Treatment of complex medical conditions evolves over time. One excellent example of this is how the diagnosis and treatment of asthma has dramatically changed in just the past 50 years. In the early 20th Century - 1930s through 1950s - physicians thought of this condition as a psychosomatic illness. Now, asthma has been called “the most common chronic health condition in the United States.”
According the the Center for Disease Control and Prevention (CDC), the incidence of asthma is growing. Here are some facts about this condition in the United States:
- One in 12 people (about 25 million, or 8 percent of the population) had asthma in 2009, compared with 1 in 14 (about 20 million, or 7 percent) in 2001.
- More than half (53 percent) of people with asthma had an asthma attack in 2008. More children (57 percent) than adults (51 percent) had an attack.
- About 1 in 10 children (10 percent) had asthma and 1 in 12 adults (8 percent) had asthma in 2009.
- About 1 in 9 (11 percent) non-Hispanic blacks of all ages and about 1 in 6 (17 percent) of non-Hispanic black children had asthma in 2009, the highest rate among racial/ethnic groups.
- The greatest rise in asthma rates is among black children and In 2015, African American children had a death rate ten times that of non-Hispanic white children.
Exacerbating this growing health problem is the fact that many parents of preschool asthmatic children do not have enough knowledge about the disease and its medications.
New Study - Are Parents Prepared to Treat Asthma?
According to a recently released study, “only about half the parents of asthmatic preschoolers had the right knowledge and medicines on hand to treat their child's breathing condition at home, and one-third of those children had empty inhalers.”
In collaboration with the Baltimore Head Start early childhood education program, the researchers, led by Dr. Michelle Eakin, an associate professor at Johns Hopkins University Medical School, interviewed the caregivers of nearly 300 children during a two-hour home interview. The children were aged 2 to 6 years (average age 4), and almost two-thirds of them had uncontrolled asthma.
Ninety-two percent of the families were African-American. The same percentage of the caregivers were one of the child's birth parents, usually the mother. Forty percent of the caregivers hadn't finished high school (and, while it was not stated in the research, it is assumed that 60 percent finished secondary school) and one-third had attended college or graduated from college.
The researchers were looking for five specific factors that indicated caregivers were ready to treat a child's asthma:
- Availability of the medication -- could parents easily locate it?
- Was the medication expired?
- Did it have a counter to indicate remaining doses?
- Was it a "rescue" drug or a controller medication?
- Did parents know dosing instructions?
Results of the study found that “of the parents who reported their kids using rescue medication, only 60 percent met all five criteria, and only 79 percent had the medication at home. Among parents whose youngsters needed controller medications, only 49 percent met all five criteria, and only 79 percent had it in the home.”
In press reports, Dr. Jennifer Appleyard, chief of allergy and immunology at St. John Hospital and Medical Center, in Detroit, called the study a "wake-up call."
"I don't think this is just in preschoolers or in African Americans or in inner-city kids, and I don't think this is all on the parents either. I think this study's findings can be extrapolated to all age groups," she said. “We need to reinforce education at every appointment, and we need to ask, ‘Do you have your inhalers? Are they expired? Do you know the proper technique?’"
Another Asthma Expert Agrees With This Study
Dr. Barbara Howard is the Co-Director and President of CHADIS, the leading screening, decision-support and patient engagement system designed to streamline patient communication and optimize healthcare. She is also an Assistant Professor of Pediatrics at Johns Hopkins University School of Medicine. She offered her thoughts about this lack of parental preparation for the treatment of asthma.
“The article by Dr. Eakin shows the gaps in care for young children with asthma that deserve education,” she said.
”Optimizing asthma care may not cure asthma but it can reduce asthma attacks. This can result in the reduction in steroid bursts, with their potential long-term damage, much less asthma emergency visits, hospitalization or even death."
“Asthma is a problem everywhere, although some reasons differ for urban and rural children. Urban children are more likely to have asthma exacerbations due to air pollution and cockroaches. Rural children may be more likely to wheeze from wood stoves, plant pollens and animal danders, although early exposure may actually decrease allergies. All children can have worsening asthma from stress, any kind of smoke, obesity, reflux or that which is exercise induced.
How Can a Pediatrician Help Parents Prepare for Childhood Asthma?
As is often the case in managing chronic childhood diseases, pediatricians are responsible for ensuring that proper treatment - both at home and in-clinic - occurs. Dr. Howard offered some suggestions as to how this might be accomplished.
“Pediatricians are the key and often the only professionals educating and preparing families to deal with asthma,” she said. “Asthma education should include prevention such as avoiding smoke, allergens and stress."
“Pediatricians are also key to teaching children and parents how to recognize asthma attacks and what to do. This includes teaching when and how to properly use inhalers, spacers or nebulizers or other medication dispensers along with the importance of adhering to prevention medications, when indicated. This education should be supplemented with a written or online ‘Asthma Treatment Plan’ for every child to be shared with teachers, coaches and other caregivers.
“Pediatricians need to understand that parents and teens may have reasons for not following their advice, however, and be skilled at the evidence-based technique of ‘Problem Solving Counseling’ to address those barriers. Our research (at CHADIS) with nearly 5000 patients showed that most children, even with persistent severity asthma, are cared for mainly during regular check-ups, rather than asthma-specific visits. This means that standard questionnaires that can help define control, adherence and barriers are generally not used. Pediatricians then recommend management without an accurate assessment of the child's status.”
What Part Can an EHR Play in Asthma Treatment?
There are several ways an electronic health records platform can help pediatricians counsel parents on preventing asthma attacks. Dr. Howard explains.
“An EHR can assist pediatricians in helping parents to prevent asthma attacks when it provides guidance, called ‘decision support,’ in an easily used format,” she said. “Some EHRs offer templates for asthma care to remind clinicians what to discuss and some create ‘Asthma Action Plans’ that can be printed for families.”
Many physicians using PCC EHR also rely on CHADIS to provide more support for asthma care.
Dr. Howard added, “The CHADIS online asthma questionnaires, when used before both asthma-specific and routine visits, can provide accurate information and reduce the burden of documentation. It does this, while providing additional revenue related to new CPT codes (96160) and clinical quality metrics.
“CHADIS suggests decision supports needed based on the pre-visit patient-generated data. For example, when pre-visit assessments suggest need for inhaler/spacer technique review, a medication device-specific video is available for in office (CPT code 94664) or home viewing.
“If pre-visit questionnaires show barriers to adherence, an option appears for moment-of-care teleprompters for the clinician to conduct evidence-based ‘Problem Solving Counseling’ and triggers related post-visit messaging. If pre-visit questionnaires suggest environmental allergies, post-visit allergen-specific education text appears for patients in a webpage.
“Guideline-based medication advice is cued for the clinician based on asthma severity and the CHADIS Care Portal stores a pre-populated ‘Asthma Treatment Plan’ for the family to consult and share, as well as patient-specific education on prevention and management.
“A national cluster, randomized control trial using a special module of CHADIS for ‘Quality Improvement’ (which includes an MOC-4 credit) resulted in children having significantly fewer asthma attacks, steroid bursts and doctor visits and more patients (100 percent) on appropriate controller treatment in the intervention group, compared with a treatment-as-usual control group.”
Chip Hart, the Director of PCC’s Pediatric Solutions consulting group and author of the popular blog Confessions of a Pediatric Practice Consultant added,
“With CHADIS just a click away for PCC’s EHR, it helps our doctors accomplish several clinical and administrative objectives. First, it is unique in delivering this kind of evidence-based support for asthma care, while easing the documentation burden. It offers an educational opportunity at every visit. It also enables the earning of the required MOC- 4 credit. Of course, it allows the pediatrician to increase revenue from clinical consultations. Most importantly, though, it’s good for the kids, which we like.”
