An Official ATS Workshop Report: Issues in Screening for Asthma in Children
Proceedings of the American Thoracic Society 06/2007; 4(2):133-41. DOI: 10.1513/pats.200604-103ST
The workshop participants concluded that, at this time, the adoption of population-based asthma case detection programs is unwarranted given the lack of evidence of improvement in health outcomes as a result of case detection. It is important to note, however, that there are advocates for nationwide asthma screenings. One such ongoing effort is sponsored by the American College of Allergy, Asthma, and Immunology; on their website, the chair of their screening effort states, "We believe the nationwide screenings help raise awareness about asthma and the fact that the disease doesn't have to lead to major lifestyle compromises. By informing people about the symptoms of asthma and by offering free screenings and consultation by an allergist, we can help improve quality of life for children and adults with asthma" (http://www.acaai.org/ public/lifeQuality/nasp/nasp.htm, accessed August 15, 2006). The actual health outcomes of these screenings, however, are unclear. Although such voluntary programs in community settings may have value, the external validity of their outcomes is limited by self-selection of the individuals choosing to be screened. The participants of this workshop believe that limited case detection programs may be appropriate in areas where there is a high prevalence of undiagnosed asthma and where newly identified patients have functional access to consistent, high-quality asthma care. Methods to identify children with significant asthma symptoms may also be appropriate. The use of case detection methods to identify children with undiagnosed asthma may be a worthy future goal. However, before this panel can recommend widescale case detection, a number of issues should be addressed: 1. Health care systems should be adapted to deliver care that optimizes health outcomes in populations that are difficult to reach through our traditional health care delivery mechanisms. The goal is to guarantee timely access to asthma care consistent with existing guidelines and access to education to improve daily self-management. Access to health behavior experts and social workers will be important to address psychosocial and health literacy issues which impact on adherence and health outcomes. 2. The primary site of asthma case detection should be the primary care clinician's office. Clinicians should be attentive to respiratory symptoms and reports of morbidity or missed school days among children. If populations are identified that are not reached by primary care, then alternative methods should be developed for other sites (possibly schools, community centers, or youth-serving organizations). In some settings, it may be prudent to combine asthma case detection with other case detection procedures that identify other common, chronic diseases, such as vision screening for myopia. 3. Tools should be refined to identify those who would benefit most from further assessment and treatment for undiagnosed and/or undertreated asthma. 4. Identification of a preclinical state for asthma may allow for true screening and treatment to prevent the onset of the disease. A better understanding of the different asthma phenotypes and their natural history is needed to help inform the nature, timing, and possibly the setting of ideal asthma case detection or screening programs. 5. The cost-effectiveness of asthma case detection programs should be examined. Until these issues are addressed, parents, school personnel, and primary health care providers should be attentive to respiratory symptoms in children. Given that public health resources within communities and schools are very limited, current efforts should seek to identify and intervene with those children who are experiencing significant morbidity from respiratory symptoms. This targeted use of resources should include connection to proper medical care to have an impact on asthma morbidity.
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ABSTRACT: Asthma is one of the most common chronic diseases of adults and children in industrialized countries, and has had a marked increase in prevalence over the past 25 years. Asthma disproportionately affects under-represented minority populations, with African Americans and (some) Hispanics having higher rates than other groups. Racial and ethnic disparities in asthma prevalence and severity exist and are partially explained by environmental, social, cultural, and economic factors. Genetic factors also clearly affect an individual's susceptibility to asthma. Numerous strategies to reduce disparities surrounding asthma incidence, morbidity, and mortality have been proposed, and a few of them are highlighted in this article. However, as a whole, these strategies have done little to reduce ethnic disparities in asthma-related morbidity. Case detection and prescription of appropriate therapy, particularly the prescription of inhaled corticosteroids, are essential but not sufficient to improve outcomes. Family and patient-centered asthma education and culturally focussed approaches in communities who share common belief sets have been shown to reduce asthma symptom days and to improve functional health status; however, most strategies have incorporated interventions to improve therapy in addition to patient education, making it difficult to determine which component (improved therapy, patient education, or both) has resulted in the improved outcomes. Language concordance and the field testing of patient materials are important for the success of educational programs, while the setting of the education (emergency departments, hospitals, communities, or schools) does not seem as important as the intervention itself. The quality of the patient-physician interaction and the cultural and cross-cultural competence of the clinician are also important factors capable of reducing disparities in the asthma care provided to minority populations and women, while the effectiveness of environmental control strategies in reducing asthma morbidity, especially in urban-dwelling, low socioeconomic groups, has had conflicting results. While there have been reasonably few community-level interventions, these interventions have been adapted to the ethnic, social, and economic characteristics of specific populations and may hold promise in the future. At the present time, interventions that improve asthma diagnosis, increase the appropriate use of inhaled corticosteroid therapy, and assure access to medication in the context of a family-centered, community-based, culturally-appropriate intervention hold the greatest promise of reducing disparities in asthma morbidity and mortality in ethnically and socioeconomically diverse populations. In all likelihood, there is no single intervention that will reduce the especially high asthma burden in minority populations. Large-scale, cost-effective, systematic, standardized approaches that are relevant to populations and are culturally, socially, and economically diverse are needed.Disease Management and Health Outcomes 01/2008; 16(2):95-105. DOI:10.2165/00115677-200816020-00004 · 0.35 Impact Factor
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ABSTRACT: A cross-sectional study showed that 130 out of 1758 (8%) primary school children without a previous asthma diagnosis had undiagnosed asthma. Thirty-eight per cent of their parents refused to visit a general practitioner for this disorder. Factors associated with the refusal were high maternal education, mild symptoms and absence of airway reversibility.Archives of Disease in Childhood 04/2008; 93(3):236-8. DOI:10.1136/adc.2007.125161 · 2.90 Impact Factor
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