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This is to certify that the
thesis entitled

EMERGENCY DEPARTMENT ASTHMA VISITS IN ADULTS:
BASELINE CHARACTERISTICS AND RISK FACTORS FOR
ASTHMA RELAPSE

presented by

SAINAN WEI

has been accepted towards fulfillment
of the requirements for the

Master of degree in Epidemiology

 

mm 2? QM

Major Professor’s Signature
5/28/04

Date

MSU is an Affirmative Action/Equal Opportunity Institution

 

 

LIBRARY
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PLACE IN RETURN BOX to remove this checkout from your record.
I To AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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EMERGENCY DEPARTMENT ASTHMA VISITS IN ADULTS: BASELINE
CHARACTERISTICS AND RISK FACTORS FOR ASTHMA RELAPSE

By

Sainan Wei

A THESIS
Submitted to
Michigan State University
In partial fulfillment of the requirements
For the degree of
MASTER OF SCIENCE
Department of Epidemiology

2004

Abstract

EMERGENCY DEPARTMENT ASTHMA VISITS IN ADULTS: BASELINE
CHARACTERISTICS AND RISK FACTORS FOR ASTHMA RELAPSE
By

Sainan Wei

Asthma is a chronic illness that has been increasing in prevalence in the United
States since 1980. Identifying patients with a high risk of relapse would be useful
in designing more effective pharmacotherapeutic, educational, and

environmental self-monitoring interventional programs.

Of the 172 enrolled patients, 138 patients had follow up information at 26 weeks
after their ED visit. The cumulative incidence of relapse up to 26 weeks was
30%. The frequency of prior hospitalization in the last 12 months was the only
risk factor identified. In a model that included age, gender, race, and asthma
severity, the patients that had 1 prior hospitalization in the last 12 months had
hazard ratio of 3.1 (95% CI 1.1-8.6). The hazard ratio increased to 3.3 (95% CI
1.4-7.8) for patients that had more than 2 hospitalizations in the last 12 months.
When severity was excluded from the model, the hazard ratios were 2.5 (95% CI
1.0-6.7) and 4.1 (95% CI 1.8-9.2) in patients who had 1 or 2 or more

hospitalizations in the last 12 months, respectively.

ACKNOWLEDGEMENTS

I am most grateful to Dr. Rachel Fisher for suggesting the idea of pursuing
Genetic Epidemiology while I was a doctoral student in the genetics program,
and for all her encouragement, patience, and instruction on myjourney into the

scientific research world.

I would like to greatly appreciate Dr. Gardiner, my academic advisor, and Dr.
Karmaus, my committee member, for their excellent guidance, support and
encouragement during my study. I would also like to thank Dr. Reeves, my thesis

advisor for his critique while I studied in the Epidemiology Department.

Last, i would like to thank my family for making my life colorful and making me try

new things all my life.

iii

TABLE OF CONTENTS

List of Tables ........................................................................... V

List of Figures ............................................................................. VI
Symbols and Abbreviations ........................................................... Vll
Chapter One: Background ............................................................ 1

Chapter Two: Materials and Methods ............................................ 8

Chapter Three: Results .............................................................. 18
Chapter Four: Discussion ............................................................. 45
Appendix A ...................................................................... 54
Appendix B ............................................................................. 63
Appendix C .............................................................................. 70
Appendix D ................................................................................ 79
List of References ..................................................................... 80

iv

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

Table 7.

Table 8.

Table 9.

Table 10.

Table 11.

LIST OF TABLES
List of previous studies on asthma relapse following ED visit

Classification of asthma severity: clinical features over last four
weeks .............................................................................

Classification of over-treatment, under-treatment and proper-
treatment ........................................................................

Comparison of included and excluded patients in Butterworth and
Blodgett ..........................................................................

Comparison of patients who completed the 26-week follow-up
with those did not ............................................................

Description of baseline characteristics of 172 adult asthma ED
visits

Association between demographic, clinical treatment and
management factors and adult asthma relapse during a 6- month
period. Univariate Cox proportional models show HR and 95%Cl

Association of asthma severity with the variables that have strong
association with asthma relapse from Cox proportional hazardous
model. ............................................................................

Summary of Model Selection | including all variables and agegrp,
race, and EDU are in 2 levels ..............................................

Summary of Model Selection ll ............................................

Final multivariate model for adult asthma relapse on a 6 month
penod ..............................................................................

4

14

15

19

24

26

36

38

41

44

LIST OF FIGURES

Figure 1. Comparison of gender in adult asthma ED visits in 2001 (data
generated from Physician Billing Company) with those in this

study ............................................................................ 20
Figure 2. Comparison of adult asthma ED visits in 2001 (data generated

from Physician Billing Company) with those in this study ......... 21
Figure 3. Flow chart of enrolled subjects ........................................... 23
Figure 4. Time interval in weeks between ED visit and the first relapse 28

Figure 5. Survival distribution of previous hospitalization for three groups
(0 time of hospitalization, 1 time of hospitalization and more
than 2 times of hospitalization in previous 12 months ............ 43

vi

AMP
COPD
CSBA
ED
ER
HIV
ICS
LABA
LM
MARC
NAEPP
NHLBI
PCP
PEF

PFM

SABA
SOB

ABBREVIATIONS

Asthma Management Plan

Chronic obstructive pulmonary disease
Combined SABA and ICS

Emergency Department

Emergency Room

Human Immunodeficiency Virus

lnhaled‘ Corticosteroid

Long-acting betaz-agnonist

Leukotriene Modifier

Multicenter Asthma Research Collaboration
The National Asthma Education and Prevention Program
National Heart Lung and Blood Institute
Primary Care Provider

Peak expiratory flow

Peak Flow Meter

Reactive Airway Disease

Short-acting betaz-agnonist

Shortness of Breath

vii

Chapter One: Background

Emergency department visits for asthma

Emergency departments (ED’s) play a crucial role in the management of asthma.
Frequently, they are main source of medical care for some populations, such as
those with low income, low education, and minorities. Use of emergency
departments by persons with asthma is one of the key manifestations of asthma
morbidity in the United States and is an important public health concern
(Mannino, 1998). Each year, despite a wide array of effective asthma treatments,
people with asthma make approximately 1.8 million visits to emergency
departments, resulting in direct medical costs in excess of $250 million dollars.
ED visits for asthma are believed by some to indicate a failure of available
primary care, and are regarded as mostly preventable (National Institutes of

Health .1997; National Heart, lung, and Blood Institute. 1995; Dales et al. 1995).

The overall age-adjusted rate of emergency room visits for asthma increased
11.9 per 10,000 between 1992 and 1995
(http://www.nhlbi.gov/healthlporf/Iung/asthma). During 1995, asthma was the
cause of more than 1.5 million emergency department visits (National Heart,
Lung and Blood Institute, 1999). There were an estimated 1.8 million ED visits for
asthma in 2000, or 67 per 10,000 people. Adults 18 years and over had 54 ED
visits per 10,000. There are large racial differences especially blacks versus

whites in the use of ED for asthma (Weiss et al. 1992; Burt et al. 1994). The ED

visit rate for blacks was 125% higher than that for whites in a study by CDC. This
same study also reported that the ED visit rate in females was about 30% higher

than for males (CDC, 2002; MMWR, 2003)

Asthma relapse following an ED visit

A thorough literature search was conducted using keywords ‘adult asthma’,
‘observational study’, ‘emergency department visit’ in MEDLINE and PubMed for
publications between 1990 to 2002, 27 references were identified, 8 articles were

finally selected in terms of relevance to this study. Table 1 lists these studies.

A significant portion of patients treated in Emergency Department (ED) for acute
asthma exacerbation suffer a relapse and require repeat ED visits, hospitalization
or other urgent medical treatment. One measure of the inappropriateness of ED
management has been the proportion of treated patients who had relapse, which
is defined as the unscheduled return to an ED or physician’s office for increasing
asthma symptoms shortly after the ED visit (Duchamte, et al. 1993; Rose, et al.
1984; Centor et al. 1984; Emerrnan, et al. 1995). The rates of relapse after ED
visit for acute asthma reported in previous studies have varied, for example,
25.3% relapse rate within 3 weeks of discharge in a cohort study of 104 adult
asthma patients (Emennan et al. 1995); six percent (6%) within 7 days, eight
percent (8%) by 10 days, and forty-five percent (45%) by 8 weeks in a cohort

study of 284 adult asthmatics (McCarTen et al. 1998); twenty-one percent (21%)

in a cohort study of 641 adult asthmatic patients and seventeen percent (17%)
relapse rates were reported within 14 days in other cohort study of 223 patients
from Emerman’s group (Emerman et al. 1998; Emerman et al. 1999). Identifying
patients with a high risk of relapse would be useful in designing more effective
pharmacotherapeutic, educational, and environmental self-monitoring

intervention programs.

Attempts to identify patients at high risk of relapse by analyzing various factors
have produced conflicting results. Clinical features such as pulse rate, respiratory
rate, peak expiratory flow rate, moderate to severe dyspnea and wheezing in a
multi-factorial analysis were reported to predict relapse (Fischl, et al. 1981) but
could not be validated in subsequent studies (Rose, et al. 1984; Centor et al.
1984). Several investigators have found that features such as frequent ED visits,
hospitalizations, and medication usage predicted relapse (Duchanne, et al. 1993;
Emerman, et al. 1995; Newcomb, etal. 1986; Li, et al. 1995). It is understandable
that studies addressing heterogeneous groups of patients may have conflicting
results. These investigations may be more a reflection of different level of

disease presentation on a population basis (Table 1).

 

 

 

 

 

 

 

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Some researchers have found a positive association between pulmonary function
testing results and subsequent relapse (Kelsen, et al. 1978; Fischl, et al. 1981;
Chapman, et al. 1991; Nowak, et al. 1982), whereas other studies have found no
such association (Rose, et al. 1984; Emerman, et al. 1995; Klaustermeyer et al.

1990, Worthington, et al. 1989).

In a large multicenter study, researchers found that a history of numerous ED
visits over the previous year, a history of urgent clinic visits over the previous
year, use of a home nebulizer, multiple asthma triggers, and duration of
symptoms between 1 and 7 days prior to presentation were all associated with
asthma recurrence during a 14-day follow-up period after controlling for age,
gender, race, and primary care provider status (Emerman, et al. 1999). In other
studies, lack of an identifiable primary care physician, three or more ED visits
within the prior 6 months, and impairment in activities of daily living within the
prior 4 weeks due to poor physical health were all found to be associated with a
higher incidence of relapse (McCarren, et al. 1998; Emerman, et al. 1995; Dales,

et al. 1995; Ducharme, et al. 1993).

In response to the public health problem of asthma, the National Asthma
Education and Prevention Program (NAEPP) promulgates guidelines for
management of asthma. The guidelines identify a number of factors such as
inappropriate medical regimens, lack of access to primary medical care, home

environmental factors, and social habits which may be associated with poor

asthma control and were associated with asthma. Based on this guideline, we
designed a questionnaire for primary ED visit and future follow-ups. Questions
about medication administration, access to primary medical care, and asthma
severity classification were designed in these questionnaires according to the

NAEPP guideline (National Institutes of Health. 1997).

The impact of asthma is not uniform across the United States, but rather
disproportionately affects different communities especially those minorities in
inner city settings (Weiss, et al. 1990; Marder, et al. 1992; Lang, et al. 1994;
Carr, et al. 1992), therefore different studies have found various absolute risks
(Emerman et al 1995; Emerman et al 1998; Emerman et al 1999; McCaneen et
al. 1998). Identifying risk factors for asthma relapse across a specific community
could guide an effective community response to the burden of asthma (Weiss, et

al. 1999).

Thesis objective

This project uses an inception cohort design of a random sample of adult asthma
patients who presentto two 50’s in Grand Rapids, Butterworth and Blodgett
hospitals. The goal is to identify contributing factors including demographic and
clinical features for the risk of first relapse over a 26 week follow-up period after

an asthma ED visit.

Chapter two: Materials and Methods

Study Overview and Study Population

The Asthma Cohort Study is one part of a three-year study in Grand Rapids
funded by Center for Disease Control (CDC). The primary objectives of the
cohort studies, including both adult and child study, are to develop a passive
asthma surveillance system and to identify contributing factors to the relapse
following an Emergency Department (ED) asthma visit. The data for this project
came from adult subjects enrolled at two hospitals in Grand Rapids, Buttenovorth
and Blodgett. Adult subjects visiting these two EDs for asthma were recruited
according to the inclusion and exclusion criteria described below. Following
enrollment, adult subjects completed two follow-up surveys by telephone at 2
weeks and 26 weeks following the initial ED visit. These surveys were
administered by trained asthma Research Nurses at Butterworth and by

Respiratory Therapists at Blodgett.

Butterworth is located in an inner city area, and Blodgett is located in a more
suburban area. Both are part of the Spectrum Health System in Grand Rapids.
They serve the population of the greater Grand Rapids area, which includes the
counties of Kent and Ottawa. The total population of this area is about 775,000
citizens, of whom approximately 9% (67,000) are minorities. The majority of
these minorities (77%) are African Americans living primarily in inner city Grand

Rapids. The ED at Butterworth hospital is located in the downtown area and

serves the inner-city population of Grand Rapids and surrounding areas. In 1999,
it had over 91,000 total emergency visits, with 1,755 adult and 1,032 pediatric
(<18 years old) visits for asthma. The ED in Blodgett hospital is located a few
miles away on the eastern side of the city. It had approximately 33,000 ED visits

in 1999, including 130 adult and 310 pediatric asthma cases.

Subject Selection

Adult asthma patients seeking treatment for an acute asthma exacerbation at
these two 503 were screened for eligibility. The diagnosis of asthma in the EDs
in this study is based on the criteria set forth by the American Thoracic Society
(American Thoracic Society, 1986). The standard management of acute asthma
exacerbations in the EDs is consistent with the NHLBI Expert Panel 2 Guidelines
(National Heart Lung and Blood Institute, 1995). Briefly, initial clinical assessment
includes a brief history, physical examination, measure of oxygen saturation, and

peak expiratory flow (PEF) (National Heart Lung and Blood Institute, 1997).

INCLUSION CRITERIA

To be included in this study, patients had to be 18 - 74 years old, and present to
the ED with evidence of exacerbation of asthma which was defined as : any

combination of wheezing, SOB (shortness of breath), chest tightness, or cough.

In addition, each patient had to have at least one of the following to be included

in the study:

a final ED discharge diagnosis of asthma, RAD (Reactive Airway
Disease), or asthmatic bronchitis,

a final ED diagnosis of chronic obstructive pulmonary disease (COPD) in
patients 5 40 years of age,

a previous physician diagnosis and/or treatment of asthma, RAD, or
asthmatic bronchitis in last two years,

a previous physician diagnosis of COPD (ever) in patients 3 40 years of
age,or

a history of using bronchodilator medication in the past year.

EXCLUSION CRITERIA

A patient was excluded from this study if any of the following conditions were

true:

had a final discharge diagnosis of chronic bronchitis or emphysema, or of
COPD in persons over 40 years of age,

had life threatening respiratory distress on presentation to the ED,

had other significant illnesses (any major chronic disease or disability such
as HIV/AIDS, immunodeficiency due to medication associated with cancer
treatment or transplant, cystic fibrosis, bronchopulmonary dysplasia, or

other chronic cardiopulmonary disease),

10

. had cognitive impairment sufficient to significantly impair ability to follow
medical advice, such as drug abuse, alcoholism, major mental illness,
anxiety disorder, senility, dementia, other psychosocial impairment,

0 had no permanent address or access to a working telephone,

0 could not communicate in English or Spanish,

. was not available for follow-up,

Data Collection

After confirming eligibility, patients were enrolled in the study after completing the
consent form. Enrolled adults were interviewed by trained staff, who completed a
visit form which included 32 questions (appendix A). Trained asthma research
nurses were used at Buttenrvorth hospital, while Respiratory Therapists were
used at Blodgett hospital. The initial visit form contained questions about
demographic characteristics, including gender, age, ethnicity, race, educational
attainment, and availability of health insurance. Questions were also posed about
past asthma history (including previous asthma diagnosis), usual asthma care
sources (including access and use of a primary care and regular asthma care
providers), prior urgent care visits (including ED and hospitalization), current
medications, and access to use of asthma equipment. The patient’s asthma

knowledge was also assessed (see appendix A for copy of questionnaire).

11

Follow-up Data

Definition of Outcome Variables

All asthma patients enrolled in this study were contacted 2 and 26-weeks after
their ED visit by telephone by two Research Nurses. A structured questionnaire
were used (see Appendix B and C). The primary outcome of the study is the self-
reported urgent medical treatment (relapse) for asthma during the 26-week
follow-up period. To determine the occurrence of relapse, each patient was
asked whether they had experienced worsening asthma that led them to go for
urgent medical treatment since they left the hospital emergency department.
Thus, our definition of relapse includes any hospitalization, unscheduled ED visit

or other urgent visit to a doctor's office for worsening asthma symptoms.

We then determined when this first relapse occurred and how many relapses the
patients had over the 6 month period of the study. For our survival analysis, only

the first relapse in the 26-week period was used.

Definition of Exposure Variables of Interest

All demographic variables such as age, gender, race and education attainment
came from interviews with the subject. Long term or chronic asthma severity was
assessed over the 4-week period prior to ED visit based on four questions
(appendix A: questions 7 to 10) according to the NHLBI guidelines (National

Institute of Health, 1997). Asthma severity was defined as severe, moderate,

12

mild persistent, and mild intermittent as assessed by determining the frequencies
over the last month of both day and night symptoms, of restricted activities, and
of any exacerbations severe enough to limit speech to only one or two words.
The classifications of severity level was based on the highest response to each

of these four questions as shown in table 2.

To examine the relative impact of recent and earlier hospitalizations on asthma
relapse during the follow-up period, we used the number of recent
hospitalizations (during 12 months prior to baseline interview) and whether or not
the patient had ever been hospitalized in the past (question 25 of Appendix A).
The patient’s current asthma treatments were considered as appropriate if their
medications meet the NHLBI guidelines relevant to their current asthma severity
(National Institute of Health, 1997). Alternatively, patients were considered as
inappropriate treatment if their current asthma medications were less than those
recommended by the guideline (National Institute of Health, 1997) (Appendix A,

question 17). For detailed information see table 2 and table 3.

13

Table 2. Classification of asthma severity: based on the evaluation of four
questions over the last four weeks

 

 

 

 

 

 

Q7. Days QB. Nights 09. Times with Q 10.
with with restricted Limiting
symptoms symptoms activities speech
Severe persistent Continual >10/week All the time Yes
Moderate Every day 5-9/week >5/week Yes
persistent
Mild persistent 3-6/week 3-4/week 3-4/week No
Mild intermittent < 2 Iweek < 2 Iweek < 2 Iweek No

 

 

 

 

 

l4

 

Table 3. Classification of inappropriate-treatment and appropriate-treatment

according to chronic asthma severity

 

inappropriate treatment

Appropriate treatment

 

Severe
persistent

Without daily combinations

in the proper treatment

Daily Long term:
ICS&LABA;

CSBA:

ICS & Theophylline
PLUS

Quick Relief:
SABA

 

Moderate
persistent

Without daily treatment in
the proper treatment

Daily Long term:
ICS;

LABA;
Theophylline
PLUS

Quick Relief:
SABA

 

Mild
persistent

Without long term control
medications at all

One Daily Long term:
ICS;

Theophylline

PLUS

Quick Relief:

SABA

 

Mild
intermittent

 

 

No medications used

 

No daily medication,
but use SABA to control
symptoms

 

Note: ICS: inhaled corticosteroid; LABA: long-acting betaz-agonist; CSBA:
combined SABA and ICS; SABA: short-acting betaz-agonist.

15

 

Statistics Analysis

Data were analyzed using SAS 8.2 software (SAS Institute, Cary, NC, USA).
Since the study was still ongoing, we restricted the data to the 172 subjects who
were enrolled up until September 16, 2002. At this time, 138 (80%) of patients
had completed the 26-week follow-up interview. All of our analyses are based on

these 138 patients.

In order to show that the sample in this study is a representative of the whole ED
population, we generated descriptive statistics of the ED patient populated in
ButtenNorth and Blodgett hospitals, Grand Rapids. We first compared the
gender, age and race distribution between the enrolled cohort and the group who
were screened but not enrolled in this study, and then we also compare the
enrolled cohort and all adult asthma ED visits in 2001 as determined by analysis

of ED billing data.

To identify the contributing factors for asthma relapse over the 26-weeks period,
we used survival analysis (Cox proportional hazard model). In order to
investigate what demographic or clinical factors were associated with asthma
relapse over the 26-weeks period. Univariate survival analysis was first
conducted followed by subsequent multivariate survival analysis. Initial candidate
variables were those associated with relapse (p<0.20) in the univariate analysis.

Backward selection procedures using PROC PHREG tie=discrete, were used for

16

variable selection. In this process, exclusion p-values were set at >0.15. We
chose to develop the model using only information collected at the initial ED visit.
Since recent hospitalizations are associated with asthma severity, we repeated
the analysis with the level of severity included and not included in the model. Age
group (18-35, over 35 years old), gender, race group (white vs. non-white), and
education attainment (up to high school graduation, or greater than high school)
were considered as a priori confounders, because these common demographic
variables have been identified as risk factor in previous studies (Adams, et al.

2000; Emerman et al. 1999).

17

Results

Description of the included hospitals and subjects

In the period up to September 2002, 172 adult asthma patients were enrolled in
the study. Of these, 120 (69.8%) subject enrolled are from Butterworth ED’s and
52 (30.2%) from Blodgett ED’s. A total of 274 subjects were screened at these 2
ED’s and 102 were not eligible or declined participants and thus not enrolled.
Subjects who were enrolled for this project did not differ in gender from those
who were screened but not enrolled, however they did differ significantly in both
race and age (Table 4). Subjects who were screened but not enrolled include
those who declined consent, had other significant illness or were not available for
follow up. Patients included in the cohort study were younger than those who
were excluded: the mean ages are 36.11112 and 40.6:t15.0 (meaniSD).
respectively (p<0.01). African Americans were more likely to be included in the

study than non-hispanic whites (Table 4).

We were also able to compare the patients population enrolled in the study to an
ED database of all adult asthma ED visits in 2001. We found that the adult
asthma ED visits enrolled in this cohort study were not different in term of gender
or age from all adult asthma ED visits in 2001 of the same age group (18-74),
e.g. percent of female visits is 74.2% in this study versus 70.8% in 2001, age
group distributions were similar between this study and 2001 data (Figures 1 and

2).

18

Table 4. Comparison of Included and Excluded Patients in Butterworth

 

 

and Blodgett
Excluded Included p-value

Sex N % N % 0.68
Male 29 39.2% 45 60.8%

Female 73 36.5% 127 63.5%

Race <0.01
White-Hispanic 3 18.8% 13 81.3%
White-Non-Hispanic 47 34.6% 89 65.4%

African American 16 22.2% 56 77.8%
Other 1 6.7% 14 93.3%
67* 172

 

* 35 subjects did not provide race indication.

19

in 2001 (data
ubjects enrolled in this study.

of gender between adult asthma ED visits

ted from billing data) with those s

Figure 1. Comparison

genera

 

 

    

   

.
.

 

 

 

 

.
.
.

_

   

\

\ X.

 

 

 

w, o/ w, % o/
00000
88888

o/ % % o/
0 0 0 0
3 2 1

 

 

Figure 2. Comparison of age in adult asthma ED visits in 2001 (data from
Physician Billing Company) with those in this study.

 

 

 

 

 

 

 

 

 

 

 

1 60%
0
( 50% ,.43.4% 479.8%)
_ 40% , DBilling
1 IEnroIled
. 30% '
l
I 20% ,, -
; 6.9% 7.3%
_ 10% ___
' 2/
18-34 rs 35-54 rs 55+
y Age groyups

 

21

By September 16, 2002, a total of 172 patients had been enrolled in this project

and 138 of them (80%) had completed the 26-week follow-up.

Of the 172 patients enrolled, 120 (70%) were from Butterworth hospital, the main
study base, and 52 (30%) were from Blodgett hospital. One hundred and fifty
(87%) had been interviewed 2 weeks after the ED visit, while 138 (82%) had
been interviewed after 26 weeks and thus completed all follow up. Of the 34
subjects for whom no 26-week follow-up was obtained, 4 (12%) declined to be
interviewed, while 30 (88%) were not reachable (Figure 3. For details, see

appendix D).

The subjects who completed follow up did not differ significantly in age, gender,
and race from those that did not complete follow up (Table 5). The mean ages for
those that completed the 26-week follow up and those that did not were

36.83115 and 33439.8 (mean tSD), respectively.

22

Figure 3. Flow chart of follow-up of enrolled subjects

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enrollment
(172)
\1 V7 \/

2-weeks FU Unable to contact Declined

(150) (19) (3)

v \I v w

26-weeks F U Declined Unable to contact Overdue

(138) (1) (28) (2)

 

 

23

 

Table 5. Comparison of patients who completed the 26-week follow-up
with those who did not

 

 

Not P-value
Interviewed Interviewed Total
Sex % % 0.08
Female 106 83.5 21 16.5 127
Male 32 71.1 13 28.9 45
Age 0.1
18-35 yr. 62 74.7 21 25.3 83
35-54 yr. 66 84.6 12 15.4 78
55+ yr. 10 90.9 1 9.1 11
Race 0.45
White Hispanic 10 76.9 3 23.1 13
White Non- 73 82.0 16 18.0 89
Hispanic
African 41 73.2 15 26.8 56
American
Other 13 92.9 1 7.1 14

 

24

Description of the baseline characteristics

Table 6 lists the baseline characteristics of the 172 subjects. The typical adult
asthma ED visitor in this project was female (74%) and white non-Hispanic
(59.3%), and presented with a complaint of short of breath (SOB), difficult
breathing or asthma. The age range was 18-74 years, and, forty nine percent
(83) were 18-34 years, forty five percent (78) were 35-54 years, and six percent
(11) were older than 55 years. Eighty one percent of them had at least high
school education. The majority of patients were classified as having mild
intermittent asthma (61%); only a few of the subjects had severe persistent
asthma (3%), so this group was combined with subjects who had moderate
persistent asthma. More than half of the subjects (59%) had private health
insurance coverage, while 14% of them had no health insurance. About 75% of
patients reported they had a primary care provider for their regular asthma care.
Thirty three percent were cigarette smokers, twenty six percent were former
cigarette smokers and thirty eight percent never smoked. Fifty eight percent of
the subjects reported they had been hospitalized for asthma overnight at least
once, but among them 44% (61) reported no hospitalizations in the last 12
months. Eighty three percent of the subjects reported ever having had an ED
visit for urgent treatment of asthma symptoms, of whom 68% had at least one ED

asthma visit in the last 12 months.

25

 

Table 6: Description of baseline characteristics of 172 adult

asthma ED visits

Age
18-34 yr.
35-54 yr.
55+ yr.

Sex
Females
Males

Race
White non-Hispanic
White Hispanic
African American
Other

Education Attainment
Less than high school
High school or GED
1-3 years of college
4-year college or more

Asthma Severity
Moderate persistent & severe
Mild persistent
Mild intermittent

Insurance Status
None
Private
Public

N

83
78
1 1

127
45

89
13
56
14

33
61
56
22

37
29
106

24
101
47

°/o

48.3
45.3
6.4

73.8
26.2

51.7
7.6
32.6
8.1

19.2
35.5
32.6
12.8

21.5
16.9
61.6

14.0
58.7
27.3

 

26

Characteristics of patients who had relapse and who did not

Thirteen of the patients (10%, 13/138) relapsed during the first 2-week follow—up
period, and 27 more (30%, 40/138) relapsed during the 2-week to the 26-week
follow-up period (Figure 4). In the future survival analysis below, not counted are
two patients who reported relapse but did not give the date when it occurred.
Descriptive characteristics for patients in this study who had relapse compared to

those that did not show in Table 7.

27

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33

Development of Cox proportional hazard model

Univariate analysis

The univariate analysis of associations between baseline characteristics and the
primary outcome of relapse during the 26-week follow-up period is listed in Table
7. The strongest associations according to the p value were for access to a
spacer, access to a peak flow meter (PFM); having ever received asthma
education from a health professional; having ever been hospitalized, frequency of
hospitalization in the last 12 months, having ever gone to an emergency room for
urgent treatment of asthma symptoms, frequency of emergency room visits for
urgent treatment of asthma symptoms, and asthma treatment appropriateness.
Because our sample size is small, we defined the significance level as 20% to
identify variables to be included in the multivariate Cox proportional hazards

model.

Modeling variables

Asthma severity can be regarded as either a risk factor, a confounder, or a
mediator on the pathway from ED visit to asthma relapse. Therefore, two models

were developed: one where severity was included and one where it was not.

34

Association of asthma severity with all variables

Several factors, such as use of a spacer, PFM, AMP, and asthma education
were strongly associated with the patients’ chronic or long-term asthma severity.
One group of variables were regarded as marker variables of asthma severity:
use of a spacer or a PFM, having an asthma management plan, having received
asthma education. Among these factors, regular use of a PFM and having an
asthma management plan were strongly associated with asthma severity
(P<0.03) (Table 8). Having ever been hospitalized overnight for asthma
symptoms, frequency of hospitalization in the last 12 months, having ever gone
to an ED for asthma symptoms, frequency of ED visits for asthma, and treatment
appropriateness are also associated with asthma severity (Table 8), but were not

regarded as marker variables.

35

Table 8. Association between asthma severity with other variables that have
strong association with asthma relapse.

 

 

Variables P
values
Age 0.03
Gender 0.25
Insurance status 0.59
Education attainment 0.43
Use spacer regularly 0.06
Use PFM regularly <0.01
Have asthma management plan 0.03
Received asthma education 0.20
Ever taken steroid <0.01
Ever been hospitalized overnight for asthma <0.01
Frequency of hospitalization in last 12 <0.01
months
Ever gone to Emergency room for asthma 0.64
Frequency of going to ED for asthma 0.04
inappropriate-treatment <0.01

 

36

Multivariate analysis

Model Selection using Marker variables

Following the univariate analysis (Table 7), all variables with p-value less than
0.20 were considered in the model selection regardless of whether we regarded
them as marker variables, e.g. indicator of asthma severity. Age, gender, race,
and education were included as potential confounders, regardless of statistical

significance. The results of this multivariate analysis are presented in Table 9.

The final model included only one significant variable-the frequency of
hospitalization in the last 12 months. This result was not affected by whether
asthma severity was considered in the model or not (based on a significance

level of 5%) (models 14 and 25).

If the significance level was increased to a 10%, two models were generated.
The model that included asthma severity identified two variables: use of a spacer
and the frequency of hospitalization over the last 12 months as significant (model
13). The model which did not consider asthma severity identified three variables:
use of a spacer, having ever received asthma education, and the frequency of

hospitalization (model 24). (For details, see Table 9).

37

 

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39

Model Selection without marker variables

The marker variables were not regarded as real risk factors, since they are
potential indicators of the underlying asthma severity. This situation arises
because the more severe the asthma, the more likely a patient is to use a spacer
and PFM, receive asthma education, and have an asthma management plan
(Table 7). Therefore, we conducted analysis where we excluded these variables.
Controlling for age, gender, race, and education, the final model included only
the frequency of hospitalization in the last 12 months at significance levels of
both 5% and 10%, regardless of whether severity was considered. The results of

this multivariate analysis are presented in Table 10.

40

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41

Kaplan-Meier survival curves for the three groups according to the

frequency of previous hospitalization in previous year

We plotted Kaplan-Meier curves based on survival function S(t) versus follow-up
time in weeks for the three groups: 0 time of hospitalization, 1 time of

hospitalization and more than 2 times of the hospitalizations (Figure 5). This plot
shows asthma patients having 0 time of hospitalization in previous year have the

best survival probability than those having 1 or 2 times of hospitalization.

Final Model

Our final model concluded that only the frequency of hospitalization in the last 12
months was a significant risk factor (table 12). With asthma severity in the model,
the hazard ratio is 3.1 (95% CI 1.1-8.6) if the patient had 1 hospitalization in the
last 12 months. When the patient had 2 or more hospitalization, the hazard ratio
increased to 3.3 (95% CI 1.4—7.8). When asthma severity was excluded from the
model, the hazard ratio declined slightly to 2.5 (95% CI 1.0-6.7) if the patient had
1 hospitalization in the last 12 months, but increased to 4.1 (95% CI 1.8-9.2) if

the patient had 2 or more hospitalizations (Table 11);

42

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43

Table 11. Final multivariate model for adult asthma relapse over a 6

month period

 

 

Models Factors Factor levels HR 95% HR CI p
value
Model 1 (Includes severity)
Age 18-35 yr. 1.36 0.67-2.74 0.4
35+ yr. 1 _ _
Sex Females 1 .37 0.57-3.26 0.48
Males 1 _ _
Race Non-white 1 .21 0.61 -2.40 0.58
White 1 _ __
Education attainment More than high school 1.81 0.91-3.63 0.09
High school or less 1 _ _

Severity1

Frequency of
hospitalization2

Model 2 (excluded severity)
Age

Sex
Race
Education attainment

Frequency of
hospitalization’

Severe 8 Moderate persistent 1.76 0.75-4.13 0.2
Mild persistent 1.64 0.68-3.95 0.27
Mild intermittent 1

More than2hospitalizations 3.28 1.38-7.76 0.01

1 hospitalization 3.09 1.10-8.64 0.03
0 hospitalization 1 _ _
18-35 yr. 1.28 0.63-2.60 0.49
35+ yr. 1 _ _
Females 1.32 0.56-3.12 0.52
Males 1 _ _
Non-white 1.2 0.61 -2.37 0.59
White 1 _ _
Beyond high school 1.86 0.93-3.71 0.08
High school or less 1 _ _

More than2hospitalizations 4.08 1.80-9.23 <0.01

1hospitalization 2.53 0.95-6.74 0.06

0 hospitalization 1

Note: 1=LRCS (2 degree of freedom), p=0.28; 2= LRCS (2 degree of freedom), p=0.001; 3=LRCS (2

degree of freedom), p<0.01;

44

Chapter four: Discussion

1. Description of patient cohort

This patient cohort comprised adults aged 18-74 years with acute asthma
presenting to the two emergency departments of Butterworth and Blodgett
Hospitals between November 2001 and September 2002. Two thirds were
female, about half of the cohort were younger than 35 years old, and more
than 60% were white. Most of the subjects were covered by private health
insurance and had at least high school education. The majority of individuals
had either mild intermittent or mild persistent asthma; only 21.5% suffered
moderate to severe asthma. The primary outcome was defined as at least
one urgent care visit for asthma after the initial ED visit, where urgent care
visit was defined as ED, or other unscheduled office visit. The short-terrn (2
weeks) rate of relapse was fairly low (10%), while the long-term (26 weeks)
rate of relapse was 30%. Gender, age distribution, education level and
insurance status were similar to other adult cohorts in the published literature,
except higher proportion of whites in our study (MaCarren, et al. 1998;

Emerman, et al. 1999; Adams, et al. 2000; Ford, et al. 2001).

The data were collected as part of the baseline assessment for the Grand

Rapids Asthma Cohort Study. Comparison of included and excluded subjects

showed that there were no significant differences between them in terms of

45

demographic characteristics indicating that this patient cohort was

representative of all ED asthma visits at the study hospitals.

2. Occurrence of relapse and risk factors for relapse

Asthma remains a common clinical condition affecting approximately 14
million people (MMWR, 1995). In 2001, an estimated 31.3 million persons
reported having had asthma diagnosed, and 20.3 million persons currently
had asthma. Each year, between 5% and 10% of these asthmatic patients
will have an acute exacerbation requiring a visit to the emergency department

(MM WR, 2003).

Despite significant advances in our understanding of asthma, relapse remains
a substantial problem. There remains a significant proportion of patients
relapsing and requiring urgent medical treatment after presenting to an ED
(Emerman, 2000). Previous studies showed that short-terrn (within 2 weeks)
relapse rates ranged from 6% to 17%, and that long-term relapse rate (8
weeks) was around 45% (MaCarren, et al. 1998; Emerman, et al. 1999;
Adams, et al. 2000; Ford, et al. 2001. Our study found a 10% of short-ten'n

and 30% of long-term relapse rate among the 138 patients.

Previous studies found the following factors were associated with asthma

relapse: knowing the name of their primary care physician (which was taken

46

as a marker for access to follow-up care), inability to obtain their discharge
medications, simple measures of pulmonary function (PEV1), frequent
previous ED visits and previous hospitalizations, multiple triggers for asthma,
use of a home nebulizer, and a duration of symptoms between 1 and 7 days
(Emerman, et al. 1998; Nowak et al. 1982; Emerman, et al. 1995; Emerman,
et al. 1999). However, other previous studies have not confirmed that these
risk factors, finding no association between pulmonary function, and duration
of symptoms, and asthma relapse. (Worthington, et al. 1989; Martin, et al.
1982; Klaustenneyer, et al. 1990; Cross, et al. 1991; Chan-Young, et al.

1996)

There is no consistent standard in the literature for a definition of relapse or
recurrence or for the length of time used to measure an asthma relapse.
However, researchers such as Emerman have defined relapse and
recurrence as an unscheduled clinic or ED visit for an asthma exacerbation,
(Emerman et al. 1998), and Camargo went on to define: relapse as the
reappearance of symptoms of asthma requiring unscheduled care within
three weeks of the initial event, and recurrence as the reappearance of
symptoms of asthma requiring unscheduled care more than three weeks after

the initial event (Camargo, 2003).

Although a number of variables were significantly associated with relapse

according to the univariate analysis with a Cox proportional hazards model

47

(based on a p value of 0.2.), including variables for access to a spacer,
access to a peak flow meter (PFM); having ever received asthma education
from a health professional; having ever been hospitalized; frequency of
hospitalization in the last 12 months; having ever gone to an emergency room
for urgent treatment of asthma symptoms in last 12 months, frequency of
emergency room visits for urgent treatment of asthma symptoms; and
appropriateness of asthma treatment in the multivariate Cox proportional
hazards model selection, but only one variable was retained in the final
model: the frequency of hospitalization for asthma treatment in the last 12
months. With asthma severity in the model, the hazard ratio is 3.1 (95% CI
1.1-8.6) if the patient had 1 hospitalization in the last 12 months. When the
patient had 2 or more hospitalization, the hazard ratio increased to 3.3 (95%
CI 1.4-7.8). When asthma severity was excluded from the model, the hazard
ratio declined slightly to 2.5 (95% CI 1.0-6.7) if the patient had 1
hospitalization in the last 12 months, but increased to 4.1 (95% CI 1.8-9.2) if

the patient had 2 or more hospitalizations.

Some of the difficulties in assessing and limiting asthma relapse reflects an
incomplete understanding of the factors that lead to ED visits. Patients
present with a variety of symptoms and in conditions that range from mild to
severe respiratory distress. It is understandable that studies addressing

heterogeneous groups of patients may have conflicting results. Larger-scale

48

studies may have greater power to identify the risk factors, allowing for

recommendations for tailored therapy or other interventions such education.

Further research should decrease asthma exacerbations and relapse, and
focus on the practicality of identifying higher-risk patients for a variety of
interventions. These include referral to an asthma specialist, efforts to
improve the management of asthma patients by primary care physicians, the
efforts to control the home environment, finally the efficacy of tailoring anti-
inflammatory and other medication interventions following ED treatment for

acute asthma.

3. Proxy or marker variables of underlying asthma severity

In our analysis, spacer use, peak flow meter (PFM) use, having an asthma
management plan(AMP), and having ever received asthma education from a
health professional were regarded as potential marker variables of asthma
severity. Use of PFM, spacer, and AMP would be expected to be higher in
patients with greater disease severity who would also be expected to have a
higher risk of relapse. Individuals using a spacer, or PFM or AMP would
therefore tend to have a higher risk for later relapse as shown previously in

table 7.

49

In the first model selection approach, we included all of these marker
variables. At a significance level of 5%, the final model included only one
significant risk factor: the frequency of hospitalization in the last 12 months.
This was We regardless of whether we included asthma severity or not in the
model. At a significance level of 10%, when we included asthma severity, the
final model included two significant risk factors: use of a spacer and the
frequency of hospitalization in the last 12 months. When asthma severity
was not included in the modeling process, the final model included three
significant risk factors: use of a spacer, having received asthma education,

and frequency of hospitalization in the last 12 months.

In the second set of model selections, we excluded all marker variables.
Regardless of whether we considered asthma severity, the final model again
included only one significant risk factor at significance levels of both 5% and
10%: the frequency of hospitalization in the last 12 months and thus result did
not change when the significance level for variable inclusion was increased

from 5 to 10%.

The decision was based on an understanding or conceptual model of disease
severity and ED use, the marker variables mentioned above are expected to
be indicators of asthma severity, not possible risk factors for later asthma

relapse. It is reasonable that they are not in the model selection.

50

4. Asthma severity as a factor for relapse

Asthma is a common disease with great variation in both severity and
etiology. Since there is no agreed-upon “gold standard” for assessing asthma
severity, this variability leads to problems for both diagnosis and treatment.
More valid assessments of asthma severity are needed, particularly for

asthma research.

In our study, the degree of asthma severity over the last 4 weeks did not
predict asthma relapse as much as expected. The Hazard Ratio for mild
persistent and mild intermittent asthma patients are 1.1 and 0.5, respectively,
compared to the combination group of severe and moderate persistent
asthma patients. This could be because the sample size in this study is
relatively small, asthma subjects in our cohort are mostly intermittent or mild
persistent (110/138, or 80%), and we had almost no subjects with severe
persistent asthma. When the severity was excluded from the multivariate
model, there was no significant effect on the final model selection. It is as
reasonable, therefore, to use the final model without asthma severity

included, as the model with asthma severity included.

4. Implications for disease management

The consistent pattern of relapse during the study suggests that many

51

patients who have more than 1 hospitalization in the last 12 months before
the current asthma ED visit are predisposed to further urgent asthma care
(relapse). In our study, patients, with prior hospitalization were between 2.5
and 3 times more likely to relapse over 6 months follow up period. Since prior
hospitalization is probably not a true causal factor, patients with prior
hospitalization needs more attention both by clinician and themselves, and it
may be a targeted risk group. Thus a future study should focus on this group
of high-risk asthma patients who had hospitalization in the previous twelve
month and develop more aggressive therapeutic regimen in order to reduce
the relapse rate among this population, according to the guidelines for the

diagnosis and management of asthma (National Institute of Health, 1997).

5. Limitation of the study

There are several limitations to this study. First, approximately 20% of the
patients were lost to follow-up at 26 weeks, including both those unable to
contact and those who declined to participate in the follow-up calls. We have
no information to estimate whether their relapse rate would be different from
those patients for whom we had follow-up, and we treated all those patients
as censored individuals. Second, we relied on patients' self-reported
information. It is possible that patients may have under-reported these
factors, e.g. smoking status, treatment appropriateness, out of

embarrassment of continued behavior they knew to be detrimental to their

52

asthma management. Also, as this is an observational study, many other
unrecognized factors such as behavior and personality can affect the data
collection. Thirdly, there is a limited sample size, which causes model
estimates to be unstable. Fourthly, there is no consistent definition of relapse
in the literature. The definition of relapse in our study is restricted to urgent
asthma treatment, or ED visit. Different definition of asthma relapse may
have different survival analysis that we currently did. Finally, the severity of
asthma patients in this study were mostly mild intermittent or mild persistent,
which leads to a lower rate of relapse, possibly explaining why asthma
severity does not at all predict relapse in our study, as expected but there was

not a large difference in relapse rate across severity groups.

Many other factors that influence relapse (e.g., patient environment, self-care,
biological factors) that could be assessed in the course of care in the ED,

were not included in our study.

6. Conclusions

One factor, the frequency of hospitalization in the last 12 months, was

identified as contributing to asthma relapse within the period of 26 weeks.

This finding could help clinicians identify higher risk asthma patients and

provide therapy more effective in preventing future asthma exacerbation.

53

Appendix A
ADULT COHORT VISIT FORM

Emergency Department (CIRCLE ONE): Gerber Blodgett Butterworth

 

 

 

 

ED visit date (mm/dd/yyyy) ....................... | | l / | | | / | | l | |
ED triage time (mi/itary- hh:mm) ........................................ | | | : | | |
Insurance Company .........
Presenting complaint .......

 

PLEASE ANSWER EVERY QUESTION. IF SUBJECT DOES NOT KNOW AN
ANSWER PLEASE WRITE IN 'DK’ (DON’T KNOW). RECORD ONLY ONE
ANSWER TO EACH QUESTION UNLESS SPECIFICALLY INSTRUCTED TO
SELECT ONE OR MORE.

A. DEMOGRAPHIC INFORMATION
1. What isyourdateofbirth (mm/dd/YYYYI | I III I III | | | |

2. Sex: Male ......................................................................................... 01
Female ..................................................................................... 02

3. Are you Spanish, Hispanic or Latino?

No ............................................................................................ 01
Yes ........................................................................................... 02

4. What is your race? (SELECT ONE % MORE)

White or Caucasian ......................................................... 01
Black or African-American ....................................................... 02
Asian ........................................................................................ 03
American Indian or Alaska Native ............................................ 04
Native Hawaiian or Pacific Islander ......................................... 05
Other race (specify— .................................................................. 06)
5. How much schooling have you completed?
Less than high school .............................................................. 01
Graduated high school or got GED .......................................... 02
1-3 years of college ................................................................. 03
4-year college degree or more ................................................. 04

54

B. ASTHMA HISTORY

6. Have you ever been told by a doctor, nurse, or other health professional that
you had asthma?

No ............................................................................................ 01
Yes ........................................................................................... 02
If Yes,

63. How old were you when you were first told by a
doctor, nurse, or other health professional that you
had asthma?

(years old) ......................................................................... |_|_|

6b. Has a doctor, nurse, or other health professional
ever said what the cause of your asthma was?

No ............................................................................................ 01
Yes (specify: ........................................................................... 02

Go. Do certain things, exposures, or activities make your asthma worse?
No ........................................................................................... 01
Yes (specify: .................................................................. 02

IF AGE AT FIRST DIAGNOSIS 215 YEARS then (ELSE SKIP TO QU 7):
6d. Were you ever told by a doctor or other medical person that your
asthma was related to any M you ever had? (IF INITIAL RESPONSE
IS NO, ASK AHAVE YOU EVER HAD A JOB OUTSIDE THE HOME?”)

No ............................................................................................ 01
Yes (SKIP TO QUESTION 6f) ................................................. 02
Never worked outside the home (SKIP TO QUESTION 7) ...... 03

6e. Did ygg ever tell a doctor or other medical person that your asthma
was related to any job you ever had?
No ............................................................................................ 01
Yes ........................................................................................... 02

6f. When you w developed symptoms of asthma, what kind of work were you
doing? For example, RN, clerical, managerial, teaching, auto mechanic, or
accountant.

(specify:

 

IF NOT WORKING WHEN ASTHMA STARTED (SKIP TO QUESTION 7)

69. What kind of business or industry was that job in? For example,
hospital, newspaper publishing, mail order house, auto repair shop, or
bank.

55

(specify:

 

The following questions are about your asthma symptoms over the last 4 weeks
that is from to (but do not refer to this current episode)

7. How often in the last 4 weeks have you had asthma symptoms during the
gay? (i.e., wheezing, a dry cough, shortness of breath, and/or chest tightness
due to asthma)

Never ....................................................................................... 01
Less than once a week ............................................................ 02
1 or 2 times a week .................................................................. 03
3 to 6 times a week .................................................................. 04
Every day ................................................................................. 05
Continually (all the time) .......................................................... 06

8. How many times over the last 4 weeks did you wake mt nigm because of
asthma symptoms? (i.e., wheezing, a dry cough, SOB, and/or chest tightness
due to asthma)

Never ....................................................................................... 01
1 or 2 times ............................................................................. 02
3 to 4 times ............................................................................. 03
5 to 9 times ............................................................................. 04
10 or more times ...................................................................... 05

9. How many times over the last 4 weeks have your activities been affected or
restricted by asthma symptoms?

Never ....................................................................................... 01
1 or 2 times .............................................................................. 02
3 to 4 times .............................................................................. 03
5 or more times ........................................................................ 04
All the time ............................................................................... 05

10. In the last 4 weeks have your asthma symptoms ever been severe enough to
limit your speech to onlv1 0L2 worgs at a time between breaths?

No ............................................................................................ 01

Yes ....................................................................................................... 02
If Yes, 103. How many times has this occurred in the last 4 weeks?

(times) ............................................................................... |_|_|

(NOTE = THE NUMBER OF SEPERATE EPISODES)
C. USUAL SOURCE OF ASTHMA CARE

56

11.00 you have a “primary care provider” or other regular source of medical
care (such as a family doctor, internist, PA, nurse practitioner or medical

clinic)?
NO (IF NO, SKIP TO QUESTION 13) ................................. 01
Yes ........................................................................................... 02

12. Does this doctor/provider/clinic take primary responsitllitv for your regular
asthma care? (i.e., directs your asthma care and writes most of your

prescriptions)

[= REGULAR ASTHMA CARE PROVIDER]
NO ............................................................................................ 01
Yes (IF YES, SKIP TO QUESTION 14) ................................ 02

13.What type of doctor/provider/clinic takes primam responsibility for your regular
asthma care? (i.e., directs your asthma care and writes most of your

 

 

prescriptions)

[= REGULAR ASTHMA CARE PROVIDER]
Emergency Department (specify: ).... 01
Med center (= urgent care center) (specify: )... 02
An asthma specialist (specify pulmonologist, allergist,
or asthma clinic ) .................. 03
Other provider/site (specify: )04

 

No regular asthma care provider (SKIP TO QUESTION 16) 05

14. How many times in the last 12 months did you visit HIE (doctor/provider/clinic)

for a regularly scheduled appointment for asthma care?

[SCHEDULED APPT. = REGULAR OR ROUTINE VISIT TO DISCUSS
ASTHMA]

(times or ‘0’ for Never) ...................................................... |_|_|

15. How many months ago was the last regularly scheduled apwintment for
asthma care with this doctor/provider/clinic?

s 1 month ago .......................................................................... 01
1 — 3 months ago ..................................................................... 02
4 - 6 months ago ...................................................................... 03
7 — 12 months ago ................................................................... 04
> 12 months ago ...................................................................... 05

16. In the last 12 months, have you visited an asthma specialist (e.g.,
pulmonologist, allergist, asthma clinic or other specialist)? (LEAVE
BLANK IF SPECIALIST IS REGULAR ASTHMA CARE PROVIDER AS
DEFINED IN QUESTION 13).

57

No ............................................................................................ 01
Yes ........................................................................................... 02

D. CURRENT ASTHMA TREATMENT, MANAGEMENT AND CONTROL

17. RECORD ALL PRESCRIPTION AND NON-PRESCRIPTION ASTHMA
RELATED MEDICATIONS USED IN THE LAST 4 WEEKS IN THE FOLLOWING
TABLE (EXCEPT SYSTEMIC STEROIDS - SEE QUESTION 18)

 

Medication Frequency Current Route Has Rx Used in
Doctor Rx’d Frequency Of Use Run last four
Out? weeks?

 

Daily QOD Wkly Daily QOD Wkly PRN PO Inh Yes No Yes No
PRN Neb

 

Daily QOD Wkly Daily QOD Wkly PRN PO Inh Yes No Yes No
PRN Neb

 

Daily QOD Wkly Daily QOD Wkly PRN PO Inh Yes No Yes No
PRN Neb

 

Daily QOD Wkly Daily QOD Wkly PRN PO Inh Yes No Yes No
PRN Neb

 

Daily QOD Wkly Daily QOD Wkly PRN PO Inh Yes NO Yes No
PRN Neb

 

Daily QOD Wkly Daily QOD Wkly PRN PO Inh Yes No Yes No
PRN Neb

 

 

Daily QOD Wkly Daily QOD Wkly PRN PO Inh Yes NO Yes No
PRN Neb

 

 

 

 

 

 

18. Have you ever taken steroids orally or by injection for a severe asthma
attack?

No ............................................................................................ 01
Yes ........................................................................................... 02

If Yes, 18a. Over the past 4 weeks, have you taken any steroids orally or by
injection for asthma? (CHECK ORAL AND INJECTION IF HAVE TAKEN BOTH)

No 01

Yes — Injection 02

Yes - Oral 03
If Yes - Oral,

18b. How many days in the past 4 weeks did you take oral steroids? |_|_|

58

 

180. How many days ago did you last take oral steroids? (days) |_|_|

IF NOT CURRENTLY USING INHALED CORTICOSTEROIDS:

19. Have you ever used an inhaled steroid for asthma?

NO ............................................................................................ 01
Yes ........................................................................................... 02

If Yes, 19a. Names (s)

 

19b. For how long did you take an inhaled steroid for asthma?|_|__|

days ......... 01
weeks ...... 02
months 69003
190. When did you last use an inhaled steroid for asthma? |_|_|
weeksO1
months ..... 02
years ago. 03
20.Are you usually able to get your asthma prescriptions filled?
NO ................................................................................................. 01
Yes ................................................................................................ 02

If NO, 20a. Why not? Specify main reason

 

21 .A spacer is a device that you put between the mouth and inhaler to make it
easier to breathe medicine into the lungs. Do you have a spacer?

NO ............................................................................................ 01
Yes ........................................................................................... 02
If Yes, 21a. How often do you use the spacer when using the inhaler?

Never ....................................................................................... 01
Rarely ...................................................................................... 02
Occasionally ............................................................................ 03
Usually ..................................................................................... 04
Always ..................................................................................... 05

 

22.A @pk flow meter measures how hard you can blow air out of the lungs. Do
you have a peak flow meter?

NO ............................................................................................ 01
Yes ........................................................................................... 02

If Yes, 22a. On average, how Often do you use the peak flow meter?

59

Rarely ...................................................................................... 01

< 1/week .................................................................................. 02
1-3/week .................................................................................. 03
4-6/week .................................................................................. 04
Daily ......................................................................................... 05
Only during exacerbations ....................................................... 06

23.Has a doctor or a nurse ever given you a written plan for you to treat your
asthma?
[= ASTHMA MANAGEMENT PLAN]

NO ............................................................................................ 01
Yes ........................................................................................... 02

24. Have you ever received education about asthma control and treatment from a
health professional?

NO ............................................................................................ 01
Yes ........................................................................................... 02

If Yes, 24a. What did you Ieam about? (CIRCLE YES OR NO FOR EACH ITEM):

Things that can trigger your asthma? .......... YES NO
Medications and treatments? ...................... YES NO
How to use an inhaler or nebulizer? ........... YES NO
How to use a peak flow meter? ................... YES NO
What to do during an asthma attack? ......... YES NO
How to use a written action plan? ............... YES NO

E. EMERGENCY ASTHMA CARE

[THE FOLLOWING ANSWERS SHOULD NOT INCLUDE THE CURRENT
EPISODE]

25. Have you ever been hospitalized overnight for treatment of asthma symptoms
[i.e., wheezing, dry cough, shortness Of breath, and/or chest tightness due to
asthma]?

NO ............................................................................................ 01
Yes ........................................................................................... 02

If Yes,
25a. How many times in the last 12 months, have Lop

stayed over night in the hospital for treatment Of
asthma symptoms? (times) .................................................. |_|_|

26. Excluding today, have you ever previously gone to an emergency room for
urgent treatment Of asthma symptoms?

60

NO ............................................................................................ 01

Yes ........................................................................................... 02
If Yes,
26a. How many times in the last 12 months, have you visited an emergency
room for urgent treatment of asthma symptoms?(times) ............. |_|_|

26b. Which emergency rooms did you visit?

 

26c. How long ago was the last visit? .................................... |_|_|
days ......... 01
weeks ...... 02
months agoO3

27.When you are having problems with asthma symptoms that require urgent
treatment - that is, treatment needed within 24 hours of recognizing a
problem, where do you usually end up going?

Regular asthma care provider (as defined previously)

 

 

 

 

 

SKIP TO QUESTION 28 ............................................... 01
Emergency Department (if after hours or RACP is NA) ........... 02
(specify:
Emergency department (ALL times) specify: 03
Med care center (specify: .............. 04
An asthma specialist (specify pulmonologist, allergist,
or asthma clinic: ....................... 05
Other provider/site (specify: .......... 06
NO specific location/provider .................................................... 07

If answer is NOT regular asthma care provider then:

27a.Why do you use this particular place for asthma care? (CHECK ALL THAT
APPLY)

 

 

NO regular asthma care provider ............................................. 01
Regular asthma care provider not available ............................. 02
Insurance company dictates .................................................... 03
NO insurance ............................................................................ 04
Other cost issues (specify: _ 05
Transport issues (specify: ....... 06
Convenience ............................................................................ 07
Best medical care .................................................................... 08
Past experience/comfort with people/place .............................. 09
Other (specify. ......................................................................... 1 O

61

28. How many times in the last 12 months did you visit a goctor's Office or Clinic
for urgent treatment of asthma symptoms? [URGENT VISIT = NOT
SCHEDULED OR SCHEDULED < 24 HRS AHEAD OF TIME. DO NOT
INCLUDE ED OR HOSPITAL VISITS]

(times or ‘0’ for never) .................................................. |_|_|

F. SMOKING HISTORY
29. Have you ever smoked cigarettes? [IF QUIT SMOKING 5 28 DAYS =

SMOKER]
Never smoke 01
Former-smoker 02
Current Smoker 03
IF CURRENT SMOKER:

 

29a. At what age did yOUI first start to smoke regularly? ...............
29b. On average, how many cigarettes sdo you smoke per day?—

IF FORMER SMOKER:
29c. At what age did you first start to smoke regularly? ...........................
29d. At what age did you QUIT smoking regularly? (yrs. old) ....... _
2%. On average, how many cigarettes did you smoke per day?

G. ASTHMA AWARENESS
Please tell us if the following statements are true or false.

30. Most people with asthma can become free of symptoms with proper
treatment.

True ......................................................................................... 01
False ........................................................................................ 02

31 .Asthma is characterized by inflammation of the airways, which if controlled
can greatly reduce symptoms.

True ......................................................................................... 01
False ........................................................................................ 02

32. If someone with asthma feels well, it is Okay to stop taking his or her
medications.

True ......................................................................................... 01
False ........................................................................................ 02

62

Appendix B

ADULT COHORT 2-WEEK FOLLOW-UP FORM
SECTION A: EMERGENCY ASTHMA VISITS

 

 

FIRST CONFIRM REGULAR ASTHMA CARE PROVIDER (RACP)
INFORMATION:

When we completed the survey during your visit to the emergency
department on _/_, we noted that the doctor/provider/clinic that takes
primary resdapnsipility for your asthma - that is, directs and writes most of
your prescriptions was:

(name)

Type of health care provider:

 

 

PCP/CLINIC ............................................................................. 01
SPECIALIST ............................................................................. 02
ED ............................................................................................ 03
MEDCENTER ........................................................................... 04
OTHER ..................................................................................... 05
NONE .................................................................................................. 06
1. Is this correct?
NO (Specify who is: 01
Yes ........................................................................................... 02

2. Since you left the hospital emergency department on |_|_|
I I I I l I | I, have you had a worsening Of your asthma
that led you to go for urgent medical treatment?
No ............................................................................................. 01
Yes ........................................................................................... 02

3. How many times has this happened since you left the
emergency department?

(times) ........................................................................... |_|_|

4. Thinking about the first time this happened, when
did you go for urgent medical treatment for your
asthma?
(mm/dd/yr) ................................. I I III I III I |

 

5. Where did you ms; go for this urgent asthma visit?
Regular asthma care provider (as defined above) ................................ 01

63

 

Med care center (specify: 03

 

 

An asthma specialist: pulmonologist ........................................ 04
An asthma specialist: allergist .................................................. 05
An asthma specialist: asthma Clinic .......................................... 06
Other provider/site (specify: 07
No specific location/provider ..................................................... 08

5a. Why did you use this particular place for asthma care?

 

 

 

(CHECK ALL THAT APPLY)
No regular asthma care provider .................................. 01
Regular asthma care provider not available ............................. 02
Insurance company dictates ..................................................... 03
No insurance ............................................................................ 04
Other cost issues (specify: 05
Transport issues (specify: 06
Convenience ............................................................................ 07
Best medical care ..................................................................... 08
Past experience/comfort with people/place .............................. 09
Other (specify: ...... 10
Severity Of episode - EMERGENCY! ....................................... 11

6. At this visit did the doctor change your asthma
medicines or make any other changes in the
management of your asthma? (PROMPT — FOR
EXAMPLE, GIVE YOU A NEW MEDICATION, OR
CHANGE THE WAY YOU USE YOUR EXISITING
MEDICATIONS, OR CHANGE THE WAY YOU
MONITOR OR MANAGE YOUR ASTHMA)
NO asthma treatment given (including nO inhaled B-agonist) ...... 01

 

 

Given inhaled III-agonist treatment but no new asthma Rx ........ 02
Change in treatment plan (specify below) ................................... 03
Details
7. Did this visit result in you being transferred to an emergency department
or hospital?
No ............................................................................................. 01
Yes (Specify ED: _02
If Yes, 7a. Were you admitted to the hospital overnight?
NO ............................................................................................. 01
Yes (Specify hospital: 02

 

IF 03 = MORE THAN ONE “RELAPSE” VISIT — REPEAT QUESTIONS FOR
SECOND VISIT SINCE PATIENT LEFT HOSPITAL. AT END OF THIS

64

SECTION CONFIRM SINCE PATIENT FIRST LEFT EMERGENCY
DEPARTMENT:

Total (cumulative) number of ED/Urgent Care visits ................

Total (cumulative) number of overnight hospitalizations ..........
SECTION B: ROUTINE ASTHMA VISITS

8. Since you left the hospital emergency department on
I have you made a follow-up appointment with

your regular asthma care provider (RACP) for an
asthma check up?

No ............................................................................................. 01
Yes ........................................................................................... 02

83. When did you first see this doctor/nurse/clinic (RACP) for an asthma
check-up?
(mm/dd/yr) ................................ | I l / | I | / |_|_|
or number Of days after ED visit (days) .................. | | | |
8b. How many asthma check-pg have you had with this
doctor/nurse/clinic (RACP) since he/she left the
emergency department?
(number of checkups) .................................................... |_|_|
8c. As a result of this visit (these visits), did the doctor change
your asthma medicines or make any other changes in the
management of his/her asthma? (PROMPT — NEW
MEDS?, OR CHANGE EXISITING MEDS?, OR CHANGE
IN MANAGEMENT OF ASTHMA?)
No ............................................................................................. 01
Yes ........................................................................................... 02

Describe:

 

9. Have you had any other doctor visits specifically related to
your asthma care and treatment since leaving the
emergency department? (i.e., NOT WITH RACP, e.g.,
ASTHMA SPECIALISTS)
NO ......................................................................................................... 01
Yes ....................................................................................................... 02

9a. When did you first see ANOTHER doctor/nurse/clinic
NOT RACP for an asthma related visit?
(mm/dd/yr) .................................. | l I / I I |/ I | l
or number of days after ED visit (days) .............................. | | l l

 

65

9b. How many asthma related visits have you had with
ANOTHER doctor/nurse/clinic (NOT RACP) since you left the
emergency department?
(number of visits) ........................................................... |_|_|

QC. Where did the visit take place and who was it with?
(CHECK MORE THAN ONE RESPONSE IF VISITS TO

 

MORE THAN ONE SPECIALIST)
Asthma specialist (specify type: 01
Specialty Asthma Clinic ............................................................ 02
Other primary care type doctor/clinic ........................................ 03
Other (specify: 04

 

Name & location

 

9d. What was the primary purpose of this (these) visit(s)?

(Describe:

9e. As a result Of this (these) visit(s), did the doctor change
your asthma medicines or make any other changes in the
management Of his/her asthma? (PROMPT — NEW
MEDS?, OR CHANGE EXISITING MEDS?, OR
CHANGE IN MANAGEMENT OF ASTHMA?)

 

No ............................................................................................. 01
Yes ........................................................................................... 02
Describe:

 

10. Have you had any other doctor visits for health
problems not related to asthma since he/she
left the hospital? (# visits) ......................................................... |_|_|

If Yes, 10a. What was visit for?

 

C. ORAL STEROIDS TREATMENT AND COMPLIANCE

[SEE FRONT PAGE OF THIS FORM — ONLY ASK QUESTION 10 IF PATIENT
SENT HOME FROM ED ON SHORT-TERM ORAL STEROID REGIMEN]:

ORAL steroid:
When you left the emergency department, you were advised to
take an oral steroid medicine called for _ days.

 

11. How many days did you actually take this medicine? (days) ...|_|_|

66

11a. Was this fewer days than originally prescribed?

NO ............................................................................................. 01
Yes ........................................................................................... 02
11b.Please think about why you did not take the as prescribed. As I

 

read you the following list, please let me know even reason that applies to you.
(CIRCLE & THAT APPLY):

I felt better and I didn't feel it was necessary ............................ 01
I experienced side effects. [real or imagined] .......................... 02
l was scared about possible side effects .................................. 03
The treatment plan was too complicated .................................. 04
I had no money to fill prescription ............................................. 05
I lost the prescription ................................................................ 06
I refused to take medicine ........................................................ 07
Doctor changed treatment ........................................................ 08
Other (Specify: 09

 

 

IF MULTIPLE RESPONSES ASK 11C. ELSE GO TO 12:

11c. Which was the most important reason that
you did not take the as
prescribed? (Q11b code #) .................................................... |_|_|

D. CURRENT SYMPTOMS, CONTROL AND QUALITY OF LIFE

12. How often in the last 2 weeks have you had asthma symptoms
during the day? (i.e., wheezing, a dry cough, shortness Of
breath, and/or chest tightness r/t asthma)

Never ............................................................................................... 01
Less than once a week .................................................................... 02
1 or 2 times a week .......................................................................... 03
3 to 6 times a week .......................................................................... 04
Every day ......................................................................................... 05
Continually (all the time) ................................................................... 06

13. How many times over the last 2 weeks did you wake up at
night because of asthma symptoms? (i.e., wheezing, a dry
cough, shortness of breath, and/or chest tightness r/t

asthma)
Never ............................................................................................... 01
1 or 2 times ...................................................................................... 02
3 to 4 times ...................................................................................... 03
5 to 9 times ...................................................................................... 04
10 or more times .............................................................................. 05

67

14.

15.

15a.

16.

17.

18.

19.

How many times over the last 2 weeks have your
activities been affected or restricteg by asthma

symptoms?
Never ............................................................................................... 01
1 or 2 times ...................................................................................... 02
3 to 4 times ...................................................................................... 03
5 or more times ................................................................................ 04
All the time ....................................................................................... 05

Over the past 2 weeks have your asthma symptoms been
severe enough to limit your speech to only 1 or g worps at a
time between breaths?

No ............................................................................................. 01
Yes ........................................................................................... 02
How many times has this occurred in the last 2 weeks? .......... |_|_|

Over the past 2 weeks how many days have you used
your quick relief medicine. (i.e., short acting
bronchodilator or rescue medicine)
(days) ............................................................................ |_|_|
Over the past 2 weeks, how much discomfort or distress
have you felt because Of asthma symptoms? Would you
say..

None ................................................................................................ 01
Mild .................................................................................................. 02
Moderate .......................................................................................... 03
Severe ............................................................................................. 04

How would you rate your asthma conman now
compared to when you first arrived to the emergency

department?
Much worse ...................................................................................... 01
A little worse ..................................................................................... 02
About the same ................................................................................ 03
A little better ..................................................................................... 04
Much better ...................................................................................... 05

Over the past 2 weeks how Often did you use your peak flow meter?
None ................................................................................................ 01
< 1/week .......................................................................................... 02
1-3/week .......................................................................................... 03
4-6/week .......................................................................................... 04
Daily ................................................................................................. 05
Only during exacerbations ................................................................ 06
Doesn’t have a PFM ............................................................................. 07

68

 

19a. Over the past 2 weeks, what were your highest and lowest peak flow
readings?

Highest reading (liters/minute) .....................................................
Lowest reading (liters/minute) ................................ | | | |

19b.Over the past 2 weeks, has the peak flow dropped below 80% of your
personnel best
No ............................................................................................. 01
Yes ........................................................................................... 02

190. What did you do when this occurred?

Details:

 

69

Appendix C
6-MONTH ADULT COHORT FOLLOW-UP FORM

SECTION A: EMERGENCY ASTHMA VISITS

1.

5a.

Is the above information correct?
NO (What data is incorrect?: .01
Yes ........................................................................................... 02

Since we last talked to you on I I I I I | l , have you

had a worsening Of asthma that required agent medical

treatment?
No ............................................................................................. 01
Yes ........................................................................................... 02

How many times has this happened since we last talked
to you?

(times) ...........................................................................

Thinking about the first time this happened since we
last talked to you. When did you go for urgent medical
treatment for your asthma?

 

 

 

 

 

 

 

(mm/dd) ....................................................... | I I / | | |

Where did you fi_rst_ go for this urgent asthma visit?
Regular asthma care provider (as defined above) ............................ 01
Hospital ED (specify: 02
Med care center (specify: 03
An asthma specialist: pulmonologist ................................................ 04
An asthma specialist: allergist .......................................................... 05
An asthma Specialist: asthma clinic .................................................. 06
Other provider/site (specify: 07
No specific location/provider ............................................................ 08

Why did you use this particular place for asthma care?

(CHECK ALL THAT APPLY)
NO regular asthma care provider .............................................. 01
Regular asthma care provider not available ..................................... 02
Insurance company dictates ............................................................. 03
NO insurance .................................................................................... 04
Other cost issues (specify: 05
Transport issues (specify: 06
Convenience .................................................................................... 07
Best medical care .......................................................................... 08
Past experience/comfort with people/place ...................................... 09
Other (specify: 10
Severity of episode — EMERGENCY! ............................................... 11

7O

6. At this visit did the doctor change your asthma
medicines or make any other changes in the
management Of your asthma? (PROMPT - FOR
EXAMPLE, GIVE YOU A NEW MEDICATION, OR

CHANGE THE WAY YOU USE YOUR EXISTING
MEDICATIONS, OR CHANGE THE WAY YOU MONITOR

OR MANAGE YOUR ASTHMA)
NO asthma treatment given (including no inhaled IS-agonist) 01
Given inhaled IS-agonist treatment but no new asthma Rx 02
Change in treatment plan (specify below) 03

Change in treatment plan (specify below) then transferred to ED 04

 

 

 

Details
7. Were you transferred to an emergency department or hospital as a result
of this visit?
NO ............................................................................................. 01
Yes (Specify ED: 02
If Yes, 7a. Were you admitted to the hospital overnight?
No ............................................................................................. 01
Yes (Specify hospital: 02

 

IF Q3 = MORE THAN ONE “RELAPSE” VISIT — REPEAT QUESTIONS FOR
SECOND VISIT SINCE 2-WEEK FU CALL COMPLETED. AT END OF THIS
SECTION CONFIRM SINCE 2-WEEK FU CALL:

Total (cumulative) number Of ED/Urgent Care visits ................

Total (cumulative) number of overnight hospitalizations .......... |_|_|

SECTION B: ROUTINE ASTHMA VISITS

IF PERSON HAD NOT YET SEEN RACP AT 2-WEEK FU CALL FOR
FOLLOW-UP VISIT

8. When did you fl_r§_t_ see this doctor/nurse/clinic (RACP) for a follow-up asthma

check-up?
(mm/dd) ....................................................... I I I / I I I
or number of days after ED visit (days) .................. | I I I

8a. Since we last talked to you, have you seen your regular
asthma care provider (RACP) again for a routine

asthma check up?

71

8b.

8c.

9a.

9b.

90.

No ......................................................................................................... 01
Yes ....................................................................................................... 02

How many routine asthma check-ups have you had with
this doctor/nurse/ clinic (RACP) since we last talked tO
you?
(number of checkups) .................................................... |_|_|

As a result of this visit (these visits), did your doctor
Change your asthma medicines or make any other
Changes in your asthma management plan? (PROMPT —
NEW MEDS?, OR CHANGE EXISTING MEDS?, OR
CHANGE IN MANAGEMENT OF ASTHMA?)

NO ............................................................................................. 01
Yes ........................................................................................... 02
Describe:

 

Have you had any other doctor visits specifically related to
your asthma care and treatment Since we last talked to you
on _ / _ ? (i.e., NOT WITH RACP, e.g., ASTHMA

SPECIALISTS)
NO ......................................................................................................... 01
Yes ....................................................................................................... 02

When did you fILS_t see ANOTHER doctor/nurse/Clinic
(NOT RACP) for an asthma-related visit?

 

 

(mm/dd) ....................................................... | | | / | |
or number of days after ED visit (days) .................. I | |
NOT APPLICABLE (first visit recorded at 2-WK F U call) ......... 99

How many asthma-related visits have you had with
ANOTHER doctor/nurse/clinic (NOT RACP) since we last
talked tO you?
(number of visits) ........................................................... |_|_|

Where did the visit take place and who was it with?
(CHECK MORE THAN ONE RESPONSE IF VISITS TO
MORE THAN ONE SPECIALIST)

 

Asthma specialist (specify type: 01
Specialty Asthma Clinic ............................................................ 02
Other primary care type doctor/clinic ........................................ 03
Other (specify: 04

 

Name 8. location

 

72

9d.

9e.

10.

If Yes,

What was the primary purpose of this (these) visit(s)?
Describe:

 

As a result of this (these) visit(s), did your doctor change
your asthma medicines or make any other changes in
your asthma management plan? (PROMPT — NEW
MEDS?, OR CHANGE EXISTING MEDS?, OR CHANGE
IN MANAGEMENT OF ASTHMA?)

NO ............................................................................................. 01
Yes ........................................................................................... 02
Describe:

 

Have you had any other doctor visits for health
problems not related to asthma since we last
talked to you on _l_? (# visits) ............................................. |_|_|

10a. What was visit for?

 

C. CURRENT ASTHMA-RELATED MEDICATIONS

11. RECORD ALL PRESCRIPTION AND NON-PRESCRIPTION ASTHMA-
RELATED MEDICATIONS USED IN THE LAST 6 MONTHS IN THE
FOLLOWING TABLE (EXCEPT SYSTEMIC STEROIDS — SEE QUESTION 11a)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication Frequency Current Route Time period Of
(name) Doctor Rx’d Frequency Of use (months)
Use (9 most recent)
Daily QOD Daily QOD PO Inh 1 2 3 4 5 6
weekly PRN Weekly PRN Neb
Daily QOD Daily QOD PO Inh 1 2 3 4 5 6
weekly PRN Weekly PRN Neb
Dai'Y 000 Daily QOD PO Inh 1 2 3 4 5 6
week'y PRN Weekly PRN Neb
Daily QOD Daily QOD PO Inh 1 2 3 4 5 6
weekly PRN Weekly PRN Neb
Daily QOD Daily QOD PO Inh 1 2 3 4 5 6
weekly PRN Weekly PRN Neb
Daily QOD Daily QOD PO Inh 1 2 3 4 5 6
weekly PRN Weekly PRN Neb
Daily QOD Daily QOD PO Inh 1 2 3 4 5 6
weekly PRN Weekly PRN Neb

 

73

 

COMMENTS:

 

11a. Over the past 6 months, have you taken any steroids orally or by injection
for asthma? (CHECK ORAL AND INJECTION IF HAVE TAKEN BOTH)

No .................................................................... 01
Yes — Injection .................................................... 02
Yes — Oral .......................................................... 03
Yes — Injection & oral .......................................... 04
If Yes - Oral,

11b. How many rounds Of oral steroids have you taken over the last 6 months? _
_ _ rounds
11C. How long ago was the last round of oral steroids? days / weeks
ago

D. CURRENT SYMPTOMS, CONTROL AND QUALITY OF LIFE

12. How often in the last 4 weeks have you had asthma symptoms
during the day? (i.e., wheezing, a dry cough, shortness Of
breath, and/or chest tightness)

Never ........................................................................................ 01
Less than once a week ............................................................. 02
1 or 2 times a week .................................................................. 03
3 to 6 times a week .................................................................. 04
Every day ................................................................................. 05
Continually (all the time) ........................................................... 06

13. How many times over the last 4 weeks did you wake up at
night because of asthma symptoms? (i.e., wheezing, a dry
cough, shortness Of breath, and/or chest tightness)

Never ........................................................................................ O1
1 or 2 times ............................................................................... 02
3 to 4 times ............................................................................... 03
5 to 9 times ............................................................................... 04
10 or more times ...................................................................... 05

14. How many times over the last 4 weeks have your
activities been gfiectep or restictgq by asthma

symptoms?
Never ........................................................................................ 01
1 or 2 times ............................................................................... 02
3 to 4 times ............................................................................... 03
5 or more times ........................................................................ 04
All the time ................................................................................ 05

74

15. Over the past 4 weeks have your asthma symptoms been
severe enough to limit your speech to only 1 (L2 word; at a
time between breaths?
No ............................................................................................. 01
Yes ........................................................................................... 02
If Yes,
158. How many times has this occurred in the last 4 weeks? . |_|_|

16. Over the past 4 weeks how many days have you had to
use your quick relief medicine (i.e., short acting
bronchodilator or rescue medicine)?

(days) ............................................................................ |_|_|

17. Over the past 4 weeks, how much discomfort or distress
have you felt because Of asthma symptoms? Would you
say...(READ RESPONSES)

None ......................................................................................... O1
Mild ........................................................................................... 02
Moderate .................................................................................. 03
Severe ...................................................................................... 04

18. How would you rate your asthma condilfln now
compared to around the time period when you went tO
the emergency department on _ / _?

Much worse .............................................................................. 01
A little worse ............................................................................. 02
About the same ........................................................................ 03
A little better ............................................................................. 04
Much better .............................................................................. 05
19. Over the past 4 weeks how Often did you use your peak flow meter?
None ......................................................................................... 01
< 1/week ................................................................................... 02
1-3/week ................................................................................... 03
4-6/week ................................................................................... 04
Daily ......................................................................................... 05
Only during exacerbations ........................................................ 06
Don’t have a PFM ..................................................................... 07

19a. What is your personal best peak flow reading? (liters/minute)
I l l l

19b. Over the past 4 weeks, what were the highest and lowest peak flow
readings?
Highest reading (liters/minute) ............................... | | I I
Lowest reading (liters/minute) ................................ | | I |

 

 

75

19c. Over the past 4 weeks, has the peak flow dropped below 80% of your

personal best?
NO ............................................................................................. 01
Yes ........................................................................................... 02

If Yes,
19d. What did you do when this occurred?

Details:

 

20. A spacer is a device that you put between the mouth and inhaler to make

it easier
to breathe medicine into the lungs. DO you have a spacer?

No ............................................................................... 01
Yes .................................................................................... 02

If Yes,
203. Over the past 4 weeks, how Often have you used the spacer when using

the inhaler?

Never ........................................................................... 01
Rarely ...................................................................................... 02
Occasionally ............................................................................ 03
Usually ..................................................................................... 04
Always ..................................................................................... 05

21. Have you received any asthma education since your initial ED visit?

 

NO ........................................................................................................ 01
Yes .....................................................................................................
.02
If Yes, 21a. What was the source of this education? — that is, who provided it?
Your regular asthma care provider .......................................... O1
Asthma specialist (allergist, or pulmonologist) ......................... 02
ED or Urgent Care Center
03
Asthma Coalition
04
Other health professional (Specify )
05

[SPECIFY TYPE OF PROFESSIONAL AND ORGANIZATION
e.g., RN-SCHOOL, RN-COMMUNTY)

21b. What did you learn about? (Circle Yes or No for each item)

Things that can trigger your asthma? YES NO

76

Medications and treatments? YES NO

How to use an inhaler or nebulizer? YES NO
How to use a peak flow meter? YES NO
What to do during an asthma attack? YES NO
How to use a written action plan? YES NO

22. Did you have an asthma management plan at the time Of the initial ED
visit?
NO ........................................................................................................ 01
Yes .....................................................................................................
..02

If No, 22a. DO you have an asthma management plan now?

23. How confident do you feel about your ability to:

23a. Manage your asthma on a day-tO-day basis? (READ AND CIRCLE

 

 

 

 

 

ONE)
Veg unsure Somewhat unsure Somewhgt confident Verv confident Don't know
1 2 3 4 5
23b. Manage or control an asthma attack or exacerbation? (READ AND
CIRCLE ONE)
Vegy unsure Somewhat unsure Somewhpt confident Very confident Don't know
1 2 3 4 5

24. If you had an asthma attack today, how likely are you to do the following?

24a. Measure the asthma severity using a PFM (READ AND CIRCLE

ONE)
Definitely Yes Probably Yes Probably Not Definitely NOT Don’t know

1 2 3 4 5

24b. Increase the amount Of rescue medication (albuterol) (either dose or

freq) (READ AND CIRCLE ONE)
Definitely Yes Probpblv Yes Probably Not Definitely NOT Don't know

1 2 3 4 5

24C. Wait to see if the symptoms subside after using the medication
before calling your doctor or going to the ED (READ AND CIRCLE
ONE)

77

Definitely Yes Probably Yes Prob_a_blv Not Definitely NOT Don’t know

 

1 2 3 4 5

25. If the symptoms continued to persist what action would you take 9%?
Call PCP ........................................................................ 01
GO directly to ED/Urgent Care - always ................................... 02
GO directly to ED/Urgent Care - if after hours and PCP N/A.... 03
Continue with treatment ........................................................... 04
Not sure ................................................................................... 05
Other (Specify) .. 05

 

26. What other actions or steps do you think would help you better control and
manage your asthma?

 

E. SMOKING HISTORY
27. Have you ever smoked cigarettes?
No (=Never) ................................................................................... 01
Yes ................................................................................................ 02
If Yes, 27a. DO you smoke now?
NO (=Former) 01 to 27b
Yes (=Current) 02 GO to 27d

If Former Smoker:
276. How long ago did you quit? (Time since QUIT must be > 30 days,
else = Current Smoker)
months years

 

If patient quit longer than 6 months ago, END OF INTERVIEW.
If patient quit within the last 6 months ago, then

27c. Why did you quit?

 

27d. Did you use any of the following products or methods to help you
quit? (CIRCLE ALL THAT APPLY)

Nicotine gum ................................................................................. 01
Nicotine patch ............................................................................... 02
Nicotine Spray ............................................................................... O3
Nicotine Inhaler ............................................................................. 04
Other doctor prescription drug (e.g., Zyban) ................................. 05
Counselling ................................................................................... 06
Other (Specify) 07

 

78

 

' nfi-L...
A

If errent Smoker:
27e. On average, how many cigarettes do you currently smoke a day?

cigarettes/day

 

27f. In the last 6 months, have you tried to quit smoking?

NO ................................................................................................. 01

Yes ................................................................................................ 02
If Yes, 279. How many times have you tried to quit?

times

 

27h. Did you use any of the following products or methods to help you
quit? (CIRCLE ALL THAT APPLY)

Nicotine gum ................................................................................. 01
Nicotine patch ............................................................................... 02
Nicotine Spray ............................................................................... 03
Nicotine Inhaler ............................................................................. 04
Other doctor prescription drug (e.g., Zyban) ................................. 05
Counseling .................................................................................... 06
Other (Specify) 07

 

79

 

 

 

 

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