthma outcomes, controlling for potential confounding variables, using a clustered design. Linear and non-linear mixed models will be used for analysis. Study inception was July 1, 2012. A causal graph theory approach was used to guide covariate selection to control for bias and confounding. DISCUSSION: Strengths of this design include a priori specification of hypotheses and methods, a large sample of patients with asthma cared for in safety-net practices, the study of real-world variations in the implementation of the medical home concept, and the innovative use of a combination of claims data, patient-reported data, clinical data from EHRs, and practice-level surveys. We address limitations in causal inference using theory, design and analysis.

Quality improvement for asthma care within a hospital-based teaching clinic.

OBJECTIVE: The aim of this study was to determine if a quality improvement intervention in a teaching clinic was associated with the following: 1) improved asthma action plan creation and distribution, 2)increased classification of asthma patients as intermittent or persistent, 3) increased prescriptions of asthma controller medications, 4) decreased emergency department visits and hospitalizations, and 5) sustainable changes in outcomes after the intervention year. METHODS: A retrospective analysis was conducted of a quality improvement project involving children aged >2 years who were diagnosed with asthma, evaluated in a large hospital-based teaching clinic. Outcomes were assessed for 1 year before and 3 years after quality improvement intervention. RESULTS: Data from children with asthma seen in the clinic over the 4 years of the study (N = 1797) were analyzed. Mixed effects model regressions showed that children after the intervention were over twofold more likely to receive an asthma action plan (using 2006 as referent, adjusted risk ratio [ARR] 2.29, 95% confidence interval [CI] 2.03-2.56 in 2007; ARR 2.40, 95% CI 2.15-2.66 in 2008; ARR 2.86, 95% CI 2.60-3.20 in 2009). Recorded assessment of asthma severity was 31% to 47% more likely post-intervention (ARR 1.31, 95% CI 1.26-1.36 in 2007, ARR 1.44 95% CI 1.38-1.50 in 2008, ARR 1.47 95% 1.41-1.54 in 2009). Controller medication prescribing increased postintervention ARR 1.08, 95% CI, 1.02-1.14 in 2007; ARR 1.11, 95% CI, 1.04-1.17 in 2008; ARR 1.11, 95% CI, 1.05-1.19 in 2009. Emergency department visits and hospitalizations trended lower postintervention (not significant). CONCLUSIONS: A quality improvement intervention in a hospital-based teaching clinic was associated with increased use of asthma action plans, classification of asthma severity, and controller medications, and possibly a trend toward fewer emergency visits and hospitalizations.

Frequency and correlates of overweight status in adolescent asthma.

BACKGROUND: Debate exists within the literature concerning whether asthma and obesity are linked as comorbid conditions. Further study is required to understand the relationship between asthma and overweight status, and developmental considerations are an important priority area. OBJECTIVE: The present study addressed gaps in the existing literature by comparing rates of overweight status among a matched sample of adolescents with and without asthma and by examining correlates of overweight status among youth with asthma. METHODS: Rates and correlates of overweight status were compared among a matched cohort of 103 adolescents with asthma, 75 adolescents with asthma characterized by history of a severe acute event, and 92 normal controls. RESULTS: Significantly higher rates of overweight status were found among the asthma groups compared to the control group and to population estimates. Significant correlates for overweight status included younger age and earlier age at asthma diagnosis, suggesting that receiving an asthma diagnoses in early childhood may increase the propensity for weight gain. CONCLUSION: Asthma and obesity are problematic comorbid conditions, and specialized obesity prevention programs may be particularly necessary at the onset of a new asthma diagnosis. CLINICAL IMPLICATIONS: Identifying and addressing the factors that may contribute to the potential for obesity among youth with asthma are key research and clinical practice priorities.

Case report: skin discoloration following administration of colloidal silver in cystic fibrosis.

PURPOSE OF REVIEW: Complementary and alternative medicine therapies are frequently combined with conventional medical treatment and can significantly affect patient care. In the following case, an adjunctive modality posed a significant health risk to the patient. RECENT FINDINGS: An 11-year-old boy with cystic fibrosis reported a bluish skin color after he began ingesting a colloidal silver solution to facilitate mucus clearance. Serum silver level was elevated to more than twice the upper limit of normal. This finding is highly suggestive of argyria, a typically permanent discoloration of the skin due to dermal silver deposits. In this child, however, the discoloration was transient and the silver level normalized when the therapy was discontinued. SUMMARY: Although a diagnosis of argyria was not formally made, this case reviews the known dangers associated with silver ingestion. Complementary and alternative medicine therapies are common and can both augment and interfere with the traditional standard of care. Informed providers who inquire about the use of these therapies can then discuss the risks and benefits of each utilized modality.

History of serious asthma exacerbations should be included in guidelines of asthma severity.

BACKGROUND: It is unclear whether asthma severity measured with consensus guidelines is better than a history of a serious asthma exacerbation in predicting current disease activity and future clinical course. OBJECTIVES: We sought to (1) compare asthma severity determined by using the Global Initiative for Asthma guidelines with a history of a serious asthma exacerbation as predictors of pulmonary function, bronchial hyperreactivity, and disease activity and (2) determine whether exacerbation history significantly adds to asthma severity in its ability to predict the same variables. METHODS: Forty-eight adolescents with a history of a serious asthma exacerbation were compared with 69 adolescents with asthma but without such a history. Groups were matched for age, sex, and ethnicity (age, 14.59 +/- 1.74 years; 56% male; 58% white). RESULTS: Forty-two percent of subjects had severe, 28% had moderate, 15% had mild persistent, and 15% had mild intermittent asthma. Asthma severity and exacerbation history were associated with pulmonary function and markers of disease activity, whereas only exacerbation history predicted bronchial hyperreactivity (P

Racial differences in T-lymphocyte response to glucocorticoids.

BACKGROUND: Asthma morbidity and mortality is increased in blacks. OBJECTIVE: The primary objective of this cross-sectional study was to determine if blacks, asthmatic or nonasthmatic, displayed diminished T-lymphocyte response to glucocorticoids in vitro compared to their white counterparts. If differences were noted, this would suggest a racial predisposition to decreased glucocorticoid responsiveness among blacks. METHODS: Asthmatic (n = 395, 27% blacks) and control (n = 202, 52% blacks) subjects recruited from National Jewish Medical and Research Center and from the surrounding community participated in the study. In vitro glucocorticoid responsiveness was determined by assessing the log-transformed concentration of dexamethasone required to suppress phytohemagglutinin-induced T-lymphocyte proliferation by 50% (log(10) IC(50)). Asthma medication history, atopic status, and spirometric lung function measures corrected for race were collected. RESULTS: Black and white asthmatic subjects had similar FEV(1) percentage of predicted values and inhaled and oral glucocorticoid requirements. Black asthmatic subjects displayed significantly diminished glucocorticoid responsiveness compared to white asthmatic subjects, as follows: median (first, third quartile) log(10) IC(50) values of 1.00 nmol (0.48, 1.83) vs 0.78 nmol (0.29, 1.45) [p = 0.028]. Similar results were found between black and white control subjects, as follows: median, 1.26 nmol (0.70, 2.14) vs 0.95 nmol (0.55, 1.48) [p = 0.01]. Age, race, and basal T-lymphocyte activity were significantly positively correlated to the log(10) IC(50) values. CONCLUSION: Our observation that black asthmatic subjects and non-asthmatic control subjects require greater concentrations of glucocorticoid in vitro to suppress T-lymphocyte activation suggests that blacks have a racial predisposition to diminished glucocorticoid responsiveness, which may contribute to their heightened asthma morbidity.

Overcoming childhood asthma disparities of the inner-city poor.

Asthmatic children living in low-income families in United States inner city communities continue to have disproportionately high rates of hospitalizations, emergency department visits, disability, and death. Current research implicates a combination of environmental, biologic, and disease mismanagement factors that underlie these poor outcomes. Multifaceted studies are underway to better understand this inner-city path to severe asthma. Efforts to optimize interventions, to implement them broadly, and to sustain them are also underway on local and national levels. It is hoped that these efforts will limit the severe consequences of asthma, narrow disparities in outcomes, and substantially reduce medical expenditures for asthma.