Asthma

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Asthma is a chronic inflammatory disease of the airways that affects about 9 percent of all U.S. children. An estimated 400,000 of these children have moderate to severe asthma. It is the most common chronic disease of childhood, and about one-fourth of those affected are less than 5 years of age. In 2006, there were 133,732 hospital stays for asthma among children aged 18 or younger. Reducing asthma-related illness continues to be a major objective for the U.S. Public Health Service.

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Children with asthma are prescribed more medications when health plans notify their doctors after a serious episode.

When managed care programs inform health care providers that a child has had a serious asthma episode, providers tend to take action by writing prescriptions for asthma drugs to prevent future episodes, according to this study. The researchers surveyed 18 Medicaid managed care plans that served 4,498 children with moderate to severe asthma in Tennessee and Washington. Of the 18 plans, 15 provided written feedback to providers on asthma care; 11 plans alerted the provider when a child visited the ED or was hospitalized. Cooper, Ray, Arbogast, et al., J Pediatr 152(4):481-488, 2008 (AHRQ Grants HS13076, HS10384).

Changing the definition of high-risk asthma may help identify those who will need the most care.

Researchers developed a revised definition of high-risk asthma to better identify youngsters who potentially will need more care for their asthma. They compared the utility of their revised definition with the more commonly used definition from the Healthcare Effectiveness Data and Information Set and found that the revised definition more closely predicted those youngsters aged 11 to 17 who needed more hospitalizations, ED visits, and oral steroid prescriptions and had higher asthma-related medical costs over a 2-year period. Bennett, Lozano, Richardson, et al., Am J Manag Care 14(7):450-456, 2008 (AHRQ Grant HS13853).

Children with asthma who get the flu are more likely than other children to wind up in the hospital.

Researchers looked at influenza hospitalizations for children aged 6 to 59 months in three counties from October 2000 to September 2004. They found that children with asthma had about four times as many hospitalizations and twice as many outpatient visits when they came down with the flu as children without asthma who got the flu. Although immunization for influenza is recommended for children with asthma, just 27 percent of parents of a child with asthma ensured that their child received the flu vaccine. In contrast, 12 to 15 percent of healthy children treated for flu had been immunized. Miller, Griffin, Edwards, et al., Pediatrics 12(1):1-8, 2008 (AHRQ Grant HS13833).

Data reported by caregivers and administrative data don't always agree on health care use by children with asthma.

Researchers compared asthma-related hospitalizations, ED visits, use of oral steroids, and outpatient visits as reported by caregiver and administrative data over 2 years. They found disagreement between the two sources of 6.1 percent for hospitalizations, 20.2 percent for ED visits, 34.3 percent for steroid use, and 83.6 percent for outpatient visits. These differences could have a negative effect on perceived quality of care and physician compensation, particularly for physicians operating in a pay-for-performance system. Lee, Fuhlbrigge, Sullivan, et al., J Asthma 44:189-194, 2007 (AHRQ Grant HS08368).

Black children with asthma are more likely than white children to be inadequately treated with controller medications.

Researchers analyzed 2002 West Virginia Medicaid claims for 300 African-American children to determine demographic and health services use factors that predict inhaled corticosteroid (ICS) use. Approximately 38 percent of the children had a prescription claim for an ICS. Children whose prescription use indicated more severe asthma were more likely to have used an ICS. There was a direct relationship between the number of claims for short-acting medications and oral corticosteroids and the likelihood of a child having a claim for an ICS. The researchers note that barriers to adequate pharmacotherapy for black children with asthma should be considered during care. Smith and Pawar, J Asthma 44(5):357-363, 2007 (AHRQ Grant HS15390).

Hospitalization rates are falling for children with asthma.

An analysis of data from AHRQ's 2006 Kids' Inpatient Database show that hospitalizations of children principally for asthma fell by almost 60,000 admissions between 1997 and 2006. However, the number of children admitted to the hospital for other conditions who also had asthma rose nearly 70,000 during the same period. Children from poorer communities, poor children with asthma as a coexisting illness, and infants 0-12 months with asthma were much more likely to be admitted to the hospital.

Go to Hospital Stays Related to Asthma for Children, 2006, HCUP Statistical Brief 58; online at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb58.jsp (Intramural).

Program improves asthma care in children.

Researchers examined asthma care and use of care among 490 children enrolled in an asthma disease management program—Easy Breathing II—and found that children with persistent asthma had a 47 percent increase in use of controller medications, a 56 percent reduction in asthma-related outpatient visits, and a 91 percent decrease in ER visits for treatment of asthma. After 5 years, 17 of the 20 private pediatric practices studied are still using Easy Breathing II. Cloutier, Wakefield, Sangeloty-Higgins, et al., Pediatrics 118(5):1880-1887, 2006 (AHRQ 11147). See also Joesch, Kim, Kieckhefer, et al., J Pediatr Health Care 20(6):374-383, 2006 (AHRQ Grant HS13110).

Modifications are needed to two algorithms commonly used to identify children with asthma.

These researchers applied Council of State and Territorial Epidemiologists (CSTE) and Health Plan Employer Data and Information Set (HEDIS) criteria to study 3,905 Medicaid-insured children and 1,458 non-Medicaid-insured children with a confirmed diagnosis of asthma or no asthma using a validated survey instrument. CSTE identified 61 percent of children with probable asthma; HEDIS identified 44 percent of children with persistent asthma. Using modified CSTE and HEDIS algorithms substantially increased sensitivity. The researchers conclude that studies using current CSTE and HEDIS algorithms underestimate asthma prevalence and overestimate asthma severity in children. Wakefield and Cloutier, Pediatric Pulmonol 41:962-971, 2006 (AHRQ Grant HS11147).

Parental use of a computer-based asthma kiosk in the emergency department elicits mixed results.

Researchers asked parents to use a computer-based kiosk in the hospital ED to enter their child's asthma symptoms, current medications, and unmet care needs. The asthma kiosk printed out a tailored plan of recommended asthma care based on the parental input. The intent was for parents to share the recommendations with their child's ED clinicians. So far, the kiosk has had a small and variable impact on asthma care quality. Physicians' limited use of kiosk-generated asthma care recommendations may explain this disappointing result. Porter, Forbes, Feldman, and Goldmann, Pediatrics 117(1), 2006; online at www.pediatrics.org (AHRQ Grant HS11660). See also Porter, Kohane, and Goldmann, JAMIA 12(3):299-305, 2005 (AHRQ Grant HS11660); Porter, Cai, Gribbons, et al., JAMIA 11:458-467, 2004 (AHRQ Grant K08 HS11660).

Enrollment in SCHIP can improve quality of care and access for children with asthma.

This study of more than 2,600 children with asthma in New York State found that after enrollment in the State Children's Health Insurance Program (SCHIP) quality of care improved for the children, and asthma-related attacks, medical visits, and hospitalizations declined. Also, the number of children lacking a usual source of care declined from 5 percent to 1 percent. Szilagy, Dick, Klein, et al., Pediatrics 117(2):486-496, 2006 (AHRQ grant HS10450).

Study uncovers higher rate of asthma among Puerto Rican children compared with other U.S. children.

Researchers analyzed 1997-2001 data on the prevalence of asthma diagnosis and asthma attacks in a sample of more than 46,500 U.S. children aged 2 to 17. Over one-fourth of Puerto Rican children in the study group were diagnosed with asthma at some point, compared with 16 percent of black children, 13 percent of white children, and 10 percent of Mexican children. Similarly, 12 percent of Puerto Rican children had suffered a recent asthma attack, compared with 7 percent of black children, 6 percent of white children, and 4 percent of Mexican children. Lara, Akinbami, Flores, and Morgenstern, Pediatrics 117(1):43-53, 2006 (AHRQ grant HS00008).

Interventions that improve pediatric asthma outcomes in clinical trials may not translate to the practice level.

Education for practice-based peer leaders and the presence of asthma nurse educators improved the use of asthma controller medications and reduced hospital visits for children with asthma who were enrolled in a randomized trial. However, when measured on all patients in the participating practices, these same interventions had no detectable impact on asthma medication use or asthma-related hospital and ER visits. Finkelstein, Lozano, Fuhlbrigge, et al., Health Services Res 40(6):1737-1757, 2005 (AHRQ Grant HS08368).

Having a usual source of care increases wellness visits among children with asthma.

Researchers analyzed data from the 1996-2000 Medical Expenditure Panel Survey (MEPS) to assess wellness visits, bronchodilator fills/refills, and ER visits of 1,726 children with asthma. Overall 95 percent of children had a usual source of care. Over the course of a year, one in ten children made at least one asthma-related visit to the ER, four in ten had at least one wellness visit, and half (50 percent) filled a rescue bronchodilator prescription. The researchers conclude that children who have a usual source of care are twice as likely as those who do not to have a wellness examination during the year. Kieckhefer, Greek, Joesch, et al., J Pediatr Health Care 19(5):285-292, 2005 (AHRQ Grant HS13110).

Primary care programs that include nurse case managers and physician peer leaders can reduce children's asthma symptoms.

According to this study, a primary care program that uses nurse case managers to educate children about their asthma and physician peer leaders to educate primary care practitioners about asthma treatment guidelines can reduce children's asthma symptoms. Children who were in the program had an average of two additional symptom-free weeks per year. The study involved 638 children aged 3 to 17 with mild to moderate persistent asthma. The annual costs of asthma care were $1,292 for intervention patients and $385 for patients who received usual asthma care. Sullivan, Lee, Blough, et al., Arch Pediatr Adolesc Med 159:428-434, 2005 (AHRQ grant HS08368). See also: Homer, Forbes, Horvitz, et al., Arch Pediatr Adolesc Med 159:464-460, 2005 (AHRQ Grant HS10411).

Ethnicity, environmental factors, and reduced pulmonary function can predict asthma severity in children.

Black or Puerto Rican ethnicity, sensitization to cockroach allergens, and spirometry tests showing reduced pulmonary function greatly increased the likelihood of severe asthma in children aged 4 to 18 who were enrolled in an asthma care program in Hartford, CT. This is the first study to show an association between asthma severity and both Puerto Rican ethnicity and decreased forced expiratory volume. Ramsey, Celedon, Sredl, et al., Pediatr Pulmonol 39:268-275, 2005 (AHRQ grant HS11147).

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Chronic Illness

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Approximately 20 million children suffer from at least one chronic health condition. About 17 percent of U.S. children have some type of developmental disorder, and 21 percent have a diagnosable mental or addictive disorder with a least minimum impairment.

Of the 200 chronic conditions and disabilities that affect young people, AHRQ's current research focuses most predominantly on diabetes, cancer, cerebral palsy, respiratory problems, and traumatic brain injury. For a description of projects and findings on other chronic illnesses, go to the sections on asthma and mental health in this program brief.

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Most parents of hospitalized children with chronic illnesses rate their child's inpatient care as excellent or very good.

Researchers surveyed 12,562 parents of children receiving care at 39 hospitals from 1997 through 1999, to gather information about coordination of care, physical comfort, confidence and trust, care continuity, and other aspects of care. They found that even though 51 percent of parents reported that their child had a chronic health problem, most of the parents rated their child's inpatient care as excellent (47 percent) or very good (32 percent). Parents of children in fair or poor health with nonchronic conditions reported the lowest quality of care. Mack, Co, Goldmann, et al., Arch Pediatr Adolesc Med 161(9):828-834, 2007 (AHRQ Grant T32 HS00063).

Benefits of antibiotics to prevent children's recurrent urinary tract infections are unclear.

Children with vesicoureteral reflux (VUR; urine flows backwards from the bladder to the kidneys) usually take daily antibiotics to prevent recurrent urinary tract infections (UTIs), according to guidance from the American Academy of Pediatrics. However, recent clinical trials have not shown a protective effect of this approach, and there is concern about the potential for breeding antibiotic-resistant bacteria. These researchers studied children ages 6 and under in a network of 27 clinical settings in three States. Of the nearly 75,000 children studied, 611 had a first UTI, and 83 had a recurrent UTI during the study. Prophylactic use of antibiotics was not associated with decreased risk of recurrent UTI but was associated with increased risk of antibiotic resistance among children in this study. Conway, Cnaan, Zaoutis, et al., JAMA 298(2):179-186, 2007 (AHRQ Grant HS10399).

Treatment of children with Crohn's disease varies widely.

Clinicians vary in their care for children with Crohn's disease (CD)—a chronic inflammatory bowel disease—mostly because there are few clinical guidelines and many treatments. These variations in care can result in differences in health care costs, quality, and outcomes, according to these researchers. They reviewed data on drugs given to 311 children newly diagnosed with CD at 10 U.S. and Canadian gastroenterology centers from January 2002 to August 2005 and found that physicians used several types of drugs to reduce children's symptoms. The drugs that offer the most benefit (immunomodulators) also carry the greatest risk, which may explain the variation in treatment. Other drugs used included steroids, antibiotics, anti-inflammatory medications, and an antibody that reduces inflammation. Kappelman, Bousvaros, Hyams, et al., Inflamm Bowel Dis 13(7):890-895, 2007 (AHRQ Grant T32 HS00063).

Chronic care model does not improve safety practices among caregivers of young children in a primary care practice.

Researchers examined the effectiveness of a chronic care model (CCM) approach to injury prevention among caregivers of children aged 0-5 in primary care settings compared with standard anticipatory guidance. Six months later, there was no difference between the two groups in the number of medically attended injuries. Sangvai, Cipriani, Colborn, and Wald, Clin Pediatr 46(3):228-235, 2007 (AHRQ Grant HS13523).

A certain skin condition may identify young patients at risk for type 2 diabetes.

Children and young adults who develop a skin condition called acanthosis nigricans (AN) have double the risk of having type 2 diabetes as other children, even after controlling for diabetes risk factors, age, and body mass index. The presence of AN can alert physicians to high risk youngsters who may need diabetes counseling, note the researchers. They analyzed diabetes risk factors and prevalence of AN among children and adults aged 7 to 39 years, who were cared for at clinics in a Southwester primary care practice-based research network. Kong, Williams, Smith, et al., Ann Fam Med 5(3):202-208, 2007 (AHRQ Grant HS13496).

Young people with congenital heart disease are hospitalized less often as they get older.

Between 18 and 23 years of age, many young people with congenital heart disease (CHD) lose public or parental health insurance and will struggle to obtain comprehensive coverage because of their preexisting condition. During this transition period, twice as many CHD patients aged 21 to 23 years are admitted to the hospital via the emergency room compared with those 15 to 17 years of age. Perhaps because most specialists in CHD are located at children's hospitals, older patients end up diversifying to general adult cardiologists and hospitals that have less experience with CHD, which may affect their outcomes. Gurvitz, Inkelas, Lee, et al., J Am Coll Cardiol 49(8):875-882, 2007 (AHRQ Grant T32 HS00046).

Parents of children with cancer need better information about their child's long-term prognosis.

Researchers compared parental and physician expectations for the likelihood of a cure and functional outcomes for children with cancer. They found that the majority of parents (61 percent) were more optimistic than physicians about the likelihood of a cure. On the other hand, parents were more pessimistic than physicians about the impact of cancer treatment on physical and cognitive functioning. They conclude that physicians need to be specific about the probability of a cure, as well as the possibility of long-term cancer- and treatment-related limitations. Mack, Cook, Wolfe, et al., J Clin Oncol 25(11):1357-1362, 2007 (AHRQ Grant T32 HS00063).

Children with cerebral palsy who undergo surgery are at increased risk of complications and poor outcomes.

According to this study, 5,614 surgeries were performed in children with cerebral palsy in 1997 to manage the nutritional, gastrointestinal, and orthopedic complications of the disease. The most common surgeries performed were gastrostomy tube placement, soft tissue musculoskeletal procedures, anti-reflux surgery, spinal fusion, and bony hip surgery. Together, these five procedures accounted for nearly 50,000 hospital days and more than $150 million in hospital charges. Spine surgery resulted in the largest difference between children with and without CP in hospital length of stay, charges, mortality, and complication rates. Murphy, Hoff, Jorgensen, et al., Pediatric Rehabil 9(3):293-300, 2006 (AHRQ Grant HS11826).

Shortage of pediatric rheumatologists limits residency training in this area for general pediatricians.

Less than one-fifth of pediatricians feel adequately trained to diagnose and treat juvenile rheumatoid arthritis, and 42 percent of them refer these children to pediatric rheumatologists. However, there is a shortage of pediatric rheumatologists, limiting both specialized care for affected children and medical education. More than 40 percent of medical directors of 127 pediatric residency programs in the United States reported that they did not have a pediatric rheumatologist on site. Mayer, Brogan, and Sandborg, Arthritis Rheum 55(6):836-842, 2006 (AHRQ Grant HS13309).

Children with type 1 diabetes can safely use the continuous subcutaneous glucose monitoring system to monitor their blood glucose levels.

The accuracy and reliability of the continuous glucose monitoring system (CGMS) have been established in adults. According to this study involving 27 patients (18 intervention and 9 control patients), it is also safe for use by children with type 1 (insulin-dependent or juvenile) diabetes. The CGMS is a tiny device that is inserted just under the skin of the abdomen where it measures levels of blood glucose every 10 seconds and sends information every 5 minutes to a device worn on a belt or the waistband of a garment. Information is transmitted to the doctor's office every 3 days so the diabetes management plan can be adusted. Children in this study who used the CGMS had significantly lower blood glucose levels after 6 months than children in the control group. Lagarde, Barrows, Davenport, et al., Pediatr Diabetes 7:159-164, 2006 (AHRQ HS10397).

Long-term outpatient use of central venous catheters in children with bone infections often results in complications.

Children who are diagnosed with acute hematogenous osteomyelitis (AHO), bone infection, usually receive several days of IV antibiotic treatment in the hospital, followed by placement of a central venous catheter in a vein that leads directly to the heart for 4 to 6 weeks of IV antibiotic therapy at home. In this study, 41 percent of children who received more than 2 weeks of IV treatment at home had one or more central venous catheter-associated complications. Many of these complications were serious enough to warrant a visit to the emergency department or readmission to the hospital. Twenty-three percent of the children had a catheter-related malfunction or displacement, 11 percent had a catheter-associated bloodstream infection, and 5 percent had a local skin infection at the site of catheter insertion. Ruebner, Keren, Coffin, et al., Pediatrics 117(4):1210-1215, 2006 (AHRQ Grant HS10399).

Diabetes screening practices vary widely among pediatricians.

The American Diabetes Association (ADA) recommends screening of children at moderate or high risk of type 2 diabetes, but this study found that only one-fifth of clinicians follow the ADA recommendation. Screening practices varied widely among pediatricians responding to this survey. When presented with three hypothetical vignettes of pediatric patients with low, moderately high, and high risk for type 2 diabetes, 21 percent adhered to the ADA recommendations, 35 percent screened only children at high risk, and 39 percent screened children at all risk levels (low, moderate, and high). Rhodes, Finkelstein, Marshall, et al., Ambulatory Pediatr 6(2):110-114, 2006 (AHRQ Grant T32 HS00063).

Use of stimulants to treat ADHD has leveled off in recent years.

Stimulants, such as methylphenidate (Ritalin) and amphetamines, are commonly prescribed to treat children with attention deficit hyperactivity disorder (ADHD). Use of these medications increased four-fold from 1987 (0.6 percent) to 1996 (2.4 percent) among U.S. children aged 18 and younger, but this trend seems to have abated. According to this study, the prevalence in use of stimulants among children aged 18 or younger was 2.7 percent in 1997 and 2.9 percent in 2002, with no statistically significant change during these 6 years. Use was highest among children aged 6-12 (4.8 percent in 2002), compared with 3.2 percent among those aged 13-19, and 0.3 percent for children younger than age 6. Zuvekas, Vitiello, and Norquist, Am J Psychiatr 163:579-585, 2006 (AHRQ Publication No. 06-R063)*

Study reveals racial disparities in receipt of vision care among children with special health care needs.

Nearly 6 percent of U.S. children with special health care needs (CSHCN) do not receive needed eyeglasses or other vision care. Black, Latino, and multiracial CSHCN are two to three times as likely to have an unmet need for vision care as white CSHCN, according to this study. These disparities persisted after controlling for differences in health status and other child and family characteristics such as insurance and income. Special needs children whose usual care provider was a generalist physician, nurse practitioner, or physician assistant were more likely to have an unmet need for vision care than children who saw a pediatrician for usual care. Heslin, Casey, Shaheen, et al., Arch Ophthal 124:895-902, 2006 (AHRQ grant HS14022).

Making treatment decisions for children with cancer is difficult for physicians and families.

Pediatric cancer care usually involves difficult and emotionally troubling decisions for physicians and families. These researchers examined the decisionmaking process from the time a child is first diagnosed, during treatment, when there is a relapse, and when death is inevitable. Popular ethical theory holds that the family should make the decisions, but sometimes the physician takes the lead. Because cure is the ultimate goal, the physician is in a better position to assume decisional priority when a cure is possible or when there is one best medical choice. On the other hand, when there are two or more clinically reasonable choices, the family is better positioned to take the lead. Whitney, Ethier, Fruge, et al., J Clin Oncol 24(1):1690-1695, 2006 (AHRQ Grant HS11289).

Children living in public housing are at increased risk for chronic health problems.

Black and Hispanic children living in public housing are two to four times as likely as children in the general population to suffer from chronic physical and mental problems, according to this study. The top five chronic conditions reported by parents for one or more children in their households were: asthma (32 percent), vision problems (24 percent), ADHD (17 percent), dental problems (16 percent), and depression (8 percent). Bazargan, Calderon, Heslin, et al., Ethn Dis 15(suppl 5):3-9, 2005 (AHRQ Grant HS14022).

Children with diabetes who need surgery must be carefully managed to prevent serious complications.

Surgery can cause life-threatening complications for children who have diabetes, and they must be carefully managed prior to surgery to ensure their diabetes is under control. Elective surgery should be postponed until metabolic control is acceptable. These authors describe a surgery management protocol for managing pediatric patients with diabetes. Rhodes, Ferrari, and Wolfsdorf, Anesth Analg 101:986-999, 2005 (AHRQ Grant HS00063).

Low-dose insulin does not affect weight or development of children at risk for type 1 diabetes.

The researchers compared differences in weight change, body mass index (BMI), and physical development between two groups of children and adolescents aged 4 to 19 who had more than a 50 percent risk of developing type 1 diabetes within 5 years. One group (55 children) received injections of low-dose insulin twice daily and an annual intravenous insulin infusion. Children in the other group (n = 45) were closely monitored but did not receive either insulin or placebo. The researchers found no differences over 2 years between the two groups for changes in weight, height, BMI, or stage of growth and development. Rhodes, Wolfsdorf, Cuthbertson, et al., Diabetes Care 28(8):1948-1953, 2005 (AHRQ Grant HS00063).

Newer HIV therapies have led to a marked decrease in illness and death among HIV-infected children.

Children who receive highly active antiretroviral therapy (HAART) are less likely than adults to achieve HIV suppression, and HIV tends to progress more rapidly among children. Unlike adults who take HAART, most children are unable to reduce their viral load below detectable levels. Nevertheless, this study of 263 HIV-infected children receiving HAART found that the majority had near-normal CD4 counts, an indicator of good immune system function. Rutstein, Gebo, Flynn, et al., Med Care 43(9 suppl):15-22, 2005 (AHRQ-supported HIV Research Network).

Researchers find an overall drop between 1991-1992 and 2000-2001 in pediatric HIV care.

This study revealed lower hospitalization rates and similar use of outpatient care among HIV-infected children in 2000-2001 compared with the pre-HAART era. This drop in care use can be attributed in part to the use of newer antiretroviral therapies, but it also corresponds with the general aging of the pediatric HIV-infected population, according to the researchers. In 1991-1992, 6 percent of pediatric patients were younger than 12 months, with no child older than 12 years. In 2000-2001, the children ranged from birth to 17 years, and less than 7 percent of children were younger than age 2. Rutstein, Gebo, Siberry, et al., Med Care 43(9):31-39, 2005 (AHRQ-supported HIV Research Network).

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