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

A qualitative study of perspectives on the acceptability and feasibility of "virtual home visits" for asthma

BACKGROUND

Asthma home-visit programs delivered by community health workers (CHWs) are an effective way to improve asthma outcomes and cost of care, through performing home environmental inspections, delivering education and hands-on demonstrations, and providing personalized behavior change support. During the COVID-19 pandemic, many in-person asthma CHW programs have been adapted to be delivered virtually, but it is unclear whether this is acceptable or feasible for clients with asthma. This qualitative study sought to identify perspectives of prior clients of the Public Health-Seattle & King County Asthma Program on acceptability and feasibility of a hypothetical virtual asthma program.

METHODS

We performed semi-structured interviews with participants speaking English, Spanish, and Somali. An a priori codebook was developed based on the Theoretical Framework of Acceptability and was revised iteratively during coding. Intra-rater reliability was established, and thematic analysis was used to determine major themes.

RESULTS

A total of 19 individuals participated (9 speaking English, 8 Spanish, and 2 Somali). Krippendorf's alpha was 0.848, indicating high intra-rater reliability. Our results demonstrated that many participants felt positively about the prospect of completing the program virtually, but they also expected a variety of challenges, the most important of which were lack of engagement with the CHW and lack of confidence in the accuracy of a virtual home inspection. Participants also varied widely in their comfort level with videoconferencing platforms and their access to adequate internet connectivity.

CONCLUSIONS

Acceptability and feasibility of virtual programming varies widely between participants, indicating that there may be no "one-size-fits-all" approach. We present several recommendations for adapting in-person asthma home visit programs to a virtual format, including considering a hybrid approach to delivery, making concerted efforts to build rapport when using videoconferencing, and deliberately evaluating the effectiveness of new adaptations, especially if a virtual environmental assessment is attempted.

Fungal diversity in homes and asthma morbidity among school-age children in New York City

BACKGROUND

Asthma development has been inversely associated with exposure to fungal diversity. However, the influence of fungi on measures of asthma morbidity is not well understood.

OBJECTIVES

This study aimed to test the hypothesis that fungal diversity is inversely associated with neighborhood asthma prevalence and identify specific fungal species associated with asthma morbidity.

METHODS

Children aged 7-8 years (n = 347) living in higher (11-18%) and lower (3-9%) asthma prevalence neighborhoods were recruited within an asthma case-control study. Fungal communities were analyzed from floor dust using high-throughput DNA sequencing. A subset of asthmatic children (n = 140) was followed to age 10-11 to determine asthma persistence.

RESULTS

Neighborhood asthma prevalence was inversely associated with fungal species richness (P = 0.010) and Shannon diversity (P = 0.059). Associations between neighborhood asthma prevalence and diversity indices were driven by differences in building type and presence of bedroom carpet. Among children with asthma at age 7-8 years, Shannon fungal diversity was inversely associated with frequent asthma symptoms at that age (OR 0.57, P = 0.025) and with asthma persistence to age 10-11 (OR 0.48, P = 0.043). Analyses of individual fungal species did not show significant associations with asthma outcomes when adjusted for false discovery rates.

DISCUSSION

Lower fungal diversity was associated with asthma symptoms in this urban setting. Individual fungal species associated with asthma morbidity were not detected. Further research is warranted into building type, carpeting, and other environmental characteristics which influence fungal exposures in homes.

The importance of skin prick test in differentiating cat sensitivities and allergies in children

BACKGROUND

The incidence of cat allergies in children has increased over the years. Children with cat allergies have mostly reported respiratory symptoms. The skin prick test (SPT) is the most preferred method to demonstrate sensitization to allergens. However, not all children who develop cat sensitization due to environmental exposure become allergic to cats. In our study, we aimed to determine the frequency of sensitization to cat and cat allergy, cat-related symptoms, and the cut-off value for the SPT that may indicate cat allergy.

METHODS

Patients aged 2-18 years, who applied to the Health Sciences University İzmir Dr Behçet Uz Pediatrics and Surgery Training and Research Hospital and Balıkesir University Application and Research Hospital Pediatric Allergy outpatient clinics between January 01, 2019 and December 31, 2020, were included in the study. Patients who underwent SPT and found to be sensitized to cat allergen, were evaluated retrospectively. Clinical and laboratory findings of the patients were recorded. Receiver operating characteristics (ROC) analysis was performed to determine the cut-off value for the SPT.

RESULTS

Sensitization to cat was detected in 140 (4%) out of 3499 patients who underwent SPT. The median age of the patients was 12 years (min-max: 5-18) and 67.1% were male. Eighty-eight (62.9%) patients were symptomatic upon contact with cats, predominantly with nasal symptoms. These patients had significantly larger cat SPT wheal size than asymptomatic patients. The cut-off value was determined as 5.5 mm with a sensitivity of 72.7% and a specificity of 61.5% (95% CI, 60.5%-78.4%). Symptoms resolved in about half of our patients by reducing contact with cats.

DISCUSSION

The present study is the first to report the frequency and clinical findings of cat sensitizations and allergies in Turkish children. For effective treatment, cat allergy must be diagnosed. In this regard, the use of a practical, readily accessible 5.5 mm cut-off point on the SPT may be helpful.

Using Randomized Controlled Trials to Estimate the Effect of Community Interventions for Childhood Asthma

INTRODUCTION

The Centers for Disease Control and Prevention's Controlling Childhood Asthma and Reducing Emergencies initiative aims to prevent 500,000 emergency department (ED) visits and hospitalizations within 5 years among children with asthma through implementation of evidence-based interventions and policies. Methods are needed for calculating the anticipated effects of planned asthma programs and the estimated effects of existing asthma programs. We describe and illustrate a method of using results from randomized control trials (RCTs) to estimate changes in rates of adverse asthma events (AAEs) that result from expanding access to asthma interventions.

METHODS

We use counterfactual arguments to justify a formula for the expected number of AAEs prevented by a given intervention. This formula employs a current rate of AAEs, a measure of the increase in access to the intervention, and the rate ratio estimated in an RCT.

RESULTS

We justified a formula for estimating the effect of expanding access to asthma interventions. For example, if 20% of patients with asthma in a community with 20,540 annual asthma-related ED visits were offered asthma self-management education, ED visits would decrease by an estimated 1,643; and annual hospitalizations would decrease from 2,639 to 617.

CONCLUSION

Our method draws on the best available evidence from RCTs to estimate effects on rates of AAEs in the community of interest that result from expanding access to asthma interventions.

Environmental justice and allergic disease: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee and the Diversity, Equity and Inclusion Committee

Environmental justice is the concept that all people have the right to live in a healthy environment, to be protected against environmental hazards, and to participate in decisions affecting their communities. Communities of color and low-income populations live, work, and play in environments with disproportionate exposure to hazards associated with allergic disease. This unequal distribution of hazards has contributed to health disparities and is largely the result of systemic racism that promotes segregation of neighborhoods, disinvestment in predominantly racial/ethnic minority neighborhoods, and discriminatory housing, employment, and lending practices. The AAAAI Environmental Exposure and Respiratory Health Committee and Diversity, Equity and Inclusion Committee jointly developed this report to improve allergy/immunology specialists' awareness of environmental injustice, its roots in systemic racism, and its impact on health disparities in allergic disease. We present evidence supporting the relationship between exposure to environmental hazards, particularly at the neighborhood level, and the disproportionately high incidence and poor outcomes from allergic diseases in marginalized populations. Achieving environmental justice requires investment in at-risk communities to increase access to safe housing, clean air and water, employment opportunities, education, nutrition, and health care. Through policies that promote environmental justice, we can achieve greater health equity in allergic disease.

Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee

The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.

Influences on indoor environmental trigger remediation uptake for children and young people with asthma: A scoping review

INTRODUCTION

Children and young people (CYP) with asthma can benefit from reduced exposure to indoor environmental allergens and triggers but may not consistently have avoidance strategies implemented. To inform future interventions to increase trigger and allergen avoidance and enhance asthma control, a greater understanding of the influences on avoidance behaviours is necessary.

METHODS

A systematic scoping review was selected to summarize evidence on what influences family uptake of indoor environmental asthma trigger avoidance strategies for CYP with asthma and identify research gaps. Primary studies of any design, including CYP (≤18 years) with asthma, and/or parent-carers, available in English and conducted since 1993, were eligible. Searches included nine databases, hand-searching reference lists and citation searching.

FINDINGS

Thirty-three articles were included and are summarized narratively due to heterogeneity. Influences appear complex and multifactorial and include barriers to strategy uptake, health beliefs and personal motivation. Research specifically related to family understanding of allergic sensitisation status and exposure risks, and how these may inform avoidance implementation is required. Patient and public involvement (PPI) was not reported in included articles, although two studies used participatory methods.

CONCLUSION

There is limited research on family asthma trigger management, particularly what influences current management behaviours. Variation in families' ability to identify important triggers, understand exposure risk and consistently reduce exposures warrants further exploratory research to explain how families reach avoidance decisions, and what future interventions should aim to address. Further PPI-informed research to address such gaps, could enable theory-based, person-centred interventions to improve the uptake of asthma trigger remediation.

PATIENT OR PUBLIC CONTRIBUTION

An asthma-specific PPI group contributed to the decision-making for the funding for the wider project this review sits within. The findings of this scoping review have informed the subsequent phases of the project, and this was discussed with PPI groups (both adult and CYP groups) when proposing the next phases of the project.

Improving Adherence in Urban Youth With Asthma: Role of Community Health Workers

BACKGROUND

The Asthma Action at Erie Trial is a comparative effectiveness trial comparing a community health worker (CHW) versus certified asthma educator (AE-C) intervention in low-income minority children.

OBJECTIVES

Determine whether asthma medication possession, adherence, technique, and triggers differ in children receiving an asthma CHW compared with an AE-C intervention.

METHODS

Children with uncontrolled asthma were randomized to receive 10 CHW home visits or 2 AE-C sessions in a clinic over 1 year. Asthma medication possession and inhaler technique were observed; adherence was measured using self-report, dose counters, and electronic monitors. Environmental triggers were captured by self-report, observation, and objective measurement. Mixed effects linear and logistic regression models were estimated for continuous and binary outcomes.

RESULTS

Children (n = 223) were mainly Hispanic (85%) and ages 5 to 16 years. Quick-relievers (82%), spacers (72%), and inhaled corticosteroid (ICS)-containing medications (44%) were tracked. Of those with uncontrolled asthma, 35% lacked an ICS prescription (n = 201). Children in the CHW arm were more likely to have an ICS prescription at 12 months (odds ratio 2.39; 95% CI 0.99-5.79). Inhaler technique improved 9.8% in the CHW arm at 6 months (95% CI 4.20-15.32). The ICS adherence improved in the CHW arm at 12 months, with a 16.0% (95% CI 2.3-29.7; P = .02) difference between arms. Differences in trigger exposure over time were not observed between arms.

CONCLUSIONS

The CHW services were associated with improved ICS adherence and inhaler technique, compared with AE-C services. More information is needed to determine the necessary dosage of intervention to sustain adherence.

An investigation of child health in relation to housing renovations for a disadvantaged immigrant population in Malmö, Sweden

Aims:

The aim of the study was to describe child health in relation to housing renovations in more than 800 rental units, consisting of repairs of dilapidated kitchens and bathrooms, in the disadvantaged neighbourhood of Herrgården in Rosengård, Malmö, Sweden.

Methods:

Data on housing conditions and self-reported health were collected during home visits to families living in Herrgården (building renovations area) and a comparison area (neighbouring Törnrosen, with generally better housing conditions). At baseline, 130 families with 359 children participated, while 51 families with 127 children participated at follow-up. All data were collected between 2010 and 2012. Additionally, regional register data on health-care usage/in- and outpatient contacts within the public health-care system between 2008 and 2013 were also collected for all 8715 children registered as living in the two areas.

Results:

Self-reported health seemed to somewhat improve in both areas, with 74% versus 86% and 78% versus 88% reporting good or very good health in Herrgården and in the comparison area at baseline and follow-up, respectively. In Herrgården, crowdedness increased, while it decreased in the comparison area. The number of health-care contacts remained stable over time in Herrgården, while it decreased in the comparison area.

Conclusions:

Partial housing renovations did not seem to result in clear health improvements as measured with the indicators used in the present study. This could possibly be due to persisting health effects due to increased crowdedness or persisting poor housing conditions, as only kitchens and bathrooms were renovated.

Community Interventions for Childhood Asthma ED Visits and Hospitalizations: A Systematic Review

A systematic review of interventions in community environments found significant reductions in childhood asthma exacerbations leading to emergency department visits and hospitalizations.

BACKGROUND AND OBJECTIVES

Structural and social determinants of childhood asthma inequities manifest within geographic communities that are often segregated. Childhood asthma disproportionately affects Black, Hispanic, and low-income populations. Community interventions have the potential to improve inequities in emergency healthcare. This systematic review was conducted to assess the effectiveness of childhood asthma community interventions and provide a conceptual model to inform implementation of future community interventions.

METHODS

Publications from PubMed, ScienceDirect, CINAHL, Cochrane Library, Web of Science, and hand searched references were examined from 2010 to 2021. Community intervention studies among children with asthma were included. Main outcomes were emergency department visits and hospitalizations. Community interventions exclusively focusing on schools or hospitals were excluded. Two reviewers independently assessed eligibility for final inclusion. Emergency healthcare findings were extracted in addition to co-benefits (eg, fewer missed school days and caregiver workdays).

RESULTS

Out of 1856 records, 26 publications met the inclusion criteria. Community interventions were categorized by care coordination (n = 8), policy and environmental changes (eg, smoke-free legislature, traffic reduction models, and green housing) (n = 8), home-based (n = 6), and community-based health services (n = 4). Selected studies indicated that community interventions significantly reduced childhood asthma emergency department visits and hospitalizations through increased caregiver self-efficacy, home environmental trigger reduction, and increased access to healthcare. Because of heterogeneity among studies, we were unable to conduct a meta-analysis.

CONCLUSIONS

Findings show significant associations between community interventions and the reduction of emergency healthcare, suggesting a protective effect for severe cases of childhood asthma.

Utilizing Real-time Technology to Assess the Impact of Home Environmental Exposures on Asthma Symptoms: Protocol for an Observational Pilot Study

BACKGROUND

It is estimated that over 60% of adults with asthma have uncontrolled symptoms, representing a substantial health and economic impact. The effects of the home environment and exposure to volatile organic compounds (VOCs) and fine particulate matter (PM_2.5) on adults with asthma remain unknown. In addition, methods currently used to assess the home environment do not capture real-time data on potentially modifiable environmental exposures or their effect on asthma symptoms.

OBJECTIVE

The aims of this study are to (1) determine the feasibility and usability of ecological momentary assessment (EMA) to assess self-report residential environmental exposures and asthma symptoms, home monitoring of objective environmental exposures (total VOCs and PM_2.5), and lung function in terms of forced expiratory volume in 1 second (FEV₁%); (2) assess the frequency and level of residential environmental exposures (eg, disinfectants/cleaners, secondhand smoke) via self-reported data and home monitoring objective measures; (3) assess the level of asthma control as indicated by self-reported asthma symptoms and lung function; and (4) explore associations of self-reported and objective measures of residential environmental exposures with self-reported and objective measures of asthma control.

METHODS

We will recruit 50 adults with asthma who have completed our online Global COVID-19 Asthma Study, indicated willingness to be contacted for future studies, reported high use of disinfectant/cleaning products, and have asthma that is not well controlled. Participants will receive an indoor air quality monitor and a home spirometer to measure VOCs, PM_2.5, and FEV₁%, respectively. EMA data will be collected using a personal smartphone and EMA software platform. Participants will be sent scheduled and random EMA notifications to assess asthma symptoms, environmental exposures, lung function, and mitigation strategies. After the 14-day data collection period, participants will respond to survey items related to acceptability, appropriateness, and feasibility.

RESULTS

This study was funded in March 2021. We pilot tested our procedures and began recruitment in April 2022. The anticipated completion of the study is 2023.

CONCLUSIONS

Findings from this feasibility study will support a powered study to address the impact of home environmental exposures on asthma symptoms and develop tailored, home-based asthma interventions that are responsive to the changing home environment and home routines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05224076; https://clinicaltrials.gov/ct2/show/NCT05224076.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39887.

Housing environments and asthma outcomes within population-based samples of adults and children in NYC

Exposure to indoor environmental risk factors is associated with patterns of asthma morbidity. In this study, we assessed the relationship between housing type (i.e., home ownership, public housing, rental assistance, rent-controlled housing and other rental housing) and asthma outcomes among New York City (NYC) adults and children (ages 1-13). We used the 2019 NYC Community Health Survey (CHS) and 2019 NYC KIDS survey to analyze associations between housing type and ever having been diagnosed with asthma ("ever asthma") and experiencing a past-year asthma attack. We further examined whether associations were modified by smoking status (among adults), smoking within the home (among children), and overweight/obesity. Among adults, living in public housing, compared to home ownership, was associated with higher odds of ever asthma (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.35, 2.84), and past-year asthma attack (OR = 2.24; 95% CI 1.21,4.18). Living in rental assistance housing was also significantly associated with ever asthma (OR = 1.75; 95% CI 1.16, 2.66). Associations between public or rental assistance housing and ever asthma were marginally non-significant among children. Associations between living in public or rental assistance housing and ever asthma were more pronounced among ever smokers than among never smokers. Housing environments remain important predictors of both pediatric and adult asthma morbidity. Associations between living in subsidized housing and asthma outcomes among adults are most apparent among ever smokers.

Allergic Asthma in the Era of Personalized Medicine

Allergic asthma is the most common asthma phenotype and is characterized by IgE sensitization to airborne allergens and subsequent typical asthmatic symptoms after exposure. A form of type 2 (T2) airway inflammation underlies allergic asthma. It usually arises in childhood and is accompanied by multimorbidity presenting with the occurrence of other atopic diseases, such as atopic dermatitis and allergic rhinitis. Diagnosis of the allergic endotype is based on in vivo (skin prick tests) and/or in vitro (allergen-specific IgE levels, component-resolved diagnosis (CRD)) documentation of allergic sensitization. Biomarkers identifying patients with allergic asthma include total immunoglobulin E (IgE) levels, fractional exhaled nitric oxide (FeNO) and serum eosinophil counts. The treatment of allergic asthma is a complex procedure and requires a patient-tailored approach. Besides environmental control involving allergen avoidance measurements and cornerstone pharmacological interventions based on inhaled drugs, allergen-specific immunotherapy (AIT) and biologics are now at the forefront when it comes to personalized management of asthma. The current review aims to shed light on the distinct phenotype of allergic asthma, ranging over its current definition, clinical characteristics, pathophysiology and biomarkers, as well as its treatment options in the era of precision medicine.

A Cost-Effectiveness Analysis of a Community Health Worker Led Asthma Education Program in South Texas

Purpose

This paper examines the cost-effectiveness of an asthma-related education program.

Materials and Methods

Using a pre and post approach, the paper calculates first changes in cost due to variations in outcome (from baseline to follow-up). We also estimate cost-effectiveness ratios for each of the eight outcomes (numbers of asthma attacks, hospital, and ER visits, and physical and emotional health, and activity levels of both children and family members).

Results

The intervention saved the household around $36 per day. Cost-effectiveness ratios ranged between less than $2.2 for children and family members’ physical and emotional health, and activity levels to between $4.1 and $82.8 for asthma attacks and hospital visits. Cost-benefit results showed minimal benefit due to conservative estimates. We could not quantify the economic value of physical and emotional health improvement seen based on the measures.

Conclusion

Cost savings and ratios suggest that such a program could reduce health disparities due to improved knowledge, decreasing exposure to asthma triggers, enhancing health outcomes, and improving the quality of life of the children with asthma and their whole family.

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Allergen Management in Children with Type 2-High Asthma

Children exposed to various indoor and outdoor allergens are placed at an increased risk of developing asthma in later life, with sensitization in these individuals being a strong predictor of disease morbidity. In addition, aeroallergen exposure influences asthma outcomes through an interplay with adverse determinants of health. The goal of this review is to provide an introductory overview of factors related to aeroallergen exposure in type 2-high childhood asthma. These include the relevance of exposure in asthma exacerbations and severity, and the evidence-base for avoidance and treatment for sensitization to these allergens. This review will focus on both indoor aeroallergens (house dust mite, pet, cockroach, mold, and rodent) and outdoor aeroallergens (pollens and molds). Treatment of aeroallergen sensitization in children with asthma includes avoidance and removal measures, although there is limited evidence of clinical benefit especially with single-strategy approaches. We will also address the interplay of aeroallergens and climate change, adverse social determinants, and the current COVID-19 pandemic, when we have seen a dramatic reduction in asthma exacerbations and emergency department visits among children. While there are many factors that are hypothesized to contribute to this reduction, among them is a reduced exposure to outdoor seasonal aeroallergens.

Using the Community Engagement Framework to Understand and Assess EJ-Related Research Efforts

Within an environmental justice frame, capacity-building has been an important component of efforts to address health disparities at the policy, system, and environment levels. While the literature is replete with studies that discuss the necessity of collective action as a means to generate power to overcome inequities, limited attention has been given to the structure of these efforts to build capacity and challenge environmental injustices. This study applies the community engagement continuum as a framework for understanding the scope of capacity-building strategies and the manner in which research investigators engage with their intended target community. Paired teams of independent analysts screened articles for relevance (n = 8452), identified records for content abstraction (n = 163), and characterized relevant studies (n = 58). Many articles discussed community engagement as being either collaborative or shared leadership (n = 32, 55.2%). While the most commonly used capacity-building strategies were organizing/social action (58.6%) and CBPR (50%), few studies were able to make an environmental impact (n = 23; 39.7%), and fewer had a direct legislative policy-related outcome (n = 13; 22.4%). This review identifies levels of collaborative involvement and strategic approaches used for strengthening community capacity in efforts of making transformative policy, systems, and environmental change.

Asthma guidelines: comparison of the National Heart, Lung, and Blood Institute Expert Panel Report 4 with Global Initiative for Asthma 2021

PURPOSE OF REVIEW

Asthma continues to be a prevalent respiratory disease that affects lives within the United States and worldwide. Clinical asthma guidelines based on scientific evidence on testing and therapeutic interventions are needed to control this disease better. To meet this need, the NAEPP (National Asthma Education and Prevention Program) and GINA (Global Initiative for Asthma) were formed to assist with best practice diagnosis and treatments for asthma. This paper reviews the subtle differences and similarities between the most recent recommendations put forth by NAEPP 2020 and GINA 2021, mainly examining the six selected topics, as well as methodology, guidance on emerging topics, and implementation.

RECENT FINDINGS

In December 2020, the National Asthma Education and Prevention Program Coordinating Committee released their focused update on fraction of exhaled nitric oxide, indoor allergen mitigation, inhaled corticosteroids, long-acting muscarinic antagonists, allergen immunotherapy, and bronchial thermoplasty. The Global Initiative for Asthma comprehensive document is published annually as a framework for all nations. Therefore, it is timely to consider the National Asthma Education and Prevention Program Coordinating Committee 2020 in relation to the GINA 2021.

SUMMARY

The comparison provides a better understanding of evidence-based recommendations for asthma. The NAEPP 2020 and GINA 2021 will equip providers with the knowledge to provide their patients with the best and most updated asthma care.

Home Dust Allergen Exposure Is Associated with Outcomes among Sensitized Individuals with Chronic Obstructive Pulmonary Disease

Rationale: Environmental exposures have been associated with adverse outcomes in chronic obstructive pulmonary disease (COPD). Approximately one-third of individuals with COPD have allergic sensitization, but it is unknown whether exposure to allergens in the home is associated with outcomes. Objectives: To determine the prevalence and associations of allergen sensitization with exposure to common indoor allergens with symptoms and exacerbation risk in COPD. Methods: Allergen sensitization to five common indoor allergens was assessed in former smokers with COPD. Home settled dust was assessed for presence of corresponding allergens. Sensitization and exposure status was determined and associations evaluated in adjusted models with longitudinal outcomes including symptoms, lung function, and exacerbations. Interactions were assessed between sensitization/exposure status and lung function. Measurements and Main Results: One hundred eighty-three individuals studied were on average 67.3 years of age (SD, 8.22) with average FEV1 of 53.2% (SD, 17.6%). Seventy-seven percent of participants were exposed to at least one tested allergen, and 17% had sensitization with corresponding allergen exposure. After adjustment, sensitization with exposure was associated with lower lung function (β, -8.29; 95% confidence interval [CI], -14.80 to -1.77), higher St. George's Respiratory Questionnaire Total Score (β, 6.71; 95% CI, 0.17 to 13.25), and higher exacerbation risk (odds ratio, 2.31; 95% CI, 1.11 to 4.79). Associations appeared to be more pronounced among individuals with lower lung function. Conclusions: Allergen exposures are common in COPD and associated with adverse outcomes among those with concomitant allergen sensitization. This study establishes allergens as an important home exposure that potentially could be addressed with comprehensive home environmental modification strategies to improve COPD outcomes.

Does improving indoor air quality lessen symptoms associated with chemical intolerance?

Aim:

To determine whether environmental house calls that improved indoor air quality (IAQ) is effective in reducing symptoms of chemical intolerance (CI).

Background:

Prevalence of CI is increasing worldwide. Those affected typically report symptoms such as headaches, fatigue, ‘brain fog’, and gastrointestinal problems – common primary care complaints. Substantial evidence suggests that improving IAQ may be helpful in reducing symptoms associated with CI.

Methods:

Primary care clinic patients were invited to participate in a series of structured environmental house calls (EHCs). To qualify, participants were assessed for CI with the Quick Environmental Exposure and Sensitivity Inventory. Those with CI volunteered to allow the EHC team to visit their homes to collect air samples for volatile organic compounds (VOCs). Initial and post-intervention IAQ sampling was analyzed by an independent lab to determine VOC levels (ng/L). The team discussed indoor air exposures, their health effects, and provided guidance for reducing exposures.

Findings:

Homes where recommendations were followed showed the greatest improvements in IAQ. The improvements were based upon decreased airborne VOCs associated with reduced use of cleaning chemicals, personal care products, and fragrances, and reduction in the index patients’ symptoms. Symptom improvement generally was not reported among those whose homes showed no VOC improvement.

Conclusion:

Improvements in both IAQ and patients’ symptoms occur when families implement an action plan developed and shared with them by a trained EHC team. Indoor air problems simply are not part of most doctors’ differential diagnoses, despite relatively high prevalence rates of CI in primary care clinics. Our three-question screening questionnaire – the BREESI – can help physicians identify which patients should complete the QEESI. After identifying patients with CI, the practitioner can help by counseling them regarding their home exposures to VOCs. The future of clinical medicine could include environmental house calls as standard of practice for susceptible patients.

Randomized trial of a portable HEPA air cleaner intervention to reduce asthma morbidity among Latino children in an agricultural community

BACKGROUND

Data on pediatric asthma morbidity and effective environmental interventions in U.S. agricultural settings are few. We evaluated the effectiveness of HEPA air cleaners on asthma morbidity among a cohort of rural Latino children.

METHODS

Seventy-five children with poorly controlled asthma and living in non-smoking homes were randomly assigned to asthma education alone or along with HEPA air cleaners placed in their sleeping area and home living room. The Asthma Control Test (ACT) score, asthma symptoms in prior 2 weeks, unplanned clinical utilization, creatinine-adjusted urinary leukotriene E4 (uLTE4 [ng/mg]), and additional secondary outcomes were evaluated at baseline, six, and 12 months. Group differences were assessed using multivariable-adjusted generalized estimating equations. Incident rate ratios of ever experiencing the metrics of poorer asthma health during follow-up (suboptimal asthma management) were estimated using Poisson regression models in secondary analysis.

RESULTS

Mean child age was 9.2 and 8.6 years in intervention and control groups, respectively, and two-thirds of participants were male. Primary analysis of repeated measures of ACT score did not differ between groups (HEPA group mean change compared to controls 10% [95% CI: - 12-39%]). A suggestion of greater decrease in uLTE4 (ng/mg creatinine) was observed (- 10% [95% CI: - 20 -1%]). Secondary analysis showed children with HEPAs were less likely to have an ACT score meeting a clinically defined cutoff for poorly controlled asthma using repeated measures (IRR: 0.45 [95% CI: 0.21-0.97]). In Poisson models, intervention participants had reduced risk of ever meeting this cutoff (IRR: 0.43 [95% CI: 0.21-0.89]), ever having symptoms in the past 2 weeks (IRR: 0.71 [95% CI: 0.52-0.98]), and lower risk of any unplanned clinical utilization (IRR: 0.35 [95% CI: 0.13-0.94]) compared to control participants.

DISCUSSION

The HAPI study showed generally improved outcomes among children in the HEPA air cleaner group. However, primary analyses did not meet statistical significance and many outcomes were subjective (self-report) in this unblinded study, so findings must be interpreted cautiously. HEPA air cleaners may provide additional benefit for child asthma health where traditional asthmagens (traffic, tobacco smoke) are not prominent factors, but larger studies with more statistical power and blinded designs are needed.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04919915 . Date of retrospective registration: May 19, 2021.

Improved 10-year cost savings for patients served by the Boston Children's Hospital Community Asthma Initiative

OBJECTIVE

To provide a 10-year follow-up of asthma cost-savings for patients served by the Community Asthma Initiative (CAI) group compared to a coarsely cost-matched comparison group from similar neighborhoods (comparison group).

METHODS

CAI provided home visits and case management services for patients identified through emergency department (ED) visits and hospitalizations. Asthma costs for the two groups were extracted from the hospital administrative database for ED visits and hospitalizations for one year before and 10 years of follow-up. To eliminate cost differences at intake, a coarse cost-matching was implemented by randomly selecting comparison patients with similar costs to CAI patients (N = 208 pairs). The difference in cost-reduction between CAI and comparison patients was used to compute the adjusted Return on Investment (aROI).

RESULTS

There were no significant differences between CAI and comparison groups, including baseline age (5.9 years [SD 2.9] v. 4.4 [SD 3.1]); Hispanic (46.2% v. 35.1%) and Black (43.9% v. 53.0%) race/ethnicity; and public insurance (71.2% v. 68.8%). The cost reduction difference for CAI was significant at one year (P = 0.0001) and two years (P = 0.03), but did not reach the level of significance for years 3-10. The CAI group had a greater cumulative cost reduction of $5,321 (P = 0.08, not significant). Average program cost per patient was $2,636. CAI broke-even after 3 years (aROI = 1.04) and yielded an adjusted ROI of 1.99 at 10 years.

CONCLUSIONS

The greater reduction in cumulative cost for CAI patients suggested a shift in trajectory at 10 years of follow-up, resulting in a positive aROI after three years.

The West Philadelphia asthma care implementation study (NHLBI#

Asthma is the most common chronic condition among children, with low-income families living in urban areas experiencing significantly higher rates. Evidence based interventions for asthma are routinely implemented in either the home, school, or primary care setting. However, even when caregivers of poor children are engaged in asthma interventions in one setting, they often have to navigate challenges in another setting, such as an under-resourced home, non-supportive school, or disengaged health care provider. The West Philadelphia Asthma Care Implementation Plan aims to compare the effectiveness of a primary care-based intervention, school-based intervention, and combined primary care and school intervention to usual care for improving asthma control in school-age children to explore if the synergistic effect of Community Health Worker (CHW) support in the home, school, and health care environments will result in improved asthma control. Children ages 5-13 with uncontrolled asthma from four West Philadelphia recruitment sites will be eligible for enrollment. The families of school age children interested in participating will be randomized to receive a primary care CHW or usual care. Those identified as attending a participating school will have a CHW-led school intervention or usual care in school. If proven effective, this care coordination program will assist caregivers in assessing resources, improving self-management skills, and ultimately reducing asthma-related ED visits and hospitalizations as well as provide additional information for healthcare systems and policy makers to inform their decisions about how and where to focus additional resources and investments in childhood asthma care to improve health outcomes.

Evaluation of Healthy South Texas Asthma Program on improving health outcomes and reducing health disparities among the underserved Hispanic population: using the RE-AIM model

Background

In the United States, childhood asthma prevalence is higher among low-income communities and Hispanic populations. Previous studies found that asthma education could improve health and quality of life, especially in vulnerable populations lacking healthcare access. This study aims to describe Healthy South Texas Asthma Program (HSTAP), an evidence-based asthma education and environmental modification program in South Texas, and evaluate its associations with health-related outcomes among Hispanic children with asthma and their families.

Methods

The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) planning and evaluation framework was used as an overarching tool to evaluate the impact of the HSTAP. This educational program included 451 children with asthma and their families living in South Texas, an impoverished area at the Texas-Mexico border. The program consisted of (a) the asthma education (2-h) for children with asthma provided by Respiratory Therapy students at the children’s schools and (b) the home visit Asthma and Healthy Homes education and walk-through sessions (at baseline and 3 months) for parents and two follow-up visits (6 and 9–12 months later) led by community health workers. The education was provided in either English or Spanish between September 2015 and August 2020 as part of the Healthy South Texas Initiative. A pre-and post-test design was implemented to assess the differences in health outcomes, knowledge, and behaviors using standardized self-reported surveys as reported by parents. Analyses included primary descriptive analyses, generalized estimating equation models, the Wilcoxon signed-rank test, and the McNemar test.

Results

The HSTAP was significantly associated with improved individual-level outcomes on the frequency of asthma-related respiratory symptoms, including shortness of breath, chest tightness, coughing, and sleep difficulty, among children with asthma, as well as an enhanced asthma knowledge in their family. This study also showed significant associations with children’s school attendance and participation in physical activities and family social events and decreased families’ worry about their asthma management.

Conclusions

The RE-AIM model was a helpful framework to assess the HSTAP on all its components. The results suggest that participation in an asthma education and environmental modification program was associated with improved individual-level health conditions and reduced health disparities among children with asthma in low-income communities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02991-8.

Housing and asthma disparities

The burden of asthma disproportionately affects minority and low-income communities, resulting in racial and socioeconomic disparities in asthma prevalence, asthma exacerbations, and asthma-related death. Social determinants of health are increasingly implicated as root causes of disparities, and healthy housing is perhaps the most critical social determinant in asthma health disparities. In many minority communities, poor housing conditions and value are a legacy of historical policies and practices imbued with structural racism, including redlining, displacement, and exclusionary zoning. As a result, poor-quality, substandard housing is a characteristic feature of many underrepresented minority communities. Consequently, structurally deficient housing stock cultivates home environments rife with indoor asthma triggers. In this review we consider the historical context of urban housing policies and practices and how these policies and practices have contributed to the substandard housing conditions for many minoritized children in the present day. We describe the impact of poor housing quality on asthma and interventions that have attempted to mitigate its influence on asthma symptoms and health care utilization. We discuss the need to promote asthma health equity by reinvesting in these neighborhoods and communities to provide healthy housing.

2020 NAEPP Guidelines Update and GINA 2021-Asthma Care Differences, Overlap, and Challenges

The 2020 National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group (NAEPP [2020 Focused Asthma Update]) guidelines and the Global Initiative for Asthma (GINA) 2021 strategy report are compared in this Rostrum article. The methodologies of each publication are described. Subsequently, 4 different selected pharmacological recommendations are compared in the 2 documents: step 1 for children 0 to 4 years of age with viral-induced wheezing, step 2 in ages 12 years and older with the intermittent use of inhaled corticosteroid, steps 3 and 4 with single-inhaler maintenance and reliever therapy with inhaled corticosteroids-formoterol (SMART), and steps 3, 4, and 5 with add-on long-acting muscarinic antagonist therapy. Nonpharmacological recommendations are also considered and contrasted, including for exhaled nitric oxide, environmental control, immunotherapy, and bronchial thermoplasty. Similarities and differences in these 2 documents are highlighted, and recommendations are made about harmonizing the approaches where possible.

Assessment of Variation in Care Following Hospital Discharge for Children with Acute Asthma

Purpose

To evaluate potential variation in care management pathways following hospital discharge for children with asthma in New South Wales, Australia.

Methods

A cross-sectional web-based survey was conducted in emergency departments (EDs) and paediatric units of public hospitals with more than five paediatric beds within New South Wales, Australia, between July 2018 and March 2019. Nursing and medical staff in EDs and paediatric units who had cared for children aged under 18 years with asthma in the preceding 12 months were invited to participate in this study. Outcome measures included use of clinical practice guidelines and asthma action plan (AAP); advice on post-hospitalization follow-up; provision of asthma education for parents/carers; availability of community-based asthma services; communication with schools/childcare services.

Results

A total of 502 participants (236 nursing and 266 medical staff, response rate=22%) from 37 hospitals were included. Overall, the use of AAP was not universal (median=90%; IQR=81–96%) with significant difference across local health districts (LHDs) (88.6%, 95% CI=85.4–91.3) and between EDs and paediatric wards (p=9.4×10⁻⁹); and a range of asthma clinical practice guidelines were used. Post-hospitalization follow-up within 2–3 days was recommended by 70% of the respondents, but only 8% reported that hospitals had a system in place to ensure follow-up compliance. Formal asthma education sessions (27% respondents) were seldom provided to parents/carers during hospital stays, especially in EDs (14% respondents). Less than 50% of the respondents were aware of any asthma community services for children and only 4% reported that schools/childcare services were notified about the child’s hospital admission for an asthma flare up.

Conclusion

There are marked variations in the post-hospitalization asthma care and community management for children in NSW. An integrated standardized model of care may improve health outcomes in children with asthma.

Community Health Worker Asthma Interventions for Children: Results From a Clinically Integrated Randomized Comparative Effectiveness Trial (2016‒2019)

Objectives. To compare asthma control for children receiving either community health worker (CHW) or certified asthma educator (AE-C) services. Methods. The Asthma Action at Erie Trial is a comparative effectiveness trial that ran from 2016 to 2019 in Cook County, Illinois. Participants (aged 5‒16 years with uncontrolled asthma) were randomized to 10 home visits from clinically integrated asthma CHWs or 2 in-clinic sessions from an AE-C. Results. Participants (n = 223) were mainly Hispanic (85%) and low-income. Both intervention groups showed significant improvement in asthma control scores over time. Asthma control was maintained after interventions ended. The CHW group experienced a greater improvement in asthma control scores. One year after intervention cessation, the CHW group had a 42% reduction in days of activity limitation relative to the AE-C group (b = 0.58; 95% confidence interval = 0.35, 0.96). Conclusions. Both interventions were associated with meaningful improvements in asthma control. Improvements continued for 1 year after intervention cessation and were stronger with the CHW intervention. Public Health Implications. Clinically integrated asthma CHW and AE-C services that do not provide home environmental remediation equipment may improve and sustain asthma control.

Development of an Asthma Home-Visit Training Program for Community Health Workers and Their Supervisors in Washington State

The community health worker (CHW) asthma home-visiting model developed by Public Health-Seattle & King County (PHSKC) is an evidence-based approach proven to improve health outcomes and quality of life. In addition, it has been shown to be an effective and culturally appropriate approach to helping people with asthma understand the environmental and behavioral causes of uncontrolled asthma, while acquiring the skills they need to control their asthma. This paper describes the development and implementation of training curricula for CHWs and supervisors in the asthma home visiting program. To facilitate dissemination, this program took advantage of the current healthcare landscape in Washington State resulting from Centers for Medicare & Medicaid Services (CMS) approval of the 1115 Medicaid Waiver project. Key aspects of the training program development included: (1) Engagement: forming a Community Advisory Board with multiple stakeholders to help prioritize training content; (2) Curriculum Development: building the training on evidence-based home-visit protocols previously developed at PHSKC; (3) Implementation of the training program; (4) Evaluation of the training; and (5) Adaptation of the training based on lessons learned. We describe key factors in the training program's improvement including the use of a community-based participatory approach to engage stakeholders at multiple phases of the project and ensure regional adaption; combining in-person and online modules for delivery; and holding learning collaboratives for post-training and technical support. We also outline our training program evaluation plan and the planned evaluation of the home visit program which the trainees will deliver, both of which follow the RE-AIM framework. However, because the COVID-19 pandemic has curtailed training activities and prohibited the trainees from implementation of these CHW home visit practices, our evaluation is currently incomplete. Therefore, this case study provides insight into the adaptation of the training program, but not the delivery of the home visit program, the outcomes of which remain to be seen.

Aligning Partners in Pediatric Health: Using Geographical Information Systems to Plan Community Coalitions

Introduction: Compared with adults, children have higher emergency department (ED) utilization for asthma exacerbation. While community coalitions have been shown to prevent ED visits for asthma, there is little guidance on where to best implement these efforts. Geographical information systems (GIS) technology can help in the selection and coordination of potential coalition partners. This report proposes a model to be used by clinicians and child health equity advocates to strategize high-impact community health interventions. The aims were to identify the clusters of ED utilization for pediatric asthma, evaluate sociodemographic features of the population within the clusters, and identify potential primary care and school community partners. Methods: This model uses ED visit data from 450 nonmilitary California hospitals in 2012. We obtained ZIP code–level counts and rates for patients younger than 18 years discharged with a diagnosis code of 493 for asthma conditions from the California Office of Statewide Health Planning and Development’s Open Portal. We applied GIS spatial analysis techniques to identify statistically significant cluster for pediatric asthma ED utilization. We then locate the candidate community partners within these clusters. Results: There were 181 720 ED visits for asthma for all age groups in 2012 with 70 127 visits for children younger than 18 years. The top 3 geographic clusters for ED utilization rates were located in Fresno, Inglewood, and Richmond City, respectively. Spatial analysis maps illustrate the schools located within 0.5– and 1-mile radii of primary care clinics and provide a visual and statistical description of the population within the clusters. Conclusion: This study demonstrates a model to help clinicians understand how GIS can aid in the selection and creation of coalition building. This is a potentially powerful tool in the addressing child health disparities.

Strategies for Improving Inhalation Technique in Children: A Narrative Review

Inhaled medicines are commonly utilized by children for various respiratory conditions and must be used effectively for the medication to reach the airways. Poor inhaler technique contributes to poorly controlled asthma with significant associated morbidity. Given the significant consequences of improper inhaler use in children, the goal of this review is to comprehensively describe existing and potential solutions to improve inhaler technique. Because children move through various settings, including clinical practices, schools, pharmacies, and homes, in their daily routine, there is great opportunity to teach and reinforce proper inhaler technique across settings. Within each setting, in-person and technology-based interventions have shown promise to improve technique. These solutions need to be more broadly adopted to deliver tailored education with support for provider training, team-based care, communication structures, and reimbursement. Such solutions hold the potential to improve inhaler use among children, with potential for decreasing morbidity and costs.

The Effect of Residential Environment on Respiratory Diseases and Pulmonary Function in Children from a Community in Jilin Province of China

Purpose

Respiratory disease is a major and increasingly global epidemic that has a great impact on humans, especially children. The purpose of this study was to identify environmental risk factors for respiratory diseases and pulmonary function in children.

Patients and Methods

A population-based, cross-sectional survey of respiratory diseases and environmental risk factors was conducted in Jilin Province, China. Complete questionnaire information was available for 2419 children, while adequate pulmonary function data were available for a subgroup of 627 children.

Results

Our study found that environmental risk factors for respiratory health in children were mainly concentrated indoors. After adjusting for demographic factors, insecticide exposure and passive smoking were risk factors for respiratory disease and industrial pollutant sources, insecticide exposure and the use of a fume exhauster may be independent risk factors for recurrent respiratory infections. The main fuel for cooking in the winter and passive smoking were the main influencing factors of pulmonary function indicators.

Conclusion

The primary risk factors differ in different respiratory diseases. Passive smoking remains a critical adverse factor for respiratory illness and pulmonary function in children, and it is important to reduce children’s exposure to passive smoking to increase pulmonary health. Insecticide exposure may be a neglected environmental risk factor, and further investigations are still needed to explore the relationship and mechanisms between insecticide exposure and children’s respiratory health.

Identification and Remediation of Environmental Exposures in Patients With Interstitial Lung Disease: Evidence Review and Practical Considerations

A relationship between inhalational exposure to materials in the environment and development of interstitial lung disease (ILD) is long recognized. Hypersensitivity pneumonitis is an environmentally -induced diffuse parenchymal lung disease. In addition to hypersensitivity pneumonitis, domestic and occupational exposures have been shown to influence onset and progression of other ILDs, including idiopathic interstitial pneumonias such as idiopathic pulmonary fibrosis. A key component of the clinical evaluation of patients presenting with ILD includes elucidation of a complete exposure history, which may influence diagnostic classification of the ILD as well as its management. Currently, there is no standardized approach to environmental evaluation or remediation of potentially harmful exposures in home or workplace environments for patients with ILD. This review discusses evidence for environmental contributions to ILD pathogenesis and draws on asthma and occupational medicine literature to frame the potential utility of a professional evaluation for environmental factors contributing to the development and progression of ILD. Although several reports suggest benefits of environmental assessment for those with asthma or certain occupational exposures, lack of information about benefits in broader populations may limit application. Determining the feasibility, long-term outcomes, and cost-effectiveness of environmental evaluation and remediation in acute and chronic ILDs should be a focus of future research.

Master Clinician and Public Health Practitioner: Selected Occupational and Environmental Pulmonary Cases

Occupational and environmental exposures contribute to the development and progression of most lung diseases, yet their impact is greatly under-recognized in clinical practice. Clinicians caring for patients with respiratory diseases should maintain a high index of suspicion for occupational and environmental contributing factors. Mastering occupational and environmental medicine clinical decision making requires specialized clinical skills. These skills include obtaining an appropriate work and exposure history; making an assessment of the magnitude and relevance of exposures and their contribution to a patient's respiratory disease; utilizing appropriate resources for evaluation and management of exposure-related disease; and considering socioeconomic and public health factors.

Sustainability of residential environmental interventions and health outcomes in the elderly

Background

Research has documented that housing conditions can negatively impact the health of residents. Asthma has many known indoor environmental triggers including dust, pests, smoke and mold, as evidenced by the 25 million people in the U.S. population who have asthma. The paper describes a follow-up study involving elder adults with asthma who participated in a multifaceted home educational and environmental intervention shown to produce significant health benefits. On average the time between the end of the prior intervention study and the follow-up was 2.3 years. The objective of this study was to evaluate whether improvements in environmental conditions and health outcomes resulting from the original Older Adult Study (OAS, multifaceted educational and environmental interventions) would be maintained or decline over time for these low income seniors with asthma.

Methods

Health assessment included data on respiratory health outcomes included the Saint George’s Respiratory Questionnaire (SGRQ) and Asthma Control Test from the original Older Adult Study (OAS) and this follow-up Older Adult Study (OAFS) along with health care utilization data. Environmental assessments included evaluation of asthma trigger activities (ATAs) and exposures before and after the original healthy homes intervention (questionnaire, home survey) and at this follow-up. Assessments were conducted in English, Khmer and Spanish.

Results

At assessment in the Older Adult Follow-up Study (OAFS), the older adults maintained some of the health improvements gained during the OAS when compared to the OAS pre-intervention baseline. However, health outcomes declined from the OAS final assessment to the OAFS (only the SGRQ Impact scores were significantly different).

Conclusion

These findings suggest that further study with a larger population is needed to determine if the significant health outcome improvements from multifaceted home educational and environmental interventions (OAS) could be more strongly maintained by providing additional follow-up “booster” interventions to this older adult population with asthma.

Avoidance of allergens as an environmental method in the prevention of inhaled allergy symptoms

Asthma and other inhaled allergies are some of the most common paediatric diseases. The association of exposure to allergens with induction and exacerbation of symptoms has been proven. The majority of allergens are permanently or periodically suspended in the air, which leads to impaired quality of life for sensitive patients. Therefore, many methods of prevention and therapy of allergic diseases have been developed. The method of allergen exposure avoidance is often the first and the most significant measure. The present research has been conducted to evaluate, based on scientific data, which measures have the most reliable evidence of effectiveness. Environmental allergen avoidance methods, despite limited evidence supporting their clinical efficacy, are listed as the main therapeutic approaches in most recommendations. The significance of the holistic approach is also emphasised: only simultaneous introduction of several avoidance methods can bring possibly beneficial effects for the patient.

The home air in agriculture pediatric intervention (HAPI) trial: Rationale and methods

BACKGROUND

Data addressing air quality effects on children with asthma in rural U.S. communities are rare. Our community engaged research partnership previously demonstrated associations between neighborhood NH3 and ambient PM2.5 and asthma in the agricultural lower Yakima Valley of Washington. As a next step, the partnership desired an intervention approach to address concerns about pediatric asthma in this largely Latino immigrant, farm worker community.

OBJECTIVE

The Home Air in Agriculture Pediatric Intervention (HAPI) sought to examine the effectiveness of enrichment of an existing asthma education program with portable high-efficiency particulate air (HEPA) cleaners designed to reduce PM2.5 and NH3. We investigated the effect of this enriched approach on these exposures and asthma health measures.

DESIGN

We randomized children with poorly controlled asthma to a control arm (current asthma education program) or an intervention arm (current asthma education program + placement of two indoor air cleaners in the family's home). Outcomes included (1) 14-day integrated samples of indoor air contaminants (PM2.5 and NH3) at baseline and one-year follow-up and (2) child asthma health metrics at baseline, midpoint (4-6 months) and one-year follow-up. These included the Asthma Control Test, symptoms days, clinical utilization, oral corticosteroid use, pulmonary function, fractional exhaled nitric oxide, and urinary leukotriene E4 concentration.

DISCUSSION

To our knowledge, this is the first randomized HEPA cleaner intervention designed to assess NH3 as well as PM2.5 and to evaluate health outcomes of children with asthma in an agricultural region.

Environmental Health Consults in Children Hospitalized with Respiratory Infections

Indoor air pollutants contribute to respiratory infections and asthma exacerbations in children. Rural Alaska Native children experience some of the highest U.S. rates of respiratory hospitalizations, which are associated with lack of in-home running water, household crowding, and woodstove use. In our previous study, in-home education and modifications reduced respiratory symptoms, and medical visits. In this study, we evaluated the feasibility of providing in-hospital environmental health consults for parents/guardians of children < 5 years old hospitalized at the Alaska Native Medical Center with respiratory infections or asthma. Environmental health specialists conducted 92 in-hospital consults and mailed Healthy Homes Toolkits to households. Local housing authorities completed low-cost home modifications in 47 eligible households. Participants reported changes in household behaviors that were specifically addressed in the consult or included in the Toolkit (e.g. allergen-impermeable pillow covers). Reported respiratory symptoms were decreased at the 6-month follow-up. Over a 2 year period the median overall medical costs for respiratory illness in study children were $70,500. Children with in-home piped water had half the daily overall medical costs than children without in-home piped water ($74 compared to $144). In this study, we demonstrate that it is feasible to provide environmental consults, mail Toolkits, and arrange home modifications to the homes of children hospitalized with respiratory illness. These findings, along with the high costs of medical care for these children, suggest in-hospital environmental health consults are a cost-effective intervention.

Effectiveness of Home Visits in Adult Patients with Asthma: A Systematic Review of Randomized Controlled Trials

BACKGROUND

The effectiveness of home visits is well discussed for children with asthma, but limited in adults.

OBJECTIVE

The present systematic review aimed to investigate the potential role of home visits in improving outcomes among adult patients with asthma.

METHODS

The systematic review was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. An extensive literature search was conducted using databases such as PubMed, ProQuest, CINAHL, The Cochrane Library, PsycINFO, and Google Scholar from inception to June 2019. The studies included were randomized controlled trials, which reported asthma outcomes in adult patients.

RESULTS

The literature search yielded 8331 publications, of which 63 studies were selected for full-text review, and of these studies, 9 studies with a total of 2011 patients were included in the final analysis. The included randomized controlled trials reported quality of life, asthma symptoms, exacerbations, health care utilization, and pulmonary function. Improvements in asthma outcomes were observed predominantly in quality of life. The effects on asthma symptom control were inconsistent. The evidence on the impact of home visits in asthma exacerbations and health care utilization was rather limited. There were no significant differences observed between intervention versus control arms in terms of pulmonary function; however, 1 study reported significant improvements in peak expiratory flow rate.

CONCLUSIONS

Home visits may serve as an adjuvant activity that complements the existing health care system-based initiatives. It may be concluded that home visits have the potential to improve outcomes in adult patients with asthma; however, the randomized controlled trials reviewed in the present systematic review reported several limitations that warrant further investigation.

Design of a home-based intervention for Houston-area African-American adults with asthma: Methods and lessons learned from a pragmatic randomized trial

A growing body of evidence demonstrates that home-based, multicomponent interventions can effectively reduce exposures to asthma triggers and decrease asthma symptoms. However, few of these studies have targeted adults. To address this and other research gaps, we designed and implemented a pragmatic randomized clinical trial, the Houston Home-based Integrated Intervention Targeting Better Asthma Control (HIITBAC) for African Americans, to assess the effectiveness of a home-based intervention to improve asthma control and quality of life in African-American adults-a population disproportionately affected by asthma. The primary goals were to help participants reduce allergens and irritants in their homes and better manage their disease through knowledge, improved medication use, and behavior change. HIITBAC had two groups: clinic-only and home-visit groups. Both groups received enhanced clinical care, but the home-visit group also received a detailed home assessment and four additional home visits spaced over roughly one year. We recruited 263 participants. Of these, 152 (57.8%) were recruited through electronic health record data, 51 (19.4%) through Emergency Medical Services data, and 60 (22.8%) through other efforts (e.g., emergency departments, community events, outreach). Seventy participants (26.6%) were lost to follow up, substantially more in the home-visit than in the clinic-only group. We describe the HIITBAC methodology and cohort, discuss lessons learned about recruitment and retention, and highlight adaptations we implemented to address these lessons.

Implementation Lessons From a Randomized Trial Integrating Community Asthma Education for Children

This study characterized and compared the implementation of clinically integrated community health workers (CHWs) to a certified asthma educator (AE-C) for low-income children with asthma. In the AE-C arm (N = 115), 51.3% completed at least one in-clinic education session. In the CHW arm (N = 108), 722 home visits were completed. The median number of visits was 7 (range, 0-17). Scheduled in-clinic asthma education may not be the optimal intervention for this patient population. CHW visit completion rates suggest that the schedule, location, and content of CHW asthma services better met patients' needs. Seven to 10 visits seemed to be the preferred CHW dose.

The Role of Home Environments in Allergic Disease

Allergic diseases are surprisingly common, chronic health conditions. The primary location where the vast majority of people are exposed to allergens and other substances is in their home. This means it is important to understand home environments and how a home's systems function and interact-and that how we occupy these spaces plays a crucial role in both environmental exposure and management of allergic disease. This review provides an overview of what is understood about home environmental exposure and its impact on our health, and proposes a systematic process for using a patient's environmental history to develop individualized, manageable and cost-effective recommendations. Once occupant-related information has been gathered, a home environmental exposure assessment should be performed focused on identifying the relationships between any identified sources of contaminants and the housing systems, and conditions that may be contributing to exposure. The results and recommendations from this assessment can then be used to guide exposure-reduction efforts by patients and/or their caregivers in an effort to improve disease management. In this review, we'll discuss three different types of home interventions-active, which must be routinely performed by the patient and/or caregiver, passive, which are interventions that work without routine, direct interaction from the homeowner, and behavioral changes in how the home environment is cleaned and maintained for long-term reduction of allergens. In this review, and others evaluated for this discussion, a significant number of home environmental assessment and intervention programs were shown to be cost effective, with the majority of programs showing a net positive return on investment. It is important to recognize that to be cost effective, the level and intensity of services offered through home visit programs need be stratified, based on the estimated health risks of the patient, in order to tailor the assessment and target the interventions to a patient's needs while maximizing cost effectiveness.

Home Visits for Children With Asthma Reduce Medicaid Costs

We conducted a multicomponent, low-cost, home intervention for children with uncontrolled asthma, the Reducing Ethnic/Racial Asthma Disparities in Youth (READY) study, to evaluate its effect on health outcomes and its return on investment. From 2009 through 2014 the study enrolled 289 children aged 2 to 13 years with uncontrolled asthma and their adult caregivers in Boston and Springfield, Massachusetts. Community health workers (CHWs) led in-home asthma management and environmental trigger remediation education over 5 visits spanning 6 months. Asthma health outcomes and indoor environment data were collected via survey, and health use costs were accessed through Massachusetts Medicaid (MassHealth). Results showed significant improvements in asthma control, health care use, and environmental trigger reduction and a positive return on investment (1.34) for participants who had 2 or more emergency department visits 1 year prior to the first home visit. The CHW asthma home visiting intervention improved trigger management, clinical outcomes, and Medicaid cost savings, demonstrating that asthma home visits improve health quality and reduce costs.

Home visits for pediatric asthma - A strategy for comprehensive asthma management through prevention and reduction of environmental asthma triggers in the home

Families often struggle to manage their child's asthma. Clinicians caring for children with asthma struggle too as they are tasked with balancing the limited time available in clinic and the need to provide comprehensive care. As a direct consequence, critical gaps in asthma care remain with respect to asthma education and the identification and reduction of environmental asthma triggers in the home. A home visit model that augments clinic-based care is a viable way to fill gaps in understanding, address incomplete adherence patterns, improve disease control by shifting the focus of asthma management to reduction of environmental asthma triggers, and bring cost savings to the health care system.

Household endotoxin reduction in the Louisa Environmental Intervention Project for rural childhood asthma

Endotoxin exacerbates asthma. We designed the Louisa Environmental Intervention Project (LEIP) and assessed its effectiveness in reducing household endotoxin and improving asthma symptoms in rural Iowa children. Asthmatic school children (N = 104 from 89 homes) of Louisa and Keokuk counties in Iowa (aged 5-14 years) were recruited and block-randomized to receive extensive (education + professional cleaning) or educational interventions. Environmental sampling collection and respiratory survey administration were done at baseline and during three follow-up visits. Mixed-model analyses were used to assess the effect of the intervention on endotoxin levels and asthma symptoms in the main analysis and of endotoxin reduction on asthma symptoms in exploratory analysis. In the extensive intervention group, dust endotoxin load was significantly reduced in post-intervention visits. The extensive compared with the educational intervention was associated with significantly decreased dust endotoxin load in farm homes and less frequent nighttime asthma symptoms. In exploratory analysis, dust endotoxin load reduction from baseline was associated with lower total asthma symptoms score (Odds ratio: 0.52, 95% confidence interval: 0.29-0.92). In conclusion, the LEIP intervention reduced household dust endotoxin and improved asthma symptoms. However, endotoxin reductions were not sustained post-intervention by residents.

Ten questions concerning the implications of carpet on indoor chemistry and microbiology

Carpet and rugs currently represent about half of the United States flooring market and offer many benefits as a flooring type. How carpets influence our exposure to both microorganisms and chemicals in indoor environments has important health implications but is not well understood. The goal of this manuscript is to consolidate what is known about how carpet impacts indoor chemistry and microbiology, as well as to identify the important research gaps that remain. After describing the current use of carpet indoors, questions focus on five specific areas: 1) indoor chemistry, 2) indoor microbiology, 3) resuspension and exposure, 4) current practices and future needs, and 5) sustainability. Overall, it is clear that carpet can influence our exposures to particles and volatile compounds in the indoor environment by acting as a direct source, as a reservoir of environmental contaminants, and as a surface supporting chemical and biological transformations. However, the health implications of these processes are not well known, nor how cleaning practices could be optimized to minimize potential negative impacts. Current standards and recommendations focus largely on carpets as a primary source of chemicals and on limiting moisture that would support microbial growth. Future research should consider enhancing knowledge related to the impact of carpet in the indoor environment and how we might improve the design and maintenance of this common material to reduce our exposure to harmful contaminants while retaining the benefits to consumers.

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.

Applying a biopsychosocial model to inner city asthma: Recent approaches to address pediatric asthma health disparities

Pediatric asthma in inner cities is often severe and children living in these urban locations with socioeconomic disadvantage experience greater asthma morbidity. There are many interconnected risk factors that individually, and in combination, enhance asthma morbidity. These include biologic factors innate to the child, such as genetics and allergen susceptibility, as well as factors related to the family and neighborhood context. The biopsychosocial model can be used to frame these risk factors and develop interventions specific to the inner city. Successful inner city asthma interventions exist and key characteristics include multi-tiered components that operate within the community to coordinate disease management resources between patients, families and health care systems.

Creating a community-based comprehensive intervention to improve asthma control in a low-income, low-resourced community

Introduction: Asthma evidence-based interventions (EBI) are implemented in the home, school, community or primary care setting. Although families are engaged in one setting, they often have to navigate challenges in another setting.Objective: Our objective is to design and implement a comprehensive plan which integrates EBI's and connects the four sectors in underserved communities such as Philadelphia.Methods: September 2015-April 2016 we implemented a three-pronged strategy to understand needs and resources of the community including 1) focus groups and key informant interviews, 2) secondary data analysis and 3) pilot testing for implementation to determine gaps in care, and opportunities to overcome those gaps.Results: Analysis of the focus group and key informant responses showed themes: diagnosis fear, clinician time, home and school asthma trigger exposures, school personnel training and communication gaps across all four sectors. EBI's were evaluated and selected to address identified themes. Pilot testing of a community health worker (CHW) intervention to connect home, primary care and school resulted in an efficient transfer of asthma medications and medication administration forms to the school nurse office for students with uncontrolled asthma addressing a common delay leading to poor asthma management in school.Conclusion: Thus far there has been limited success in reducing asthma disparities for low-income minority children. This study offers hope that strategically positioning CHWs may work synergistically to close gaps in care and result in improved asthma control and reduced asthma disparities.

A Multicomponent, Multi-Trigger Intervention to Enhance Asthma Control in High-Risk African American Children

Introduction

We evaluated the effectiveness and feasibility of implementation of a multicomponent, multi-trigger (MCMT) intervention through a public health department in a high risk population of African American children.

Methods

This was a pragmatic quasi-experimental pretest–posttest study. The population consisted of African American children enrolled in Medicaid and Children’s Medical Services who had poorly controlled asthma. The MCMT intervention included 4 educational sessions and home asthma trigger reduction. Parents reported outcomes at baseline and at 1 to 3 months, 6 months, and 12 months after the MCMT intervention. Analysis used the McNemar χ² test and Student t test for paired observations. Data were collected during 2014 through 2016 in Augusta, Georgia.

Results

The number of children with asthma that was assessed as well controlled increased from 4 to 17 out of 20 (P < .001). Compared with baseline, at 12 months parents reported fewer days of school missed (6.4 vs 4.2, P = .01), fewer emergency department visits (1.7 vs 0.6, P = .02) and fewer hospitalizations (0.59 vs 0.18, P = .05). The most common environmental interventions were dust mitigation, getting a mattress or pillow protector, and cockroach mitigation.

Conclusion

An MCMT intervention in high risk African American children with poorly controlled asthma administered through the health department was associated with significant improvements in asthma control, days of school missed, and emergency department visits. Broader implementation of these strategies is warranted.

Targeting quality of life in asthmatic children: The MyTEP pilot randomized trial

BACKGROUND

Quality of life (QoL) is an important outcome in the management of children with asthma. Mobile Health (m-Health) and Therapeutic Education Programs (TEPs) are increasingly recognized as essential components of pediatric asthma management to improve disease outcomes.

OBJECTIVE

To evaluate the effect of an education program (MyTherapeutic Education Program, MyTEP) that couples multidisciplinary TEP intervention with an m-Health Program (mHP) in improving QoL in asthmatic children.

METHODS

This single-center study employed a nonblinded randomized clinical trial design. Italian-speaking children (6-11 years) with mild-moderate asthma were eligible for participation. Participants were randomly paired 1:1 with a control group that received mHP (smartphone app) or an intervention group that received MyTEP (TEP plus a smartphone app). Patients were followed up for 3 months. Descriptive statistics, Least Square (LS) mean change and Generalized Linear Mixed model were used for analysis.

RESULTS

Fifty patients were enrolled. The Pediatric Asthma Quality of Life Questionnaire (PAQLQ) score improved in both MyTEP (p = 0.014) and mHP (p = 0.046) with the minimally clinically significant difference of ⩾0.5 points reached in 23% of MyTEP and in 16% of mHP. Changes in PAQLQ scores were significantly greater in MyTEP than in mHP (LS mean difference: 0.269 p = 0.05). PAQLQ score was: positively associated with MyTEP (p = 0.023) and study time (p = 0.002); and inversely associated with current passive smoke exposure (p = 0.003).

CONCLUSION

Despite the small sample size and short observation period, this study demonstrated that implementing a multidisciplinary TEP with an m-Health program results in gains in QoL of children with asthma.