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Presentation and treatment of asthma among native children in southwest Alaska delta

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Our objective was to determine if a different presentation of asthma among Eskimo children in southwest Alaska influenced treatment for asthma. Data regarding symptoms, medication use, and hospitalization were obtained from the medical records of 58
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  Pediatric Pulmonology 39:28–34 (2005) Presentation and Treatment of Asthma Among NativeChildren in Southwest Alaska Delta Margaret Kurzius-Spencer,  MS ,  MPH , 1 Steven Wind,  MA , 2 David Van Sickle,  MA , 2 Patricia Martinez,  MD ,  MPH , 3 and Anne Wright,  PhD 1 * Summary.  Our objective was to determine if a different presentation of asthma among Eskimochildren in southwest Alaska influenced treatment for asthma. Data regarding symptoms,medicationuse,andhospitalizationwereobtainedfromthemedicalrecordsof58Eskimochildrendiagnosedwithasthma.Halfofthechildrenalsohadadiagnosisofchroniclungdisease(CLD),and57% had a history of allergies. CLD was associated with significantly more visits for wheeze( P  ¼ 0.02), asthma ( P  < 0.005), and lower respiratory tract illnesses ( P  < 0.005), and a greaterincidence ( P  < 0.005) and frequency ( P  < 0.005) of hospitalizations. Allergy status showed nosimilar relation with utilization of health services. Inhaled corticosteroids were prescribed for aminority (38%) of these asthmatic children. Allergic children tended to be more likely to receiveinhaledsteroids,andtheyreceivedsignificantlymoreprescriptionsforinhaledsteroidscomparedto children without allergies. Those with CLD only were no more likely to receive inhaled steroidsthan other children, despite their higher incidence of hospitalization. Although the proportion ofchildren with CLD or allergy did not differ significantly by village, there were significant regionaldifferencesinhealthcareutilizationandmedicationuse.Inconclusion,whileCLDwastheprimarydeterminant of healthcare utilization among these native children with asthma, only allergicchildrenwithCLDweremorelikelytoreceiveinhaledsteroids.  PediatrPulmonol.2005;39:28–34.   2004 Wiley-Liss, Inc. Key words: asthma; Alaska Native; Native American; chronic lung disease; wheeze;treatment; pediatric asthma. INTRODUCTION Several recent studies suggested that asthma is animportant health problem among Native American andAlaska Native children. A study conducted at JemezPueblo in New Mexico 1 found that the rate of physician-diagnosed asthma were more than double that reported innationalsurveys(12.3%vs.5%).Similarly,alargesurveyof 13–18-year-old children in North Carolina found thatbeing Native American was associated with significantlyhigher odds for developing asthma relative to whites,higherthanthoseforeitherAfricanAmericanorHispanicchildren. 2 Finally, among 0–17-year-olds in Washingtonstate, 3 hospitalizations due to asthma among NativeAmericans were more than twice those of other ethnicgroups (528 vs. 232 per 100,000, respectively).The literature also suggests that the presentation of respiratory illness among Native Americans and AlaskaNatives may differ from other populations. As early as1979, Houston et al. 4 reported that the prevalence of chronic cough and bronchial wall thickening among agroup of Indian children in northern Saskatchewan wasimpressive, although prevalence figures were not pro-vided. While bronchiectasis is rare among non-nativechildren in industrialized countries, with prevalenceestimated at 0.2/10,000 in the 1980s–1990s, 5 this con-dition is common among Alaska Native children. Onestudy found that 10% of 5–8-year-old Alaska Nativechildren not hospitalized as infants for respiratorysyncytial virus infection had evidence of bronchiectasison chest radiographs at age 2 years. 6 These observationssuggest that the presentation of asthma may differ forNative American/Alaska Native (NA/AN) children, byvirtue of unusual comorbidities and/or potential physio-logic differences. 1 Arizona Respiratory Center, University of Arizona, Tucson, Arizona. 2 Department of Anthropology, University of Arizona, Tucson, Arizona. 3 Alaska Native Medical Center, Anchorage, Alaska.Grant sponsor: National Institute of Allergy and Infectious Diseases; Grantnumber: AI39785.*Correspondence to: Dr. Anne Wright, Arizona Respiratory Center,Arizona Health Sciences Center, 1501 N. Campbell Ave., PO Box245030, Tucson, AZ 85724. E-mail: awright@arc.arizona.eduReceived 26 March 2004; Revised 28 June 2004; Accepted 30 June 2004.DOI 10.1002/ppul.20132Published online 5 November 2004 in Wiley InterScience(www.interscience.wiley.com).   2004 Wiley-Liss, Inc.  In2000,weinterviewedparentsofNativechildrenwithasthmalivinginSWAlaskatoinvestigatebeliefsandotherfactors that might affect the diagnosis and treatment of asthma. 7 The present analysis characterizes the presenta-tion of asthma among these children based on data frommedical records, and assesses how presentation and otherfactors may influence treatment. We hypothesized thatallergy is less prevalent among asthmatic Alaska Nativechildren compared with asthmatics in other populations,andthatthisdifferenceinpresentationwouldinfluencethetreatment of their asthma. METHODSThe Setting This part of southwest Alaska is a sparsely populatedarea of subarctic tundra, dominated by lakes, ponds, andtidal flats. Most of the population resides in one majortown, which serves as a hub of local commerce andhealthcare, or in 52 rural villages spread throughout theregion. There is no road system connecting the villages,hencetravelbetweenthetownandthevillagesisprimarilyby small plane, riverboat, or snowmobile.The healthcare needs of the region’s widely dispersedpopulation, which is almost 90% Eskimo, are served by acorporation, which operates 47 village and subregionalclinics and a hospital in the town. Village clinics arestaffed by lay health workers who receive a 4-monthtraining course enabling them to treat common illnessesbased on clinical guidelines. 8 Health aides discuss signsand symptoms of presenting patients with physicians atthe regional hospital in the town via telephone on a dailybasis. Physicians make quarterly visits to villages toconduct specialty clinics (e.g., pediatrics), examine pa-tients,andconfirmthehealthaides’diagnoses.Inaddition,many children with uncontrolled asthma are seen by avisiting pediatric pulmonologist approximately once ayear. Patients requiring more specialized care for eitheracuteillnessesorchronicsymptomsareflowntothetown. Sample Selection for Interviews A study of factors that might affect the diagnosis andtreatment of respiratory problems among Alaska Nativefamilies was approved by the health corporation for theregionandthetown;fivevillagesintheregionalsoagreedto participate. A list of children aged 3–18 years who hadbeen coded as having asthma or reactive airways disease(i.e., were identified with ICD-9 code 493 in the regionaldatabase) was provided by the corporation for eachparticipating community. The researchers scheduled aweek-longvisittoeachofthecommunitiesin2000,whichallowed sufficient time to interview between 4.8% (in thetown) and 25% (at Village A) of the asthmatic childrenidentified at each site. Prior to the researchers’ arrival, thestafffrom thevillage clinic telephoned parents of some of the children on the list to schedule appointments with theresearcher. After obtaining informed consent, unstruc-tured interviews were conducted with the parentsor guardians of 76 children from 67 families. Since thefocus of the srcinal study was to document the range of beliefs regarding asthma, 5 no attempt was made to selectparticular families. Medical Record Reviews Permission was obtained at the time of the interview toreview the medical records of the children. Trips weremade in 2001 to four of the villages and to the town toconduct chart reviews. We were unable to complete themedical record review on 12 individuals due to missingrecords, difficulty getting to one of the villages, or insuf-ficient time to complete all reviews in a particular village.Another child died from unrelated causes, and fivechildren had no confirmed diagnosis of either asthma orreactive airways disease (RAD) in their medical records.(Theterms‘‘asthma’’and‘‘RAD’’areusedsynonymouslyby many local providers, and are considered synonymousforthepurposesofthisanalysis.)Thus,58childrenwhoseparents were interviewed and who had a confirmed diag-nosis of asthma or RAD in their medical records wereincluded in the analyses presented here. Medical recorddata were thus available for 22.5% of asthmatic childrenidentified in the villages, and 4.5% of asthmatic childrenwho received care in the town.Information (symptoms, diagnoses, treatments pre-scribed, and details of hospitalizations) was collected forevery encounter with the healthcare system at whichrespiratory symptoms were noted, from birth to age 18.Data from medical records were entered directly into alaptop computer, using Microsoft Access software. Re-searchers worked in pairs, with one person locating andreadingoutrelevantdatawhilethesecondenteredthedatainto the database. Analyses For each of these asthmatic children, the numbers of clinic visits for cough, wheeze, asthma/RAD, and lowerrespiratory tract illnesses (LRIs) were recorded. A childwas considered as having had an LRI if he/she was seenfor bronchitis, bronchiolitis, pneumonia, pneumonitis,or croup. Return visits for respiratory symptoms within3 weeks of the initial LRI diagnosis were not counted asnew LRIs. In addition, the numbers of prescriptions forinhaledsteroids,otherinhaledanti-inflammatory medica-tions (e.g., cromolyn), bronchodilators, and antibioticswere also counted from the medical records. To assurecomparability, the number of visits for each symptom andmedication type was adjusted for the number of years Pediatric Asthma in Southwest Alaska 29  between the first and last entry into the medical record(years of follow-up). The percent of children hospitalizedfor asthma or RAD, and the number of times a child washospitalized, were also calculated.Children were classified with regard to whether theyhad allergies and/or chronic lung disease (CLD). A childwas considered to be allergic if there was mention of anallergic condition, such as eczema, allergic rhinitis, oratopy, associated with any encounter in the medical re-cord. No objective information was available on allergy,such as IgE levels or skin test response. Children wereclassified as having chronic lung disease if a diagnosis of bronchiectasis, ‘‘chronic lung disease,’’ chronic obstruc-tive pulmonary disease (COPD), or bronchopulmonarydysplasia (BPD) was recorded in the chart. Children witha notation of ‘‘recurrent pneumonia’’ or who had at leastfive episodes of pneumonia and/or bronchiolitis within1 year were also considered to have CLD. Standardnonparametric (Mann-Whitney U, Kruskal-Wallis analy-sis of ranks, and chi-square) and parametric ( t  -tests andANOVA) statistics were run using SPSS 12.0 to comparenumber of symptom visits, hospitalizations, and prescrip-tions by disease status and village.Permission for the project was obtained from the Uni-versity of Arizona Human Subjects Committee, thecorporation, and the traditional councils of participatingvillages. RESULTSPopulation Characteristics Of the 58 children, 15 were from the town and 43 werefrom one of four villages. The medical records of all58 children confirmed that they had been diagnosed ashaving asthma or RAD by a physician, nurse practitioner,or physician’s assistant. The mean age (  SD) of thechildren was 10.2 years (  4.4) at the time the interviewwas conducted, and 54% were male. There were signi-ficant differences in mean age of the children at time of interview among villages ( P < 0.011), but no significantdifferences in the percentage diagnosed with CLD orallergy by village (Table 1). The mean number of years of medical record follow-up was 10.3 years (  4.4). Thechildren whose parents were interviewed but for whommedical record data were lacking were significantlyyounger (mean age, 6.7 years;  P < 0.005), but they didnot differ significantly in gender from those withcompleted reviews. Visits for Lower Respiratory Tract Illnessesand Respiratory Symptoms A healthcare provider was consulted on average for15.7 episodes of LRI per child (range, 0–44), or the ad- justed equivalent of 1.94 (  1.7) episodes of LRI per childperyearoffollow-up.Themajorityoftheseepisodeswereseen by lay health workers in village clinics, in conjunc-tion with telephone consultation with a physician. Thus,while a physician was usually not involved in the exami-nation, lower respiratory tract symptoms such as wheezewere reported in virtually all cases.The total number of clinic visits for respiratory symp-toms (including cough, wheeze, rhonchi, rales, or retrac-tions) ranged from 3–109 per child, for an adjustedaverage of 3.4 respiratory visits per child per year of follow-up. Visits for cough and wheeze were very fre-quent: on average, each child was seen by a healthcareprovider 2.3 times per year for wheeze and 1.9 times peryear for cough. Cough was a common symptom evenamong children without a diagnosis of chronic lungdisease (1.5 vs. 2.4 visits per year in which cough wasreported in children without and with CLD, respectively). Comorbid Conditions Halfofthe58childrenhadchroniclungdisease:13witha diagnosis of bronchiectasis or CLD, 8 with recurrentpneumonia or bronchiolitis, 3 with COPD, and 1 withBPD. There was no significant difference in age betweenthose with and without CLD (9.4 vs. 10.9 years,respectively).Almost 57% of the children were seen at the clinics foreczema and/or allergies (allergic rhinitis, seasonal aller-gies, or notation of ‘‘allergic’’). In this population, onlythreechildrenwerenotedashavinghadallergyskin-prick tests, and in two of these cases, testing was done inconjunction with another research project. TABLE 1—Population Characteristics by Village Village N of children in study Mean age (  SD) at interview % diagnosed with CLD % diagnosed with allergyVillage A 10 8.4 (  3.8) 80.0 80.0Village B 11 9.6 (  4.9) 63.6 54.5Village C 11 12.7 (  3.7) 36.4 72.7Village D 11 7.5 (  3.2) 36.4 27.3Town 16 11.9 (  4.2) 37.5 50.0 P -value 0.011 1 0.119 2 0.098 21 Analysis of variance. 2 Likelihood ratio  w 2 . 30 Kurzius-Spencer et al.  Predictors of Respiratory Morbidity Having a diagnosis of chronic lung disease was asso-ciated with significant excess respiratory morbidity(Table 2), as demonstrated by the higher number of visitsper year for wheeze ( P < 0.02), asthma ( P < 0.005), andlower respiratory tract illnesses ( P < 0.008). ChildrenwithCLDwerealsomorelikelytohavebeenhospitalized( P < 0.005), and to have been hospitalized more fre-quently than children without CLD ( P < 0.005). In con-trast, when these same outcomes were considered inallergic vs. nonallergic asthmatics, there were no differ-encesinnumberofvisitsforwheeze,cough,orLRIs,orinnumber of hospital visits between groups. Medication Use Only 38% of the children in this study were prescribedinhaled corticosteroids for routine management of theirasthma (i.e., during a clinic visit for respiratory symp-toms),andonly36%receivedprescriptionsforothertypesof anti-inflammatory medications. Inhaled steroids wereprescribed at only 12.8% of visits for wheeze and at only23.7%ofvisitsforasthma/RAD.Thosechildrenwhoweretreated with inhaled steroids and those treated with anti-inflammatories appeared to be sicker and were seen forasthma 2–3 times more often than those not treated withsteroids or anti-inflammatories (both  P < 0.001).In contrast to steroidal and nonsteroidal anti-inflam-matory medications, bronchodilators (mostly albuteroland metaprel) and antibiotics were prescribed for all butone child, and they were prescribed frequently (Fig. 1).The number of prescriptions for bronchodilators wassignificantly correlated with the number of nonsteroidalanti-inflammatories prescribed (r ¼ 0.616,  P < 0.00001)and with the number of antibiotics prescribed (r ¼ 0.529, P < 0.001), and marginally correlated with the number of corticosteroids prescribed (r ¼ 0.235,  P < 0.08) and thefrequency of visits for asthma (r ¼ 0.693,  P < 0.00001).At the vast majority of symptomatic visits, however, nomedication was prescribed. Comorbid Predictors of Treatment Prescriptionpatternsvariedsubstantially,dependingonthe presence of either CLD or allergy (Table 3). Allergystatus showed some relationship with the use of inhaledsteroids: 57% of allergic children received inhaledsteroids vs. 43% of nonallergic children ( P < 0.06).Themean number of prescriptions for inhaled steroids alsovaried by allergy status ( P < 0.04). Inhaled steroid usewas also higher in children with both CLD and allergiesthan in children without this combination of diagnoses( P < 0.022). For other anti-inflammatory medications, adiagnosis of either allergy or CLD was associated withsignificantlymoreprescriptions.Incontrast,childrenwithCLD, regardless of allergy status, received significantlymore prescriptions for antibiotics ( P < 0.002) and bron-chodilators ( P < 0.0004) than children without CLD.Although the majority of children (65.5%) were neverhospitalized for asthma/RAD, 15.5% were hospitalizedonce,5.2%twice,10.3%threetimes,and3.4%sixormoretimes. Inhaled steroids were prescribed at a clinic visit foronly 30% of children who had been hospitalized for theirasthma. Regional Variability in Asthma Treatmentand Hospitalization There was substantial variability among villages inhealthcare utilization for respiratory symptoms and inmedications used in asthma treatment (Table 4). Therewerenosignificantvillagedifferencesintheuseofinhaledsteroids ( P < 0.71). However, Village C tended to use TABLE 2—Healthcare Utilization for Respiratory Symptoms/Illness by Presence of Chronic Lung Disease and Allergy 1 CLD status Allergic status (N)Adjusted mean number of clinic visits per year Hospitalizations for asthma/RADWheeze Asthma LRIs % hospitalizedMean no. of admissions per childYes Allergic (19) 2.5 1.8 2.2 52.6 1.6Nonallergic (10) 4.2 0.9 3.0 50.0 1.1Total (29) 3.1 1.5 2.5 51.7 1.5No Allergic (14) 1.0 0.5 0.9 14.3 0.3Nonallergic (15) 2.0 0.5 1.8 20.0 0.3Total (29) 1.5 0.5 1.4 17.2 0.3 P -valuesCLD status 0.018 2 0.005 2 0.008 2 0.005 4 0.005 2 Allergic status 0.451 2 0.093 2 0.338 2 0.731 4 0.710 2 CLD and allergic status 0.025 3 0.021 3 0.013 3 0.044 4 0.049 31 Visits were adjusted for number of years between first and last entry in medical record. See Methods for more detail. 2 Mann-Whitney U-test. 3 Kruskal-Wallis rank test. 4 Likelihood ratio  w 2 test. Pediatric Asthma in Southwest Alaska 31  more inhaled steroids despite having the fewest visits forwheeze and a prevalence of CLD comparable to Betheland Village D, and had the lowest incidence of hospita-lizations. Town children, too, had a relatively low rate of hospitalizationandahighrateofuseofinhaledsteroids.Incontrast, Village D had the highest number of visits perchild year for LRIs and wheeze, the lowest use of inhaledsteroids, and a high rate of hospitalizations. DISCUSSION Thisanalysissuggeststhatthepresentationofasthmainthis group of Alaska Native children differs from that inother populations, with CLD being common but allergybeing infrequent relative to other populations. 9 Themodest use of inhaled steroids in these asthmatic childrenappears to be in part attributable to the low prevalence of allergy. Finally, there are substantial regional differencesin the presentation and treatment of asthma.The high prevalence of chronic lung disease amongAlaska Natives relative to other populations in the indus-trialized world was reported previously. 5,6,10–13 What isnew from this analysis is the finding that the presence of CLD is the most important determinant of respiratorymorbidity and healthcare utilization including hospi-talization among asthmatics in this population. Thecause of the high prevalence of chronic lung disease inthese native children (50%) is unknown, but may beattributable to severity and frequency of RSV infec-tions, 13,14 high rates of environmental tobacco smokeexposure, 7 otherlocal exposures such as airbornedust, 7 orgenetic susceptibilities.At the vast majority of visits, neither inhaled steroidsnorotheranti-inflammatorymedicationswereprescribed,despite frequent visits per year for respiratory symptoms.Bronchodilators were prescribed approximately 10 timesmore often than either inhaled steroids or other anti-inflammatory medications at clinic visits for wheeze.While this may be appropriate in connection with LRIs,only 30% of children who had been hospitalized for theirasthmawereevergivenaprescriptionforinhaledsteroids.Low use ofinhaled steroidsis hardly uniqueto this group,as it was reported in several other populations 15,16 andmay result from both provider 17 and patient 18 factors.Nevertheless,ourfindingssuggestthattheincreaseduseof  Fig. 1. Number of children receiving each type of medication atclinicvisits. TABLE 3—Mean Number of Times Each Medication Was Prescribed Per Year of Follow-Up by Chronic Lung Disease andAllergic Status CLD status Allergic statusAdjusted mean number of prescriptions per yearInhaled steroids Other anti-inflammatories Bronchodilators AntibioticsYes Allergic (19) 0.51 0.47 3.7 2.9Nonallergic (10) 0.07 0.21 1.9 2.5Total (29) 0.36 0.38 3.1 2.7No Allergic (14) 0.10 0.18 0.79 0.67Nonallergic (15) 0.07 0.03 1.2 1.7Total (29) 0.09 0.10 1.0 1.2 P -valuesCLD status 0.105 1 0.009 1 0.0004 1 0.002 1 Allergic status 0.038 1 0.027 1 0.138 1 0.561 1 CLD and allergic status 0.102 2 0.016 2 0.0001 2 0.001 21 Mann-Whitney U-test. 2 Kruskal-Wallis rank test. 32 Kurzius-Spencer et al.
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