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PubMed2000

Asthma morbidity 6 yrs after an effective asthma self-management programme in a Maori community.

A 6-month Maori community-based asthma self-management programme, involving a "credit card" asthma self-management plan, has previously been shown to be an effective and acceptable system for reducing asthma morbidity. The effectiveness of the asthma self-management programme and participants' self-management behaviour was assessed 6 yrs after the formal end of the programme. Participants were surveyed at the time of enrollment, and 1, 2, and 6 yrs after completing the programme. In each survey, participants were questioned on markers of asthma morbidity and use of medical services during the previous 12 months. Self-management behaviour was assessed using a questionnaire at 2 years and 6 yrs. Of the 69 original participants, 47 (68%) were surveyed after 6 yrs. They generally had reduced severe asthma morbidity and emergency use of health services from baseline. In particular, the proportion who had an emergency visit to a general practitioner had decreased from 41% to 18% (p=0.02). However, the percentage of nights woken due to asthma had returned to preintervention levels, and the proportion of participants taking prescribed regular inhaled steroid had decreased from 91% to 53% (p<0.001). Compared with 2 yrs after completion of the asthma programme, self-management behaviour had also deteriorated, with 29% versus 73% (p<0.001) using their peak flow meter daily when their asthma was "getting bad" and 41% versus 86% (p<0.001) using the "credit card" plan to increase the amount of inhaled steroids in the last year. Although the programme participants were still experiencing reduced morbidity from their asthma 6 yrs after the end of the self-management programme, the benefits were less than those observed at 2 yrs. These findings suggest that under-recognition and under-treatment of asthma with appropriate amounts of inhaled steroids is a major factor contributing to asthma morbidity in this indigenous rural community. To obtain enduring benefits from a self-management system of care continued reinforcement of self-management skills seems to be an essential component of any follow-up.

Adult↗
PubMed2002

Maternal asthma, infant feeding, and the risk of asthma in childhood.

Controversy surrounds the issue of whether children with asthmatic mothers should be breast-fed. The aim of this study was to investigate whether maternal asthma status alters the association between asthma and breast-feeding. In a cohort study of 2602 West Australian children enrolled before birth and followed prospectively, we collected data on method of infant feeding, maternal asthma (as reported by parental questionnaire), atopy (as measured by skin prick test), and current asthma (defined as a physician's diagnosis of asthma and wheeze in the last year) at 6 years of age. The risk of childhood asthma increased if exclusive breast-feeding was stopped (other milk was introduced) before 4 months (odds ratio, 1.28; 95% CI, 1.01-1.62; P =.038), and this risk was not altered by atopy or maternal asthma status. After adjusting for covariates, exclusive breast-feeding for less than 4 months was a significant risk factor for current asthma (odds ratio, 1.35; 95% CI, 1.00-1.82; P =.049). There was no formal statistical interaction between breast-feeding and maternal asthma status (P =.970). In this study maternal asthma status did not modify the association between asthma and breast-feeding duration. We recommend that infants with or without a maternal history of asthma be exclusively breast-fed for 4 months and beyond.

Asthma↗
PubMed2001

Can asthma education improve clinical outcomes? An evaluation of a pediatric asthma education program.

Asthma is a common, costly, and chronic disease that has a significant impact on children, their families, and the health care system. This study investigated whether formal asthma education can reduce asthma severity and morbidity and further questioned whether the method of education is an important factor in this process. Study subjects were recruited from the emergency department of the Royal Children's Hospital, Melbourne (RCHM), and controls were recruited from the neighboring Western Hospital, Sunshine (WHS). Subject parents were randomized to receive face-to-face education, group education, or home-based video education. Controls had similar medical treatment but received no formal asthma education. Subject and control parents were asked to complete questionnaires before the intervention and at 1, 6, and 12 months. These questionnaires measured demographics, the levels of parent asthma knowledge, anxiety, child asthma severity, and morbidity. Results showed that any method of education increased parent asthma knowledge and immediately decreased their anxiety and child asthma morbidity scores. Despite this, asthma severity was reduced only when knowledge was imparted in an interactive, face-to-face setting. When this happened, asthma severity scores were significantly reduced in both the short- and long-term. These findings call into question mass asthma education campaigns and have important implications for the design of future asthma education programs.

Adult↗
PubMed2003

Occupational asthma: a valid model for adult asthma?

PURPOSE OF REVIEW: Developments in the understanding of causes and natural history of occupational asthma may allow improved primary, secondary and tertiary preventive strategies for occupational asthma. This may also lead to improved understanding of preventable contributing factors to the development and severity of nonoccupational asthma. RECENT FINDINGS: Animal studies have demonstrated the opportunity to identify chemical sensitizers relevant to asthma. Studies of genetic markers in occupational asthma pose logistic difficulties, but preliminary studies suggest that glutathione S-transferase genotypes may predispose to development of occupational asthma induced by diisocyanates and these have also been implicated in nonoccupational asthma. Some occupational sensitizers/irritants are also found outside the workplace and may be relevant in nonoccupational asthma, for example cleaning agents, epoxy glues, hairdressing products. Accidental exposures to high concentrations of respiratory irritants have the potential to induce new asthma as well as aggravate underlying asthma in both occupational and nonoccupational settings. SUMMARY: Better understanding of the pathogenesis of occupational asthma is important for affected workers, and also has potential relevance for nonoccupational asthma.

Adult↗
PubMedDate not supplied

Substance P-immunoreactive nerves in endobronchial biopsies in cough-variant asthma and classic asthma.

BACKGROUND: Unlike classic asthma, cough-variant asthma does not show any evidence of airway obstruction. The main symptom is a dry cough with little known pathophysiology. Hypersensitivity of the cough receptors in cough-variant asthma and an increase in the sensory nerve density of the airway epithelium in persistent dry cough patients have been reported. Therefore, it is possible that there is a higher sensory nerve density in cough-variant asthma patients than in classic asthma patients. OBJECTIVES: This study was undertaken to compare the substance P (SP)-immunoreactive nerve density in mucosal biopsies of cough-variant asthma patients, classic asthma patients, and in control subjects. METHODS: Bronchoscopic biopsies were performed in 6 cough-variant asthma patients, 14 classic asthma patients, and 5 normal controls. The tissues obtained were stained immunohistochemically. The SP-immunoreactive nerve density was measured in the bronchial epithelium using a light microscope at 400 x magnification. RESULTS: SP- immunoreactive nerve density for the cough-variant asthma group was significantly higher than that of the classic asthma group (p = 0.001), and of the normal control group (p = 0.006). CONCLUSIONS: It is possible that a sensory nerve abnormality within the airway may be related to hypersensitivity of the cough receptor, and that this may be one of the pathophysiologies of cough-variant asthma.

Adult↗
PubMed2005

Are the asthma guideline goals achieved in daily practice? A population-based study on treatment adequacy and the control of asthma.

BACKGROUND: The guidelines for asthma recommend that the use of anti-inflammatory therapy should be adapted to the severity of the disease. However, few data are available to assess the adequacy of the use of drugs and its influence on the control of asthma in 'real life'. METHODS: The adequacy of the current use of anti-asthmatic medication according to the Global Initiative for Asthma (GINA) guidelines was assessed in a random sample of 400 asthmatics identified in the frame of the Italian Study on Asthma in Young Adults. Asthma severity was assessed using the GINA criteria; accordingly, a patient was classified as receiving inadequate treatment if his/her current use of drugs was lower than that suggested by the guidelines for the corresponding severity level. The absence of asthma attacks in the last 3 months was used as an indicator of the disease control. RESULTS: Fifty-five percent of the patients had persistent asthma. Overall, 48% (95% CI 41.2-54.8) of persistent asthmatics were receiving inadequate treatment, and 66% (95% CI 59.5-72.4) had not used their medication daily over the past 3 months. Persistent asthmatics who were inadequately treated had a significantly greater frequency of asthma attacks (geometric mean ratio 3.7; 95% CI 2.1-6.6) than those using an adequate dose of medication. Mild and moderate persistent asthmatics using an adequate medication regimen reported a low number of asthma attacks (median 0). At the multivariate analysis, a good control of the disease was positively associated with an adequate dose of anti-inflammatory medication (OR = 2.2; 95% CI 1.1-4.5) and was negatively associated with a later onset of asthma (OR = 0.96; 95% CI 0.93-0.99) and severe asthma (OR = 0.37; 95% CI 0.17-0.81). CONCLUSIONS: Despite the increase in the use of inhaled corticosteroids, half of the persistent asthmatics from the general population are using a medication regimen below their severity level. When the use of drugs follows the GINA guideline recommendations, a good control of asthma is also achievable in the daily management of the disease, particularly in the case of mild and moderate asthmatics.

Adult↗
PubMed1997

Changing prevalence of asthma in school children: evidence for diagnostic changes in asthma in two surveys 13 yrs apart.

It is still unclear whether the reported increase in the prevalence of asthma is real or due to changes in diagnostic criteria. The objectives of this study were to compare the prevalence of diagnosed asthma with the prevalence of respiratory symptoms, and to compare the association between asthma and other atopic diseases in 1981 and 1994. The study populations comprised randomly selected school classes in Oslo in 1981 (n=1,772) and 1994 (n=2,577). The main outcomes in these comparable cross-sectional studies of children, 6-16 yrs of age, were parent-reported prevalence of diagnosed asthma, respiratory symptoms, eczema and hay fever. The questionnaire was identical in 1981 and 1994. The response rates were 94% (1,674 out of 1,772) in 1981 and 85% (2,188 out of 2,577) in 1994. The lifetime prevalence of asthma increased from 3.4% in 1981 to 9.3% in 1994; odds ratio (OR) 2.9 (95% confidence interval (95% CI) 2.1-4.0) comparing 1994 to 1981. The prevalence of occasional wheezing increased from 9.0 to 10.8%; OR 1.2 (95% CI 1.0-1.5), and attacks of wheezing from 3.7 to 6.8%; OR 1.8 (95% CI 1.3-2.5). Survival analyses for 3 year birth cohorts showed that asthma was more readily diagnosed in the latest birth cohort (1985-1988). The association between asthma and other atopic diseases decreased during the period under study. The increase in diagnosed asthma and respiratory symptoms supports a true increase in asthma. However, the larger increase in diagnosed asthma than wheezing and a reduced association between asthma and other atopic diseases suggest that the increase in asthma may be explained, in part, by changes in diagnostic criteria.

Adolescent↗
PubMed2005

Breaking the access barrier: evaluating an asthma center's efforts to provide education to children with asthma in schools.

OBJECTIVE: To evaluate an asthma education program for children with asthma that is delivered in their school by certified asthma educators from a local hospital-based asthma center. STUDY DESIGN: Randomized controlled trial. SETTING: Twenty-six elementary schools located in a suburb of Toronto. PARTICIPANTS: A total of 256 children in grades 2 to 5 with asthma and their parents were randomized to control and experimental groups. INTERVENTION: Children in the experimental group received the "Roaring Adventures of Puff" asthma education program over the course of six weekly 1-h sessions. Those in the control group continued receiving usual care. MEASUREMENTS AND RESULTS: Data collection involved measuring asthma quality of life, self-efficacy for managing asthma, school absenteeism, days of interrupted activity, health services use, and parental loss of time from work. Quality of life and self-efficacy data were collected from the children at baseline and 2 months. Telephone parental interviews conducted over 1 year were used to collect data on the remaining variables. Unpaired t test, analysis of variance, and chi2 test were used to determine whether differences existed between the groups. The results are reported as the mean +/- SD. The experimental group demonstrated higher scores than the control group for self-efficacy (3.6 +/- 0.7 vs 3.8 +/- 0.9, respectively; p < 0.05) and quality of life (5.0 +/- 1.4 vs 5.5 +/- 1.4, respectively; p < 0.05). At 1 year, the experimental group demonstrated fewer mean urgent health-care visits (2.5 +/- 2.5 vs 1.7 +/- 1.9 visits per year, respectively; p < 0.01), days of missed school (4.3 +/- 5.7 vs 3.0 +/- 4.4 days per year, respectively; p > 0.05), and days of interrupted activity (9.1 +/- 10.5 vs 6.2 +/- 7.3 days per year; p < 0.01) related to asthma than the control group. There were no differences between the groups for parental work absenteeism or scheduled asthma visits. CONCLUSION: Providing an asthma education program to children in their school can significantly improve quality of life and reduce the burden of childhood asthma.

Asthma↗
PubMed2004

Multi-colored simplified asthma guideline reminder: why pragmatic asthma tools are needed in real-world practice.

Asthma is a chronic disease that is highly prevalent around the world with increasing societal and economic burden. National Asthma Educational and Preventive Program (NAEPP) and Global Initiative for Asthma (GINA) are evidence-based documents designed to help clinicians make appropriate decisions for their patients and to reduce undesirable variation in the care of asthmatic patients. It is a generally accepted fact that asthma specialists achieved better and improved asthma outcomes for their patients when compared with primary care physicians (PCPs). These outcome differences are somewhat related to PCPs' poor adherence to published NAEPP guidelines. Multi-Colored Simplified Asthma Guideline Reminder (MSAGR) is the first user-friendly single-sheet convenient asthma tool designed for clinicians after barriers to the poor adherence to asthma guidelines in primary care settings were identified. Voluntary acceptance and utilization of MSAGR resulted in fewer emergency room visits and hospitalizations for their patients. General acceptance of MSAGR (more than 1 million copies requested by clinicians globally), and overwhelming positive comments by asthma care providers, strongly advocate a need for real-time, pragmatic clinical tools not only in asthma, but also in other chronic diseases such as chronic obstructive pulmonary disease, diabetes mellitus, hypertension, and depression, etc. In this brief review, we discuss how clinicians, patients, and payers are utilizing these simplified asthma tools to improve asthma care in their community.

Adult↗
PubMed1998

Adverse asthma outcomes among children hospitalized with asthma in California.

OBJECTIVE: To use administrative data to determine whether adverse asthma outcomes for pediatric asthma hospitalizations are related to specific clinical and nonclinical patient characteristics. DESIGN: Cross-sectional study. SETTING: All pediatric (0 to 17 years of age) asthma-related hospital discharges, 1986 to 1993, in California. PATIENTS: A total of 113 974 eligible patients with asthma-related discharges. MAIN OUTCOME MEASURE: Adverse asthma outcomes (intubation, cardiopulmonary arrest, and death). RESULTS: Adverse asthma outcomes occurred in 0.48% of subjects. The frequency of adverse asthma outcomes increased during the 1990s compared with 1986. After controlling for differences in gender, age, specific comorbid conditions, year, race, and insurance type, adverse asthma outcomes were more likely to occur in the 5- to 11-year-old group (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 1.13-1.69) and in the 12- to 17-year-old group (OR: 4.48; CI: 3.20-6.21) compared with those children in the 0 to 4-year-old age group. Asian Pacific-American children were more likely (OR: 1.59; CI: 1.24-2.59) than were white children to experience an adverse asthma outcome. Children who had a secondary diagnoses of pneumonia (OR: 1.54; CI: 1. 19-2.00) also were more likely to experience an adverse asthma outcome. The odds of an adverse outcome increased progressively after 1986, becoming significant after 1989. Gender and insurance type were not associated with increased odds of experiencing an adverse asthma outcome. CONCLUSIONS: Adverse asthma outcomes among hospitalized children are increasing in the 1990s and are associated with specific clinical and nonclinical patient characteristics.

Adolescent↗
PubMed1999

The relationship between psychosocial factors and asthma morbidity in inner-city children with asthma.

OBJECTIVE: Children living in the inner city are affected disproportionately by asthma morbidity and mortality. Previous research has shown that behavioral and psychosocial factors affect asthma morbidity in children. The National Cooperative Inner-City Asthma Study investigated the factors that contribute to asthma morbidity among inner-city children. This article examines the relationship between psychosocial factors and asthma morbidity in this population. METHODS: A total of 1528 English- and Spanish-speaking children 4 to 9 years of age with asthma and their primary caretakers were recruited from 8 research centers in 7 metropolitan inner-city areas in the United States. Psychosocial variables were assessed at baseline and included measures of child and caretaker mental health, caretaker's problems with alcohol, life stress, social support, and parenting style. Morbidity measures were evaluated at baseline and at 3-, 6-, and 9-month follow-up intervals. These included number of hospitalizations and unscheduled visits for asthma in the past 3 months and number of days of wheeze and functional status in the previous 2-week period. RESULTS: Of the psychosocial variables assessed, mental health had the strongest relationship to children's asthma morbidity. Children whose caretakers had clinically significant levels of mental health problems were hospitalized for asthma at almost twice the rate as children whose caretakers did not have significant mental health problems. Children with clinically significant behavior problems had significantly more days of wheeze and poorer functional status in the follow-up period. CONCLUSION: Psychosocial factors, particularly the mental health of children and caretakers, are significant factors in predicting asthma morbidity. They may need to be included in intervention programs aimed at decreasing asthma morbidity in inner-city children with asthma in order for these programs to be successful.

Asthma↗
PubMed1997

Subjective symptomatology of asthma: validation of the asthma symptom checklist in an outpatient Spanish population.

The objective of this study was to validate the Asthma Symptom Checklist (ASC) so that it could be reliably used to assess the subjective symptomatology of asthma attacks in our context. Subjective symptomatology of asthma was examined in a group of 100 adult Spanish outpatients (57 women, 43 men; 17-69 years of age) with asthma. All of them completed the modified version of the ASC as well as questionnaires of depression, anxiety, and self-management of asthma (self-efficacy expectancies and health care utilization). Data about duration and severity of asthma, as well as dyspnea and %FEV1, were also recorded. The highest reliability Cronbach alpha indexes were for the panic-fear and fatigue scales. The oblique rotation of the ASC revealed five correlated factors (53% of the total variance explained): 1) panic-fear, 2) airways obstruction, 3) airways obstruction and panic-fear, 4) fatigue and irritability, 5) hyperventilation. The structure of factors was revalidated using orthogonal (varimax) rotation. Construct validity was examined by Person product-moment coefficient correlations, ANOVAs (asthma severity x ASC scores), and t-tests (sex by ASC scores). Panic-fear showed the best construct validity, as it was related to the severity of the asthma and the use of high-cost health care resources. There were no differences in ASC scores either on the basis of the asthma severity or on the sex of patients. The ASC factors represent stable components of subjective symptomatology of asthma attacks, especially with regard to the panic-fear and the hyperventilation subscales; however, the structure of the checklist as a whole was not identical to those reported in other studies. Correlations of the ASC with clinical variables related to asthma severity support the construct validity of the instrument and confirm its utility to evaluate the subjective symptomatology of asthma attacks in outpatients.

Adolescent↗
PubMed2001

The predictive value of asthma medications to identify individuals with asthma--a study in German general practices.

BACKGROUND: The assessment of prescribing performance by aggregated measures mainly developed from automated databases is often helpful for general practitioners. For asthma treatment, the frequently applied ratio of anti-inflammatory to bronchodilator drugs may, however, be misleading if the specificity of a drug for the treatment of asthma, compared with other diseases, is unknown. AIM: To test the association of specific drugs with the diagnosis of asthma compared with other diagnoses. DESIGN OF STUDY: Cross-sectional study analysing prescription data from a retrospective chart review. SETTING: Eight general practices and one community respiratory practice in a town in Northern Germany. METHOD: All patients in the participating practices who received at least one of the 50 asthma drugs most frequently prescribed in Germany within the past 12 weeks were identified. Odds ratios (ORs) with 95% confidence intervals (ClI) were calculated to reveal any association between a specific drug and the diagnosis of asthma. The unit of analysis was the item prescribed. RESULTS: Topical betamimetics (e.g salbutamol, fenoterol) were the most often prescribed asthma drugs in the general practices (52.1 ) and in the respiratory practice (57.6%). Inhaled steroids accounted for 15% and 13%; systemic steroids accounted for 10% and 13%, respectively. In the general practices, inhaled betamimetics had a moderate marker function for asthma (OR = 2.0; 95% CI = 1.14-3.58). A fixed oral combination drug of clenbuterol plus ambroxol was a marker drug against asthma (OR = 0.35; 95% CI = 0.20-0.61). In the respiratory practice, the diagnosis of asthma was strongly marked by fixed combinations of cromoglycate plus betamimetics (OR = 29.0; 95% CI = 6.86-122.24) and moderately by inhaled betamimetics (OR = 2.6; 95% CI = 1.28-5.14). In contrast, systemic steroids (OR = 0.24; 95% CI 0.10-0.57) and even inhaled steroids (OR = 0.46; 95% ClI= 0.22-0.96) proved to contradict the diagnosis of asthma. CONCLUSION: Only betamimetics were markers for asthma patients in both types of practices; inhaled steroids, however, were not. Combinations of cromoglycate were markers in the respiratory practice only. Limited specificity of drugs for a disease (e.g asthma) should be taken into account when analysing prescribing data that are not diagnosis linked.

Adult↗
PubMed1998

Design and implementation of a patient education center for the Childhood Asthma Management Program. Childhood Asthma Management Program Research Group.

OBJECTIVES: To design, develop, and distribute asthma education materials relevant to the Childhood Asthma Management Program (CAMP), a National Heart, Lung and Blood Institute sponsored comprehensive clinical trial. This trial is designed to evaluate the relative efficacy of three treatment strategies on asthma control, and lung growth and development in children with asthma. APPROACH: A Patient Education Center (PEC) was established to prepare CAMP-specific asthma educational materials that would promote consistent implementation of the CAMP protocol, adherence to study medications and record keeping requirements and retention in the trial. The PEC has the responsibility to design the asthma education program and to provide support to the study clinical center coordinators/educators who maintain direct and ongoing contact with the participants. PARTICIPANTS: A total of 1,041 children with asthma age 5 through 12 years were enrolled in the trial between November 1993 and September 1995 at 8 clinical centers. PROCESS: The three major tenets of self-management were highlighted in the CAMP patient education program: anticipate problems before they arise, determine the appropriate responses, and rehearse and practice behaviors that are effective solutions. CAMP education was standardized across centers to provide consistency in the implementation of the protocol. The program was structured to be comprehensive in order to address the various issues encountered by the participants and their caretakers, including background information on asthma and asthma therapy, instructions on following the study protocol (taking medication and monitoring symptoms and peak flow), and clear steps for handling asthma exacerbations. Materials were prepared in the form of handouts, handbooks, and videos. Instructional manuals were also prepared on the use of these materials for the nurse coordinators at each clinical center. CONCLUSIONS: The CAMP approach to asthma education was planned with the realization that patient education is essential to successful treatment and must be fully integrated into the patient's routine care. The CAMP education materials are readily available in a national repository and could be used for asthma education programs in a practice setting or another clinical research effort.

Asthma↗
PubMed2000

Combined inhaled anticholinergic agents and beta-2-agonists for initial treatment of acute asthma in children.

BACKGROUND: Anti-cholinergic agents and beta2-agonist drugs are both bronchodilators used to reverse acute bronchospasm in children with asthma. These drugs have different modes of action, so may have complementary or additive effects. OBJECTIVES: The objective of this review was to assess the effects of adding inhaled anti-cholinergics to beta2-agonists in acute paediatric asthma. SEARCH STRATEGY: We searched Medline (1966 to 1996), Embase (1980 to 1995), Cinahl (1982 to 1995) and reference lists of studies. We also contacted drug manufacturers and researchers. SELECTION CRITERIA: Randomised trials comparing the combination of inhaled anti-cholinergics and beta2-agonists with beta2-agonists alone in children aged 18 months to 17 years with acute asthma. DATA COLLECTION AND ANALYSIS: Assessments of trial quality and data extraction were done by two reviewers independently. MAIN RESULTS: Ten trials involving a total of 836 children were included. Most trials were of high quality. When only one dose of anti-cholinergic inhalation was added to beta2-agonist therapy, there was an improvement in forced expiratory volume in one second after 60 minutes with combination therapy (weighted mean difference 16.1%, 95% confidence interval 5.5 to 26. 7% reduction). There was no reduction in hospital admission (odds ratio 0.80, 95% confidence interval 0.35 to 1.82, using a random effects model). For multiple doses in children with severe asthma, there was a reduction in forced expiratory volume in 1 second (weighted mean difference 9.8% predicted, 95% confidence interval 6. 5 to 13.1% predicted). There may also be a reduction in hospital admission (odds ratio 0.62, 95% confidence interval 0.38 to 0.99). Eleven children would need to be given multiple doses of anti-cholinergics in combination with beta2-agonists to avoid one hospital admission compared to children given beta2-agonists alone. REVIEWER'S CONCLUSIONS: In children with acute asthma, the addition of multiple doses of anti-cholinergics to inhaled beta2-agonists appears to improve lung function modestly and may decrease hospital admission. There is no associated increase in adverse effects. Single doses of anti-cholinergics may improve lung function in children with severe asthma, but do not appear to reduce hospital admissions.

Administration, Inhalation↗
PubMed2002

Improving asthma outcomes and self-management behaviors of inner-city children: a randomized trial of the Health Buddy interactive device and an asthma diary.

BACKGROUND: Asthma is an important cause of morbidity, absence from school, and use of health services among children. Computer-based educational programs can be designed to enhance children's self-management skills and to reduce adverse outcomes. OBJECTIVE: To assess the effectiveness of an interactive device programmed for the management of pediatric asthma. DESIGN: A randomized controlled trial (66 participants were in the intervention group and 68 were in the control group). SETTING: Interventions conducted at home and in an outpatient hospital clinic. PARTICIPANTS: Inner-city children aged 8 to 16 years diagnosed as having asthma by a physician. INTERVENTION: An asthma self-management and education program, the Health Buddy, designed to enable children to assess and monitor their asthma symptoms and quality of life and to transmit this information to health care providers (physicians, nurses, or other case managers) through a secure Web site. Control group participants used an asthma diary. MAIN OUTCOME MEASURES: Any limitation in activity was the primary outcome. Secondary outcomes included perceived asthma symptoms, absence from school, any peak flow reading in the yellow or red zone, and use of health services. RESULTS: After adjusting for covariates, the odds of having any limitation in activity during the 90-day trial were significantly (P =.03) lower for children randomized to the Health Buddy. The intervention group also was significantly (P =.01) less likely to report peak flow readings in the yellow or red zone or to make urgent calls to the hospital (P =.05). Self-care behaviors, which were important correlates of asthma outcomes, also improved far more for the intervention group. CONCLUSION: Compared with the asthma diary, monitoring asthma symptoms and functional status with the Health Buddy increases self-management skills and improves asthma outcomes.

Adolescent↗
PubMed2004

A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study.

BACKGROUND: Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines. OBJECTIVE: To evaluate the effectiveness of 2 asthma care improvement strategies in primary care. DESIGN: Two-year randomized controlled clinical trial. SETTING: Forty-two primary care pediatric practices affiliated with 4 managed care organizations. PARTICIPANTS: Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations. INTERVENTIONS: Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care. MAIN OUTCOME MEASURES: Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts). RESULTS: Six hundred thirty-eight children completed baseline evaluations, representing 64% of those screened and eligible. Mean +/- SD age was 9.4 +/- 3.5 years; 60% were boys. Three hundred fifty (55%) were taking controller medication. Mean +/- SD annualized asthma symptom days was 107.4 +/- 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95% confidence interval [CI], - 16.9 to 3.6), a nonsignificant difference, but had a 36% (95% CI, 11% to 54%) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95% CI, - 24.7 to -2.1) fewer symptom days annually (-12% from baseline; P =.02) and a 39% (95% CI, 11% to 58%) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95% CI, 1.00 to 1.09]). CONCLUSIONS: Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.

Administration, Oral↗
PubMed2003

Intranasal corticosteroids for asthma control in people with coexisting asthma and rhinitis.

BACKGROUND: Allergic rhinitis and asthma are mediated by similar allergic mechanisms. They may represent two manifestations of the same united airway disease and therefore intranasal corticosteroids (INCS) could improve asthma. Nevertheless none of the asthma guidelines have advocated intranasal corticosteroids for asthma. OBJECTIVES: To assess the efficacy of intranasal corticosteroids on asthma outcomes in people with rhinitis and asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trials register, the Cochrane Central Register of Controlled Trials (Issue 1, 2003), MEDLINE and reference lists of articles. We also contacted researchers in the field. Last search updated in March 2003. SELECTION CRITERIA: Randomised controlled trials comparing intranasal corticosteroids to intranasal placebo or to other traditional asthma treatments were included. Intrabronchial corticosteroids were not allowed but a device combining intranasal and intrabronchial corticosteroid was considered as being a primary INCS technique and was therefore also compared to placebo. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Quality assessment for the 14 eligible studies was performed using the Jadad score and by ranking allocation concealment. Statistical analysis for continuous data was done by weighted mean difference or standardised mean difference. MAIN RESULTS: Fourteen trials involving 477 people were included. Meta-analysis for asthma outcomes failed to show a statistically significant benefit of INCS in asthma. However, for symptom scores and forced expiratory volume in one second, the trend favoured a beneficial effect of INCS. For asthma symptom scores (two parallel studies), the standardised mean difference was 0.61 (95% confidence interval (CI) -0.04 to 1.26). Meta-analysis for forced expiratory volume in one second (five parallel studies) gave a standardised mean difference of 0.31 (95% CI -0.04 to 0.65). In the parallel studies, meta-analysis of peak expiratory flow gave a standardised mean difference of -0.10 Litres/min (95% CI -0.55 to 0.35) for mean peak flow (three studies). Meta-analysis for methacholine airway responsiveness (three parallel studies) showed a standardised mean difference of -0.20 (-95% CI 0.64 to 0.24). REVIEWER'S CONCLUSIONS: Intranasal corticosteroids were well tolerated. While INCS tended to improve asthma symptoms and forced expiratory volume in one second, the results did not reach significance. The combination of intranasal plus intrabronchial corticosteroids should remain the current clinical practice until more research is done.

Administration, Intranasal↗