Access to Pediatric Asthma Specialty Care: A Survey and Geospatial Analysis Across a Rural State

James C Bohnhoff,1,2 Dana Schwartz,3 Anya Cutler,2 Jill S Halterman4 1Department of Pediatrics, MaineHealth, Portland, ME, USA; 2Center for Interdisciplinary Population & Health Research, MaineHealth Institute for Research, Westbrook, ME, USA; 3Undergraduate Studies, Hamilton College, Clinton, NY, USA; 4Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USACorrespondence: James C Bohnhoff, Department of Pediatrics, MaineHealth, 1577 Congress St, Fl 1, Portland, ME, 04102, USA, Tel +1 207 661 1392, Email [email protected]: Although children with asthma have improved outcomes when accessing asthma specialists (allergist/immunologists and pediatric pulmonologists), this care may not be available if no specialists are located nearby, or if nearby specialists do not accept children or a given child’s insurance. We aimed to describe the physical proximity of children to pediatric asthma specialty care in a largely rural state and to assess the degree to which the availability of pediatric specialty asthma care was impacted by provider nonacceptance of pediatric patients and patients with Medicaid insurance.Methods: We conducted a telephone survey of pediatric pulmonology and allergy/immunology practices in the rural state of Maine and adjacent areas during June and July 2024, asking whether they accepted pediatric patients, whether they accepted pediatric patients with Maine Medicaid insurance, and their wait times for new patient appointments. We assessed the association of acceptance policies and clinician specialty (allergy vs pulmonology), training (physician vs advanced practice provider), and state (Maine vs other) using Fisher’s exact tests and we calculated the travel time to the nearest provider locations for children across Maine.Results: Among 49 asthma specialists in and around Maine, 41 (84%) accepted pediatric patients. Eighty-nine percent of Maine providers and 6% of out-of-state providers accepted children with Maine Medicaid insurance. The median distance to any asthma specialist was 30.5 minutes (IQR 17.2, 51.0) and 18% of children would need to travel > 60 minutes for care.Conclusion: Nearly one in five children in Maine would be required to travel more than 60 minutes to reach an asthma specialist, nearly one in five allergy providers do not accept children, and few out of state providers accept Maine Medicaid insurance. Future research should assess the impacts of these barriers on children’s receipt of care.Plain Language Summary: In this study, the authors contacted the offices of asthma specialists in and around Maine to ask whether each specialist accepted children, and whether they accepted Maine Medicaid insurance. We tested whether patient acceptance policies differed by specialty, training, and location of the specialists. We also used census data to calculate the distance from all children in Maine to the nearest specialist. Of 49 pediatric asthma specialists in and around Maine, we found that only 41 (84%) accepted pediatric patients. Pediatric pulmonary specialists and in-state providers were more likely to accept children with Maine Medicaid insurance. Half of children would travel 30 or more minutes to reach the nearest specialist. This study raises concerns that children with Medicaid, especially along state borders, may have fewer options for needed asthma specialty care.Keywords: pediatrics, barriers to care, rurality, insurance, disparitie

LPS-induced NF??B enhanceosome requires TonEBP/NFAT5 without DNA binding

NF??B is a central mediator of inflammation. Present inhibitors of NF??B are mostly based on inhibition of essential machinery such as proteasome and protein kinases, or activation of nuclear receptors; as such, they are of limited therapeutic use due to severe toxicity. Here we report an LPS-induced NF??B enhanceosome in which TonEBP is required for the recruitment of p300. Increased expression of TonEBP enhances the NF??B activity and reduced TonEBP expression lowers it. Recombinant TonEBP molecules incapable of recruiting p300 do not stimulate NF??B. Myeloid-specific deletion of TonEBP results in milder inflammation and sepsis. We discover that a natural small molecule cerulenin specifically disrupts the enhanceosome without affecting the activation of NF??B itself. Cerulenin suppresses the pro-inflammatory activation of macrophages and sepsis without detectable toxicity. Thus, the NF??B enhanceosome offers a promising target for useful anti-inflammatory agents.ope

Suboptimal asthma care for immigrant children: results of an audit study

<p>Abstract</p> <p>Background</p> <p>Little is known on the scope and nature of ethnic inequalities in suboptimal asthma care for children. This study aimed to assess (1) ethnic differences in suboptimal asthma care for children with an asthma exacerbation who consulted a physician, and (2) ethnic differences in the nature of suboptimal care.</p> <p>Methods</p> <p>All children aged 6–16 years who during a period of six months consulted the paediatric department of the Academic Medical Centre-University of Amsterdam or one of the six regional primary care centres with an asthma exacerbation were included. Clinical guidelines were systematically converted to review criteria following the strategy as proposed by the Agency for Health Care Policy and Research. Based upon these review criteria and their experience experts of two multidisciplinary panels retrospectively assessed the quality of care and its (possible) failure to prevent the occurrence of asthma exacerbation.</p> <p>Results</p> <p>Only a small number of children (n = 35) were included in the analysis as a result of which the ethnic differences in suboptimal care were not significant. However, the results do indicate immigrant children, in particular 'other non-Western' children (n = 11), more frequently to receive suboptimal care related to the asthma exacerbation when compared to ethnic Dutch children. Furthermore, we found the nature of suboptimal care to differ with under-prescribing in the 'other non-Western' group (n = 11), lack of information exchange between physicians in the Surinamese/Antillean group (n = 12) and lack of education, and counselling of patients and parents in the ethnic Dutch (n = 12) as the most relevant factor.</p> <p>Conclusion</p> <p>Ethnic inequalities in the scope and nature of suboptimal asthma care for children in the Netherlands seem to exist. For the non-western immigrant groups the results indicate the importance of the prescription behaviour of the medical doctor, as well as the supervision by one health care provider.</p

Asthma self-assessment in a Medicaid population

<p>Abstract</p> <p>Background</p> <p>Self-assessment of symptoms by patients with chronic conditions is an important element of disease management. A recent study in a commercially-insured population found that patients who received automated telephone calls for asthma self-assessment felt they benefitted from the calls. Few studies have evaluated the effectiveness of disease self-assessment in Medicaid populations. The goals of this study were to: (1) assess the feasibility of asthma self-assessment in a population predominantly insured by Medicaid, (2) study whether adding a gift card incentive increased completion of the self-assessment survey, and (3) evaluate how the self-assessment affected processes and outcomes of care.</p> <p>Methods</p> <p>We studied adults and children aged 4 years and older who were insured by a Medicaid-focused managed care organization (MCO) in a pre- and post-intervention study. During the pre-incentive period, patients with computerized utilization data that met specific criteria for problematic asthma control were mailed the Asthma Control Test (ACT), a self-assessment survey, and asked to return it to the MCO. During the intervention period, patients were offered a $20 gift card for returning the completed ACT to the MCO. To evaluate clinical outcomes, we used computerized claims data to assess the number of hospitalization visits and emergency department visits experienced in the 3 months after receiving the ACT. To evaluate whether the self-management intervention improved processes of care, we conducted telephone interviews with patients who returned or did not return the ACT by mail.</p> <p>Results</p> <p>During the pre-incentive period, 1183 patients were identified as having problems with asthma control; 25 (2.0%) of these returned the ACT to the MCO. In contrast, during the incentive period, 1612 patients were identified as having problems with asthma control and 87 (5.4%) of these returned the ACT to the MCO (p < 0.0001). Of all 95 ACTs that were returned, 87% had a score of 19 or less, which suggested poor asthma control.</p> <p>During the 3 months after they received the ACT, patients who completed it had similar numbers of outpatient visits, emergency department visits, and hospitalizations for asthma as patients who did not complete the ACT. We completed interviews with 95 patients, including 28 who had completed the ACT and 67 who had not. Based on an ACT administered at the time of the interview, patients who had previously returned the ACT to the MCO had asthma control similar to those who had not (mean scores of 14.2 vs. 14.6, p = 0.70). Patients had similar rates of contacting their providers within the past 2 months whether they had completed the mailed ACT or not (71% vs. 76%, p = 0.57).</p> <p>Conclusion</p> <p>Mailing asthma self-assessment surveys to patients with poorly controlled asthma was not associated with better asthma-associated outcomes or processes of care in the Medicaid population studied. Adding a gift card incentive did not meaningfully increase response rates. Asthma disease management programs for Medicaid populations will most likely need to involve alternative strategies for engaging patients and their providers in managing their conditions.</p

Early detection and counselling intervention of asthma symptoms in preschool children: study design of a cluster randomised controlled trial

Background. Prevention of childhood asthma is an important public health objective. This study evaluates the effectiveness of early detection of preschool children with asthma symptoms, followed by a counselling intervention at preventive child health centres. Early detection and counselling is expected to reduce the prevalence of asthma symptoms and improve health-related quality of life at age 6 years. Methods/design. This cluster randomised controlled trial was embedded within the Rotterdam population-based prospective cohort study Generation R in which 7893 children (born between April 2002 and January 2006) participated in the postnatal phase. Sixteen child health centres are involved, randomised into 8 intervention and 8 control centres. Since June 2005, an early detection tool has been applied at age 14, 24, 36 and 45 months at the intervention centres. Children who met the intervention criteria received counselling intervention (personal advice to parents to prevent smoke exposure of the child, and/or referral to the general practitioner or asthma nurse). The primary outcome was asthma diagnosis at age 6 years. Secondary outcomes included frequency and severity of asthma symptoms, health-related quality of life, fractional exhaled nitric oxide and airway resistance at age 6 years. Analysis was according to the intention-to-treat principle. Data collection will be completed end 2011. Discussion. This study among preschool children provides insight into the effectiveness of early detection of asthma symptoms followed by a counselling intervention at preventive child health centres. Trial registration. Current Controlled Trials ISRCTN15790308

Prescription of respiratory medication without an asthma diagnosis in children: a population based study

Background. In pre-school children a diagnosis of asthma is not easily made and only a minority of wheezing children will develop persistent atopic asthma. According to the general consensus a diagnosis of asthma becomes more certain with increasing age. Therefore the congruence between asthma medication use and doctor-diagnosed asthma is expected to increase with age. The aim of this study is to evaluate the relationship between prescribing of asthma medication and doctor-diagnosed asthma in children age 0-17. Methods. We studied all 74,580 children below 18 years of age, belonging to 95 GP practices within the second Dutch national survey of general practice (DNSGP-2), in which GPs registered all physician-patient contacts during the year 2001. Status on prescribing of asthma medication (at least one prescription for beta2-agonists, inhaled corticosteroids, cromones or montelukast) and doctor-diagnosed asthma (coded according to the International Classification of Primary Care) was determined. Results. In total 7.5% of children received asthma medication and 4.1% had a diagnosis of asthma. Only 49% of all children receiving asthma medication was diagnosed as an asthmatic. Subgroup analyses on age, gender and therapy groups showed that the Positive Predictive Value (PPV) differs significantly between therapy groups only. The likelihood of having doctor-diagnosed asthma increased when a child received combination therapy of short acting beta2-agonists and inhaled corticosteroids (PPV = 0.64) and with the number of prescriptions (3 prescriptions or more, PPV = 0.66). Both prescribing of asthma medication and doctor-diagnosed asthma declined with age but the congruence between the two measures did not increase with age. Conclusion. In this study, less than half of all children receiving asthma medication had a registered diagnosis of asthma. Detailed subgroup analyses show that a diagnosis of asthma was present in at most 66%, even in groups of children treated intensively with asthma medication. Although age strongly influences the chance of being treated, remarkably, the congruence between prescribing of asthma medication and doctor-diagnosed asthma does not increase with age

Lung function, asthma symptoms, and quality of life for children in public housing in Boston: a case-series analysis

BACKGROUND: Children in urban public housing are at high risk for asthma, given elevated environmental and social exposures and suboptimal medical care. For a multifactorial disease like asthma, design of intervention studies can be influenced by the relative prevalence of key risk factors. To better understand risk factors for asthma morbidity in the context of an environmental intervention study, we conducted a detailed baseline evaluation of 78 children (aged 4–17 years) from three public housing developments in Boston. METHODS: Asthmatic children and their caregivers were recruited between April 2002 and January 2003. We conducted intake interviews that captured a detailed family and medical history, including questions regarding asthma symptom severity, access to health care, medication usage, and psychological stress. Quality of life was evaluated for both the child and caregiver with an asthma-specific scale. Pulmonary function was measured with a portable spirometer, and allergy testing for common indoor and outdoor allergens was conducted with skin testing using the prick puncture method. Exploratory linear and logistic regression models evaluating predictors of respiratory symptoms, quality of life, and pulmonary function were conducted using SAS. RESULTS: We found high rates of obesity (56%) and allergies to indoor contaminants such as cockroaches (59%) and dust mites (59%). Only 36% of children with persistent asthma reported being prescribed any daily controller medication, and most did not have an asthma action plan or a peak flow meter. One-time lung function measures were poorly correlated with respiratory symptoms or quality of life, which were significantly correlated with each other. In multivariate regression models, household size, body mass index, and environmental tobacco smoke exposure were positively associated with respiratory symptom severity (p < 0.10). Symptom severity was negatively associated with asthma-related quality of life for the child and the caregiver, with caregiver (but not child) quality of life significantly influenced by caregiver stress and whether the child was in the intensive care unit at birth. CONCLUSION: Given the elevated prevalence of multiple risk factors, coordinated improvements in the social environment, the built environment, and in medical management would likely yield the greatest health benefits in this high-risk population

An eQTL Analysis of Partial Resistance to Puccinia hordei in Barley

Background - Genetic resistance to barley leaf rust caused by Puccinia hordei involves both R genes and quantitative trait loci. The R genes provide higher but less durable resistance than the quantitative trait loci. Consequently, exploring quantitative or partial resistance has become a favorable alternative for controlling disease. Four quantitative trait loci for partial resistance to leaf rust have been identified in the doubled haploid Steptoe (St)/Morex (Mx) mapping population. Further investigations are required to study the molecular mechanisms underpinning partial resistance and ultimately identify the causal genes.Methodology/Principal Findings - We explored partial resistance to barley leaf rust using a genetical genomics approach. We recorded RNA transcript abundance corresponding to each probe on a 15K Agilent custom barley microarray in seedlings from St and Mx and 144 doubled haploid lines of the St/Mx population. A total of 1154 and 1037 genes were, respectively, identified as being P. hordei-responsive among the St and Mx and differentially expressed between P. hordei-infected St and Mx. Normalized ratios from 72 distant-pair hybridisations were used to map the genetic determinants of variation in transcript abundance by expression quantitative trait locus (eQTL) mapping generating 15685 eQTL from 9557 genes. Correlation analysis identified 128 genes that were correlated with resistance, of which 89 had eQTL co-locating with the phenotypic quantitative trait loci (pQTL). Transcript abundance in the parents and conservation of synteny with rice allowed us to prioritise six genes as candidates for Rphq11, the pQTL of largest effect, and highlight one, a phospholipid hydroperoxide glutathione peroxidase (HvPHGPx) for detailed analysis.Conclusions/Significance - The eQTL approach yielded information that led to the identification of strong candidate genes underlying pQTL for resistance to leaf rust in barley and on the general pathogen response pathway. The dataset will facilitate a systems appraisal of this host-pathogen interaction and, potentially, for other traits measured in this populatio