Outcomes of a home-based environmental remediation for urban children with asthma

Modifiable factors associated with pediatric asthma readmissions: a multi-center linked cohort study

OBJECTIVES

To (a) identify rates of hospital readmission and emergency department (ED) re-presentation for asthma within a 12-month period, (b) estimate the effects of modifiable hospital, general practitioner (GP) and home environmental factors on hospital readmission, ED re-presentations and rescue oral corticosteroid use.

METHODS

We recruited 767 children aged 3-18 years who were admitted to 3 hospitals in Victoria, Australia between 2017 and 2018 with a validated diagnosis of asthma on chart review. Primary outcome was hospital readmission with asthma within 12 months of index admission. Secondary outcomes were ED re-presentation for asthma and rescue oral corticosteroid use. All outcomes were identified through linked administrative datasets. Their caregivers and 277 nominated GPs completed study surveys regarding the home environment and their usual asthma management practices respectively.

RESULTS

Within 12 months of an index admission for asthma 263 (34.3%) participants were readmitted to a hospital for asthma, with participants between the ages of 3-5 years accounting for 69.2% of those readmitted. The estimated effect of GP reported guideline discordant care on the odds of readmission was OR 1.57, 95% CI 1.00-2.47, p = 0.05. None of the hospital or home environmental factors appeared to be associated with hospital readmissions.

CONCLUSIONS

Hospital readmissions among Australian children with asthma are increasing, and linked datasets are important for objectively identifying the health services burden of asthma. They also confirm the important role of the GP in the management of pediatric asthma.

Social Risk Interventions and Health Care Utilization for Pediatric Asthma: A Systematic Review and Meta-analysis

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.

Household determinants of biocontaminant exposures in Canadian homes

Exposure to biocontaminants, such as dust mites, animal dander, bacteria, and mold, is associated with a range of health effects. This study identified household characteristics associated with indoor biocontaminant loadings in four Canadian cities. Floor dust was collected in 290 Canadian homes in Edmonton, Halifax, Montreal, and Windsor. The dust samples were analyzed for house dust mite allergens (Der f 1 and Der p 1), cat allergen (Fel d 1), cockroach allergen (Bla g 1), beta-(1,3)-D-glucan, and endotoxin. Household information was obtained through questionnaires and home inspections. We performed univariate and multivariate analyses to identify household determinants of biocontaminant loadings and mold odor presence. We observed large regional variations for all biocontaminants, except for cockroach allergen. The ranges of the contaminants measured in loadings and concentrations were similar to that of previous Canadian studies. Household characteristics including presence of carpeting, low floor cleaning frequency, older home age, presence of pets, and indoor relative humidity above 45% were positively associated with the presence of multiple indoor biocontaminants. High floor cleaning frequency and use of dehumidifiers were negatively associated with the presence of multiple indoor biocontaminants. Mold odor was positively associated with older home age, past water damage, and visible mold growth.

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.

Reducing asthma hospitalisations in at-risk children: A systematic review

AIM

To identify interventions that reduce hospitalisations and improve related outcomes in children at risk of asthma hospital admissions.

METHODS

Medline, Embase, Pubmed and Cochrane Library search from January 2002 to April 2020.

INCLUSION CRITERIA

randomised controlled trials of any intervention for children with asthma who are at risk of hospitalisations.

OUTCOMES

hospitalisation (primary outcome), rescue oral corticosteroid use, school absences, quality of life and cost-effectiveness.

RESULTS

Twelve randomised controlled trials were conducted with 2719 participants. Due to heterogeneity of interventions and reporting of outcomes, a meta-analysis was not conducted. Multi-modal interventions comprising caregiver education, reduction of home environmental allergens and regular follow-up reduced hospitalisations, rescue corticosteroid use and improved quality of life. Cost-effectiveness was not reported. Three studies scored an overall low risk of bias, and nine had some concerns.

CONCLUSION

Multi-modal interventions can be effective in reducing hospitalisations, rescue oral corticosteroid use and quality of life but cost-effectiveness is unknown.

Community-based interventions for childhood asthma using comprehensive approaches: a systematic review and meta-analysis

Objective

We conducted a systematic review and meta-analysis to determine the effectiveness of comprehensive community-based interventions with ≥ 2 components in improving asthma outcomes in children.

Methods

A systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Cochrane Library and hand search of reference collections were conducted to identify any research articles published in English between 2000 and 2019. All studies reporting community-based asthma interventions with ≥ 2 components (e.g., asthma self-management education, home environmental assessment or care coordination etc.) for children aged ≤ 18 years were included. Meta-analyses were performed using random-effects model to estimate pooled odds ratio (OR) with 95% confidence intervals (CIs).

Results

Of the 2352 studies identified, 21 studies were included in the final analysis: 19 pre-post interventions, one randomised controlled trial (RCT) and one retrospective study. Comprehensive asthma programs with multicomponent interventions were associated with significant reduction in asthma-related Emergency Department (ED) visits (OR = 0.26; 95% CI 0.20–0.35), hospitalizations (OR = 0.24; 95% CI 0.15–0.38), number of days (mean difference = − 2.58; 95% CI − 3.00 to − 2.17) and nights with asthma symptoms (mean difference = − 2.14; 95% CI − 2.94 to − 1.34), use of short-acting asthma medications/bronchodilators (BD) (OR = 0.28; 95% CI 0.16–0.51), and increase use of asthma action plan (AAP) (OR = 8.87; 95% CI 3.85–20.45).

Conclusion

Community-based asthma care using more comprehensive approaches may improve childhood asthma management and reduce asthma related health care utilization.

Managing Asthma in Adolescents and Adults: 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program

IMPORTANCE

Asthma is a major public health problem worldwide and is associated with excess morbidity, mortality, and economic costs associated with lost productivity. The National Asthma Education and Prevention Program has released the 2020 Asthma Guideline Update with updated evidence-based recommendations for treatment of patients with asthma.

OBJECTIVE

To report updated recommendations for 6 topics for clinical management of adolescents and adults with asthma: (1) intermittent inhaled corticosteroids (ICSs); (2) add-on long-acting muscarinic antagonists; (3) fractional exhaled nitric oxide; (4) indoor allergen mitigation; (5) immunotherapy; and (6) bronchial thermoplasty.

EVIDENCE REVIEW

The National Heart, Lung, and Blood Advisory Council chose 6 topics to update the 2007 asthma guidelines based on results from a 2014 needs assessment. The Agency for Healthcare Research and Quality conducted systematic reviews of these 6 topics based on literature searches up to March-April 2017. Reviews were updated through October 2018 and used by an expert panel (n = 19) that included asthma content experts, primary care clinicians, dissemination and implementation experts, and health policy experts to develop 19 new recommendations using the GRADE method. The 17 recommendations for individuals aged 12 years or older are reported in this Special Communication.

FINDINGS

From 20 572 identified references, 475 were included in the 6 systematic reviews to form the evidence basis for these recommendations. Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (as-needed short-acting β2-agonists [SABAs] for rescue therapy). In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended. Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma). Fractional exhaled nitric oxide testing is recommended to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma. Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms. When used, allergen mitigation should be allergen specific and include multiple allergen-specific mitigation strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort.

CONCLUSIONS AND RELEVANCE

Asthma is a common disease with substantial human and economic costs globally. Although there is no cure or established means of prevention, effective treatment is available. Use of the recommendations in the 2020 Asthma Guideline Update should improve the health of individuals with asthma.

2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group

The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders:A rigorous process was undertaken to develop these evidence-based guidelines. The Agency for Healthcare Research and Quality's (AHRQ) Evidence-Based Practice Centers conducted systematic reviews on these topics, which were used by the Expert Panel Working Group as a basis for developing recommendations and guidance. The Expert Panel used GRADE (Grading of Recommendations, Assessment, Development and Evaluation), an internationally accepted framework, in consultation with an experienced methodology team for determining the certainty of evidence and the direction and strength of recommendations based on the evidence. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups. To assist clincians in implementing these recommendations into patient care, the new recommendations have been integrated into the existing Expert Panel Report-3 (EPR-3) asthma management step diagram format.

A randomized controlled trial of a community health worker delivered home-based asthma intervention to improve pediatric asthma outcomes

OBJECTIVE

The objective of this study was to evaluate the effects of using Community Health Workers (CHWs) to deliver the home-based Wee Wheezers asthma education program on asthma symptoms among children with persistent asthma.

METHODS

In this randomized controlled trial of 151 children aged 2-9 years with persistent asthma, we assigned 75 to the intervention and 76 to the control. The primary outcome was caregiver-reported asthma symptom days. Secondary outcomes included asthma-related healthcare utilization, caregivers' asthma knowledge, illness perception and management behaviors, MDI-spacer administration technique, and home environmental triggers. Outcomes were collected at baseline, 3, 6, 9 and 12 months. A repeated measurements analytic approach with generalized estimating equations was used. To account for missing data, multiple imputation methods were employed.

RESULTS

At 3 and 6 months, improvement in symptom days was not significantly different between groups. However, at 9 and 12 months, the reduction in asthma symptom days was 2.15 and 2.31 days more respectively for those in the intervention group compared to the control. Improvements in MDI-spacer technique, knowledge and attitudes were significant throughout follow-up. Improvement in habits regarding MDI use was significant at 3 and 6 months, and asthma routines were improved at 3 months. However, there was no change in asthma-related healthcare utilization or home environmental triggers.

CONCLUSION

Using CHWs to deliver a home-based asthma education program to caregivers of children with persistent asthma led to improvements in symptom days and several secondary outcomes. Expanding the use of CHWs to provide home-based interventions can help reduce disparities in children's health outcomes.

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.

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.

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.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children

IMPORTANCE

As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources.

OBJECTIVE

To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019.

EXPOSURES

Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers.

MAIN OUTCOMES AND MEASURES

Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017).

RESULTS

Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid.

CONCLUSIONS AND RELEVANCE

In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.

How can we support children, adolescents and young adults in managing chronic health challenges? A scoping review on the effects of patient education interventions

Objectives

This scoping review aims to give a comprehensive and systematic overview of published evaluations and the potential impact of patient education interventions for children, adolescents and young adults who are living with chronic illness and/or impairment loss.

Methods

Relevant literature published between 2008 and 2018 has been comprehensively reviewed, with attention paid to variations in study, intervention and patient characteristics. Arksey and O'Malley's framework for scoping studies guided the review process, and thematic analysis was undertaken to synthesize extracted data.

Results

Of the 7214 titles identified, 69 studies were included in this scoping review. Participant‐reported benefits of the interventions included less distress from symptoms, improved medical adherence and/or less use of medication, and improved knowledge. The majority of studies measuring physical activity and/or physiologic outcomes found beneficial effects. Interventions were also beneficial in terms of decreased use of urgent health care, hospitalization, visits to general practitioner and absence from school. By sharing experiences, participants had learned from each other and attained new insight on how they could manage illness‐related challenges.

Discussion

Study results corroborate previous research suggesting that different types of patient education interventions have a positive impact on children, adolescents and young adults, but research on this field is still in a starting phase. The results summed up in the current review supports the utility of patient education interventions that employ behavioural strategies tailored to the developmental needs of children, adolescents and young adults with different cultural backgrounds.

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

CONTEXT

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

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

CONTEXT

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

OBJECTIVE

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME MEASURE(S)

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

RESULTS

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

CONCLUSION

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

Lay-led and peer support interventions for adolescents with asthma

BACKGROUND

Adolescents with asthma are at high risk of poor adherence with treatment. This may be compounded by activities that worsen asthma, in particular smoking. Additional support above and beyond routine care has the potential to encourage good self-management. We wanted to find out whether sessions led by their peers or by lay leaders help to reduce these risks and improve asthma outcomes among adolescents.

OBJECTIVES

To assess the safety and efficacy of lay-led and peer support interventions for adolescents with asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register, which contains reports of randomised trials obtained from multiple electronic and handsearched sources, and we searched trial registries and reference lists of primary studies. We conducted the most recent searches on 25 November 2016.

SELECTION CRITERIA

Eligible studies randomised adolescents with asthma to an intervention led by lay people or peers or to a control. We included parallel randomised controlled trials with individual or cluster designs. We included studies reported as full text, those published as abstract only and unpublished data.

DATA COLLECTION AND ANALYSIS

Two review authors screened the searches, extracted numerical data and study characteristics and assessed each included study for risk of bias. Primary outcomes were asthma-related quality of life and exacerbations requiring at least a course of oral steroids. We graded the analyses and presented evidence in a 'Summary of findings' table.We analysed dichotomous data as odds ratios, and continuous data as mean differences (MD) or standardised mean differences, all with a random-effects model. We assessed clinical, methodological and statistical heterogeneity when performing meta-analyses, and we described skewed data narratively.

MAIN RESULTS

Five studies including a total of 1146 participants met the inclusion criteria for this review. As ever with systematic reviews of complex interventions, studies varied by design (cluster and individually randomised), duration (2.5 to 9 months), setting (school, day camp, primary care) and intervention content. Most risk of bias concerns were related to blinding and incomplete reporting, which limited the meta-analyses that could be performed. Studies generally controlled well for selection and attrition biases.All participants were between 11 and 17 years of age. Asthma diagnosis and severity varied, as did smoking prevalence. Three studies used the Triple A programme; one of these studies tested the addition of a smoke-free pledge; another delivered peer support group sessions and mp3 messaging to encourage adherence; and the third compared a peer-led asthma day camp with an equivalent camp led by healthcare practitioners.We had low confidence in all findings owing to risk of bias, inconsistency and imprecision. Results from an analysis of asthma-related quality of life based on the prespecified random-effects model were imprecise and showed no differences (MD 0.40, 95% confidence interval (CI) -0.02 to 0.81); a sensitivity analysis based on a fixed-effect model and a responder analysis suggested small benefit may be derived for this outcome. Most other results were summarised narratively and did not show an important benefit of the intervention; studies provided no analysable data on asthma exacerbations or unscheduled visits (data were skewed), and one study measuring adherence reported a drop in both groups. Effects on asthma control favoured the intervention but findings were not statistically significant. Results from two studies with high levels of baseline smoking showed some promise for self-efficacy to stop smoking, but overall nicotine dependence and smoking-related knowledge were not significantly better in the intervention group. Investigators did not report adverse events.

AUTHORS' CONCLUSIONS

Although weak evidence suggests that lay-led and peer support interventions could lead to a small improvement in asthma-related quality of life for adolescents, benefits for asthma control, exacerbations and medication adherence remain unproven. Current evidence is insufficient to reveal whether routine use of lay-led or peer support programmes is beneficial for adolescents receiving asthma care.Ongoing and future research may help to identify target populations for lay-led and peer support interventions, along with attributes that constitute a successful programme.

Impact of Community Health Workers on Use of Healthcare Services in the United States: A Systematic Review

BACKGROUND

As the US transitions to value-based healthcare, physicians and payers are incentivized to change healthcare delivery to improve quality of care while controlling costs. By assisting with the management of common chronic conditions, community health workers (CHWs) may improve healthcare quality, but physicians and payers who are making choices about care delivery also need to understand their effects on healthcare spending.

METHODS

We searched PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycINFO, Embase, and Web of Science from the inception of each database to 22 June 2015. We included US-based studies that evaluated a CHW intervention for patients with at least one chronic health condition and reported cost or healthcare utilization outcomes. We evaluated studies using tools specific to study design.

RESULTS

Our search yielded 2,941 studies after removing duplicates. Thirty-four met inclusion and methodological criteria. Sixteen studies (47%) were randomized controlled trials (RCTs). RCTs typically had less positive outcomes than other study designs. Of the 16 RCTs, 12 reported utilization outcomes, of which 5 showed a significant reduction in one or more of ED visits, hospitalizations and/or urgent care visits. Significant reductions reported in ED visits ranged from 23%-51% and in hospitalizations ranged from 21%-50%, and the one significant reduction in urgent care visits was recorded at 60% (p < 0.05 for all).

DISCUSSION

Our results suggest that CHW interventions have variable effects, but some may reduce costs and preventable utilization. These findings suggest that it is possible to achieve reductions in care utilization and cost savings by integrating CHWs into chronic care management. However, variations in cost and utilization outcomes suggest that CHWs alone do not make an intervention successful. The paucity of rigorous studies and heterogeneity of study designs limited conclusions about factors associated with reduced utilization.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Home visits are needed to address asthma health disparities in adults

Research on asthma frequently recruits patients from clinics because the ready pool of patients leads to easy access to patients in office waiting areas, emergency departments, or hospital wards. Patients with other chronic conditions, and with mobility problems, face exposures at home that are not easily identified at the clinic. In this article, we describe the perspective of the community health workers and the challenges they encountered when making home visits while implementing a research intervention in a cohort of low-income, minority patients. From their observations, poor housing, often the result of poverty and lack of social resources, is the real elephant in the chronic asthma room. To achieve a goal of reduced asthma morbidity and mortality will require a first-hand understanding of the real-world social and economic barriers to optimal asthma management and the solutions to those barriers.

Evaluation of a Home-Based Environmental and Educational Intervention to Improve Health in Vulnerable Households: Southeastern Pennsylvania Lead and Healthy Homes Program

This evaluation examined whether participation in a home-based environmental educational intervention would reduce exposure to health and safety hazards and asthma-related medical visits. The home intervention program focused on vulnerable, low-income households, where children had asthma, were at risk for lead poisoning, or faced multiple unsafe housing conditions. Home visitors conducted two home visits, two months apart, consisting of an environmental home assessment, Healthy Homes education, and distribution of Healthy Homes supplies. Measured outcomes included changes in participant knowledge and awareness of environmental home-based hazards, rate of children’s asthma-related medical use, and the presence of asthma triggers and safety hazards. Analysis of 2013–2014 baseline and post-intervention program data for a cohort of 150 families revealed a significantly lower three-month rate (p < 0.05) of children’s asthma-related doctor visits and hospital admissions at program completion. In addition, there were significantly reduced reports of the presence of home-based hazards, including basement or roof leaks (p = 0.011), plumbing leaks (p = 0.019), and use of an oven to heat the home (p < 0.001). Participants’ pre- and post- test scores showed significant improvement (p < 0.05) in knowledge and awareness of home hazards. Comprehensive home interventions may effectively reduce environmental home hazards and improve the health of asthmatic children in the short term.

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

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTIONS

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

RESULTS

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

CONCLUSION

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

Cost-consequence analysis of multimodal interventions with environmental components for pediatric asthma in the state of Maryland

BACKGROUND

Applied environmental strategies for asthma control are often expensive, but may save longer-term healthcare costs. Whether these savings outweigh additional costs of implementing these strategies is uncertain.

METHODS

We conducted a systematic review to estimate the expenditures and savings of environmental interventions for asthma in the state of Maryland. Direct costs included hospitalizations, emergency room, and clinic visits. Indirect expenditures included costs of lost work productivity and travel incurred during the usage of healthcare services. We used decision analysis, assuming a hypothetical cohort of the approximated 49,290 pediatric individuals in Maryland with persistent asthma, to compare costs and benefits of environmental asthma interventions against the standard of care (no intervention) from the societal perspective.

RESULTS

Three interventions among nine articles met the inclusion criteria for the systematic review: 1) environmental education using medical professionals; 2) education using non-medical personnel; and 3) multi-component strategy involving education with non-medical personnel, allergen-impermeable covers, and pest management. All interventions were found to be cost-saving relative to the standard of care. Home environmental education using non-medical professionals yielded the highest net savings of $14.1 million (95% simulation interval (SI): $-.283 million, $19.4 million), while the multi-component intervention resulted in the lowest net savings of $8.1 million (95% SI: $-4.9 million, $15.9 million). All strategies were most sensitive to the baseline number of hospitalizations in those not receiving targeted interventions for asthma.

CONCLUSIONS

Limited environmental reduction strategies for asthma are likely to be cost-saving to the healthcare system in Maryland and should be considered for broader scale-up in other economically similar settings.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of the environment on asthma control

Asthma is a complex condition that requires individualized interventions. The purpose of this article is to describe the relationship between the physical and social environments with asthma symptoms, present evidence that supports environmental interventions in asthma control and the implications for asthma management. There is evidence that indoor and outdoor allergens relate to asthma morbidity. Knowledge about which environmental exposures present risk is essential because many of these exposures can be modified, reduced, or eliminated. The community health nurse should provide care relative to the client's indoor and outdoor environment and existing allergens.

The role of lay health workers in pediatric chronic disease: a systematic review

BACKGROUND

Children with chronic diseases represent a high-cost and resource-intensive population of children. With continued gaps in chronic disease management and persistent fragmentation in the health care system, stakeholders are seeking new strategies to address the needs of these children.

OBJECTIVE

We sought to systematically assess the effectiveness of lay health worker interventions in improving health care utilization, symptom management, and family psychosocial outcomes for children with chronic conditions.

DATA SOURCE

PubMed, PsycINFO, and Web of Science (January 1961 to February 2013).

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We developed a strategy to search citations to identify relevant articles. Search terms included randomized controlled trial (RCT), lay worker, parent mentor, peer mentor, peer educator, community health workers, community health aids, patient advocate, patient facilitator, patient liaison, promotoras(es), care ambassadors, patient navigator, and nonprofessional. Additional studies were identified by searching the reference lists of retrieved articles and contacting clinical experts. RCTs of lay health worker interventions for children with chronic conditions were included. Studies were restricted to those concentrated on children 0-18 years of age with chronic illnesses.

STUDY APPRAISAL AND SYNTHESIS METHODS

Abstracts were independently screened by 2 reviewers. Articles with relevant abstracts underwent full text review and were evaluated for inclusion criteria. A structured tool was used to abstract data from selected articles. Because of the heterogeneous interventions and outcomes, we did not conduct a meta-analysis.

RESULTS

The search yielded 736 unique articles, of which 17 met inclusion criteria. All interventions focused on specific conditions: asthma, type I diabetes, obesity, and failure to thrive. Interventions were heterogeneous in frequency, mode, and duration of interactions between lay health workers and subjects. Several interventions were multifaceted, including both one-on-one and group interactions. Improved outcomes most commonly reported were reduced urgent care use, decreases in symptoms, fewer missed work and school days, and increased parental quality of life. One study demonstrated that lay health worker interventions were cost-effective.

CONCLUSIONS

Lay health workers interventions in children with chronic conditions may lead to modest improvements in urgent care use, symptoms, and parental psychosocial outcomes. Such interventions may also be cost-effective. Future research should focus on interventions targeted toward other chronic conditions such as sickle cell disease or cystic fibrosis and medically complex children whose conditions are noncategorical.

A framework to evaluate the cultural appropriateness of intervention research

Marked racial disparities exist in the prevalence, mortality, and treatment of asthma, between African American and White children and adolescents, despite increases in intervention trials to improve asthma outcomes. Yet, interventions to improve African American children's health must be culturally appropriate. To date, limited frameworks are available to decide whether an intervention tested with a targeted minority population employs a culturally appropriate design. In this article, we applied Bernal, Bonilla, and Bellido's ecological validity model to examine the cultural appropriateness of 12 randomized controlled trials of asthma self-management interventions published from 2000 to 2010. Most frequently met criteria were culturally appropriate methods of development and/or adaptation of interventions and inclusion of theoretical models. Least often met criteria were incorporating metaphors pertinent to participants and application of the language dimension. Based on this analysis, it is clear that an overarching framework is needed to guide the development of culturally targeted interventions.

Community-based approaches to controlling childhood asthma

The prevalence and burden of childhood asthma remain high and are increasing. Asthma hot spot neighborhoods around the country face particular challenges in controlling the effects of the condition. Increasing attention is being paid to developing interventions that recognize the child and family as the primary managers of disease and to introducing assistance that reaches beyond the clinical care setting into the places where families live and work. A range of types of community-focused interventions has been assessed in the past decade in schools, homes, and community health clinics, and programs using electronic media and phone links have been evaluated. Stronger evidence for all these approaches is needed. However, school-based programs and community coalitions designed to bring about policy and systems changes show particular promise for achieving sustainable improvements in asthma control. Research is needed that emphasizes comparisons among proven asthma control interventions, translation of effective approaches to new settings and communities, and institutionalization of effective strategies.

Outcomes of Asthma Education and Healthy Homes Curriculum Provided Through Community Health Workers in South Texas Colonias

Background. Childhood asthma rates are highest among minorities and among those who reside in low-income communities. This is especially true of children who reside in colonias, which are defined as substandard housing communities in irregular rural settlements located along the US-Mexico border. This study aimed to evaluate the knowledge acquired by participants before and after an educational intervention was provided. Methods. This study used the healthy homes training approach, including integrated pest management, identification of asthma triggers, and asthma case management, to increase asthma management awareness and control. This dual training approach combined a healthy homes module with asthma education and was implemented by certified promotoras (community health workers) in South Texas colonias. Promotoras are generally trusted and respected individuals who live in or around the communities in which they work. The promotoras identified and trained 108 parents of children aged between 5 and 12 years in households in Hidalgo County with lifetime asthma diagnosed by his/her physician and of children who may not have been diagnosed by a health professional with asthma but suffer from symptoms of asthma. Results. Asthma management and healthy homes knowledge, including attitudes and practices, significantly improved among parents after the implementation of the dual training program. Of the 108 participants, 78% had never received asthma education, 78% had a child with lifetime asthma diagnosed by his/her physician, and 32% reported having medical insurance. Pretest and posttest comparison results based on 9 out of 14 questions related to asthma triggers and healthy home principles showed a significant improvement in knowledge gained among the participants. Regardless of the study limitations (self-report instrument for the pretest and the posttest), the results showed that families in colonias living with asthma benefit from an integrated training approach.

Home-based educational interventions for children with asthma

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

What Is the Evidence That Environmental Remediation Programs Are Effective in Urban Children With Allergic Asthma? An Integrated Review

Children with allergic asthma living in urban areas are exposed to heavy loads of allergens that adversely affect their health. The purpose of this inquiry was to determine if environmental remediation programs for urban exposures are effective. Research articles relevant to this topic were obtained by conducting a literature search of the Cumulative Index of Nursing and Allied Health Literature, PubMed Plus, and Google Scholar databases. Search terms included combinations of asthma, environmental remediation, environmental triggers, environmental interventions, urban, and allergies. Out of 27 articles retrieved, 14 meeting inclusion and exclusion criteria were retained. When considered together, it appears that multiple-trigger environmental remediation programs are more effective than single- trigger programs in reducing asthma morbidity. To produce the best outcome, these programs should be tailored to a child’s specific sensitization and exposure. Asthma educators play a role in allergen remediation programs, beginning with educating their patients about environmental triggers and referring them, as needed, to more intensive remediation programs and resources.

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

CONTEXT

A recent systematic review of home-based, multi-trigger, multicomponent interventions with an environmental focus showed their effectiveness in reducing asthma morbidity among children and adolescents. These interventions included home visits by trained personnel to assess the level of and reduce adverse effects of indoor environmental pollutants, and educate households with an asthma client to reduce exposure to asthma triggers. The purpose of the present review is to identify economic values of these interventions and present ranges for the main economic outcomes (e.g., program costs, benefit-cost ratios, and incremental cost-effectiveness ratios).

EVIDENCE ACQUISITION

Using methods previously developed for Guide to Community Preventive Services economic reviews, a systematic review was conducted to evaluate the economic efficiency of home-based, multi-trigger, multicomponent interventions with an environmental focus to improve asthma-related morbidity outcomes. A total of 1551 studies were identified in the search period (1950 to June 2008), and 13 studies were included in this review. Program costs are reported for all included studies; cost-benefit results for three; and cost-effectiveness results for another three. Information on program cost was provided with varying degrees of completeness: six of the studies did not provide a list of components included in their program cost description (limited cost information), three studies provided a list of program cost components but not a cost per component (partial cost information), and four studies provided both a list of program cost components and costs per component (satisfactory cost information).

EVIDENCE SYNTHESIS

Program costs per participant per year ranged from $231-$14,858 (in 2007 U.S.$). The major factors affecting program cost, in addition to completeness, were the level of intensity of environmental remediation (minor, moderate, or major), type of educational component (environmental education or self-management), the professional status of the home visitor, and the frequency of visits by the home visitor. Benefit-cost ratios ranged from 5.3-14.0, implying that for every dollar spent on the intervention, the monetary value of the resulting benefits, such as averted medical costs or averted productivity losses, was $5.30-$14.00 (in 2007 U.S.$). The range in incremental cost-effectiveness ratios was $12-$57 (in 2007 U.S.$) per asthma symptom-free day, which means that these interventions achieved each additional symptom-free day for net costs varying from $12-$57.

CONCLUSIONS

The benefits from home-based, multi-trigger, multicomponent interventions with an environmental focus can match or even exceed their program costs. Based on cost-benefit and cost-effectiveness studies, the results of this review show that these programs provide a good value for dollars spent on the interventions.

Telephone case management for asthma: an acceptable and effective intervention within a diverse pediatric population

BACKGROUND

Asthma disproportionately affects low-income and medically underserved children; additional tools are needed in the effort to improve asthma care.

OBJECTIVES

We reviewed the implementation of a telephone case management program provided by community health workers (CHWs) as an alternative to home visits, to examine its efficiency, acceptability, and capacity to identify and address challenges with asthma management.

METHODS

This retrospective cohort study included children (and their caregivers) presenting for scheduled visits to a comprehensive asthma clinic at an urban, public hospital during 2007.

RESULTS

Overall, 83.2% of caregivers were contacted for follow-up. Of those not reachable, one-third had been discharged from the clinic, and most of the remainder later returned for a subsequent visit. Latino patients were more likely not to be reached by telephone (p < .001). Following the implementation of telephone case management, the number of patient visits to the asthma clinic increased by almost one-third.

CONCLUSIONS

Telephone case management identified problems which were successfully addressed through improved patient care practices and system changes within the clinic. Telephone case management by CHWs can be an efficient, acceptable mechanism to supplement comprehensive asthma care in a diverse, urban pediatric population.

Educational and behavioral interventions for asthma: who achieves which outcomes? A systematic review

OBJECTIVES

Randomized clinical trial (RCT) data reviewed for outcomes and processes associated with asthma educational and behavioral interventions provided by different types of health professionals.

METHODS

Cochrane Collaboration, MEDLINE, PUBMED, Google Scholar search from 1998 to 2009 identified 1650 articles regarding asthma educational and behavioral interventions resulting in 249 potential studies and following assessment produced a final sample of 50 RCTs.

RESULTS

Approaches, intended outcomes, and program providers vary greatly. No rationale provided in study reports for the selection of specific outcomes, program providers, or program components. Health care utilization and symptom control have been the most common outcomes assessed. Specific providers favor particular teaching approaches. Multidisciplinary teams have been the most frequent providers of asthma interventions. Physician-led interventions were most successful for outcomes related to the use of health care. Multidisciplinary teams were best in achieving symptom reduction and quality of life. Lay persons were best in achieving self-management/self-efficacy outcomes. Components most frequently employed in successful programs are skills to improve patient-clinician communication and education to enhance patient self-management. Fifty percent of interventions achieved reduction in the use of health care and one-third in symptom control. A combination approach including self-management and patient-clinician communication involving multidisciplinary team members may have the greatest effect on most outcomes.

CONCLUSIONS

The extent to which and how different providers achieve asthma outcomes through educational and behavioral interventions is emerging from recent studies. Health care use and symptom control are evolving as the gold standard for intervention outcomes. Development of self-management and clinician-patient communication skills are program components associated with success across outcomes and providers.

Indigenous healthcare worker involvement for Indigenous adults and children with asthma

BACKGROUND

Asthma education is regarded as an important step in the management of asthma in national guidelines. Racial, ethnicity and socio-economic factors are associated with markers of asthma severity, including recurrent acute presentations to emergency health facilities. Worldwide, indigenous groups are disproportionately represented in the severe end of the asthma spectrum. Appropriate models of care are important in the successful delivery of services, and are likely contributors to improved outcomes for people with asthma.

OBJECTIVES

To determine whether involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programs, improves asthma related outcomes in indigenous children and adults with asthma.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases, review articles and reference lists of relevant articles. The latest search was in January 2010.

SELECTION CRITERIA

All randomised controlled trials comparing involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programs for indigenous people with asthma.

DATA COLLECTION AND ANALYSIS

Two independent review authors selected data for inclusion, a single author extracted the data. Both review authors independently assessed study quality. We contacted authors for further information. As it was not possible to analyse data as "intention-to-treat", we analysed data as "treatment received".

MAIN RESULTS

Two studies fulfilled inclusion criteria involving 133 children randomised to an asthma education programme involving an IHW, compared to a similar education programme without an IHW. One study was not strictly Indigenous. 110 of these children completed the trials. Children's asthma knowledge score was significantly better in the group that had IHW education compared with control (mean difference 3.30; 95% CI 1.07 to 5.53), parents' asthma knowledge score (standardised mean difference (SMD) 1.23; 95% CI 0.59 to 1.87), parents' asthma skill score (SMD 0.67; 95% CI 0.28 to 1.06) and days absent from school (100% school-aged children in the intervention group missed <7 days, 21% of controls missed 7-14 days, difference = 21%, 95%CI 5-36%). There was no significant difference in mean number of exacerbations (per year) between groups. There was no difference in quality of life or children's asthma skill score; both were limited to one study only and the direction favoured IHW group. There were no studies in adults.

AUTHORS' CONCLUSIONS

The involvement of IHW in asthma programs targeted for their own ethnic group in 2 small trials was beneficial in improving most, but not all asthma outcomes in children with asthma. It is very likely that involvement of an IHW is beneficial. However as exacerbation frequency was not significantly different between groups, we cannot be confident of the results in all settings. Nevertheless, given the complexity of health outcomes and culture as well as the importance of self-determination for indigenous peoples, the practice of including IHW in asthma education programs for indigenous children and adults with asthma is justified, but should be subject to further randomised controlled trials.

Impact of a household environmental intervention delivered by lay health workers on asthma symptom control in urban, disadvantaged children with asthma

OBJECTIVES

We examined whether a home-based educational and environmental intervention delivered by lay health educators would improve asthma symptom control in inner-city children with asthma.

METHODS

Children 2 to 16 years of age with diagnosed asthma and at least 1 asthma-related hospitalization or 2 emergency visits in the prior year were randomly assigned into 2 groups (immediate and delayed intervention) in a crossover study. Each group participated in the active phase (intervention) and the inactive phase. Outcomes included asthma symptoms, albuterol use, emergency department visits, hospitalizations, and trigger reduction.

RESULTS

A total of 264 primarily Black (94%) children were enrolled. The mean number of emergency visits decreased by 30% and inpatient visits decreased by 53% (P < .001) after the intervention. Reductions were seen in pests, presence of carpets in bedrooms, and dust. Nighttime wheezing was significantly reduced after the intervention in both groups (P < .001).

CONCLUSIONS

Lay health educators effectively reduced asthma triggers and increased caregiver asthma knowledge, which resulted in reduced emergency department visits, hospitalizations, and asthma symptoms. The relationships formed between the caregivers and the lay health educators appeared to positively impact asthma outcomes in this disadvantaged population.

Recent innovations to improve asthma outcomes in vulnerable children

PURPOSE OF REVIEW

Despite overall improvements in asthma care through an increasing evidence base, disparities in outcomes of children of ethnic minorities and low socioeconomic status are well documented across healthcare systems. New interventions to reduce gaps in outcomes among these children are continually being evaluated. This article reviews the most relevant and influential recent studies.

RECENT FINDINGS

A number of interventions aimed at vulnerable children with asthma have been successful. Most of these include a component of education and self-management. There is some evidence that culturally competent care produces improved outcomes, whereas stronger evidence exists for multifaceted programs and community health workers providing home visits for education and environmental allergen reduction. Targeting children and families through school-based programs may be an effective outreach strategy. Use of novel technologies such as educational messages on MP3 players shows promise in reaching at-risk adolescents.

SUMMARY

There are promising strategies proven to significantly decrease disparities in asthma among vulnerable children. Further research must be performed to elucidate the interventions that produce the greatest impact on asthma-related outcomes while being feasible, sustainable, and cost-effective.

Community health workers and environmental interventions for children with asthma: a systematic review

Community health worker (CHW)-delivered, home-based environmental interventions for pediatric asthma were systematically reviewed. Seven PubMed/MEDLINE listed randomized controlled trials that encompassed the following intervention criteria were identified: (1) home-based; (2) delivered by a CHW; (3) delivered to families with children with asthma; and (4) addressed multiple environmental triggers for asthma. Details of research design, intervention type, and setting, interventionist, population served, and the evaluated outcomes were abstracted. Outcome assessment was broad and non-uniform. Categories included direct mediators of improved health outcomes, such as trigger-related knowledge, trigger reduction behaviors and allergen or exposure levels, and asthma-related health outcomes: change in lung function, medication use, asthma symptoms, activity limitations, and health care utilization. Indirect mediators of health outcomes, or psychosocial influences on health, were measured in few studies. Overall, the studies consistently identified positive outcomes associated with CHW-delivered interventions, including decreased asthma symptoms, daytime activity limitations, and emergency and urgent care use. However, improvements in trigger reduction behaviors and allergen levels, hypothesized mediators of these outcomes, were inconsistent. Trigger reduction behaviors appeared to be tied to study-based resource provision. To better understand the mechanism through which CHW-led environmental interventions cause a change in asthma-related health outcomes, information on the theoretical concepts that mediate behavior change in trigger control (self-efficacy, social support) is needed. In addition, evaluating the influence of CHWs as clinic liaisons that enhance access to health professionals, complement clinic-based teaching, and improve appropriate use of asthma medications should be considered, alongside their effect on environmental management. A conceptual model identifying pathways for future investigation is presented.

Asthma disparities in urban environments

Asthma continues to disproportionately affect minority and low-income groups, with African American and Latino children who live in low-socioeconomic-status urban environments experiencing higher asthma morbidity and mortality than white children. This uneven burden in asthma morbidity has been ever increasing despite medical advancement. Many factors have contributed to these disparities in the areas of health care inequities, which result in inadequate treatment; poor housing, which leads to increased exposure to asthma allergens; and social and psychosocial stressors, which are often unappreciated. Interventions to reduce individual areas of disparities have had varying successes. Because asthma is a complex disease that affects millions of persons, multifaceted comprehensive interventions that combine all evidence-based successful strategies are essential to finally closing the gap in asthma morbidity.

Indigenous healthcare worker involvement for Indigenous adults and children with asthma

BACKGROUND

Asthma education is regarded as an important step in the management of asthma in national guidelines. Racial and socio-economic factors are associated with markers of asthma severity, including recurrent acute presentations to emergency health facilities. Worldwide, indigenous groups are disproportionately represented in the severe end of the asthma spectrum. Appropriate models of care are important in the successful delivery of services, and are likely contributors to improved outcomes for people with asthma.

OBJECTIVES

To determine whether involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programmes, improves asthma related outcomes in indigenous children and adults with asthma.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases, review articles and reference lists of relevant articles. The latest search was in December 2006.

SELECTION CRITERIA

All randomised controlled trials comparing involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programmes for indigenous people with asthma.

DATA COLLECTION AND ANALYSIS

Two independent review authors selected data for inclusion, a single author extracted the data. Both review authors independently assessed study quality. We contacted authors for further information. As it was not possible to analyse data as "intention-to-treat", we analysed data as "treatment received".

MAIN RESULTS

Only a single study was applicable for this review, and included 24 children randomised to an asthma education programme involving an IHW, compared to a similar intervention without an IHW. Twenty two of these children completed the trial. Only one outcome (asthma knowledge in children, mean difference of 3.30 units, 95% CI 1.07 to 5.53) significantly favoured the IHW involvement group. However, although not statistically significant, all the outcomes favoured the group that had IHW involvement in the asthma education program. There were no studies in adults.

AUTHORS' CONCLUSIONS

The involvement of IHW in asthma programs targeted for their own ethnic group in one small trial was beneficial for some but not all asthma outcomes. Thus there is insufficient data to be confident that the involvement of IHW is beneficial in all settings. Nevertheless, given the complexity of health outcomes and culture as well as the importance of self-determination for indigenous peoples, the practice of including IHW in asthma education programs for indigenous children and adults with asthma is justified, but should be subject to further randomised controlled trials.