Beliefs and barriers to follow-up after an emergency department asthma visit: a randomized trial.
ABSTRACT Studies in urban emergency departments (EDs) have found poor quality of chronic asthma care and identified beliefs and barriers associated with low rates of follow-up with a primary care provider (PCP).
To develop an ED-based intervention including asthma symptom screening, a video addressing beliefs and a mailed reminder; and measure the effect on PCP follow-up and asthma-related outcomes.
This randomized, controlled trial enrolled children aged 1 to 18 years who were discharged after asthma treatment in an urban pediatric ED. Control subjects received instructions to follow-up with a PCP within 3 to 5 days. In addition, intervention subjects (1) received a letter to take to their PCP if they screened positive for persistent asthma symptoms, (2) viewed a video featuring families and providers discussing the importance of asthma control, and (3) received a mailed reminder to follow-up with a PCP. All subjects were contacted by telephone 1, 3, and 6 months after the ED visit, and follow-up was confirmed by PCP record review. Asthma-related quality of life (AQoL), symptoms, and beliefs about asthma care were assessed by using validated surveys.
A total of 433 subjects were randomly assigned, and baseline measures were similar between study groups. After the intervention and before ED discharge, intervention subjects were more likely to endorse beliefs about the benefits of follow-up than controls. However, rates of PCP follow-up during the month after the ED visit (44.5%) were similar to control subjects (43.8%) as were AQoL, medication use, and ED visits.
An ED-based intervention influenced beliefs but did not increase PCP follow-up or asthma-related outcomes.
Article: Reported difficulties in access to quality care for children with asthma in the inner city.[show abstract] [hide abstract]
ABSTRACT: To characterize perceived access and barriers to quality health care for asthma among the caregivers of children in the inner city. Multicenter, cross-sectional survey. Eight sites in 7 major metropolitan US inner cities. A systematic sample of children with asthma, aged 4 to 9 years, and their caregivers who resided in census tracts in which at least 30% of the households were below the 1990 federal poverty guidelines, recruited from 25 primary care clinics and 13 emergency departments (EDs) from November 1, 1992, through October 31, 1993. Of the 1528 children enrolled, 1376 had physician-diagnosed asthma and form the basis of this report. This group was further divided into 284 children (20.6%) who met all recruitment criteria for severe asthma and 207 (15.0%) with mild asthma who met none. Of parents in the total sample, 95.6% reported a usual place for short-term asthma care for their child; 75.4% used the ED. Children with severe asthma were significantly more likely to use the ED than those with mild asthma (84.3% vs 63.0%; P<.01). A usual place for follow-up asthma care was reported by 96.7% of subjects. There were no differences in access or type of facility used by asthma severity. More than half the study group reported difficulty in accessing care for acute asthma attacks and for follow-up care with no differences by asthma severity. Among those with severe asthma, 47.5% used inhaled steroids or cromolyn, 52.8% used a spacer device if they had been prescribed a metered dose inhaler, and 21.2% of children older than 6 years were prescribed a peak flowmeter. Patients with mild asthma were significantly less likely to report use of all 3 items (steroids or cromolyn, 1.4%; spacer device, 15.4%; and peak flowmeter, 3.1%, respectively; P<.01). Although access to asthma care among children in US inner cities appears adequate as determined by the traditional measure of reporting a regular source of care, barriers are frequently reported, as are deficiencies in the quality of medical care.Archives of Pediatrics and Adolescent Medicine 05/1998; 152(4):333-9. · 4.14 Impact Factor
Article: Inhibition of carcinoma cell invasion and liver metastases formation by the cysteine proteinase inhibitor E-64.[show abstract] [hide abstract]
ABSTRACT: Cysteine proteinases, in particular cathepsins B and L, have been implicated in tumor invasion and are thought to be important mediators of metastasis. Using two clonal sublines of the Lewis lung carcinoma with distinct patterns of metastasis, we previously reported that H-59 carcinoma cells, which are highly invasive and preferentially metastatic to the liver, express high levels of cathepsin L and lower levels of cathepsin B whereas M-27 cells which are less invasive and only moderately metastatic to the lung express cathepsin B only. In the present study, the role of these enzymes in invasion and metastasis, in particular the involvement of cysteine proteinases in liver metastasis of H-59 cells was further investigated. Using a reconstituted basement membrane (Matrigel) invasion assay we found that the cysteine proteinase inhibitor, E-64, blocked the invasion of H-59 cells under conditions which did not affect cell viability. A more minor but significant inhibitory effect (up to 32%) was also seen with the propeptide of cathepsin B, implicating this enzyme in the invasion process. Furthermore, treatment of H-59 cells with E-64 inhibited experimental liver metastases formation by up to 90%. On the other hand, invasion of M-27 cells could not be blocked by cysteine proteinase inhibitors even under conditions which resulted in complete abrogation of intracellular enzymatic activity, as assessed using synthetic substrates. Together, these results confirm our previous conclusion that the two carcinoma sublines utilize distinct proteolytic mechanisms for invasion and identify the cysteine proteinases as key mediators of H-59 carcinoma invasion and metastasis.Clinical and Experimental Metastasis 04/1997; 15(2):121-9. · 3.52 Impact Factor