Are childhood oral health behaviours and experiences associated with dental anxiety in adolescence?

BACKGROUND: Dental anxiety is associated with untreated dental caries. Understanding which childhood behaviours or experiences have the strongest association with later dental anxiety may help focus preventive strategies, subsequently limiting the burden of dental caries and anxiety. AIM: The aim of this study was to explore whether behaviours and experiences during childhood were associated with adolescent dental anxiety. DESIGN: Data were obtained from the Avon Longitudinal Study of Parents and Children (ALSPAC). Multivariable logistic regression was used to explore associations between adolescent dental anxiety and childhood behaviours and experiences. 1791 participants answered questions about oral health behaviours and experiences at 8 years of age and dental anxiety questions aged 17 years. RESULTS: Children with experience of invasive dental treatment were more likely to have dental anxiety at 17 years of age than those who had not experienced dental treatment (OR 1.63; 95% CI: 1.12, 2.37; p = .011). Irregular dental attenders in childhood had over three times the odds of dental anxiety by adolescence, compared with regular attenders (OR 3.67 95% CI: 1.52, 8.88; p = .004). CONCLUSIONS: Adolescent dental anxiety is associated with invasive treatment and irregular dental attendance in childhood. A history of irregular attendance or invasive treatment may serve as a useful predictor when considering dental anxiety in young adult patients. Early preventive care supports good attendance and oral health. These actions may have secondary effects of reducing future dental anxiety.

Flow impacts of hot/cold zone infection control procedures during the COVID-19 pandemic in the emergency department.

BACKGROUND: The COVID-19 pandemic forced emergency departments (EDs) to change operations to minimize nosocomial infection risk. Many EDs cohort patients using provincial screening tools at triage. Despite cohorting, staff exposures occurred in the 'cold zone' due to lack of personal protective equipment (PPE) use with patients deemed low risk, resulting in staff quarantines. The cohorting strategy was perceived to lengthen time to physician initial assessment and ED length of stay times in our ED without protecting staff well enough due to varying PPE use. The objective of this study was to assess the impact of hot/cold zones for patient cohorting during a viral pandemic on ED length of stay. METHODS: We conducted an interrupted time series analysis 3 weeks before and after the removal of hot/cold zone care space cohorting in our ED. In the before period, staff did not routinely wear full PPE to see cold zone patients. After removal, staff wore full PPE to see almost all patients. We collected data on ED length of stay, physician initial assessment times, arrival-to-room times, patient volumes, Canadian Triage Acuity Score (CTAS), admissions, staff hours of coverage, as well as proportions of patients on droplet/contact precautions and COVD-19 positive patients. The primary outcome was median ED length of stay. RESULTS: After the removal of the hot/cold divisions, there was a decrease in the adjusted median ED length of stay by 24 min (95% CI 14; 33). PPE use increased in the after arm of the study. The interrupted time series analysis suggested a decrease in median ED length of stay after removal, although the change in slope and difference did not reach statistical significance. CONCLUSION: Cohorted waiting areas may provide a safety benefit without operational compromise, but cohorting staff and care spaces is likely to compromise efficiency and create delays.

RéSUMé: CONTEXTE: La pandémie de COVID-19 a contraint les services d'urgence (SU) à modifier leur fonctionnement afin de minimiser le risque d'infection nosocomiale. De nombreux SU regroupaient des patients à l'aide d'outils de dépistage provinciaux au triage. Malgré la constitution de cohortes, les expositions du personnel se sont produites dans la "zone froide" en raison du manque d'utilisation d'équipements de protection individuelle (EPI) avec des patients jugés à faible risque, ce qui a entraîné la mise en quarantaine du personnel. Dans notre service d'urgence, la stratégie de cohorte a été perçue comme prolongeant l'évaluation initiale des médecins et la durée du séjour dans le service sans pour autant protéger suffisamment le personnel en raison de l'utilisation variable des EPI. L'objectif de cette étude était d'évaluer l'impact des zones chaudes/froides pour le regroupement de patients lors d'une pandémie virale sur la durée du séjour à l'urgence. MéTHODES: Nous avons réalisé une analyse de séries chronologiques interrompues trois semaines avant et après la suppression de la cohorte d'espace de soins en zone chaude/froide dans nos urgences. Au cours de la période précédente, le personnel ne portait pas systématiquement un EPI complet pour voir les patients des zones froides. Après le retrait, le personnel a porté un EPI complet pour voir presque tous les patients. Nous avons recueilli des données sur la durée du séjour aux urgences, les délais d'évaluation initiale par les médecins, les délais d'arrivée en salle, le volume de patients, L'échelle canadienne de triage et de gravité (ÉTG), les admissions, les heures de couverture du personnel, ainsi que les proportions de patients ayant reçu des précautions contre les gouttelettes et les contacts et de patients positifs au COVD-19. Le critère de jugement principal était la durée médiane du séjour aux urgences. RéSULTATS: Après la suppression des divisions chaudes/froides, la durée médiane ajustée du séjour aux urgences a diminué de 24 minutes (IC à 95 % : 14 ; 33). L'utilisation des EPI a augmenté dans le groupe suivant de l'étude. L'analyse des séries chronologiques interrompues suggère une diminution de la durée médiane de séjour aux urgences après le retrait, bien que le changement de la pente et de la différence n'ait pas atteint la signification statistique. CONCLUSION: Les zones d'attente en cohorte peuvent offrir un avantage en matière de sécurité sans compromis sur le plan opérationnel, mais le regroupement du personnel et des espaces de soins est susceptible de compromettre l'efficacité et de créer des retards.

Implementation of Ontario's emergency department asthma care pathway for adults: determinants of uptake.

OBJECTIVE: The Ontario Government funded the development and implementation of a standardized adult emergency department (ED) asthma care pathway (EDACP). We aimed to describe baseline patterns of ED use by adults for asthma in Ontario, Canada, and determine site characteristics associated with the EDACP implementation workshop attendance and subsequent pathway implementation. METHODS: All Ontario EDs were offered EDACP implementation workshops by the Lung Assocation-Ontario between 2008 and 2011, and were surveyed regarding site implementation status as of October, 2013. Survey data were linked by site to Ontario's administrative health databases. Logistic regression models investigated the association between site and patient characteristics and: a) workshop attendance; b) pathway implementation. RESULTS: In the 2 years prior to EDACP implementation, there were 41 143 asthma visits to 167 sites by adults (62.3% female). Asthma-related return visits within 72 h varied by hospital type (teaching 2.1%, community 2.8%, small 4.0%; p < 0.05). Implementation workshops were attended by staff from 122 sites (72.6%). Implementation status was known for 108 sites and varied by hospital type (p < 0.001), but not workshop attendance (p = 0.11). By 2013, 47% of all hospitals were using or planning to use the EDACP. Uptake was more likely in community hospitals. CONCLUSIONS: Ontario adult asthma ED visitors are more often women. Asthma-related return visits are uncommon, but significantly higher in small community hospitals. This provincial QI initiative reached almost 75% of Ontario EDs, and achieved almost 50% implementation rate within 2 years. Factors other than workshop attendance, such as hospital size, were associated with EDACP implementation.

Assessing the burden of childhood asthma: validation of electronic versions of the Mini Pediatric and Pediatric Asthma Caregiver's Quality of Life Questionnaires.

PURPOSE: To validate electronic versions of the Mini Pediatric and Pediatric Asthma Caregiver's Quality of Life Questionnaires (MiniPAQLQ and PACQLQ, respectively), determine completion times and correlate QOL of children and caregivers. METHODS: A total of 63 children and 64 caregivers completed the paper and electronic MiniPAQLQ or PACQLQ. Agreement between versions of each questionnaire was summarized by intraclass correlation coefficients (ICC). The correlation between MiniPAQLQ and PACQLQ scores from child-caregiver pairs was assessed using Pearson's correlation coefficient. RESULTS: There was no significant difference (mean difference = 0.1, 95% CI -0.1, 0.2) in MiniPAQLQ Overall Scores between paper (5.9 ± 1.0, mean ± SD) and electronic (5.8 ± 1.0) versions, or any of the domains. ICCs ranged from 0.89 (Overall) to 0.86 (Emotional Function). Overall PACQLQ scores for both versions were comparable (5.9 ± 0.9 and 5.8 ± 1.0; mean difference = 0.0; 95% CI -0.1, 0.2). ICCs ranged from 0.81 (Activity Limitation) to 0.88 (Emotional Function). The electronic PACQLQ took 26 s longer (95% CI 11, 41; p < 0.001). Few participants (3-11%) preferred the paper format. MiniPAQLQ and PACQLQ scores were significantly correlated (all p < 0.05) for Overall (r paper = 0.33, r electronic = 0.27) and Emotional Function domains (r paper = 0.34, r electronic = 0.29). CONCLUSIONS: These electronic QOL questionnaires are valid, and asthma-related QOL of children and caregivers is related.

The development and test re-test reliability of a work-related asthma screening questionnaire.

OBJECTIVE: Work-related asthma (WRA) is under-recognized and delays in recognition contribute to long-term morbidity. The objective of the project was to develop a WRA screening questionnaire for use by primary care providers in the assessment of individuals with asthma, and to evaluate the respondent burden, test re-test reliability and face validity of the questionnaire. METHODS: A literature search was undertaken and an expert advisory committee was convened. A questionnaire was drafted and assessed for feasibility of use and content validity. The study enrolled patients with asthma attending outpatient clinics and an asthma education center. Participants were asked to respond to the questionnaire on two occasions, and comment on the content (face validity) and ease of completion (respondent burden). Ethics approval was obtained from an institutional review board. RESULTS: A 14-item self-administered screening questionnaire was created. Thirty-nine participants were recruited, and 26 participants completed a second administration of the questionnaire. The items on the relation of asthma symptoms to work demonstrated substantial agreement between testings. The workplace exposures items were found to have good reproducibility. The majority of participants denied that items were repetitive, not useful or difficult to understand. CONCLUSIONS: We have developed a WRA screening questionnaire designed to aid primary care providers in the recognition of possible WRA. The tool exhibited content and face validity, good test re-test reliability and low respondent burden. Participant feedback is being considered in revisions of the questionnaire.

Development and implementation of an electronic asthma record for primary care: integrating guidelines into practice.

RATIONALE: Evidence-based practice may be enhanced by integrating knowledge translation tools into electronic medical records (EMRs). We examined the feasibility of incorporating an evidence-based asthma care map (ACM) into Primary Care (PC) EMRs, and reporting on performance indicators. METHODS: Clinicians and information technology experts selected 69 clinical and administrative variables from the ACM template. Four Ontario PC sites using EMRs were recruited to the study. Certified Asthma Educators used the electronic ACM for patient assessment and management. De-identified data from consecutive asthma patients were automatically transmitted to a secure central server for analysis. RESULTS: Of the four sites recruited, two sites using "stand-alone" EMR systems were able to incorporate the selected ACM variables into an electronic format and participate in the pilot. Data were received on 161 visits by 130 patients aged 36.5 ± 26.9 (mean ± SD) (range 2-93) years. Ninety-four percent (65/69) of the selected ACM variables could be analyzed. Reporting capabilities included: individual patient, individual site and aggregate reports. Reports illustrated the ability to measure performance (e.g. number of patients in control, proportion of asthma diagnoses confirmed by an objective measure of lung function), benchmark and use EMR data for disease surveillance (e.g. number of smokers and the individuals with suspected work-related asthma). CONCLUSIONS: Integration of this evidence-based ACM into different EMRs was successful and permitted patient outcomes monitoring. Standardized data definitions and terminology are essential in order for EMR data to be used for performance measurement, benchmarking and disease surveillance.

Comparison of asthma control criteria: importance of spirometry.

AIMS: To compare the measurements of asthma control using Canadian Thoracic Society (CTS) Asthma Management Consensus Summary and Global Initiative for Asthma (GINA) guidelines composite indices with and without spirometry. METHODS: Asthma control parameters were extracted from electronic medical records (EMRs) of patients ≥6 years old at two primary care sites. Asthma control ratings calculated according to CTS and GINA criteria were compared. RESULTS: Data were available from 113 visits by 93 patients, aged 6-85 years (38.7 ± 24.8; mean ± SD). The proportion of visits at which individuals' asthma was completely controlled was 22.1% for CTS symptoms only and 9.7% for CTS with spirometry (p < .01); and 17.7% versus 14.1% for GINA symptoms only versus symptoms with spirometry (p = .125). CONCLUSIONS: Asthma control ratings using GINA and CTS criteria are discordant in more than half of the patients deemed "in control" by at least one scale. Differences in the spirometry criterion threshold are primarily responsible for this discordance. Failure to include spirometry as part of the control index consistently overestimates asthma control and may underestimate future risk of exacerbations.

Asthma care pathways in the emergency department.

PURPOSE OF REVIEW: The purpose of this review is to describe recent evidence of the efficacy and effectiveness of clinical pathways for the assessment and management of severe acute asthma in children and adults in the emergency department (ED). The review will highlight examples of successful knowledge translation initiatives and their ability to support adherence to Best Practice Guidelines. RECENT FINDINGS: Recent studies reveal that management of pediatric and adult asthma in the ED setting often differs from that which is recommended in clinical practice guidelines. Single and multicenter North American studies have consistently found care gaps. Barriers to adherence to evidence-based management guidelines are numerous. Care pathways are knowledge translation tools that provide a means of applying knowledge translation principles to overcome these barriers, integrate guidelines into practice and optimize patient outcomes. Evidence from a recent Ontario multicenter asthma clinical pathway initiative is highlighted, demonstrating increased adherence to certain aspects of ED care, improved patient recollection of teaching done in the ED and increased referral rates. These findings strengthen the evidence supporting the development and implementation of standardized evidence-based asthma clinical pathways. SUMMARY: Gaps between current and best practices persist for the management of asthma in children and adults in North American EDs. There is robust evidence in support of ED asthma clinical pathways to optimize asthma care and outcomes in this setting.

Multicentre evaluation of an emergency department asthma care pathway for adults.

OBJECTIVE: We sought to determine whether a standardized emergency department (ED) asthma care pathway (ACP) for adults would be accepted by ED staff, improve adherence to Canadian ED asthma management guidelines and improve patient outcomes. METHODS: Ten Ontario hospital EDs (5 intervention, 5 control) participated in a 5-month pre-post intervention study. Emergency department management, admissions, repeat ED visits and ED length of stay were compared between sites and by ACP use versus nonuse at intervention sites. RESULTS: The ACP was used in 101 of 383 visits (26.4%) at 5 intervention sites. Use of the ACP varied significantly between sites, ranging from 6% to 60% (p < 0.001). When compared with control sites, there were significant increases in the use of metered dose inhalers (MDIs), inhaled steroids, referrals, documentation of teaching, patient recollection of teaching (all with a p < 0.001) and oxygen (p = 0.001). Use of peak expiratory flow rate (PEFR) measurements decreased in both intervention and control sites. Increased PEFR documentation and systemic steroid use in the ED and on discharge were only found in patients who were on the ACP at intervention sites. Admissions increased from 3.9% to 9.4% at intervention sites in contrast to control sites, where they remained fairly stable (p = 0.016), but did not differ by ACP use. The length of stay for discharged patients increased by a mean of 16 minutes for ACP patients at intervention sites (p = 0.002). There were no statistically significant differences in repeat ED visits. CONCLUSION: Adoption of a standardized ED ACP for adults is highly variable. Despite modest uptake, which averaged 26%, beneficial changes in specific aspects of asthma care delivery were found, notably in referrals and recollection of teaching done during the ED visit, without a substantial increase in ED length of stay. These changes may lead to improvements in outcomes, such as reduced relapse rates, which this study was not designed or powered to detect. Provincial and national implementation strategies that address barriers to clinical pathway adoption are warranted and have the potential to improve adherence to guidelines and outcomes for asthma patients.

Emergency department adult asthma care pathway: healthcare providers' perceived utility and barriers to implementation.

Clinical pathways provide an outline for evidence-based care and can reduce variation of care across many healthcare settings including the emergency department (ED). The purpose of this study was to examine healthcare providers' perceptions of an ED Asthma Care Pathway (EDACP) and identify barriers to implementation. Following a 6-month pilot implementation of the EDACP, healthcare providers (physicians, nurses, respiratory therapists, and administrators) at 5 Ontario EDs were surveyed about the content, format, and usefulness of the pathway, as well as barriers to implementation. A focus group was convened to further explore these factors. In total, 207 of 338 mailed surveys were returned. Approximately 60% of respondents felt that the pathway was a useful tool, which enabled adherence with asthma guidelines (81%), decreased variation in patient care (79%), decreased uncertainty in patient management (73%), and increased their knowledge of best practice (87%). Time constraints and length of the pathway were common barriers. Healthcare providers perceive the EDACP to be a useful knowledge translation and guideline implementation tool, which promotes best practices. Although barriers to adoption of the tool have been identified, these may guide content revisions and inform the process for a successful provincial implementation strategy.

Perceived control and quality of life in asthma: impact of asthma education.

The purpose of this study was to determine the relationship between patients' perception of asthma control and generic and asthma-specific quality of life (QOL) post-completion of a behavior modification-based adult asthma education program. A secondary objective was to examine associations between changes in perceived control of asthma and generic and asthma-specific QOL. Outcome measures were collected via an asthma management questionnaire (AMQ), generic (SF-36) and asthma-specific (AQLQ) QOL questionnaires, and a perceived control of asthma questionnaire (PCAQ). The cohort (n = 55) consisted of predominately female (75%), married (56%), middle income (46%) patients with severe asthma (65%) who had completed a university or college education (20%) and were working full-time (42%). The mean age was 45.2 (SD = 17.5) years. Perceived control of asthma and generic and asthma-specific quality of life significantly improved after completing the behavior modification-based adult asthma education program. Significant associations were found between perceived control of asthma (PCAQ) and both generic (SF-36) and asthma-specific QOL (AQLQ). Baseline PCAQ was related to all four domains and the total score of the AQLQ and 5 of the 8 domains of the SF-36. PCAQ was related to 3 of the 4 AQLQ domains at 3 months and total AQLQ score at both 1 and 3 months post-education. PCAQ was related to all 8 domains of the SF-36 at 1 month; and 4 of 8 domains at 3 months. Change in PCAQ (deltaPCAQ) was related to change in symptom score, emotional functioning, and total AQLQ score from baseline to 1 month and change in symptom score from baseline to 3 months. In conclusion, perceived control of asthma in patients participating in a behavior modification-based asthma education program was related to generic and disease-specific QOL. An improvement in PCAQ was associated with improved QOL following asthma education. Using the PCAQ as part of an asthma educational needs assessment may be a quick, simple way to identify and target education towards asthma patients with low perceived control.

Outcomes of asthma education: results of a multisite evaluation.

BACKGROUND: This observational study compared the effectiveness of a standardized adult asthma education program administered in a variety of sites and practice settings on health care utilization, absenteeism, amount of leisure time missed and quality of life (using the Medical Outcomes Study 36-Item Short Form 1.0 [SF-36]). METHODS: Seven asthma centres participated in an uncontrolled, multicentre, prospective, observational study using a pre-post design. Variables included hospital- and community-based centres, an academic hospital setting and the presence or absence of physician attendance. Trained asthma educators administered a guided self- management education program, and standardized questionnaires were used for patient assessment at baseline and six months after education. RESULTS: Of the 517 patients enrolled at baseline, 396 were eligible for the six-month follow-up. Follow-up data were available for 252 patients. SF-36 data were collected for 241 patients at six sites, with follow-up data available for 103 of 155 eligible patients. Asthma education was associated with substantial improvements in scheduled and unscheduled physician visits, unscheduled specialist visits, emergency department visits, hospital admissions, hospitalized days, missed work or school days and missed days of leisure time. There were also statistically significant improvements in all but one SF-36 domain. These improvements were comparable across all geographical sites and physical settings. CONCLUSIONS: Standardized asthma education appears to be effective when administered in a variety of practice settings, and may be associated with significant improvements in patient outcomes. The significant decline in health care utilization implies that substantial health care savings may occur as a result of the implementation of standardized asthma education programs.