The current rate of childhood asthma in the United States is at a historically high 10%, according to recent research. Clinical practice guidelines recommend that clinicians provide parents and caregivers of children with asthma a regularly updated written asthma management plan. They are also recommended to administer annual influenza immunization for all children with asthma, prescribe daily controller medications in high-risk children, and screen for environmental tobacco exposure.
Few studies have assessed compliance with recommendations that have been set forth by national medical societies and associations. It has been speculated that population-level surveys may provide such information and help identify social determinants of health and unique considerations that may benefit from tailored interventions.
Learning From California
For a study published in Population Health Management, Ulfat Shaikh, MD, MPH, MS, and Robert S. Byrd, MD, MPH, sought to determine the quality of life and healthcare utilization of children with asthma. “We used 2011-2012 data from the California Health Interview Survey because it is well collected and the sampling procedure used is excellent,” explains Dr. Shaikh. “The data are quite likely generalizable to the rest of the country because the population of California does not have significantly different rates of asthma than other states. We also wanted to use these data from 44,000 households to help identify ways in which pediatric asthma care could be improved.”
Dr. Shaikh says she and Dr. Byrd found several gaps between current practice and national recommendations for asthma care. “We found that children with asthma tended to use the emergency room more than they should,” she says. One-third of children in the study had received emergency department or urgent care for asthma in the past year. Of these patients, 19% did so because of an inability to see their primary care provider. Importantly, more than 96% of children in the study had a usual source of primary care.
“Although national guidelines advocate for influenza immunization for all children with asthma,” says Dr. Shaikh, “the influenza immunization rate in our study population was about 50%, which is about the same as in the general population.”
It is recommended that providers ensure that all children with asthma have a written care management plan and that they update the plan as medications are updated, according to Dr. Shaikh. “We found that less than 40% of children with asthma were actually given a written asthma management plan by their doctors in the past year,” she says. “With nearly all of these patients having identified a primary source of care, the issue is not access to primary care; it’s essentially that the care being delivered through the medical home is fragmented.”
A disparity was uncovered based on parents’ education level, explains Dr. Shaikh (Table). Parents who had completed a high school education or received more schooling were more likely to have received asthma action plans from their children’s providers when compared with parents who had lower levels of education. “It’s important that clinicians gauge parent education, parent literacy, and parent health literacy,” Dr. Shaikh adds. “We should target parents who may need extra asthma education for their children.”
The findings reinforce other studies that have discovered a high prevalence of asthma in African-American children when compared with children of other ethnicities. However, Drs. Shaikh and Byrd also found a high prevalence of asthma in Asian children, which has not been reported in previous research.
“In terms of preventative care, there was a difference in the self-reported health status that parents of children with asthma reported when compared with parents of children in the general population,” says Dr. Shaikh (Table). “Half of the parents of children aged 2 to 11 reported their child’s health status as excellent, whereas only 30% of parents of children diagnosed with asthma said their child’s health status was excellent.”
Addressing the Issues
According to Dr. Shaikh, the study findings highlight the need for better care coordination among children with asthma. “Physicians should be better supported by other healthcare providers, including school nurses who often treat asthma exacerbations and pharmacists who can counsel parents on the appropriate use of inhalers and other medications” she says. “Even among children who see a pulmonologist, it’s critical to get messages back to primary care providers on how to improve the coordination of care.”
Dr. Shaikh adds that it is important for pulmonologists to work with the medical home and coordinate care. “They should make sure the primary care provider helps the child follow-up with their medications, develops action plans, understands the importance of influenza vaccinations, and educates the family. Specialists working in isolation—treating kids with asthma without proper coordination with their primary care provider—results in poor outcomes.”
Readings & Resources (click to view)
Shaikh U, Byrd R. Population health considerations for pediatric asthma: findings from the 2011–2012 California Health Interview survey. Popul Health Manag. 2015 Jun 23 [Epub ahead of print]. Available at http://online.liebertpub.com/doi/abs/10.1089/pop.2015.0015.
Moorman J, Akinbami L, Bailey C, et al. National surveillance of asthma: United States, 2001–2010. Vital Health Stat 3. 2012;35:1-67.
Bollinger M, Mudd K, Boldt A, et al. Prescription fill patterns in underserved children with asthma receiving subspecialty care. Ann Allergy Asthma Immunol. 2013;111:185-189.
Wright A. Epidemiology of asthma and recurrent wheeze in childhood. Clin Rev Allergy Immunol. 2002;22:33-44.