Search

OBJECTIVE: It is unclear whether research participation effects contribute to an improvement in asthma symptoms during clinical trials in the absence of any active intervention. We examined the impact of additional follow-up surveys on caregiver-reported symptoms among control subjects in a series of randomized controlled asthma trials. METHODS: We analyzed baseline and follow-up data for children (3–10 yrs.) with poorly controlled persistent asthma that participated as control subjects in 1 of 3 randomized trials of urban school-based asthma care (study duration: 7–10 months). We compared mean symptom-free days (SFD) per 2 weeks between baseline and final follow-up; performed bivariate regressions to explore associations between demographics and changes in SFD; and performed multivariate random-effects generalized least square regression to examine the relationship between number of follow-ups beyond baseline (range: 1–10) and changes in SFD over time. RESULTS: 516 children were enrolled as controls across the 3 trials (mean age 7.5 yrs., 61% Black, 28% Hispanic, 81% Medicaid). Mean SFDs increased significantly from baseline to final follow-up (7.8 to 11.4 days, P

Asthma is the most common chronic disease of childhood in the United States, disproportionately affecting urban, poor, and minority children. Adolescents are at high risk for poor asthma outcomes and for depressive symptoms. The purpose of this study is to investigate associations between depressive symptoms and asthma-related clinical and functional outcomes among urban teens.We used baseline data from a 3-arm randomized trial, School-Based Asthma Care for Teens, in Rochester, NY. We used the Center for Epidemiological Studies Depression Scale with a standard cutoff score of 16 to identify subjects at risk for clinical depression. We used structured in-home surveys and validated scales to assess clinical and functional outcomes and conducted bivariate and multivariate analyses to evaluate differences between groups.We identified 277 eligible teens (ages 12 to 16, 80% participation, 54% black, 34% Hispanic, 45% female, 84% on Medicaid). Overall, 28% reported depressive symptoms. Teens with depressive symptoms experienced greater asthma symptom severity and more acute health care utilization for asthma (all P.001); however, there was no difference in preventive care use between groups. Teens with depressive symptoms also reported lower asthma-related quality of life (P.001), less sleep (P.001), and more limitation in mild (adjusted odds ratio [aOR], 2.60; 95% confidence interval [CI], 1.34-5.02) and moderate (aOR, 2.56; 95% CI, 1.41-4.61) activity and in gym (aOR, 2.33; 95% CI, 1.30-4.17).Depressive symptoms are prevalent among urban teens with asthma and are associated with worse asthma-related clinical outcomes, functional limitation, and quality of life. Providers should consider depression as a significant comorbidity that may impact multiple aspects of daily life for this population.

Objective : Unstructured parental comments could solicit important information about children's asthma, yet are rarely captured in clinical asthma questionnaires. This mixed-methods study describes parents’ written responses to an open-ended question in a validated asthma questionnaire. Methods : The Pediatric Asthma Control and Communication Instrument (PACCI) asthma questionnaire was administered to parents of children with asthma symptoms presenting to 48 pediatric primary care offices (PPCP), 1 pediatric pulmonology office, and 1 emergency department (ED). Responses to the question, “Please write down any concern or anything else you would like your doctor to know about your child's asthma” were analyzed using a phenomenological approach until thematic saturation was achieved for each site. Logistic regressions tested whether sociodemographic and clinical characteristics were associated with responding to the open-ended question. Results : Of 7,988 parents who completed the PACCI, 954 (12%) responded to the open-ended question - 2% in PPCP, 31% in the ED and 50% in the pulmonary setting. More severe asthma was associated with higher odds of responding (OR, 2.01; 95% CI, 1.42-2.84). Based on responses provided, we identified three communication types: 1) clarifying symptoms; 2) asking questions; and 3) communicating distress. Responses also covered five asthma-related themes: 1) diagnostic uncertainty; 2) understanding asthma etiology and prognosis; 3) medication management; 4) impact on child function; and 5) personal asthma characteristics. Conclusion : Parents of children with severe asthma provided clarifying details, asked questions, and relayed health concerns and distress. All of these topics may not be easily captured by closed-ended asthma questionnaires. What's New : The thematic analysis in this study suggests that open-ended questions may make unique contributions to content of closed-ended asthma questionnaires, particularly for severe asthmatics seen outside of the primary care setting.

OBJECTIVES: To compare the abilities of teens with uncontrolled persistent asthma and their caregivers to identify inhaled medications and state correct indications for use; examine medication responsibility within dyads; and determine whether responsibility is associated with knowledge about inhaled therapies. DESIGN/METHODS: In the baseline survey for the School-Based Asthma Care for Teens (SB-ACT) trial, we separately asked caregivers and teens to: 1) identify the teen’s inhaled asthma therapies by name and from a picture chart (complete matches considered “concordant”); 2) describe indications of use for each medication; 3) describe the allocation of responsibility for medication use within dyads. We limited analyses to dyads in which either member reported at least one rescue and one inhaled controller medication; we used McNemar and Pearson chi-square tests. RESULTS: 136 dyads were analyzed. More caregivers than teens concordantly identified medications (63% vs 31%, p

Objective Although national asthma guidelines recommend use of validated questionnaires to improve asthma care, little is known about the extent to which these questionnaires are patient-centered. This qualitative study evaluated parent perceptions of a validated asthma questionnaire. Methods We administered the Pediatric Asthma Control and Communication Instrument for the Emergency Department (PACCI-ED) to parents of children 2 to 17 years old presenting to a large urban pediatric ED for asthma care and assessed their perceptions of the tool's utility and acceptability via a structured interview. Responses were recorded, transcribed, and analyzed using a phenomenological approach. Results Eighty-three parents participated. Qualitative analysis revealed 2 major themes (with 5 subthemes). The first major theme (and 3 subthemes) was that the PACCI-ED facilitated communication with the health care team and caregivers: improving communication 1) with ED providers, 2) in other settings such as schools, and 3) in the primary care setting where the relationship with primary care providers was felt to be variable. The second major theme (and 2 subthemes) was that the PACCI-ED increased parents’ capacity to manage their child's asthma: by helping parents understand 1) what symptoms were related to asthma and 2) how those symptoms might change over time. Conclusions Parents perceive that the PACCI-ED is acceptable and useful for facilitating communication in the ED and other health care settings, and for building parent capacity to track and manage their child's asthma. A validated structured asthma questionnaire in the ED may facilitate patient-centered asthma care.

While a number asthma questionnaires have been validated, most have not been used in an emergency department (ED) setting, nor evaluated patient feedback or clinical benefit. We sought to evaluate parent feedback on an asthma questionnaire used in an ED setting.We recruited parents of children 2-17 years old presenting to a tertiary pediatric ED for asthma care. Parents first completed then rated the Pediatric Asthma Control and Communication Instrument (PACCI-ED).One hundred seventy-four parents (84%) completed surveys. Approximately two-thirds were Latinx, and 82% completed high school. Ninety-three percent of children had uncontrolled asthma. Parents endorsed the PACCI-ED: as easy to answer (94%); useful in understanding their child's asthma (83%); used the right words to describe their child's condition (95%); and would help the ED physician (93%) and primary care provider (PCP) (89%) better understand their child's asthma. Eleven percent reported that the PACCI-ED interfered with ED care. Parents with lower health literacy were more likely to agree the PACCI-ED asked more complete questions about their child's asthma than the ED physician (64% vs 45%, P = .02). Parents of children with uncontrolled asthma were more likely to agree that the PACCI-ED should become part of regular ED care (88% vs 62%, P = .02). Parents were more likely to agree that the PACCI-ED would help their PCP understand their child's asthma if they had a lower income (92% vs 50%, P.001), less education (100% vs 88%, P = .004), were Latinx (94% vs 83%, P = .006), or were not using controller medication (93% vs 83%, P = .03).Parents endorse an asthma questionnaire as valuable during an ED encounter. Because it is endorsed to be valuable to parents, this questionnaire could be used to facilitate patient-centered asthma care.

Objective Premature infants are at high risk for respiratory disease, and secondhand smoke (SHS) exposure further increases their risk for developing respiratory illness and asthma. Yet, SHS exposure remains problematic in this vulnerable population. Our objective was to evaluate the effects of brief asthma education plus motivational interviewing counseling on reducing SHS exposure and improving respiratory outcomes in premature infants compared to asthma education alone. Methods Caregivers and their infants ≤32 weeks' gestational age were enrolled after discharge from a neonatal intensive care unit in Rochester, New York, from 2007 to 2011. Participants (N = 165, 61% Medicaid insurance, 35% Black, 19% Hispanic, 59% male) were stratified by infant SHS exposure and randomly assigned to treatment or comparison groups. Results Caregivers in the treatment group reported significantly more home smoking bans (96% vs 84%, P = .03) and reduced infant contact with smokers after the intervention (40% vs 58%, P = .03), but these differences did not persist long term. At study end (8 months after neonatal intensive care unit discharge), treatment group infants showed significantly greater reduction in salivary cotinine versus comparison (−1.32 ng/mL vs −1.08 ng/mL, P = .04), but no significant differences in other clinical outcomes. Conclusions A community-based intervention incorporating motivational interviewing and asthma education may be helpful in reducing SHS exposure of premature infants in the short term. Further efforts are needed to support sustained protections for this high-risk group and ultimately, prevent acute and chronic respiratory morbidity. Strategies for successfully engaging families during this stressful period warrant attention.

Objective Clinician prompts increase the likelihood of guideline-recommended corrective actions (preventive medication prescription, dose change, and/or adherence promotion) for symptomatic children with poorly controlled or persistent asthma in the primary care setting, but it is unclear if all children equally benefit. The objectives of this study were to identify whether asthma severity, visit type, and current preventive medication use were predictive of corrective actions during visits for children with symptomatic asthma, and determine whether these factors modified the effect of a prompting intervention. Methods We conducted prespecified subgroup analyses of a cluster randomized controlled trial of physician prompting that promoted guideline-based asthma management for urban children with symptomatic asthma. We tested predictors of corrective actions with bivariate and multivariate multilevel logistic regressions, compared intervention effects across factor categories via stratified analyses, and characterized effect modification with interaction term analyses. Results Prompting intervention exposure, moderate/severe disease, asthma-focused visits, and current preventive medication use were predictive of corrective actions. The prompting intervention significantly increased the rate of corrective actions for children across categories of disease severity, visit type, and preventive medication use. However, the intervention effect was significantly smaller for children already using a preventive medication (adjusted odds ratio [OR], 2.01; 95% confidence interval [CI], 1.19–3.38) compared with children without preventive medication use (adjusted OR, 6.25; 95% CI, 3.39–11.54). Conclusions Prompting increases the likelihood of corrective actions during clinic encounters; however, children already using preventive medication benefit less. It is critical for providers to recognize the need for corrective actions among these symptomatic children.

Objective Despite numerous policy statements and an increased focus on transition of care, little is known about young adults who experience delayed transition to adult providers. Methods We used cross-sectional data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey between 1998 and 2008 to examine delayed transition among young adults ages 22 to 30. We defined delayed transition as continuing to visit a pediatrician after the age of 21 years. Results Overall, we found that 1.3% (95% confidence interval [CI] 1.1–1.7) of visits by young adults to primary care physicians were seen by pediatricians, approximately 445,000 visits per year. We did not find a significant change in delayed transition during the past decade ( β = −.01; P = .77). Among young adults, visits to pediatricians were more likely than visits to adult-focused providers to be for a chronic disease (25.7% vs 12.6%; P = .002) and more likely to be billed to public health insurance (23.5% vs 14.1%; P = .01). In adjusted models, visits by young adults to pediatric healthcare providers were more likely associated with chronic disease (adjusted relative risk [ARR] 2.2; 95% CI 1.5–3.4), with public health insurance (ARR 1.9; 95% CI 1.3–2.9), or with no health insurance (ARR 1.9; 95% CI 1.1–3.4). Conclusions Although most young adult visits were to adult providers, a considerable number of visits were to pediatricians, indicating delayed transition of care. There has been no substantial change in delayed transition during the past decade. Visits by young adults with chronic disease, public health insurance, or no health insurance were more likely to experience delayed transition of care.

The aim of this study was to describe nocturnal asthma symptoms among urban children with asthma and assess the burden of sleep difficulties between children with varying levels of nocturnal symptoms.We analyzed baseline data from 287 urban children with persistent asthma (aged 4-10 years) enrolled in the School-Based Asthma Therapy trial; Rochester, New York. Caregivers reported on nocturnal asthma symptoms (number of nights/2 weeks with wheezing or coughing), parent quality of life (Juniper's Pediatric Asthma Caregivers Quality of Life Questionnaire), and sleep quality by using the validated Children's Sleep Habits Questionnaire. We used bivariate and multivariate statistics to compare nocturnal asthma symptoms with sleep quality/quantity and quality of life.Most children (mean age, 7.5 years) were black (62%); 74% had Medicaid. Forty-one percent of children had intermittent nocturnal asthma symptoms, 23% mild persistent, and 36% moderate to severe. Children's average total sleep quality score was 51 (range, 33-99) which is above the clinically significant cutoff of 41, indicating pervasive sleep disturbances among this population. Sleep scores were worse for children with more nocturnal asthma symptoms compared with those with milder symptoms on total score, as well as several subscales, including night wakings, parasomnias, and sleep disordered breathing (all P.03). Parents of children with more nocturnal asthma symptoms reported their child having fewer nights with enough sleep in the past week (P = .018) and worse parent quality of life (P.001).Nocturnal asthma symptoms are prevalent in this population and are associated with poor sleep quality and worse parent quality of life. These findings have potential implications for understanding the disease burden of pediatric asthma.

Objective To determine whether systematic use of a validated social-emotional screening instrument in a primary care setting is feasible and improves detection of social-emotional problems among youth in foster care. Methods Before-and-after study design, following a practice intervention to screen all youth in foster care for psychosocial problems using the Strengths and Difficulties Questionnaire (SDQ), a validated instrument with 5 subdomains. After implementation of systematic screening, youth aged 11 to 17 years and their foster parents completed the SDQ at routine health maintenance visits. We assessed feasibility of screening by measuring the completion rates of SDQ by youth and foster parents. We compared the detection of psychosocial problems during a 2-year period before systematic screening to the detection after implementation of systematic screening with the SDQ. We used chart reviews to assess detection at baseline and after implementing systematic screening. Results Altogether, 92% of 212 youth with routine visits that occurred after initiation of screening had a completed SDQ in the medical record, demonstrating high feasibility of systematic screening. Detection of a potential mental health problem was higher in the screening period than baseline period for the entire population (54% vs 27%, P Conclusions Systematic screening for potential social-emotional problems among youth in foster care was feasible within a primary care setting and doubled the detection rate of potential psychosocial problems.

Objectives The aim of this study was to compare the reported receipt of family-centered care between parents of white and black children with autism spectrum disorders (ASD) in the United States, and to disentangle the associations of race and ASD on different aspects of family-centered care. Methods Parents of 35 386 children, aged 0 to 17 years, were surveyed by the National Survey of Children with Special Health Care Needs (NS-CSHCN) 2005–2006. Autism was defined by the question, "To the best of your knowledge, does [child] currently have autism or autism spectrum disorder, that is, ASD?" Family-centered care was measured with 5 key indicators on a 4-point Likert scale. Univariate and multivariate analyses were used, with adjustment for the complex sampling design. Results The prevalence of autism in this sample was 5.4% (n = 1869). We found that, among children with SHCN but no ASD, more white parents than black parents reported receiving family-centered care. Further, fewer parents of both white children and black children with ASD reported receiving family-centered care compared with those with a child who had special needs other than ASD. Lastly, among parents with a child with ASD, being black was associated with lower reporting of family-centered care for 3 of 5 items. In multivariate analyses, black parents with a child with ASD had 2 to 5 times greater odds of not reporting family-centered care on each item compared with white parents without a child with ASD. Conclusion Targeted efforts are needed to improve family-centered care for parents with a child with ASD, and particularly for black families.

Objective To describe screen time use and factors related to screen time among urban children with persistent asthma. Methods We analyzed data for 224 children (aged 3 to 10 years) with persistent asthma. Parents reported on children's asthma severity, screen time use, and family practices regarding screen time. We asked parents: “On weekdays [and weekends] on average, over a 24-hour period, how many hours of screen time does your child have?” Parents also reported activity limitation due to asthma, and activities their child engaged in during times of activity limitation. Results Most children were male (58%), black (65%), and had Medicaid (74%); average screen time was 3.4 hours per day. Most parents (74%) reported that their child had >2 hours of screen time per day, and one-third were concerned that their child had too much screen time. Many children (63%) engaged in screen time activities during activity limitation due to asthma. Children who needed to slow down or stop normal activity due to asthma had more screen time compared with children who didn't need to slow down (3.51 hours vs 2.44 hours, P = .02). Additionally, children who engaged in screen time activities during times of physical limitation had more screen time compared with children who engaged in other activities (3.67 hours vs 2.99 hours, P = .01). Conclusions We found that urban children with asthma, particularly those with activity limitation, have excessive use of screen time. Strategies are needed to avoid activity limitation by improving asthma care and to empower families with alternative strategies to avoid excess screen time.

Objective To determine caregiver ability to name their child's inhaled asthma medications, and examine whether perceived ease of remembering names is associated with accurate naming and asthma outcomes. Methods As part of the School-Based Telemedicine-Enhanced Asthma Management trial in Rochester, New York, we asked caregivers of children with persistent asthma to: 1) name their child's inhaled medications, and 2) indicate agreement with the statement, "it is easy to remember the names of my child's asthma medications." We limited analyses to subjects with 1 inhaled medication. Reported names were compared with canisters available during a home visit; complete matches were considered concordant. We compared ease of remembering names with concordance, asthma symptoms, and adherence using bivariate and multivariate analyses. Results Overall, 141 caregivers (87%) had children with 1 inhaled medication (62% black race, 68% Medicaid). Most (74%) perceived it easy to remember medication names, yet only 46% reported names concordant with medications at home. Caregivers who did not easily remember medication names were less likely to concordantly name available medications (23% vs 54%; P = .002), and more likely to report that their child experienced >2 symptom days per week (33% vs 16%; P = .03), >2 symptom nights per month (31% vs 12%; P = .02), and missed >1 dose(s) of preventive medication in the previous 2 weeks (52% vs 28%; P = .03). Findings were consistent in multivariate regression analyses. Conclusions Caregivers of urban children with persistent asthma who considered medication names difficult to remember were less able to accurately name available medications, and reported worse control and medication adherence. Greater attention to medication identification might improve outcomes in this population.

Objective To describe which National Heart Lung and Blood Institute preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery varies by asthma symptom severity. Methods We approached children (2 to 12 years old) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit. Results We identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009 to January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs non-asthma-related visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14–0.84), trigger reduction discussion (OR 0.39, 95% CI 0.19–0.82), recommendation of follow-up (OR 0.40, 95% CI 0.19–0.87), and receipt of action plan (OR 0.37, 95% CI 0.16–0.86). Conclusions Many children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.

Objective Recent initiatives seek to incorporate efficient, evidence-based practices into primary care. This study tested the feasibility, impact, and acceptance of incorporating a DVD of newborn anticipatory guidance into routine well-child care. Methods This randomized trial tested a 15-minute educational DVD intervention versus control condition with paper handouts on newborn anticipatory guidance. We recruited parents of newborns ≤1 month old presenting for their first visit. Blinded research assistants conducted telephone follow-up 2 weeks later and medical chart reviews 2 months after enrollment. Clinic staff and providers completed semistructured surveys to rate the intervention. Primary outcomes included parent knowledge of infant development, self-efficacy with infant care skills, and problem-solving competence. Results We enrolled 137 subjects (response rate 82%). Scores on knowledge, self-efficacy, and problem solving were high at baseline for both groups and did not significantly change. More parents in the DVD group reported feeling prepared to care for their baby after the visit (94% vs 81%, P = .03), feeling high confidence bathing their baby (93% vs 78%, P = .01), and recognizing congestion (70% vs 52%, P = .03) compared to the control group. Those in the DVD group also had fewer additional office visits between birth and 2 months ( P = .01). Staff and providers agreed the DVD was useful for patients (88%) and did not disrupt patient flow (93%). Conclusions A DVD of newborn anticipatory guidance was feasible, well accepted, and had a positive impact in a pediatric practice. Video and other technologies represent an efficient, innovative way to reach parents as part of the office encounter.

Objectives Many parents struggle to secure high-quality, consistent child care services, and this may impact employment decisions. Our objectives were to determine the type of employment problems that parents attribute to difficulties in securing child care and to identify whether having a child with behavior problems and/or chronic illness is independently associated with child care–related employment problems in the United States. Methods This study included parents of children aged 0 to 13 years by using household-level sampling from the nationally representative random digit dial survey Gallup panel. We included 9 measures of child care–related employment problems. Poststratification weights were applied based on census region, income, and education by using Stata's poststratification commands. Results A survey was conducted of 1431 households with at least 1 parent employed. Overall, 46% of households reported 1 or more child care–related employment change. Being absent from work (21%) and changing the work schedule (27%) were the most prevalent changes reported. Two-parent households were significantly less likely to report child care–related employment changes compared with single parent households. Households with a stay-at-home parent were less likely to report child care–related absenteeism but more likely to report recently quitting work compared with households without a stay-at-home parent. Having a child with behavior problems or a serious chronic health condition was associated with double to triple odds of many child care–related employment problems. Conclusions Child care–related employment problems are common among families with a child with chronic illness or behavior problems. These findings support the need for pediatricians and policy makers to strive for the implementation of more parent-friendly labor conditions.