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Coaston A, Lee SJ, Johnson JK, Weiss S, Hoffmann T, Stephens C. Factors associated with mobile medical clinic use: a retrospective cohort study. Int J Equity Health 2023; 22:195. [PMID: 37749529 PMCID: PMC10521435 DOI: 10.1186/s12939-023-02004-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/05/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Mobile medical clinics have been used for decades to provide primary and preventive care to underserved populations. While several studies have examined their return on investment and impact on chronic disease management outcomes in the Mid-Atlantic and East Coast regions of the United States, little is known about the characteristics and clinical outcomes of adults who receive care aboard mobile clinics on the West Coast region. Guided by the Anderson Behavioral Model, this study describes the predisposing, enabling, and need factors associated with mobile medical clinic use among mobile medical clinic patients in Southern California and examines the relationship between mobile clinic utilization and presence and control of diabetes and hypertension. METHODS We conducted a retrospective cohort study of 411 adults who received care in four mobile clinic locations in Southern California from January 1, 2018, to December 31, 2019. Data were collected from patient charts on predisposing (e.g., sex, race, age), enabling (e.g., insurance and housing status), and need (e.g., chronic illness) factors based on Andersen's Behavioral Model. Zero-truncated negative binomial regression was used to examine the association of chronic illness (hypertension and diabetes) with number of clinic visits, accounting for potential confounding factors. RESULTS Over the course of the 2-year study period, 411 patients made 1790 visits to the mobile medical clinic. The majority of patients were female (68%), Hispanic (78%), married (47%), with a mean age of 50 (SD = 11). Forty-four percent had hypertension and 29% had diabetes. Frequency of mobile clinic utilization was significantly associated with chronic illness. Patients with hypertension and diabetes had 1.22 and 1.61 times the rate of mobile medical clinic visit than those without those conditions, respectively (IRR = 1.61, 95% CI, 1.36-1.92; 1.22, 95% CI, 1.02-1.45). CONCLUSIONS Mobile clinics serve as an important system of health care delivery, especially for adults with uncontrolled diabetes and hypertension.
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Affiliation(s)
- Angela Coaston
- California Baptist University, College of Nursing, 8432 Magnolia Ave, Riverside, Ca, 92504, USA.
| | - Soo-Jeong Lee
- University of California, San Francisco, CA, 94143, USA
| | | | - Sandra Weiss
- University of California, San Francisco, CA, 94143, USA
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The Role of Access and Cost-Effectiveness in Managing Asthma: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE 2022; 10:2109-2116. [PMID: 35525532 PMCID: PMC9353043 DOI: 10.1016/j.jaip.2022.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 03/25/2022] [Accepted: 04/12/2022] [Indexed: 12/21/2022]
Abstract
Background Inconsistent and unequal access to medical care is an issue that predates the COVID19 pandemic, which only worsened the problem. Limited access to care from asthma specialists and other specialists treating comorbid diseases may adversely affect asthma. Objective The purpose of this review is to identify health disparities associated with access to care for asthma, and cost-effectiveness of therapies and interventions addressing this health disparity. Methods A narrative systematic review was undertaken using MeSH searches of English language articles published in CINAHL, Scopus, or PubMed. Results A total of 725 articles were identified. Barriers recognized from the literature included access to diagnostic spirometry, access to specialists, medication formulary restrictions, and issues leading to medical nonadherence. Telemedicine, school-based health care interventions, digital applications, and non–office-based digital spirometry could be used to address these gaps in access to asthma care while potentially being cost-effective. Conclusion With the widespread adoption of telemedicine because of the pandemic, and adoption of other mobile services, we now have potential tools that can increase access to asthma care, which can help address this health care inequity. Evidence is limited, but favorable, that some of these tools may be cost-effective.
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Coaston A, Lee SJ, Johnson J, Hardy-Peterson M, Weiss S, Stephens C. Mobile Medical Clinics in the United States Post-Affordable Care Act: An Integrative Review. Popul Health Manag 2022; 25:264-279. [PMID: 35442787 PMCID: PMC10772318 DOI: 10.1089/pop.2021.0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite changes brought about by the 2010 Affordable Care Act (ACA), millions of individuals are still unable to access health care in the United States. Mobile medical clinics have been an invisible force of care delivery for vulnerable and marginalized populations for decades; however, little is known about their impact post-ACA. Guided by the Anderson Behavioral Model, the purpose of this article was to review and critique the state of the current literature about mobile medical clinics in the United States since 2010. Following Whittemore and Knafl's integrative review methodology, the search was conducted in 6 databases and delivered 1934 results; 341 articles were removed as duplicates. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, 2 independent reviewers screened and adjudicated the remaining titles, abstracts, and full-texts, yielding 12 articles in the final review. The Mixed Methods Appraisal Tool (MMAT) was used to evaluate the quality of the articles. Studies revealed variation in quality, study design, and location; and diversity of chronic diseases and populations addressed (eg, children with asthma, complementary alternative medicine use with children, adults with diabetes and hypertension, patients with chronic disease with an emphasis on the patient experience, utilization patterns in migrant farmers). Mobile medical clinics provide care for the prevention, treatment, and management of chronic illness and their wide geographic spread confirms their broad use across the United States. They provide a return on investment through emergency room avoidance, decreasing hospital length of stay, and improving chronic disease management.
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Affiliation(s)
- Angela Coaston
- Department of Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Soo-Jeong Lee
- Department of Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Julene Johnson
- Department of Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | | | - Sandra Weiss
- Department of Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | - Caroline Stephens
- Department of Community Health Systems, School of Nursing, University of California San Francisco, San Francisco, California, USA
- University of Utah College of Nursing, Salt Lake City, Utah, USA
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Tyris J, Keller S, Parikh K. Social Risk Interventions and Health Care Utilization for Pediatric Asthma: A Systematic Review and Meta-analysis. JAMA Pediatr 2022; 176:e215103. [PMID: 34870710 PMCID: PMC8649910 DOI: 10.1001/jamapediatrics.2021.5103] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Social determinants of health (SDOH) correlate with pediatric asthma morbidity, yet whether interventions addressing social risks are associated with asthma outcomes among children is unclear. OBJECTIVE To catalog asthma interventions by the social risks they address and synthesize their associations with asthma-related emergency department (ED) visits and hospitalizations among children. DATA SOURCES PubMed, Scopus, PsycINFO, SocINDEX, CINAHL, and references of included full-text articles were searched from January 1, 2008, to June 16, 2021. STUDY SELECTION Included articles were US-based studies evaluating the associations of interventions addressing 1 or more social risks with asthma-related ED visits and hospitalizations among children. The systematic review included 38 of the original 641 identified articles (6%), and the meta-analysis included 19 articles (3%). DATA EXTRACTION AND SYNTHESIS Data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. The SDOH intervention clusters were identified by grouping studies according to the social risks they addressed, using the Healthy People 2020 SDOH framework. Random-effects models created pooled risk ratios (RRs) as the effect estimates. MAIN OUTCOMES AND MEASURES Patients with ED visits or hospitalizations were the primary outcomes. Subgroup analyses were conducted by an SDOH intervention cluster. Sensitivity analyses were conducted for each, removing outlier studies and studies failing to meet the minimum quality threshold. RESULTS In total, 38 studies were included in the systematic review, with 19 of these studies providing data for the meta-analysis (5441 participants). All interventions addressed 1 or more of the health, environment, and community domains; no interventions focused on the economy or education domains. In the primary analysis, social risk interventions were associated with decreased ED visits (RR, 0.68; 95% CI, 0.57-0.81; I2 = 70%) and hospitalizations (RR, 0.50; 95% CI, 0.37-0.68; I2 = 69%). In subgroup analyses, the health, environment, and community intervention cluster produced the lowest RR for ED visits (RR, 0.53; 95% CI, 0.44-0.64; I2 = 50%) and for hospitalizations (RR, 0.33; 95% CI, 0.20-0.55; I2 = 71%) compared with other intervention clusters. Sensitivity analyses did not alter primary or subgroup effect estimates. CONCLUSIONS AND RELEVANCE The results of this systematic review and meta-analysis indicate that social risk interventions are associated with decreased asthma-related ED visits and hospitalizations among children. These findings suggest that addressing social risks may be a crucial component of pediatric asthma care to improve health outcomes.
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Affiliation(s)
- Jordan Tyris
- Division of Hospital Medicine, Children’s National Hospital, Washington, DC,George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Susan Keller
- Division of Hospital Medicine, Children’s National Hospital, Washington, DC
| | - Kavita Parikh
- Division of Hospital Medicine, Children’s National Hospital, Washington, DC,George Washington University School of Medicine and Health Sciences, Washington, DC
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Improved asthma outcomes among at-risk children in a pharmacist-led, interdisciplinary school-based health clinic: A pilot study of the CAReS program. J Am Pharm Assoc (2003) 2021; 62:519-525.e1. [PMID: 34863634 DOI: 10.1016/j.japh.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 11/01/2021] [Accepted: 11/04/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Disparities in access to care and outcomes have been identified among children with asthma living in underserved communities. The Caring for Asthma in our Region's Schoolchildren program was established to reduce disparities by providing school-based, comprehensive asthma care by a pharmacist-led, interdisciplinary team to high-risk pediatric populations in the Greater Pittsburgh area. OBJECTIVE To investigate program impact on follow-up appointment attendance, delivery of guideline-based care, asthma control, asthma morbidity (emergency department [ED] visits, oral corticosteroid [OCS] requirement), and asthma-related knowledge and quality of life. METHODS The study enrolled 50 children with asthma from 6 elementary schools (September 2014-December 2017). Children completed 5 visits over a 3-month period. McNemar's test assessed improvement in guideline-based controller therapy use and reduced morbidity (ED visits or OCS requirement). Generalized estimating equation analyses determined the significance of monthly improvements in asthma control, asthma knowledge, and quality of life. RESULTS A 100% show rate was achieved in nearly all participants (92.0%). Most of the patients were African-American (56%). In children with persistent disease, only 21.4% were prescribed controller therapy at baseline, which improved to 78.5% upon enrollment (P < 0.05). Asthma control statistically significantly improved (P < 0.05), and a reduction in percentage of patients who required an ED visit or an OCS burst pre-to postintervention was also statistically significant (31.3% vs. 14.6%, P < 0.05). The goal of 100% treatment plan knowledge was achieved in 67% of caregivers within 1 month and increased from 6% to 60% in children over 3 months (P < 0.05). Asthma-related quality of life also improved statistically significantly pre-to postintervention (P < 0.05). CONCLUSIONS Disparities in asthma outcomes owing to inadequate access to health care can be addressed. Improved asthma control, asthma medication knowledge, quality of life, and reduced morbidity in high-risk pediatric patients are achievable as demonstrated by our study. Our findings support the feasibility and value of a pharmacist-led, interdisciplinary school-based health care delivery model in providing comprehensive asthma care to at-risk pediatric populations.
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Perry TT, Turner JH. School-Based Telemedicine for Asthma Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:2524-2532. [PMID: 31706484 DOI: 10.1016/j.jaip.2019.08.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/06/2019] [Accepted: 08/06/2019] [Indexed: 10/25/2022]
Abstract
Asthma affects 10% of school-age children in the United States. These numbers nearly double in high-risk populations such as low-income and minority populations. Patients in these populations frequently live in communities that are medically underserved, with limited resources to implement comprehensive asthma interventions. It is important for researchers and clinicians to explore avenues to reduce the burden of illness in this population. Incorporating innovative strategies such as school-based telemedicine programs can potentially reduce morbidity, health care utilization, work absenteeism for caregivers, and school absenteeism for children with asthma. The aim of this review is to discuss the potential benefits of school-based asthma telemedicine programs, explore potential implementation models, and provide a comprehensive review of the literature including programs that use telemedicine in schools to assist with the management of asthma. Telemedicine is a feasible approach to increasing access to primary and specialty asthma care; however, there is a need for future randomized trials to establish best practices for implementation of telemedicine programs to aid in the care for children in school settings.
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Affiliation(s)
- Tamara T Perry
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Ark; Arkansas Children's Research Institute, Little Rock, Ark.
| | - Jessica H Turner
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Ark; Arkansas Children's Research Institute, Little Rock, Ark
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Harris K, Kneale D, Lasserson TJ, McDonald VM, Grigg J, Thomas J. School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review. Cochrane Database Syst Rev 2019; 1:CD011651. [PMID: 30687940 PMCID: PMC6353176 DOI: 10.1002/14651858.cd011651.pub2] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes. OBJECTIVES This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses. SEARCH METHODS We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017. SELECTION CRITERIA Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control. DATA COLLECTION AND ANALYSIS We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ). MAIN RESULTS We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence). AUTHORS' CONCLUSIONS School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.
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Affiliation(s)
- Katherine Harris
- Queen Mary University of LondonCentre for Child Health, Blizard InstituteLondonUKE1 2AT
| | - Dylan Kneale
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of Education20 Bedford WayLondonUKWC1H 0AL
| | - Toby J Lasserson
- Cochrane Central ExecutiveEditorial & Methods DepartmentSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Vanessa M McDonald
- The University of NewcastleSchool of Nursing and Midwifery, Priority Reseach Centre for Asthma and Respiratory DiseaseLocked Bag 1000New LambtionNewcastleNSWAustralia2305
| | - Jonathan Grigg
- Queen Mary University of LondonCentre for Child Health, Blizard InstituteLondonUKE1 2AT
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of Education20 Bedford WayLondonUKWC1H 0AL
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Morphew T, Galant SP. Can asthma be well controlled with NAEPP guideline care in morbidly obese children? The Breathmobile. Ann Allergy Asthma Immunol 2018; 122:167-174. [PMID: 30394336 DOI: 10.1016/j.anai.2018.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/21/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Obesity is thought to be associated with poor asthma control, increased health resource utilization, and reduced responsiveness to inhaled corticosteroids. OBJECTIVE Based on previous experience, our hypothesis was that by improved access to comprehensive guideline care, outcomes in normal weight would be comparable in obese children with asthma. METHODS This was a retrospective cohort study of predominately Hispanic children (3-18 years of age) in underserved areas of Orange County, California, who enrolled in the Breathmobile Program from 2003 to 2012. Outcomes were examined by using Cox regression and generalized estimating equations analyses, adjusted for potential confounding factors. RESULTS Clinical outcomes in more than 1,200 children followed up for a mean of 6 visits (standard deviation [SD] = 2.2) across 403 days (SD = 112) were improved, on average, regardless of body mass index (BMI). Morbidly obese (MOB) patients were able to achieve significant reductions of approximately 60% or more in report of emergency department (ED) visits, hospitalizations, school absenteeism, usual exercise limitations, and exacerbations to levels that were comparable those of normal weight (NW) patients. The importance of close follow-up, particularly for the MOB patient, was evidenced by achieving 80% cumulative probability of well controlled asthma by visit 3, similar to patients in lower BMI risk groups with good adherence, when the visit interval did not exceed 90 days. These outcomes were achieved across all BMI groups with similar mean step of therapy, adjusted for severity (P < .001). CONCLUSION Access to effective community-based care where trust, education, and continuity of care consistent with National Asthma Education and Prevention Program (NAEPP) guidelines is possible, as demonstrated by the Breathmobile Program, can provide an opportunity for children with asthma in all BMI categories to achieve well-controlled disease.
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Affiliation(s)
- Tricia Morphew
- Morphew Consulting, LLC, Bothell, Washington; Children's Hospital of Orange County, Orange, California.
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Orsak G, Starnes K, Ledlow G. Examining the Return on Investment of the Breath of Life Mobile Pediatric Asthma Clinic in a Rural Region with Small Metropolitan Statistical Areas. Hosp Top 2018; 96:95-101. [PMID: 30277451 DOI: 10.1080/00185868.2018.1488546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The current study sought to examine the return on investment (ROI) of a mobile pediatric asthma clinic in a rural region with small metropolitan statistical areas, in terms of reduced costs attributed to preventable emergency department visits, inpatient admission, school absenteeism, cost of education, and parent work absenteeism. For fiscal years 2015 and 2016, an average return of $1.32 and a community ROI of $1.45 was estimated. Estimated benefits were $445,125.00 and cost avoidance was $263,853.01. A mobile pediatric asthma clinics operating in less densely populated regions is able to yield a positive ROI.
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Affiliation(s)
- Gabriela Orsak
- a Department of Epidemiology and Biostatistics , University of Texas Health Science Center at Tyler , Tyler , Texas , USA
| | - Kate Starnes
- b Department of Healthcare Policy, Economics and Management , University of Texas Health Science Center at Tyler , Tyler , Texas , USA
| | - Gerald Ledlow
- b Department of Healthcare Policy, Economics and Management , University of Texas Health Science Center at Tyler , Tyler , Texas , USA
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Perry TT, Halterman JS, Brown RH, Luo C, Randle SM, Hunter CR, Rettiganti M. Results of an asthma education program delivered via telemedicine in rural schools. Ann Allergy Asthma Immunol 2018; 120:401-408. [PMID: 29471032 DOI: 10.1016/j.anai.2018.02.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 01/19/2018] [Accepted: 02/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Asthma morbidity is high in low-income children living in rural US regions, yet few interventions have been designed to decrease the asthma burden in rural populations. OBJECTIVE To examine the effect of a school-based asthma education program delivered by telemedicine in children living in an impoverished rural region. METHODS We conducted a cluster randomized trial with rural children 7 to 14 years old by comparing a school-based telemedicine asthma education intervention with usual care. The intervention provided comprehensive asthma education by telemedicine to participants and provided evidence-based treatment recommendations to primary care providers. RESULTS Of the 393 enrolled children, median age was 9.6 years, 81% were African American, and 47% lived in households with an annual income less than $14,999. At enrollment, 88% of children reported uncontrolled asthma symptoms. At the end of the intervention, there were no statistically significant differences in reported symptom-free days (primary outcome) for the intervention or usual-care group. Participants in the intervention group reported significantly higher use of peak flow meters to monitor asthma and reported taking their asthma medications as prescribed more frequently compared with the usual-care group. There were no changes in other outcome measures, including quality of life, self-efficacy, asthma knowledge, or lung function, between groups. CONCLUSION Although there was some evidence of behavior change among intervention participants, these changes were inadequate to overcome the significant morbidity experienced by this highly symptomatic rural impoverished population. Future interventions should be designed with a multifaceted approach that considers caregiver engagement, distance barriers, and inadequate access to asthma providers in rural regions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01167855.
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Affiliation(s)
- Tamara T Perry
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Arkansas Children's Research Institute, Little Rock, Arkansas.
| | - Jill S Halterman
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Rita H Brown
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Chunqiao Luo
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Arkansas Children's Research Institute, Little Rock, Arkansas
| | | | | | - Mallikarjuna Rettiganti
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Arkansas Children's Research Institute, Little Rock, Arkansas
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Bouchelle Z, Rawlins Y, Hill C, Bennet J, Perez LX, Oriol N. Preventative health, diversity, and inclusion: a qualitative study of client experience aboard a mobile health clinic in Boston, Massachusetts. Int J Equity Health 2017; 16:191. [PMID: 29100517 PMCID: PMC5670702 DOI: 10.1186/s12939-017-0688-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 10/30/2017] [Indexed: 12/03/2022] Open
Abstract
Background There are approximately 2000 mobile health clinics operating in the United States. While researchers have established that mobile health clinics can be cost effective and improve outcomes, there is scant research examining the healthcare experience on a mobile health clinic from patients’ perspectives. Methods Data were gathered from interviews with 25 clients receiving care on a Boston-based mobile health clinic and analyzed using grounded theory methodology. Results Emerging patterns in the data revealed three relational and three structural factors most significant to participants’ experience of care on The Family Van. Relational factors include providers who 1) Communicate understandably, 2) Create a culture of respect and inclusivity, and 3) Are diverse with knowledge of the community. Structural factors include 1) A focus on preventative health and managing chronic disease, 2) Expeditious, free, and multiple services, and 3) Location. Conclusions The participant accounts in this report serve to expand on prior research exploring mobile health clinics’ role in patients’ healthcare, to more clearly define the most salient aspects of the mobile health clinic model for the patients they serve, and to give voice to patients too seldom heard in the academic literature. Electronic supplementary material The online version of this article (10.1186/s12939-017-0688-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zoe Bouchelle
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Yasmin Rawlins
- Columbia University College of Physicians and Surgeons, New York, NY, USA
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Yu SWY, Hill C, Ricks ML, Bennet J, Oriol NE. The scope and impact of mobile health clinics in the United States: a literature review. Int J Equity Health 2017; 16:178. [PMID: 28982362 PMCID: PMC5629787 DOI: 10.1186/s12939-017-0671-2] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 09/24/2017] [Indexed: 11/24/2022] Open
Abstract
As the U.S. healthcare system transforms its care delivery model to increase healthcare accessibility and improve health outcomes, it is undergoing changes in the context of ever-increasing chronic disease burdens and healthcare costs. Many illnesses disproportionately affect certain populations, due to disparities in healthcare access and social determinants of health. These disparities represent a key area to target in order to better our nation's overall health and decrease healthcare expenditures. It is thus imperative for policymakers and health professionals to develop innovative interventions that sustainably manage chronic diseases, promote preventative health, and improve outcomes among communities disenfranchised from traditional healthcare as well as among the general population. This article examines the available literature on Mobile Health Clinics (MHCs) and the role that they currently play in the U.S. healthcare system. Based on a search in the PubMed database and data from the online collaborative research network of mobile clinics MobileHealthMap.org , the authors evaluated 51 articles with evidence on the strengths and weaknesses of the mobile health sector in the United States. Current literature supports that MHCs are successful in reaching vulnerable populations, by delivering services directly at the curbside in communities of need and flexibly adapting their services based on the changing needs of the target community. As a link between clinical and community settings, MHCs address both medical and social determinants of health, tackling health issues on a community-wide level. Furthermore, evidence suggest that MHCs produce significant cost savings and represent a cost-effective care delivery model that improves health outcomes in underserved groups. Even though MHCs can fulfill many goals and mandates in alignment with our national priorities and have the potential to help combat some of the largest healthcare challenges of this era, there are limitations and challenges to this healthcare delivery model that must be addressed and overcome before they can be more broadly integrated into our healthcare system.
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Affiliation(s)
- Stephanie W. Y. Yu
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, 21 Sassoon Rd, Pokfulam, Hong Kong, Special Administrative Region of China
| | - Caterina Hill
- Department of Global Health and Social Medicine, Harvard Medical School, c/o The Family Van, 1542 Tremont St, Roxbury, MA 02120 USA
| | - Mariesa L. Ricks
- Harvard Business School, Soldiers Field, Boston, MA 02163 USA
- Harvard University T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 USA
| | - Jennifer Bennet
- The Family Van: Harvard Medical School, 1542 Tremont St, Roxbury, MA 02120 USA
| | - Nancy E. Oriol
- Harvard Medical School, 260 Longwood Ave, Suite 244, Boston, MA 02115 USA
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 USA
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Morphew T, Scott L, Li M, Galant SP, Wong W, Garcia Lloret MI, Jones F, Bollinger ME, Jones CA. Mobile health care operations and return on investment in predominantly underserved children with asthma: the breathmobile program. Popul Health Manag 2014; 16:261-9. [PMID: 23941048 DOI: 10.1089/pop.2012.0060] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Underserved populations have limited access to care. Improved access to effective asthma care potentially improves quality of life and reduces costs associated with emergency department (ED) visits. The purpose of this study is to examine return on investment (ROI) for the Breathmobile Program in terms of improved patient quality-adjusted life years saved and reduced costs attributed to preventable ED visits for 2010, with extrapolation to previous years of operation. It also examines cost-benefit related to reduced morbidity (ED visits, hospitalizations, and school absenteeism) for new patients to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits). This is a retrospective analysis of data for 15,986 pediatric patients, covering 88,865 visits, participating in 4 Southern California Breathmobile Programs (November 16, 1995-December 31, 2010). The ROI calculation expressed the cost-benefit ratio as the net benefits (ED costs avoided+relative value of quality-adjusted life years saved) over the per annum program costs (∼$500,000 per mobile). The ROI across the 4 California programs in 2010 was $6.73 per dollar invested. Annual estimated emergency costs avoided in the 4 regions were $2,541,639. The relative value of quality-adjusted life years saved was $24,381,000. For patients new to the Breathmobile Program during 2008-2009 who engaged in care (≥3 visits), total annual morbidity costs avoided per patient were $1395. This study suggests that mobile health care is a cost-effective strategy to deliver medical care to underserved populations, consistent with the Triple Aims of Therapy.
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Affiliation(s)
- Tricia Morphew
- California Chapter of the Asthma and Allergy Foundation of America (AAFA), Los Angeles, California, USA.
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Knighton AJ, Flood A, Speedie SM, Harmon B, Smith P, Crosby C, Payne NR. Does initial length of stay impact 30-day readmission risk in pediatric asthma patients? J Asthma 2013; 50:821-7. [PMID: 23789734 DOI: 10.3109/02770903.2013.816726] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Accountable care puts pressure on hospitals to manage care episodes. Initial length of stay (ILOS) and readmission risk are important elements of a care episode and measures of care quality. Understanding the association between these two measures can guide hospital efforts in managing care episodes. This study was designed to explore the association between ILOS and readmission risk in a cohort of pediatric asthma patients. MATERIALS AND METHODS The sample cohort (n = 4965) consisted of all asthma patients discharged from Children's Hospitals and Clinics of Minnesota (CHC MN) from January 2008 through August 2012. Asthma discharges included cases with a principal diagnosis of asthma or certain respiratory cases with asthma listed as a secondary diagnosis. Multiple logistic regression was used to test associations, adjusting for covariates. RESULTS Adjusting for covariates, we found no significant association between ILOS and readmission (OR: 1.04 [95% CI: 0.98-1.10]). Analyzing ILOS categorically by length of stay, one-day stays did not have a significantly higher readmission risk (OR:1.27 [95% CI: 0.87-1.85]) than two-day stays, which had the lowest observed readmission risk. Risk increased as ILOS exceeded two days but was not significantly different by day. We found no association when comparing the difference in actual versus expected ILOS and readmission risk (shorter than expected OR: 1.13 [95% CI: 0.74-1.71]; longer than expected OR: 0.97 [95% CI: 0.69-1.38]). CONCLUSIONS Attempts to prolong ILOS would dramatically increase costs with little impact on readmissions. For example, increasing one-day visits to two-day visits would increase hospital patient days 38% (1870 d) in this cohort while decreasing total readmissions by 3.8% [95% CI: 3.6-4.0%]. Understanding the mechanisms that impact readmissions is essential in evaluating cost-effective approaches to improving patient outcomes and lowering the cost of care.
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Affiliation(s)
- Andrew J Knighton
- Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota , Minneapolis , USA
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15
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Butz AM, Kub J, Bellin MH, Frick KD. Challenges in providing preventive care to inner-city children with asthma. Nurs Clin North Am 2013; 48:241-57. [PMID: 23659811 DOI: 10.1016/j.cnur.2013.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although the scientific understanding of the pathophysiology of asthma and the quality of asthma therapies have significantly improved over the past 30 years, asthma morbidity remains high and preventive care low for inner-city children. This article focuses on 4 major challenges to providing preventive care (family and patient attitudes and beliefs, lack of access to quality medical care, psychosocial factors, environmental factors) based on prior evidence and the authors' observation of these challenges in research with inner-city children with asthma over the past decade. Cost issues related to preventive care are addressed, and recommendations provide for pediatric nurses.
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Affiliation(s)
- Arlene M Butz
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Eakin MN, Rand CS, Bilderback A, Bollinger ME, Butz A, Kandasamy V, Riekert KA. Asthma in Head Start children: effects of the Breathmobile program and family communication on asthma outcomes. J Allergy Clin Immunol 2011; 129:664-70. [PMID: 22104603 DOI: 10.1016/j.jaci.2011.10.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 09/26/2011] [Accepted: 10/05/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND Asthma morbidity and mortality rates are high among young inner-city children. Lack of routine primary care provider visits, poor access to care, and poor patient-physician communication might be contributing factors. OBJECTIVE This study evaluated the effects of providing Breathmobile services only, a Facilitated Asthma Communication Intervention (FACI) only, or both Breathmobile plus FACI on asthma outcomes relative to standard care. METHODS Children with asthma (n = 322; mean age, 4 years; 53% male; 97% African American) were recruited from Head Start programs in Baltimore City and randomized into 4 groups. Outcome measures included symptom-free days (SFDs), urgent care use (emergency department visits and hospitalizations), and medication use (courses of oral steroids and proportion taking an asthma controller medication), as reported by caregivers at baseline, 6-month, and 12-month assessments. Generalized estimating equations models were conducted to examine the differential treatment effects of the Breathmobile and FACI compared with standard care. RESULTS Children in the combined treatment group (Breathmobile plus FACI) had an increase of 1.7 (6.6%) SFDs that was not maintained at 12 months. In intent-to-treat analyses the FACI-only group had an increase in the number of emergency department visits at 6 months, which was not present at 12 months or in the post hoc as-treated analyses. No significant differences were found between the intervention groups compared with those receiving standard care on all other outcome measures. CONCLUSIONS Other than a slight improvement in SFDs at 6 months in the Breathmobile plus FACI group, the intervention components did not result in any significant improvements in asthma management or asthma morbidity.
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Affiliation(s)
- Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA
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Scott L, Morphew T, Bollinger ME, Samuelson S, Galant S, Clement L, O'Cull K, Jones F, Jones CA. Achieving and maintaining asthma control in inner-city children. J Allergy Clin Immunol 2011; 128:56-63. [PMID: 21531451 DOI: 10.1016/j.jaci.2011.03.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 03/17/2011] [Accepted: 03/18/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite guidelines-defined care, inner-city children of low socioeconomic status have poor asthma control. OBJECTIVE This study evaluated time to achieve control, maintenance of control, and factors associated with well controlled asthma for pediatric patients receiving specialty-based asthma care in mobile asthma clinics designed to reduce barriers to delivering effective asthma care (the Breathmobile Program). METHODS Existing clinical data collected from January 1998 to June 2008 for 7822 pediatric patients with asthma (34,339 visits) enrolled in similarly structured mobile asthma programs across the United States evaluated the effect of asthma control on the reduction of asthma-related morbidity, time to achieve asthma control, maintenance of asthma control, and factors associated with well controlled asthma. RESULTS Comparison of pre and post year data for subjects enrolled in the program for at least 1 year revealed reductions in the percentage of patients reporting emergency department visits (mean, 66%), hospitalizations (mean, 84%), and missed school days ≥5/year (mean, 78%). Well controlled asthma was achieved by visit 3 for an estimated 80% of patients. Factors contributing to well controlled asthma include non-African American race, visit interval <90 days, and adherence to prescribed therapy. CONCLUSION This study demonstrates the ability to achieve and maintain asthma control in high-risk populations in association with intensive, accessible, guidelines-defined care with close follow-up.
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Affiliation(s)
- Lyne Scott
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA.
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