Status of Asthma Control in Pediatric Primary Care: Results from the Pediatric Asthma Control Characteristics and Prevalence Survey Study (ACCESS)

doi:10.1016/j.jpeds.2010.02.017

The Journal of Pediatrics

Volume 157, Issue 2, August 2010, Pages 276-281.e3

https://doi.org/10.1016/j.jpeds.2010.02.017 Get rights and content

Objective

To estimate the prevalence of uncontrolled asthma in pediatric patients with asthma visiting their primary care provider for any medical reason.

Study design

This was a cross-sectional survey conducted at 29 pediatric care sites across the United States. Children age 4-17 years with self- or caregiver-reported asthma completed the Childhood Asthma Control Test (C-ACT) or the Asthma Control Test (ACT) and responded to demographic and health-related questions. Uncontrolled asthma was defined as a C-ACT or ACT score ≤19.

Results

A total of 2429 children with a diagnosis of asthma (or caregivers) completed the survey. The prevalence of uncontrolled asthma was 46%. The prevalence of uncontrolled asthma was 35% in patients seen for a nonrespiratory complaint versus 54% in those seen for a respiratory complaint. Children seen for a non–respiratory-related complaint with uncontrolled asthma were more likely to have missed 1 or more school days in the previous 4 weeks compared with children with controlled asthma (53% vs 24%).

Conclusions

These findings highlight the impact of uncontrolled asthma not only in children seen for respiratory complaints, but also in those seen for nonrespiratory complaints. Pediatric care providers should consider evaluating asthma control on a regular basis regardless of the reason for the visit.

Section snippets

Methods

This was a multi-site, cross-sectional study in patients with asthma who visited a pediatric health care provider for any reason between January and May 2008 (study #ADA111119). The primary measure, “uncontrolled asthma,” was defined as a binary variable and based on a total C-ACT (in patients age 4-11 years) or ACT (in patients age 12-17 years) score ≤19.3, 6 The 29 participating sites were identified using a publicly available list of physicians (online Yellow Pages) within geographic regions

Results

Based on number of subjects provided by participating HCPs, approximately 5219 children age 4-17 with a history of asthma were seen during the data collection period. Of these, 2572 patients expressed interest in the study and were screened. After screening, 104 patients were ineligible and 21 declined to participate, leaving a total of 2447 patients age 4-17 years with asthma enrolled in the study. Eighteen of these patients were excluded from the analysis (12 who were outside the age range

Discussion

Our data indicate that 46% of the children with asthma visiting a pediatrician for both respiratory and nonrespiratory reasons had uncontrolled asthma symptoms. This finding is are consistent with previously reported rates of uncontrolled asthma in children in primary care settings (37%-64%);10, 11, 12, 13 however, this is the first study with a large sample size to quantify the prevalence of uncontrolled asthma using a clinically validated asthma control assessment tool (ACT or C-ACT) in a

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Asthma control in children, socioeconomic inequality and health care
2023, Anales de Pediatria
La desigualdad socioeconómica (DSE) puede afectar negativamente al control del asma. El objetivo de este estudio fue identificar la relación de la DSE con el control del asma y la calidad de vida de los cuidadores.
El nivel socioeconómico se determinó por área de residencia, según la tasa de riesgo de pobreza (TRP). La población pediátrica de Castilla y León se estratificó en terciles de TRP, y se seleccionó una muestra mediante muestreo aleatorio estratificado, identificando a los niños (6-14 años) con asma activa en los registros clínicos de centros de atención primaria. La información se obtuvo mediante cuestionarios cumplimentados por los padres. Las variables primarias fueron el control del asma y la calidad de vida de los cuidadores. Se analizó su relación con la DSE, la calidad de la atención sanitaria y factores individuales (como el nivel educativo de los padres) mediante modelos multivariantes de regresión.
El tercil de TRP no se relacionó con ninguna medida de control del asma, calidad de vida ni calidad de la asistencia. El nivel educativo de la madre (educación media o superior) se asociaba a menor riesgo de consulta no programada/urgente (OR = 0,50; IC 95%: 0,27-0,95; p = 0,034) y el del padre a menor riesgo de asma mal controlada (OR = 0,51; IC 95%: 0,28-0,94; p = 0,030).
En la población que hemos estudiado, no se encuentra asociación entre DSE, medida por área de residencia, y el control del asma en niños. Otros factores, como la educación de los padres, pueden ser factores protectores.
Socioeconomic inequality (SEI) can adversely affect asthma control. The aim of this study was to establish the association of SEI with asthma control in children and caregiver quality of life.
We assessed socioeconomic status based on the area of residence, according to the at risk of poverty rate (ARPR). After stratifying the paediatric population of Castilla y León (an autonomous community in Spain) in ARPR tertiles, we selected participants by stratified random sampling, and identified children with asthma aged 6–14 years from the health records of primary care centres. We collected data through questionnaires completed by parents. The primary outcomes were asthma control and caregiver quality of life. We assessed their association with SEI, health care quality measures and individual factors (such as parental educational attainment) by means of multivariate regression models.
The ARPR tertile was not associated with asthma control, quality of life or health care quality. A medium or high maternal educational attainment was associated with a lower risk of making an unscheduled or urgent visit (OR=.50; 95% CI: .27-.95; P=.034) and paternal educational attainment was associated with a lower risk of uncontrolled asthma (OR=.51; 95% CI: .28-.94; P=.030).
In the sample under study, SEI assessed at the local level was not associated with asthma control in children. Other factors, such as parental educational attainment, may have a protective effect.
Tiotropium in children and adolescents with asthma
2020, Annals of Allergy, Asthma and Immunology
Asthma is a major cause of morbidity in children, despite the availability of various treatments. In adults, tiotropium—a long-acting muscarinic antagonist—as add-on therapy to an inhaled corticosteroid with or without a long-acting β₂-agonist provides clinical benefit with a safety profile similar to placebo.
To review published evidence on the efficacy and safety of tiotropium as add-on a long-acting muscarinic antagonist therapy in children and adolescents with asthma that is uncontrolled despite use of an inhaled corticosteroid with or without additional controller medication(s).
We searched PubMed from inception until June 12, 2018, for randomized controlled trials of children and adolescents aged 1 to 17 years treated with tiotropium and reporting a primary outcome of any pulmonary function test and a secondary outcome of adverse events.
Overall, 7 randomized controlled trials of 1902 preschool children (aged 1-5 years; n = 102), school-age children (aged 6-11 years; n = 905), and adolescents (aged 12-17 years; n = 895) with moderate to severe asthma were included in the analysis. Once-daily tiotropium (5, 2.5, or 1.25 μg) improved lung function parameters, including peak and trough forced expiratory volume in 1 second, vs placebo. Commonly reported adverse events across treatment groups included asthma worsening or exacerbations, decreased peak expiratory flow rate, nasopharyngitis, viral respiratory tract infection, and respiratory tract infection.
Once-daily tiotropium as add-on therapy is efficacious and safe in adolescents and children with moderate to severe asthma. These results support the expanded indication by regulatory authorities for add-on tiotropium in patients 6 years or older.
Treatment Adherence in Young Children with Asthma
2019, Immunology and Allergy Clinics of North America
Citation Excerpt :
An estimated 6.8 million children in the United States are affected by asthma,1 which places them at significant risk for hospitalizations, emergency room visits, and school absences.2–4
Natural Language Processing for Asthma Ascertainment in Different Practice Settings
2018, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
Among 72 subjects who met PAC in this study, only 24 had a physician diagnosis of asthma (33%). Given the younger age of the cohort (median age, 2.3 years; interquartile range, 2.0-2.6 years; and range, 1.5-3.1 years), this may not be surprising, but this is one of the reasons why children this age are often not included in large-scale asthma studies.47,48 Criteria-based NLP algorithm for asthma will help identify children with recurrent asthma symptoms regardless of age on a population level.
We developed and validated NLP-PAC, a natural language processing (NLP) algorithm based on predetermined asthma criteria (PAC) for asthma ascertainment using electronic health records at Mayo Clinic.
To adapt NLP-PAC in a different health care setting, Sanford Children Hospital, by assessing its external validity.
The study was designed as a retrospective cohort study that used a random sample of 2011-2012 Sanford Birth cohort (n = 595). Manual chart review was performed on the cohort for asthma ascertainment on the basis of the PAC. We then used half of the cohort as a training cohort (n = 298) and the other half as a blind test cohort to evaluate the adapted NLP-PAC algorithm. Association of known asthma-related risk factors with the Sanford-NLP algorithm–driven asthma ascertainment was tested.
Among the eligible test cohort (n = 297), 160 (53%) were males, 268 (90%) white, and the median age was 2.3 years (range, 1.5-3.1 years). NLP-PAC, after adaptation, and the human abstractor identified 74 (25%) and 72 (24%) subjects, respectively, with 66 subjects identified by both approaches. Sensitivity, specificity, positive predictive value, and negative predictive value for the NLP algorithm in predicting asthma status were 92%, 96%, 89%, and 97%, respectively. The known risk factors for asthma identified by NLP (eg, smoking history) were similar to the ones identified by manual chart review.
Successful implementation of NLP-PAC for asthma ascertainment in 2 different practice settings demonstrates the feasibility of automated asthma ascertainment leveraging electronic health record data with a potential to enable large-scale, multisite asthma studies to improve asthma care and research.
Tiotropium in asthma: What is the evidence and how does it fit in?
2016, World Allergy Organization Journal
Citation Excerpt :
Asthma control consists of 2 domains: current impairment or day-to-day asthma control (absence of symptoms, minimal reliever use, and normal activity levels and lung function) and control of future risk (absence of exacerbations, prevention of decline in lung function, and absence of side effects from drugs) [3, 4]. Despite major advances in the management of asthma made in the 1970s with the introduction of inhaled corticosteroids (ICS) and again in the 1980s with the introduction of long-acting beta agonists (LABA) [5]; and with the development of national and international management guidelines [1, 2], many patients, including children and adolescents remain uncontrolled and remain at risk of exacerbations [6–8]. In 2011, the Innovative Medicine Initiative (IMI) proposed that these patients should be divided into those with “difficult-to-control asthma” and those with “severe refractory asthma.” [9].
Despite current therapeutic approaches asthma remains uncontrolled in a significant proportion of patients. Short-acting anticholinergic bronchodilators have a very long history of use in asthma, and recent data confirms the importance of acetylcholine as both a bronchoconstrictor and as a regulator of inflammation and remodeling in the lungs. Data from a comprehensive clinical trial programme, as well as use in primary care, show the efficacy and safety of tiotropium in adults with mild to moderate asthma when it is added to ICS and in severe asthma when it is added to high doses of ICS plus LABA, as well as in adolescents. Tiotropium is cost effective and its benefits are not restricted to particular phenotypes, making it a useful addition to the therapeutic options recommended by the Global Initiative for Asthma (GINA) for people with poorly controlled asthma at steps 4 & 5.
Retrospective cohort analysis of healthcare claims in the United States characterising asthma exacerbations in paediatric patients
2016, World Allergy Organization Journal
Citation Excerpt :
Asthma has been estimated to affect up to 10 % of children in the US [1]. Furthermore, the prevalence of uncontrolled asthma in children remains high despite widespread availabilityy of effective controller medications [2–5]. Lack of adherence to maintenance therapies such as inhaled corticosteroids, may lead to poor asthma control, particularly in older children [6].
Background Asthma is the most common chronic disease in childhood and places a significant burden on public and private health systems. This retrospective cohort analysis utilised administrative healthcare claims data (US Clinformatics™ Multiplan database; compliant with the US Department of Health & Human Services Health Insurance Portability and Accountability Act) to characterise asthma exacerbations requiring intervention in a US paediatric patient population.
Methods Patients aged > 1–17 years with a recorded asthma diagnosis and receiving treatment were identified in the US Clinformatics™ Multiplan database over a 9-year period (2004–2012). Both incident and prevalent cases of asthma were included, with the most recently recorded asthma diagnosis designated as the index date. The 12-month period following the index date was analysed for asthma exacerbations, defined as an event requiring treatment with systemic corticosteroid or resulting in an asthma-related hospitalisation or emergency department visit.
Results Data from 734,114 children with asthma (41.5 % females, 58.5 % males) were analysed, of this cohort 34.4 % experienced ≥ 1 exacerbation during the follow-up period. The proportion who experienced ≥ 1 exacerbation increased from 28.9 % in 2004 to 36.3 % in 2012, based on the reported index date. Their mean annual exacerbation frequency was 1.4; 85.8 % of exacerbations were defined by systemic corticosteroids use. A consistent trend of increased exacerbation incidence in the fall and early winter was observed, in particular exacerbations defined by systemic corticosteroid use. A greater proportion of asthma-related hospitalisations were associated with younger age.
Conclusions Approximately one-third of children experienced ≥ 1 exacerbation in real-world clinical practice. A targeted treatment approach with a focus on those with a history of recurrent exacerbations is recommended to improve asthma control. This targeted approach could also minimise the frequent systemic corticosteroid exposure particularly at an early age when side effects of systemic corticosteroids are more pronounced.

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: Supported by GlaxoSmithKline. A.G. and R.Z. are employed by RTI Health Solutions, a business unit of RTI International, a nonprofit research organization. RTI Health Solutions receives funding from multiple pharmaceutical companies, including GlaxoSmithKline. W.L., R.S., and H.O. are employed by GlaxoSmithKline.

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Original ArticleStatus of Asthma Control in Pediatric Primary Care: Results from the Pediatric Asthma Control Characteristics and Prevalence Survey Study (ACCESS)

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

J Allergy Clin Immunol

J Allergy Clin Immunol

Ambul Pediatr

Guidelines for the diagnosis and management of asthma: Expert Panel Report 3. NIH Publication 08 4051

Development and validation of a questionnaire to measure asthma control

Eur Respir J

Association of asthma control with health care utilization and quality of life

Am J Respir Crit Care Med

The Asthma Quiz for Kidz: a validated tool to appreciate the level of asthma control in children

Can Respir J

Original Article
Status of Asthma Control in Pediatric Primary Care: Results from the Pediatric Asthma Control Characteristics and Prevalence Survey Study (ACCESS)