Asthma is an obstructive lung disease characterized by episodes of bronchial hyperreactivity and constriction that occur in response to viral infections or other triggers such as allergens, irritants, and exercise. Appropriate clinical management-including regular checkups for asthma, comprehensive pharmacologic therapy, written plans, teaching children and caretakers to recognize early signs and symptoms of an attack, and avoiding allergens and other triggers-can play a role in controlling asthma and reducing the burden of asthma on patients, caretakers, family members, and society at large. Asthma self-management, the direct involvement of patients or their caregivers in strategies to control their disease, has become an important asset in asthma care.1 Asthma self-management reduces emergency department (ED) visits, hospitalizations, missed school days, unscheduled office visits, and asthma-related healthcare costs.2-11
The National Heart, Lung, and Blood Institute (NHLBI) recommend periodic assessment and monitoring of asthma by healthcare providers:12,13
* All patients with asthma should be taught by their healthcare provider how to manage their asthma.
* All patients with asthma should have regular checkups specifically to discuss their asthma with their healthcare provider.
* All patients with asthma should be given a written action plan by their healthcare provider based on signs and symptoms and peak expiratory flow, especially patients with moderate or severe persistent asthma and patients with a history of severe exacerbations.
* All patients with asthma should be prescribed proper pharmacologic therapy to prevent and control asthma symptoms, to reduce the frequency and severity of exacerbations, and to reverse airflow obstruction.
* All patients should be trained to use their inhalers or spacers* A spacer is a chamber fitted to a metered dose inhaler to improve the delivery of the inhaled medication. properly to ensure the effectiveness of pharmacologic therapy, and physicians should monitor the technique.
* Patients and caretakers should be trained to recognize signs and symptoms of asthma, which may indicate inadequate asthma control and the need for additional therapy.
* Patients and caretakers should be trained to use peak flow meters properly.
* Patients and caretakers should be taught about allergens and irritants that can trigger or make their asthma worse.
The Georgia Childhood Asthma Survey was conducted to assess asthma management practices in Georgia, to identify areas in which improvements may be needed, and to guide activities of organizations and agencies in Georgia working to reduce the burden of asthma in children.
Methods
Study design
We conducted a random-digit-dialed telephone survey of households in Georgia from October 2002 through February 2003. Households without children were ineligible. For households with one or more children aged 17 years or younger, interviewers asked to speak to the primary caretaker. For all children in the household, caretakers were asked about asthma and medication use for asthma or breathing problems. For those reporting asthma or medication use, further questions about use of healthcare services, activity restriction, education by providers, tobacco smoke exposure, and asthma triggers were asked. Many questions were identical to those on the previous Georgia Childhood Asthma Survey conducted in 2000.14 New questions concerning management training and practices were patterned after the National Asthma Survey.15
Dispositions of telephone calls
Of the 26,963 telephone numbers called, 6,648 (25%) calls were made to eligible households (containing a child aged 17 years or younger). There were 2,699 calls (10%) of unknown eligibility and 17,616 calls (65%) to ineligible numbers. Among the 6,648 households with children, 2,121 households (32%) with 3,896 children completed the survey. The American Association for Public Opinion Research cooperation rate [COOP3 = interviews/(interviews + partials + refusals)] for eligible households was 44 percent.16 Most households (87%) in our survey had one telephone line. In Georgia, 8 percent of households do not have a telephone line.17
Case definitions
Asthma was defined according to the Council of State Territorial Epidemiologist case classification of probable asthma: the child was ever diagnosed with asthma, and (1) still has asthma, (2) takes prescription medicine for asthma, or (3) had an asthma attack/wheeze episode in the past 12 months.18
Household exposure to tobacco smoke was defined as a "yes" answer to either of the two questions about smoking: (1) "During the past week, did you or anyone living in your household smoke cigarettes, cigars, or pipes inside the house?" or (2) "During the past week, did you or anyone living in your household smoke cigarettes, cigars or pipes away from the house, such as outside, in the car, or at another building?"
Use of quick-relief medicine was defined as a "yes" answer to the question: "Does the child have prescription medicine that [he/she] uses for quick-relief or rescue medicine when [he/she] is having asthma problems or an asthma attack?" Quick-relief medicine was defined for the respondent as a medicine that is used to give fast relief from asthma symptoms. Respondents were also told that the quick-relief medicine may be used during an asthma episode or attack, or when a person is feeling "tight" or is coughing or wheezing or having other asthma symptoms.
Use of long-term control medication was defined as a "yes" answer to the question: "Does the child take prescription medicine to control asthma over the long term?" Long-term control medicine was defined for the respondent as a medication used to control asthma over the long term by reducing or preventing airway inflammation.
Statistical analysis
Household and caretaker data were weighted according to the number of telephone lines in the household. Child data were weighted according to the number of telephone lines in the household and to the 2000 Georgia Census population. To account for the complex survey design (eg, some caretakers had more than one child with asthma), data were analyzed at the household and child level using SUDAAN software. More detailed information concerning the methodology can be obtained from the description of the 2000 survey.14
Stratified analysis
To determine whether management practices were associated with demographic characteristics of the children with asthma or estimates of severity of asthma, stratified analyses were performed using SUDAAN software. The management practices examined included presence of written action plan (yes, no), regular checkup (yes, no), training in recognition of signs and symptoms (yes, no), training in trigger recognition (yes, no), and training in asthma management (yes, no). The demographic variables included age group (0-4, 5-12, and 13-17 years), race-sex category (White male, White female, Black male, Black female), household annual income (in thousands, <$20, $20-<$35, $35-<$50, $50-<$75, >=$75), and caretaker level of education (less than high school, high school, more than high school). The estimates of asthma severity included attack in past 12 months (yes, no), ED visit in past 12 months (yes, no), hospitalization in past 12 months (yes, no), and medication use (control medication prescribed, only quick-relief medication prescribed, no medication prescribed).
Results
Survey respondents
Most primary caretakers reported their race as White (70%) or Black (23%). Seven percent of caretakers reported that their highest level of education was less than high school, 55 percent reported high school or some college, and 37 percent reported they were a college graduate or higher; 1 percent refused to disclose their level of education. Ten percent reported that their household income was less than $20,000, 20 percent reported $20,000 to less than $35,000, 15 percent reported $35,000 to less than $50,000, 18 percent reported $50,000 to less than $75,000, and 25 percent reported $75,000 or more; 13 percent refused to disclose their income. Of the participating households, 95 percent had healthcare coverage for the children, 65 percent of which was through an employer and 26 percent through a government program such as Medicaid. Most respondents (96%) reported that they had one place they usually went for medical care for the children, which in most cases (81%) was a doctor's office or a health maintenance organization.
Children with asthma
Of the 3,896 children from 2,121 households in the survey, 372 children from 333 households had asthma. The weighted prevalence estimates indicated that approximately 10 percent (95% CI 9%-11%) of children aged 17 years or younger in Georgia had asthma in 2002-2003, similar to the prevalence of 11 percent (95% CI 9%-12%) in 2000. Asthma was more common among boys (11%; 95% CI 10%-13%) than among girls (8%; 95% CI 7%-10%). Within race-sex subgroups, the prevalence was highest in Black males (13%; 95% CI 10%-17%). Prevalence in White males was 11 percent (95% CI 9%-12%), in Black females was 10 percent (95% CI 7%-13%), and in White females was 8% percent (95% CI 6%-9%). The prevalence of asthma in children aged 4 years or younger was 9 percent (95% CI 7%-10%), in children aged 5-12 years was 11 percent (95% CI 9%-13%), and in children aged 13-17 years was 8 percent (95% CI 7%-10%). Asthma prevalence was higher in children living in households with incomes less than $20,000 (15%; 95% CI 11%-19%) than in children living in households with incomes of $75,000 or more (8%; 95% CI 6%-10%). The prevalence of asthma was 12 percent (95% CI 8%-17%) in children whose primary caretaker had less than a high school education, 10 percent (95% CI 8%-11%) in those whose primary caretakers had completed high school, and 9 percent (95% CI 7%-11%) in those whose primary caretaker had completed college.
Asthma management practices
Among children with asthma, 84 percent (95% CI 79%-88%) used prescription medicine, including 36 percent (95% CI 30%-42%) with prescriptions for control and quick-relief medicine, 14 percent (95% CI 10%-18%) with a prescription only for control medicine, and 34 percent (95% CI 28%-39%) with a prescription only for quick-relief medicine (Figure 1). The NHLBI guidelines state that the use of two or more quick-relief treatments per week or about two prescriptions per year may indicate a need for control medicine to reduce inflammation and prevent exacerbations.12 Among children with asthma who had a prescription only for quick-relief medicine, 55 percent (95% CI 46%-65%), or 19 percent (95% CI 13%-21%) of all children with asthma, used two or more prescriptions per year (Figure 1).
In Georgia, 30 percent (95% CI 25%-36%, approximately 64,000) of children with asthma did not have regular asthma checkups and 66 percent (95% CI 60%-72%, approximately 137,000) did not have a written plan to help them manage their asthma (Table 1). The prevalence estimates for other indicators of care ranged from 30 percent (95% CI 24%-37%) for no training on use of spacers to 6 percent (95% CI 2%-9%) for no training on use of inhalers.
Children who visited an ED within the past 12 months were more likely than children who had not visited the ED to have regular checkups for their asthma (Table 2). Children whose caretakers were high school graduates were more likely than children whose parents were not high school graduates to have a written management plan. Children who had a prescription for control medication were more likely to have regular checkups and a written management plan than children who had prescription for quick-relief medication only or no medication prescribed. The prevalence of training on how to manage one's asthma, recognize the signs and symptoms of an attack, or things that can trigger an attack did not differ by demographic characteristics or indicators of severity.
Most caretakers (87%; 95% CI 84%-91%) of children with asthma said they were aware of exposures that trigger asthma attacks in their child. As reported by caretakers, the prevalence of known triggers ranged from 85 percent (95% CI 81%-89%) for viruses to 10 percent (95% CI 6%-13%) for cockroaches (Figure 2).
In Georgia, environmental tobacco smoke was the third most common asthma trigger reported by caregivers, affecting more than two thirds of children with asthma. Children with asthma for whom tobacco smoke was a reported trigger were just as likely to be exposed to tobacco smoke at home (35%; 95% CI 28%-42%) as were children with asthma for whom tobacco smoke was not reported as a trigger (32%; 95% CI 21%-44%) and children without asthma (31%; 95% CI 29%-34%).
Discussion
The NHLBI guidelines were developed to reduce asthma morbidity and mortality by improving disease management practices of healthcare providers and patients.12,13 The 2002-2003 Georgia Childhood Asthma Survey provides statewide estimates of management practices for children with asthma. These estimates can guide program efforts to reduce the burden of asthma and can also serve as a baseline for evaluation of statewide progress.
We are not aware of other population-based studies of asthma management. Most of our findings, however, are similar to findings from clinic-based and intervention studies. For example, in Georgia, 66 percent of children with asthma had no written action plan compared with 71 percent of children admitted to the ED at the Children's Hospital of Philadelphia.19 In Georgia, 13 percent of caretakers were unaware of their children's asthma triggers compared with 15 percent reported in the National Cooperative Inner-City Asthma Study.20 In Georgia, 35 percent of children with asthma were exposed to tobacco smoke at home compared with 32 percent in inner-city home management and primary care practices in Bronx, NY.21
We do not have a good measure of asthma severity; therefore, we cannot directly compare our findings with those from several studies, indicating that more than 50 percent of children with severe asthma do not have long-term control medications as recommended.19-24 Our survey indicates, however, that 19 percent of children with asthma in Georgia have prescriptions for quick-relief medications only and fill more than two prescriptions per year. We presume that these children have severe asthma and should be receiving control medications.
In our survey, few demographic characteristics of caretakers or indicators of asthma severity of the children were significantly associated with the prevalence of asthma management. The few differences noted suggest that children with more severe disease are more likely to have regular checkups and written management plans. If services are consciously or unconsciously rationed, it is appropriate that children with more severe disease should receive these services. On the other hand, children in households with less well-educated caretakers are less likely to have a written management plan, suggesting that special efforts may be needed to transmit information to those families.
This survey has limitations. The caretakers reported all information, and may not have known or remembered the most accurate responses to all questions. This was a telephone survey and respondents remained anonymous; therefore, information could not be verified. Caretakers may not have remembered training or written action plans that they received, and a survey of providers may give different results. Furthermore, we inquired only whether various types of training had been received; we did not attempt to assess the quantity or accuracy of information retained from the training or by other means.
Our data suggest priority areas for provider and patient education efforts. First, 66 percent of children with asthma in Georgia do not have a written action plan. Second, 19 percent of children have prescriptions only for quick-relief medications and fill two or more prescriptions per year, suggesting that they should also be taking control medications. Third, 35 percent of children with asthma for whom tobacco smoke is a known trigger are exposed to tobacco smoke in the home. Other areas in which improvements could be made include regular checkups for asthma, training on recognizing the signs and symptoms of an attack, and training on trigger recognition. Improvements in these areas in Georgia, and most likely elsewhere, would reduce the burden of asthma on the individuals with the disease, caretakers, family members, and society at large.
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