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Copyright 2004byLynn Carole Smith

This dissertation is dedicated to my husband Blaine, for his unwavering support; and tomy parents Gil and Claire Desjardins and my brother Mark, for always believing in myability and for encouraging me to be a permanent student.

ACKNOWLEDGMENTSI gratefully acknowledge my dissertation chair, Rinda Alexander, Ph.D., for herencouragement during the course of my doctoral studies. She has been a source ofsupport and inspiration to me since my early days as a graduate student.I am also grateful to the University of Central Florida for granting me aneducational leave to complete this dissertation. I thank my colleagues (Jacquie ByersPh.D.; and Mary Lou Sole, Ph.D.) for sharing their expertise with a novice researcher. Ithank Jean Leuner, Ph.D., Director, for supporting my leave of absence despite hardshipto the School of Nursing. I would like to acknowledge Sigma Theta Tau (Theta EpsilonChapter) for partial funding of this project.Finally, I would also like to express my deepest appreciation to my dissertationcommittee members: Paul Duncan, Ph.D., Susan Schaffer, Ph.D. and Hossein Yarandi,Ph.D., for their contributions and encouragement. Special thanks go to Dr. Yarandi forhis invaluable assistance with the statistical analysis.iv

TABLE OF CONTENTSpageACKNOWLEDGMENTS . ivLIST OF TABLES. viiABSTRACT. viiiCHAPTER1INTRODUCTION .1Background of the Problem .2Purpose of the Study.4Significance/Rationale.52REVIEW OF THE LITERATURE .8Theoretical Framework.8Review of the Literature .13Conclusion .253RESEARCH DESIGN.27Site Characteristics .27Sample .28Data-Collection Methods.29Design and Ethical Considerations.34Statistical Procedures.364ANALYSIS AND RESULTS.38Sample Characteristics.38Predisposing, Enabling and Need Based Characteristics. .41Follow-Up Results .45Analytical Results for Hypotheses.455DISCUSSION AND RECOMMENDATIONS .50Strengths .50v

Study Challenges .50Sample Demographics .52Follow-Up.54Hypotheses.55Clinical Implications.58Recommendations for Future Research.60Conclusion .61APPENDIXAPARENT QUESTIONNAIRE.62BPARENT CONSENT .65CASSENT FOR CHILDREN AGE 7-17 YEARS.70LIST OF REFERENCES.71BIOGRAPHICAL SKETCH .76vi

LIST OF TABLESTablePage2-1Summary of studies of childhood asthma and pediatric ED utilization.214-1Frequency and percent* of demographic data for the total sample and subjectswho did, and did not achieve follow-up .404-2Frequency and percent* of predisposing variables for the total sample, andsubjects who did, and did not achieve follow-up. .414-3Frequency and percent* of enabling variables for the total sample, and subjectswho did, and did not achieve follow-up. .424-4Frequency and percent* of need-related variables for the total sample, andsubjects who did, and did not achieve follow up. .444-5Frequency and percent* of health behaviors for the total sample, and subjectswho did, and did not achieve follow up. .454-6Results of a stepwise logistic regression model to the data for the dependentvariable follow-up .49vii

Abstract of Dissertation Presented to the Graduate Schoolof the University of Florida in Partial Fulfillment of theRequirements for the Degree of Doctor of PhilosophyCHILDHOOD ASTHMA: EMERGENCY DEPARTMENTFOLLOW-UP DETERMINANTSByLynn Carole SmithMay 2004Chair: Rinda AlexanderMajor Department: NursingLow-income, minority, and uninsured children use the emergency department (ED)more often for asthma care, and suffer increased mortality and morbidity compared totheir less vulnerable peers. This comparative correlational study used the BehavioralModel of Health Services Utilization to examine predisposing, enabling and need-relatedcharacteristics of families who use the ED for care of childhood asthma, and determinantsof follow-up care.A convenience sample of 63 children presenting to the ED for asthma care wereenrolled. Data were collected from parents, ED providers, and medical records. Thedependent variable was follow-up care within 30 days of the ED visit. Specifichypotheses were as follows: 1) Families who obtain follow-up care will differ inpredisposing, enabling, and need characteristics from families who do not obtain followup care; 2) Families who fail to obtain follow-up care will differ in predisposing,enabling, and need characteristics from families who obtain follow-up care; and 3)viii

Families who use the ED for childhood asthma will exhibit common predisposing,enabling, and need characteristics.Two-thirds of the subjects did not follow up as directed. Logistic regression wasused to test the study hypotheses. Mother’s level of education was significantlyassociated with no follow-up (p 0.0282). At the 10% level of significance, the combinedeffects of travel time to usual source of care, wait time, smoker in the home, fur-bearingpet in the home, parent-evaluated severity, provider-evaluated severity, and providerevaluated severity for the previous year predicted no follow-up. Odds Ratio (OR) of nofollow-up were higher for children with more severe asthma (OR 12.44) or older mothers(OR 2.14).Subject enrollment was insufficient to achieve statistical power and may haveinfluenced these findings. Additional study limitations included nonrandom sampleselection, use of a correlational design, and self-report measures.This study has direct implications for nursing practice, education, and research.Follow-up of children with asthma is not occurring at the desired levels; thereforeadditional steps to remove barriers to follow-up should be taken. A larger study exploringED follow-up determinants should be conducted, as well as a study of nursinginterventions to improve follow-up.ix

CHAPTER 1INTRODUCTIONChildhood asthma has been a condition of interest to health care providers for manyyears. Scores of research articles have been written about the pathophysiology, etiology,risk factors for, and treatment of childhood asthma. Parents of children with asthmadescribe the most frightening aspect of the disease as its sudden tendency to exacerbate or“attack.” Nocturnal symptoms are particularly troublesome. Research of asthmapathophysiology has made healthcare providers aware that asthma exacerbations occur asa result of inflammation in the lungs, and are generally preceded by warning signs.Understanding of (and rapid response to) asthma warning signs can enable a parent torespond appropriately to initial inflammatory changes, thus avoiding or lessening theseverity of a flare.According to Guidelines for the Diagnosis and Management of Asthma, (NationalInstitutes of Health, 1997) effective management of asthma involves four key elements:controlling exposure to asthma triggers, managing asthma with medicine, monitoring thedisease, and educating asthma patients to become partners in their own care. A majorgoal of the National Institutes of Health (NIH) is to reduce the number of hospitalizationsand emergency department (ED) visits for asthma. Follow-up care, by a primary careprovider or asthma specialist, is recommended after acute, unscheduled asthma care inorder to provide education, achieve improved asthma symptom control, and develop along-term management plan.1

2Background of the ProblemChildhood AsthmaAsthma is the most prevalent cause of childhood disability in the United States,affecting 2.7 million children (National Center for Health Statistics, 2000). Children withasthma use 3.1 times as many prescriptions; miss three times as much school; andexperience 1.9 times as many ambulatory visits, 2.2 times as many ED visits, and 3.5times as many hospitalizations as children without asthma (Lozano, Sullivan, Smith, &Weiss, 1999). Despite therapeutic breakthroughs, 149 U.S. children (1 to 15 years of age)died in 1997 of asthma-related causes (National Center for Health Statistics, 2000).Race appears to be an important contributing factor to disability and death fromchildhood asthma. In the U.S., the overall prevalence of asthma for nonwhite children isonly slightly higher than for whites; yet the death, hospitalization, and ED-visit rates forthese children are more than twice the rates for white children (Wade et al., 1997).Access to Health Care for Vulnerable ChildrenFor children, lack of access to adequate health care has been associated withdecreased health supervision and decreased management and control of chronic illness(Davidson, Klein, Settipane, & Alario, 1994). Children from vulnerable groups (minorityracial backgrounds, poor, and uninsured) are more likely to lack a usual source of carethan are a reference group of white, nonpoor, insured children (Newacheck, Hughes, &Stoddard, 1996). Lack of access to primary health care providers has been associatedwith increased ED use for many populations (Grossman, Rich, & Johnson, 1998).ED UtilizationAnalysis of the 1988 National Health Interview Survey on Child Health determinedthat African American children, children from single-parent households, children with

3mothers who did not complete high school, and children living in urban settings weremore likely to cite the ED as a usual source of care (Halfon, Newacheck, Wood, & St.Peter, 1996). Even when a more appropriate usual source of care existed, there was oftena lack of after-hours and weekend coverage. Families who used neighborhood healthcenters for routine care were twice as likely to report use of ED for sick care than werethose who used private physician’s offices or HMOs (Halfon et al., 1996).ED Utilization for Childhood AsthmaNonscheduled acute or emergency care suggests poor asthma management andpredicts suboptimal outcomes (Sullivan et al., 1996). In the U.S., asthma was the tenthmost common principal diagnosis in ED visits for children and adults in 1996 (NationalCenter for Health Statistics, 2000). In many cases, the ED visit occurred because thefamily lacked the tools, medication, knowledge or confidence to manage the disease athome (Sherman & Capen, 1997).Vulnerable children from low-income or minority families, use the ED morefrequently for asthma exacerbations, and experience increased mortality and morbiditycompared to their less vulnerable counterparts. Analysis of the 1988 National Maternaland Infant Health Survey and 1991 Longitudinal Follow-Up Survey determined thatpoverty and African American race were the most important determinants of ED use forasthma (Miller, 2000).Follow-up Care after an ED Visit for Childhood AsthmaIn a national study of inner-city children with asthma, 58% of study participantsfound it difficult to obtain care for an asthma attack as well as for follow-up visits (Kattanet al., 1997). The perceived difficulty obtaining acute or follow-up care for asthmaoccurred despite the fact that over 92% of the children in the study had insurance

4coverage. In a study of inner-city children presenting to the ED for asthma care, thelikelihood of follow-up increased when ED staff either made appointments for theparents, or clearly indicated the need for follow-up appointments (Leickly et al., 1998).The most common reason for not making (or keeping) a follow-up appointment was thatthe child was well. The perception that follow-up is not needed when the acute wheezingepisode has resolved may represent a lack of understanding about the chronic nature ofthe disease and the underlying role of inflammation in the cycle of remission andexacerbation.Purpose of the StudyThe purpose of this research study is threefold: To investigate determinants of (and barriers to) the achievement of follow-up careafter an ED visit for children with asthma; To identify predisposing, enabling, and need-related variables associated with useof the ED by children with asthma; and To prospectively test a leading model of health services utilization for predictiveability.This study used a comparative descriptive/correlational design. Sixty-three children(ages 1 to 18 years) presenting to the ED for treatment of asthma were enrolled. The sitechosen was the pediatric emergency department of a tertiary care center in centralFlorida.The Behavioral Model of Health Services Utilization guided this study (Andersen,1995). This model uses a systems perspective to link individual, environmental, patientrelated and provider-related variables associated with decisions to seek care. Thevariables studied were chosen based on the model and based on critical review of theliterature of vulnerable children, children with asthma, and other vulnerable populations.

5In conceptualizing the likelihood of achieving follow-up care as a measure of overallvulnerability to health care utilization (and identifying the barriers to follow-up care)health care providers can use the information collected in this study to test popularassumptions about ED use and health care delivery for children with asthma.Specific Aims1.To identify key determinants that are associated with the greatest likelihood ofobtaining recommended follow-up care after an asthma-related ED visit.2.To identify key determinants that are associated with the greatest likelihood offailing to obtain recommended follow-up care after an asthma-related ED visit.3.To evaluate predisposing, enabling, and need characteristics of families who havepresented to the ED with a child with an acute episode of asthma.HypothesesThree study hypotheses were proposed. Although they appear similar at firstglance, there is a subtle difference between the first two hypotheses. The study wasdesigned so that logistic regression analysis would result in two separate equations; thefirst outlining determinants of follow-up, and the second outlining determinants of nofollow-up. Study hypotheses are as follows.1. Families who obtain follow-up care will differ in predisposing, enabling, and needcharacteristics from families who do not obtain follow-up care.2. Families who fail to obtain follow-up care will differ in predisposing, enabling, andneed characteristics from families who obtain follow up care.3. Families who utilize the ED as a source of care for childhood asthma will exhibitcommon predisposing, enabling, and need characteristics.Significance/RationaleThe NIH Guidelines call for close follow-up, evaluation, education, and support ofall children with asthma; and for follow-up after any acute episode that necessitated anED visit (National Institutes of Health, 1997). To manage their child’s asthma effectively,

6parents need an asthma action plan that spells out when and how to take medicinescorrectly, as well as what to do when symptoms worsen. Episodic, crisis-orientedtreatment of childhood asthma exacerbations, without adequate daily control ofsymptoms, can lead to permanent airway remodeling, significant linear growth delay, andlife-threatening immune-system suppression from repeated use of oral steroids.Because of time constraints, the chaotic learning environment, and lack ofcontinuity, the ED is not the optimal environment for providing disease-specificeducation. This education is best provided by primary care providers or asthmaspecialists (National Institutes of Health, 1997). Education of families with children whoregularly use the ED for asthma care may well be problematic. Interventions targetingthis population have met with mixed results, and the cost is prohibitive (Shields, Griffin,& McNabb, 1990). Moreover, a percentage of families obtain follow-up care as directedwithout any intervention (Leickly et al., 1998). In an era of cost containment andoutcomes-based evaluation, it is important to focus intervention efforts on families whoare at greatest risk of not obtaining follow-up care and/or who have difficulty adhering toa prescribed management plan.LimitationsThe sample was a convenience sample of participants presenting to the ED on ashift when either the primary investigator or a full-time pediatric ED nurse was available.Not all shifts were equally represented. It is possible that patients presenting to the ED onthe u

Childhood asthma has been a condition of interest to health care providers for many years. Scores of research articles have been written about the pathophysiology, etiology, risk factors for, and treatment of childhood asthma. Parents of children with asthma describe the most frightening aspect of th

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