Global strategy for asthma management and prevention

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

Self-management approaches for people with chronic conditions: a review.

The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity.

ContextDelayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events.ObjectivesTo characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process.Data SourcesMEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies.Study SelectionObservational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18).Data ExtractionData from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer.Data SynthesisDirect communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents.ConclusionsDeficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.

https://jamanetwork.com/journals/jama/articlepdf/205790/jrv70001_831_841.pdf

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.

Objective: To investigate whether parents of asthmatic children would stop smoking or alter their smoking habits to protect their children from environmental tobacco smoke. Design: Randomised controlled trial. Setting: Tayside and Fife, Scotland. Participants: 501 families with an asthmatic child aged 2-12 years living with a parent who smoked. Intervention: Parents were told about the impact of passive smoking on asthma and were advised to stop smoking or change their smoking habits to protect their child9s health. Main outcome measures: Salivary cotinine concentrations in children, and changes in reported smoking habits of the parents 1 year after the intervention. Results: At the second visit, about 1 year after the baseline visit, a small decrease in salivary cotinine concentrations was found in both groups of children: the mean decrease in the intervention group (0.70 ng/ml) was slightly smaller than that of the control group (0.88 ng/ml), but the net difference of 0.19 ng/ml had a wide 95% confidence interval (−0.86 to 0.48). Overall, 98% of parents in both groups still smoked at follow up. However, there was a non-significant tendency for parents in the intervention group to report smoking more at follow up and to having a reduced desire to stop smoking. Conclusions: A brief intervention to advise parents of asthmatic children about the risks from passive smoking was ineffective in reducing their children9s exposure to environmental tobacco smoke. The intervention may have made some parents less inclined to stop smoking. If a clinician believes that a child9s health is being affected by parental smoking, the parent9s smoking needs to be addressed as a separate issue from the child9s health. Key messages Many asthmatic children are exposed to high levels of environmental tobacco smoke A brief intervention informing parents of asthmatic children on the harmful effects of passive smoking did not lead to a reduction in exposure of their children to tobacco smoke Low rates of smoking cessation were found in both the intervention group and the control group Some parents may have been less inclined to stop smoking after the intervention Brief interventions requesting smokers to stop for another person9s health seem ineffective

https://www.bmj.com/content/bmj/318/7196/1456.1.full.pdf

Advising parents of asthmatic children on passive smoking: randomised controlled trial

BACKGROUND: Children with parents who smoke are often exposed to high levels of environmental tobacco smoke, and children with asthma are particularly susceptible to the detrimental effects of passive smoking. Data were collected from parents who smoke and from their asthmatic children. The families are currently taking part in a randomised controlled trial to test an intervention designed to reduce passive smoking in children with asthma. This paper reports on the baseline data. Questionnaire data and cotinine levels were compared in an attempt to assess exposure and to identify factors which influence exposure of the children. The aim of the study was to identify the scope for a reduction in passive smoking by these children. METHODS: A sample of 501 families with an asthmatic child aged 2-12 years was obtained. Factors influencing passive smoking were assessed by interviewing parents. Cotinine levels were measured from saliva samples using gas liquid chromatography with nitrogen phosphorous detection. RESULTS: Cotinine levels in children were strongly associated with the age of the child, the number of parents who smoked, contact with other smokers, the frequency of smoking in the same room as the child, and crowding within the home. Parental cotinine levels, the amount smoked in the home, and whether the home had a garden also exerted an independent effect on cotinine levels in the children. CONCLUSIONS: Many children are exposed to high levels of environmental tobacco smoke and their cotinine levels are heavily dependent upon proximity to the parent who smokes. Parents who smoke have a unique opportunity to benefit their child's health by modifying their smoking habits within the home.

https://thorax.bmj.com/content/thoraxjnl/52/9/766.full.pdf

What determines levels of passive smoking in children with asthma

Objective: To test whether an audit facilitator could alter the pattern of diagnosis and treatment of childhood asthma. Design: Randomised stratified controlled trial. Setting: 12 general practices in Tayside. Subjects: 3373 children aged 1-15 inclusive who had symptoms suggestive of asthma or possible asthma drawn from a systematic review of 10 725 general practice case records. Intervention: Children were targeted for a clinical review by their general practitioner or practice nurses. Main outcome measures: Asthma related consultations, precriptions, hospital attendances, and health service costs 12 months before and after study. Results: Compared with controls (n=1563) the intervention group (n=1585) had more practice initiated consultations for asthma (relative risk 2.18 (95% confidence interval 1.74 to 2.73)), new diagnoses of asthma (2.83 (2.26 to 3.54)), and past diagnoses reaffirmed (1.30 (1.08 to 1.58)), and they were more frequently prescribed inhaled cromoglycate (1.52 (1.02 to 2.25)). Hospital inpatient day rates fell from 152 to 122 in the intervention group and rose from 69 to 117 in the control group between the year before and the year after study. Total primary care costs rose from pounds sterling30118 to pounds sterling37243 in the intervention group and fell from pounds sterling29131 to pounds sterling27990 in the control group. Hospital care cost fell in the intervention group from pounds sterling25406 to pounds sterling20727 and rose in the control group from pounds sterling12699 to pounds sterling19650. Conclusion: An audit facilitator can favourably influence the pattern of diagnosis and treatment of childhood asthma in general practice. This may have an impact on health service costs. Key messages Key messages Controlled trial of an audit facilitator is feasible in primary care Intervention of an audit facilitator resulted in desirable changes in the diagnosis and treatment of asthma in children in general practice Such intervention may also have had an impact on the use of hospital resources and on health care expenditure

http://europepmc.org/articles/PMC2549220?pdf=render

Controlled trial of an audit facilitator in diagnosis and treatment of childhood asthma in general practice

Objective: To investigate whether asthma or its treatment impairs children9s growth, after allowing for socioeconomic group. Design: 4 year follow up of a cohort of children aged 1-15. Setting: 12 general practices in the Tayside region of Scotland. Subjects: 3347 children with asthma or features suggestive of asthma registered with the general practices. Main outcome measures: Height and weight standard deviation scores. Results: Children who lived in areas of social deprivation (assessed by postcode) had lower height and weight than their contemporaries (mean standard deviation score −0.26 (SD 1.02) and −0.18 (1.15) respectively, P Conclusion: Most children with asthma were of normal height and weight and had normal growth rates. However, children receiving high doses of inhaled steroids and requiring both general practice and hospital services had a significant reduction in their stature. This effect was independent from but smaller than the effect of socioeconomic group on stature. Key messages Social deprivation has an adverse effect on the height and weight of children irrespective of any disease process Neither asthma nor its treatments had any noticeable effect on the height and weight of most of the children in this primary care study Children who received high doses of inhaled corticosteroids and used hospital services for asthma were shorter and lighter than their contemporaries after social deprivation was allowed for Children receiving high doses of inhaled corticosteroids had lower than normal growth rates

https://www.bmj.com/content/bmj/316/7132/668.1.full.pdf

Effect of asthma and its treatment on growth: four year follow up of cohort of children from general practices in Tayside, Scotland

BACKGROUND—Passive smoking is a major cause of respiratory morbidity in children. However, few studies give accurate estimates of the health effects of passive smoking in children with asthma using an objective measure of exposure. The effects of passive smoking using salivary cotinine levels to measure exposure were investigated.
METHODS—A sample of 438 children aged 2-12 years with asthma who had a parent who smoked were recruited in Tayside and Fife, Scotland. Health service contacts for asthma, assessed from GP case records, were used as a proxy for morbidity.
RESULTS—A weak U-shaped relationship was found between the salivary cotinine level and health service contacts for asthma: compared with low cotinine levels those with moderate cotinine levels had a reduced contact rate (relative rate (RR) = 0.91, 95% confidence interval (CI) 0.80 to 1.05), whereas high cotinine levels were associated with an increased rate of contact (RR = 1.19, 95% CI 1.05 to 1.37). In contrast, a strong association was seen with the amount the parent reported smoking in front of the child: the higher the level the fewer visits were made for asthma (RR for everyday exposure = 0.66, 95% CI 0.56 to 0.77). This effect was not seen for non-respiratory visits. Demographic factors, age of child, and number of children in the family all had a powerful effect on the number of visits for asthma. The parents' perception of asthma severity was associated with visit frequency independent of actual severity (derived from drug treatment).
CONCLUSION—High levels of parental smoking in the home are associated with a reduction in health care contacts for asthma. This could be due to a lack of awareness of asthma symptoms among heavy smokers or a reluctance to visit the GP. Children with asthma who have parents who smoke heavily may not be receiving adequate management.

https://thorax.bmj.com/content/thoraxjnl/56/1/9.full.pdf

R A Clark

Papers

Advising parents of asthmatic children on passive smoking: randomised controlled trial

What determines levels of passive smoking in children with asthma

Controlled trial of an audit facilitator in diagnosis and treatment of childhood asthma in general practice

Effect of asthma and its treatment on growth: four year follow up of cohort of children from general practices in Tayside, Scotland

Does passive smoking increase the frequency of health service contacts in children with asthma