Original Article
Very Poorly Controlled Asthma in Urban Minority Children: Lessons Learned

https://doi.org/10.1016/j.jaip.2017.08.007Get rights and content

Background

Very poorly controlled (VPC) asthma in children is associated with ongoing acute exacerbations but factors associated with VPC are understudied.

Objective

To examine the risk factors associated with VPC asthma in urban minority children.

Methods

This descriptive study examined asthma control levels (well-controlled [WC], not well-controlled [NWC], and VPC) at baseline and 6 months in children participating in an ongoing randomized controlled trial of an emergency department/home environmental control intervention. Data collection occurred during the index emergency department visit and included allergen-specific IgE and salivary cotinine testing and caregiver interview of sociodemographic and child health characteristics. Follow-up data were collected at 6 months. Unadjusted analyses examined the association of sociodemographic and health characteristics by level of asthma control. Multivariate analysis tested significant factors associated with VPC asthma at 6 months.

Results

At baseline most children were categorized with VPC asthma (WC, 0%; NWC, 47%; VPC, 53%) and rates of VPC minimally improved at 6 months (WC, 13%; NWC, 41%; VPC, 46%). Risk for VPC asthma was twice as likely in children with allergic rhinitis (odds ratio [OR], 2.42), having 2 or more primary care provider asthma visits within the past 3 months (OR, 2.77), or caregiver worry about medication side effects (OR, 2.13) and 3 to 4 times more likely when asthma control was assessed during the fall or spring season (OR: fall, 3.32; spring, 4.14).

Conclusions

Improving asthma control in low-income, high-risk children with VPC asthma requires treatment of comorbidities, attention to caregiver medication beliefs, and adept use of stepwise therapy.

Section snippets

Design and study setting

This descriptive study was a subanalysis of data obtained from an ongoing randomized controlled trial testing the efficacy of an ED/home-based environmental control intervention in young inner-city children who had frequent ED visits for asthma.21 Families of children aged 3 to 12 years were recruited and enrolled during an asthma ED visit from August 2013 through February 2016. Inclusion criteria were physician-diagnosed persistent and uncontrolled (NWC or VPC) asthma based on current national

Baseline health and sociodemographic characteristics

Children were primarily male (65%), black (93%), and Medicaid insured (94%) with a mean age of 6.4 ± 2.7 years at baseline (Table I). Caregivers were the child's biological mother (92%), single (74%), had a mean age of 31.3 ± 7.5 years, were high school graduates or higher educated (80%), and poor based on a household income of less than $30,000 (61%). At baseline most children were categorized with moderate persistent (46%) or severe persistent (29%) asthma and most were categorized with VPC

Discussion

In a group of young urban minority children with persistent asthma and high ED utilization, almost half (46%) had persistent VPC asthma over 6 months. The lack of improvement in asthma control confirms the challenge in managing uncontrolled asthma in urban minority children without individualizing treatment for each child. Personalized management should include identifying biomarkers of allergen sensitization and environmental exposures, and assessing allergic comorbidities, as performed in our

Acknowledgements

We appreciate Mary Gates, Amanda Manning, and Cheyenne McCray for the collection of data and the families for their participation in the study.

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    This work was supported by the National Institute of Nursing Research, National Institutes of Health (NIH) (grant no. NR013486). The study is registered with ClinicalTrials.gov with number NCT01981564. This publication was made possible by the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part by grant number UL1 TR 000424-06 from the National Center for Advancing Translational Sciences (NCATS), a component of the NIH, and the NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Johns Hopkins ICTR, NCATS or NIH.

    Conflicts of interest: A. M. Butz, M. Bellin, S. S. Mudd, J. Ogborn, C. Lewis-Land, and M. E. Bollinger have received research support from the National Institutes of Health (NIH), National Institute of Nursing Research (NINR) (grant no. NR013486). M. Tsoukleris has received consultancy fees from Johns Hopkins University School of Medicine and has received fees for the management of pharmacy data collection processes and related analysis. J. Kub has received research support from the NIH, NINR (grant no. NR013486), and receives royalties for a textbook. T. Morphew has received research support from the NIH, NINR (grant no. NR013486), and has received consultancy fees, fees for participation in review activities, and payment for writing/reviewing the manuscript from Morphew Consulting, LLC.

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