Childhood Asthma -- Assess, Treat, and Reassess!
Childhood Asthma -- Assess, Treat, and Reassess!
Liu AH, Gilsenan AW, Stanford RH, Lincourt W, Ziemiecki R, Ortega H
J Pediatr. 2010;157;276-281
Liu and colleagues note that an estimated 9% of children have been diagnosed with asthma, and approximately half of those can expect an exacerbation of asthma each year. Given that the preponderance of asthma-related studies in children occur in inpatient or emergency department (ED) settings, this study aimed to assess control of children's asthma in outpatient settings with validated instruments. The children were seen in 29 primary care settings across the United State from January to May 2008. The sites did not have an asthma focus or a specialist in the practice, nor did they previously employ the questionnaires used in this study. Each site was expected to enroll approximately 85 children.
The primary objective was to determine the prevalence of uncontrolled asthma. The primary measure of control was score on the Childhood Asthma Control Test for children 4-11 years of age or the Asthma Control Test for children 12-17 years. Each child had a history of provider-diagnosed asthma. Children were excluded for chronic respiratory diseases other than asthma or if they had not used asthma medications in the 12 months before enrollment. Data collected for the study included whether the primary reason for the index visit was respiratory or nonrespiratory in nature, demographics of the children, history of asthma exacerbations, ED visits for asthma, hospitalizations for asthma, environmental triggers, and measures of school performance.
More than 5000 children meeting study criteria were seen in the practices during the enrollment period, and 2429 (47% of eligible children) were included in the study. Boys comprised 56% of the sample, and the racial/ethnic breakdown was 39% white, 22% black, and 30% Hispanic. Mean age was 9.2 years. Insurance coverage was 45% private and 46% public, and 1.4% had no insurance. The parents' educational backgrounds varied -- only 14.5% had less than a high school diploma, 44% had a high school diploma, and 42% had some education after high school. Respiratory symptoms were present in 53% of visits, and 15% of children were exposed to secondhand smoke in their primary household.
The investigators calculated an overall (across all subgroups) weighted (by age) prevalence of uncontrolled asthma of 46% (95% confidence interval, 43%-48%). The prevalence of uncontrolled asthma was slightly higher among children seen for respiratory visits (54%) vs nonrespiratory visits (35%). In addition, the rates of exacerbation (oral steroid burst, ED visit for asthma, or hospitalization for asthma) were 50% of children in whom asthma was not controlled compared with 33% of children in whom it was. Children with uncontrolled asthma were more than twice as likely to have missed at least 1 day of school in the previous month (67% vs 29%, P < .0001), and their parents were more likely to have missed work. The patterns of higher rates of exacerbation and greater chance of missing school or work were present when the investigators analyzed children seen for respiratory and nonrespiratory symptoms separately, but the rates were higher among children seen for respiratory symptoms. The investigators concluded that 46% of all children with asthma visiting a pediatrician have uncontrolled asthma.
It is worth noting that this is a visit sample, not a sample of all children with asthma. Therefore, these percentages probably overestimate the level of uncontrolled asthma in a given population because children with well-controlled asthma are less likely to make a provider visit. However, even if the "true" prevalence is half of that reported here, it is still high. I try to illustrate to our residents and medical students the cascade that must occur just to appropriately deliver controller therapy to an asthmatic. The provider must recognize that the patient has asthma and then accurately assess the severity. The provider must then prescribe appropriate controllers, and the patients must fill the prescription, use proper technique, and follow dosing frequency recommendations. Finally, patients must accurately assess their own symptoms or performance (eg, with home peak flow monitoring) to provide feedback to the provider to determine whether the prescribed therapy is meeting its objective. With even a 10% decrement at each of those steps, one can easily understand how such a large proportion of children with asthma making a provider visit would not have controlled asthma. Therefore, Liu and colleagues (and others) advocate screening for asthma control at every encounter, and these data support that recommendation.
It is also worth noting that even among children with "controlled" asthma in this study, 28.5% used at least 1 steroid burst during the previous 12 months, 10% had an urgent care visit, and 2% were hospitalized. So, the take-home message is assess, treat, and reassess!
Abstract
Status of Asthma Control in Pediatric Primary Care: Results From the Pediatric Asthma Control Characteristics and Prevalence Survey Study (ACCESS)
Liu AH, Gilsenan AW, Stanford RH, Lincourt W, Ziemiecki R, Ortega H
J Pediatr. 2010;157;276-281
Study Summary
Liu and colleagues note that an estimated 9% of children have been diagnosed with asthma, and approximately half of those can expect an exacerbation of asthma each year. Given that the preponderance of asthma-related studies in children occur in inpatient or emergency department (ED) settings, this study aimed to assess control of children's asthma in outpatient settings with validated instruments. The children were seen in 29 primary care settings across the United State from January to May 2008. The sites did not have an asthma focus or a specialist in the practice, nor did they previously employ the questionnaires used in this study. Each site was expected to enroll approximately 85 children.
The primary objective was to determine the prevalence of uncontrolled asthma. The primary measure of control was score on the Childhood Asthma Control Test for children 4-11 years of age or the Asthma Control Test for children 12-17 years. Each child had a history of provider-diagnosed asthma. Children were excluded for chronic respiratory diseases other than asthma or if they had not used asthma medications in the 12 months before enrollment. Data collected for the study included whether the primary reason for the index visit was respiratory or nonrespiratory in nature, demographics of the children, history of asthma exacerbations, ED visits for asthma, hospitalizations for asthma, environmental triggers, and measures of school performance.
More than 5000 children meeting study criteria were seen in the practices during the enrollment period, and 2429 (47% of eligible children) were included in the study. Boys comprised 56% of the sample, and the racial/ethnic breakdown was 39% white, 22% black, and 30% Hispanic. Mean age was 9.2 years. Insurance coverage was 45% private and 46% public, and 1.4% had no insurance. The parents' educational backgrounds varied -- only 14.5% had less than a high school diploma, 44% had a high school diploma, and 42% had some education after high school. Respiratory symptoms were present in 53% of visits, and 15% of children were exposed to secondhand smoke in their primary household.
The investigators calculated an overall (across all subgroups) weighted (by age) prevalence of uncontrolled asthma of 46% (95% confidence interval, 43%-48%). The prevalence of uncontrolled asthma was slightly higher among children seen for respiratory visits (54%) vs nonrespiratory visits (35%). In addition, the rates of exacerbation (oral steroid burst, ED visit for asthma, or hospitalization for asthma) were 50% of children in whom asthma was not controlled compared with 33% of children in whom it was. Children with uncontrolled asthma were more than twice as likely to have missed at least 1 day of school in the previous month (67% vs 29%, P < .0001), and their parents were more likely to have missed work. The patterns of higher rates of exacerbation and greater chance of missing school or work were present when the investigators analyzed children seen for respiratory and nonrespiratory symptoms separately, but the rates were higher among children seen for respiratory symptoms. The investigators concluded that 46% of all children with asthma visiting a pediatrician have uncontrolled asthma.
Viewpoint
It is worth noting that this is a visit sample, not a sample of all children with asthma. Therefore, these percentages probably overestimate the level of uncontrolled asthma in a given population because children with well-controlled asthma are less likely to make a provider visit. However, even if the "true" prevalence is half of that reported here, it is still high. I try to illustrate to our residents and medical students the cascade that must occur just to appropriately deliver controller therapy to an asthmatic. The provider must recognize that the patient has asthma and then accurately assess the severity. The provider must then prescribe appropriate controllers, and the patients must fill the prescription, use proper technique, and follow dosing frequency recommendations. Finally, patients must accurately assess their own symptoms or performance (eg, with home peak flow monitoring) to provide feedback to the provider to determine whether the prescribed therapy is meeting its objective. With even a 10% decrement at each of those steps, one can easily understand how such a large proportion of children with asthma making a provider visit would not have controlled asthma. Therefore, Liu and colleagues (and others) advocate screening for asthma control at every encounter, and these data support that recommendation.
It is also worth noting that even among children with "controlled" asthma in this study, 28.5% used at least 1 steroid burst during the previous 12 months, 10% had an urgent care visit, and 2% were hospitalized. So, the take-home message is assess, treat, and reassess!
Abstract
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