Stressful life events, caregiver depressive symptoms, and child asthma symptom-free days: a longitudinal analysis.

OBJECTIVE: To examine relationships among stressful life events (SLE), caregiver depression, and asthma symptom free days (SFDs) in publicly insured Black children aged 4-12 years with persistent asthma. METHODS: Secondary analysis of longitudinal data from a clinical trial assessing the efficacy of a six-month parental stress management intervention. Using repeated measures Poisson regression, we constructed four models of SLE (Rochester Youth Development Stressful Life Events scale-Parent Items), caregiver depression (Center for Epidemiologic Studies Depression scale ≥ 11), and child asthma symptom-free days (SFDs) in the prior 14 days. RESULTS: There was no association between SLE and child SFDs, but there was for caregiver depression (Incidence Rate Ratio [IRR]: 0.904; 95% CI 0.86-0.95). The interaction between SLE and caregiver depression was not significant. A specific SLE (recent serious family accident or illness) predicted fewer child SFDs (IRR: 0.91, 95% CI: 0.85-0.98). In the interaction model between caregiver depression and recent accident/illness, caregiver depression was associated with fewer child SFDs (IRR: 0.95, 95% CI: 0.91-0.99) as was the interaction between caregiver depression and recent accident/illness (IRR: 0.77, 95% CI 0.66-0.91); but the relationship between recent accident/illness and child SFDs was not (IRR: 1.00, 95% CI, 0.92-1.09), meaning accident/illness was only associated with fewer child SFDs among depressed caregivers. CONCLUSIONS: In a sample of publicly insured Black children with persistent asthma, caregiver depression was negatively associated with child SFDs while overall SLE were not. A recent family accident or illness was negatively associated with child SFDs only when the caregiver was depressed.

Creation and validation of a citywide pediatric asthma registry for the District of Columbia.

OBJECTIVE: To create and validate a citywide pediatric Asthma Registry to improve the care and outcomes of children and adolescents in Washington, DC through data-driven quality improvement (QI). METHODS: All available electronic health record data from inpatient and outpatient domains of Children's National Hospital were aggregated from an existing enterprise data warehouse. Inclusion criteria included asthma relevant ICD-10 codes over the prior 24 months. Available Asthma Registry measures include patient demographics, ambulatory visits, hospital admissions, persistent asthma diagnoses, and prescription of controller medications. Data capture was validated using US Census data and current asthma prevalence estimate of the Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: The registry identified 15,991 DC children and adolescents with asthma aged 0-17 years, inclusive, at the end of 2020. This was 14.2% higher than the estimate of 14,001 children derived from BRFSS. Characteristics of those in the registry included: mean age of 9.5 (1.4) years, 57.9% male, 72.3% Black, and 66.7% publicly insured. Over the prior 24 months, 30.3% had ≥1 emergency department visit, and 10.5% had ≥1 hospital admission. Controller medications were prescribed for 59.6% of children with persistent asthma. Rates varied by sampled primary care practice sites. CONCLUSIONS: A population-level pediatric asthma registry captures more children and adolescents with asthma in DC then a BRFSS-derived estimate, and provides city-wide measures of asthma-related utilization. The registry allows for stratification by primary care practice locations and asthma characteristics, supporting the design, implementation, and evaluation of QI projects at the practice, health system, and population levels.Supplemental data for this article can be accessed at publisher's website.

Randomized clinical trial of parental psychosocial stress management to improve asthma outcomes.

OBJECTIVE: Because higher parental psychosocial stress is associated with worsened asthma outcomes in children, we sought to determine if a parent-focused stress management intervention would improve outcomes among their at-risk African American children. METHODS: We enrolled self-identified African American parent-child dyads (children aged 4-12 years old with persistent asthma, no co-morbidities, on Medicaid) in a prospective, single-blind, randomized clinical trial with follow-up at 3, 6, and 12 months. All children received care based on the guidelines of the National Institutes of Health. Developed with extensive local stakeholder engagement, the intervention consisted of four individual sessions with a community wellness coach (delivered over 3 months) supplemented with weekly text messaging and twice monthly group sessions (both delivered for 6 months). The main outcome was asthma symptom-free days in the prior 14 days by repeated measures at 3 and 6 months follow-up. RESULTS: We randomized 217 parent-child dyads and followed 196 (90.3%) for 12 months. Coaches completed 338/428 (79%) of all individual sessions. Symptom-free days increased significantly from baseline in both groups at 3, 6, and 12 months, but there were no significant differences between groups over the first 6 months. At 12 months, the intervention group sustained a significantly greater increase in symptom-free days from baseline [adjusted difference = 0.92 days, 95% confidence interval (0.04, 1.8)]. CONCLUSION: The intervention did not achieve its primary outcome. The efficacy of providing psychosocial stress management training to parents of at-risk African American children with persistent asthma in order to improve the children's outcomes may be limited. CLINICALTRIALS.GOV: NCT02374138.

Wellness coaches in intervention delivery: pediatric asthma as an example.

Asthma is the most common chronic illness among children, and parental psychosocial stress is a well-documented mediator of poor pediatric asthma outcomes. However, few interventions have targeted parental stress as a means for improving child asthma outcomes. The purpose of the study is to describe the feasibility and acceptability of the use of wellness coaches in a parent-focused stress management intervention in pediatric asthma. Data on the feasibility of wellness coach recruitment and training, intervention delivery and fidelity, and acceptability are provided from a randomized controlled trial intervention group sample of 107 African American parents of children aged 4-12 years (M = 6.6 years) with persistent asthma. Implementation of intervention strategies is described. Two wellness coaches were recruited and trained, and they conducted the four-session intervention for the study. The majority (79%) of possible intervention sessions were completed. The fidelity ratings of coach implementation of the intervention were high and indicated that 92%-95% of target intervention content was covered during the sessions. Participants reported high acceptability of working with the wellness coaches. Use of wellness coaches in a parent-focused stress management pediatric asthma intervention was feasible and acceptable. Using wellness coaches for parent interventions may be applicable across other pediatric conditions and has the potential to change clinical practice.

A pilot randomized trial of school-based administration of inhaled corticosteroids for at-risk children with asthma.

OBJECTIVE: To investigate whether high adherence to inhaled corticosteroids (ICS) among disadvantaged urban public school children on public insurance with persistent asthma is achievable by having school nurses administer morning doses on each day that school is in session. DESIGN/METHODS: This was a pilot prospective randomized clinical trial of home versus school nurse-administered ICS among children on Medicaid enrolled in grades K-8. The primary outcome was the proportion of expected morning doses of ICS given to the intervention group in school over the 60-day treatment period. Secondary outcomes included the relative proportions of expected doses (morning, evening, and total), asthma-related morbidity, quality of life, and health-care utilization. RESULTS: A total of 46 patients were enrolled (mean age 8.21 ± 2.45; 56.5% male; 91.3% non-Hispanic, African-Americans), and follow-up data were available for 44/46 (95.7%) patients. The groups did not differ in age, gender, race/ethnicity, or asthma severity. The intervention group received 91.7% of expected morning doses of ICS at school over the 60-day treatment period (95% CI [87.7, 95.5]). Intervention patients reported significantly less functional limitation (42.9% vs. 73.9%, p = 0.04), adjustment to family life (23.8% vs. 56.5%, p = 0.03), and sleep loss (1.7 vs. 4.1 nights in last 2 weeks, p = 0.035) than control patients at the end of the 60-days study period. There were no differences in unscheduled health-care utilization by group. CONCLUSIONS: These pilot data suggest that school-based administration of ICS has the potential to achieve high adherence to morning doses of ICS on school days among urban, disadvantaged, and largely minority children with asthma.

Using stakeholder engagement to develop a patient-centered pediatric asthma intervention.

Stakeholder engagement has the potential to develop research interventions that are responsive to patient and provider preferences. This approach contrasts with traditional models of clinical research in which researchers determine the study's design. This article describes the effect of stakeholder engagement on the design of a randomized trial of an intervention designed to improve child asthma outcomes by reducing parental stress. The study team developed and implemented a stakeholder engagement process that provided iterative feedback regarding the study design, patient-centered outcomes, and intervention. Stakeholder engagement incorporated the perspectives of parents of children with asthma; local providers of community-based medical, legal, and social services; and national experts in asthma research methodology and implementation. Through a year-long process of multidimensional stakeholder engagement, the research team successfully refined and implemented a patient-centered study protocol. Key stakeholder contributions included selection of patient-centered outcome measures, refinement of intervention content and format, and language framing the study in a culturally appropriate manner. Stakeholder engagement was a useful framework for developing an intervention that was acceptable and relevant to our target population. This approach might have unique benefits in underserved populations, leading to sustainable improvement in health outcomes and reduced disparities.

Enrolling African-American and Latino patients with asthma in comparative effectiveness research: Lessons learned from 8 patient-centered studies.

BACKGROUND: African-American and Latino patients are often difficult to recruit for asthma studies. This challenge is a barrier to improving asthma care and outcomes for these populations. OBJECTIVES: We sought to examine the recruitment experiences of 8 asthma comparative effectiveness studies that specifically targeted African-American and Latino patients, and identify the solutions they developed to improve recruitment. METHODS: Case report methodology was used to gather and evaluate information on study design, recruitment procedures and outcomes from study protocols and annual reports, and in-depth interviews with each research team. Data were analyzed for themes, commonalities, and differences. RESULTS: There were 4 domains of recruitment challenges: individual participant, institutional, research team, and study intervention. Participants had competing demands for time and some did not believe they had asthma. Institutional challenges included organizational policies governing monetary incentives and staff hiring. Research team challenges included ongoing training needs of recruitment staff, and intervention designs often were unappealing to participants because of inconveniences. Teams identified a host of strategies to address these challenges, most importantly engagement of patients and other stakeholders in study design and troubleshooting, and flexibility in data collection and intervention application to meet the varied needs of patients. CONCLUSIONS: Asthma researchers may have greater success with recruitment by addressing uncertainty among patients about asthma diagnosis, engaging stakeholders in all aspects of study design and implementation, and maximizing flexibility of study and intervention protocols. However, even with such efforts, engagement of African-American and Latino patients in asthma research may remain low. Greater investment in research on engaging these populations in asthma research may ultimately be needed to improve their asthma care and outcomes.

Increased identification of the primary care provider as the main source of asthma care among urban minority children.

OBJECTIVE: Urban, minority, and disadvantaged youth with asthma frequently use emergency departments (EDs) for episodic asthma care instead of their primary care providers (PCPs). We sought to increase the rate of guardians' identification of the PCP as the source of asthma care for their children through integrated electronic health records and care coordination. METHODS: In this prospective cohort study, we implemented an electronic communication process between an asthma specialty clinic and PCPs coupled with short-term care coordination in sample of youth aged 2-12 years with asthma and surveyed their guardians at baseline and 3 and 6 months after the intervention. RESULTS: Guardians of 50 children (median age 5.8 years, 64% male, 98% African American, 94% public insurance) were enrolled. Compared to baseline, at 3 and 6 months after the intervention, significantly more guardians reported that the PCP was their child's primary asthma health care provider [70% at baseline, 85% at 3 months, 83% at 6 months (time averaged adjusted OR 77.4, 95% CI 3.0, 2027.1]. Further, significantly more guardians reported that they took their child to the PCP when the child experienced problems with his/her asthma [16% at baseline, 35% at 3 months, 41% at 6 months (time averaged adjusted odds ratio (OR) 10.6, 95% CI 2.7, 41.7]. CONCLUSION: Care in a subspecialty asthma clinic augmented by electronic communication with PCPs and short term care coordination was associated with significantly improved identification of PCPs as the primary source of asthma care in a cohort of urban minority youth.

Low rates of follow-up with primary care providers after pediatric emergency department visits for respiratory tract illnesses.

OBJECTIVES: We sought to determine diagnosis-specific rates of follow-up with primary care providers (PCPs) after emergency department (ED) visits for respiratory tract illnesses. We hypothesized that follow-up rates would be higher among patients with acute infectious illnesses than among those with asthma. METHODS: This was a retrospective cohort study of a random sample of patients aged 0 to 12 years discharged over a 12-month period from an urban, tertiary care pediatric ED with 4 different respiratory tract illnesses (asthma, bronchiolitis, croup, and pneumonia). Primary care provider follow-up was examined for associations with sociodemographic and clinical factors and with subsequent ED visits. RESULTS: Rates of follow-up in the overall cohort were low: 23.6% (95% confidence interval, 19.7-27.4) by 7 days and 40.5% (95% confidence interval, 36.0-44.9) by 30 days. Compared with patients with asthma, the relative risks (RRs) of follow-up within 7 and 30 days were significantly higher among patients with bronchiolitis and pneumonia, but not with croup. For the cohort as a whole, the RR of follow-up within 7 and 30 days significantly decreased for each 1-year increase in age, and the RR of follow-up within 7 days significantly increased with the provision of explicit ED discharge instructions recommending follow-up. Among patients with asthma, follow-up with PCPs within 30 days was not associated with decreased ED visits for asthma over the following year. CONCLUSIONS: Rates of PCP follow-up were globally low but significantly higher for patients with acute infectious illnesses, for younger patients, and for those receiving explicit ED discharge instructions.