Asthma symptoms, morbidity, and antiinflammatory use in inner-city children

Background. Asthma is a major cause of morbidity that disproportionately af fects inner-city children. For children with persistent asthma, defined as having asthma symptoms 3 or more days per week or 3 or more nights per mont h, national guidelines recommend the use of daily antiinflammatory agents. Despite these recommendations, antiinflammatory agents remain underused, pa rticularly in inner-city children with high asthma morbidity. Objectives. The objectives of our study were to determine: 1) whether persi stent asthma symptoms in inner-city children are related to acute care util ization and to the frequency of acute exacerbations; 2) whether children wi th persistent asthma are receiving recommended daily antiinflammatory agent s; and 3) whether antiinflammatory medication use relates to sociodemograph ic factors, caretaker self-efficacy, the frequency of primary care visits, and/or measures of quality asthma care. Design and Methods. A 64-item telephone survey was administered between Jul y 1996 and June 1997 to 219 parental caretakers of 2- to 12-year-old childr en who had been hospitalized with asthma at an inner-city medical center be tween January 1995 and February 1996. Persistent asthma symptoms were asses sed by inquiring about the frequency of daily and nocturnal asthma symptoms over the last 4 weeks. Children's asthma severity was classified by applyi ng the 1997 National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines' severity classification scheme based on the frequency of asthm a symptoms. Asthma morbidity was defined as the frequency of acute asthma e xacerbations, emergency department visits and hospitalizations. Daily antii nflammatory medication use was compared by sociodemographic factors, careta ker self-efficacy, frequency of primary care visits, and measures of qualit y asthma home management. Results. In this sample, quantifying persistent asthma symptoms and applyin g the NAEPP symptom criteria identified 17% of the children with mild inter mittent asthma, 27% with mild persistent asthma and 56% with moderate to se vere persistent asthma. There were no differences in the age of the childre n in the 3 groups (mean age: 6 years). Asthma morbidity, as measured by the number of asthma exacerbations in the last 6 months, was significantly hig her in the children with moderate to severe persistent asthma compared with children with mild intermittent asthma (9.8 vs 3.5) or mild persistent ast hma (9.8 vs 4.5). In addition, there were significantly more emergency depa rtment visits in the moderate to severe group than in the mild persistent ( 3.05 vs 1.69) or mild intermittent group (3.05 vs 1.76). Lastly, as asthma symptom frequency increased, there were trends toward more hospitalizations and more days hospitalized. Overall, 35% of the 219 families reported giving daily antiinflammatory med ications to their child (mostly cromolyn sodium). Of the 181 children (83%) who met NA-EPP symptom criteria for persistent asthma, only 39% were recei ving daily antiinflammatory treatment. Of the children with symptoms of mod erate to severe asthma, only 15% were receiving inhaled steroids in contras t to the guidelines' recommendations. Use of antiinflammatory agents was not related to caretaker sociodemographi c factors or self-efficacy scores. Measures of quality asthma home manageme nt, which included use of mattress covers, written plans, and peak flow met ers, correlated positively with use of antiinflammatory agents. Children wh ose families reported using daily antiinflammatory medications had more pri mary care visits in the last 6 months than those children not receiving ant iinflammatory medications. Conclusion. Questioning parents about the frequency of their child's asthma symptoms is an important, inexpensive, and readily accessible bedside and office tool that may aid in the detection of persistent symptoms and help d irect therapy. Our study suggests that classifying asthma severity by quant ifying persistent asthma symptoms, as defined in the NAEPP Guidelines, is a clinically useful tool that relates to asthma morbidity. In our sample of previously hospitalized children with asthma, 83% met 1997 NAEPP symptom cr iteria for persistent asthma, and yet only 35% were receiving daily antiinf lammatory agents. Use of antiinflammatory agents correlated positively with other indicators of quality asthma home management. Additional work is nec essary to increase appropriate use of antiinflammatory agents in this popul ation, and in particular, to increase inhaled steroid use for children with moderate or severe symptoms.