An exploration of factors underlying asthma care and morbidity: A factor analysis of clinical variables

doi:10.1016/j.jaci.2008.05.021

Journal of Allergy and Clinical Immunology

Volume 122, Issue 2, August 2008, Pages 328-334.e5

https://doi.org/10.1016/j.jaci.2008.05.021 Get rights and content

Background

Clinical risk models use recognized risk factors to identify patients at risk for future asthma morbidity. However, the low predictive values of these models suggest an important need to re-evaluate risk assessment strategies.

Objective

To use exploratory factor analysis to define underlying factors operative in asthma treatment and morbidity, and characterize their interrelationships and association with 6-month morbidity.

Methods

Children (n = 197) presenting to an emergency department for an acute asthma episode were followed for 6 months (follow-up data available for 84%). Baseline data included demographics, asthma history, current and past symptoms, and current treatment and management. Factor analysis was used to summarize the underlying relationships between variables. Correlations between factors and 6-month morbidity were calculated.

Results

Factor analysis revealed that 4 factors provided a parsimonious summary of the variables. The factors were labeled current symptom severity, quality of care indicators, previous severe disease, and sociodemographic factors. Positive correlations were observed between quality of care, current symptom severity, and previous severe disease. The factor describing sociodemographic factors was inversely related to current symptom severity and quality of care. Previous severe disease significantly predicted 6-month morbidity.

Conclusion

Quality of care was better in subjects with increased current symptoms or previous severe disease, but poorer in individuals with adverse sociodemographic factors. Previous severe disease was the only factor associated with 6-month morbidity, suggesting that current assessment methods do not adequately account for all underlying factors likely operative in asthma morbidity.

Section snippets

Study population

The study population consists of a prospective cohort of 197 children (age 2-17 years) who presented to 1 of 3 EDs for the evaluation and treatment of an acute asthma exacerbation in western Michigan. The 3 hospitals were chosen to represent an urban, suburban, and rural location to ensure breadth of sampling. Children were eligible if they presented with signs and symptoms compatible with an acute asthma exacerbation (shortness of breath, coughing, wheezing, or chest tightness), and had a

Results

A total of 197 subjects were enrolled over a 1-year period, and follow-up information was available for 166 (84%). Five subjects were excluded from the factor analysis because of missing data, leaving 161 subjects for factor correlations. Demographic information of the subjects is displayed in Table I. The majority of the subjects was seen at the urban hospital and was more likely to be white and male. The specific observed variables, including risk definitions and distribution, are displayed

Discussion

The current study identified 4 factors that explain most of the variance observed in common clinical variables in the management and follow-up of a cohort of children with asthma. The current factor analysis differs from risk stratification tools or risk assessment models in that we are attempting to identify the latent variables (underlying constructs) that are reflected by commonly used observed variables, describe how these factors interrelate, and observe their association with morbidity as

References (61)

E.F. Juniper et al.
Measurement properties and interpretation of three shortened versions of the asthma control questionnaire
Respir Med
(2005)
C.S. Rand et al.
Emergency department visits by urban African American children with asthma
J Allergy Clin Immunol
(2000)
B.W. Taylor
The identification of high-risk asthmatic children using the emergency department asthma visit count
J Emerg Med
(1999)
C.L. Joseph et al.
Racial differences in emergency department use persist despite allergist visits and prescriptions filled for anti-inflammatory medications
J Allergy Clin Immunol
(1998)
W.E. Berger et al.
The utility of the Health Plan Employer Data and Information Set (HEDIS) asthma measure to predict asthma-related outcomes
Ann Allergy Asthma Immunol
(2004)
M. Schatz et al.
Validation of a beta-agonist long-term asthma control scale derived from computerized pharmacy data
J Allergy Clin Immunol
(2006)
B.H. Fiese et al.
Family asthma management routines: connections to medical adherence and quality of life
J Pediatr
(2005)
E. Rosi et al.
Sputum analysis, bronchial hyperresponsiveness, and airway function in asthma: results of a factor analysis
J Allergy Clin Immunol
(1999)
M. Grazzini et al.
Relevance of dyspnoea and respiratory function measurements in monitoring of asthma: a factor analysis
Respir Med
(2001)
M. Schatz et al.
Relationships among quality of life, severity, and control measures in asthma: an evaluation using factor analysis
J Allergy Clin Immunol
(2005)

L.J. Akinbami et al.

Trends in childhood asthma: prevalence, health care utilization, and mortality

Pediatrics

(2002)

National Center for Health Statistics: Center for Disease Control. 2006 National Health Interview Survey. Available at:...

R.L. Cowie et al.

Predicting emergency department utilization in adults with asthma: a cohort study

J Asthma

(2001)

R.J. Adams et al.

Factors associated with hospital admissions and repeat emergency department visits for adults with asthma

Thorax

(2000)

J.G. Donahue et al.

Inhaled steroids and the risk of hospitalization for asthma

JAMA

(1997)

R.J. Adams et al.

Impact of inhaled anti-inflammatory therapy on hospitalization and emergency department visits for children with asthma

Pediatrics

(2001)

S.J. Bartlett et al.

Maternal depressive symptoms and emergency department use among inner-city children with asthma

Arch Pediatr Adolesc Med

(2001)

L. Blais et al.

Inhaled corticosteroids and the prevention of readmission to hospital for asthma

Am J Respir Crit Care Med

(1998)

T.A. Lieu et al.

Computer-based models to identify high-risk adults with asthma: is the glass half empty or half full?

J Asthma

(1999)

J.A. Finkelstein et al.

Comparing asthma care for Medicaid and non-Medicaid children in a health maintenance organization

Arch Pediatr Adolesc Med

(2000)

Cited by (6)

Asthma control in children, socioeconomic inequality and health care
2023, Anales de Pediatria
La desigualdad socioeconómica (DSE) puede afectar negativamente al control del asma. El objetivo de este estudio fue identificar la relación de la DSE con el control del asma y la calidad de vida de los cuidadores.
El nivel socioeconómico se determinó por área de residencia, según la tasa de riesgo de pobreza (TRP). La población pediátrica de Castilla y León se estratificó en terciles de TRP, y se seleccionó una muestra mediante muestreo aleatorio estratificado, identificando a los niños (6-14 años) con asma activa en los registros clínicos de centros de atención primaria. La información se obtuvo mediante cuestionarios cumplimentados por los padres. Las variables primarias fueron el control del asma y la calidad de vida de los cuidadores. Se analizó su relación con la DSE, la calidad de la atención sanitaria y factores individuales (como el nivel educativo de los padres) mediante modelos multivariantes de regresión.
El tercil de TRP no se relacionó con ninguna medida de control del asma, calidad de vida ni calidad de la asistencia. El nivel educativo de la madre (educación media o superior) se asociaba a menor riesgo de consulta no programada/urgente (OR = 0,50; IC 95%: 0,27-0,95; p = 0,034) y el del padre a menor riesgo de asma mal controlada (OR = 0,51; IC 95%: 0,28-0,94; p = 0,030).
En la población que hemos estudiado, no se encuentra asociación entre DSE, medida por área de residencia, y el control del asma en niños. Otros factores, como la educación de los padres, pueden ser factores protectores.
Socioeconomic inequality (SEI) can adversely affect asthma control. The aim of this study was to establish the association of SEI with asthma control in children and caregiver quality of life.
We assessed socioeconomic status based on the area of residence, according to the at risk of poverty rate (ARPR). After stratifying the paediatric population of Castilla y León (an autonomous community in Spain) in ARPR tertiles, we selected participants by stratified random sampling, and identified children with asthma aged 6–14 years from the health records of primary care centres. We collected data through questionnaires completed by parents. The primary outcomes were asthma control and caregiver quality of life. We assessed their association with SEI, health care quality measures and individual factors (such as parental educational attainment) by means of multivariate regression models.
The ARPR tertile was not associated with asthma control, quality of life or health care quality. A medium or high maternal educational attainment was associated with a lower risk of making an unscheduled or urgent visit (OR=.50; 95% CI: .27-.95; P=.034) and paternal educational attainment was associated with a lower risk of uncontrolled asthma (OR=.51; 95% CI: .28-.94; P=.030).
In the sample under study, SEI assessed at the local level was not associated with asthma control in children. Other factors, such as parental educational attainment, may have a protective effect.
Factors associated with severity and exacerbation of asthma: A baseline analysis of the COhort for Reality and Evolution of adult asthma in Korea (COREA)
2009, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
Indeed, children with persistent asthma with previous exacerbations are more likely to have a repeat exacerbation despite controller treatment.29 Miller et al30 also revealed that previous severe disease was an important risk factor to identify patients at risk for future asthma morbidity in children. In our study, most patients with incidents of acute asthma exacerbation had persistent AHR, poor lung function during treatment, a history of smoking, and a long duration of asthma.
Asthma presents with heterogeneous features, and patients show various phenotypes of differing severities. Therefore, it is necessary to define reliable predictable clinical factors that influence severity. To date, few large-scale studies have gathered clinical data on adult asthma patients in Asia.
To establish an adult asthma cohort in Korea and to define significant factors associated with asthma severity and exacerbation.
Researchers from 11 university hospitals have established an asthma cohort termed the COhort for Reality and Evolution of adult Asthma in Korea (COREA). We classified the severity of asthma into 3 groups: mild, moderate, and severe. In this article, the first analysis of our cohort, we evaluate various clinical factors associated with the severity and exacerbation of asthma using data from 1,260 asthma patients.
Physician-evaluated severity of asthma was associated with a history of asthma exacerbation (P < .001), a history of smoking (P < .001), symptom duration (P = .007), and treatment duration (P < .001). It was also significantly correlated with predicted forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) values and FEV₁/FVC ratio (all P < .001). Previous exacerbation was associated with smoking (P = .02), predicted FVC and FEV₁ values (both P < .001), FEV₁/FVC ratio (P = .02), airway hyperresponsiveness (P = .002), and duration of disease (P < .001).
Previous exacerbation, duration of disease, and decrease in lung function were important clinical indices associated with asthma severity in the COREA study patients. Our long-term follow-up study is expected to soon yield more accurate and detailed outcomes.
Follow-up Care for Children With Asthma After Emergency Department Visits
2009, Clinical Pediatric Emergency Medicine
Citation Excerpt :
Focus groups suggest that beliefs and misconceptions about asthma are among the most important barriers to establishing ongoing care [37]. Miller et al [38] evaluated risk factors for future asthma morbidity in a cohort of children and found that previous severe disease was the only factor that predicted 6-month morbidity. For many children, an ED visit represents either severe disease or the perception of severe disease for the parents [31,39,40].
Current guidelines recommend that all children obtain follow-up within 1 to 4 weeks after an emergency department (ED) visit for acute asthma. Follow-up may be an important link to reestablish regular care with the primary care provider, review reasons for the ED visit, and update the home management plan. Obtaining follow-up from the ED can be challenging. Studies have reported baseline follow-up rates between 7% and 44% without intervention. Successful interventions report follow-up rates of 36% to 78%. Studies that demonstrated improved follow-up from the ED found methods to personalize care such as individualized education, assistance with follow-up, and/or providing medications or transportation free of charge. A few studies effectively used computer-based interventions in the ED. As electronic systems become more common in the ED, integrating asthma care, personalized education, and scheduling follow-up in real time may be possible.
Advances in adult asthma diagnosis and treatment and health outcomes, education, delivery, and quality in 2008
2009, Journal of Allergy and Clinical Immunology
Citation Excerpt :
Although the rate of asthma-related ED use by white individuals decreased between 1998 and 2005, since 2000 it has actually increased for black patients. Miller et al54 used factor analysis, a statistical method of summarizing relationships among a large set of variables,55 to explore factors determining future asthma morbidity in children who had an ED visit for asthma. Although the analysis used a cohort of children, it may be applicable in adults.
In 2008 the Journal reported new findings in management of asthma. Dosing schedules of inhaled steroids have been modified and individualized. New, more costly propellants are replacing ozone-depleting chlorofluorocarbons. An association of asthma with pneumococcal disease has been observed. Smoking bans in public places are eliminating second-hand smoke and reducing asthma-related emergency department visits among adults. In contrast with these advances, however, disparity in asthma morbidity persists: black persons compared with white persons have a 4-fold greater risk of an asthma-related emergency department visit.
Past asthma exacerbation in children predicting future exacerbation: a systematic review
2022, ERJ Open Research
Severe asthma: Why do some children not respond to treatment?
2010, Current Pediatric Reviews

: Disclosure of potential conflict of interest: F. L. Oswald has received research support from Navy Personnel Research Studies and the College Board. The rest of the authors have declared that they have no conflict of interest.

View full text

Asthma and lower airway diseaseAn exploration of factors underlying asthma care and morbidity: A factor analysis of clinical variables

Background

Objective

Methods

Results

Conclusion

Section snippets

Study population

Results

Discussion

Respir Med

J Allergy Clin Immunol

J Emerg Med

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

J Allergy Clin Immunol

J Pediatr

J Allergy Clin Immunol

Respir Med

J Allergy Clin Immunol

Chest

Chest

Chest

Immunol Allergy Clin North Am

Chest

J Allergy Clin Immunol

Pediatr Clin North Am

Respir Med

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

Trends in childhood asthma: prevalence, health care utilization, and mortality

Pediatrics

Predicting emergency department utilization in adults with asthma: a cohort study

J Asthma

Factors associated with hospital admissions and repeat emergency department visits for adults with asthma

Thorax

Inhaled steroids and the risk of hospitalization for asthma

JAMA

Impact of inhaled anti-inflammatory therapy on hospitalization and emergency department visits for children with asthma

Pediatrics

Maternal depressive symptoms and emergency department use among inner-city children with asthma

Arch Pediatr Adolesc Med

Inhaled corticosteroids and the prevention of readmission to hospital for asthma

Am J Respir Crit Care Med

Computer-based models to identify high-risk adults with asthma: is the glass half empty or half full?

J Asthma

Comparing asthma care for Medicaid and non-Medicaid children in a health maintenance organization

Arch Pediatr Adolesc Med

Asthma and lower airway disease
An exploration of factors underlying asthma care and morbidity: A factor analysis of clinical variables