- Email: [email protected]
Pharmacist-led screening program for an inner-city pediatric population
RESEARCH NOTES
Pharmacist-led screening program for an inner-city pediatric population Jennifer Padden Elliott, Chelsea Harrison, Chelsea Konopka, Jennifer Wood, Nicole Marcotullio, Phil Lunney, David Skoner, and Deborah Gentile
Abstract Objectives: To identify the prevalence of asthma, obesity, hypertension, and environmental tobacco smoke (ETS) exposure among youth and provide recommendations for follow-up care. Methods: This cross-sectional study consisted of 12 health screenings for children between 5 and 17 years of age in various inner city, lower socioeconomic, and predominantly black communities throughout the city of Pittsburgh, PA. The screenings were conducted by pharmacists and student pharmacists from April 2010 to April 2012. Asthma, obesity, hypertension, and ETS screenings were offered at each event. Results: A total of 144 children (50% girls, 89% black, non-Hispanic) were enrolled. Sixteen percent of the study population had a previous diagnosis of asthma; 4% were poorly controlled, and 18% were identified as having potential, undiagnosed asthma. Fifty-three percent were at an unhealthy weight (0.7% underweight, 24.3% overweight, 28.5% obese), 24% had abnormal blood pressure (12.8% prehypertension, 8.5% stage 1 hypertension, 2.8% stage 2 hypertension), and 26% had ETS exposure equivalent to that of smokers (0.7% light smokers, 17.5% smokers, and 7.7% heavy smokers). Overall, 177 specific referrals were made. The incidence of hypertension (P <0.001) and the proportion of ETS equivalent to heavy smokers increased (P = 0.019) with increased weight classification. Conclusion: Within this self-selected inner city, predominantly black pediatric population, there were high rates of positive screens for potential asthma, obesity, hypertension, and smoking. Additionally, the risk for high ETS exposure and hypertension increased with increasing weight. This study highlights the importance of pharmacists in disease screening and the need for alternative prevention and management strategies in disparate pediatric populations. J Am Pharm Assoc. 2015;55:413–418. doi: 10.1331/JAPhA.2015.14273
Journal of the American Pharmacists Association
T
he prevalence of chronic disease continues to rise in the pediatric population.1–3 Current estimates indicate that 9.5% of children in the United States have asthma, 17% are obese, and 0.3% have hypertension, with disproportionate disease burden among poor and minority children.4–10 Along with obesity and hypertension, environmental tobacco smoke (ETS) exposure is a major risk factor for cardiovascular disease (CVD).11 Although current data indicate that the prevalence of cigarette smoking has declined among middle school students, there has been no change in reported openness to trying cigarette smoking.12,13 Exposure to ETS is also a risk factor for developing asthma and is associated with poorer asthma control.14,15 Preventive health screenings are a potential means to decrease morbidity and mortality from chronic diseases.16 The U.S. Preventive Services Task Force (USPSTF) has recommended that children aged 6 years and older be screened for obesity and that school children and adolescents be screened for cigarette smoking.17,18 Currently, there are no routine screening recommendaJennifer Padden Elliott, PharmD, Assistant Professor, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Chelsea Harrison, PharmD, Postgraduate Year 2 Ambulatory Care Resident, Cleveland Clinic, Cleveland, OH; at the time of project completion, Student Pharmacist, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Chelsea Konopka, Student Pharmacist, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Jennifer Wood, Student Pharmacist, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Nicole Marcotullio, PharmD, at time of project completion, Assistant Professor, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Phil Lunney, PhD, Senior Associate, Lachman Consultants, New York, NY; at the time of project completion, PhD candidate, Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA David Skoner, MD, Division Director, Allergy, Asthma, and Immunology, Allegheny Health Network, Pittsburgh, PA Deborah Gentile, MD, Director of Research, Allergy, Asthma, and Immunology, Allegheny Health Network, Pittsburgh, PA Correspondence: Jennifer Padden Elliott, PharmD, Mylan School of Pharmacy, Duquesne University, 600 Forbes Avenue, 308 Bayer Learning Center, Pittsburgh, PA 15282; [email protected] Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Funding: This study was funded, in part, under grants from the Pennsylvania Department of Health and For Your Good Health, LLC. Received December 15, 2014. Accepted for publication March 20, 2015. Published online in advance of print June 26, 2015.
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tions for hypertension or asthma in the pediatric population. Babb et al. described the need for pharmacist involvement in screening programs that focus on areas such as hypertension, asthma, smoking cessation, and patient education.19 Because of known discrepancies in health care access and disease prevalence in disparate populations,5,7,8,20 pharmacists and student pharmacists conducted 12 health screenings in various inner city, lower socioeconomic, and predominantly black communities.
Objectives The primary objective of this study was to identify the prevalence of asthma, obesity, hypertension, and ETS among youth, and provide recommendations for follow-up care. The secondary objective was to identify relationships between patient demographics, asthma, body mass index (BMI), hypertension, and ETS exposure.
Methods The Institutional Review Board at Duquesne University approved this cross-sectional study. Twelve health screenings were conducted over a period of 2 years at 12 different after-school programs that were located in lower socioeconomic, predominantly black neighborhoods throughout the city of Pittsburgh, PA. The Office of Service Learning at Duquesne University helped to identify these programs. A letter explain-
Key Points Background: ❚❚ The prevalence of chronic disease in childhood continues to rise and disproportionately affect poor and minority children. ❚❚ Preventive health screenings are a potential means to decrease morbidity and mortality from chronic diseases. ❚❚ This study is the first to evaluate pharmacist and student pharmacist directed pediatric health screenings for asthma, obesity, hypertension, and environmental tobacco smoke in the inner-city setting. Findings: ❚❚
❚❚
Pharmacists and student pharmacists identified high rates of positive screens for potential asthma, obesity, hypertension and smoking in this inner-city, predominantly black pediatric population. This study highlights the importance of pharmacists in preventive care and the need for alternative prevention and management strategies in disparate pediatric populations.
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ing the study and an informed consent form was sent home with 1,000 children attending these programs. All children between 5 and 17 years of age at the selected programs were eligible to participate in the study, regardless of prior diagnoses or individual risk of disease. Study personnel obtained written consent and assent prior to participation in the study. Asthma, BMI, obesity, and ETS exposure screenings were offered to all children who elected to participate in the study. Children and caregivers were allowed to choose specific or all screening assessments they wanted to complete. Caregivers received a report of all screening assessments and were instructed to follow-up with their child’s primary care provider for any abnormal screening results. Specific referrals were made only when the participant did not have a primary care provider. Student pharmacists from Duquesne University conducted the health screening assessments under the supervision of physician and pharmacist faculty. Physician and pharmacist faculty conducted several training sessions prior to the health screenings. Student pharmacists were required to demonstrate proficiency in all assessments prior to participation in the screening events. Demographic information, including age, gender, race, and ethnicity, was collected from caregivers at time of consent. Caregiver report of lifetime asthma diagnosis was collected at time of consent. Spirometry (KoKo Legend portable spirometer) was used to measure lung function and further classify asthma status. According to current guidelines, spirometry is an essential objective measure to establish the diagnosis of asthma.21 Student pharmacists conducted the spirometry screening at each event, with guidance and interpretation of results provided by physician faculty. Student pharmacists reviewed proper technique and coached each child to obtain three acceptable and reproducible results. Of the three results obtained from each child, the highest forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were reported. The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents was used along with spirometry results to further classify children with a previous asthma diagnosis according to level of control. This validated self-assessment tool was used to determine if asthma was controlled from the child and caregiver perspective. The ATAQ for children and adolescents is a 7-item questionnaire that identifies problems in the areas of symptom control, behavior, attitude, self-efficacy, and communication.22 The asthma screening classification system described by Elliott et al. was used in this study (Table 1).23 Height was measured in centimeters (cm) using a portable stadiometer and weight was measured in kilograms (kg) via a digital scale. BMI was calculated and the Centers for Disease Control and Prevention (CDC) BMI-for-age percentiles were used to classify particiJournal of the American Pharmacists Association
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Table 1. Asthma screening classification system Classification No asthma Potential asthma Previously diagnosed asthma Controlled asthma Not well controlled asthma Poorly controlled asthma
Caregiver report of asthma diagnosis Noa Noa Yesb Yesc Yesc
FEV1 or FEV1/FVC
ATAQ score
≥85%a <85%a
NA NA
≥85%b <85%c <85%c
0b 1–2c 3–7c
Abbreviations used: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ATAQ, asthma therapy assessment questionnaire; NA not applicable. a Both criteria (caregiver report and pulmonary function) needed for classification. b All three criteria (caregiver report, pulmonary function, and ATAQ score) needed for classification. c Two criteria (caregiver report plus either pulmonary function or ATAQ score) needed for classification.
pants as: underweight (<5th percentile), healthy weight (5th percentile to 85th percentile), overweight (85th to 95th percentile), and obese (≥95th percentile).24 Blood pressure was evaluated according to recommendations from the National Heart Lung and Blood Institute’s Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Appropriately sized blood pressure cuffs were used and participants were seated for approximately 5 minutes prior to obtaining a blood pressure reading. Participants were considered normotensive if their blood pressure was less than 90th percentile, prehypertensive if their blood pressure was between 90th and 95th percentile, stage 1 hypertensive if their blood pressure was between 95th and 99th percentile plus 5 mm Hg, and stage 2 hypertensive if their blood pressure was more than 99th percentile plus 5 mm Hg for their age, gender, and height.25 Blood pressure was repeated twice if the first assessment was equal to or more than 90th percentile and the average of the three readings was recorded. Data on previous diagnosis of hypertension, caffeine intake, or stimulant medication use was not recorded. SmokeCheck (MicroDirect) hand-held portable monitors were used to measure exhaled carbon monoxide (CO) levels to evaluate exposure to ETS. The noninvasive monitors give patients instant, visible proof of CO levels in their lungs in parts per million (ppm). Participants were classified into the following smoking categories based upon CO level and manufacturer recommendations: CO ppm: 0–6 = nonsmoker; 7–10 = light smoker; 11–20 = smoker; ≥20 = heavy smoker. Participants with CO levels greater than 6 ppm were asked if they or someone they live with smokes; however, these data were not collected as part of the study and were used for referral purposes only. Descriptive statistics and simple tests of hypotheses were conducted using JMP version 10 from SAS Institute (Cary, NC) depending upon the scale of measurement for the specific independent and dependent variables being tested. A hypothesis test of association Journal of the American Pharmacists Association
between two categorical variables was investigated using a two-way contingency test and a chi-square test statistic. Logistic regression was used for testing hypotheses between a categorical dependent variable and a continuous independent response, whereas a one-way analysis of variance was used for testing the reverse case involving a categorical independent variable and a continuous dependent variable. The alpha level for statistical significance was established as 0.05.
Results Of the 1,000 informed consent forms that were distributed to caregivers, written consent and assent was obtained from 144 participants (mean age, 9.1 ± 3.1 years [range, 5–17 years], 50% girls, 89% black, non-Hispanic, 6% white, non-Hispanic). Table 2 describes the results of the asthma, obesity, hypertension, and ETS screenings. Sixteen percent of participants had a prior diagnosis of asthma, of which 4% were considered poorly controlled, and 18% were identified as having potential, undiagnosed asthma. Twenty-four percent were overweight, 29% obese, 13% prehypertensive, 9% stage 1 hypertensive, and 3% stage 2 hypertensive. Eighteen percent had CO levels consistent with smokers and 8% with heavy smokers. Over the 2-year study period, 171 specific referrals for follow-up care were made: 4 for previously diagnosed, uncontrolled asthma, 19 for potential undiagnosed asthma, 18 for prehypertension, 12 for stage 1 hypertension, 4 for stage 2 hypertension, 1 for underweight, 35 for overweight, 41 for obesity, and 37 for ETS exposure. There was an increased incidence of hypertension with increased weight classification (P <0.001), and the proportion of heavy smokers increased with increased weight classification (P = 0.019). The majority of participants were identified as black, non-Hispanic (89%); therefore, associations between racial/ethnic characteristics and disease could not be evaluated. No significant associations were found between age, gender, and disease conditions.
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Table 2. Asthma, obesity, hypertension, and ETS screening results Classification Asthma screeninga No asthma Potential asthma Previously diagnosed asthma Control unknownb Well controlled Poorly controlled Obesity screening Underweight Healthy weight Overweight Obese Hypertension screeningc Normal Prehypertension Stage 1 hypertension Stage 2 hypertension ETS screeningd Nonsmoker (CO ppm 0–6) Light smoker (CO ppm 7–10) Smoker (CO ppm 11–20) Heavy smoker (CO ppm ≥20)
N (%) 106 70 (66%) 19 (17.9%) 17 (16.1%) 11 (10.4%) 2 (1.9%) 4 (3.8%) 144 1 (0.7%) 67 (46.5%) 35 (24.3%) 41 (28.5%) 141 107 (75.9%) 18 (12.8%) 12 (8.5%) 4 (2.8%) 143 106 (74.1%) 1 (0.7%) 25 (17.5%) 11 (7.7%)
Abbreviations used: ETS, environmental tobacco smoke; CO, carbon monoxide; ATAQ, asthma therapy assessment questionnaire. Thirty-eight caregivers did not include information on previous asthma diagnosis; we were unable to determine asthma classification for these children. a
Eleven children with a caregiver reported prior diagnosis of asthma elected not to complete the spirometry and/or ATAQ assessment resulting in an unknown level of asthma control. b
Three children elected not to complete the hypertension screening.
c
One child elected not to complete the ETS exposure screening.
d
Discussion The primary objective of this study was to identify the prevalence of asthma, obesity, hypertension, and ETS among youth, and provide recommendations for follow-up care. Sixteen percent of participants had a prior diagnosis of asthma. This parent-reported prevalence rate is consistent with previous reports of asthma prevalence among black, non-Hispanic children,5 who comprised 89% of our study population. Asthma control was not determined in the majority of participants with previously diagnosed asthma due to children or parents electing not to complete the spirometry and/or ATAQ assessments. However, 4% of the study population with a previous diagnosis of asthma were determined to have poorly controlled asthma, which is associated with significant disease burden, decreased quality of life, and increased health care use.21 An alarming 18% of children whose caregivers reported no asthma history were identified to have potential undiagnosed asthma. These findings suggest that the actual prevalence of asthma among this population of predominantly black children 416 JAPhA | 5 5 :4 | JUL /AUG 2 0 1 5
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residing in the inner city, in lower socioeconomic neighborhoods, may be much higher than national estimates (9.5%), including those higher estimates in black (16%) and lower socioeconomic (13%) children.4,5 The majority of the study population (53.5%) was determined to be at an unhealthy weight; with 0.7% underweight, 24.3% overweight, and 28.5% obese. The rates of obesity in this cohort are more than 1.5 times that of national childhood obesity estimates (17%).6,7 Therefore, it is not surprising that the rates of hypertension in this population followed the same trend. Eleven percent of the study population had blood pressure measurements consistent with hypertension, more than double the index rates reported by Lo et al.10 Additionally, 12.8% are at risk of developing hypertension in the near future, with blood pressure measurements consistent with prehypertension. Obesity and hypertension in childhood have been associated with risk factors for cardiovascular disease such as the development of early myocardial changes, coronary and carotid artery pathology, and left ventricular hypertrophy.26 Cigarette smoking also has detrimental effects on the cardiovascular system and remains the leading preventable cause of premature disease and death in the United States.27 More than 25% of the study population had exhaled CO levels consistent with those of smokers. The estimated prevalence of smoking in this population is more than five times that of self-reported prevalence rates collected from schoolbased surveys in middle school children.12 Therefore, it is likely that a portion of children with CO levels consistent with smoking may not have been active smokers themselves, but exposed to significant second-hand smoke. Regardless of smoking status, a large percentage of participants in this study were exposed to ETS. The secondary objective of this study was to identify relationships among patient demographics, asthma, BMI, hypertension, and ETS exposure. Two significant relationships were identified. There was an increased incidence of hypertension with increased weight classification (P <0.001), which is consistent with previous reports.28,29 Interestingly, and contrary to previous reports in adults,30 there was a significant association between weight status and ETS exposure, with the proportion of ETS-equivalent heavy smokers increasing with increased weight classification (P = 0.019). This finding, however, is consistent with current literature in adolescents, which supports an association between smoking, poor food choice, and sedentary activity31 and the notion that adolescent cigarette smoking increases vulnerability to risk of obesity in young adulthood.32 This study is the first to evaluate pharmacist and student pharmacist directed pediatric health screenings for asthma, obesity, hypertension, and ETS in the innercity setting. Consistent with the 2013 Center for the Advancement of Pharmacy Education Educational Outcomes,33 student pharmacists should be trained to assist Journal of the American Pharmacists Association
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pharmacists to conduct pediatric health screenings. It is recommended that student pharmacists already be trained and familiar with these screenings in the adult population so that they are comfortable with the assessments and training can focus on differences in the approach to the pediatric patient and interpretation of results. Pediatric health screenings can also be conducted at community pharmacies, outpatient clinics, and health fairs. In these settings, supervising pharmacists can design such activities in which student pharmacists can help with the planning and marketing of the event, decrease the time burden of conducting such an event, and increase the number of children that can be screened.
Limitations Several limitations need to be considered when interpreting the results of this study. The convenience sample can introduce self-selection bias, which makes the interpretation of their representativeness difficult. In our sample, 89% of children reported race to be black and only 6% reported white, whereas county-wide data indicates that 13.3% of the population is black and 81.3% white.34 Therefore, our convenience sample was not representative of the population, and results should be interpreted with caution. Caregiver recall of lifetime asthma diagnosis was used to classify asthma and caregiver reported medical histories can be unreliable. Caregiver and child recall was also used to further classify asthma control. Although the ATAQ is a validated self-assessment tool, recall bias and symptom perception limit the accuracy of patient self-report and self-assessment. Another potential limitation was using spirometry as a screening tool because there was limited time to teach and coach subjects to achieve optimal technique. Poor technique and effort could have resulted in falsely elevated numbers of children being identified as having potential asthma and poorly controlled asthma. With regard to the hypertension screening, Lo et al. revealed that many children who present with an initial blood pressure measurement consistent with hypertension do not go on to have guideline-defined hypertension, which includes blood pressure measurements consistent with hypertension on three or more occasions.10,25 There is evidence that inflammatory lung diseases, such as asthma, may elevate exhaled CO levels.35 Therefore, asthma status could have elevated CO levels, independent of tobacco smoke exposure. Although this study resulted in disease identification, we do not know what effect, if any, screening and referral had on physician follow-up, formal diagnosis, treatment, and health outcomes. Future studies are needed to determine the effect of disease recognition through screenings in disparate populations on health care utilization and health status.
Journal of the American Pharmacists Association
Conclusion In summary, this study reveals that disease burden in disparate populations may be greater than current national estimates. Within this self-selected inner city, predominantly black population, there were high rates of positive screens for potential asthma, obesity, hypertension, and smoking. Additionally, the risk for smoking and hypertension increased with increasing weight. This study highlights the utility of pharmacists in disease screening and the need for alternative prevention and management strategies in disparate pediatric populations. Future studies are needed that focus on decreasing disease disparity and improving health outcomes in high-risk pediatric populations. References 1. Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6–28. 2. Sorof JM, Lai D, Turner J, et al. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics. 2004;113(3):475–482. 3. Trends in asthma morbidity and mortality. American Lung Association. 2014. http://www.lung.org/finding‐cures/our‐research/ trend‐reports/asthma‐trend‐report.pdf. Accessed March 25, 2014. 4. 2011 lifetime asthma, current asthma, asthma attacks among those with current asthma. 2011 National Health Interview Survey (NHIS) Data. Centers for Disease Control and Prevention. 2013. http://www.cdc.gov/asthma/nhis/2011/data.htm. Accessed March 25, 2014. 5. Summary health statistics for U.S. children: National Health Interview Survey, 2011. Vital Health Statistics. Centers for Disease Control and Prevention. 2012. http://www.cdc.gov/nchs/data/ series/sr_10/sr10_254.pdf. Accessed March 25, 2014. 6. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–814. 7. Skelton JA, Cook SR, Auinger P, et al. Prevalence and trends of severe obesity among U.S. children and adolescents. Acad Pediatr. 2009;9(5):322–329. 8. Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation. 2007;116:1488–1496. 9. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298:874–879. 10. Lo JC, Sinaiko A, Chandra M, et al. Prehypertension and hypertension in community-based pediatric practice. Pediatrics. 2013;131:e415–e424. 11. Ezzati M, Hoorn SV, Lopez AD, et al. Comparative quantification of mortality and burden of disease attributable to selected risk factors. In Global Burden of Disease and Risk Factors. 2nd ed. New York, NY: Oxford University Press; 2007:241–268. 12. Centers for Disease Control and Prevention. Tobacco use among middle and high school students: United States, 2000– 2009. MMWR Morb Mortal Wkly Rep. 2010;59:1063–1067. j apha.org
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13. Mowery PD, Farrelly MC, Haviland ML, et al. Progression to established smoking among US youth. Am J Public Health. 2004;94:331–337. 14. Sippel JM, Pedula KL, Vollmer WM, et al. Associations of smoking with hospital-based care and quality of life in patients with obstructive airway disease. Chest. 1999;115(3):691–696. 15. Soyseth V, Kongerud J, Boe J. Postnatal maternal smoking increases the prevalence of asthma but not of bronchial hyperresponsiveness or atopy in their children. Chest. 1995;107(2):389–394. 16. Nelson DE, Bland S, Powell-Griner E, et al. State trends in health risk factors and receipt of clinical preventive services among U.S. adults during the 1990s. JAMA. 2002;287:2659– 2667. 17. U.S. Preventive Services Task Force. Screening for obesity in children and adolescents: U.S. preventive services task force recommendation statement. Pediatrics. 2010;125(2):361–367. 18. Moyer V. Primary care interventions to prevent tobacco use in children and adolescents: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(8):552– 557. 19. Babb VJ, Babb J. Pharmacist involvement in Healthy People 2010. J Am Pharm Assoc. 2003;43(1):56–60. 20. Starfield B. US child’s health: what’s amiss, and what should be done about it? Health Aff (Millwood). 2004;23(5):165–170.
25. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(suppl 2):555–576. 26. Sorof J, Daniels S. Obesity hypertension in children: a problem of epidemic proportions. Hypertension. 2002; 40:441–447. 27. Office of the Surgeon General. The health consequences of smoking—50 years of progress. Rockville, MD: U.S. Department of Health and Human Services; 2014. 28. Macedo ME, Trigueiros D, De Freitas F. Prevalence of high blood pressure in children and adolescents. Influence of obesity. Rev Port Cardiol. 1997;16:27–28. 29. Sorof JM, Poffenbarger T, Franco K, et al. Isolated systolic hypertension, obesity, and hyperkinetic hemodynamic states in children. J Pediatr. 2002;140:660–666. 30. Plurphanswat N, Rodu B. The association of smoking and demographic characteristics on body mass index and obesity among adults in the U.S., 1999–2012. BMC Obes. 2014;1:18. 31. Lytle L, Kelder S, Perry C, Klepp K. Covariance of adolescent health behaviors: the class of 1989 study. Health Educ Res. 1995;10(2):133–146. 32. Huang D, Lanza H, Anglin M. Association between adolescent substance use and obesity in young adulthood: a group-based dual trajectory analysis. Addict Behav. 2013;38(11):2653–2660.
21. Guidelines for the diagnosis and management of asthma: National Asthma Education and Prevention Program Expert Panel Report 3. Bethesda, MD: U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program, 2007.
33. Medina MS, Plaza CM, Stowe CD, et al. Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes 2013. Am J Pharm Educ. 2013;77(8):162.
22. Skinner EA, Diette GB, Algatt-Bergstrom PJ, et al. The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents. Dis Manag. 2004;7(4):305–313.
35. Zayasu K, Sekizawa K, Okinaga S, et al. Increased carbon monoxide in the exhaled air of asthmatic patients. Am J Respir Crit Care Med. 1997;156:1140–1143.
34. State and County QuickFacts, Allegheny County, Pennsylvania. United States Census Bureau. 2015. http://quickfacts.census. gov/qfd/states/42/42003.html. Accessed March 19, 2015.
23. Elliott J, Marcotullio N, Skoner D, et al. An asthma sports camp series to identify children with possible asthma and cardiovascular risk factors. J Asthma. 2014;51(3):267–274. 24. About BMI for children and teens. Centers for Disease Control and Prevention. http://www.cdc.gov/healthyweight/assessing/ bmi/childrens_bmi/about_childrens_bmi.html. Accessed April 16, 2014.
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Journal of the American Pharmacists Association
Pharmacist-led screening program for an inner-city pediatric population Jennifer Padden Elliott, Chelsea Harrison, Chelsea Konopka, Jennifer Wood, Nicole Marcotullio, Phil Lunney, David Skoner, and Deborah Gentile
Abstract Objectives: To identify the prevalence of asthma, obesity, hypertension, and environmental tobacco smoke (ETS) exposure among youth and provide recommendations for follow-up care. Methods: This cross-sectional study consisted of 12 health screenings for children between 5 and 17 years of age in various inner city, lower socioeconomic, and predominantly black communities throughout the city of Pittsburgh, PA. The screenings were conducted by pharmacists and student pharmacists from April 2010 to April 2012. Asthma, obesity, hypertension, and ETS screenings were offered at each event. Results: A total of 144 children (50% girls, 89% black, non-Hispanic) were enrolled. Sixteen percent of the study population had a previous diagnosis of asthma; 4% were poorly controlled, and 18% were identified as having potential, undiagnosed asthma. Fifty-three percent were at an unhealthy weight (0.7% underweight, 24.3% overweight, 28.5% obese), 24% had abnormal blood pressure (12.8% prehypertension, 8.5% stage 1 hypertension, 2.8% stage 2 hypertension), and 26% had ETS exposure equivalent to that of smokers (0.7% light smokers, 17.5% smokers, and 7.7% heavy smokers). Overall, 177 specific referrals were made. The incidence of hypertension (P <0.001) and the proportion of ETS equivalent to heavy smokers increased (P = 0.019) with increased weight classification. Conclusion: Within this self-selected inner city, predominantly black pediatric population, there were high rates of positive screens for potential asthma, obesity, hypertension, and smoking. Additionally, the risk for high ETS exposure and hypertension increased with increasing weight. This study highlights the importance of pharmacists in disease screening and the need for alternative prevention and management strategies in disparate pediatric populations. J Am Pharm Assoc. 2015;55:413–418. doi: 10.1331/JAPhA.2015.14273
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T
he prevalence of chronic disease continues to rise in the pediatric population.1–3 Current estimates indicate that 9.5% of children in the United States have asthma, 17% are obese, and 0.3% have hypertension, with disproportionate disease burden among poor and minority children.4–10 Along with obesity and hypertension, environmental tobacco smoke (ETS) exposure is a major risk factor for cardiovascular disease (CVD).11 Although current data indicate that the prevalence of cigarette smoking has declined among middle school students, there has been no change in reported openness to trying cigarette smoking.12,13 Exposure to ETS is also a risk factor for developing asthma and is associated with poorer asthma control.14,15 Preventive health screenings are a potential means to decrease morbidity and mortality from chronic diseases.16 The U.S. Preventive Services Task Force (USPSTF) has recommended that children aged 6 years and older be screened for obesity and that school children and adolescents be screened for cigarette smoking.17,18 Currently, there are no routine screening recommendaJennifer Padden Elliott, PharmD, Assistant Professor, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Chelsea Harrison, PharmD, Postgraduate Year 2 Ambulatory Care Resident, Cleveland Clinic, Cleveland, OH; at the time of project completion, Student Pharmacist, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Chelsea Konopka, Student Pharmacist, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Jennifer Wood, Student Pharmacist, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Nicole Marcotullio, PharmD, at time of project completion, Assistant Professor, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA Phil Lunney, PhD, Senior Associate, Lachman Consultants, New York, NY; at the time of project completion, PhD candidate, Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA David Skoner, MD, Division Director, Allergy, Asthma, and Immunology, Allegheny Health Network, Pittsburgh, PA Deborah Gentile, MD, Director of Research, Allergy, Asthma, and Immunology, Allegheny Health Network, Pittsburgh, PA Correspondence: Jennifer Padden Elliott, PharmD, Mylan School of Pharmacy, Duquesne University, 600 Forbes Avenue, 308 Bayer Learning Center, Pittsburgh, PA 15282; [email protected] Disclosure: The authors declare no relevant conflicts of interest or financial relationships. Funding: This study was funded, in part, under grants from the Pennsylvania Department of Health and For Your Good Health, LLC. Received December 15, 2014. Accepted for publication March 20, 2015. Published online in advance of print June 26, 2015.
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tions for hypertension or asthma in the pediatric population. Babb et al. described the need for pharmacist involvement in screening programs that focus on areas such as hypertension, asthma, smoking cessation, and patient education.19 Because of known discrepancies in health care access and disease prevalence in disparate populations,5,7,8,20 pharmacists and student pharmacists conducted 12 health screenings in various inner city, lower socioeconomic, and predominantly black communities.
Objectives The primary objective of this study was to identify the prevalence of asthma, obesity, hypertension, and ETS among youth, and provide recommendations for follow-up care. The secondary objective was to identify relationships between patient demographics, asthma, body mass index (BMI), hypertension, and ETS exposure.
Methods The Institutional Review Board at Duquesne University approved this cross-sectional study. Twelve health screenings were conducted over a period of 2 years at 12 different after-school programs that were located in lower socioeconomic, predominantly black neighborhoods throughout the city of Pittsburgh, PA. The Office of Service Learning at Duquesne University helped to identify these programs. A letter explain-
Key Points Background: ❚❚ The prevalence of chronic disease in childhood continues to rise and disproportionately affect poor and minority children. ❚❚ Preventive health screenings are a potential means to decrease morbidity and mortality from chronic diseases. ❚❚ This study is the first to evaluate pharmacist and student pharmacist directed pediatric health screenings for asthma, obesity, hypertension, and environmental tobacco smoke in the inner-city setting. Findings: ❚❚
❚❚
Pharmacists and student pharmacists identified high rates of positive screens for potential asthma, obesity, hypertension and smoking in this inner-city, predominantly black pediatric population. This study highlights the importance of pharmacists in preventive care and the need for alternative prevention and management strategies in disparate pediatric populations.
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ing the study and an informed consent form was sent home with 1,000 children attending these programs. All children between 5 and 17 years of age at the selected programs were eligible to participate in the study, regardless of prior diagnoses or individual risk of disease. Study personnel obtained written consent and assent prior to participation in the study. Asthma, BMI, obesity, and ETS exposure screenings were offered to all children who elected to participate in the study. Children and caregivers were allowed to choose specific or all screening assessments they wanted to complete. Caregivers received a report of all screening assessments and were instructed to follow-up with their child’s primary care provider for any abnormal screening results. Specific referrals were made only when the participant did not have a primary care provider. Student pharmacists from Duquesne University conducted the health screening assessments under the supervision of physician and pharmacist faculty. Physician and pharmacist faculty conducted several training sessions prior to the health screenings. Student pharmacists were required to demonstrate proficiency in all assessments prior to participation in the screening events. Demographic information, including age, gender, race, and ethnicity, was collected from caregivers at time of consent. Caregiver report of lifetime asthma diagnosis was collected at time of consent. Spirometry (KoKo Legend portable spirometer) was used to measure lung function and further classify asthma status. According to current guidelines, spirometry is an essential objective measure to establish the diagnosis of asthma.21 Student pharmacists conducted the spirometry screening at each event, with guidance and interpretation of results provided by physician faculty. Student pharmacists reviewed proper technique and coached each child to obtain three acceptable and reproducible results. Of the three results obtained from each child, the highest forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were reported. The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents was used along with spirometry results to further classify children with a previous asthma diagnosis according to level of control. This validated self-assessment tool was used to determine if asthma was controlled from the child and caregiver perspective. The ATAQ for children and adolescents is a 7-item questionnaire that identifies problems in the areas of symptom control, behavior, attitude, self-efficacy, and communication.22 The asthma screening classification system described by Elliott et al. was used in this study (Table 1).23 Height was measured in centimeters (cm) using a portable stadiometer and weight was measured in kilograms (kg) via a digital scale. BMI was calculated and the Centers for Disease Control and Prevention (CDC) BMI-for-age percentiles were used to classify particiJournal of the American Pharmacists Association
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Table 1. Asthma screening classification system Classification No asthma Potential asthma Previously diagnosed asthma Controlled asthma Not well controlled asthma Poorly controlled asthma
Caregiver report of asthma diagnosis Noa Noa Yesb Yesc Yesc
FEV1 or FEV1/FVC
ATAQ score
≥85%a <85%a
NA NA
≥85%b <85%c <85%c
0b 1–2c 3–7c
Abbreviations used: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ATAQ, asthma therapy assessment questionnaire; NA not applicable. a Both criteria (caregiver report and pulmonary function) needed for classification. b All three criteria (caregiver report, pulmonary function, and ATAQ score) needed for classification. c Two criteria (caregiver report plus either pulmonary function or ATAQ score) needed for classification.
pants as: underweight (<5th percentile), healthy weight (5th percentile to 85th percentile), overweight (85th to 95th percentile), and obese (≥95th percentile).24 Blood pressure was evaluated according to recommendations from the National Heart Lung and Blood Institute’s Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Appropriately sized blood pressure cuffs were used and participants were seated for approximately 5 minutes prior to obtaining a blood pressure reading. Participants were considered normotensive if their blood pressure was less than 90th percentile, prehypertensive if their blood pressure was between 90th and 95th percentile, stage 1 hypertensive if their blood pressure was between 95th and 99th percentile plus 5 mm Hg, and stage 2 hypertensive if their blood pressure was more than 99th percentile plus 5 mm Hg for their age, gender, and height.25 Blood pressure was repeated twice if the first assessment was equal to or more than 90th percentile and the average of the three readings was recorded. Data on previous diagnosis of hypertension, caffeine intake, or stimulant medication use was not recorded. SmokeCheck (MicroDirect) hand-held portable monitors were used to measure exhaled carbon monoxide (CO) levels to evaluate exposure to ETS. The noninvasive monitors give patients instant, visible proof of CO levels in their lungs in parts per million (ppm). Participants were classified into the following smoking categories based upon CO level and manufacturer recommendations: CO ppm: 0–6 = nonsmoker; 7–10 = light smoker; 11–20 = smoker; ≥20 = heavy smoker. Participants with CO levels greater than 6 ppm were asked if they or someone they live with smokes; however, these data were not collected as part of the study and were used for referral purposes only. Descriptive statistics and simple tests of hypotheses were conducted using JMP version 10 from SAS Institute (Cary, NC) depending upon the scale of measurement for the specific independent and dependent variables being tested. A hypothesis test of association Journal of the American Pharmacists Association
between two categorical variables was investigated using a two-way contingency test and a chi-square test statistic. Logistic regression was used for testing hypotheses between a categorical dependent variable and a continuous independent response, whereas a one-way analysis of variance was used for testing the reverse case involving a categorical independent variable and a continuous dependent variable. The alpha level for statistical significance was established as 0.05.
Results Of the 1,000 informed consent forms that were distributed to caregivers, written consent and assent was obtained from 144 participants (mean age, 9.1 ± 3.1 years [range, 5–17 years], 50% girls, 89% black, non-Hispanic, 6% white, non-Hispanic). Table 2 describes the results of the asthma, obesity, hypertension, and ETS screenings. Sixteen percent of participants had a prior diagnosis of asthma, of which 4% were considered poorly controlled, and 18% were identified as having potential, undiagnosed asthma. Twenty-four percent were overweight, 29% obese, 13% prehypertensive, 9% stage 1 hypertensive, and 3% stage 2 hypertensive. Eighteen percent had CO levels consistent with smokers and 8% with heavy smokers. Over the 2-year study period, 171 specific referrals for follow-up care were made: 4 for previously diagnosed, uncontrolled asthma, 19 for potential undiagnosed asthma, 18 for prehypertension, 12 for stage 1 hypertension, 4 for stage 2 hypertension, 1 for underweight, 35 for overweight, 41 for obesity, and 37 for ETS exposure. There was an increased incidence of hypertension with increased weight classification (P <0.001), and the proportion of heavy smokers increased with increased weight classification (P = 0.019). The majority of participants were identified as black, non-Hispanic (89%); therefore, associations between racial/ethnic characteristics and disease could not be evaluated. No significant associations were found between age, gender, and disease conditions.
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Table 2. Asthma, obesity, hypertension, and ETS screening results Classification Asthma screeninga No asthma Potential asthma Previously diagnosed asthma Control unknownb Well controlled Poorly controlled Obesity screening Underweight Healthy weight Overweight Obese Hypertension screeningc Normal Prehypertension Stage 1 hypertension Stage 2 hypertension ETS screeningd Nonsmoker (CO ppm 0–6) Light smoker (CO ppm 7–10) Smoker (CO ppm 11–20) Heavy smoker (CO ppm ≥20)
N (%) 106 70 (66%) 19 (17.9%) 17 (16.1%) 11 (10.4%) 2 (1.9%) 4 (3.8%) 144 1 (0.7%) 67 (46.5%) 35 (24.3%) 41 (28.5%) 141 107 (75.9%) 18 (12.8%) 12 (8.5%) 4 (2.8%) 143 106 (74.1%) 1 (0.7%) 25 (17.5%) 11 (7.7%)
Abbreviations used: ETS, environmental tobacco smoke; CO, carbon monoxide; ATAQ, asthma therapy assessment questionnaire. Thirty-eight caregivers did not include information on previous asthma diagnosis; we were unable to determine asthma classification for these children. a
Eleven children with a caregiver reported prior diagnosis of asthma elected not to complete the spirometry and/or ATAQ assessment resulting in an unknown level of asthma control. b
Three children elected not to complete the hypertension screening.
c
One child elected not to complete the ETS exposure screening.
d
Discussion The primary objective of this study was to identify the prevalence of asthma, obesity, hypertension, and ETS among youth, and provide recommendations for follow-up care. Sixteen percent of participants had a prior diagnosis of asthma. This parent-reported prevalence rate is consistent with previous reports of asthma prevalence among black, non-Hispanic children,5 who comprised 89% of our study population. Asthma control was not determined in the majority of participants with previously diagnosed asthma due to children or parents electing not to complete the spirometry and/or ATAQ assessments. However, 4% of the study population with a previous diagnosis of asthma were determined to have poorly controlled asthma, which is associated with significant disease burden, decreased quality of life, and increased health care use.21 An alarming 18% of children whose caregivers reported no asthma history were identified to have potential undiagnosed asthma. These findings suggest that the actual prevalence of asthma among this population of predominantly black children 416 JAPhA | 5 5 :4 | JUL /AUG 2 0 1 5
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residing in the inner city, in lower socioeconomic neighborhoods, may be much higher than national estimates (9.5%), including those higher estimates in black (16%) and lower socioeconomic (13%) children.4,5 The majority of the study population (53.5%) was determined to be at an unhealthy weight; with 0.7% underweight, 24.3% overweight, and 28.5% obese. The rates of obesity in this cohort are more than 1.5 times that of national childhood obesity estimates (17%).6,7 Therefore, it is not surprising that the rates of hypertension in this population followed the same trend. Eleven percent of the study population had blood pressure measurements consistent with hypertension, more than double the index rates reported by Lo et al.10 Additionally, 12.8% are at risk of developing hypertension in the near future, with blood pressure measurements consistent with prehypertension. Obesity and hypertension in childhood have been associated with risk factors for cardiovascular disease such as the development of early myocardial changes, coronary and carotid artery pathology, and left ventricular hypertrophy.26 Cigarette smoking also has detrimental effects on the cardiovascular system and remains the leading preventable cause of premature disease and death in the United States.27 More than 25% of the study population had exhaled CO levels consistent with those of smokers. The estimated prevalence of smoking in this population is more than five times that of self-reported prevalence rates collected from schoolbased surveys in middle school children.12 Therefore, it is likely that a portion of children with CO levels consistent with smoking may not have been active smokers themselves, but exposed to significant second-hand smoke. Regardless of smoking status, a large percentage of participants in this study were exposed to ETS. The secondary objective of this study was to identify relationships among patient demographics, asthma, BMI, hypertension, and ETS exposure. Two significant relationships were identified. There was an increased incidence of hypertension with increased weight classification (P <0.001), which is consistent with previous reports.28,29 Interestingly, and contrary to previous reports in adults,30 there was a significant association between weight status and ETS exposure, with the proportion of ETS-equivalent heavy smokers increasing with increased weight classification (P = 0.019). This finding, however, is consistent with current literature in adolescents, which supports an association between smoking, poor food choice, and sedentary activity31 and the notion that adolescent cigarette smoking increases vulnerability to risk of obesity in young adulthood.32 This study is the first to evaluate pharmacist and student pharmacist directed pediatric health screenings for asthma, obesity, hypertension, and ETS in the innercity setting. Consistent with the 2013 Center for the Advancement of Pharmacy Education Educational Outcomes,33 student pharmacists should be trained to assist Journal of the American Pharmacists Association
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pharmacists to conduct pediatric health screenings. It is recommended that student pharmacists already be trained and familiar with these screenings in the adult population so that they are comfortable with the assessments and training can focus on differences in the approach to the pediatric patient and interpretation of results. Pediatric health screenings can also be conducted at community pharmacies, outpatient clinics, and health fairs. In these settings, supervising pharmacists can design such activities in which student pharmacists can help with the planning and marketing of the event, decrease the time burden of conducting such an event, and increase the number of children that can be screened.
Limitations Several limitations need to be considered when interpreting the results of this study. The convenience sample can introduce self-selection bias, which makes the interpretation of their representativeness difficult. In our sample, 89% of children reported race to be black and only 6% reported white, whereas county-wide data indicates that 13.3% of the population is black and 81.3% white.34 Therefore, our convenience sample was not representative of the population, and results should be interpreted with caution. Caregiver recall of lifetime asthma diagnosis was used to classify asthma and caregiver reported medical histories can be unreliable. Caregiver and child recall was also used to further classify asthma control. Although the ATAQ is a validated self-assessment tool, recall bias and symptom perception limit the accuracy of patient self-report and self-assessment. Another potential limitation was using spirometry as a screening tool because there was limited time to teach and coach subjects to achieve optimal technique. Poor technique and effort could have resulted in falsely elevated numbers of children being identified as having potential asthma and poorly controlled asthma. With regard to the hypertension screening, Lo et al. revealed that many children who present with an initial blood pressure measurement consistent with hypertension do not go on to have guideline-defined hypertension, which includes blood pressure measurements consistent with hypertension on three or more occasions.10,25 There is evidence that inflammatory lung diseases, such as asthma, may elevate exhaled CO levels.35 Therefore, asthma status could have elevated CO levels, independent of tobacco smoke exposure. Although this study resulted in disease identification, we do not know what effect, if any, screening and referral had on physician follow-up, formal diagnosis, treatment, and health outcomes. Future studies are needed to determine the effect of disease recognition through screenings in disparate populations on health care utilization and health status.
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Conclusion In summary, this study reveals that disease burden in disparate populations may be greater than current national estimates. Within this self-selected inner city, predominantly black population, there were high rates of positive screens for potential asthma, obesity, hypertension, and smoking. Additionally, the risk for smoking and hypertension increased with increasing weight. This study highlights the utility of pharmacists in disease screening and the need for alternative prevention and management strategies in disparate pediatric populations. Future studies are needed that focus on decreasing disease disparity and improving health outcomes in high-risk pediatric populations. References 1. Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6–28. 2. Sorof JM, Lai D, Turner J, et al. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics. 2004;113(3):475–482. 3. Trends in asthma morbidity and mortality. American Lung Association. 2014. http://www.lung.org/finding‐cures/our‐research/ trend‐reports/asthma‐trend‐report.pdf. Accessed March 25, 2014. 4. 2011 lifetime asthma, current asthma, asthma attacks among those with current asthma. 2011 National Health Interview Survey (NHIS) Data. Centers for Disease Control and Prevention. 2013. http://www.cdc.gov/asthma/nhis/2011/data.htm. Accessed March 25, 2014. 5. Summary health statistics for U.S. children: National Health Interview Survey, 2011. Vital Health Statistics. Centers for Disease Control and Prevention. 2012. http://www.cdc.gov/nchs/data/ series/sr_10/sr10_254.pdf. Accessed March 25, 2014. 6. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–814. 7. Skelton JA, Cook SR, Auinger P, et al. Prevalence and trends of severe obesity among U.S. children and adolescents. Acad Pediatr. 2009;9(5):322–329. 8. Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation. 2007;116:1488–1496. 9. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298:874–879. 10. Lo JC, Sinaiko A, Chandra M, et al. Prehypertension and hypertension in community-based pediatric practice. Pediatrics. 2013;131:e415–e424. 11. Ezzati M, Hoorn SV, Lopez AD, et al. Comparative quantification of mortality and burden of disease attributable to selected risk factors. In Global Burden of Disease and Risk Factors. 2nd ed. New York, NY: Oxford University Press; 2007:241–268. 12. Centers for Disease Control and Prevention. Tobacco use among middle and high school students: United States, 2000– 2009. MMWR Morb Mortal Wkly Rep. 2010;59:1063–1067. j apha.org
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RESEARCH NOTES
13. Mowery PD, Farrelly MC, Haviland ML, et al. Progression to established smoking among US youth. Am J Public Health. 2004;94:331–337. 14. Sippel JM, Pedula KL, Vollmer WM, et al. Associations of smoking with hospital-based care and quality of life in patients with obstructive airway disease. Chest. 1999;115(3):691–696. 15. Soyseth V, Kongerud J, Boe J. Postnatal maternal smoking increases the prevalence of asthma but not of bronchial hyperresponsiveness or atopy in their children. Chest. 1995;107(2):389–394. 16. Nelson DE, Bland S, Powell-Griner E, et al. State trends in health risk factors and receipt of clinical preventive services among U.S. adults during the 1990s. JAMA. 2002;287:2659– 2667. 17. U.S. Preventive Services Task Force. Screening for obesity in children and adolescents: U.S. preventive services task force recommendation statement. Pediatrics. 2010;125(2):361–367. 18. Moyer V. Primary care interventions to prevent tobacco use in children and adolescents: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(8):552– 557. 19. Babb VJ, Babb J. Pharmacist involvement in Healthy People 2010. J Am Pharm Assoc. 2003;43(1):56–60. 20. Starfield B. US child’s health: what’s amiss, and what should be done about it? Health Aff (Millwood). 2004;23(5):165–170.
25. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(suppl 2):555–576. 26. Sorof J, Daniels S. Obesity hypertension in children: a problem of epidemic proportions. Hypertension. 2002; 40:441–447. 27. Office of the Surgeon General. The health consequences of smoking—50 years of progress. Rockville, MD: U.S. Department of Health and Human Services; 2014. 28. Macedo ME, Trigueiros D, De Freitas F. Prevalence of high blood pressure in children and adolescents. Influence of obesity. Rev Port Cardiol. 1997;16:27–28. 29. Sorof JM, Poffenbarger T, Franco K, et al. Isolated systolic hypertension, obesity, and hyperkinetic hemodynamic states in children. J Pediatr. 2002;140:660–666. 30. Plurphanswat N, Rodu B. The association of smoking and demographic characteristics on body mass index and obesity among adults in the U.S., 1999–2012. BMC Obes. 2014;1:18. 31. Lytle L, Kelder S, Perry C, Klepp K. Covariance of adolescent health behaviors: the class of 1989 study. Health Educ Res. 1995;10(2):133–146. 32. Huang D, Lanza H, Anglin M. Association between adolescent substance use and obesity in young adulthood: a group-based dual trajectory analysis. Addict Behav. 2013;38(11):2653–2660.
21. Guidelines for the diagnosis and management of asthma: National Asthma Education and Prevention Program Expert Panel Report 3. Bethesda, MD: U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program, 2007.
33. Medina MS, Plaza CM, Stowe CD, et al. Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes 2013. Am J Pharm Educ. 2013;77(8):162.
22. Skinner EA, Diette GB, Algatt-Bergstrom PJ, et al. The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents. Dis Manag. 2004;7(4):305–313.
35. Zayasu K, Sekizawa K, Okinaga S, et al. Increased carbon monoxide in the exhaled air of asthmatic patients. Am J Respir Crit Care Med. 1997;156:1140–1143.
34. State and County QuickFacts, Allegheny County, Pennsylvania. United States Census Bureau. 2015. http://quickfacts.census. gov/qfd/states/42/42003.html. Accessed March 19, 2015.
23. Elliott J, Marcotullio N, Skoner D, et al. An asthma sports camp series to identify children with possible asthma and cardiovascular risk factors. J Asthma. 2014;51(3):267–274. 24. About BMI for children and teens. Centers for Disease Control and Prevention. http://www.cdc.gov/healthyweight/assessing/ bmi/childrens_bmi/about_childrens_bmi.html. Accessed April 16, 2014.
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