Underuse of Asthma Controller Medications in Children
Underuse of Asthma Controller Medications in Children
Smith LA, Bokhour B, Hohman KH, et al
Pediatrics. 2008;122:760-769
The authors pointed out that previous studies have shown that only 40% of children with asthma are well controlled, despite national practice guidelines on how to identify, classify, and treat asthma. The authors sought to obtain more detailed information than previous studies to determine parental behaviors that might influence poor asthma control.
The authors also collected data on clinical and demographic predictors of asthma control in order to compare the relative influence of the modifiable factors (eg, parental beliefs) vs other more "traditional" factors that correlated with asthma control, such as sociodemographic factors. The data about parental beliefs included information in regard to general health beliefs about asthma, beliefs and concerns about asthma medications, parents' definitions of good asthma control, whether the family had asthma medication routines, whether there were competing priorities within the home, and concern over poor parent-provider communication, among other issues.
The subjects were 2-12 years old and were drawn from 2 health plans in the northeastern United States. The authors used claims data within the health plans to identify subjects with asthma, and then they conducted phone interviews to collect data for comparisons. The authors were interested in identifying determinants of 2 outcomes: poor control of asthma and underuse of controller medications.
The authors defined suboptimal control as asthma symptoms at least 4 days in the past 2 weeks, rescue inhaler use at least 4 times in the past 2 weeks, or nocturnal symptoms at least 2 times in the past month. Patients who had suboptimal control and did not use a controller medication at least 6 days per week were considered to underuse controller medications. The authors used measures of asthma-related healthcare utilization (number of asthma-related emergency department visits, asthma-related clinic visits, and oral steroid use) to adjust for asthma severity.
The authors assessed parental expectations in regard to 4 statements: expectation of being symptom-free most of the time, expectation of little school absence, expectation of little physical limitation, and expectation of no emergency department visits or hospitalizations. Parents' definitions of what constitutes "good control" were estimated by asking them what symptom frequency constitutes good control and whether the parents would consider a child with asthma symptoms 2 days per week as being "in good control." If the child did not exhibit good control by guideline definitions but parents considered the child's asthma to be in good control, then the parental beliefs were considered discordant with the child's actual control status.
The authors enrolled 754 subjects: 26% black, 21% Hispanic, and 42% white. Only 63% of the children exhibited symptom frequencies consistent with good control. Of the children with poor asthma control, only 48% had adequate use of controllers. Almost two thirds of parents (62%) rated their child's asthma as "excellent" or "very good." Twelve percent of the parents were discordant in their estimate of their child's level of control and his or her actual symptoms. Thirty-five percent of parents considered their child's asthma "intermittent" and did not recognize it as a chronic condition.
Parents generally had low expectations for child functioning, and 22% considered symptoms of at least twice per week as good control. Suboptimal control was most prevalent among Hispanic children (51%), followed by black children (37%) and white children (32%). Of interest, 38% of parents reported that a provider had instructed them to use controllers intermittently.
There was a notable correlation between underuse of controllers and parental underestimate of symptom severity. In multivariable analyses, the authors identified 2 modifiable factors associated with suboptimal control: low parental expectation of the child's function and competing priorities within the family. Characteristics predicting controller underuse included low parental expectation of the child's function, discordant parental estimate of asthma control, and poor home medication routines. In both multivariable models, race/ethnicity was not a significant predictor.
The authors concluded that there are several potentially modifiable factors that correlate with poor control of asthma and suboptimal use of controller medications for asthma.
There is a lot of detail in this article, and I've only touched on some of the analyses completed. However, the take-home message is general: First, when confronted with a patient who is not doing well, clinicians should explore parental beliefs with regard to function to see whether parents set expectations that are too low. Second, explore parental understanding of medications, especially whether caregivers are administering the controller medications only intermittently. Concern about the safety of medications was a contributing factor to underuse of controllers in these parents, so explore that possibility with parents who appear "noncompliant." Finally, helping parents to develop a simple plan for a set time and place for the child to take his or her medicines has potential to improve use and symptom scores. Addressing these issues is time-consuming, but it has the potential to produce some notable symptom benefits to the child.
Abstract
Modifiable Risk Factors for Suboptimal Control and Controller Medication Underuse Among Children With Asthma
Smith LA, Bokhour B, Hohman KH, et al
Pediatrics. 2008;122:760-769
Summary
The authors pointed out that previous studies have shown that only 40% of children with asthma are well controlled, despite national practice guidelines on how to identify, classify, and treat asthma. The authors sought to obtain more detailed information than previous studies to determine parental behaviors that might influence poor asthma control.
The authors also collected data on clinical and demographic predictors of asthma control in order to compare the relative influence of the modifiable factors (eg, parental beliefs) vs other more "traditional" factors that correlated with asthma control, such as sociodemographic factors. The data about parental beliefs included information in regard to general health beliefs about asthma, beliefs and concerns about asthma medications, parents' definitions of good asthma control, whether the family had asthma medication routines, whether there were competing priorities within the home, and concern over poor parent-provider communication, among other issues.
The subjects were 2-12 years old and were drawn from 2 health plans in the northeastern United States. The authors used claims data within the health plans to identify subjects with asthma, and then they conducted phone interviews to collect data for comparisons. The authors were interested in identifying determinants of 2 outcomes: poor control of asthma and underuse of controller medications.
The authors defined suboptimal control as asthma symptoms at least 4 days in the past 2 weeks, rescue inhaler use at least 4 times in the past 2 weeks, or nocturnal symptoms at least 2 times in the past month. Patients who had suboptimal control and did not use a controller medication at least 6 days per week were considered to underuse controller medications. The authors used measures of asthma-related healthcare utilization (number of asthma-related emergency department visits, asthma-related clinic visits, and oral steroid use) to adjust for asthma severity.
The authors assessed parental expectations in regard to 4 statements: expectation of being symptom-free most of the time, expectation of little school absence, expectation of little physical limitation, and expectation of no emergency department visits or hospitalizations. Parents' definitions of what constitutes "good control" were estimated by asking them what symptom frequency constitutes good control and whether the parents would consider a child with asthma symptoms 2 days per week as being "in good control." If the child did not exhibit good control by guideline definitions but parents considered the child's asthma to be in good control, then the parental beliefs were considered discordant with the child's actual control status.
The authors enrolled 754 subjects: 26% black, 21% Hispanic, and 42% white. Only 63% of the children exhibited symptom frequencies consistent with good control. Of the children with poor asthma control, only 48% had adequate use of controllers. Almost two thirds of parents (62%) rated their child's asthma as "excellent" or "very good." Twelve percent of the parents were discordant in their estimate of their child's level of control and his or her actual symptoms. Thirty-five percent of parents considered their child's asthma "intermittent" and did not recognize it as a chronic condition.
Parents generally had low expectations for child functioning, and 22% considered symptoms of at least twice per week as good control. Suboptimal control was most prevalent among Hispanic children (51%), followed by black children (37%) and white children (32%). Of interest, 38% of parents reported that a provider had instructed them to use controllers intermittently.
There was a notable correlation between underuse of controllers and parental underestimate of symptom severity. In multivariable analyses, the authors identified 2 modifiable factors associated with suboptimal control: low parental expectation of the child's function and competing priorities within the family. Characteristics predicting controller underuse included low parental expectation of the child's function, discordant parental estimate of asthma control, and poor home medication routines. In both multivariable models, race/ethnicity was not a significant predictor.
The authors concluded that there are several potentially modifiable factors that correlate with poor control of asthma and suboptimal use of controller medications for asthma.
Viewpoint
There is a lot of detail in this article, and I've only touched on some of the analyses completed. However, the take-home message is general: First, when confronted with a patient who is not doing well, clinicians should explore parental beliefs with regard to function to see whether parents set expectations that are too low. Second, explore parental understanding of medications, especially whether caregivers are administering the controller medications only intermittently. Concern about the safety of medications was a contributing factor to underuse of controllers in these parents, so explore that possibility with parents who appear "noncompliant." Finally, helping parents to develop a simple plan for a set time and place for the child to take his or her medicines has potential to improve use and symptom scores. Addressing these issues is time-consuming, but it has the potential to produce some notable symptom benefits to the child.
Abstract
Source...