The impact of health education on frequency and cost of health care use by low income children with asthma

Cost-effectiveness of adherence-enhancing interventions: a quality assessment of the evidence

OBJECTIVE

To determine whether the current cost-effectiveness evidence on adherence-enhancing interventions (AEIs) was of sufficient quality to aid in decision-making regarding medication adherence policies.

DATA SOURCES

A computerized search of Embase, MEDLINE, Cinahl, Econlit, NHSEED, Psychlit, EPIC, and Cochrane databases (1980-April 2004) was performed. English-language human subject articles were identified using the key words compliance, adherence, concordance, patient assistance, therapeutic alliance, costs, economics, efficiency, resource use/utilization, cost-of-illness, cost-effectiveness, cost-minimization, cost-utility, and cost-benefit.

STUDY SELECTION AND DATA EXTRACTION

Studies that appeared to assess the cost-effectiveness of medication AEIs were included. Methodologic rigor was assessed using 15 minimum quality criteria.

DATA SYNTHESIS

We found 45 comparative studies in 43 publications. Asthma (14 studies) and psychiatric illness (12 studies) were most commonly investigated. In 33 studies, interventions were educational, 18 had multiple components, and 23 did not appear to be linked to proven reasons for nonadherence. Reporting of adherence and outcome results was often unclear. Cost data were poorer quality than outcome data, using average or estimated costs and omitting some cost elements. Nine studies carried out incremental economic analysis. No study met all quality criteria.

CONCLUSIONS

We were not able to make definitive conclusions about the cost-effectiveness of AEIs due to the heterogeneity of the studies found and incomplete reporting of results. Important policy decisions need to be made about nonadherence; however, they are currently being made in a vacuum of adequate information. AEIs must be based on reasons for nonadherence and be evaluated using accepted clinical and economic quality criteria.

Successful school-based intervention for inner-city children with persistent asthma

OBJECTIVE

Because children attend school daily, school-based interventions for children with persistent asthma could provide effective disease management for inner-city asthmatic children. The Kunsberg School in Denver, Colorado, enrolls children with chronic diseases, including asthma, into a daily program of school-based disease management. This study sought to determine the impact of the Kunsberg program on asthma utilization.

METHODS

Children attending Kunsberg (n=18) who received primary care at Denver Health were compared with a group of matched control children who also received primary care at Denver Health, but did not attend Kunsberg (n=36). Asthma-related utilization for an average of 2.9 years before and after Kunsberg enrollment was assessed.

RESULTS

The 18 Kunsberg and 36 control subjects were mostly minority children in low-income families, without significant demographic differences between groups. Compared with controls, the Kunsberg cohort experienced fewer hospitalizations (0.5 vs. 0.9 hospitalizations/subject/ year, p=0.05), fewer emergency department (ED) visits (1.4 vs. 2.8 ED visits/ subject/year, p=0.04), and fewer follow-up visits for asthma (3.7 vs. 5.0 visits/subject/ year, p=0.01) in the time period (mean 2.9 years; range 1-6 years) following the intervention. Hospital- and clinic-based asthma utilization costs decreased 80% following enrollment in the school (8122 dollars/year to 1588 dollars/year per child), compared to a 19% decrease in the control group. Among the Kunsberg children with hospitalizations prior to school enrollment (n=8), hospital days decreased from 3.5 days to 0.1 days annually (p<0.01), ED visits decreased from 2.1 to 0.6 visits annually (p=0.02), and follow-up visits decreased from 6.8 to 2.1 visits annually (p=0.02). As part of their school program, 89% of Kunsberg enrollees received inhaled corticosteroids daily on a monitored basis while at school.

CONCLUSIONS

The Kunsberg school program improved asthma control and reduced disease severity for at-risk inner-city asthmatic children, leading to cost reduction for asthma management. Directly observed controller therapy at school can be an important component of a school-based program for children with chronic conditions.

Increasing asthma awareness among physicians: impact on patient management and satisfaction

Our objective was to investigate the impact of increased asthma awareness among primary care physicians on the asthma control and satisfaction of their patients. Physicians attended an asthma education session with emphasis on patient-physician partnership followed by 4 month monitored follow-up of patients aged 5-44 years with mild to moderate asthma. Findings were compared with a group of patients whose physician attended the session but did not participate in the follow-up and two other control groups. The study included pediatricians and general practitioners of Maccabi Healthcare Services and their patients. Asthma symptoms were rated by patients and physicians. Data on drug prescription and use were derived from the Maccabi central database. Patient response and satisfaction and physician satisfaction were evaluated by telephone interviews. Mean asthma symptom score improved from 2.0 to 1.1 in the study group of patients (p < 0.001). The use of reliever drugs decreased concomitantly with a rise in controller drugs in all patients. An improvement in asthma status was reported by 64% of the study patients and 39% of non-participating patients (p = 0.007). Fifty-eight percent of the patients rated their competence to deal with asthma as high before the intervention compared to 62% of the participating and 55% of the non-participating patients after the intervention (p = 0.002). Most physicians claimed that simply increasing their awareness on asthma led to beneficial results in their patients. Physician education followed by monitored follow-up enhanced asthma control and patient satisfaction. Nevertheless, physician education alone appears to have a significant isolated impact on asthma control.

Asthma management across the life span: the child with asthma

Childhood asthma has an adverse impact on children, families, and society. Treatment of asthma presents special challenges related to diagnosis, ongoing symptom monitoring, and treatment when the patient is a child. To be effective, treatment needs to be medically sound and developmentally appropriate.

Environmental management of asthma at top-ranked U.S. managed care organizations

We evaluated the status of nationally top-ranked managed care organizations' (MCOs) asthma disease management programs to identify "best practices" in the environmental treatment and control of asthma. Application materials were developed and mailed to the top 34 managed care organizations, as determined by the ranked results from the October 1998 edition of US News and World Report. Based on the results of a staff and panel review, five applicants were selected for site visitation. The results of the site visits determined two finalists and three runners-up. We recommend that MCOs integrate population and community-based strategies and seek an emphasis on prevention. We encourage collaborations with other organizations and agencies. We endorse home visitation to assess environmental factors and also support use of telephonic case management. We think that smoking cessation programs should be coordinated with asthma management. We consider it important to use alternative forms of communication such as the Internet. And we find that it is important to be mindful of language, culture, and literacy.

Evaluation of an education program for elementary school children with asthma

To evaluate the effectiveness of a comprehensive asthma management education program for 7- to 12-year-old children with asthma, entitled Roaring Adventures of Puff (RAP), 18 elementary schools in Edmonton were randomized to intervention and control groups. Participating in the program were 76 students with asthma in the intervention schools and 86 in the control schools. Children in the intervention schools had statistically significant improvements in unscheduled doctor visits, missed school days, moderate-to-severe parent rating of severity, severity of shortness of breath, limitations in the kind of play, and correct use of medications. Unscheduled doctor visits and missed school days were the only significant improvements in the control group; however, improvements were about half that of the intervention group. The results showed that a comprehensive, school-based asthma education program is feasible and improves outcomes.

Management of chronic disease by patients

Chronic conditions dominate health care in most parts of the world, including the United States. Management of a disease by the patient is central to control of its effects. A wide range of influences in the person's social and physical environments enhance or impede management efforts. Interventions to improve management by patients can produce positive outcomes including better monitoring of a condition, fewer symptoms, enhanced physical and psychosocial functioning, and reduced health care use. Successful programs have been theory based. Self-regulation is a promising framework for the development of interventions. Nonetheless, serious gaps in understanding and improving disease management by patients remain because of an emphasis on clinical settings for program delivery, neglect of the factors beyond patient behavior that enable or deter effective management, limitations of study designs in much work to date, reliance on short-term rather than long-term assessments, and failure to evaluate the independent contribution of various program components.

Johns Hopkins Pediatrics at Home: Asthma Critical Pathway

The rise of chronic illnesses, such as asthma, in the inner city indicates a need to assess residences for asthma triggers and to provide education on the management of asthma symptoms to the child, caregiver, and family. Through the use of the asthma critical pathway at Johns Hopkins Pediatrics at Home, the assessment, teaching, and follow-up are accomplished. The purpose of this article is to explain why this type of home visit is needed and to present what needs to be included in such a program for organized reimbursable home care visits.

Comparison of multiple environmental factors for asthmatic children in public housing

Nine families of a public housing development in Boston were enrolled in a pilot asthma intervention program designed to gather dense environmental data and generate hypotheses about the relative importance of different contaminants and the viability of interventions. Despite formidable challenges working with this inner-city population, the project team succeeded in gaining active support for the project by forming a partnership with a community-based organization and by building positive relationships between the field team and the residents. Families were provided with physical interventions such as air filters, industrial cleaning and mattress covers to each apartment. Indoor temperature was high and relative humidity low during winter. Insulation of exposed steam pipes did not lower temperature. Cockroach, mouse and pet antigen levels were variable and frequently high in settled dust. Viable fungal spore levels were variable and high in some apartments. Dust-mite allergen levels were below the level of concern. Industrial cleaning led to transient reduction in mouse and cockroach antigen burden. Mattress and pillow covers lowered dust-mite antigen in bedrooms, but not living rooms. Nitrogen dioxide (NO2) levels exceeded ambient concentrations due to use of gas stoves and concentrations of particulate matter with aerodynamic diameter <2.5 microm (PM2.5) were above ambient levels because of smoking. Air filtering systems did not reduce PM levels. Several volatile organic compounds (VOCs) were above adverse risk concentrations. We hypothesize that our findings are consistent with a multifactorial model for exacerbation of asthma in this population and that no single problem dominates.

The impact of a large-scale population-based asthma management program on pediatric asthma patients and their caregivers

BACKGROUND

The consequences of pediatric asthma include missed school attendance, limitations in physical activity, and increased health care utilization and costs. Caregivers of asthmatic children are affected through missed work days and decreased job productivity. In response to these issues, a disease management program encompassing asthmatic children and their caregivers was developed as part of the core services offered to members of a large, national health care plan.

OBJECTIVE

To determine the impact of the asthma management program on pediatric asthma patients and their caregivers over a 12-month period.

METHODS

In this longitudinal study, 401 randomly selected member households with asthmatic children from 17 regional markets completed surveys before and after 12 months of participation in the asthma management program. Program interventions, which were tailored according to risk and need status, included various staggered educational mailings, reminder aids, videos, a peak expiratory flow rate meter, and telephonic case management. The Asthma Quality Assessment System survey, a battery of self-reported quality indicators, was used to solicit information from parents or caregivers of asthmatic children on issues pertaining to quality of life, asthma management skills and knowledge, and lost work/school days related to asthma.

RESULTS

Statistically significant postprogram outcomes were observed in various domains, including a reduction in adverse utilization, symptomatology, and restricted activity days for children and lost work days for adult caretakers.

CONCLUSIONS

These findings demonstrate that a large-scale population-based intervention program can produce measurable clinical and economic benefits, thereby lessening the burden of asthma on the family unit.

Educational interventions for asthma in children

BACKGROUND

Self-management education programs have been developed for children with asthma, but it is unclear whether such programs improve outcomes.

OBJECTIVES

To determine the efficacy of asthma self-management education on health outcomes in children.

SEARCH STRATEGY

Systematic search of the Cochrane Airways Group's and Cochrane Schizophrenia Group's Special Registers of Controlled Trials and hand searches of the reference lists of relevant review articles.

SELECTION CRITERIA

Randomized and controlled clinical trials of asthma self-management education programs in children and adolescents aged 2 -18 years.

DATA COLLECTION AND ANALYSIS

All studies were assessed independently by two reviewers. Disagreements were settled by consensus. Study authors were contacted for missing data or to verify methods. Subgroup analyses examined the impact of type and intensity of educational intervention, self-management strategy, trial type, asthma severity, adequacy of follow-up, and study quality.

MAIN RESULTS

Of 45 trials identified, 32 studies involving 3706 patients were eligible. Asthma education programs were associated with moderate improvement in measures of airflow (standardized mean difference [SMD] 0.50, 95% confidence interval [CI] 0.25 to 0.75) and self-efficacy scales (SMD 0.36, 95% CI 0.15 to 0.57). Education programs were associated with modest reductions in days of school absence (SMD -0.14, 95% CI -0.23 to -0.04), days of restricted activity (SMD -0.29, 95% CI -0.49 to -0.08), and emergency room visits (SMD -0.21, 95% CI -0.33 to -0.09). There was a reduction in nights disturbed by asthma when pooled using a fixed-effects but not a random-effects model. Effects of education were greater for most outcomes in moderate-severe, compared with mild-moderate asthma, and among studies employing peak flow versus symptom-based strategies. Effects were evident within the first 6 months, but for measures of morbidity and health care utilization, were more evident by 12 months.

REVIEWER'S CONCLUSIONS

Asthma self-management education programs in children improve a wide range of measures of outcome. Self-management education directed to prevention and management of attacks should be be incorporated into routine asthma care. Conclusions about the relative effectiveness of the various components are limited by the lack of direct comparisons. Future trials of asthma education programs should focus on morbidity and functional status outcomes, including quality of life, and involve direct comparisons of the various components of interventions.

Cost effectiveness of guideline advice for children with asthma: a literature review

Asthma is an important chronic disease among children. This study reviews the cost effectiveness of interventions in the long-term care of asthmatic children and compares these results with treatment advice in four current guidelines. Cost-effectiveness studies were searched for in Medline, Embase, Healthstar, Biosis, and the Office of Health Economics-Health Economic Evaluations Database (OHE-HEED), and the Cochrane Library was searched for meta-analyses of clinical trials. In the four reviewed guidelines, cost effectiveness is not explicitly used as a criterion. The cost-effectiveness studies show sufficient evidence for the cost effectiveness of treatment with inhaled steroids and for self-management programs for severe asthmatic patients. Inclusion of these results in the guidelines would not lead to significant changes in current treatment advice. The effectiveness of various measures for trigger avoidance is not fully proven, and hence neither is their cost effectiveness. Available information on the cost effectiveness of cromolyn could be used to focus the guidelines. Finally, evidence exists that organizational interventions, e.g., the employment of asthma nurses, can result in cost savings, but it is unclear to what extent these results can be generalized. More cost-effectiveness studies are needed, especially on long-acting bronchodilators and self-management programs for mild and moderate asthma, in order to help make the guidelines more informative and reduce the differences between them.

The cost-effectiveness of an inner-city asthma intervention for children

BACKGROUND

Comprehensive management efforts to reduce asthma morbidity among children in urban areas with high levels of poverty and large minority populations have been inconclusive. The National Cooperative Inner-City Asthma Study (NCICAS) demonstrated improved symptom outcomes but did not evaluate cost-effectiveness in this population.

OBJECTIVE

We sought to examine the incremental cost-effectiveness of a comprehensive social worker-based education program and environmental control in children with asthma stratified by baseline level of asthma control.

METHODS

We performed a prospective cost-effectiveness analysis alongside a randomized trial. A total of 1033 children and their families residing in 8 inner-city urban areas in the United States were enrolled in the NCICAS. Outcomes included symptom-free days, cost per symptom-free day gained, and annual costs of asthma morbidity compared by baseline symptom control, previous hospitalization, and previous unscheduled physician visits.

RESULTS

The NCICAS intervention significantly reduced asthma symptoms. First-year intervention costs were 245 US dollars higher for the intervention children compared with those receiving usual care. There were no additional intervention-related costs during the second year. When compared with usual care, the intervention improved outcomes at an average additional cost of 9.20 US dollars per symptom-free day gained (95% CI, -12.56 to 55.29 US dollars). The intervention was cost saving in 3 strata of children with increasing asthma severity.

CONCLUSIONS

A multifaceted asthma intervention program reduced symptom days and was cost-effective for inner-city children with asthma. In children with more severe disease, the intervention was substantially more effective and reduced costs compared with that seen in control children. Organizations serving this population should consider this strategy as part of a comprehensive disease-management program for asthma.

Impact of an asthma program on the quality of life of children in an urban setting

A comprehensive asthma program involving a pharmacist and physician evaluated quality of life (QOL) for children with asthma and the relationship between changes in QOL and traditional outcomes. The program consisted of aggressive medical management and a comprehensive education program. Children were from an inner-city population who had been referred to a specialist. Twenty of the 29 children enrolled in the program were available for 1-year follow-up. Significant improvements were seen in overall QOL scores and in each domain in the instrument, which exceeded the minimal important difference. A strong relationship was not found between changes in QOL total score and changes in asthma questionnaire score, frequency of nocturnal asthma, symptomatic days, and exercise tolerance. Further research is necessary to support these findings.

Management of children with severe asthma exacerbation in the emergency department

Although acute asthma is a very common cause of emergency department visits in children, there is as yet insufficient evidence for the establishment of a standardized treatment protocol. The aim of this review is to describe updated information on the management of asthma exacerbations in the pediatric emergency department. Oxygen is the first-line treatment of acute asthma exacerbations in the emergency department to control hypoxemia. It is accompanied by the administration of beta(2)-adrenoceptor agonists followed by corticosteroids. beta(2)-Adrenoceptor agonists have traditionally been administered by nebulization, although spacers have recently been introduced and proven, in many cases, to be as effective as nebulization. Oral prednisolone, with its reliability, simplicity, convenience and low cost, should remain the treatment of choice for the most severe asthma exacerbations, when the lung airways are extremely contracted and filled with secretions. Recently, several studies have shown that high-dose inhaled corticosteroids are at least as effective as oral corticosteroids in controlling moderate to severe asthma attacks in children and therefore should be considered an alternative treatment to oral corticosteroids in moderate to severe asthma attacks. Studies of other drugs have shown that ipratropium bromide may be given only in addition to beta(2)-adrenoceptor agonists; theophylline has no additional benefit, and magnesium sulfate has no clear advantage. Comprehensive asthma management should also include asthma education, measures to prevent asthma triggers, and training in the use of inhalers and spacers. Proper management will avoid most asthma attacks and reduce admission and readmission to emergency departments.

Measuring success in the treatment of children in the emergency department setting: process versus outcomes?

The current best design practices for clinical studies require consideration of the assessment of end points that combine key processes and outcomes. Process assessment measures events in the pathway on which a more important intermediate or ultimate health outcome depends. Process assessment can be either formative or summative. Outcomes assessment relates to identifying the results related to a process, and is most often defined as the change in a patient's current or future health state. The development of process and outcomes measures for any study is difficult, and children and emergency department settings present unique sets of issues worth highlighting. This article presents an overview of issues relating to choice of process and outcomes measures in studies of pediatric emergency medicine. Asthma care is used to illustrate the complex issues surrounding the measurement of success in management in the emergency department setting.

Strengthening asthma education to enhance disease control

This article focuses on reducing the barriers to effectively applying what is known about asthma patient education. One barrier to effective asthma control in individuals and populations is failure to recognize the range of influences on patients trying to manage their disease, including actions of family, clinicians, friends and neighbors, work or school mates, and significant people and organizations in the wider social environment. Another deterrent is failing to assist patients in developing their self-regulation skills. Other barriers are the lack of attention to the patients' asthma management goals (as opposed to clinical objectives) and overlooking signs that indicate follow-up education is needed. Five actions taken by health-care professionals could significantly enhance the effectiveness of asthma education: (1) make messages to patients and core skills taught consistent with national asthma guidelines; (2) focus on developing the patient's ability to self-regulate; (3) develop comprehensive plans for treatment and education that assign clinicians to appropriate educative roles; (4) use clinician communication techniques demonstrated to enhance asthma management by patients; and (5) ensure that all providers of education are themselves trained to achieve actions 1 to 4.

Custo-efetividade de programa de educação para adultos asmáticos atendidos em hospital-escola de instituição pública

Introdução: A asma pouco controlada acarreta custo econômico substancial para o sistema de saúde, principalmente, decorrente de gastos diretos. Programas de educação podem levar à redução desses custos. Objetivo: Avaliar os custos econômicos diretos resultantes da implantação de um programa de educação para asmáticos quando comparado com o atendimento usual especializado. Método: Foram calculados, retrospectivamente, e comparados os custos diretos de um programa de educação e do atendimento usual ao asmático. As hospitalizações, visitas ao pronto-socorro e visitas ambulatoriais, em ambos os grupos, foram registradas durante o período da intervenção educacional. Os valores utilizados para o cálculo desses custos foram baseados nos dados disponíveis no banco de dados do Datasus de 1996. O custo total com medicação/paciente no grupo educação (E) e controle (C) foi baseado no consumo de medicação durante o mês anterior à ultima visita e estimado pelo guia farmacêutico de fevereiro de 1996. Os valores finais foram convertidos em US dólar. Resultados: O custo médio direto em US dólar por paciente (US$) dos grupos C e E e a diferença de custos (delta) entre os dois foram, respectivamente: para hospitalizações - US$183, US$0, delta = $183; visitas ao PS - US$14, US$ 5, delta = US$9; visitas ambulatoriais agendadas - US$10, US$24, delta = -US$14; medicações - US$124,3, US$195,6, delta = -US$71,3. O custo total foi de US$331 para o grupo C e US$224 para o grupo E, o que permitiu redução de gastos da ordem de US$107/paciente do grupo educação em relação ao controle. Conclusão: No grupo educação o custo total com medicamentos é superior ao observado no grupo controle, refletindo maior gasto com medicação de prevenção. Entretanto, a implantação do programa de educação leva a redução dos gastos com hospitalização e visitas ao PS, o que diminui os custos totais e torna o programa economicamente atrativo.

Influence of sociodemographics on the health-related quality of life of pediatric patients with asthma and their caregivers

The relationship between socioeconomic variables and the health-related quality of life (HQL) of children with asthma and their caregivers was examined. The Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and Pediatric Asthma Caregivers Quality of Life Questionnaire (PACQLQ) were administered to 99 pediatric asthmatic patients and caregivers in two specialty clinics. Sociodemographic data was obtained from medical records and additional questions. The relationship between sociodemographic variables and HQL was determined using multiple linear regression. The mean patient age was 12.6+/-2.1 years, more were male and from a minority race. The mean age of caregivers was 41.2+/-8.5 years; most were female and were fom a minority race. Patients tended to rate their asthma severity as mild to moderate, while caregivers tended to rate patients in the moderate to severe category. Based on prescribed medications, most patients had mild to moderate asthma. Household income was consistently associated with patient-perceived HQL. Less consistent associations were seen with other variables. Household income and the caregiver's perception of asthma severity were associated with all caregiver HQL domains. It was concluded that household income was most consistently associated with the HQL of asthmatic pediatric patients and their caregivers.

Evaluation of an asthma management program for Chinese children with mild-to-moderate asthma in Hong Kong

There is inconclusive evidence on the efficacy of outpatient clinic-based asthma management programs (AMP) in children. We hypothesized that an AMP based on key symptoms could improve outcome measures of asthma in Chinese children in Hong Kong. This study involved an outpatient clinic-based prospective cohort of Chinese children with asthma. Each patient received one 2-hr session of AMP which was conducted by a pediatric nurse specialist. Asthma outcomes were measured at baseline and at 6 and 12 months after completion of AMP. Demographic data, family history of allergic diseases, and changes in inhaled steroid therapy were also recorded. A total of 106 asthmatic children were enrolled, and they showed a significant decrease in nocturnal cough, wheezing attacks, and subjective assessment of severity at 6 and 12 months following participation in AMP, compared with their baseline status. Acute asthmatic attacks, unscheduled outpatient attendance, emergency room visits, school absenteeism, and number and duration of hospitalizations were also reduced during the follow-up period. Significantly more (21%) children were reported to use inhaled beclomethasone at the end of the study. Nocturnal cough, wheeze, and symptoms due to rhinitis improved significantly after AMP. In conclusion, our cohort of Chinese children with mild-to-moderate asthma used significantly more inhaled corticosteroids and practiced more measures to control house dust mites at the end of the 1-year treatment period. The main reason for better asthma control appeared to be related to the increased use of inhaled steroids, although some additional decrease in nocturnal cough, wheeze, and allergic rhinitis was found after adjusting for the use of inhaled corticosteroids.

Novel computer-based assessment of asthma strategies in inner-city children

BACKGROUND

Childhood asthma continues to be a growing medical concern in the United States, affecting > 17 million children in 1998. The mortality rate from asthma in children aged 5 to 14 years has nearly doubled, from 1.7 deaths per million to 3.2 deaths per million between 1980 and 1993.

OBJECTIVE

To evaluate the use of artificial neural networks (ANNs) to rate problem-based strategies for asthma management in a defined population of children.

METHODS

The participants in our study were recruited from a local inner-city medical facility in Los Angeles. The majority of participants had received the diagnosis of mild-to-moderate-persistent asthma. Each participant was given 10 asthma-based problems and asked to manage them. Each management decision and its order were entered into a database. This database was used to train an artificial neural network (ANN). The trained ANN was then used to cluster the various performances, and outputs were evaluated graphically.

RESULTS

Three hundred five performances were analyzed through our trained neural network. Our ANN classified five major clusters representing different approaches to solving an acute asthma case.

CONCLUSIONS

ANNs can build rich models of complex phenomena through a training and pattern-recognition process. Such networks can solve classification problems with ill-defined categories in which the patterns are deeply hidden within the data, and models of behavior are not well defined. In our pilot study, we have shown that ANNs can be useful in automating evaluation and improving our understanding of how children manage their asthma.

Risk factors for lack of asthma self-management knowledge among ED patients not on inhaled steroids

The study objective was to estimate the level of asthma knowledge and self-management skills among asthmatic patients who are not on inhaled corticosteroids and who present with acute asthma to the emergency department (ED). The design was to interview of patients by telephone at 90 to 100 days after enrollment in the Fourth Multicenter Airways Research Collaboration (MARC-4), a randomized trial comparing inhaled fluticasone versus placebo in addition to standard post-ED therapy. The setting was a multicenter trial involving 41 US urban EDs. Persons aged 12 to 54, not on inhaled steroids, who presented to the ED with acute asthma were studied. Of the 617 patients enrolled on MARC-4 405 (66%) were contacted. Mean (+/-SD) age was 30 (+/-11); 54% were women; acute asthma severity was 44% moderate and 56% severe; and 9% had prior intubation. Twenty percent (95% CI 16%-24%) responded that asthma could not be monitored and 40% (95% CI 35%-44%) scored low on a hypothetical acute asthma attack scenario. Predictors for lack of asthma knowledge and self-management skills were: less than a high school education; current smoking; lower median household income; and no history of steroid use. These data suggest that many ED patients with asthma have poor knowledge of asthma monitoring and poor self-management skills and that a "high risk" group is also identifiable. Efforts to design and implement an ED-based educational program should be tailored to better meet the needs of this high risk group.

Patient education provided to asthmatic children: a historical cohort study of the implementation of NIH recommendations

NIH guidelines for treatment of childhood asthma emphasize educating both patients and family about avoiding triggers and providing information to support self-management of asthma. To determine the extent to which primary care providers had implemented these recommendations, we examined the patient education provided to a cohort of asthmatic children (n = 331) between January and December 1994. During 1994 education of any type was documented for less than half the children. Provision of education was associated with asthma severity: An action plan for exacerbations was discussed with the majority with moderate or severe asthma (61%). Avoiding triggers (aOR: 2.38, 95% CI: 1.37-4.12) and treatment goals (aOR: 3.14, 95% CI: 1.46-6.75), were more likely to be discussed with children who were prescribed inhaled anti-inflammatory medication, after adjustment for asthma severity and age. Limited implementation of the NIH recommendations by primary care providers in our study may have reduced their impact on the management of childhood asthma.

Health economics of asthma and rhinitis. II. Assessing the value of interventions

Health care providers and payers are being asked to weigh data on the economic impact of new interventions along with clinical evidence when making decisions about the care of patients. The notion of incorporating formal health economic assessments into clinical and resource decisions is a difficult concept for many in the health care sector. However, it is the reality in today's environment. To effectively participate in these ongoing discussions, clinicians and other decision makers must be able to understand and critically assess the evidence on economic impact of medical interventions. This second of 2 articles describes the elements of comparative economic evaluations, reviewing the published literature on asthma and rhinitis in an attempt to critically appraise the studies from the perspective of one who might use data for decision making. Unfortunately, the quality of the economic evidence in these two disease states is not extensive. Until better economic analyses are conducted and made available, the allocation of resources for asthma and allergic rhinitis will continue to primarily rely on expert opinion rather than evidence-based literature.

Assessing the quality of asthma care provided to Medicaid patients enrolled in managed care organizations in Connecticut

BACKGROUND

Many states have enrolled Medicaid beneficiaries in managed care organizations (MCOs). Few assessments of the quality of asthma care provided by these new programs are available.

OBJECTIVE

To describe the quality of care provided to asthmatic Medicaid children enrolled in MCOs.

METHODS

For this cross-sectional survey, a chart abstraction tool was developed to evaluate fulfillment of key performance measures chosen from a national guideline for asthma diagnosis and management. These measures were prescription of an inhaled anti-inflammatory medication, accomplishment of patient education, evaluation of exposure to environmental triggers of asthma, and administration of influenza vaccination. From State of Connecticut administrative databases, a random sampling of Medicaid children, ages 5 to 18 years, enrolled in four MCOs was selected. Chart entries from July 1, 1996 to June 30, 1997 were reviewed using the abstraction tool. Accomplishment of performance measures was evaluated for the total sample and for children who were high utilizers of medical services (at least one ED visit or hospitalization during the study period).

RESULTS

For 80 high utilizers among 315 children, completion of performance measures was suboptimal: 46% were prescribed inhaled steroids; an action plan was outlined for 43%; evaluation of patient or family tobacco use was documented for 56%; evaluation of the presence of a pet for 43% or mite exposure for 19%; and allergy skin testing or RAST was accomplished for 15%.

CONCLUSIONS

This information suggests that opportunities exist to improve the quality of care for these children.

Family rituals as a protective factor for children with asthma

OBJECTIVE

To examine how one aspect of family life, notably family rituals and routines, may protect children with asthma from anxiety-related symptoms.

METHODS

Eighty-six families (43 children with asthma, 43 healthy comparison children) participated in the study. Children completed measures of anxiety (Revised Child Manifest Anxiety Scale) and health. Parents completed measures of stress (Parenting Stress Index), family rituals (Family Routines Questionnaire), and family health.

RESULTS

Families that reported more meaning in their family routines had children who reported lower levels of anxiety. Mother endorsement of family ritual meaning and father endorsement of family ritual routine were most strongly related to lower levels of anxiety. Support for the protective function of meaningful family rituals was stronger when a general health stress model was used rather than the presence or absence of asthma alone.

CONCLUSIONS

Family rituals may serve a protective function for children with asthma under conditions of heightened parenting stress.

School-based identification of asthma in a low-income population

The increase in the prevalence, morbidity, and mortality of asthma among children over the last decade has been well documented, especially among low-income minority children. Hypotheses for the increases in morbidity and mortality include limited access to primary care services and the failure to recognize the presence and severity of asthma. The University of Miami Pediatric Mobile Clinic (Mobile Clinic) Asthma Intervention Program is designed to identify underserved asthmatic children at school and offer them culturally sensitive care. Nine elementary schools with low income, predominantly Hispanic and African-American populations regularly served by the Mobile Clinic, were chosen for study participation. All 5,800 students who were enrolled in kindergarten through third grade were given letters at the time of registration by their homeroom teachers about the asthma program. Caretakers who returned the questionnaire and reported that the student had asthma symptoms were invited to have the student undergo a medical evaluation in the Mobile Clinic. Over a 2-year period, caretakers of 423 students (7.3% of all students) expressed an interest in further evaluating their child's respiratory health. Of these, we enrolled and evaluated 154 in the Mobile Clinic's Asthma Intervention Program. The Mobile Clinic physicians identified 145 of the enrollees as having asthma. These results indicate that in elementary schools serving predominantly low-income minority populations, a large fraction of the asthmatic population (estimated prevalence, 6-10%) can be identified by a school-based letter. Further, in a subset of asthmatic students (children of interested caretakers), there is good agreement between caretaker responses and physician diagnosis of asthma. Since school attendance is mandatory, school-based methods may be an effective method for identifying low-income children with asthma.

Racial differences in physiologic parameters related to asthma among middle-class children

BACKGROUND

Asthma morbidity and mortality are higher in the United States for African-American (AA) children when compared to European-American (EA) children.

STUDY OBJECTIVES

To explore racial differences in physiologic factors associated with pediatric asthma severity.

DESIGN

Cross-sectional.

METHODS

We analyzed data from two groups of children in suburban Detroit, one of which contains non-urban, middle-class AA children, a group not usually included in childhood asthma studies. All children were 6 to 8 years of age. Clinical evaluations included medical history, physical examination, skin testing, spirometry, and methacholine challenge.

RESULTS

The study population (n = 569) was 14% African American, 51% of the participants were male, and the mean age was 6.8 +/- 0.4 years. Socioeconomic status (parental education) was similar overall by race, although some strata-specific differences were observed. The prevalence of physician-diagnosed asthma was 10% for both AA and EA groups. AA children were more reactive to methacholine than EA children (42% vs 22%, respectively; p = 0.001), and had significantly higher total IgE than EA children (geometric mean, 60. 6 vs 27.5 IU/mL; p = 0.001). Serum IgE was related to methacholine reactivity in EA children (p = 0.001), but not AA children (p = 0. 73). These differences remained after adjustment for gender, age, parental education, parental smoking, and maternal smoking during pregnancy.

CONCLUSIONS

Our data support previous reports of racial differences in lung volume, airway responsiveness, and serum IgE concentrations. We found a racial difference in the relationship between total serum IgE and airway responsiveness that is unreported elsewhere. Overall, our results suggest that AA children may be predisposed to asthma.

Superior clinical outcomes of inner city asthma patients treated in an allergy clinic

BACKGROUND

Asthma morbidity and mortality continue to increase especially in the inner cities despite medical advances in disease management.

OBJECTIVE

To investigate the clinical outcomes of inner city asthma patients treated in an allergy clinic.

METHODS

Phase 1 involved random review of medical records of 100 asthma patients treated in an allergy clinic for 2 consecutive years, assessing the frequency of hospitalizations, emergency room visits (ERV) and asthma severity during three periods; 1 year prior to initial visit (year 0) and during the first (year 1) and second (year 2) years of intervention. Phase 2 involved administration of quality of life (QOL) survey to 23 patients volunteered from allergy clinic (group I), and 21 patients volunteered from emergency room (group II), treated by primary care or emergency room physicians during the previous year.

RESULTS

The frequency of hospitalizations and ERV significantly declined over time (P < .001) with greatest declines during year 1. Disease severity of all patients significantly declined over time (P < .001); good compliers had significant improvement over poor compliers (P < .023). Quality of life scores were significantly lower for both groups than for the general population; and although the scores were higher in the allergy clinic group than in the non-allergy clinic group, significant differences were achieved only in mental health and social functioning domains.

CONCLUSIONS

Patients treated in an allergy clinic demonstrate superior clinical outcomes.

Watch, Discover, Think, and Act: a model for patient education program development

In this report we describe the development of the Watch, Discover, Think and Act asthma self-management computer program for inner-city children with asthma. The intervention focused on teaching two categories of behaviors--asthma specific behaviors such as taking preventive medication and self-regulatory processes such as monitoring symptoms and solving asthma problems. These asthma self-management behaviors were then linked with empirical and theoretical determinants such as skills and self-efficacy. We then further used behavioral science theory to develop methods such as role modeling and skill training linked to the determinants. We matched these theoretical methods to practical strategies within the computer simulation and created a culturally competent program for inner-city minority youth. Finally, we planned a program evaluation that linked program impact and outcomes to the theoretical assumptions on which the intervention was based.

Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children

An interactive multimedia computer game to enhance self-management skills and thereby improve asthma outcomes in inner city children with asthma was evaluated. Subjects aged 6-17 were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual-care comparison. The main character in the game could match the subject on gender and ethnicity. Characteristics of the protagonist's asthma were tailored to be like those of the subject. Subjects played the computer game as part of regular asthma visits. Time between pre- and post-test varied from 4 to 15.6 months (mean, 7.6 months). Analysis of covariance, with pre-test scores, age, and asthma severity as covariates, found that the intervention was associated with fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior for those in the intervention condition. Interactions with covariates were found and discussed in terms of variable efficacy of the intervention.

Bronchopulmonary hygiene physical therapy for chronic obstructive pulmonary disease and bronchiectasis

BACKGROUND

Bronchopulmonary hygiene physical therapy is a form of chest physical therapy including chest percussion and postural drainage to remove lung secretions. These are applied commonly to patients with both acute and chronic airway diseases. Despite controversies in the literature regarding its efficacy, it remains in use in a variety of clinical settings. The various forms of this therapy are labour intensive and need to be evaluated.

OBJECTIVES

The objective of this review was to assess the effects of bronchial hygiene physical therapy in people with chronic obstructive pulmonary disease and bronchiectasis.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles up to July 1997. We also wrote to study authors.

SELECTION CRITERIA

Randomised trials in which postural drainage, chest percussion, vibration, chest shaking, directed coughing or forced exhalation technique was compared to other drainage or breathing techniques, placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two reviewers applied the inclusion and exclusion criteria on masked publications independently. They assessed the trial quality independently. Only data from the first arm of crossover trials were included.

MAIN RESULTS

The seven included trials involved six comparisons and a total of 126 people. The trials were small and not generally of high quality. The results could not be combined as trials addressed different patient groups and outcomes. In most comparisons, bronchial hygiene physical therapy produced no significant effects on pulmonary function, apart from clearing sputum in chronic obstructive pulmonary disease and in bronchiectasis.

REVIEWER'S CONCLUSIONS

There is not enough evidence to support or refute the use of bronchial hygiene physical therapy in people with chronic obstructive pulmonary disease and bronchiectasis.

A tool to organize instructions at discharge after treatment of asthmatic children in an emergency department

Asthma exacerbations continue to be a major cause of visits to emergency departments (ED). Comprehensive care in the outpatient setting, with planning for early intervention for exacerbations, can reduce emergency visits. Thus, a major goal of ED intervention is to establish a link between the patient and the provider of ongoing asthma care, where complete education can be achieved and reinforced over time. When designing the Asthma 1-2-3 Plan discharge teaching tool for the ED, consideration was given to educational format, readability, patient population, and setting in which education was to be delivered. To evaluate use of the plan, ED records of patients enrolled in a separate asthma study, the Neighborhood Asthma Coalition (NAC), were audited for two 8-month intervals, May-December 1993 (before initiation of the plan) and May December 1994 (starting 1 month after completion of pilot testing on the plan in the ED). To evaluate effectiveness of the plan, records of physicians who cared for children in the NAC were evaluated. The database was reviewed for the date of the first visit for planned review of asthma that occurred after the acute asthma ED visit. After introduction of the plan, the proportion of children told to return to the physician for follow-up increased from 54% to 81%. The proportion of children given advice to return to their physician within the recommended 3 days or less increased from 11% to 54%. Chi2 Analyses showed that these changes were both statistically significant (p<0.0001). The plan was not effective in achieving increased follow-up visits for regular asthma care, in that 7% returned for follow-up within 7 days after an ED visit before the plan and only 6% returned for such a visit after the Plan. Successful initiation of a focused discharge teaching tool into the routine of the ED increased appropriate advice given at time of discharge from the ED. Although unsuccessful in increasing appropriate follow-up, the present intervention uses the ED not as a base for asthma education, but as a point for contacting patients in need of regular care and education, and for promoting access to that regular care.

A randomized clinical trial to reduce asthma morbidity among inner-city children: results of the National Cooperative Inner-City Asthma Study

OBJECTIVE

To evaluate a family-focused asthma intervention designed for inner-city children 5 to 11 years old with moderate to severe asthma.

STUDY DESIGN

Randomized, multisite, controlled trial to minimize symptom days (wheeze, loss of sleep, reduction in play activity) measured by a 2-week recall assessed at 2-month intervals over a 2-year follow-up period. The intervention was tailored to each family's individual asthma risk profile assessed at baseline.

RESULTS

Averaged over the first 12 months, participants in the intervention group (n = 515) reported 3.51 symptom days in the 2 weeks before each follow-up interview compared with 4.06 symptom days for the control group (n = 518), a difference of 0.55 (95% CI, 0.18 to 0.92, P =.004). The reduction among children with severe asthma was approximately 3 times greater (1.54 d/2 wk). More children in the control group (18.9%) were hospitalized during the intervention compared with children in the intervention group (14. 8%), a decrease of 4.19% (CI, -8.75 to 0.36, P =.071). These improvements were maintained in the intervention group during the second year of follow-up, during which they did not have access to the asthma counselor.

CONCLUSIONS

We demonstrated that an individually tailored, multifaceted intervention carried out by Masters-level social workers trained in asthma management can reduce asthma symptoms among children in the inner city.

A randomized controlled trial of a pediatric asthma outreach program

BACKGROUND

Previous studies have shown that asthma education and case management may reduce asthma emergency care, hospitalizations, and expenditures.

OBJECTIVE

We sought to study the effect of an asthma outreach program (AOP), a team-based, case-management intervention, on emergency ward (EW) and hospital use.

METHODS

Fifty-seven patients aged 1 to 15 years with the diagnosis of asthma based on the usual clinical practice criteria who were continuously enrolled in a staff-model health maintenance organization for a period of at least 2 consecutive years were randomized into 2 intervention groups. The control group received a single intensive asthma education intervention, and the AOP group received the same initial education but then was followed-up by an asthma case management nurse throughout the intervention period.

RESULTS

EW visits, hospitalizations, and total outside-of-health-plan expenditures (consisting of EW and hospital expenses, as well as miscellaneous costs, such as ambulance, durable medical equipment, tertiary referrals, and home care) were assessed from claims filed for a year before and after enrollment. Control group patients experienced significant reductions in EW visits (39%), hospitalizations (43%), and outside-of-health-plan costs (28%), possibly as a result of the baseline educational intervention received by all enrolled patients, in conjunction with regression to the mean. AOP group patients experienced significant reductions in EW visits, (73%, P =.0002), hospitalizations (84%, P =.0012), and outside-of-health-plan use (82%, P <.0001). When compared with the control group, AOP group patients demonstrated additional significant reductions in EW visits (57%, P <.05), hospitalizations (75%, P <.05), and outside-of-health-plan use (71%, P <.001). Estimates of direct savings to the health plan ranged from $7.69 to $11.67 for every dollar spent on the AOP nurse's salary, depending on assumptions.

CONCLUSIONS

Asthma patients in a staff-model health maintenance organization decreased their resource use between 57% to 75% by participation in an AOP as compared with a randomized control group receiving only an educational intervention. Substantial savings were achieved compared with the cost of the AOP nurse.

Monitoring the dissemination of an educational protocol on pediatric asthma in family practice: a test of associations between dissemination variables

Many asthma education programs aim at reducing morbidity. Now that effective programs are available, the next step is the nationwide dissemination to achieve morbidity reduction. A dissemination of a tested program has been undertaken in Dutch primary care, guided by the Diffusion of Innovation theory. It was hypothesized that greater awareness and concern and/or receptivity about asthma self-management would make it more likely that family physicians would adopt the program. Family physicians were considered more likely to adopt the program if they saw it as an improvement on their current way of providing education, as easy to use, and as having observable outcomes. It was expected that once the program had been adopted, and as it was being implemented, it would increasingly be perceived by its users as successful. Finally, more perceived success of performance was expected to be related to continued use. Both longitudinal and cross-sectional data largely confirmed the hypotheses.

The challenge of inner-city asthma

Racial and ethnic minorities of low socioeconomic status residing in urban environments currently referred to as inner cities appear to represent a population that is disproportionately at high risk for asthma morbidity and mortality. Epidemiologic studies suggest that key risk factors contributing to asthma morbidity within the inner city include social demography, the physical environment (indoor and outdoor), and health care access and quality. This epidemiologic literature has helped to define opportunities for successful intervention strategies in these high-risk populations. Studies of the effectiveness of community-based and health system-based interventions with specific focus on inner-city populations are beginning to emerge in the literature.

Intervention mapping: a process for developing theory- and evidence-based health education programs

The practice of health education involves three major program-planning activities: needs assessment, program development, and evaluation. Over the past 20 years, significant enhancements have been made to the conceptual base and practice of health education. Models that outline explicit procedures and detailed conceptualization of community assessment and evaluation have been developed. Other advancements include the application of theory to health education and promotion program development and implementation. However, there remains a need for more explicit specification of the processes by which one uses theory and empirical findings to develop interventions. This article presents the origins, purpose, and description of Intervention Mapping, a framework for health education intervention development. Intervention Mapping is composed of five steps: (1) creating a matrix of proximal program objectives, (2) selecting theory-based intervention methods and practical strategies, (3) designing and organizing a program, (4) specifying adoption and implementation plans, and (5) generating program evaluation plans.

Parental self-efficacy and asthma self-management skills

PURPOSE

To determine whether a formal asthma self-management program and social support using lay health advisors increases parent self-efficacy in the management of their child's asthma, and whether parent self-efficacy predicts asthma self-management skills.

DESIGN

Quasi-experimental with four time points measured over 2 years.

PARTICIPANTS

Low-income, primarily Hispanic parents (N = 303) of children with moderately severe to severe asthma.

SETTING

A Southwestern university medical setting in a rural state.

MAIN OUTCOME MEASURES

Parent self-efficacy and parent asthma self-management skill score scales.

RESULTS

Parent self-efficacy increased significantly from baseline, but there were no significant differences between the control and treatment groups. The increase in self-efficacy was apparent at 6 months, then leveled off. Parent self-efficacy at either baseline or 12 months did not predict parents' asthma self-management skill score.

CONCLUSIONS

Individual education was just as effective as group education in increasing parental self-efficacy. Parents felt more comfortable treating asthma episodes than preventing them, thus clinicians need to spend time teaching preventive strategies.

Behavioral and environmental factors associated with acute exacerbation of asthma

BACKGROUND

The relapse rate following treatment for acute asthma is high. While previous studies have evaluated the utility of pulmonary function measurements to identify patients likely to relapse, the results are conflicting. The purpose of this study was to evaluate other correctable, risk factors that may be associated with relapse.

PARTICIPANTS

Two hundred twenty-three patients treated in the emergency department during 1994, including those either admitted or discharged.

METHODS

Patient interviews to identify behavioral and environmental risk factors for asthma exacerbation. Telephone contact and medical record review to determine incidence of relapse.

RESULTS

Two hundred twenty-three patients were enrolled of whom follow-up data were available for 152 (68%). Twenty-one percent of the patients relapsed within 14 days. Relapse was associated with the lack of an identifiable primary care physician and inability to obtain discharge medications. There was no relationship between relapse and the use of a spacer, hypoallergenic pillow or mattress cover, cigarette smoking, the presence of pets in the home, or weekly carpet cleaning.

CONCLUSION

Even following hospitalization for acute asthma, there is a significant relapse rate. Improving patients' access to primary care physicians and to appropriate medications may decrease the relapse rate. Although a significant portion of patients have behavioral and environmental risk factors for asthma exacerbation including cigarette smoking and failure to maintain a hypoallergenic environment, these factors are not associated with short-term relapse.

Outcomes analysis of a summer asthma camp

Forty children with moderate to severe asthma were enrolled in an asthma camp. Changes in peak flow meter (PFM) and metered-dose inhaler (MDI) technique, health care utilization, and school absenteeism were evaluated. The mean post-PFM score at the end of camp (8.9 +/- 0.3) was significantly higher (p < .0001) than the pre PFM score (6.0 +/- 3.4). The mean post-MDI score (6.5 +/- 1.5) was significantly higher (p < 0.0001) than the pre-MDI score (4.1 +/- 1.8). Emergency room visits decreased by 59%, hospitalizations decreased by 83%, and school absenteeism decreased from 266 to 188 days. Health care savings totaled $2014 per child enrolled.