Children and Adolescents, 1988
–
2008
WHAT’S KNOWN ON THIS SUBJECT: Preventive asthma medications (PAMs) are a primary management strategy to control asthma morbidity. Little is known about changes over time in prevalence of PAM use among children and adolescents in the United States.
WHAT THIS STUDY ADDS: Our analysis demonstrates an increase in use of PAMs among children and adolescents with current asthma in the United States from 1988–1994 to 2005–2008, but racial and ethnic disparities in use of PAMs persist.
abstract
OBJECTIVE:To examine trends in preventive asthma medication (PAM) use among children with current asthma in the United States from 1988 to 2008.
METHODS:We performed a cross-sectional analysis of PAM use among 2499 children aged 1 to 19 years with current asthma using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) during 3 time periods: 1988–1994, 1999–2002, and 2005–2008. PAMs included inhaled corticosteroids, leukotriene receptor antagonists, long-actingb-agonists, mast-cell stabilizers, and methylxanthines.
RESULTS:Among children with current asthma, there was an increase in the use of PAMs from 17.8% (SE: 3.3) in 1988–1994 to 34.9% (SE: 3.3) in 2005–2008 (P , .001 for trend). Adjusting for age, gender, race/ ethnicity, and health insurance status, the odds of PAM use were higher in 2005–2008 compared with 1988–1994 (adjusted odds ratio [aOR] = 2.6; 95% confidence interval [CI]: 1.5–4.5). A multivariate analysis, combining all 3 time periods, showed lower use of PAMs among non-Hispanic black (aOR = 0.5 [95% CI: 0.4–0.7]) and Mexican American (aOR = 0.6 [95% CI: 0.4–0.9]) children compared to non-Hispanic white children. PAM use was also lower in 12 to 19 year olds compared with 1 to 5 year olds and also in children who did not have health insurance compared with those who did.
CONCLUSIONS: Between 1988 and 2008, the use of PAM increased among children with current asthma. Non-Hispanic black and Mexican American children, adolescents aged 12 to 19 years, and uninsured children with current asthma had lower use of PAM. Pediatrics
2012;129:62–69
AUTHORS:Brian K. Kit, MD, MPH,a,b,cAlan E. Simon, MD,d
Cynthia L. Ogden, PhD,aand Lara J. Akinbami, MDc,d
aDivision of Health and Nutrition Examination Surveys anddOffice
of Analysis and Epidemiology, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland;bEpidemic Intelligence Service, Scientific Education
and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia; andcUnited
States Public Health Service, Rockville, Maryland
KEY WORDS
asthma; anti-asthmatic agents; health care disparities; medically uninsured; quality indicators, health care
ABBREVIATIONS
aOR—adjusted odds ratio CI—confidence interval
NAEPP—National Asthma Education and Prevention Program NHANES—National Health and Nutrition Examination Survey PAM—preventive asthma medication
Dr Kit contributed to conception and design, acquisition of data, analysis and interpretation of the data, and drafting the article; Dr Simon contributed to conception and design, analysis and interpretation of the data, and revising the article; Dr Ogden contributed to conception and design, acquisition of data, analysis and interpretation of the data, and revising the article; and Dr Akinbami contributed to conception and design, analysis and interpretation of the data, and revising the article. All authors providedfinal approval for submission of the article to
Pediatrics.
Thefindings and conclusions in this report are those of the authors and not necessarily of the National Center for Health Statistics, Centers for Disease Control and Prevention. www.pediatrics.org/cgi/doi/10.1542/peds.2011-1513 doi:10.1542/peds.2011-1513
Accepted for publication Sep 9, 2011
Address correspondence to Brian K. Kit, MD, MPH, 3311 Toledo Rd, Room 4419, Hyattsville, MD 20782. E-mail: igd0@cdc.gov PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2012 by the American Academy of Pediatrics
In 2009, the prevalence of current asthma was 9.6% among children and adolescents in the United States, the highest prevalence measured.1,2
Child-hood asthma is associated with sig-nificant disease burden, including limitations in physical activity, missed school, emergency department visits, hospitalizations, and death.1,2Despite
declines since the early- to mid-1990s in some measures of asthma disease burden, including mortality and hos-pitalizations, children and adolescents continue to experience significant as-thma morbidity.2For example, in 2005–
2007, children and adolescents aged 0 to 17 years experienced 640 000 em-ergency department visits and 10.5 million missed school days as a result of asthma.1
The burden of asthma among specific racial and ethnic communities is even more substantial. Compared with white children, American Indian, Alaska Natives, and black children have significantly higher asthma prevalence.1,2
Further-more, high asthma prevalence among some Latino groups, particularly Puerto Rican children, has been described.1,2
Higher asthma-related emergency de-partment visits, hospitalizations, and mortality among black children, com-pared with white children, further
de-fine the disparities in asthma disease burden that exist among children and adolescents in the United States.1,2
Control of asthma symptoms and pre-vention of adverse asthma outcomes are goals of asthma management as outlined in the National Asthma Educa-tion and PrevenEduca-tion Program’s (NAEPP) asthma treatment guidelines, which werefirst released in 1991.3Preventive
asthma medications (PAMs) are the primary management strategy recom-mended by these guidelines to control asthma symptoms among children with persistent asthma. In addition to PAMs, other evidence-based strategies for asthma control include asthma trigger
avoidance4,5 and asthma management
education.6,7
Despite known benefits,8–13 PAMs
re-main underutilized.14–22A previous
re-port with a national sample estimated between 28.5% and 32.8% of children and adolescents with current asthma used PAMs in 2003 to 2005.23
Further-more, minority children have been less likely to receive adequate preventive therapy.15,19,22,24–27 What is unknown,
however, is whether the use of PAM has increased or decreased over time or if efforts to address racial and ethnic disparities have reduced the differ-ences in use between groups.28 The
authors of this study examine trends in the use of PAMs among children and adolescents with current asthma in the United States from 1988 to 2008. The authors also examine disparities in PAM use.
METHODS
Study Design
The National Health and Nutrition Exam-ination Survey (NHANES) is a nationally representative, multistage probability sample of the US civilian, noninstitu-tionalized population conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention. NHANES initially was con-ducted as a periodic survey (including NHANES III from 1988–1994). Since 1999, however, NHANES has been in thefield continuously, and data are released in 2-year increments. Participants in NHANES receive a detailed in-person home interview followed by a physical examination at a mobile examination center, as described elsewhere.29,30
Written informed consent for data col-lection was obtained from all partic-ipants aged 16 years and older. A proxy, typically a parent or guardian, provided informed consent for children younger than 16 years. The survey was approved by the National Center for Health Sta-tistics ethics review board.
Survey Years
Data from NHANES III, collected from 1988–1994 and 4 additional NHANES data releases, were included in this analysis: 1999–2000, 2001–2002, 2005– 2006, and 2007–2008. To increase sam-ple size and statistical reliability of estimates, multiple data releases were combined. Thefinal categorization of survey years for this analysis was 1988– 1994, 1999–2002, and 2005–2008. The data years 2003–2004 were excluded to create 3 roughly comparable survey periods. The unweighted interview re-sponse rate ranged from 78% to 84% for the data releases; additional details are available elsewhere.31
Current Asthma
During the in-home interview, par-ticipants or their proxy for children younger than 16 years of age were asked, “Has a doctor or health pro-fessional ever told you that you have asthma?” and “Do you still have as-thma?”Consistent with previous epi-demiologic studies, a participant was considered to have current asthma if an affirmative response to both ques-tions was provided.2,32
PAMs
Data on prescription medication use were collected during the home in-terview. Participants were asked,“Have you taken or used any prescription medicines in the past month?” Partic-ipants with an affirmative response were asked to provide the medication containers for the interviewer to re-view. If the container was not avail-able, use of the medication was self- or proxy-reported.
A medication was categorized as a PAM if it was listed as a long-term controller medication in the NAEPP as-thma treatment guidelines.3Specifically,
PAMs included the following medication classes: inhaled corticosteroids, leuko-triene receptor antagonists, long-acting
factured with more than 1 class of PAM contributed to each class of PAM contained within the medication. Be-cause the NAEPP treatment guidelines delineate indications for use of multi-ple PAMs, the authors examined use of multiple asthma medications by cat-egorizing the number of PAMs as 1 or more (any PAM) and 2 or more ($2 PAM).
Demographic and Health Insurance Variables
Age was categorized as 1 to 5 years, 6 to 11 years, and 12 to 19 years. Race/ ethnicity was categorized as non-Hispanic white, non-Hispanic black, Mexican American, and“other” based on self-reported race and ethnicity. In all survey years included in the analysis, non-Hispanic black participants were oversampled, and in all years except 2007–2008, Mexican American partic-ipants were oversampled. Beginning in 2007–2008, Latino participants overall, rather than solely Mexican American participants, were oversampled; how-ever, sufficient numbers of Mexican American participants were retained to follow trends in health outcomes.33
Children for whom race/ethnicity was categorized as“other”are included in overall estimates, but results for this group are not reported separately. Sta-tus of health insurance coverage was asked of all participants at the time of the interview. PAM use did not differ between privately and publically insured youth. To increase statistical power, health insurance coverage status was examined dichotomously as insured (public or private insurance) versus uninsured. Less than 1% of children and adolescents were missing health insurance data; these individuals were excluded from health insurance analy-ses. Family income also was considered for inclusion in this study but was found to be highly correlated with health
. fi
Lemeshow Goodness-of-Fit Test, was better when health insurance was used, so health insurance rather than income was included in thefinal analyses.
Statistical Analysis
Prevalence estimates and SEs were calculated for use of any PAM,$2 PAMs, and each PAM class overall and by age, gender, race/ethnicity, and health in-surance status. Trends by time period in the use of PAMs were tested using logistic regression models. In instances in which sufficient data were available for only 2 time periods, differences be-tween time periods were tested with a Student’sttest. To describe disparities in use of PAM during the most recent time period, 2005–2008, prevalence esti-mates are reported, and differences between non-Hispanic white partic-ipants and both non-Hispanic black and Mexican American participants were tested with a Student’sttest.
Multivariate logistic regression analyses were performed to test the trends in use of PAMs over survey periods while adjusting for the confounding effects of age, gender, race/ethnicity, and health insurance status. All variables in the multivariate logistic regression anal-ysis were analyzed as categorical vari-ables. aORs and 95% CIs are reported. Because the prevalence of the out-come (use of PAM) was.10%, the OR yielded by logistic regression overesti-mates relative risk.
Statistical analyses were performed using SAS software version 9.2 (SAS Institute Inc, Cary, NC), and SUDAAN software version 10.0 (RTI, Research Triangle Park, NC) was used to account for the complex design of the survey. Sample weights, which account for differential probabilities of selection, nonresponse, and noncoverage, were used to obtain estimates represen-tative of the noninstitutionalized US
fi
No adjustment for multiple compar-isons was made.
Analytic Sample
In 1988–1994, a total of 13 062 boys and girls aged 1 to 19 years were inter-viewed. In 1999–2002, a total of 9672 participants were interviewed, and in 2005–2008, 8574 participants were in-terviewed. Participants with missing or incomplete data for current asthma status or prescription medication use were excluded (n= 95). Of the remain-ing 34 057 children and adolescents, there were 2499 with reported current asthma (767 in 1988–1994, 870 in 1999– 2002, and 862 in 2005–2008), which comprised our analytic sample. De-mographics of the sample are de-scribed in Table 1.
RESULTS
Overall, among children and adoles-cents aged 1 to 19 years with current asthma, there was an increasing trend in the use of PAM (1988–1994: 17.8%; 1999–2002: 21.1%; and 2005–2008: 34.9%;
P,.001 for trend) (Table 2). In
strati-fied analyses, children 1 to 5 years and 6 to 11 years of age, boys and girls, non-Hispanic white children, non-non-Hispanic black children, Mexican American chil-dren, and insured youth each had an increase in use of PAM from 1988– 1994 to 2005–2008 (P,.05 for each trend). In contrast, the estimated in-creases between 1988–1994 and 2005– 2008 for use of PAM among adolescents 12 to 19 years of age and uninsured youth were not statistically significant.
compared with 1988–1994, reported use of inhaled corticosteroids increased (4.7% vs 23%,P,.001 for trend). In 2005–2008, compared with 1999–2002, reported use of leukotriene receptor antagonists (7.2% vs 21%,P, .001) and long-acting b-agonists (3% vs 11.4%,P,.001) increased. Use of$2 PAMs increased from 1999–2002 to 2005–2008 (5.6% vs 16.5%,P,.001). Reported use of inhaled corticosteroids among non-Hispanic black and Mexican
American children and adolescents did not differ significantly from non-Hispanic white children and adoles-cents for the 2005–2008 survey years (Table 4).
In multivariate logistic regression anal-ysis, controlling for potential shifts in the age, gender, race/ethnicity, and health insurance status of children with current asthma, there was still an in-creased odds of PAM use in 2005–2008 as compared with 1988–1994 (aOR = 2.6;
95% CI: 1.5–4.5) (Table 5). In 1999–2002, compared with 1988–1994, the odds of PAM use did not statistically differ. The odds of PAM use were lower among non-Hispanic black children (aOR = 0.5; 95% CI: 0.4–0.7) and Mexican American children (aOR: 0.6; 95% CI: 0.4–0.9) compared with non-Hispanic white dren. Adolescents, compared with chil-dren 1 to 5 years of age (aOR: 0.5; 95% CI: 0.4–0.8), and uninsured children compared with insured children (aOR: 0.6; 95% CI: 0.4–0.9), had a lower odds of PAM use. There were no statistically significant differences by gender in the odds of PAM use. All possible 2-way interactions were tested in our final models; there were no significant in-teractions.
DISCUSSION
Overall, among children and adoles-cents with current asthma, use of PAM increased from 1988–1994 to 2005–2008. Use of anti-inflammatory medication classes (eg, inhaled cor-ticosteroids and leukotriene receptor antagonists) also increased between 1988–1994 and 2005–2008. Additional changes in use of PAM during our study period include an increase in long-actingb-agonists and use of 2 or more classes of PAM.
Our estimates for use of PAM are gen-erally consistent with those reported by the Agency for Healthcare Quality and Research using data from the Medical Expenditures Panel Survey. For example, in 2003, 2004, and 2005, the Agency for Healthcare Quality and Re-search reported that 28.5%, 32.8%, and 30.6%, respectively, of children and ado-lescents aged 0 to 17 years with current asthma used PAM.23 To our knowledge,
there are no other nationally represen-tative studies that describe the use of PAM among children and adolescents with current asthma before 2003 or after 2005.
TABLE 1 Sample Sizes and Descriptive Information for the Analytic Sample, 1988–1994, 1999–2002, and 2005–2008
1988–1994 1999–2002 2005–2008
Sample sizea 767 870 862
Age, y (% total)
1–5 19.5 21.9 18.8
6–11 34.2 33.5 33.2
12–19 46.3 44.7 48.0
Gender (% total)
Male 51.5 57.1 55.5
Female 48.5 42.9 44.5
Race/ethnicity (% total)
Non-Hispanic white 66.9 55.6 59.3
Non-Hispanic black 18.2 20.3 20.4
Mexican American 6.7 7.8 8.5
Other 8.2 16.4 11.8
Health insurance status (% total)
Insured 87.4 91.1 91.6
Uninsured 12.6 8.9 8.4
Source: NHANES.
aSample size is unweighted; all other estimates are weighted.
TABLE 2 Percent of Children and Adolescents With Current Asthma Using PAMs Over Time by Age, Gender, Race/Ethnicity, and Health Insurance Status
Preventive Asthma Medications, % (SE)
1988–1994 1999–2002 2005–2008
Totala 17.8 (3.3) 21.1 (2.0) 34.9 (3.3)
Age, y
1–5a 11.7 (3.3) 28.3 (4.9) 43.1 (5.4)
6–11b 23.9 (5.6) 21.3 (3.6) 45.2 (6.1)
12–19 15.8 (4.1) 17.5 (2.3) 24.7 (3.3)
Gender
Boysc 19.5 (4.0) 22.0 (2.3) 39.5 (4.6)
Girlsb 15.9 (3.6) 20.1 (3.1) 29.2 (4.5)
Race/ethnicity
Non-Hispanic whitec 20.4 (4.9) 23.0 (3.3) 40.0 (4.7)
Non-Hispanic blackc 16.2 (2.5) 13.9 (1.7) 26.9 (2.6)
Mexican Americana 11.0 (2.8) 17.5 (2.6) 29.3 (3.6)
Health insurance status
Insureda 18.5 (3.8) 22.5 (2.2) 36.0 (3.6)
Uninsured 12.7 (4.3) 10.5 (3.5) 21.7 (4.4)
Source: NHANES.
aSignificant trend from 1988–1994 to 2005–2008,P,.001. bSignificant trend from 1988–1994 to 2005–2008,P,.05. cSignificant trend from 1988–1994 to 2005–2008,P,.01.
Over the past 30 years, there have been advances in asthma research, includ-ing greater knowledge of the role of
inflammation in symptom development and chronic airway remodeling.34,35
Additionally, clinical research also has demonstrated the benefits of PAMs, particularly anti-inflammatory medica-tions, in reducing asthma morbidity8–13
and achieving asthma control.36,37 To
this end, our findings of an increase over time in the proportion of chil-dren with asthma using PAMs, and anti-inflammatory medications specifically, parallel advances in asthma research.
Use of long-acting b-agonists alone, without concurrent use of another PAM, is associated with adverse health outcomes, including death,38,39and is
not recommended by the NAEPP. In our analysis, we sought to examine trends in the prevalence of long-acting
b-agonist use alone, but these esti-mates were not statistically reliable. However, by 2005–2008,∼96% of chil-dren and adolescents with current as-thma who used long-actingb-agonists
adolescents who used long-acting
b-agonists alone did not significantly change the estimates presented in our analysis. The risks of long-acting
b-agonist use are not inconsequential, however, and to further examine the role of long-actingb-agonists in asthma management, plans for clinical trials have been reported recently.40
Similar to other studies,15,19,22,24–27we
report racial and ethnic disparities in the use of PAMs among children with asthma. Given that underutilization of PAMs may contribute to racial dis-parities in asthma outcomes, we were interested in trends in PAM use among racial/ethnic groups.3,24 Our results
demonstrate there were increases in the use of PAMs among each examined racial and ethnic group. We further ex-amined whether the relationship be-tween race and ethnicity and PAM use changed over time by assessing effect modification between race/ethnicity and survey time periods. Because there was no evidence of effect modification in our analysis, our results demonstrate persistence of disparities in PAM use between non-Hispanic white children and both non-Hispanic black and Mexican American children during our study period.
Another group with relatively low use of PAMs is adolescents 12 to 19 years of age. National data show that asthma morbidity in the adolescent age group is similar to that among younger ages, and although a rare event among chil-dren, the asthma death rate is simi-lar between adolescents and young children.2 Adolescence is a period of
increasing responsibility for asthma medication administration41and also is
associated with decreased adherence to medications,42despite the remaining
need for preventive medications. Al-though adherence to asthma medi-cations is a recognized problem for
1988–1994, % (SE) 1999–2002, % (SE) 2005–2008, % (SE)
Any PAMa 17.8 (3.3) 21.1 (2) 34.9 (3.3)
Inhaled corticosteroida 4.7 (1.3) 12.4 (1.7) 23.0 (2.0)
Leukotriene receptor antagonistb Not availablec 7.2 (1.3) 21.0 (3.1)
Methylxanthines 10.4 (2.8) —e —e
Mast-cell stabilizers 4.9 (1.8)d 5.2 (1.4) —e
Long-actingb-agonistb —e 3.0 (1.0)d 11.4 (1.4)
$2 PAMsb —e 5.6 (1.2) 16.5 (1.6)
Source: NHANES.
aSignificant trend from 1988–1994 to 2005–2008,P,.001. bSignificant difference between 1999–2002 and 2005–2008,P,.001.
cNo medications in this asthma medication class were approved by the US Food and Drug Administration during this time
period.
dDoes not meet standard of statistical reliability and precision (relative SE$30% but,40%). eDoes not meet standard of statistical reliability and precision (relative SE$40%).
TABLE 4 Percent of Children Aged 1 to 19 Years With Current Asthma Using Specific PAMs by Race/Ethnicity, 2005–2008
Non-Hispanic White Children, % (SE)
Non-Hispanic Black Children, % (SE)
Mexican American Children, % (SE) Any PAM 40.0 (4.7) 26.9 (2.6)a 29.3 (3.6)
Inhaled corticosteroid 24.2 (3.0) 22.3 (2.1) 24.4 (3.7) Leukotriene receptor antagonist 26.0 (4.7) 11.3 (2.3)b 13.4 (2.4)a
Long-actingb-agonist 14.5 (2.4) 8.0 (1.4)a 9.5 (2.3)
$2 PAMs 19.7 (2.4) 12.0 (1.8)b 14.3 (2.9)
Source: NHANES.
aSignificant difference from non-Hispanic white children,P,.05. bSignificant difference from non-Hispanic white children,P,.01.
TABLE 5 Logistic Regression Analysis of PAM Use Among Children and Adolescents With Current Asthma
Descriptive Information Covariates Survey
1988–1994 Reference 1999–2002 1.3 (0.7–2.2) 2005–2008 2.6 (1.5–4.5)a
Age, y
1–5 Reference
6–11 1 (0.7–1.4) 12–19 0.5 (0.4–0.8)a
Gender
Male Reference
Female 0.8 (0.5–1.1) Race/ethnicity
Non-Hispanic white Reference Non-Hispanic black 0.5 (0.4–0.7)a
Mexican American 0.6 (0.4–0.9)b
Health insurance status
Insured Reference
Uninsured 0.6 (0.4–0.9)b
Source: NHANES.
children of all ages,15,43–47 lower
ad-herence among adolescents as com-pared with younger children may have contributed to the differences by age in use of PAMs. Other factors, however, including low utilization of primary care services during adolescence,48also may
have contributed to ourfindings of low use of PAMs among adolescents.
In our analysis, children and adoles-cents without health insurance cover-age had lower use of PAM than those who were insured, which is consistent with other literature that has explored associations between health insurance coverage and prescription medication use among children and adolescents.49,50
A study in New York State revealed that after previously uninsured children with asthma acquired health insurance through the State Children’s Health Insurance Program, their parents re-ported substantially fewer problems obtaining asthma medication.51 Lower financial barriers52,53 and greater
ac-cess to a usual source of care54–56may
partly explain higher use of PAM among insured children compared with unin-sured children and adolescents.
There are several factors that may have contributed to the increase in use of PAMs over time. The NAEPP asthma treatment guidelines were first re-leased in 1991 and subsequently up-dated in 1997 and 2007, with an interim update in 2002.3The concerted efforts
to educate health care professionals, patients and their families, and the public about the importance of infl am-mation in the pathology of asthma and the value of preventive medications in averting adverse outcomes may have contributed to increases in the use of PAM. Entirely new classes of PAMs, in-cluding leukotriene receptor antagonists,
became available during our study period.57Similarly, the growth of
direct-to-consumer advertising of pharma-ceuticals during this period has been documented,58and such advertisements
may increase medication use.59
Al-though still other factors may have contributed to ourfindings, our study suggests that any changes in the pop-ulation composition by age, gender, race/ethnicity, and health insurance status of children and adolescents with current asthma did not fully ex-plain the increase in PAM usage over time.
A sensitivity analysis was conducted to assess if patterns of PAM use during the most current survey years, 2005– 2008, were similar to those observed in our full analytic sample. In a model with all covariates shown in Table 5 except for survey time period, we ob-served similar associations with PAM for the remaining covariates, that is, lower odds of PAM use in non-Hispanic white children, Mexican American chil-dren, older chilchil-dren, and uninsured children. Because of decreased sample size, however, not all associations were statistically significant.
Our study has several strengths. Pre-scription medication data were ob-tained during an in-home interview by trained interviewers who verified most of the reported medications based on review of the medication containers. Additionally, the sample was nationally representative. There are also limita-tions to our study. We are unable to classify asthma severity using the NAEPP criteria, although underutiliza-tion of PAMs among children and ado-lescents with persistent asthma has been well documented.14–21Additional
studies are needed to accurately define
and describe the proportion of chil-dren and adolescents untreated for persistent asthma using NAEPP crite-ria. In 2005–2008, we were able to ex-amine PAM use among individuals with potentially more severe disease,
de-fined as either use of PAM or limi-tations in physical activity because all children and adolescents in this survey period were asked about limitations in physical activity due to respiratory difficulties. Among youth with poten-tially more severe disease, lower use of PAM among non-Hispanic black par-ticipants, Mexican American partic-ipants, and adolescents was observed, and aORs were similar to those re-ported for our main analysis; however, the sample sizes for uninsured chil-dren were too small in this restricted sample to produce a reliable estimate (results not shown). Finally, residual confounding from factors not assessed, including provider practice type60 and
continuity of health insurance cover-age,32also may be a limitation of this
study.
CONCLUSIONS
Between 1988 and 2008, more children with asthma were treated with PAMs. Further, there were changes in the classes of PAMs used and an increase in the simultaneous use of multiple asthma medications. Improved asthma management, including increased use of PAMs, may have contributed to the declines in childhood asthma mor-bidity.61Future research may focus on
identifying interventions effective in improving delivery of asthma care con-sistent with NAEPP’s asthma treatment guidelines, including PAM use, and re-ducing disparities in PAM use.
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PRESIDENTIAL PARDON:I did not buy a live turkey this year for Thanksgiving, so when I purchased my bird from the store, it did not so much resemble a bird but a large round package wrapped in plastic. The anonymity of the package may be one reason why I did not feel any remorse planning my holiday meal. However, I wonder what would have happened if I had gone to a farm and selected one to be slaughtered from a gaggle of live turkeys. Would I have felt differently? Would I have bought the turkey and then released it? After all, the President of the United States pardons a turkey each Thanksgiving. As reported onCNN.com(Holidays: November 22, 2011), the tradition of a Presidential turkey pardon dates back to when Abraham Lincoln was in office. Minutes before the scheduled demise of a pet turkey raised by his son Tad for the holiday meal, Tad burst into a cabinet meeting and pleaded with his father not to kill the bird. President Lincoln wrote the order for a reprieve on a card and the turkey was granted its freedom. The tradition of annual Presidential turkey pardons, however, is a much more recent phenomenon. President Eisen-hower was presented a turkey each Thanksgiving holiday by the National Turkey Federation. President Eisenhower, parsimonious in all his pardons, simply ate the birds. President George H.W. Bush began the modern tradition of pardons in 1989. When presented with a live gobbler for the holiday meal he decreed that the turkey would not be eaten by anyone and granted an official presidential pardon. This year two birds will be selected for pardon. After a Rose garden ceremony, the birds will be taken to Mount Vernon Estates and Gardens where they will be on display until January. A protected environment for the pardoned turkeys seems like a good idea. I am pretty sure that pardoned domesticated turkeys released into the wild in our neck of the woods would not survive too long. As for me, having raised and then eaten the sheep I raised, I think that“I like Ike.”
Noted by WVR, MD
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DOI: 10.1542/peds.2011-1513 originally published online December 5, 2011;
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