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

The burden of systemic corticosteroid use in asthma management in Asia

For most patients, asthma can be effectively managed using inhaled medications. However, patients who have severe and/or uncontrolled asthma, or who experience exacerbations, may require systemic corticosteroids (SCSs) to maintain asthma control. Although SCS are highly effective in this regard, even modest exposure to these medications can increase the risk for long-term, adverse health outcomes, such as type 2 diabetes, renal impairment, cardiovascular disease and overall mortality. Clinical and real-world data from studies investigating asthma severity, control and treatment practices around the globe have suggested that SCS are overused in asthma management, adding to the already substantial healthcare burden experienced by patients. Throughout Asia, although data on asthma severity, control and SCS usage are limited and vary widely among countries, available data strongly suggest a pattern of overuse consistent with the broader global trend. Coordinated changes at the patient, provider, institutional and policy levels, such as increasing disease awareness, promoting better adherence to treatment guidelines and increasing availability of safe and effective alternatives to SCS, are likely necessary to reduce the SCS burden for patients with asthma in Asia.

Effect of asthma education on health outcomes in children: a systematic review

BACKGROUND

It remains unknown whether child-oriented asthma education is associated with better health outcomes. This meta-analysis investigated the effects of asthma education on hospitalisation and emergency department and clinic visits.

METHODS

We searched the Cochrane Library, PubMed and EMBASE for relevant studies from inception to 4 July 2021, and selected studies that reported hospitalisation or emergency department or clinic visits as outcomes. The participants were only children. Two authors independently selected the studies, assessed the quality of the included studies and retrieved the data. A third senior author was engaged to resolve disagreements. Fifteen longitudinal studies were included for the systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 was used as the standard of reporting (PRISMA registration ID is 284509).

FINDINGS

Compared with the control group, the asthma education group had 54% lower hospitalisation risk (95% CI 0.32 to 0.66), and 31% lower emergency department visit risk (95% CI 0.59 to 0.81). Sensitivity analysis showed that the asthma education group had a reduced clinic visit risk (risk ratio (RR)=0.80, 95% CI 0.67 to 0.97). Subgroup analysis showed that asthma education involving both children and parents/guardians was associated with fewer hospitalisations (RR=0.38, 95% CI 0.24 to 0.59) and emergency department visits (RR=0.69, 95% CI 0.57 to 0.83). Asthma education in hospitals or non-hospitals can reduce the risk of hospitalisation and emergency department visits. However, only education in the hospitals was associated with the reduction of clinical visits (RR=0.45, 95% CI 0.22 to 0.92).

INTERPRETATION

Education is effective for controlling asthma, especially for reducing hospitalisation and emergency department and clinic visits. Education involving both children and parents/guardians is more effective than that involving only children. The setting of asthma education does not impact its effect to a large extent.

A systematic review of the cost-effectiveness of medicationadherence-enhancing intervention for asthma

Objective: This systematic review aimed to evaluate the cost-effectiveness of medication adherence-improving interventions in patients with asthma.Data source: Search engines including PubMed, Scopus and EBSCOhost were used to locate relevant studies from the inception of the databases to 19 October 2018. Drummond's checklist was used to appraise the quality of the economic evaluation.Study selection: Economic studies evaluating the cost-effectiveness of medication adherence enhancing interventions for asthmatic patients were selected. Relevant information including study characteristics, quality assessment, health outcomes and costs of intervention were narratively summarized. The primary outcome of interest was cost-effectiveness (CE) values and the secondary outcomes were costs, medication adherence and clinical consequences.Results: Twenty studies including 11 randomized controlled trials, 6 comparative studies and 3 modeled studies using Markov models were included in the review. Among these, 15 studies evaluated an educational intervention with 13 showing cost-effectiveness in improving health outcomes. The CE of an internet-based intervention showed similar results between groups, while 3 studies of simplified drug regimens and adding a technology-based training program achieved the desirable cost-effectiveness outcome.Conclusion: Overall, our results would support that all of the identified medication adherence-enhancing interventions were cost-effective considering the increased adherence rate, improved clinical effectiveness and the reduced costs of asthma care. However, it was not possible to identify the most cost-effective intervention. More economic studies with sound methodological conduct will be needed to provide stronger evidence in deciding the best approach to improve medication adherence.

Return on investment of self-management education and home visits for children with asthma

OBJECTIVE

Priorities of the Centers for Disease Control and Prevention's 6|18 Initiative include outpatient asthma self-management education (ASME) and home-based asthma visits (home visit) as interventions for children with poorly-controlled asthma. ASME and home visit intervention programs are currently not widely available. This project was to assess the economic sustainability of these programs for state asthma control programs reimbursed by Medicaid.

METHODS

We used a simulation model based on parameters from the literature and Medicaid claims, controlling for regression to the mean. We modeled scenarios under various selection criteria based on healthcare utilization and age to forecast the return on investment (ROI) using data from New York. The resulting tool is available in Excel or Python.

RESULTS

Our model projected health improvement and cost savings for all simulated interventions. Compared against home visits alone, the simulated ASME alone intervention had a higher ROI for all healthcare utilization and age scenarios. Savings were primarily highest in simulated program participants who had two or more asthma-related emergency department visits or one inpatient visit compared to those participants who had one or more asthma-related emergency department visits. Segmenting the selection criteria by age did not significantly change the results.

CONCLUSIONS

This model forecasts reduced healthcare costs and improved health outcomes as a result of ASME and home visits for children with high urgent healthcare utilization (more than two emergency department visits or one inpatient hospitalization) for asthma. Utilizing specific selection criteria, state based asthma control programs can improve health and reduce healthcare costs.

A cost-effectiveness threshold analysis of a multidisciplinary structured educational intervention in pediatric asthma

OBJECTIVE

Asthma educational interventions have been shown to improve several clinically and economically important outcomes. However, these interventions are costly in themselves and could lead to even higher disease costs. A cost-effectiveness threshold analysis would be helpful in determining the threshold value of the cost of educational interventions, leading to these interventions being cost-effective. The aim of the present study was to perform a cost-effectiveness threshold analysis to determine the level at which the cost of a pediatric asthma educational intervention would be cost-effective and cost-saving.

METHODS

A Markov-type model was developed in order to estimate costs and health outcomes of a simulated cohort of pediatric patients with persistent asthma treated over a 12-month period. Effectiveness parameters were obtained from a single uncontrolled before-and-after study performed with Colombian asthmatic children. Cost data were obtained from official databases provided by the Colombian Ministry of Health. The main outcome was the variable "quality-adjusted life-years" (QALYs).

RESULTS

A deterministic threshold sensitivity analysis showed that the asthma educational intervention will be cost-saving to the health system if its cost is under US$513.20. Additionally, the analysis showed that the cost of the intervention would have to be below US$967.40 in order to be cost-effective.

CONCLUSIONS

This study identified the level at which the cost of a pediatric asthma educational intervention will be cost-effective and cost-saving for the health system in Colombia. Our findings could be a useful aid for decision makers in efficiently allocating limited resources when planning asthma educational interventions for pediatric patients.

Tailored Education to Increase Self-Efficacy for Caregivers of Children With Asthma: A Randomized Controlled Trial

We examined the efficacy of a tailored education program using touch-screen computers for caregivers of young children with asthma, aged 0 to 6 years. Fifty-three caregivers (mean age, 36.54 years; 51 mothers and two fathers) were recruited during typical visits to a national children's hospital. Caregivers were assigned randomly to 28 in the tailored education or 25 in the booklet education groups. The tailored education group received messages generated by a computer program, and the researchers provided them with counseling. The booklet education group only received an educational booklet. The primary outcome variable was parental self-efficacy and its subscales (ie, medication behavior, environmental behavior, barriers to self-management, and consultation behavior). The tailored education group showed an increase in barriers to management and asthma knowledge compared with the booklet education group. Over time, caregivers' quality of life improved significantly in both groups. Tailored education programs for caregivers of asthmatic children require further educational content modifications to match the learners' characteristics more closely. This study supports the notion that the development of patient education with tailored computer programs improves parental quality of life of asthma.

Economic Evidence for US Asthma Self-Management Education and Home-Based Interventions

The health and economic burden of asthma in the United States is substantial. Asthma self-management education (AS-ME) and home-based interventions for asthma can improve asthma control and prevent asthma exacerbations, and interest in health care-public health collaboration regarding asthma is increasing. However, outpatient AS-ME and home-based asthma intervention programs are not widely available; economic sustainability is a common concern. Thus, we conducted a narrative review of existing literature regarding economic outcomes of outpatient AS-ME and home-based intervention programs for asthma in the United States. We identified 9 outpatient AS-ME programs and 17 home-based intervention programs with return on investment (ROI) data. Most programs were associated with a positive ROI; a few programs observed positive ROIs only among selected populations (eg, higher health care utilization). Interpretation of existing data is limited by heterogeneous ROI calculations. Nevertheless, the literature suggests promise for sustainable opportunities to expand access to outpatient AS-ME and home-based asthma intervention programs in the United States. More definitive knowledge about how to maximize program benefit and sustainability could be gained through more controlled studies of specific populations and increased uniformity in economic assessments.

Asthma Patient Education

Patient education is a very important aspect of the treatment of asthma. Success of therapy is highly dependent upon patients' knowledge of asthma and the correct use of their medications. Over the last decade the morbidity and mortality rates due to asthma have increased. Education of patients is necessary to reduce these rates. Pharmacists can play a major role in the education of patients. Pharmacists are readily available and see most patients frequently for refills. Regular use of anti-inflammatory medications, use of β2-agonists for rescue therapy, and prevention of exercise induced asthma, and correct inhaler technique should be stressed. Spacer devices and peak flow meters should be routinely recommended by pharmacists. Educational aids such as handouts, pamphlets, and video tapes are available from many different organizations that can help make education more time efficient. Asthma education is a rewarding service to offer asthma patients and helps to develop loyalty as well as overall better health care for patients.

The Evolution of an Innovative Heart Disease Management Program for Older Women: Integrating Quantitative and Qualitative Methods in Practice

Few studies in the literature describe how to combine quantitative and qualitative methods to enhance the development of health education interventions. This article describes the evolution and refinement of an innovative disease management program “take PRIDE” for older adults with heart disease. Over 15 years, information obtained from data collection methods including telephone interviews, focus groups, face-to-face interviews, and program process data illuminated and guided subsequent refinement of the program and led to new iterations for different participants. Qualitative and quantitative data were incorporated into the two key areas of program development (theoretical framework, objectives, format, and content) and evaluation (evaluation design, sampling, and measurement). Combining both types of data enhanced the opportunity to detect needed program changes, to increase understanding of the mechanisms by which the program effects were produced, and to enhance the relevance of the program to different groups of program participants.

Self-Management of Chronic Disease by Older Adults

This article summarizes the literature describing the at-home management of and psychosocial coping with five chronic diseases (heart disease, asthma, chronic obstructive pulmonary disease, arthritis, and diabetes) by the general population of adults. It also reviews the literature describing self-management of these chronic diseases by older adults. Conclusions drawn subsequent to the review are (a) that there are strong commonalities in the essential nature of tasks that exist across disease entities, (b) that the context for self-management of disease by the ill elderly is likely to differ somewhat from the context for other age groups. Questions for future research are posed.

Innovations in health information technologies for chronic pulmonary diseases

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic obstructive lung disorders in the US that affect over 49 million people. There is no cure for asthma or COPD, but clinical guidelines exist for controlling symptoms that are successful in most patients that adhere to their treatment plan. Health information technologies (HITs) are revolutionizing healthcare by becoming mainstream tools to assist patients in self-monitoring and decision-making, and subsequently, driving a shift toward a care model increasingly centered on personal adoption and use of digital and web-based tools. While the number of chronic pulmonary disease HITs is rapidly increasing, most have not been validated as clinically effective tools for the management of disease. Online communities for asthma and COPD patients are becoming sources of empowerment and support, as well as facilitators of patient-centered research efforts. In addition to empowering patients and facilitating disease self-management, HITs offer promise to aid researchers in identifying chronic pulmonary disease endotypes and personalized treatments based on patient-specific profiles that integrate symptom occurrence and medication usage with environmental and genomic data.

Developing Asthma-Friendly Childcare Centers with Online Training and Evaluation

In 2011, the Florida Asthma Coalition (FAC) began offering its Asthma-Friendly Childcare Center (AFCC) training online. This course teaches childcare center employees the fundamentals of effective asthma management. It covers basic asthma physiology, ways to recognize asthma attacks, techniques to help children experiencing attacks, and strategies to create healthy environments for asthmatics. A team of health services researchers evaluated both years of the online training. Evaluators used a quasi-experimental design with pretest, posttest, and follow-up assessment. Questions measured knowledge gain and retention, user satisfaction, and implementation of management strategies. Over 650 people from nearly all 67 Florida counties took AFCC training online between 2011 and 2013. Test scores improved by a minimum of 11% points in all program years evaluated. Gains in both knowledge and confidence were substantial and highly significant across years. While individual trainees did forget some content on follow-up, they seemed to retain the specific messages most relevant for their own workplaces. Most trainees also planned to implement multiple management strategies recommended by the training. A large majority of participants rated the training as excellent on all quality metrics, including relevance of content and time efficiency of the online format. Nearly all respondents perceived the training as useful for both providing improved care and fulfilling licensure or certification requirements. Many participants also indicated that their centers would pursue formal certification as AFCCs via the program offered by FAC. The online AFCC course performed strongly in its first years, yielding both high participant satisfaction and substantial improvement in workplace asthma management activity. This training holds promise for introducing and improving multidimensional asthma management strategies at childcare facilities nationwide.

Asthma 101 for Schools: Successes and Challenges in Transitioning to Online Delivery

Florida Asthma Program staff worked with evaluators from the Florida State University College of Medicine to assess participation and quality of the American Lung Association’s Asthma 101 asthma management education program for school faculty and staff between 2011 and 2014. This included transitioning the program to an online training format for the 2013–2014 school year. Asthma 101 helps school personnel master the basics of asthma physiology and management, with content tailored specifically for elementary and secondary educational settings. The program is assessed with questionnaires at multiple timepoints, yielding a quasi-experimental evaluation design. Evaluators reviewed quantitative data from pretests and qualitative and quantitative data from post-program satisfaction questionnaires. Program spreadsheets listing the dates for delivery and number of attendees were also reviewed. Overall, evaluation findings were positive. In the 2011–2012 program year, 16 different course sessions were offered, and more than half of enrolled participants came from Title I schools. A total of 228 people were trained. In the 2012–2013 program year, 19 different course sessions were offered. Enrollment totals (638) and matching pre- and posttest totals (562) soundly exceeded the target metric of 425. At least 170 (27%) of a total of 638 participants could be verified as coming from the target demographic of Title I school faculty and staff. In the 2013–2014 program year, the course was offered online on a rolling basis via the Florida TRAIN course management system. Enrollment remained high and learner outcomes remained consistently strong across all content areas for knowledge and satisfaction. A total of 406 people participated in the training; complete pre- and posttest data were available for 341 of these individuals; and satisfaction data were available for 325. Of the 406 trainees, 199 (49%) reported working for Title I schools. Evaluation yielded very positive results. An overwhelming majority of participants reported finding the course consistently strong across the board and highly impactful for their own ability to help students manage their asthma effectively. Most participants also reported that they would change/improve their asthma management behaviors in the workplace. Recommendations were developed to help expand future program reach.

Using indirect comparisons to compare interventions within a Cochrane review: a tool for comparative effectiveness research

AIM

Assessing relative performance among competing interventions is an important part of comparative effectiveness research. Bayesian indirect comparisons add information to existing Cochrane reviews, such as which intervention is likely to perform best. However, heterogeneity variance priors may influence results and, potentially, clinical guidance.

METHODS

We highlight the features of Bayesian indirect comparisons using a case study of a Cochrane review update in asthma care. The probability that one self-management educational intervention outperforms others is estimated. Simulation studies investigate the effect of heterogeneity variance prior distributions.

RESULTS

Results suggest a 55% probability that individual education is best, followed by combination (39%) and group (6%). The intervention with few trials was sensitive to prior distributions.

CONCLUSION

Bayesian indirect comparisons updates of Cochrane reviews are valuable comparative effectiveness research tools.

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.

Development of online diary and self-management system on e-Healthcare for asthmatic children in Taiwan

OBJECTIVE

Many regional programs of the countries educate asthmatic children and their families to manage healthcare data. This study aims to establish a Web-based self-management system, eAsthmaCare, to promote the electronic healthcare (e-Healthcare) services for the asthmatic children in Taiwan. The platform can perform real time online functionality based upon a five-tier infrastructure with mutually supportive components to acquire asthma diaries, quality of life assessments and health educations.

METHODS

We have designed five multi-disciplinary portions on the interactive interface functioned with the analytical diagrams: (1) online asthma diary, (2) remote asthma assessment, (3) instantaneous asthma alert, (4) diagrammatical clinic support, and (5) asthma health education. The Internet-based asthma diary and assessment program was developed for patients to process self-management healthcare at home. In addition, the online analytical charts can help healthcare professionals to evaluate multi-domain health information of patients immediately.

RESULTS

eAsthmaCare was developed by Java™ Servlet/JSP technology upon Apache Tomcat™ web server and Oracle™ database. Forty-one voluntary asthmatic children (and their parents) were intervened to examine the proposed system. Seven domains of satisfiability assessment by using the system were applied for approving the development. The average scores were scaled in the acceptable range for each domain to ensure feasibility of the proposed system.

CONCLUSION

The study revealed the details of system infrastructure and developed functions that can help asthmatic children in self-management for healthcare to enhance communications between patients and hospital professionals.

Examining household asthma management behavior through a microeconomic framework

National guidelines on the effective management of pediatric asthma have been promoted for over 20 years, yet asthma-related morbidity among low-income children remains disproportionately high. To date, household and clinical interventions designed to remediate these differences have been informed largely by a health behavior framework. However, these programs have not resulted in consistent sustained improvements in targeted populations. The continued funding and implementation of programs based on the health behavior framework leads us to question if traditional behavioral models are sufficient to understand and promote adaptation of positive health management behaviors. We introduce the application of the microeconomic framework to investigate potential mechanisms that can lead to positive management behaviors to improve asthma-related morbidity. We provide examples from the literature on health production, preferences, trade-offs and time horizons to illustrate how economic constructs can potentially add to understanding of disease management. The economic framework, which can be empirically observed, tested, and quantified, can explicate the engagement in household-level activities that would affect health and well-being. The inclusion of a microeconomic perspective in intervention research may lead to identification of mechanisms that lead to household decisions with regard to asthma management strategies and behavior. The inclusion of the microeconomic framework to understand the production of health may provide a novel theoretical framework to investigate the underlying causal behavioral mechanisms related to asthma management and control. Adaptation of an economic perspective may provide new insight into the design and implementation of interventions to improve asthma-related morbidity in susceptible populations.

Cost-effectiveness of the School-Based Asthma Therapy (SBAT) program

BACKGROUND AND OBJECTIVE

Impoverished urban children suffer disproportionately from asthma and underuse preventive asthma medications. The objective of this study was to examine cost-effectiveness (CE) of the School-Based Asthma Therapy (SBAT) program compared with usual care (UC).

METHODS

The analysis was based on the SBAT trial, including 525 children aged 3 to 10 years attending urban preschool or elementary school who were randomized to either UC or administration of 1 dose of preventive asthma medication at school by the school nurse each school day. The primary outcome was the mean number of symptom-free days (SFDs). The impact of the intervention on medical costs was estimated by using parent-reported child health services utilization data and average national reimbursement rates. We estimated the cost of running the program using wages for program staff. Productivity costs were estimated by using value of parent lost time due to child illness. CE of the SBAT program compared with UC was evaluated based on the incremental CE ratio.

RESULTS

The health benefit of the intervention was equal to ∼158 SFD gained per each 30-day period (P < .05) per 100 children. The programmatic expenses summed to an extra $4822 per 100 children per month. The net saving due to the intervention (reduction in medical costs and parental productivity, and improvement in school attendance) was $3240, resulting in the incremental cost-savings difference of $1583 and CE of $10 per 1 extra SFD gained.

CONCLUSIONS

The SBAT was effective and cost-effective in reducing symptoms in urban children with asthma compared with other existing programs.

The Effect of Educational and Modifying Intervention on Asthma Control among Adolescents: a Randomized Clinical Trial

INTRODUCTION

Controlling over allergens and environmental irritants is one of the essential elements of controlling asthma. Asthma control in adolescents is a challenge. The current study was performed with the goal of investigating the effect of an educational and modifying intervention about asthma triggers on asthma control among adolescents.

METHODS

The current study was a randomized clinical trial. 60 adolescents of 12-18 years of age participated in this study. The participants were randomly divided into the two control and experimental groups. The Juniper's Asthma Control Questionnaire was completed by the adolescents before and 5 weeks after the intervention. Training sessions, planning for modification of asthma triggers and telephone follow-up were performed in the experimental group.

RESULTS

There was a significant difference between the asthma control score before and after the intervention in the control and experimental groups. The asthma control status improved in the experimental group. In other words, the educational interventions to modify asthma triggers were effective in improving asthma control.

CONCLUSION

Since this intervention method can improve the asthma control in adolescents, it is recommended that adolescents directly participate in such programs about asthma triggers and the education become less parent-centred. Moreover, the necessity of such an intervention in clinics and outpatient clinics is emphasized.

Outcomes associated with a negotiated asthma treatment plan

Negotiated treatment plans are increasingly recommended in asthma clinical care. However, limited data are available to indicate whether this more patient-engaged process results in improved health outcomes. The aim of this study was to determine the associations between the presence of a negotiated treatment plan and the outcomes related to adherence to the medical regimen, symptom control, and health care use. The focus of the study was on women, the subgroup of adult patients, who are most vulnerable for negative asthma outcomes. Data were collected by telephone interview and medical record review from 808 women diagnosed with asthma at baseline, first year, and second year follow-up. Associations were examined between the presence of a negotiated treatment plan at baseline and subsequent asthma outcomes. Women with a negotiated treatment plan reported more adherent to prescribed asthma medicines (odds ratio (OR) = 2.41, 95% confidence interval (CI) = (1.82, 3.19)) and those with a plan and using oral steroids at baseline had less oral steroid use at follow-up (OR = 0.21, 95% CI = (0.05, 0.93)). Women with a negotiated plan also had more days (17%, 95% CI = (8, 27)) and nights (31%, 95% CI = (16, 48)) with symptoms than those without such a plan. No differences in hospitalizations, emergency department visits, or urgent physician office visits were noted between the groups. Patients with higher education levels were more likely to have a negotiated treatment plan. Negotiated treatment plans appear to have achieved greater adherence to prescribed asthma medicines and less need for oral steroids but were not related to fewer symptoms of asthma or reductions in urgent health care use. Additional strategies may be needed to reduce symptom and health services utilization outcomes.

Translating evidence-based interventions into practice: the design and development of the Merck Childhood Asthma Network, Inc. (MCAN)

Pediatric asthma is a multifactorial disease, requiring complex, interrelated interventions addressing children, families, schools, and communities. The Merck Childhood Asthma Network, Inc. (MCAN) is a nonprofit organization that provides support to translate evidence-based interventions from research to practice. MCAN developed the rationale and vision for the program through a phased approach, including an extensive literature review, stakeholder engagement, and evaluation of funding gaps. The analysis pointed to the need to identify pediatric asthma interventions implemented in urban U.S. settings that have demonstrated efficacy and materials for replication and to translate the interventions into wider practice. In addition to this overall MCAN objective, specific goals included service and system integration through linkages among health care providers, schools, community-based organizations, patients, parents, and other caregivers. MCAN selected sites based on demonstrated ability to implement effective interventions and to address multiple contexts of pediatric asthma prevention and management. Selected MCAN program sites were mature institutions or organizations with significant infrastructure, existing funding, and the ability to provide services without requiring a lengthy planning period. Program sites were located in communities with high asthma morbidity and intended to integrate new elements into existing programs to create comprehensive care approaches.

Home-based educational interventions for children with asthma

BACKGROUND

While guidelines recommend that children with asthma should receive asthma education, it is not known if education delivered in the home is superior to usual care or the same education delivered elsewhere. The home setting allows educators to reach populations (such as the economically disadvantaged) that may experience barriers to care (such as lack of transportation) within a familiar environment.

OBJECTIVES

To perform a systematic review on educational interventions for asthma delivered in the home to children, caregivers or both, and to determine the effects of such interventions on asthma-related health outcomes. We also planned to make the education interventions accessible to readers by summarising the content and components.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register of trials, which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearched respiratory journals and meeting abstracts. We also searched the Education Resources Information Center database (ERIC), reference lists of trials and review articles (last search January 2011).

SELECTION CRITERIA

We included randomised controlled trials of asthma education delivered in the home to children, their caregivers or both. In the first comparison, eligible control groups were provided usual care or the same education delivered outside of the home. For the second comparison, control groups received a less intensive educational intervention delivered in the home.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, assessed trial quality and extracted the data. We contacted study authors for additional information. We pooled dichotomous data with fixed-effect odds ratio and continuous data with mean difference (MD) using a fixed-effect where possible.

MAIN RESULTS

A total of 12 studies involving 2342 children were included. Eleven out of 12 trials were conducted in North America, within urban or suburban settings involving vulnerable populations. The studies were overall of good methodological quality. They differed markedly in terms of age, severity of asthma, context and content of the educational intervention leading to substantial clinical heterogeneity. Due to this clinical heterogeneity, we did not pool results for our primary outcome, the number of patients with exacerbations requiring emergency department (ED) visit. The mean number of exacerbations requiring ED visits per person at six months was not significantly different between the home-based intervention and control groups (N = 2 studies; MD 0.04; 95% confidence interval (CI) -0.20 to 0.27). Only one trial contributed to our other primary outcome, exacerbations requiring a course of oral corticosteroids. Hospital admissions also demonstrated wide variation between trials with significant changes in some trials in both directions. Quality of life improved in both education and control groups over time.A table summarising some of the key components of the education programmes is included in the review.

AUTHORS' CONCLUSIONS

We found inconsistent evidence for home-based asthma educational interventions compared to standard care, education delivered outside of the home or a less intensive educational intervention delivered at home. Although education remains a key component of managing asthma in children, advocated in numerous guidelines, this review does not contribute further information on the fundamental content and optimum setting for such educational interventions.

WITHDRAWN: 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 January 2007. 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. An update search carried out in January 2007 did not identify any new studies for inclusion.

AUTHORS' 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.

Promoting best-care practices in childhood asthma: quality improvement in community health centers

OBJECTIVE

Outpatient asthma management remains suboptimal. We previously reported significant improvements in asthma guideline adherence and outcomes in children by using quality-improvement processes and community health workers. We hypothesized that a larger project could achieve comparable outcome improvements with streamlined quality-improvement processes and decreased technical assistance.

METHODS

Seventeen clinics treating 12 000 children with asthma were evaluated through interviews of a subset of patients with persistent or high-risk asthma (n=761) at baseline and at 12 and 21 months and chart reviews randomly selected from all patients with asthma at baseline and 12 and 24 months (n=2040). Multidisciplinary teams developed data-driven continuous quality-improvement activities. Asthma coordinators provided patient education and were active team members.

RESULTS

Study children were predominantly Hispanic (77%) and black (11%); 60% were enrolled in Medicaid, and 9% were uninsured. Comparing results between baseline and the 21-month follow-up, significantly fewer families reported emergency-department visits (29.6% vs 9.3%), hospitalizations (10.9% vs 3.4%), frequent daytime symptoms (44.0% vs 11.7%), and missed school days (28.7% vs 13.6%); significantly more reported confidence in asthma management (70.6% vs 95.5%); and quality-of-life scores increased significantly for both children and caregivers (all P<.05). Cross-sectional data revealed significant clinic-wide improvements in symptom documentation, health care use, and review of action plans.

CONCLUSIONS

On a larger scale, this approach realized impressive changes in provider clinical practice associated with major improvements in health outcomes. It holds great potential for significantly reducing asthma-related morbidity among low-income children.

Characteristics of successful asthma programs

OBJECTIVE

We identified characteristics of interventions associated with positive asthma outcomes to understand how programs can be improved.

METHODS

We identified asthma interventions from the peer-reviewed literature or through a nomination process for unpublished programs. Initially, we identified 532 interventions. Of those, 223 met our eligibility criteria (e.g., focus on asthma, completed an evaluation, and demonstrated at least one asthma-related health outcome) and provided information on program components and processes, administration, evaluation, and findings through telephone interviews, program documents, and published reports. We analyzed bivariate relationships between programmatic factors and outcomes using Chi-square statistics, Fisher's exact tests, and unconditional logistic regression. We confirmed findings for all programs by analyzing the subset with published results in peer-reviewed journals.

RESULTS

Our findings indicated that programs were more likely to report a positive impact on health outcomes if they (1) were community based, (2) engaged the participation of community-based organizations, (3) provided program components in a clinical setting, (4) provided asthma training to health-care providers, (5) collaborated with other organizations and institutions and with government agencies, (6) designed a program for a specific racial/ethnic group, (7) tailored content or delivery based on individual health or educational needs, and (8) conducted environmental assessments and tailored interventions based on these assessments.

CONCLUSIONS

Positive asthma outcomes were associated with specific program characteristics: being community centered, clinically connected, and continuously collaborative. Program developers and implementers who build these characteristics into their interventions will be more likely to realize desired asthma outcomes.

The Impact of Childhood Asthma on Parental Quality of Life

Measuring the quality of life of caregivers is important for interventions designed for young children with asthma. However, little is known about the impact of childhood asthma on parental quality of life for certain subgroups. This study included the families of young urban children with mild persistent to severe persistent asthma. The goal was to evaluate the relationship between caregivers' quality of life and the children's asthma severity, and to consider the influence of sociodemographic factors on the caregivers' quality of life. Children age 3-7 years (63% male, 59% Black, 75% Medicaid), with mild persistent to severe persistent asthma, were identified from a school-based screening survey. Caregiver quality of life was assessed at baseline and at the end of the study using the Paediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ). Pearson correlation coefficients were used to assess the relationship between the PACQLQ and parent-reported asthma symptoms during the same time period. For all measures of severity, there was a significant correlation with quality of life (range r=0.23-0.51, all p<.01). Improvements in the PACQLQ correlated with decreases in symptom scores including symptom days (r=-0.27, p<.001) and symptom nights (r=-0.22, p=.005). In a multivariate model, Hispanic ethnicity, the use of daily maintenance medications, and exposure to secondhand smoke independently predicted worse quality of life scores. We conclude that the caretaker's quality of life, as assessed by the PACQLQ, is directly influenced by the child's asthma severity as well as other family factors among a group of young urban children with significant asthma.

[Economic cost of treating the patient with asthma in Spain: the AsmaCost study]

OBJECTIVE

This analysis of the cost of asthma in Spain includes both direct health care costs and indirect costs arising from illness.

PATIENTS AND METHODS

Prospective, 12-month observational cohort study of adult patients with asthma diagnosed according to the guidelines of the Global Initiative for Asthma (GINA) and the adapted Spanish criteria (GEMA). We recorded information on health care resources utilized (medications, medical visits, emergency care, hospital admissions, and tests) and indirect costs (patient travel or transfer costs and workdays lost).

RESULTS

A total of 627 patients throughout Spain were studied. Of these, 21.2% had intermittent asthma, 24.6% mild asthma, 27.6% moderate asthma, and 26.6% severe asthma. The total societal cost of asthma (including indirect costs) was euro1726 (95% confidence interval [CI], euro1314-euro2154) per patient annually. Indirect costs accounted for 11.2% of the total. The cost to the National Health Service was euro1533 (95% CI, euro1133-euro1946) per patient annually. The cost of asthma was higher for patients older than 65 years (euro2079) and for those with more severe disease (euro959 for intermittent asthma; euro1598, mild asthma; euro1553, moderate asthma; and euro2635 severe asthma). Based on these findings, the total annual cost of asthma in Spain is estimated to be euro1480 million (95% CI, euro382-euro2565 million) for patients with demonstrated bronchial hyperreactivity and euro3022 million (95% CI, euro2472-euro3535 million) for patients diagnosed based on symptoms alone.

CONCLUSIONS

The average annual cost of asthma in adults in Spain comes to euro1726 per patient, considering both direct and indirect costs. The average annual cost per patient to the National Health Service is euro1533.

Interventions for educating children who are at risk of asthma-related emergency department attendance

BACKGROUND

Asthma is the most common chronic childhood illness and is a leading cause for paediatric admission to hospital. Asthma management for children results in substantial costs. There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management.

OBJECTIVES

To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trials Register, including the MEDLINE, EMBASE and CINAHL databases, and reference lists of trials and review articles (last search May 2008).

SELECTION CRITERIA

We included randomised controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We pooled dichotomous data with a fixed-effect risk ratio. We used a random-effects risk ratio for sensitivity analysis of heterogenous data.

MAIN RESULTS

A total of 38 studies involving 7843 children were included. Following educational intervention delivered to children, their parents or both, there was a significantly reduced risk of subsequent emergency department visits (RR 0.73, 95% CI 0.65 to 0.81, N = 3008) and hospital admissions (RR 0.79, 95% CI 0.69 to 0.92, N = 4019) compared with control. There were also fewer unscheduled doctor visits (RR 0.68, 95% CI 0.57 to 0.81, N = 1009). Very few data were available for other outcomes (FEV1, PEF, rescue medication use, quality of life or symptoms) and there was no statistically significant difference between education and control.

AUTHORS' CONCLUSIONS

Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.

A randomized controlled trial of asthma self-management support comparing clinic-based nurses and in-home community health workers: the Seattle-King County Healthy Homes II Project

OBJECTIVE

To compare the marginal benefit of in-home asthma self-management support provided by community health workers (CHWs) with standard asthma education from clinic-based nurses.

DESIGN

Randomized controlled trial.

SETTING

Community and public health clinics and homes.

PARTICIPANTS

Three hundred nine children aged 3 to 13 years with asthma living in low-income households.

INTERVENTIONS

All participants received nurse-provided asthma education and referrals to community resources. Some participants also received CHW-provided home environmental assessments, asthma education, social support, and asthma-control resources.

OUTCOME MEASURES

Asthma symptom-free days, Pediatric Asthma Caretaker Quality of Life Scale score, and use of urgent health services.

RESULTS

Both groups showed significant increases in caretaker quality of life (nurse-only group: 0.4 points; 95% confidence interval [CI], 0.3-0.6; nurse + CHW group: 0.6 points; 95% CI, 0.4-0.8) and number of symptom-free days (nurse only: 1.3 days; 95% CI, 0.5-2.1; nurse + CHW: 1.9 days; 95% CI, 1.1-2.8), and absolute decreases in the proportion of children who used urgent health services in the prior 3 months (nurse only: 17.6%; 95% CI, 8.1%-27.2%; nurse + CHW: 23.1%; 95% CI, 13.6%-32.6%). Quality of life improved by 0.22 more points in the nurse + CHW group (95% CI, 0.00-0.44; P = .049). The number of symptom-free days increased by 0.94 days per 2 weeks (95% CI, 0.02-1.86; P = .046), or 24.4 days per year, in the nurse + CHW group. While use of urgent health services decreased more in the nurse + CHW group, the difference between groups was not significant.

CONCLUSION

The addition of CHW home visits to clinic-based asthma education yielded a clinically important increase in symptom-free days and a modest improvement in caretaker quality of life.

Relapse after emergency department discharge for acute asthma

OBJECTIVES

The objectives were to determine patient and treatment-response factors associated with relapse after emergency department (ED) treatment for acute asthma.

METHODS

Subjects aged 18-55 years who were treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview and telephone contact 2 weeks later.

RESULTS

Of 695 enrolled patients, 604 (86.9%) were discharged from the ED; follow-up was available in 529 (87.5%); 63% were female and the median age was 29 years. Most patients were discharged on oral (70.8%) and inhaled (60.1%) corticosteroids (CS); 2-week treatment adherences were 93.3 and 80.9%, respectively. Relapse occurred in 9.2% at 1 week (95% confidence interval [CI] = 7.1% to 12.0%) and 13.9% (95% CI = 11% to 17%) at 2 weeks. In multivariable modeling, factors associated with relapse were ethnicity (risk ratio [RR] white = 0.66; 95% CI = 0.52 to 0.83); female gender (RR = 1.57; 95% CI = 1.14 to 2.09); any ED visits in the past 2 years (RR = 1.47; 95% CI = 1.18 to 1.80); ever admitted for asthma treatment (RR = 1.83; 95% CI = 1.09 to 2.84); use of combined inhaled CS plus long-acting beta(2)-agonists (RR = 1.39; 95% CI = 1.07 to 1.78) and of oral CS (RR = 1.35; 95% CI = 1.12 to 1.59) at the time of ED presentation.

CONCLUSIONS

Ethnicity (white), female gender, prior ED visits and admissions for asthma, and recent treatments (especially oral CS) were associated with asthma relapse, which remains relatively common. Future research is required to target this high-risk group.

Effects of asthma education on children's use of acute care services: a meta-analysis

OBJECTIVE

National Heart, Lung, and Blood Institute clinical practice guidelines strongly recommend that health professionals educate children with asthma and their caregivers about self-management. We conducted a meta-analysis to estimate the effects of pediatric asthma education on hospitalizations, emergency department visits, and urgent physician visits for asthma.

PATIENTS AND METHODS

Inclusion criteria included enrollment of children aged 2 to 17 years with a clinical diagnosis of asthma who resided in the United States. Pooled standardized mean differences and pooled odds ratios were calculated. Random-effects models were estimated for all outcomes assessed.

RESULTS

Of the 208 studies identified and screened, 37 met the inclusion criteria. Twenty-seven compared educational interventions to usual care, and 10 compared different interventions. Among studies that compared asthma education to usual care, education was associated with statistically significant decreases in mean hospitalizations and mean emergency department visits and a trend toward lower odds of an emergency department visit. Education did not affect the odds of hospitalization or the mean number of urgent physician visits. Findings from studies that compared different types of asthma education interventions suggest that providing more sessions and more opportunities for interactive learning may produce better outcomes.

CONCLUSIONS

Providing pediatric asthma education reduces mean number of hospitalizations and emergency department visits and the odds of an emergency department visit for asthma, but not the odds of hospitalization or mean number of urgent physician visits. Health plans should invest in pediatric asthma education or provide health professionals with incentives to furnish such education. Additional research is needed to determine the most important components of interventions and compare the cost-effectiveness of different interventions.

Improving asthma-related health outcomes among low-income, multiethnic, school-aged children: results of a demonstration project that combined continuous quality improvement and community health worker strategies

OBJECTIVE

The purpose of this work was to improve asthma-related health outcomes in an ethnically and geographically disparate population of economically disadvantaged school-aged children by using a team-based approach using continuous quality improvement and community health workers.

PATIENTS AND METHODS

A demonstration project was conducted with 7 community clinics treating approximately 3000 children with asthma 5 to 18 years of age. The overall clinic population with asthma was assessed for care-process changes through random cross-sectional chart reviews at baseline and 24 months (N = 560). A subset of patients with either moderate or severe persistent asthma or poorly controlled asthma (N = 405) was followed longitudinally for specific asthma-related clinical outcomes, satisfaction with care, and confidence managing asthma by family interview at baseline and at 12 or 24 months. Patient-centered and care-process outcomes included patient/parent assessment of quality of care and confidence in self-management, asthma action plan review, and documentation of guideline-based indicators of quality of care. Direct clinical outcomes included daytime and nighttime symptoms, use of rescue medications, acute care and emergency department visits, hospitalizations, and missed school days. Each clinic site's degree of adherence to the intervention model was evaluated and ranked to examine the correlation between model adherence and outcomes.

RESULTS

Cross-sectional data showed clinic-wide improvements in the documentation of asthma severity, review of action plans, health services use, and asthma symptoms. At follow-up in the longitudinal sample, fewer patients reported acute visits, emergency department visits, hospitalizations, frequent daytime and nighttime symptoms, and missed school days compared with baseline. More patients reported excellent or very good quality of care and confidence in asthma self-management. Linear regression analysis of the clinical sites' model adherence ranks against site-level combined scores estimating overall outcomes, clinical outcomes, and improvements in clinical care processes showed significant linear correlations with R2 > or = 0.60.

CONCLUSIONS

The demonstration produced major improvements in asthma-related care processes and clinical outcomes. Closer adherence to the demonstration model was directly associated with better outcomes.

An internet-based interactive telemonitoring system for improving childhood asthma outcomes in Taiwan

A randomized, controlled trial was conducted to assess the effectiveness of Blue Angel for Asthma Kids, an Internet-based interactive asthma educational and monitoring program, used in the management of asthmatic children. One hundred sixty-four (n = 164) pediatric patients with persistent asthma were enrolled and randomized into two study groups for a 12-week controlled trial. The intervention group had 88 participants who were taught to monitor their peak expiratory flows (PEF) and asthma symptoms daily on the Internet. They also received an interactive response consisting of a self-management plan from the Blue Angel monitoring program. The control group had 76 participants who received a traditional asthma care plan consisting of a written asthma diary supplemented with instructions for self-management. Disease control was assessed by weekly averaged PEF values, symptom scores, and asthma control tests. Adherence measures were assessed by therapeutic and diagnostic monitoring. Outcome was assessed by examining quality of life and retention of asthma knowledge. The data were analyzed by comparing results before and after the trial. At the end of trial, the intervention group decreased nighttime (-0.08 +/- 0.33 vs. 0.00 +/- 0.20, p = 0.028) and daytime symptoms (-0.08 +/- 0.33 vs. 0.01 +/- 0.18, p =0.009); improved morning (241.9 +/- 81.4 vs. 223.1 +/- 55.5, p =0.017) and night PEF (255.6 +/- 86.7 vs. 232.5 +/- 55.3, p =0.010); increased adherence rates (p < 0.05); improved well-controlled rates (70.4% vs. 55.3%, p < 0.05); improved knowledge regarding self-management (93.2% vs. 70.3%, p < 0.05); and improved quality of life (6.5 +/- 0.5 vs. 4.3 +/- 1.2 on a 7-point scale, p < 0.05) when compared with conventional management. The Internet-based asthma telemonitoring program increases selfmanagement skills, improves asthma outcomes, and appears to be an effective and well-accepted technology for the care of children with asthma and their caregivers.

A library-site asthma education program for inner-city communities

Asthma education programs are reportedly effective for children and adolescents. Urban and minority children continue to have poor asthma outcomes and limited access to asthma education programs. The purpose of this study was to determine whether a library-based asthma education program, the Columbus Ohio Partnership for Inner-City Asthma Education (COPICAE), offered to urban and minority children (with their parents) could improve asthma-related outcomes and reduce billing claims for asthma-related hospital visits. A prospective/observational study was conducted to evaluate asthma-related outcomes of 87 children who completed 6 hours of asthma education using telephone follow-up at 12 and 24 months with a scored Living With Asthma Survey (LWAS). Hospital billing claims for asthma as the primary diagnosis were compared over a 24-month period for 64 children who completed 6 hours of asthma education with an age and zip code match control. Two separate focus groups with Spanish-speaking and English-speaking parents who completed 6 hours of asthma education with their children obtained parental perspectives about the asthma education classes. LWAS follow-up data were obtained on 67% of the participants at year 1 and 43% at year 2. Compared to pre-intervention mean scores, there were decreases in scores to all LWAS items. Parents reported improvements in compliance with asthma medication use and overall control of their child's asthma. Parents also found the information from the asthma education classes to be "beneficial." Total asthma-related billing claims for children who completed 6 hours of asthma education decreased 63.2%, while those for age and zip code matched controls increased 0.7%. Inner-city and minority children (with their parents) who attended 6 hours of asthma education offered in a public library showed improvements in asthma-related outcomes over a 24-month period and decreased billing claims for asthma-related hospital visits. Parents found 6 hours of asthma education to be beneficial in gaining basic knowledge about asthma and improving their child's illness control and self-esteem in living with asthma.

Impact of asthma education received from health care providers on parental illness representation in childhood asthma

The burden of asthma has increased dramatically despite increased understanding of asthma and new medication regimens. Data reported here are part of a larger study investigating factors that influence parental asthma illness representation and the impact of this representation on treatment outcomes, including the parent/health care provider relationship. We investigated the influence of asthma related education provided by health care providers on these outcomes. After interviewing 228 parents of children with asthma, we found that asthma education received from the child's health care providers positively influenced parental belief systems, especially attitudes towards anti-inflammatory medications and facts about asthma. Parents who reported receiving more education also reported stronger partnerships with their child's health care provider.

Addressing asthma in Texas: development of a school-based asthma surveillance program for Texas elementary schools

To address asthma in the state, in October 2000, the Texas Department of State Health Services (DSHS) and the American Lung Association of Texas held a joint meeting of asthma professionals from across the state, with a primary purpose of identifying major issues and potential strategies and actions to be taken. These discussions became the basis of the 2001 Texas State Asthma Plan, which has since been adopted to guide state efforts in asthma surveillance, management, education, and advocacy. The primary purpose of this project, which was conducted with and funded by the DSHS and the Centers for Disease Control and Prevention, has been to develop and implement an asthma surveillance program for Texas school-aged children. The program has been implemented with a sample (n = 42,409) of students from the Texas Education Agency's region IV. An important goal has been to determine the feasibility of conducting school-based statewide asthma surveillance and assist with establishing a network for ongoing, systematic collection, analysis, interpretation, and dissemination of asthma data. This project is expected to become part of a wider asthma surveillance network that will include mortality, hospital discharge, and Behavioral Risk Factor Surveillance System (BRFSS) data. It will also provide information not typically captured by surveillance programs, including the BRFSS, which rely heavily upon a previous diagnosis of asthma to determine both lifetime and current prevalence of asthma. Results from this project indicate that such reliance on a previous diagnosis may considerably underestimate the prevalence of disease-particularly in the Latino population

Written action plans for asthma in children

BACKGROUND

While all asthma consensus statements recommend the use of written action plan (WAP) as a central part of asthma management, a recent systematic review of randomised trials highlighted the paucity of trials where the only difference between groups was the provision or not of a written action plan.

OBJECTIVES

The objectives of this review were firstly to evaluate the independent effect of providing versus not providing a written action plan in children and adolescents with asthma, and secondly to compare the effect of different written action plans.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register (November 2004), which is derived from searches of CENTRAL, MEDLINE, EMBASE, CINAHL, as well as handsearched respiratory journals, and meeting abstracts. We also searched bibliographies of included studies and identified review articles.

SELECTION CRITERIA

Randomised controlled trials were included if they compared a written action plan with no written action plan, or different written action plans with each other.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, assessed trial quality and extracted the data. Study authors were contacted for additional information.

MAIN RESULTS

Four trials (three RCTs and one quasi-RCT) involving 355 children were included. Children using symptom-based WAPs had lower risk of exacerbations which required an acute care visit (N = 5; RR 0.73; 95% CI 0.55 to 0.99). The number needed to treat to prevent one acute care visit was 9 (95% CI 5 to 138). Symptom monitoring was preferred over peak flow monitoring by children (N = 2; RR 1.21; 95% CI 1.00 to 1.46), but parents showed no preference (N = 2; RR 0.96; 95% CI 0.18 to 2.11). Children assigned to peak flow-based action plans reduced by 1/2 day the number of symptomatic days per week (N = 2; mean difference: 0.45 days/week; 95% CI 0.04 to 0.26). There were no significant group differences in the rate of exacerbation requiring oral steroids or admission, school absenteeism, lung function, symptom score, quality of life, and withdrawals.

AUTHORS' CONCLUSIONS

The evidence suggests that symptom-based WAP are superior to peak flow WAP for preventing acute care visits although there is insufficient data to firmly conclude whether the observed superiority is conferred by greater adherence to the monitoring strategy, earlier identification of onset of deteriorations, higher threshold for presentation to acute care settings, or the specific treatment recommendations.

Asthma management practices among children in Georgia

BACKGROUND

Asthma self-management, the involvement of patients or their caregivers in the management of their disease, reduces healthcare visits and costs. We assessed selected asthma self-management practices among a representative sample of children in Georgia to guide statewide asthma control programs.

METHODS

A random-digit-dialed telephone survey of 2,121 households with 3,896 children 17 years of age or younger was conducted. Primary caretakers were asked about asthma and medication use of their children. Child data were weighted according to the number of telephone lines in the household and to the 2000 Georgia Census population.

RESULTS

Approximately 10 percent of children in Georgia had asthma. Among children with asthma, 30 percent did not have regular asthma checkups and 66 percent did not have a written management plan; 19 percent filled 2 or more prescriptions per year for quick-relief medicine but did not take control medication. For children with asthma for whom tobacco exposure was a known trigger, 35 percent were exposed to tobacco smoke in the home.

CONCLUSIONS

Opportunities exist to improve self-management, pharmacotherapy, and exposure to triggers for children with asthma. These data can be used to guide organizations and agencies working to reduce the burden of asthma.

A randomized clinical trial of clinician feedback to improve quality of care for inner-city children with asthma

CONTEXT

Barriers impede translating recommendations for asthma treatment into practice, particularly in inner cities where asthma morbidity is highest.

METHODS

The purpose of this study was to test the effectiveness of timely patient feedback in the form of a letter providing recent patient-specific symptoms, medication, and health service use combined with guideline-based recommendations for changes in therapy on improving the quality of asthma care by inner-city primary care providers and on resultant asthma morbidity. This was a randomized, controlled clinical trial in 5- to 11-year-old children (n = 937) with moderate to severe asthma receiving health care in hospital- and community-based clinics and private practices in 7 inner-city urban areas. The caretaker of each child received a bimonthly telephone call to collect clinical information about the child's asthma. For a full year, the providers of intervention group children received bimonthly computer-generated letters based on these calls summarizing the child's asthma symptoms, health service use, and medication use with a corresponding recommendation to step up or step down medications. We measured the number and proportion of scheduled visits resulting in stepping up of medications, asthma symptoms (2-week recall), and health care use (2-month recall).

RESULTS

In this population, only a modest proportion of children whose symptoms warranted a medication increase actually had a scheduled visit to reevaluate their asthma treatment. However, in the 2-month interval after receipt of a step-up letter, 17.1% of the letters were followed by scheduled visits in the intervention group compared with scheduled visits 12.3% of the time by the control children with comparable clinical symptoms. Asthma medications were stepped up when indicated after 46.0% of these visits in the intervention group compared with 35.6% in the control group, and when asthma symptoms warranted a step up in therapy, medication changes occurred earlier among the intervention children. Among children whose medications were stepped up at any time during the 12-month study period, those in the intervention group experienced 22.1% fewer symptom days and 37.9% fewer school days missed. The intention-to-treat analysis showed no difference over the intervention year in the number of symptom days, yet there was a trend toward fewer days of limited activity and a significant decrease in emergency department visits by the intervention group compared with controls. This 24% drop in emergency department visits resulted in an intervention that was cost saving in its first year.

CONCLUSIONS

Patient-specific feedback to inner-city providers increased scheduled asthma visits, increased asthma visits in which medications were stepped up when clinically indicated, and reduced emergency department visits.

Outcomes of a Web-based patient education program for asthmatic children and adolescents

BACKGROUND

Asthma is the most common chronic disease among children in Germany. Approaches to reduce the burden of asthma include patient education to improve self-management skills.

STUDY OBJECTIVES

We determined whether a continuous Internet-based education program (IEP) as an add-on to a standardized patient management program (SPMP) improves health outcomes of asthma patients at a favorable benefit-cost ratio.

PATIENTS AND METHODS

A total of 438 asthmatic patients aged 8 to 16 years in 36 study centers were enrolled during a 6-month period. We performed a prospective cost-benefit analysis alongside a nonrandomized trial. At baseline and at 6 months and 12 months, health service utilization data were collected.

INTERVENTIONS

Study participants were assigned to a control group and two intervention groups. Patients in both intervention groups participated in an SPMP. Additionally, patients in one intervention group received the IEP.

RESULTS

Utilization of various health-care services decreased significantly in both intervention groups. From a payer perspective, the benefit-cost ratio of the traditional education program was 0.55. Adding the IEP improved the ratio (0.79). For patients with moderate or severe asthma, the benefit-cost ratios were 1.07 and 1.42 (with IEP), respectively.

CONCLUSIONS

The IEP offers the potential to decrease the burden of disease and to realize incremental morbidity cost savings. Subgroup analysis demonstrated that within 1 year, the savings exceed the intervention costs in patients with moderate or severe asthma.

Improved asthma care after enrollment in the State Children's Health Insurance Program in New York

BACKGROUND

Uninsured children with asthma are known to face barriers to asthma care, but little is known about the impact of health insurance on asthma care.

OBJECTIVES

We sought to assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with asthma.

DESIGN

Parents of a stratified random sample of new enrollees in New York's SCHIP were interviewed by telephone shortly after enrollment (baseline, n = 2644 [74% of eligible children]) and 1 year later (follow-up, n = 2310 [87%]). Asthma was defined by parent report using questions based on National Heart, Lung, and Blood Institute criteria. A comparison group (n = 401) who enrolled in SCHIP 1 year later was interviewed as a test for secular trends.

MAIN OUTCOME MEASURES

Access (having a usual source of care [USC], unmet health needs, problems receiving acute asthma care), asthma-related medical visits, quality (continuity of care at the USC, problems receiving chronic asthma care, use of antiinflammatory medications), and asthma outcomes (change in asthma care or severity) were the main outcome measures used. Bivariate and multivariate analyses compared measures at baseline (year before SCHIP) versus follow-up (year during SCHIP).

RESULTS

Three-hundred eighty-three children (14%) had asthma at baseline, and 364 had asthma at follow-up (16%). No secular trends were detected between the baseline study group and the comparison group. After enrollment in SCHIP, improvements were noted in access: lacking a USC (decrease from 5% to 1%), unmet health needs (48% to 21%), and problems getting to the USC for asthma (13 to 4%). Children had fewer asthma-related attacks and medical visits after SCHIP (mean number of attacks: 9.5 to 3.8: mean number of asthma visits: 3.0 to 1.5; hospitalizations: 11% to 3%). Quality of asthma care improved for general measures (most/all visits to USC: 53% to 94%; mean rating of provider: 7.9 to 8.8 of 10) and asthma-specific measures (problems getting to the USC for asthma care when child was well: 13% to 1%). More than two thirds of the parents at follow-up reported that both quality of asthma care and asthma severity were "better or much better" than at baseline, generally because of insurance coverage or lower costs of medications and medical care.

CONCLUSIONS

Enrollment in New York's SCHIP was associated with improvements in access to asthma care, quality of asthma care, and asthma-specific outcomes. These findings suggest that health insurance improves the health of children with asthma.

The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers

OBJECTIVES

We assessed the effectiveness of a community health worker intervention focused on reducing exposure to indoor asthma triggers.

METHODS

We conducted a randomized controlled trial with 1-year follow-up among 274 low-income households containing a child aged 4-12 years who had asthma. Community health workers provided in-home environmental assessments, education, support for behavior change, and resources. Participants were assigned to either a high-intensity group receiving 7 visits and a full set of resources or a low-intensity group receiving a single visit and limited resources.

RESULTS

The high-intensity group improved significantly more than the low-intensity group in its pediatric asthma caregiver quality-of-life score (P=.005) and asthma-related urgent health services use (P=.026). Asthma symptom days declined more in the high-intensity group, although the across-group difference did not reach statistical significance (P=.138). Participant actions to reduce triggers generally increased in the high-intensity group. The projected 4-year net savings per participant among the high-intensity group relative to the low-intensity group were 189-721 dollars.

CONCLUSIONS

Community health workers reduced asthma symptom days and urgent health services use while improving caregiver quality-of-life score. Improvement was greater with a higher-intensity intervention.