Effectiveness of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity: a community guide systematic review

A reintroduction of environmental mite allergen control strategies for asthma treatment and the debate on their effectiveness

Asthma affects three hundred million people worldwide. The effectiveness of house dust mite allergen control for asthma treatment is debatable. One aspect that has been little discussed in existing meta-analyses is the possible role of environmental strategies. Here, we reintroduce the previously defined strategies for mite allergen control and discuss their importance to the debate on clinical effectiveness. The strategy of concurrent bedroom interventions is related to the combined use of a priori defined interventions, while the strategy of exposure-based control relates to the treatment of relevant textiles after assessing exposure. The air purification strategy aims to purify the human breathing zone of airborne allergens. In Western European patient practice, the use of these strategies differs. A post hoc study of the dominant Cochrane review by Gøtzsche and Johansen (Cochrane Database of Systematic Reviews, 2008, Art. No: CD001187) appears to indicate that a majority of the underlying trials reported on the strategy of concurrent bedroom interventions, which were mainly executed in a minimal manner. Some trials have reported on the air purification strategy and may potentially alter the debate on effectiveness. No trial has reported on the strategy of exposure-based control. We therefore hypothesize that the absence of evidence for the effectiveness of mite allergen control for asthma treatment applies to the strategy of concurrent bedroom interventions. The evidence-based effectiveness of the exposure-based control strategy appears to be undetermined. The results of our post hoc reanalysis urge that future meta-analyses of mite allergen control should a priori define the environmental strategy under study. Future trials of mite allergen control are warranted to test the exposure-based strategy as well as the sparsely tested strategy of air purification.

Asthma Prevalence Among Medicaid-Enrolled Children

BACKGROUND

Small-area asthma prevalence measures, which are crucial for targeting interventions, are currently sparsely available for children.

OBJECTIVE

To provide measures of in-contact asthma prevalence for the 2012 Medicaid child population so as to highlight areas in need of targeted asthma interventions.

METHODS

Using the 2012 Medicaid Analytic eXtract claims files, we developed 2 prevalence metrics differentiated by persistent and diagnosed asthma. We developed prevalence measures at the state, county, and census tract levels, with statistical inferences to highlight areas of high prevalence where interventions should be focused. We compared the measures with asthma prevalence estimates derived from a sample of the child population that self-reported whether they have been diagnosed with asthma regardless of in-contact asthma.

RESULTS

A total of 1.98 million (8.1%) and 1.71 million (6.9%) Medicaid-enrolled children were identified with in-contact asthma diagnosis and persistent asthma, respectively. Among 40 states, 17 had lower prevalence estimates for the Medicaid-enrolled children compared with similar child asthma self-reported prevalence estimates from the Centers for Disease Control and Prevention. High-prevalence regions spanned primarily in the southern Midwest region, from Texas to West Virginia and from Illinois to north Florida.

CONCLUSION

There are large variations in the differences between the self-reported estimates from the Centers for Disease Control and Prevention for the general population and the in-contact estimates for the Medicaid-enrolled children, highlighting potential asthma misdiagnosis in the Medicaid population in many states. Small-area estimates point to areas of high prevalence, consistently throughout the south and southeast.

Trends in Racial and Ethnic Disparities in Childhood Asthma in Miami, Florida: 2005-2013

Nationally, racial and ethnic disparities in childhood asthma plateaued from 2005 to 2013. We assessed trends in childhood asthma in Miami, Florida using Youth Risk Behavior Surveillance System (YRBSS) data and emergency department (ED) utilization and hospitalization rates by zip code population characteristics. Asthma prevalence in Miami did not vary significantly by race/ethnicity in YRBSS respondents in 2005 (16.2-17.2%, all groups), but rose in African-Americans and Hispanics and declined in Whites by 2013 to 27.9, 20.9 and 12.6%, respectively (P = 0.02). Median asthma ED visit rates rose from 106.8 (2006-2008) to 138.2 (2011-2013; P = 0.004) per 10,000 children. High-poverty and majority African-American zip codes were 6.3 and 7.3 times more likely to have asthma ED visit rates > 200 than others (P < 0.001). In high-poverty zip codes, majority African-American population was not associated with significantly higher ED utilization. In low-poverty zip codes, the association became stronger. Greater poverty explains much, but not all of Miami African-Americans' higher asthma risk.

School exposure and asthma

OBJECTIVE

To provide a comprehensive overview of common school exposures and the association between school exposures and pediatric asthma morbidity.

DATA SOURCES

A comprehensive literature review was performed using PubMed.

STUDY SELECTIONS

Full-length, peer-reviewed studies published in English were considered for review. In vivo, in vitro, and animal studies were excluded. Studies of school exposure to cockroach, mouse, dust mite, dog, cat, molds, pollution, and endotoxin associated with asthma and asthma morbidity were considered.

RESULTS

The current literature establishes an association between school exposure and pediatric asthma morbidity. There is a need for ongoing research to evaluate the effects of school-based environmental interventions on asthma morbidity.

CONCLUSION

It is evident that the indoor school environment is a significant reservoir of allergens, molds, pollutants, and endotoxin and that there is an association between school exposure and pediatric asthma morbidity. School-based interventions have the potential for substantial individual, community, and public health benefit. It is important that researchers continue to study the health effects associated with school exposures and assess cost-effectiveness of multifaceted school-based interventions.

Asthma, COPD, and home environments: Interventions with older adults

BACKGROUND

We describe a multifaceted home environmental intervention project involving low-income older adults with asthma who have a greater risk of asthma-related respiratory impacts because they spend up to 90% of their time in the home where many allergens and respiratory irritants are found. Although sufficient evidence suggests that home interventions are effective in improving health of children with asthma, the Task Force on Community Preventive Services has stated that evidence is insufficient for the effectiveness of home interventions on adults with asthma.

OBJECTIVE

To evaluate the hypothesis that multifaceted home environmental interventions improve the respiratory health and reduce asthma triggers for older adults with asthma.

METHODS

We conducted community health worker-led interventions in the homes of 86 low-income older adults (age 62 or older) diagnosed with asthma, residing in public and private subsidized housing in Lowell, Massachusetts, from 2014 to 2017. Health and environmental assessment at baseline and follow-up 1 year later included collecting data on respiratory health, quality of life, medication use, doctor/emergency room/hospital visits, using the St. George Respiratory Questionnaire and Asthma Control Test and evaluation of asthma trigger activities and exposures through questionnaires and home surveys. Interventions included education on asthma and environmental triggers and environmental remediation.

RESULTS

Statistically significant reductions in self-reported environmental asthma triggers and health improvements were found in the following areas: doctor visits, use of antibiotics for chest problems, respiratory symptoms and quality of life indicators, and asthma control (ACT score).

CONCLUSION

Our results provide evidence that multifaceted home interventions are effective in improving the environmental quality and respiratory health of an older adult population with asthma.

Pervasive Income-Based Disparities In Inpatient Bed-Day Rates Across Conditions And Subspecialties

Building a culture of health in hospitals means more than participating in community partnerships. It also requires an enhanced capacity to recognize and respond to disparities in utilization patterns across populations. We identified all pediatric hospitalizations at Cincinnati Children's Hospital Medical Center, in the period 2011-16. Each hospitalized child's address was geocoded, allowing us to calculate inpatient bed-day rates for each census tract in Hamilton County, Ohio, across all causes and for specific conditions and pediatric subspecialties. We then divided the census tracts into quintiles based on their underlying rates of child poverty and calculated bed-day rates per quintile. Poorer communities disproportionately bore the burden of pediatric hospital days. If children from all of the county's census tracts spent the same amount of time in the hospital each year as those from the most affluent tracts, approximately twenty-two child-years of hospitalization time would be prevented. Of particular note were "hot spots" in high-poverty census tracts neighboring the hospital, where bed-day rates were more than double the county average. Hospitals that address disparities would benefit from a more comprehensive understanding of the culture of health-a culture that is more cohesive inside the hospital and builds bridges into the community.

The Exposome and Asthma

This article on exposome and asthma focuses on the interaction of patients and their environments in various parts of their growth, development, and stages of life. Indoor and outdoor environments play a role in pathogenesis via levels and duration of exposure, with genetic susceptibility as a crucial factor that alters the initiation and trajectory of common conditions such as asthma. Knowledge of environmental exposures globally and changes that are occurring is necessary to function effectively as medical professionals and health advocates.

Childhood Asthma Disparities in Chicago: Developing Approaches to Health Inequities

We conducted a needs assessment to develop an evidence-based, locally tailored asthma care implementation plan for high-risk children with asthma in Chicago. Our team of health policy experts, clinicians, researchers, and designers included extensive stakeholder engagement (N = 162) in a mixed-methods community needs assessment. Results showed the lines of communication and collaboration across sectors were weak; caregivers were the only consistent force and could not always manage this burden. A series of recommendations for interventions and how to implement and measure them were generated. Cooperative, multidisciplinary efforts grounded in the community can target wicked problems such as asthma.

Impact of home remediation and household education on indoor air quality, respiratory visits and symptoms in Alaska Native children

Alaska Native children experience high rates of lower respiratory tract infections (LRTIs) and lung conditions, which are associated with substandard indoor air quality (IAQ). We conducted an intervention of home remediation and education to assess the impact on IAQ, respiratory symptoms and LRTI visits. We enrolled households of children 1-12 years of age with lung conditions. Home remediation included improving ventilation and replacing leaky woodstoves. We provided education about IAQ and respiratory health. We monitored indoor airborne particles (PM2.5), CO2, relative humidity and volatile organic compounds (VOCs), and interviewed caregivers about children's symptoms before, and for 1 year after intervention. We evaluated the association between children's respiratory visits, symptoms and IAQ indicators using multiple logistic regression. A total of 60 of 63 homes completed the study. VOCs decreased (coefficient = -0.20; p < 0.001); however, PM2.5 (coeff. = -0.010; p = 0.89) did not decrease. Burning wood for heat, VOCs and PM2.5 were associated with respiratory symptoms. After remediation, parents reported decreases in runny nose, cough between colds, wet cough, wheezing with colds, wheezing between colds and school absences. Children had an age-adjusted decrease in LRTI visits (coefficient = -0.33; p = 0.028). Home remediation and education reduced respiratory symptoms, LRTI visits and school absenteeism in children with lung conditions.

Common allergies in urban adolescents and their relationships with asthma control and healthcare utilization

BACKGROUND

Urban adolescents suffer a disproportionate burden of asthma morbidity, often in association with allergies. Literature is limited on comparing various types of allergies regarding prevalence and associations with asthma morbidity in urban dwelling adolescents. The purpose of this study was to examine the prevalence of common allergies reported by urban adolescents and to assess their relationships to healthcare utilization and asthma control.

METHODS

Study participants included 313 urban adolescents (12-20 years of age) with persistent asthma who were recruited from three states in the United States. Self-report data were collected on nine indoor and outdoor allergies, healthcare utilization, and asthma exacerbation. Logistic regressions and zero-inflated Poisson regressions were conducted to examine the relationships between allergies and asthma morbidity.

RESULTS

The mean age of participants was 14.58 (± 1.97) and 52% were female, and 79% were black. Seventy-three percent (n = 229) reported one or more allergies. Dust mite and grass allergies were most common, each reported by 50%. The prevalence of pest allergies (cockroach and mouse) was 27.5% and 19%, respectively. Those with pest allergies were more likely to report ED visits (cockroach- Odds Ratio (OR) = 2.16, 95% CI 1.18-3.94, p = .01; mouse- OR = 2.13, 95% CI 1.09-4.07, p = .02), specialist visits (cockroach-OR = 2.69, 95% CI 1.60-4.54, p < .001; mouse- OR = 2.06, 95% CI 1.15-3.68, p = .01) and asthma exacerbation (cockroach-OR = 2.17, 95% CI 1.26-3.74, p < .001; mouse- OR = 2.30, 95% CI 1.26-4.18, p = .01). Cockroach allergies were associated with 2.2 times as many nights in the hospital (95% CI 1.053-3.398, p = 0.036) and 2.2 times as many specialist visits (95% CI 1.489-3.110, p < 0.001), and mouse allergy was associated with 1.6 times as many ED visits (95% CI 1.092-2.257, p = 0.015) compared to those without pest allergies.

CONCLUSIONS

Concomitant occurrence of allergies is ubiquitous among urban adolescents with asthma. Only pest allergies, of those examined, appear to have implications for poorly controlled asthma, exacerbation and acute healthcare utilization. To reduce asthma burden in urban adolescents, identification and management of high-risk adolescents with pest allergen sensitization and exposure are warranted.

Bedroom Allergen Exposure Beyond House Dust Mites

PURPOSE OF REVIEW

The review provides insight into recent findings on bedroom allergen exposures, primarily focusing on pet, pest, and fungal exposures.

RECENT FINDINGS

Large-scale studies and improved exposure assessment technologies, including measurement of airborne allergens and of multiple allergens simultaneously, have extended our understanding of indoor allergen exposures and their impact on allergic disease. Practical, streamlined methods for exposure reduction have shown promise in some settings, and potential protective effects of early-life exposures have been further elucidated through the investigation of specific bacterial taxa. Advances in molecular allergology have yielded novel data on sensitization profiles and cross-reactivity. The role of indoor allergen exposures in allergic disease is complex and remains incompletely understood. Advancing our knowledge of various co-exposures, including the environmental and host microbiome, that interact with allergens in early life will be crucial for the development of efficacious interventions to reduce the substantial economic and social burden of allergic diseases including asthma.

"Pay for Success" Financing and Home-Based Multicomponent Childhood Asthma Interventions: Modeling Results From the Detroit Medicaid Population

Policy Points: The Pay for Success (PFS) financing approach has potential for scaling the implementation of evidence-based prevention interventions in Medicaid populations, including a range of multicomponent interventions for childhood asthma that combine home environment risk mitigation with medical case management. Even though this type of intervention is efficacious and cost-saving among high-risk children with asthma, the main challenges for implementation in a PFS context include legal and regulatory barriers to capturing federal Medicaid savings and using them as a source of private investor repayment. Federal-level policy change and guidance are needed to support PFS financing of evidence-based interventions that would reduce expensive acute care among Medicaid enrollees.

CONTEXT

Pay for Success has emerged as a potential financing mechanism for innovative and cost-effective prevention programs. In the PFS model, interventions that provide value to the public sector are implemented with financing from private investors who receive a payout from the government only if the metrics identified in a performance-based contract are met. In this nascent field, little has been written about the potential for and challenges of PFS initiatives that produce savings and/or value for Medicaid.

METHODS

In order to elucidate the basic economics of a PFS intervention in a Medicaid population, we modeled the potential impact of an evidence-based multicomponent childhood asthma intervention among low-income children enrolled in Medicaid in Detroit. We modeled outcomes and a comparative benefit-cost analysis in 3 risk-based target groups: (1) all children with an asthma diagnosis; (2) children with an asthma-related emergency department visit in the past year; and (3) children with an asthma-related hospitalization in the past year. Modeling scenarios for each group produced estimates of potential state and federal Medicaid savings for different types or levels of investment, the time frames for savings, and some overarching challenges.

FINDINGS

The PFS economics of a home-based asthma intervention are most viable if it targets children who have already experienced an expensive episode of asthma-related care. In a 7-year demonstration, the overall (undiscounted) modeled potential savings for Group 2 were $1.4 million for the federal Medicaid and $634,000 for the state Medicaid programs, respectively. Targeting children with at least 1 hospitalization in the past year (Group 3) produced estimated potential savings of $2.8 million to federal Medicaid and $1.3 million to state Medicaid. However, current Medicaid rules and regulations pose significant challenges for capturing federal Medicaid savings for PFS payouts.

CONCLUSIONS

A multicomponent intervention that provides home remediation and medical case management to high-risk children with asthma has significant potential for PFS financing in urban Medicaid populations. However, there are significant administrative and payment challenges, including the limited ability to capture federal Medicaid savings and to use them as a source of investor repayment. Without some policy reform and clear guidance from the federal government, the financing burden of PFS outcome payments will be on the state Medicaid program or some other state-level funding source.

Consensus document on dog and cat allergy

The prevalence of sensitization to dogs and cats varies by country, exposure time and predisposition to atopy. It is estimated that 26% of European adults coming to the clinic for suspected allergy to inhalant allergens are sensitized to cats and 27% to dogs. This document is intended to be a useful tool for clinicians involved in the management of people with dog or cat allergy. It was prepared from a consensus process based on the RAND/UCLA method. Following a literature review, it proposes various recommendations concerning the diagnosis and treatment of these patients, grounded in evidence and clinical experience. The diagnosis of dog and cat allergy is based on a medical history and physical examination that are consistent with each other and is confirmed with positive results on specific IgE skin tests. Sometimes, especially in polysensitized patients, molecular diagnosis is strongly recommended. Although the most advisable measure would be to avoid the animal, this is often impossible and associated with a major emotional impact. Furthermore, indirect exposure to allergens occurs in environments in which animals are not present. Immunotherapy is emerging as a potential solution to this problem, although further supporting studies are needed.

Evidence-based pediatric asthma interventions and outcome measures in a healthy homes program: An integrative review

OBJECTIVE

Asthma disproportionately impacts and has poorer outcomes in low-income, minority, and inner-city children. The home environment has a profound impact on a child's asthma. Home-based asthma visits have the potential to positively impact a child's asthma, especially in targeted populations. The purpose of this integrative review is 1.) to explore the effectiveness of home-based education and environmental measures and 2.) to explore specific indicators and tools to measure pediatric asthma control and program effectiveness.

DATA SOURCES

Medline, CINHAL, and Ovid databases were searched from 2010 to 2017 utilizing the keywords healthy homes AND asthma and home based interventions AND asthma.

STUDY SELECTIONS

A total of 71 articles were retrieved of which 27 articles met the inclusion criteria of English language, human subjects, and the inclusion of pediatric populations. Three additional articles were hand-searched from previous references. In total, 30 articles were reviewed. A quality appraisal was conducted utilizing standardized appraisal tools.

RESULTS

Home-based asthma education and environmental interventions have proven to be effective. The programs reviewed varied in types of interventions, intensity and duration, the type of provider, length of follow-up, and outcome measures. Successful programs were patient-centered, included a home assessment and individualized education and interventions, and were collaborative. Multiple outcome indicators such as health care utilization, asthma control, missed days of school or productivity, asthma symptoms, and verification of environmental remediation have been utilized.

CONCLUSION

Home-based asthma programs can be beneficial to children with poorly controlled asthma and have the potential to be cost-effective.

A Cost-Benefit Analysis of a State-Funded Healthy Homes Program for Residents With Asthma: Findings From the New York State Healthy Neighborhoods Program

CONTEXT

Despite considerable evidence that the economic and other benefits of asthma home visits far exceed their cost, few health care payers reimburse or provide coverage for these services.

OBJECTIVE

To evaluate the cost and savings of the asthma intervention of a state-funded healthy homes program.

DESIGN

Pre- versus postintervention comparisons of asthma outcomes for visits conducted during 2008-2012.

SETTING

The New York State Healthy Neighborhoods Program operates in select communities with a higher burden of housing-related illness and associated risk factors.

PARTICIPANTS

One thousand households with 550 children and 731 adults with active asthma; 791 households with 448 children and 551 adults with asthma events in the previous year.

INTERVENTION

The program provides home environmental assessments and low-cost interventions to address asthma trigger-promoting conditions and asthma self-management. Conditions are reassessed 3 to 6 months after the initial visit.

MAIN OUTCOME MEASURES

Program costs and estimated benefits from changes in asthma medication use, visits to the doctor for asthma, emergency department visits, and hospitalizations over a 12-month follow-up period.

RESULTS

For the asthma event group, the per person savings for all medical encounters and medications filled was $1083 per in-home asthma visit, and the average cost of the visit was $302, for a benefit to program cost ratio of 3.58 and net benefit of $781 per asthma visit. For the active asthma group, per person savings was $613 per asthma visit, with a benefit to program cost ratio of 2.03 and net benefit of $311.

CONCLUSION

Low-intensity, home-based, environmental interventions for people with asthma decrease the cost of health care utilization. Greater reductions are realized when services are targeted toward people with more poorly controlled asthma. While low-intensity approaches may produce more modest benefits, they may also be more feasible to implement on a large scale. Health care payers, and public payers in particular, should consider expanding coverage, at least for patients with poorly controlled asthma or who may be at risk for poor asthma control, to include services that address triggers in the home environment.

An Evaluation of a State-Funded Healthy Homes Intervention on Asthma Outcomes in Adults and Children

CONTEXT

Reducing exposure to environmental triggers is a critical part of asthma management.

OBJECTIVE

To evaluate the impact of a healthy homes intervention on asthma outcomes and assess the impact of different targeting strategies.

SETTING

The New York State (NYS) Healthy Neighborhoods Program (HNP) operates in select communities with a higher burden of housing-related illness and associated risk factors.

PARTICIPANTS

Residents with asthma were recruited through 3 mechanisms: door-to-door canvassing (CANVASSED), 752 residents in 457 dwellings; referrals from community partners (REFERRED), 573 residents in 307 dwellings; referrals of Medicaid enrollees with poorly controlled asthma (TARGETED), 140 residents in 140 dwellings.

INTERVENTION

The NYS HNP provides visual assessments and low-cost interventions to identify and address asthma triggers and trigger-promoting conditions in the home environment. Conditions are reassessed during a revisit conducted 3 to 6 months after the initial visit.

MAIN OUTCOME MEASURE(S)

The analysis compares improvements across the 3 groups for measures of asthma self-management, health care access, morbidity, and environmental conditions. An asthma trigger score characterizing the extent of multiple triggers in a dwelling was also calculated.

RESULTS

Among 1465 adults and children, there were significant improvements in environmental conditions and self-reported self-management, health care access, and asthma morbidity outcomes for each group. The improvement was greatest in the TARGETED group for most outcomes, but selected measures of self-management and health care access were greater in the other groups. The mean improvement was significantly greater in the TARGETED group.

CONCLUSION

Targeting the intervention to people with poorly controlled asthma maximizes improvements in trigger avoidance and asthma morbidity; however, other recruitment strategies are effective for impacting endpoints related to health care access and self-management. This evaluation demonstrates that a low-intensity home-based environmental intervention is effective as well as practical and feasible. Health care payers, state and local health departments, and others should consider investing in these home-based services as part of a comprehensive asthma care package.

The role of the indoor environment: Residential determinants of allergy, asthma and pulmonary function in children from a US-Mexico border community

The El Paso Children's Health Study examined environmental risk factors for allergy and asthma among fourth and fifth grade schoolchildren living in a major United States-Mexico border city. Complete questionnaire information was available for 5210 children, while adequate pulmonary function data were available for a subset of 1874. Herein we studied indoor environmental health risk factors for allergy and asthma. Several indoor environmental risk factors were associated with allergy and asthma. In particular, we found that ant and spider pest problems, pet dogs, fireplace heat, central air conditioning, humidifier use, and cooking with gas stoves were positively associated with both allergy and asthma prevalence. With regards to asthma severity, our analysis indicated that exposure to pet dogs increased monotonically with increasing asthma severity while the lack of any heat source and gas stove use for cooking decreased monotonically with increasing asthma severity. Lung function also decreased among children who lived in homes with reported cockroach pest problem in the past year without concurrent use of pesticides. These effects on pulmonary function were present even after excluding children with a current physician's diagnosis of asthma. Clinicians and public health professionals may need to look closely at the contribution of these indoor risk factors on pulmonary health and quality of life among susceptible populations.

Outcomes of the Montana Asthma Home Visiting Program: A home-based asthma education program

OBJECTIVE

Asthma is a common disease in children. Home-based, multi-trigger, multi-component interventions with an environmental focus have been shown to be effective to address asthma in children. The objective of this study was to assess the outcomes and feasibility of implementing a specific asthma home visiting (HV) program in a rural area.

METHODS

Children aged 0-17 years with uncontrolled asthma were enrolled in an asthma HV program that included six contacts over a 12-month period delivered by a registered nurse specifically trained in asthma education and trigger removal in eleven counties in the rural state of Montana. Between June 2010 and December 2016, data on asthma symptoms and asthma self-management skills were collected at baseline and throughout the program. In June 2017, they were analyzed to assess changes in asthma control and quality of life over time among participants completing all six contacts.

RESULTS

Since June 2010, 152 of 338 enrolled children completed all six contacts outlined in the program (45%). Participants who completed the program reported significant improvements in asthma control test scores, self-management skills, and self-efficacy related to asthma management. These results improved the longer participants remained in the program.

CONCLUSIONS

These findings suggest that it is feasible to implement a 12-month HV program using local public health resources in a rural area as outcomes improved over this time period.

Clinician Agreement, Self-Efficacy, and Adherence with the Guidelines for the Diagnosis and Management of Asthma

BACKGROUND

The 2007 Guidelines for the Diagnosis and Management of Asthma provide evidence-based recommendations to improve asthma care. Limited national-level data are available about clinician agreement and adherence to these guidelines.

OBJECTIVE

To assess clinician-reported adherence with specific guideline recommendations, as well as agreement with and self-efficacy to implement guidelines.

METHODS

We analyzed 2012 National Asthma Survey of Physicians data for 1412 primary care clinicians and 233 asthma specialists about 4 cornerstone guideline domains: asthma control, patient education, environmental control, and pharmacologic treatment. Agreement and self-efficacy were measured using Likert scales; 2 overall indices of agreement and self-efficacy were compiled. Adherence was compared between primary care clinicians and asthma specialists. Logistic regression models assessed the association of agreement and self-efficacy indices with adherence.

RESULTS

Asthma specialists expressed stronger agreement, higher self-efficacy, and greater adherence with guideline recommendations than did primary care clinicians. Adherence was low among both groups for specific core recommendations, including written asthma action plan (30.6% and 16.4%, respectively; P < .001); home peak flow monitoring, (12.8% and 11.2%; P = .34); spirometry testing (44.7% and 10.8%; P < .001); and repeated assessment of inhaler technique (39.7% and 16.8%; P < .001). Among primary care clinicians, greater self-efficacy was associated with greater adherence. For specialists, self-efficacy was associated only with increased odds of spirometry testing. Guideline agreement was generally not associated with adherence.

CONCLUSIONS

Agreement with and adherence to asthma guidelines was higher for specialists than for primary care clinicians, but was low in both groups for several key recommendations. Self-efficacy was a good predictor of guideline adherence among primary care clinicians but not among specialists.

Psychosocial Factors in Severe Pediatric Asthma

Asthma is the most common chronic illness among children in the United States and can impact nearly all aspects of functioning. Most research suggests that children with severe asthma display more emotional and behavioral problems than their healthy peers. These psychological difficulties are associated with increased risk for functional impairments and problematic disease course. Multidisciplinary teams that assess and treat these psychosocial factors using psychoeducational and behavioral interventions are important for children whose asthma is poorly controlled. Future research should examine the ways in which stress, emotions, and immune functions interact, so as to develop more preventative interventions.

NIAID, NIEHS, NHLBI, and MCAN Workshop Report: The indoor environment and childhood asthma-implications for home environmental intervention in asthma prevention and management

Environmental exposures have been recognized as critical in the initiation and exacerbation of asthma, one of the most common chronic childhood diseases. The National Institute of Allergy and Infectious Diseases; National Institute of Environmental Health Sciences; National Heart, Lung, and Blood Institute; and Merck Childhood Asthma Network sponsored a joint workshop to discuss the current state of science with respect to the indoor environment and its effects on the development and morbidity of childhood asthma. The workshop included US and international experts with backgrounds in allergy/allergens, immunology, asthma, environmental health, environmental exposures and pollutants, epidemiology, public health, and bioinformatics. Workshop participants provided new insights into the biologic properties of indoor exposures, indoor exposure assessment, and exposure reduction techniques. This informed a primary focus of the workshop: to critically review trials and research relevant to the prevention or control of asthma through environmental intervention. The participants identified important limitations and gaps in scientific methodologies and knowledge and proposed and prioritized areas for future research. The group reviewed socioeconomic and structural challenges to changing environmental exposure and offered recommendations for creative study design to overcome these challenges in trials to improve asthma management. The recommendations of this workshop can serve as guidance for future research in the study of the indoor environment and on environmental interventions as they pertain to the prevention and management of asthma and airway allergies.

Removing asthma triggers and improving children's health: The Asthma Partnership Demonstration project

BACKGROUND

Studies have revealed the efficacy of home-based environmental interventions on reduction of asthma symptoms as a strategy for managing asthma in children. A focus on education and behavior change alone is generally too limited to reduce exposure to asthma triggers that exist because of adverse housing conditions.

OBJECTIVE

To demonstrate that housing conditions as a focus of a health intervention should be considered more widely as an effective means of addressing serious health problems such as asthma.

METHODS

Residences of 41 families of children identified with some of the highest rates of asthma-related hospital visits were assessed for the presence of asthma triggers.

RESULTS

The intervention had a positive effect on lessening the effect of the child's asthma on the family's lives and activities. Reductions in frequency of negative effects of children's asthma on sleeping, job or work around the house, and family activity plans, fewer worries or concerns about children getting enough sleep and performing normal daily activities, and fewer adverse effects of children's asthma medications were reported. Reduced use of asthma medication, medication applications, and health visits were noted. Households with return visits had 50% lower hospital bills for childhood asthma treatment.

CONCLUSION

Home environment conditions that lead to or exacerbate asthma may be reduced or eliminated by making minor repairs and introducing reasonable cleaning regimens that address sources of asthma triggers. This can produce greater awareness on the part of families about the presence of asthma triggers and motivate future action to address the conditions associated with these triggers.

Care transition interventions for children with asthma in the emergency department

The emergency department (ED) is a critical point of identification and treatment for some of the most high-risk children with asthma. This review summarizes the evidence regarding care transition interventions originating in the ED for children with uncontrolled asthma, with a focus on care coordination and self-management education. Although many interventions on care transition for pediatric asthma have been tested, only a few were actually conducted in the ED setting. Most of these targeted both care coordination and self-management education but ultimately did not improve attendance at follow-up appointments with primary care providers, improve asthma control, or reduce health care utilization. Conducting any ED-based intervention in the current environment is challenging because of the many demands on ED providers and staff, poor communication within and outside of the medical sector, and caregiver/patient burden. The evidence to date suggests that ED care transition interventions should consider expanding beyond the ED to bridge the multiple sectors children with asthma navigate, including health care settings, homes, schools, and community spaces. Patient-centered approaches may also be important to ensure adequate intervention design, enrollment, retention, and evaluation of outcomes important to children and their families.

HUD Housing Assistance Associated With Lower Uninsurance Rates And Unmet Medical Need

To investigate whether receiving US Department of Housing and Urban Development (HUD) housing assistance is associated with improved access to health care, we analyzed data on nondisabled adults ages 18-64 who responded to the 2004-12 National Health Interview Survey that were linked with administrative data from HUD for the period 2002-14. To account for potential selection bias, we compared access to care between respondents who were receiving HUD housing assistance at the time of the survey interview (current recipients) and those who received HUD assistance within twenty-four months of completing the survey interview (future recipients). Receiving assistance was associated with lower uninsurance rates: 31.8 percent of current recipients were uninsured, compared to 37.2 percent of future recipients. Rates of unmet need for health care due to cost were similarly lower for current recipients than for future recipients. No effect of receiving assistance was observed on having a usual source of care. These findings provide evidence that supports the effectiveness of housing assistance in improving health care access.

Sensitization to Common Aeroallergens in Asthmatic Children in the Eastern Region of Saudi Arabia

Background:

Allergic disorders, particularly bronchial asthma, are one of the most common chronic childhood diseases. Bronchial asthma is more prevalent among children of the Eastern Province of Saudi Arabia compared with the other provinces. Environmental factors play major roles in the disease pathogenesis in genetically predisposed hosts. In this study, we characterize the pattern of allergenicity in asthmatic children in the Eastern Province of Saudi Arabia.

Materials and Methods:

This study is a retrospective, cross-sectional analysis of skin sensitization profiles of 100 Saudi asthmatic children living in Al-Khobar, Saudi Arabia. The group compromised 32 females and 68 males, aged 5–14 years with a mean age of 8.98 ± 2.93 years. Skin prick tests were performed in a regional tertiary center, in the period between January 2011 and December 2012, using a variety of indoor and outdoor allergens.

Results:

The most common indoor sensitizing allergens found were the house dust mite (54%), cat fur (53%) and the German cockroach (26%). Among outdoor allergens, Salsola kali was the most common (48%), followed by Timothy grass (23%) and Chenopodium album (23%). Among trees, Prosopis glandulosa was found to be the most prevalent sensitizer (19%). Among the molds, Alternaria and Aspergillus species were the most prevalent (21% each).

Conclusion:

A high rate of sensitization to aeroallergens was found in asthmatic children living in Al-Khobar city. The pattern of sensitization found in our study reflects the newly altered nature of an ancient humid desert that has been influenced by the recent artificial modernization of the region.

Environmental triggers and avoidance in the management of asthma

Identifying asthma triggers forms the basis of environmental secondary prevention. These triggers may be allergenic or nonallergenic. Allergenic triggers include indoor allergens, such as house dust mites (HDMs), molds, pets, cockroaches, and rodents, and outdoor allergens, such as pollens and molds. Clinical observations provide support for the role of HDM exposure as a trigger, although avoidance studies provide conflicting results. Molds and their metabolic products are now considered to be triggers of asthma attacks. Pets, dogs, and especially cats can undoubtedly trigger asthmatic symptoms in sensitized subjects. Avoidance is difficult and rarely adhered to by families. Cockroach allergens contribute to asthma morbidity, and avoidance strategies can lead to clinical benefit. Mouse allergens are mostly found in inner-city dwellings, but their implication in asthma morbidity is debated. In the outdoors, pollens can induce seasonal asthma in sensitized individuals. Avoidance relies on preventing pollens from getting into the house and on minimizing seasonal outdoor exposure. Outdoor molds may lead to severe asthma exacerbations. Nonallergenic triggers include viral infections, active and passive smoking, meteorological changes, occupational exposures, and other triggers that are less commonly involved. Viral infection is the main asthma trigger in children. Active smoking is associated with higher asthma morbidity, and smoking cessation interventions should be personalized. Passive smoking is also a risk factor for asthma exacerbation. The implementation of public smoking bans has led to a reduction in the hospitalization of asthmatic children. Air pollution levels have been linked with asthmatic symptoms, a decrease in lung function, and increased emergency room visits and hospitalizations. Since avoidance is not easy to achieve, clean air policies remain the most effective strategy. Indoor air is also affected by air pollutants, such as cigarette smoke and volatile organic compounds generated by building and cleaning materials. Occupational exposures include work-exacerbated asthma and work-related asthma.

Housing characteristics and indoor air quality in households of Alaska Native children with chronic lung conditions

Alaska Native children experience high rates of respiratory infections and conditions. Household crowding, indoor smoke, lack of piped water, and poverty have been associated with respiratory infections. We describe the baseline household characteristics of children with severe or chronic lung disease participating in a 2012-2015 indoor air study. We monitored indoor PM2.5, CO2 , relative humidity %, temperature, and VOCs and interviewed caregivers about children's respiratory symptoms. We evaluated the association between reported children's respiratory symptoms and indoor air quality indicators using multiple logistic regression analysis. Compared with general US households, study households were more likely overcrowded 73% (62%-82%) vs 3.2% (3.1%-3.3%); had higher woodstove use as primary heat source 16% (9%-25%) vs 2.1% (2.0%-2.2%); and higher proportion of children in a household with a smoker 49% (38%-60%) vs 26.2% (25.5%-26.8%). Median PM2.5 was 33 μg/m3 . Median CO2 was 1401 ppm. VOCs were detectable in all homes. VOCs, smoker, primary wood heat, and PM2.5>25 μg/m3 were associated with higher risk for cough between colds; VOCs were associated with higher risk for wheeze between colds and asthma diagnosis. High indoor air pollutant levels were associated with respiratory symptoms in household children, likely related to overcrowding, poor ventilation, woodstove use, and tobacco smoke.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions

BACKGROUND

Asthma is the most common chronic disease of childhood and a leading cause of hospitalization in children. A primary goal of asthma control is prevention of hospitalizations. A hospital admission is the single strongest predictor of future hospital admissions for asthma. The 30-day asthma readmission rate at our institution was significantly higher than that of other hospitals in the Children's Hospital Association. As a result, a multifaceted quality improvement project was undertaken with the goal of reducing the 30-day inpatient asthma readmission rate by 50% within two years.

METHODS

Analysis of our institution's readmission patterns, value stream mapping of asthma admission, discharge, and follow-up processes, literature review, and examination of comparable successful programs around the United States were all utilized to identify potential targets for intervention. Interventions were implemented in a stepwise manner, and included increasing inhaler availability after discharge, modifying asthma education strategies, and providing in-home post-discharge follow-up. The primary outcome was a running 12-month average 30-day inpatient readmission rate. Secondary outcomes included process measures for individual interventions.

RESULTS

From a peak of 7.98% in January 2013, a steady decline to 1.65% was observed by July 2014, which represented a 79.3% reduction in 30-day readmissions.

CONCLUSION

A significant decrease in hospital readmissions for pediatric asthma is possible, through comprehensive, multidisciplinary quality improvement that spans the continuum of care.

A single intervention for cockroach control reduces cockroach exposure and asthma morbidity in children

BACKGROUND

Exposure to cockroaches is an important asthma trigger, particularly for children with asthma living in inner cities. Integrated pest management is the recommended approach to cockroach abatement; however, it is costly and difficult to implement. The impact of reducing cockroach exposure on asthma outcomes is not known.

OBJECTIVE

We sought to test the use of a single intervention, insecticidal bait, to reduce cockroach exposure in the home of children with asthma in New Orleans and to examine the impact of cockroach reduction on asthma outcomes.

METHODS

One hundred two children aged 5 to 17 years with moderate to severe asthma were enrolled in a 12-month randomized controlled trial testing the use of insecticidal bait on cockroach counts and asthma morbidity. Homes were visited 6 times and asthma symptoms were assessed every 2 months.

RESULTS

After adjustment, intervention homes had significantly fewer cockroaches than did control homes (mean change in cockroaches trapped, 13.14; 95% CI, 6.88-19.39; P < .01). Children in control homes had more asthma symptoms and unscheduled health care utilization in the previous 2 weeks (1.82, 95% CI, 0.14-3.50, P = .03; 1.17, 95% CI, 0.11-2.24, P = .03, respectively) and a higher proportion of children with FEV₁ of less than 80% predicted (odds ratio, 5.74; 95% CI, 1.60-20.57; P = .01) compared with children living in intervention homes.

CONCLUSIONS

Previous research has demonstrated improvement in asthma health outcomes using multifaceted interventions. The strategic placement of insecticidal bait, which is inexpensive, has low toxicity, and is widely available, resulted in sustained cockroach elimination over 12 months and was associated with improved asthma outcomes. This single intervention may be an alternative to multifaceted interventions currently recommended to improve asthma morbidity.

Breathe Easy at Home: A Qualitative Evaluation of a Pediatric Asthma Intervention

The Breathe Easy at Home Program enables clinicians to refer asthmatic patients to Boston Inspectional Services Department (ISD) if they suspect housing conditions trigger symptoms. The authors conducted one-on-one interviews with clinicians (n = 10) who referred patients, and focus groups with inspectors from the ISD (n = 9) and a variety of stakeholders (n = 13), to gain insight into program function and implementation. Clinician interviews revealed inconsistencies in enrollment approaches, dissatisfaction with the web-based system, and patient follow-up difficulties. Inspectors identified barriers to working effectively with residents and landlords, and the stakeholder focus group highlighted successes of an unusual institutional collaboration. Interviews and focus groups identified strong and personal rapport between clinicians, inspectors, and patients as key to program retention, and that participating families required additional support throughout the process. Despite recommendations for improvement in program implementation, clinicians, inspectors, and stakeholders felt that the program overall improved both the home environment and asthma outcomes.

Translating a Proven Pediatric Healthy Homes Asthma Intervention to Adults

Asthma is a serious public health concern, disproportionately affecting urban, minority populations. Chicago's West and Southwest sides are among the most burdened by asthma and environmental conditions that exacerbate asthma. Home-based, community health worker (CHW)-led interventions have repeatedly demonstrated effectiveness in addressing pediatric asthma. However, evidence of such interventions among adults is limited. Helping Chicago's Westside Adults Breathe and Thrive is a longitudinal cohort study that assesses the effectiveness of a CHW-led asthma and healthy homes intervention for adults. One of the first of its kind, the program aims to improve asthma control and quality of life among adults with poorly controlled asthma. This article provides a framework for implementing the intervention from start to finish. CHWs make five or six home visits over the course of 12 months, providing comprehensive and individualized asthma education to study participants. They work closely with participants to conduct home environmental assessments, collaboratively developing techniques to eliminate or avoid asthma triggers. They also assist with smoking cessation, comorbidities, and health system navigation. Between December 1, 2013, and August 31, 2015, 202 participants enrolled in the program. This article reports on successes, challenges, and recommendations from the program's first 21 months of operation.

Housing code violation density associated with emergency department and hospital use by children with asthma

Local agencies that enforce housing policies can partner with the health care system to target pediatric asthma care. These agencies retain data that can be used to pinpoint potential clusters of high asthma morbidity. We sought to assess whether the density of housing code violations in census tracts-the in-tract asthma-relevant violations (such as the presence of mold or cockroaches) divided by the number of housing units-was associated with population-level asthma morbidity and could be used to predict a hospitalized patient's risk of subsequent morbidity. We found that increased density in housing code violations was associated with population-level morbidity independent of poverty, and that the density explained 22 percent of the variation in rates of asthma-related emergency department visits and hospitalizations. Children who had been hospitalized for asthma had 1.84 greater odds of a revisit to the emergency department or a rehospitalization within twelve months if they lived in the highest quartile of housing code violation tracts, compared to those living in the lowest quartile. Integrating housing and health data could highlight at-risk areas and patients for targeted interventions.

Home Environmental Interventions for the Prevention or Control of Allergic and Respiratory Diseases: What Really Works

Home health care workers interventions have been implemented in western countries to improve health status of patients with respiratory diseases especially asthma and allergic illnesses. Twenty-six controlled studies dealing with prevention and control of these diseases through home environmental interventions were reviewed. After a comprehensive description of the characteristics of these studies, the effectiveness of each intervention was then evaluated in terms of participants' compliance with the intervention program, improvement of quality of the indoor environment, and finally improvement of health outcomes, in detailed tables. Limitations and biases of the studies are also discussed. Overall, this review aims at giving a toolbox for home health care workers to target the most appropriate measures to improve health status of the patient depending on his and/or her environment and disease. Only a case-by-case approach with achievable measures will warrant the efficacy of home interventions. This review will also provide to the research community a tool to better identify targets to focus in future evaluation studies of home health care workers action.

Effective education parameters for trigger remediation in underserved children with asthma: A systematic review

OBJECTIVES

The prevalence of asthma is highest in minority children living in urban areas. Pediatric asthma research has focused on self-management education and trigger remediation using a multi-trigger, multi-component educational intervention approach. The purpose of this systematic review was to identify common educational parameters of these proposed interventions. The review also sought to identify which clinical outcomes improved with multi-trigger, multi-component educational interventions.

DATA SOURCES

PubMed, SCOPUS and ProQuest Dissertations were searched between 2000 to 2014 using the following terms: asthma; urban population or poverty area; environmental remediation; health education; allergens or dust mites or cockroaches or mold or mice or rats.

STUDY SELECTIONS

Studies were included if they met the following criteria: 1) participants were minority children identified as underserved; 2) there was a multi-trigger and multi-component intervention; 3) asthma severity was classified as persistent; and 4) asthma control was classified as not well controlled.

RESULTS

A total of 531 articles were retrieved of which 17 met the inclusion criteria. The interventions lacked consistency in their explanation. Most studies were vague in reporting pedagogical methods and educational content. Few studies reported a theoretical framework to guide their approach. Over half the studies did not report a learning assessment nor health literacy of the caregiver or the child with asthma. Yet all of the findings demonstrated statistically significant results in some or all of their primary outcomes.

CONCLUSION

Overall, the research lacked clarity in the approach to impact asthma outcomes and reduces the opportunity to substantiate the findings through replication.

Allergen sensitization profiles in a population-based cohort of children hospitalized for asthma

RATIONALE

Allergen sensitization is associated with asthma morbidity. A better understanding of allergen sensitization patterns among children hospitalized for asthma could help clinicians tailor care more effectively. To our knowledge, however, sensitization profiles among children hospitalized for asthma are unknown.

OBJECTIVES

We sought to describe allergen sensitization profiles and the distribution of self-reported in-home exposures among children hospitalized for asthma. We also sought to assess how sensitization profiles varied by sociodemographic and clinical factors.

METHODS

This population-based cohort study includes data for 478 children, aged 4-16 years, hospitalized for an asthma exacerbation. Predictors included child age, race, sex, insurance status, reported income, salivary cotinine, exposure to traffic-related air pollution, asthma and atopic history, and season of admission. Outcomes included serum IgE specific to Alternaria alternata/A. tenuis, Aspergillus fumigatus, American cockroach, mouse epithelium, dust mite (Dermatophagoides pteronyssinus and farinae), cat dander, and dog dander (deemed sensitive if IgE ≥ 0.35). Self-reported adverse exposures included mold/mildew, water leaks, cockroaches, rodents, and cracks or holes in the walls or ceiling. Presence of carpeting and furry pets was also assessed.

MEASUREMENTS AND MAIN RESULTS

More than 50% of included patients were sensitized to each of Alternaria, Aspergillus, dust mite, cat dander, and dog dander; 28% were sensitized to cockroach and 18% to mouse. Roughly 68% were sensitized to three or more allergens with evidence of clustering. African American children, compared with white children, were more likely to be sensitized to Alternaria, Aspergillus, cockroach, and dust mite (all P<0.01). White children were more likely to be sensitized to mouse, cat, and dog (all P<0.01). Lower income was associated with cockroach sensitization whereas higher income was associated with dog and cat sensitization (all P<0.01). Atopic history was associated with sensitization to three or more allergens (P<0.01). Although 42% reported exposure to at least one adverse in-home exposure (and 72% to carpet, 51% to furry pets), only weak relationships were seen between reported exposures and sensitizations.

CONCLUSIONS

Most children admitted to the hospital for asthma exacerbations are sensitized to multiple indoor allergens. Atopy on the inpatient unit serves as a potential target for improvement in chronic asthma management.

Community Health Worker Home Visits for Medicaid-Enrolled Children With Asthma: Effects on Asthma Outcomes and Costs

OBJECTIVES

We sought to estimate the return on investment of a streamlined version of an evidence-based community health worker (CHW) asthma home visit program.

METHODS

We used a randomized parallel group trial of home visits by CHWs to Medicaid-enrolled children with uncontrolled asthma versus usual care.

RESULTS

A total of 373 participants enrolled in the study (182 in the intervention group and 191 in the control group, of whom 154 and 179, respectively, completed the study). The intervention group had greater improvements in asthma symptom-free days (2.10 days more over 2 weeks; 95% CI =  1.17, 3.05; P < .001) and caretakers' quality of life (0.43 units more; 95% CI = 0.20, 0.66; P < .001) and a larger reduction in urgent health care utilization events (1.31 events fewer over 12 months; 95% CI = -2.10, -0.52; P = .001). The intervention arm compared with the control arm saved $1340.92 for the $707.04 additional costs invested for the average participant. The return on investment was 1.90.

CONCLUSIONS

A streamlined CHW asthma home visit program for children with uncontrolled asthma improved health outcomes and yielded a return on investment of 1.90.

Effects of Symptom Perception Interventions on Trigger Identification and Quality of Life in Children with Asthma

BACKGROUND

Management of individual triggers is suboptimal in practice. In this project, we investigated the impact of symptom perception interventions on asthma trigger identification and self-reported asthma quality of life.

METHODS

Children with asthma (n=227) participated in three asthma education sessions and then were randomized first to one of three home monitoring conditions (symptom monitoring and peak flow training with feedback, peak flow training without feedback, or no peak flow training) and then subsequently to one of three resistive load discrimination training conditions (signal detection training with feedback, signal detection training without feedback, or no training). Triggers were reported at enrollment, following home monitoring, and following discrimination training; quality of life was measured after home monitoring and after resistive load testing.

RESULTS

Symptom perception interventions resulted in increases in reported triggers, which increased reliably as a function of home monitoring, and increased further in participants who completed discrimination training with feedback. Increases in the number of reported asthma triggers were associated with decreases in quality of life.

DISCUSSION

Patients may benefit from strategies that make trigger-symptom contingencies clear. Complementary strategies are needed to address changes in the perceived burden of asthma which comes from awareness of new asthma triggers.

Effects of an Asthma Training and Monitoring Program on Children's Disease Management and Quality of Life

OBJECTIVES

To determine the effects of an asthma training and monitoring program on children's disease management and quality of life.

MATERIAL AND METHODS

The sample consisted of 120 children and their parents. Data were collected during, at the beginning, and at the end of the 3-month monitoring period using four forms and a quality of life scale. After an initial evaluation, approaches to control symptoms and asthma triggers and measures that might be taken for them were taught to the children and parents. The children recorded the conditions of trigger exposure, experience of disease symptoms, their effects on daily activities, and therapeutic implementations on a daily basis.

RESULTS

During the 3-month monitoring period, the number of days when the children were exposed to triggers (p=0.000) and experienced disease symptoms decreased to a statistically significant level (p=0.006). Majority of domestic triggers disappeared, but those stemming from the structure of the house and non-domestic triggers indicated no change (p>0.05). Moreover, 30.8% of the children applied to a physician/hospital/emergency service, 4.2% of the children were hospitalized, and 30% of them could not go to school. The number of times when the children applied to a physician/hospital/emergency (p=0.013), the number of times they used medicines (p=0.050), and the number of days they could not go to school (p=0.002) decreased at a statistically significant level, and their quality of life increased (p=0.001).

CONCLUSION

Asthma training and monitoring program decreased children's rate of experiencing asthma symptoms and implementations of therapeutic purposes and increased their life quality.

House Dust Mite Respiratory Allergy: An Overview of Current Therapeutic Strategies

Although house dust mite (HDM) allergy is a major cause of respiratory allergic disease, specific diagnosis and effective treatment both present unresolved challenges. Guidelines for the treatment of allergic rhinitis and asthma are well supported in the literature, but specific evidence on the efficacy of pharmacotherapy treatment for known HDM-allergic patients is weaker. The standard diagnostic techniques--skin prick test and specific IgE testing--can be confounded by cross-reactivity. However, component-resolved diagnosis using purified and recombinant allergens can improve the accuracy of specific IgE testing, but availability is limited. Treatment options for HDM allergy are limited and include HDM avoidance, which is widely recommended as a strategy, although evidence for its efficacy is variable. Clinical efficacy of pharmacotherapy is well documented; however, symptom relief does not extend beyond the end of treatment. Finally, allergen immunotherapy has a poor but improving evidence base (notably on sublingual tablets) and its benefits last after treatment ends. This review identifies needs for deeper physician knowledge on the extent and impact of HDM allergy in respiratory disease, as well as further development and improved access to molecular allergy diagnosis. Furthermore, there is a need for the development of better-designed clinical trials to explore the utility of allergen-specific approaches, and uptake of data into guidance for physicians on more effective diagnosis and therapy of HDM respiratory allergy in practice.

Mexican-American caregivers' perceptions about asthma management: a photovoice study

OBJECTIVE

The purpose of this study is to report how photovoice was used to (1) ascertain Mexican-American caregiver perspectives about asthma management, and (2) engage caregivers in dissemination.

METHODS

Eleven Mexican-American caregivers of children with asthma were recruited and given cameras to photograph what helped or hindered their ability to care for their child. Participants prioritized which images to share, discussed the images with the group, and wrote accompanying titles and captions in four photovoice sessions. Sessions were in Spanish and occurred in a community setting. Participants presented their work to peers and community members. Identified issues were subsequently categorized by investigators according to the four components of asthma care.

RESULTS

Participants prioritized 32 phototexts, the majority of which (n = 20, 63%) reflected activities associated with environmental control. Caregivers highlighted asthma triggers, and suggested ways to maintain indoor air quality (IAQ) through home cleaning. The need for policies that enforce smoking bans in shared housing and public places was identified as an important strategy to improve outdoor air quality. "Education for a Partnership in Asthma Care" was represented in six (19%) phototexts. Five phototexts (16%) represented "Assessment and Monitoring". Only one phototext (3.13%) primarily represented "Medications".

CONCLUSIONS

Results support the need for active partnerships between caregivers and providers. Photographs can serve as the basis for reciprocal education between patient and provider, especially in the area of environmental triggers. Provider visits should include assessment, strategies and resources to maximize IAQ. Photovoice facilitates caregivers' ability to advocate for improved asthma management and health equity.

National standards for asthma self-management education

BACKGROUND

Asthma education reimbursement continues to be an issue in the United States. Among the greatest barriers is the lack of a standardized curriculum for asthma self-management education recognized by a physician society, non-physician health care professional society or association, or other appropriate source. The applicable Current Procedural Terminology codes for self-management education and training are 98960 through 98962, stating that "if a practitioner has created a training curriculum for educating patients on management of their medical condition, he or she may employ a non-physician health care professional to provide education using a standardized curriculum for patients with that disease." Without a standardized curriculum, reimbursement from payers is beyond reach.

OBJECTIVE

Representatives from the Joint Council of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; American Academy of Allergy, Asthma, and Immunology; American Lung Association; American Thoracic Society; National Asthma Educator Certification Board; American College of Chest Physicians; and Association of Asthma Educators gathered to write a standardized curriculum as a guideline for payer reimbursement.

METHODS

The Task Force began with a review of the American Lung Association and American Thoracic Society's Operational Standards for Asthma Education. Board members of the National Asthma Educator Certification Board incorporated comments, rationale, and references into the document.

RESULTS

This document is the result of final reviews of the standards completed by the Task Force and national health care professional organizations in September 2014.

CONCLUSION

This document meets the requirements of Current Procedural Terminology codes 98960 through 98962 and establishes the minimum standard for asthma self-management education when teaching patients or caregivers how to effectively manage asthma in conjunction with the professional health care team.

Evaluation of Diverse Community Asthma Interventions: Balancing Health Outcomes with Developing Community Capacity for Evidence-Based Program Measurement

The challenge of evaluating community asthma management programs is complicated by balancing the emphasis on health outcomes with the need to build community process capacity for conducting and monitoring evidence-based programs. The evaluation of a Georgia Childhood Asthma Management Program, a Healthcare Georgia Foundation-supported initiative for multiple diverse programs and settings, provides an example of an approach and the results that address this challenge. A "developmental evaluation" approach was applied, using mixed methods of quantitative and qualitative data collection and analysis, to assess the progress of community asthma prevention programs in building community within the context of: where the community is starting, community-level systems changes, and the community's progress toward becoming more outcome measurement oriented and evidence based. Initial evaluation efforts revealed extensive mobilization of community assets to manage childhood asthma. However, there were minimal planned efforts to assess health outcomes and systems changes, and the lack of a logic model-based program design linking evidence-based practices to outcomes. Following developmental technical assistance within evaluation efforts, all programs developed logic models, linking practices to outcomes with data collection processes to assess progress toward achieving the selected outcomes. This developmental approach across diverse projects and communities, along with a quality improvement benchmarking approach to outcomes, created a focus on health status outcome improvement. Specifically, this approach complemented an emphasis on an improved community process capacity to identify, implement, and monitor evidence-based asthma practices that could be used within each community setting.