Barriers in Asthma Care for Children in Primary Care
Barriers in Asthma Care for Children in Primary Care
Introduction There are many barriers to treating children with asthma. Barriers limit access with subsequent disturbances in quality outcomes. This study explored the difference in quality outcomes, utilization outcomes, parental knowledge, and barriers to care between children who had controlled versus uncontrolled asthma.
Method Data were analyzed between two intact groups of caregivers of children with asthma. Caregivers in both groups completed the Asthma Knowledge Test and the Asthma Barrier Questionnaire.
Results Caregivers (n = 62) were primarily mothers (85.5%). Children with uncontrolled asthma missed 33.3% more days of school. The caregivers of the children with controlled asthma answered more questions on the Asthma Knowledge Test correctly and had a lower score on the Asthma Barrier Questionnaire.
Discussion Asthma control is essential. By identifying barriers to care, health care providers can build an action care plan to individualize each patient's needs.
Asthma is a disease that affects millions of children every day. Asthma is often defined as a chronic inflammatory disease of the airways "that can be life threatening" (Rance, 2008, p. 256). It is a complex disease with a variety of recurring symptoms that include bronchial hyper-responsiveness, airflow obstruction, and an underlying inflammatory process (National Heart, Lung, and Blood Institute [NHLBI], 2007). Since 1999, children between the ages of 5 to 17 years have had the highest incidence of asthma, causing limitations of activity and representing one of the most common chronic illnesses of childhood (NHLBI, 2007).
Asthma is the most common chronic disease in childhood (World Health Organization, 2013). Almost 7 million children (10% of the U.S. population) younger than 18 years have asthma (Viswanathan et al., 2011). Asthma accounts for half a million hospitalizations each year and is the leading diagnosis for children 1 to 17 years of age (Bloom, Cohen, & Freeman, 2009). African American and Puerto Rican children have higher hospitalization and mortality rates associated with asthma than do children of other races or ethnic backgrounds (Bloom et al., 2009). African American children have a 60% increase in prevalence rate, a 250% increase in hospitalization rate, a 260% increase in emergency department (ED) visit rate, and a 500% increase in death rate compared with White children (Centers for Disease Control and Prevention [CDC], 2014). Inner-city living conditions typically are crowded and less sanitary, which creates greater exposure to allergens and an increased risk of developing asthma (Warman, Johnson Silver, & Wood, 2009).
Asthma directly costs the United States $19.7 billion each year, with the largest single expenditure of $6.2 billion annually attributed to prescription medication cost (American Lung Association [ALA], 2012). Asthma is the third leading cause of hospitalizations in children younger than 15 years (ALA, 2012) and is responsible for 12.8 million lost school days and 14.5 million lost work days each year (ALA, 2012).
Asthma is a major childhood disability and places a significant burden on children and their families. Appropriate asthma management enables children and their families to enjoy quality of life. However, asthma is underdiagnosed and undertreated, which leads to a burden for children and families by restricting activities and mobility. Availability of treatment plans and disease management guidelines have failed to reduce the incidence of uncontrolled or inadequately controlled asthma within the pediatric population (Chapman, 2008). Uncontrolled asthma can lead to increased morbidity and mortality, impaired quality of life, and increased absenteeism from work and school (ALA, 2012). Seid (2008)) demonstrated an inverse relationship between parental knowledge related to asthma self-care and the incidence of uncontrolled asthma. Additionally, there are many potential barriers in treating children with asthma. Barriers limit access with subsequent disturbances in quality outcomes (Bryant-Stephens & Li, 2004.) It is unknown which of the following barriers is the leading barrier: family resources, access to health care services, cost, or following the proper NHLBI guidelines for care.
In 2007, the National Asthma Education Prevention Plan (NAEPP) issued the third Expert Panel Report (EPR-3), a set of evidence-based clinical practice guidelines that incorporated the best practices for people with asthma to control their disease and provide guidance in asthma management for clinicians (NHLBI, 2007). The overarching goals of the NAEPP guidelines are to (a) improve the quality of care and asthma outcomes, (b) close the disparity gap for quality asthma care, (c) enhance early disease recognition, and (d) promote principles of patient-centered care (NHLBI, 2007).
After a survey was completed by 202 inner-city primary care providers, Wisnivesky and colleagues (2008)) found that adherence to the NAEPP guidelines was 62% for inhaled corticosteroid (ICS) use, 9% for asthma action plan use, and 10% for allergy testing. The most common adherence barrier for health care providers was a lack of outcome expectancy and poor provider self-efficacy (Wisnivesky et al., 2008).
The EPR-3 recommended that patients be encouraged to use self-assessment tools (NHLBI, 2007). Assessing asthma control can help the provider evaluate both current status and identify patients at risk for future health impairment. The Asthma Control Test (ACT) is a validated instrument that categorizes the degree of disease control (NHLBI, 2007). The ACT is a five-item questionnaire, administered in the provider's office, that evaluates patient-report shortness of breath, asthma control, use of rescue medication, productivity at school, and nighttime awakenings due to asthma symptoms (Nathan et al., 2004). The childhood asthma control test (C-ACT) is used for children ages 4 to 11 years (NHLBI, 2007). The C-ACT has seven questions (three are completed by the child's parent and four are completed by the child and parent together) that produce a score from 0 to 27. The NAEPP uses the ACT score to categorize degree of disease control. A score of 20 or more indicates well-controlled asthma; a score of 16 through 19 indicates not well-controlled asthma; and a score of 15 or lower indicates poorly controlled asthma (NHLBI, 2007). Findings show if the patient has a score lower than 20 on the ACT or C-ACT, this score indicates poor control, and if there is a correlation with a low forced expiratory volume in the first second (FEV1), a change may be needed in the patient's therapy (Rance, 2011).
The Asthma Knowledge Quiz was used in a community education program for parents in the inner city of Philadelphia. The Asthma Knowledge Quiz is a 16-item multiple choice test of the participants' content knowledge about asthma management (Bryant-Stevens & Li, 2004). It includes four main topics: asthma symptoms, triggers, prevention, and appropriate use of devices and medications (Bryant-Stevens & Li, 2004). A study validating the Asthma Knowledge Quiz demonstrated the correlation between the parents with high and low knowledge level and the level of disease of the child. A low score on the Asthma Knowledge Quiz yielded a child with uncontrolled asthma (Rodriquez Martinez & Sossa, 2005).
Despite the best effort of health care providers, children with asthma are especially vulnerable to barriers. The role of barriers such as pragmatics (e.g., transportation, taking time off work, and office hours), health knowledge and beliefs, and negative expectations of care (Seid, Sobo, Gelhard, & Vami, 2004) have made their marks in health care. In one study of inner-city children with asthma, parents reported a long wait, insurance, rude staff, and inability to pay for medications as barriers in optimal asthma care (Seid et al., 2004). Primary care providers serve as the "gatekeepers" in eliminating these barriers for their patients. Primary care providers need to work together with the patient to help improve quality outcomes, which can only be done through open communication. A recent study indicated that poor outcomes are often due to a cascade of factors that include patient health literacy, medication beliefs, patient-provider communication, and health care access (Canino, McQuaid, & Rand, 2009). Asthma cannot be controlled effectively unless patients have affordable access to a full range of services and quality of care. The Institute of Medicine draws an important distinction between differences in treatment that result from variations in need and preferences for health care and those that result from systematic variables within the health care system or discrimination due to health care or any other barrier the patient may face (Stewart et al., 2010).
This project evaluated the impact of asthma control on quality outcomes, utilization outcomes, parental knowledge, and barriers to care. With health care reform, most primary care sites are now becoming medical homes for patients. Primary care providers are being asked to look at the health care plans of the patient and find the best medications for the child. The question should be the opposite. Medical offices should look at the patient and family as a unit and see what medications will work best for them. Most of the empirical studies in current published research have been in the inner cities. In this study, the researchers explored care in a pediatric primary care setting. A caregiver needs to address many factors and levels as a result of the complexity of the family. Not every patient is the cookie-cutter patient. Each one is different, with a different set of challenges. The provider will not know which obstacles the patient and family face until the question is asked. Currently a variety of tools are used to evaluate asthma symptoms. This study helped show the importance of using tools in every patient with asthma.
All caregivers need to be given the correct amount of knowledge to teach them about the disease state of their child. Educating the patient and caregiver will help them know the correct medications to give at the vital time of an acute illness. The tools used in this study showed that it does make a difference in the outcome of the patients' care. If the caregiver does not understand how to deliver the care and has barriers to the care, the patient is at risk for poor asthma care. The Institute of Medicine indicated that the ideal care is the equal care for each patient. The patient is already vulnerable because of the disease status; he or she should not be vulnerable as a result of provider negligence. As health care providers, advanced practice nurses (APNs) are obligated to reach for those goals.
During this study, the APN explored differences in parental knowledge and perceived barriers between parents with children diagnosed with uncontrolled or controlled asthma. The relationship between the parental knowledge asthma statuses was explored. Children and families depend on APNs for guidance as they navigate the complexity of managing the chronicity of this disease. With a good understanding of family dynamics, APNs can assist families in controlling barriers to asthma care and can reduce the incidence of uncontrolled asthma. APNs should be cognizant of the needs of the patients because each patient is unique. Each visit will be different. Each patient will be different. Open communication with children and their families may provide opportunities to identify barriers to care early in the disease process and improve patient outcomes.
The purpose of this project was to explore differences in quality outcomes, utilization outcomes, parental knowledge, and barriers to care between children with controlled asthma and uncontrolled asthma. Quality outcomes included missed school days and missed work days for caregivers. Utilization outcomes included albuterol use, ED visits, and inpatient hospital admissions. Parental knowledge included information related to asthma self-care. The study used two intact groups of parents/caregivers with children from ages 4 to 12 years who had asthma (controlled and uncontrolled). Parents in both groups completed the Asthma Knowledge Test (Appendix A) and the Asthma Barrier Questionnaire (Appendix B) during a routine primary care visit and ranked their top barriers to receiving asthma care. Completing both questionnaires took the caregivers on average 5 minutes.
Abstract and Introduction
Abstract
Introduction There are many barriers to treating children with asthma. Barriers limit access with subsequent disturbances in quality outcomes. This study explored the difference in quality outcomes, utilization outcomes, parental knowledge, and barriers to care between children who had controlled versus uncontrolled asthma.
Method Data were analyzed between two intact groups of caregivers of children with asthma. Caregivers in both groups completed the Asthma Knowledge Test and the Asthma Barrier Questionnaire.
Results Caregivers (n = 62) were primarily mothers (85.5%). Children with uncontrolled asthma missed 33.3% more days of school. The caregivers of the children with controlled asthma answered more questions on the Asthma Knowledge Test correctly and had a lower score on the Asthma Barrier Questionnaire.
Discussion Asthma control is essential. By identifying barriers to care, health care providers can build an action care plan to individualize each patient's needs.
Introduction
Asthma is a disease that affects millions of children every day. Asthma is often defined as a chronic inflammatory disease of the airways "that can be life threatening" (Rance, 2008, p. 256). It is a complex disease with a variety of recurring symptoms that include bronchial hyper-responsiveness, airflow obstruction, and an underlying inflammatory process (National Heart, Lung, and Blood Institute [NHLBI], 2007). Since 1999, children between the ages of 5 to 17 years have had the highest incidence of asthma, causing limitations of activity and representing one of the most common chronic illnesses of childhood (NHLBI, 2007).
Asthma is the most common chronic disease in childhood (World Health Organization, 2013). Almost 7 million children (10% of the U.S. population) younger than 18 years have asthma (Viswanathan et al., 2011). Asthma accounts for half a million hospitalizations each year and is the leading diagnosis for children 1 to 17 years of age (Bloom, Cohen, & Freeman, 2009). African American and Puerto Rican children have higher hospitalization and mortality rates associated with asthma than do children of other races or ethnic backgrounds (Bloom et al., 2009). African American children have a 60% increase in prevalence rate, a 250% increase in hospitalization rate, a 260% increase in emergency department (ED) visit rate, and a 500% increase in death rate compared with White children (Centers for Disease Control and Prevention [CDC], 2014). Inner-city living conditions typically are crowded and less sanitary, which creates greater exposure to allergens and an increased risk of developing asthma (Warman, Johnson Silver, & Wood, 2009).
Asthma directly costs the United States $19.7 billion each year, with the largest single expenditure of $6.2 billion annually attributed to prescription medication cost (American Lung Association [ALA], 2012). Asthma is the third leading cause of hospitalizations in children younger than 15 years (ALA, 2012) and is responsible for 12.8 million lost school days and 14.5 million lost work days each year (ALA, 2012).
Asthma is a major childhood disability and places a significant burden on children and their families. Appropriate asthma management enables children and their families to enjoy quality of life. However, asthma is underdiagnosed and undertreated, which leads to a burden for children and families by restricting activities and mobility. Availability of treatment plans and disease management guidelines have failed to reduce the incidence of uncontrolled or inadequately controlled asthma within the pediatric population (Chapman, 2008). Uncontrolled asthma can lead to increased morbidity and mortality, impaired quality of life, and increased absenteeism from work and school (ALA, 2012). Seid (2008)) demonstrated an inverse relationship between parental knowledge related to asthma self-care and the incidence of uncontrolled asthma. Additionally, there are many potential barriers in treating children with asthma. Barriers limit access with subsequent disturbances in quality outcomes (Bryant-Stephens & Li, 2004.) It is unknown which of the following barriers is the leading barrier: family resources, access to health care services, cost, or following the proper NHLBI guidelines for care.
In 2007, the National Asthma Education Prevention Plan (NAEPP) issued the third Expert Panel Report (EPR-3), a set of evidence-based clinical practice guidelines that incorporated the best practices for people with asthma to control their disease and provide guidance in asthma management for clinicians (NHLBI, 2007). The overarching goals of the NAEPP guidelines are to (a) improve the quality of care and asthma outcomes, (b) close the disparity gap for quality asthma care, (c) enhance early disease recognition, and (d) promote principles of patient-centered care (NHLBI, 2007).
After a survey was completed by 202 inner-city primary care providers, Wisnivesky and colleagues (2008)) found that adherence to the NAEPP guidelines was 62% for inhaled corticosteroid (ICS) use, 9% for asthma action plan use, and 10% for allergy testing. The most common adherence barrier for health care providers was a lack of outcome expectancy and poor provider self-efficacy (Wisnivesky et al., 2008).
The EPR-3 recommended that patients be encouraged to use self-assessment tools (NHLBI, 2007). Assessing asthma control can help the provider evaluate both current status and identify patients at risk for future health impairment. The Asthma Control Test (ACT) is a validated instrument that categorizes the degree of disease control (NHLBI, 2007). The ACT is a five-item questionnaire, administered in the provider's office, that evaluates patient-report shortness of breath, asthma control, use of rescue medication, productivity at school, and nighttime awakenings due to asthma symptoms (Nathan et al., 2004). The childhood asthma control test (C-ACT) is used for children ages 4 to 11 years (NHLBI, 2007). The C-ACT has seven questions (three are completed by the child's parent and four are completed by the child and parent together) that produce a score from 0 to 27. The NAEPP uses the ACT score to categorize degree of disease control. A score of 20 or more indicates well-controlled asthma; a score of 16 through 19 indicates not well-controlled asthma; and a score of 15 or lower indicates poorly controlled asthma (NHLBI, 2007). Findings show if the patient has a score lower than 20 on the ACT or C-ACT, this score indicates poor control, and if there is a correlation with a low forced expiratory volume in the first second (FEV1), a change may be needed in the patient's therapy (Rance, 2011).
The Asthma Knowledge Quiz was used in a community education program for parents in the inner city of Philadelphia. The Asthma Knowledge Quiz is a 16-item multiple choice test of the participants' content knowledge about asthma management (Bryant-Stevens & Li, 2004). It includes four main topics: asthma symptoms, triggers, prevention, and appropriate use of devices and medications (Bryant-Stevens & Li, 2004). A study validating the Asthma Knowledge Quiz demonstrated the correlation between the parents with high and low knowledge level and the level of disease of the child. A low score on the Asthma Knowledge Quiz yielded a child with uncontrolled asthma (Rodriquez Martinez & Sossa, 2005).
Despite the best effort of health care providers, children with asthma are especially vulnerable to barriers. The role of barriers such as pragmatics (e.g., transportation, taking time off work, and office hours), health knowledge and beliefs, and negative expectations of care (Seid, Sobo, Gelhard, & Vami, 2004) have made their marks in health care. In one study of inner-city children with asthma, parents reported a long wait, insurance, rude staff, and inability to pay for medications as barriers in optimal asthma care (Seid et al., 2004). Primary care providers serve as the "gatekeepers" in eliminating these barriers for their patients. Primary care providers need to work together with the patient to help improve quality outcomes, which can only be done through open communication. A recent study indicated that poor outcomes are often due to a cascade of factors that include patient health literacy, medication beliefs, patient-provider communication, and health care access (Canino, McQuaid, & Rand, 2009). Asthma cannot be controlled effectively unless patients have affordable access to a full range of services and quality of care. The Institute of Medicine draws an important distinction between differences in treatment that result from variations in need and preferences for health care and those that result from systematic variables within the health care system or discrimination due to health care or any other barrier the patient may face (Stewart et al., 2010).
This project evaluated the impact of asthma control on quality outcomes, utilization outcomes, parental knowledge, and barriers to care. With health care reform, most primary care sites are now becoming medical homes for patients. Primary care providers are being asked to look at the health care plans of the patient and find the best medications for the child. The question should be the opposite. Medical offices should look at the patient and family as a unit and see what medications will work best for them. Most of the empirical studies in current published research have been in the inner cities. In this study, the researchers explored care in a pediatric primary care setting. A caregiver needs to address many factors and levels as a result of the complexity of the family. Not every patient is the cookie-cutter patient. Each one is different, with a different set of challenges. The provider will not know which obstacles the patient and family face until the question is asked. Currently a variety of tools are used to evaluate asthma symptoms. This study helped show the importance of using tools in every patient with asthma.
All caregivers need to be given the correct amount of knowledge to teach them about the disease state of their child. Educating the patient and caregiver will help them know the correct medications to give at the vital time of an acute illness. The tools used in this study showed that it does make a difference in the outcome of the patients' care. If the caregiver does not understand how to deliver the care and has barriers to the care, the patient is at risk for poor asthma care. The Institute of Medicine indicated that the ideal care is the equal care for each patient. The patient is already vulnerable because of the disease status; he or she should not be vulnerable as a result of provider negligence. As health care providers, advanced practice nurses (APNs) are obligated to reach for those goals.
During this study, the APN explored differences in parental knowledge and perceived barriers between parents with children diagnosed with uncontrolled or controlled asthma. The relationship between the parental knowledge asthma statuses was explored. Children and families depend on APNs for guidance as they navigate the complexity of managing the chronicity of this disease. With a good understanding of family dynamics, APNs can assist families in controlling barriers to asthma care and can reduce the incidence of uncontrolled asthma. APNs should be cognizant of the needs of the patients because each patient is unique. Each visit will be different. Each patient will be different. Open communication with children and their families may provide opportunities to identify barriers to care early in the disease process and improve patient outcomes.
The purpose of this project was to explore differences in quality outcomes, utilization outcomes, parental knowledge, and barriers to care between children with controlled asthma and uncontrolled asthma. Quality outcomes included missed school days and missed work days for caregivers. Utilization outcomes included albuterol use, ED visits, and inpatient hospital admissions. Parental knowledge included information related to asthma self-care. The study used two intact groups of parents/caregivers with children from ages 4 to 12 years who had asthma (controlled and uncontrolled). Parents in both groups completed the Asthma Knowledge Test (Appendix A) and the Asthma Barrier Questionnaire (Appendix B) during a routine primary care visit and ranked their top barriers to receiving asthma care. Completing both questionnaires took the caregivers on average 5 minutes.
