Implementation of standardized asthma management programs in outpatient settings.

PURPOSE OF REVIEW: This article reviews new approaches, facilitators, barriers, and opportunities to increasing adoption of standardized asthma management programs in the outpatient care setting. RECENT FINDINGS: Primary care clinicians providing asthma care in the outpatient setting are challenged by the complexity of guidelines and want standardization of tools that are easy to use and that can be integrated within their practice's workflow. Programs that integrate clinical decision support tools within a practice's electronic health record and provide support from specialists may enhance uptake of asthma management programs in the outpatient setting and reduce asthma morbidity. Lack of an implementation science framework, consideration for organizational context, and clinician buy-in are recently recognized barriers to adoption of asthma programs and improved asthma outcomes. In addition, many of these interventions are labor intensive, costly, and may not be capable of wide dissemination because of the EHR interoperability problem. CONCLUSION: Programs that simplify the guidelines, integrate clinical decision support within the EHR, and ground their approach with an implementation science framework may improve the quality of asthma care provided in the outpatient setting.

Implementation of a pediatric asthma management program in rural primary care clinics.

OBJECTIVE: Rural communities experience a significant asthma burden. We pilot tested the implementation of Easy Breathing, a decision support program for improving primary care provider adherence to asthma guidelines in a rural community, and characterized asthma risk factors for enrollees. METHODS: We implemented Easy Breathing in two rural primary care practices for two years. Patient demographics, exposure histories, asthma severity, asthma medications, and treatment plans were collected. Providers' adherence to guidelines included the frequency of children with persistent asthma who were prescribed guidelines-based therapy and the frequency of children with a written asthma treatment plan on file. Clinicians provided feedback on the feasibility and acceptability of Easy Breathing using a validated survey tool and through semi-structured interviews. RESULTS: Two providers implemented the program. Enrollment included 518 children, of whom 135 (26%) had physician-confirmed asthma. After enrollment into Easy Breathing, 75% of children with asthma received a written asthma treatment plan All children with persistent asthma were prescribed an anti-inflammatory drug as part of their treatment plan. Providers (n = 2) rated Easy breathing as highly acceptable (M = 4.5), feasible (M = 4.5), and appropriate (M = 4.5). Qualitative feedback was positive, with suggestions to integrate the paper-based program into the electronic health record system for broader uptake. Enrollees with asthma were more likely to have a family history of asthma and endorse exposure to tobacco smoke and cockroaches. CONCLUSIONS: Easy Breathing shows promise as a decision support system that can be implemented in rural, medically underserved communities via primary care.

Risk Factors for Pediatric Asthma Readmissions: A Systematic Review.

OBJECTIVE: To systematically review the literature on pediatric asthma readmission risk factors. STUDY DESIGN: We searched PubMed/MEDLINE, CINAHL, Scopus, PsycINFO, and Cochrane Central Register of Controlled Trials for published articles (through November 2019) on pediatric asthma readmission risk factors. Two authors independently screened titles and abstracts and consensus was reached on disagreements. Full-text articles were reviewed and inclusion criteria applied. For articles meeting inclusion criteria, authors abstracted data on study design, patient characteristics, and outcomes, and 4 authors assessed bias risk. RESULTS: Of 5749 abstracts, 74 met inclusion criteria. Study designs, patient populations, and outcome measures were highly heterogeneous. Risk factors consistently associated with early readmissions (≤30 days) included prolonged length of stay (OR range, 1.1-1.6) and chronic comorbidities (1.7-3.2). Risk factors associated with late readmissions (>30 days) included female sex (1.1-1.6), chronic comorbidities (1.5-2), summer discharge (1.5-1.8), and prolonged length of stay (1.04-1.7). Across both readmission intervals, prior asthma admission was the most consistent readmission predictor (1.3-5.4). CONCLUSIONS: Pediatric asthma readmission risk factors depend on the readmission interval chosen. Prior hospitalization, length of stay, sex, and chronic comorbidities were consistently associated with both early and late readmissions. TRIAL REGISTRATION: CRD42018107601.

Hair cortisol concentrations among urban and rural-dwelling mother-child dyads, La Romana, Dominican Republic.

Hair cortisol concentrations (HCC) were studied in mother-child dyads of La Romana, Dominican Republic (DR), a low-income city, and of the surrounding bateyes, sugarcane plantation villages with inhabitants frequently of Haitian descent. Populations of low socioeconomic status (SES) experience hypothalamic-pituitary-adrenal (HPA) axis dysregulation. Urban communities may be increasingly exposed to stressors such as crime and concentrated poverty whereas rural communities may be devoid of important community resources. As a result, the experience of stress in poverty may differ by place of residence. The goal of this study was to examine differences in HCC among urban and rural-dwelling mother-child dyads in socioeconomically disadvantaged communities surrounding La Romana, DR. Forty-five mother/child dyads were enrolled in La Romana and 45 at several bateyes surrounding La Romana. Mothers were ≥18 years and children were between 7 and 14 years. Mothers self-reported perceived stress and demographic factors. Hair samples were collected from mothers and children, and HCC was assessed using enzyme-linked immunosorbent assays. General linear models examined associations between socioeconomic factors and HCC, and between maternal and child HCC. HCC were measured in 88 maternal and 87 child samples (N = 175). Mothers living in a batey had higher HCC than those living in La Romana (p = 0.001). HCC was positively associated among maternal-child dyads (p = 0.001). Further, Haitian-born mothers as a population who frequently live in a rural batey experienced higher HCC (p = 0.025) that may partially be explained by discriminatory practices in the DR. This research helps to elucidate the impact of urban and rural environmental settings on HCC.Lay summaryThis study focuses on chronic stress, measured by hair cortisol levels, among a low-income population of Dominican and Haitian mother-child pairs who live in urban and rural settings. We found that Haitian-born mothers, who frequently live in a rural batey, had higher hair cortisol levels than Dominican born mothers. Hair cortisol levels between mothers and their children were positively associated. This study addresses the impact of urban and rural environments on the stress response among socioeconomically disadvantaged persons living in an upper middle income country who bear an excessive burden of psychosocial stress.

Asthma management in school: parents' and school personnel perspectives.

Objective: Effective asthma management at school can help students with asthma stay healthy, learn better and participate fully during their school day. This study sought to understand school-based asthma care from the perspective of parents and school personnel to improve asthma care at school. Methods: A cross-sectional study was conducted in Hartford, CT. School personnel from 59 schools and 322 parents/guardians were invited to participate. Four cross-sectional surveys using Likert-type scales assessed parental and school personnel satisfaction, confidence in managing asthma, policy awareness, management of asthma during physical activity, and perceived gaps surrounding school-based asthma care. Results: 263/322 (82%) eligible parents of children with asthma (mean age 8.5 ± 4.3, 56% Hispanic, 30% African American) completed surveys. Thirty six school nurses (62%), 131 teachers (8%), 14 coaches (14%), and 17 school principals (29%) participated. 90% of parents were satisfied with asthma management in school. School nurses were more aware of asthma policies than teachers (74% vs. 24%, p < 0.001). 34% of school nurses, 30% of teachers and 36% of coaches were unaware of asthma-related absences. 14% of physical education teachers/coaches reported no asthma training. Conclusion: In this convenience sample of parents and school personnel, parents reported overall satisfaction regarding the asthma care their children receive at school, yet a number of gaps pertaining to school-based asthma care were identified. Increased asthma training and enhanced communication among school personnel is needed to address these gaps. National guidelines and resources are readily available to improve asthma care at school.

Building Bridges for Asthma Care: Reducing school absence for inner-city children with health disparities.

BACKGROUND: Children with asthma are at increased risk for experiencing health and educational disparities because of increased school absence. School nurses are well positioned to support asthma management and improve school attendance. OBJECTIVE: We sought to implement and assess the effect of the Building Bridges for Asthma Care Program on improving school attendance and measures of asthma control. METHODS: Children with asthma (age, 5-14 years) in the Denver Public School System (n = 240) and the Hartford Public School System (n = 223) were enrolled in the Building Bridges Program during the 2013-2014 and 2014-2015 school years and followed until the end of the second school year. The primary outcome was school absence, with secondary outcomes, including asthma control, measured based on Childhood Asthma Control Test or the Asthma Control Test scores and rescue inhaler use. RESULTS: Participants experienced a 22% absolute decrease in school absenteeism, the number of children with an Asthma Control Test/Childhood Asthma Control Test score of less than the control threshold of 20 decreased from 42.7% to 28.8%, and bronchodilator use greater than 2 times per week decreased from 35.8% to 22.9% (all changes were significant, P < .01). CONCLUSIONS: Children enrolled in the Building Bridges for Asthma Care Program experienced reduced school absence and improved asthma control.

Building Bridges for Asthma Care Program: A School-Centered Program Connecting Schools, Families, and Community Health-Care Providers.

Asthma imposes tremendous burden on children, families, and society. Successful management requires coordinated care among children, families, health providers, and schools. Building Bridges for Asthma Care Program, a school-centered program to coordinate care for successful asthma management, was developed, implemented, and evaluated. The program consists of five steps: (1) identify students with asthma; (2) assess asthma risk/control; (3) engage the family and student at risk; (4) provide case management and care coordination, including engagement of health-care providers; and (5) prepare for next school year. Implementation occurred in 28 schools from two large urban school districts in Colorado and Connecticut. Significant improvements were noted in the proportions of students with completed School Asthma Care Plans, a quick-relief inhaler at school, Home Asthma Action/Treatment Plans and inhaler technique (p < .01 for all variables). Building Bridges for Asthma Care was successfully implemented extending asthma care to at-risk children with asthma through engagement of schools, health providers, and families.

Hair cortisol, perceived stress, and social support in mother-child dyads living in an urban neighborhood.

Women and children belonging to a racial/ethnic minority bear a disproportionate burden of psychosocial stress that increases their vulnerability to adverse health outcomes. Hair cortisol has been rapidly advanced as a biomarker of the intensity and course of the stress response over time and may provide an opportunity to increase our understanding of the role of psychological stress in health. However, research on the link between hair cortisol levels and subjective measures of maternal and child stress among low-income and minority individuals is limited. The goal of this study was to examine the association between stress and hair cortisol in low income, minority women and children who experience disproportionate exposure to chronic stress. A convenience sample of 54 minority mother/child dyads from a busy primary care clinic in the second poorest medium-sized city in the US participated in the study. Mothers self-reported perceived stress, social support, household characteristics and other demographic factors, and their children (ages 7-14 years) reported on the perceived level of safety in their neighborhood and exposure to violence as markers of child stress. Three-centimeter hair samples were collected from both mothers and children during the clinic visit, and hair cortisol levels were assessed via enzyme-linked immunosorbent assays. Linear regression models examined associations between maternal and child hair cortisol, and between hair cortisol and perceived stress level in women, and moderation by social support. Maternal hair cortisol was not significantly associated with mother's perceived stress. Maternal and child hair cortisol levels were positively associated (p = .007) but this association was not moderated by maternal perceived social support. These findings suggest that hair cortisol is strongly associated among this sample of minority mother-child dyads and is not moderated by social support.

Understanding clinicians' attitudes toward a mobile health strategy to childhood asthma management: A qualitative study.

OBJECTIVES: Mobile technology for childhood asthma can provide real-time data to enhance care. What real-time adherence information clinicians want, how they may use it, and if the data meet their clinical needs have not been fully explored. Our goal was to determine whether pediatric primary care and pulmonary clinicians believe if a sensor-based mobile intervention is useful in caring for patients with asthma. METHODS: We recruited participants from 3 urban, primary care and 1 pulmonary practice from July to September 2015 in Hartford, CT. Forty-one participated in four focus groups, which included a demonstration of the technology. Participants were probed with open-ended questions on the type, frequency, and format of inter-visit patient information they found useful. RESULTS: 41 participants (mean age 49 (±13.7) years) were board-certified clinicians (41% MDs and 20% mid-level practitioners), practiced medicine on an average of 19 (±14) years, were primarily white (59%) and women (78%). Clinicians wanted 1) adherence to prescribed inhaler therapy and 2) data on inhaler technique. Clinicians wanted it at the time of a scheduled clinic visit but also wanted inter-visit alerts for excessive use of rescue therapy. Pulmonologists liked the mobile spirometer's provision of inter-visit lung function data; pediatricians did not share this view. Concerns with data accuracy were raised due to families who shared inhalers, access to smartphones, and protection of health information. CONCLUSIONS: Overall, clinicians view an asthma mobile health technology as enhancing the patient-centered medical home. Pediatric primary care clinicians and pulmonologists want different information from a mobile app.

Implementing school asthma programs: Lessons learned and recommendations.

Despite significant advances in the treatment of asthma and the development of evidence-based and evidence-informed guidelines, childhood asthma morbidity remains high. One measure of asthma-associated morbidity is school absenteeism. In this rostrum we summarize key themes from 3 articles in this special issue on school-centered asthma programs. All 3 articles in this series describe several common themes that are essential for successful school-based interventions. These themes include the importance of trust and building strong partnerships, the importance of interaction and communication between multiple key stakeholders (ecological framework), the central and often overlooked role of the primary care clinician, the need for sustainable resources, and the importance of context and public policy. We then discuss how to apply the framework of implementation research to inform and evaluate school-based interventions. Finally, we make a series of recommendations for future work.

Mismatch between asthma symptoms and spirometry: implications for managing asthma in children.

OBJECTIVES: To examine the concordance between spirometry and asthma symptoms in assessing asthma severity and beginning therapy by the general pediatrician. STUDY DESIGN: Between 2008 and 2012, spirometry testing was satisfactorily performed in 894 children (ages 5-19 years) whose asthma severity had been determined by their pediatrician using asthma guideline-based clinical criteria. Spirometry-determined asthma severity using national asthma guidelines and clinician-determined asthma severity were compared for concordance using weighted Kappa coefficients. RESULTS: Thirty percent of participants had clinically determined intermittent asthma; 32%, 33%, and 5% had mild, moderate, and severe, persistent asthma, respectively. Increasing disease severity was associated with decreases in the forced expiratory volume in 1 second/forced vital capacity (FVC) ratio (P < .001), the forced expiratory volume in 1 second/FVC% predicted (P < .0001), and the FVC% predicted (P < .01). In 319 children (36%), clinically determined asthma severity was lower than spirometry-determined severity. Concordance was 0.16 (95% CI 0.10, 0.23), and when adjusted for bias and prevalence, was 0.20 (95% CI 0.17, 0.23). When accounting for age, sex, exposure to smoke, and insurance type, only spirometry-determined asthma severity was a significant predictor of agreement (P < .0001), with worse agreement as spirometry-determined severity increased. CONCLUSIONS: Concordance between spirometry and asthma symptoms in determining asthma severity is low even when guideline-based clinical assessment tools are used. Because appropriate therapy reduces asthma morbidity and is guided by disease severity, results from spirometry testing could better guide pediatricians in determining appropriate therapy for their patients with asthma.

Prenatal stress and hair cortisol in a sample of Latina women.

BACKGROUND: Stress during pregnancy adversely impacts maternal and infant health. Dysregulation of the hypothalamic pituitary axis is a mediator of the relationship between stress and health. Evidence supporting an association between prenatal chronic stress and cortisol is limited, and the majority of research published has been conducted amongst White participants, who experience less chronic stress than people of color. AIM: This study investigated associations between various measures of prenatal stress and hair cortisol concentrations which is a biomarker of the integrated stress response in a sample of Latina participants during the third trimester of pregnancy. METHOD: Pregnant women (n=45) were surveyed with scales measuring chronic stress, perceived stress, pregnancy-related and pregnancy-specific anxiety. Hair samples were collected as an objective neuroendocrine measure of chronic stress. Linear regression analyses were performed to assess associations between stress measures and hair cortisol. Pre-pregnancy BMI, smoking during pregnancy, and steroid use during pregnancy were used as covariates in adjusted models. RESULTS: Chronic stress, operationalized as maternal reports of neighborhood/housing strain, daily activities and relationship strain, discrimination, and financial strain, was significantly associated with higher hair cortisol concentrations. No significant associations were found between hair cortisol and perceived stress, pregnancy-related anxiety, nor pregnancy-specific anxiety in adjusted models. CONCLUSION: Chronic stress may be a more robust correlate of physiological stress, as measured by hair cortisol in pregnancy, than other common measures of prenatal stress and anxiety.

Smoking cessation and counseling: A mixed methods study of pediatricians and parents.

OBJECTIVE: Pediatric providers play an important role in parental and youth smoking cessation. The goal of this study was to understand smoking cessation attitudes of parents and the behaviors, confidence and self-efficacy of pediatricians related to providing smoking cessation counseling to parents and youth. METHODS: A mixed methods study was conducted in a convenience sample of families (n = 1,549) and pediatric primary care clinicians (n = 95) in Connecticut using surveys and focus groups from April, 2016 to January, 2017. RESULTS: The smoking rate (cigarettes or electronic cigarettes) among all households surveyed was 21%. Interest in quitting smoking was high (71%) and did not differ based on smoking amount, duration, type of community of residence (urban, rural, etc), or race/ethnicity. For example, compared to participants who smoked for <10 years, those who smoked ≥20 years had a similar interest in quitting (OR = 1.12; 95% CI: 0.85-1.48). Ninety percent of clinicians surveyed asked parents about their smoking behavior at least annually but 36% offered no smoking cessation counseling services or referral. Clinicians almost always reported counseling youth about the dangers of nicotine and tobacco use (99%), were more confident about counseling youth than parents (p<0.01) and reported low self-efficacy about smoking cessation and prevention counseling of parents and youth. Ninety-three percent of clinicians opined that electronic cigarettes were equally or more dangerous than cigarettes but 34% never counseled youth about the dangers of electronic cigarettes. CONCLUSIONS: Clinicians frequently screen parents about their smoking behaviors, but rarely provide smoking cessation counseling and express low confidence in this activity. Clinicians are more confident counseling youth than parents. Clinicians also recognize the dangers of electronic cigarettes, yet they infrequently counsel youth about these dangers.

A Case of Acute Motor Sensory Axonal Neuropathy: A Variant of Guillain-Barré Syndrome, with Possible Syndrome of Irreversible Lithium-Effectuated Neurotoxicity.

Acute Motor Sensory Axonal Neuropathy (AMSAN) is a rare and severe variant of Guillain-Barré syndrome (GBS) that has a prolonged recovery course. GBS is often suspected due to ascending muscle weakness, sensation difficulties, respiratory compromise, and antecedent diarrhea. The diagnosis of GBS is supported by cerebrospinal fluid analysis showing albuminocytologic dissociation. Electromyogram and nerve conduction study confirm the diagnosis and allow for further classification by variant. Treatment involves either IV immune globulins or plasmapheresis, and patients typically recover. However, depending on the variant and severity, patients may ultimately require prolonged mechanical ventilation with tracheostomy. In these cases, they may continue to have persistent muscle and sensation abnormalities requiring long-term care. We present a unique case of a 38-year-old female patient with decade-long use of lithium for bipolar disorder that presented with acute lithium toxicity. Though she was ultimately diagnosed with AMSAN, the Syndrome of Irreversible Lithium-Effectuated Neurotoxicity (SILENT) may have also contributed to her persistent neurological sequelae.

A School Nurse-Led Asthma Program Reduces Absences: Evaluation of Easy Breathing for Schools.

OBJECTIVE: To evaluate whether school nurses can assist pediatricians in providing asthma care and reduce school absenteeism through a program called Easy Breathing for Schools (EzBfS), a 5-element school nurse-led asthma management program and the effectiveness in reducing school absenteeism. METHODS: Fifteen public school nurses in an urban community implemented EzBfS during the 2015-16 and 2016-17 school years. Program elements included assessment of asthma risk and asthma control, asthma education, medication review, and a pediatrician communication tool. School absence for any reason was the primary outcome; absentee rates for students with asthma enrolled in the program were compared to students with asthma in the entire school population using negative binomial regression. RESULTS: School nurses enrolled 251/2,126 students with physician-confirmed asthma (2015-16: n = 114 and 2016-17: n = 137). Sixty eight percent of participants were Latino and 25% were Black with a mean age of 8.7 ± 2.2 years. Absentee rates were higher in children with asthma compared to children without asthma (8.3% vs 7.0% absent, respectively P < .001). Students enrolled in the program experienced a 25% decrease in absentee rate after adjusting for age, sex, race/ethnicity, and school year (rate ratio = 0.75, 95% confidence interval, 0.67, 0.85) as compared to students with asthma not enrolled in the program. Participants also demonstrated improvement in inhaler technique score (P < .001). Ninety two percent of the nurses were satisfied with the program. CONCLUSION: EzBfS, a pragmatic, nurse-led asthma management program, was successfully implemented by school nurses and significantly decreased school absences among a sample of students with asthma.

Exposure to secondhand smoke and asthma severity among children in Connecticut.

OBJECTIVE: To determine whether secondhand smoke (SHS) exposure is associated with greater asthma severity in children with physician-diagnosed asthma living in CT, and to examine whether area of residence, race/ethnicity or poverty moderate the association. METHODS: A large childhood asthma database in CT (Easy Breathing) was linked by participant zip code to census data to classify participants by area of residence. Multinomial logistic regression models, adjusted for enrollment date, sex, age, race/ethnicity, area of residence, insurance type, family history of asthma, eczema, and exposure to dogs, cats, gas stove, rodents and cockroaches were used to examine the association between self-reported exposure to SHS and clinician-determined asthma severity (mild, moderate, and severe persistent vs. intermittent asthma). RESULTS: Of the 30,163 children with asthma enrolled in Easy Breathing, between 6 months and 18 years old, living in 161 different towns in CT, exposure to SHS was associated with greater asthma severity (adjusted relative risk ratio (aRRR): 1.07 [1.00, 1.15] and aRRR: 1.11 [1.02, 1.22] for mild and moderate persistent asthma, respectively). The odds of Black and Puerto Rican/Hispanic children with asthma being exposed to SHS were twice that of Caucasian children. Though the odds of SHS exposure for publicly insured children with asthma were three times greater than the odds for privately insured children (OR: 3.02 [2.84,3,21]), SHS exposure was associated with persistent asthma only among privately insured children (adjusted odds ratio (aOR): 1.23 [1.11,1.37]). CONCLUSION: This is the first large-scale pragmatic study to demonstrate that children exposed to SHS in Connecticut have greater asthma severity, clinically determined using a systematic approach, and varies by insurance status.