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OBJECTIVE: To evaluate the effect of different modalities of centralized reminder/recall (autodialer, text, mailed reminders) on increasing childhood influenza vaccination. STUDY DESIGN: Two simultaneous randomized clinical trials conducted from October 2017 to April 1, 2018, in New York State and Colorado. There were 61 931 children in New York (136 practices) and 23 845 children in Colorado (42 practices) who were randomized to different centralized reminder/recall modalities-4 arms in New York (autodialer, text, mailed, and no reminder control) and 3 arms in Colorado (autodialer, mailed, and no reminder control). The message content was similar across modalities. Up to 3 reminders were sent for intervention arms. The main outcome measure was receipt of ≥1 influenza vaccine. RESULTS: In New York, compared with the control arm (26.6%), postintervention influenza vaccination rates in the autodialer arm (28.0%) were 1.4 percentage points higher (adjusted risk ratio, 1.06; 95% CI, 1.02-1.10), but the rates for text (27.6%) and mail (26.8%) arms were not different from controls. In Colorado, compared with the control arm (29.9%), postintervention influenza vaccination rates for the autodialer (32.9%) and mail (31.5%) arms were 3.0 percentage points (adjusted risk ratio, 1.08; 95% CI, 1.03-1.12) and 1.6 percentage points (adjusted risk ratio, 1.06; 95% CI, 1.02-1.10) higher, respectively. Compared with the control arm, the incremental cost per additional vaccine delivered was $20 (New York) and $16 (Colorado) for autodialer messages. CONCLUSIONS: Centralized reminder/recall for childhood influenza vaccine was most effective via autodialer, less effective via mail, and not effective via text messages. The impact of each modality was modest. Compared with no reminders, the incremental cost per additional vaccine delivered was also modest for autodialer messages. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03294473 and NCT03246100.

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BACKGROUND: Self-management of moderate-to-severe asthma depends on the patient's ability to (1) navigate (access health care to obtain diagnoses and treatment), (2) use inhaled corticosteroids (ICSs) properly, and (3) understand ICS function. OBJECTIVE: We sought to test whether navigation skills (medication recall, knowledge of copay requirements, and ability to provide information needed for a medical visit about a persistent cough unresponsive to medication) are related to other self-management skills and health literacy. METHODS: A 21-item Navigating Ability (NAV2) questionnaire was developed, validated, and then read to adults with moderate-to-severe asthma. ICS technique was evaluated by using scales derived from instructions in national guidelines; knowledge of ICS function was evaluated by using a validated 10-item questionnaire. Spearman correlation was computed between NAV2 score and these questionnaires and with numeracy (Asthma Numeracy Questionnaire) and print literacy (Short Test of Functional Health Literacy in Adults). RESULTS: Two hundred fifty adults participated: age, 51 ± 13 years; 72% female; 65% African American; 10% Latino; 50% with household income of less than $30,000/y; 47% with no more than a 12th-grade education; and 29% experienced hospitalizations for asthma in the prior year. A higher NAV2 score was associated with correct ICS technique (ρ = 0.24, P = .0002), knowledge of ICSs (ρ = 0.35, P < .001), better print literacy (ρ = 0.44, P < .001), and numeracy (ρ = 0.41, P < .001). CONCLUSIONS: Patients with poor navigational ability are likely to have poor inhaler technique and limited understanding of ICS function, as well as limited numeracy and print literacy. Clinicians should consider these elements of self-management for their effect on asthma care and as a marker of more general health literacy deficits.

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INTRODUCTION: Poor self-management by families is an important factor in explaining high rates of asthma morbidity in Puerto Rico, and for this reason we previously tested a family intervention called CALMA that was found effective in improving most asthma outcomes, but not effective in increasing the use of controller medications. CALMA-plus was developed to address this issue by adding to CALMA, components of provider training and screening for asthma in clinics. METHODS: Study participants were selected from claims Medicaid data in San Juan, Puerto Rico. After screening, 404 children in eight clinics were selected after forming pairs of clinics and randomizing the clinics) to CALMA-only or CALMA-plus. RESULTS: For all three primary outcomes at 12 months, the mean differences between treatment arms were small but in the predicted direction. However, after adjusting for clinic variation, the study failed to demonstrate that the CALMA-plus intervention was more efficacious than the CALMA-only intervention for increasing controller medication use, or decreasing asthma symptoms. Both groups had lower rates of asthma symptoms and service utilization, consistent with previous results of the CALMA-only intervention. CONCLUSIONS: Compliance of providers with the intervention and training, small number of clinics available and the multiple barriers experienced by providers for medicating may have been related to the lack of difference observed between the groups. Future interventions should respond to the limitations of the present study design and provide more resources to providers that will increase provider participation in training and implementation of the intervention.

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OBJECTIVES: To explore knowledge, awareness, and attitudes among caregivers of hospitalized children with regard to methicillin-resistant Staphylococcus aureus (MRSA). STUDY DESIGN: We developed and administered a bedside questionnaire to caregivers of hospitalized children in contact isolation for MRSA colonization or infection. RESULTS: Of 104 caregivers approached, 100 (96%) consented to participate. The caregivers' children included 28 (28%) newly recognized as colonized or infected with MRSA during the hospitalization and 72 (72%) previously identified as colonized or infected with MRSA. Eighteen (18%) caregivers had no knowledge of MRSA. Twenty-nine (29%) were unaware that their child had MRSA, including caregivers of 9 newly identified patients with MRSA and 20 patients with previously identified MRSA. Of the 71 caregivers aware of their child's MRSA status, 89% had concerns; 77% worried about risks of future MRSA infection, 51% worried about spreading MRSA, and 16% described a feeling of stigma. Worries were more common among caregivers of children with newly identified MRSA (P < .05). CONCLUSION: Caregivers of children hospitalized with MRSA are frequently unaware that their child has MRSA. Among those aware of their child's MRSA status, many have concerns and worries. Caregivers of children with newly identified MRSA more often are worried and may need additional education and reassurance.

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BACKGROUND: Disparities exist in asthma medication dispensing between children with public insurance and those with private insurance under a Managed Care Medicaid system in Puerto Rico. OBJECTIVES: Island-wide medical claims data were used to examine the extent to which differences between the private and public health care sectors affect medication dispensing and health care utilization among asthmatic children. METHODS: Children 3-18 years old with at least one service claim [outpatient, hospitalization, or emergency department (ED) visit] for asthma or reactive airway disease from 2005 to 2006 were selected. Chi-square analyses compared medication dispensing and health care utilization between the public and private sectors. Negative binomial regression identified factors associated with the mean dispensing rate of prescriptions for anti-inflammatory controller medication (CM). RESULTS: Private insurance families (n = 28,088) were dispensed significantly more CM (48.3% vs. 12.0%) and quick relief medication (47.4% vs. 44.6%) than public insurance families (n = 13,220). The dispensing of inhaled corticosteroids (24.4% vs. 6.7%) and leukotriene modifiers and cromolyn (31.4% vs. 5.7%) was dramatically higher in the private sector. In contrast, emergency room use was significantly higher among public insurance children (51.7% vs. 13.8%). Multivariate analysis showed that age, number of ß-agonists, and type of insurance was associated with CM dispensing; private insurance showed the greatest effect. CONCLUSION: Asthmatic Puerto Rican children enrolled in public insurance were significantly less likely to be dispensed CM than children with private insurance; suggesting that under-treatment of public insured children may substantially contribute to increased asthma morbidity in this population as evidenced by significantly higher rates of ED visits. CAPSULE SUMMARY: A disparity exists in asthma medication dispensing between children with public insurance compared with those with private insurance under a Managed Care Medicaid system in Puerto Rico. If asthma disparities in medication dispensing are to be reduced, then a better understanding of the complex ways in which multiple variables related to the health care system policies, socioeconomic factors, family and provider interactions, as well as the relative weight that each one contributes to the observed inequalities is needed.

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BACKGROUND: There are substantial disparities in dispensing patterns of long term control medications for asthma among children in Puerto Rico with public insurance as compared to those with private insurance. Public health insurance policy in Puerto Rico includes the cost of medications in the capitation paid to the primary care physicians and clinics. METHODS: Survey questionnaires were mailed to all pediatricians enrolled in the Puerto Rico College of Physicians (n=798) in addition to some pediatricians not enrolled in the College (n=25) for a total of 823 pediatricians. Of these, 722 were eligible pediatricians with 458 responding to the survey for a response rate of 63.4%. RESULTS: Most of the respondents expressed being moderately to very familiar with the National Asthma Education and Prevention Program (NAEPP) guidelines (71.7%) and with the NAEPP recommendations for controller asthma medication use (73.5%). Inadequate capitation to cover asthma medication (86.2%) and lack of adequate health insurance coverage of the patient (83.2%) however, were the most frequent barriers reported by pediatricians for prescribing controller asthma medication to children with public health insurance. The most frequent strategies used to provide controller asthma medication to these children were prescription of oral medications (59.5%) and giving away samples (44.7%). CONCLUSIONS: Current public health insurance policy in Puerto Rico creates a disincentive to the appropriate prescription of long term control medication for children with asthma. To improve the quality of asthma care of children in Puerto Rico, revision of this public health insurance policy is necessary.

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STUDY OBJECTIVES: To determine the prevalence of habitual snoring (HS) and its association with symptoms of rhinitis in a Latin American country and, secondarily, to assess how commonly physicians address rhinitis in the community. PATIENTS OR PARTICIPANTS: Six- to twelve-year-old school-aged children. POPULATION AND METHODS: We designed a cross-sectional, community-based study of the pediatric population, centered in schools of Guayaquil, Ecuador. The study was evaluated and approved by the ethical committee of the Hospital Luis Vernaza as a local institution. MEASUREMENTS AND RESULTS: A 15.1% prevalence of HS was reported among 806 responders out of 1193 surveys. The frequency of HS was associated with the number of rhinitis symptoms and a previous diagnosis of rhinitis, with those reporting 2 rhinitic symptoms being more likely to report HS (p=0.01). Only a small minority of caregivers reported being aware of either HS or rhinitis as health problems. CONCLUSIONS: HS is a highly prevalent symptom among Ecuadorian children, and the prevalence is further increased if the diagnosis of rhinitis or even >1 rhinitis symptom is concomitantly present. Since few caregivers of HS children are informed about the causes and consequences of this condition, increased health education about this condition is needed.

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Substantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared with non-Latino white subjects. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex, and interrelated sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Several strategies that could be applied in clinical settings to reduce asthma disparities are described, including the need for routine assessment of the patient's beliefs, financial barriers to disease management, and health literacy and the provision of cultural competence training and communication skills to health care provider groups.

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OBJECTIVE: To examine the relationship between depressive symptoms and asthma beliefs (self-efficacy and empowerment), child asthma outcomes, and caregiver's quality of life among Puerto Rican caregivers of children with asthma. METHODS: The caregivers of 221 children with persistent bronchial asthma were stratified into those with no/low or high levels of depressive symptoms. Differences between the groups in caregiver self-efficacy, family empowerment, child asthma outcomes, and quality of life were examined. RESULTS: Caregivers with more depressive symptoms reported lower self-efficacy, less empowerment, less symptom-free days and nights for their children, and a lower quality of life compared to caregivers with no or fewer depressive symptoms. CONCLUSIONS: Depressive symptoms among Puerto Rican caregivers were associated with asthma beliefs, children's asthma symptoms, and caregiver quality of life. Our findings reinforce the importance of physician screening skills in recognizing caregiver depression in parents of asthma patients.

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BACKGROUND: Island and mainland Puerto Rican children have the highest rates of asthma and asthma morbidity of any ethnic group in the United States. OBJECTIVE: We evaluated the effectiveness of a culturally adapted family asthma management intervention called CALMA (an acronym of the Spanish for "Take Control, Empower Yourself and Achieve Management of Asthma") in reducing asthma morbidity in poor Puerto Rican children with asthma. METHODS: Low-income children with persistent asthma were selected from a national health plan insurance claims database by using a computerized algorithm. After baseline, families were randomly assigned to either the intervention or a control group. RESULTS: No significant differences between control and intervention group were found for the primary outcome of symptom-free days. However, children in the CALMA intervention group had 6.5% more symptom-free nights, were 3 times more likely to have their asthma under control, and were less likely to visit the emergency department and be hospitalized as compared to the control group. Caregivers receiving CALMA were significantly less likely to feel helpless, frustrated, or upset because of their child's asthma and more likely to feel confident to manage their child's asthma. CONCLUSION: A home-based asthma intervention program tailored to the cultural needs of low income Puerto Rican families is a promising intervention for reducing asthma morbidity.

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OBJECTIVE: Examine the association between emotional quality-of-life (QOL) and asthma morbidity in adolescents with asthma. STUDY DESIGN: Cross-sectional survey of 185 adolescents with asthma 11 to 17 years of age cared for in three managed care organizations (MCOs) in the United States. The asthma-specific Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and a short version of the generic Child Health and Illness Profile-Adolescent Edition (CHIP-AE) were used to assess emotional QOL. Asthma morbidity measures were: asthma control, emergency department (ED) visits, hospitalizations, doctor visits for worsening asthma, and missed school because of asthma. RESULTS: Of the adolescents surveyed, 45% reported feeling depressed, 41% had ED visits, and 30% missed >or=1 day of school because of asthma. Poorer asthma-specific emotional QOL was associated with poorer control of asthma symptoms ( P < .0001), missed school (OR 7.1, P < .05), and doctor visits for worsened asthma (OR = 7.0, P < .05). CONCLUSIONS: Emotional symptoms related to asthma are common in adolescents with persistent asthma and asthma-specific QOL is related to increased asthma morbidity, healthcare use, and school absenteeism. Adolescents with high morbidity from asthma exhibit poorer QOL. Therefore, the evaluation of asthma-specific emotional QOL should be included in the assessment of adolescents with asthma.

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