Implementation of an asthma intervention in the inner city

Improving childhood asthma outcomes in East Harlem: the East Harlem Asthma Center of Excellence's Asthma Counselor Program

OBJECTIVES

To evaluate the effectiveness of the Asthma Counselor Program, a program of the New York City Department of Health and Mental Hygiene, designed to improve asthma outcomes among children.

METHODS

We used a pre-post study design among children who enrolled in the program. We included self-reported outcome measures by comparing the previous 12 months (captured at intake) to the 12 months following program enrollment. To calculate the 12 months after enrollment, we added the number of outcome events reported at each follow-up session, which are conducted approximately three months apart, to compute 12-month (or "year-end") post-enrollment outcomes.

RESULTS

We enrolled 136 children during the study period (2018); 85 children remained in the program for 12 months and 51 became lost-to-follow-up. Among those who remained in the program, at the "year-end" session, there were statistically significant reductions in the mean number of asthma-related unscheduled healthcare appointments or urgent-care visits (73%), uses of prednisone (65%), asthma-related school absences (60%), asthma-related ED visits (57%), and asthma-related hospitalizations (50%).

CONCLUSIONS

Twelve months after children enrolled in the program, they had significantly improved asthma outcomes. Our findings, along with results from similar studies, support multicomponent interventions, especially those led by masters-level social workers.

Assessment of a University-Based Outpatient Asthma Education Program for Children

INTRODUCTION

To assess the effect of a pediatric asthma intervention program on reducing asthma morbidity.

METHODS

Study eligibility criteria included aged less than 18 years and at least two office visits for asthma in the previous year. Patients were randomly assigned to either the control or intent to intervene group. The intervention included home visits and education on the basic pathophysiology of asthma, self-management techniques, modification of asthma triggers, and proper use of asthma medications by a certified nurse educator.

RESULTS

Using simple randomization, 901 eligible pediatric patients with asthma were assigned; 458 to the control and 443 to the intent to intervene group. Of the 443 patients randomized to the intent to intervene group, 271 received the asthma education intervention. Most of the remaining 172 patients in the intent to intervene group did not receive the intervention owing to not having an appointment during the study period. Only 27 families allowed a home visit. After controlling for the difference in sex, children in the intent to intervene group had significantly less total clinic visits (incidence rate ratio [IRR] = 0.53, p < .01), and steroid bursts (IRR = 0.47, p < .01) than controls.

DISCUSSION

The implementation of a pediatric asthma education program decreased both the total clinic visits and the need for steroid bursts consistent with better asthma control. We demonstrated the benefit of a dedicated asthma educator in university-based community practice and recommend this intervention be considered a standard of care for children with asthma in all health-care settings.

Effectiveness of Evidence-Based Asthma Interventions

BACKGROUND AND OBJECTIVES

Researchers often struggle with the gap between efficacy and effectiveness in clinical research. To bridge this gap, the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) study adapted an efficacious, randomized controlled trial that resulted in evidence-based asthma interventions in community health centers.

METHODS

Children (aged 5-12 years; N = 590) with moderate to severe asthma were enrolled from 3 intervention and 3 geographically/capacity-matched control sites in high-risk, low-income communities located in Arizona, Michigan, and Puerto Rico. The asthma intervention was tailored to the participant's allergen sensitivity and exposure, and it comprised 4 visits over the course of 1 year. Study visits were documented and monitored prospectively via electronic data capture. Asthma symptoms and health care utilization were evaluated at baseline, and at 6 and 12 months.

RESULTS

A total of 314 intervention children and 276 control children were enrolled in the study. Allergen sensitivity testing (96%) and home environmental assessments (89%) were performed on the majority of intervention children. Overall study activity completion (eg, intervention visits, clinical assessments) was 70%. Overall and individual site participant symptom days in the previous 4 weeks were significantly reduced compared with control findings (control, change of -2.28; intervention, change of -3.27; difference, -0.99; P < .001), and this result was consistent with changes found in the rigorous evidence-based interventions.

CONCLUSIONS

Evidence-based interventions can be successfully adapted into primary care settings that serve impoverished, high-risk populations, reducing the morbidity of asthma in these high-need populations.

Minimal difference in the prevalence of asthma in the urban and rural environment

Multiple risk factors can be modified to decrease asthma incidence. It is important to understand early risks to decrease exposure to harmful conditions in the environment that can trigger asthma which may not be clinically evident in children until they reach adulthood. A retrospective literature review of articles on the prevalence of asthma in the urban versus rural environment was initiated in order to understand the effect of the environment on asthma. The urban-living effect is a global problem in the face of growing population, industrialization and pollution. The socioeconomic dichotomy in the urban versus rural environment also affects access and quality of health care.

Articles reviewed had differences in the urban versus rural prevalence of asthma. However, further analysis of specific risk factors and socioeconomic trends that increased susceptibility to asthma was the same in these studies. Some rural areas may have similar environmental and socioeconomic issues that place them at the same risk for the development of asthma as their urban counterparts.

Urban locations generally tend to have the prototype environment that can lead to the predisposition of asthma. Ultimately, the incidence of asthma can be decreased if these environmental and socioeconomic issues are addressed. However, every effort is needed from the level of the individual to the community at large.

The implementation of Good For The Neighborhood: a participatory community health program model in four minority underserved communities

To describe the participatory approach used to develop "Good For The Neighborhood" (GFTN), a community program to improve the health of four underserved communities. A core program was developed involving a "park and stay" approach to impact four underserved predominately minority communities (two predominately African American, 1 predominately Latino, and the Seneca Nation of Indians). The core program includes health screenings, risk assessments, health education, and exposure to health services. An extensive tracking and evaluation system was developed to determine participation and impact on the community. Multi-methods (key informant interviews, focus groups, surveys) were implemented to gain feedback from community partners and participants as to how to adopt the program to meet the needs of the community. GFTN has been sustained for over 3 years and has reached over 3,500 predominately minority individuals in four communities with 1/3 of participants engaging regularly in the program. The program has evolved in the four communities to meet specific needs. A "park and stay" approach in partnership with the community has led to a strong program that community partners and residents embrace. Community ownership and social networking, including word-of-mouth from residents is essential to establishing a successful program.

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

OBJECTIVE

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

DESIGN

Randomized controlled trial.

SETTING

Community and public health clinics and homes.

PARTICIPANTS

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

INTERVENTIONS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Moderate and vigorous exercise programs in children with asthma: safety, parental satisfaction, and asthma outcomes

BACKGROUND

Previous research suggests that physical activity programs may improve fitness and reduce symptoms in children with asthma, but few studies have included severe asthmatics and focused on safety and parental satisfaction with the programs.

OBJECTIVE

To examine safety, parental satisfaction, and pre- to post-intervention changes in symptoms and quality of life (QOL) in a pilot study of the impact of vigorous physical activity (swimming) and moderate-intensity activity (golf) on inner-city children with asthma.

DESIGN/METHODS

Children with asthma (7-14 years old) residing in Milwaukee's highest asthma prevalence zip codes were randomized to a 9-week swimming or golf program. Pre- and post-intervention data were obtained on safety, parental satisfaction, asthma symptoms, quality of life, and urgent asthma physician visits.

RESULTS

Twenty-eight children in the swimming group and 17 in the golf group completed the program. Combined group analysis (N = 45) revealed that only six symptom exacerbations occurred during 1,125 person-sessions of swimming and golf (all resolved with bronchodilator therapy), 92% of parents were very or extremely satisfied with the program, and post-exercise decreases were observed in asthma symptom severity scores (9.3-7.3, P < 0.001), improved parental QOL (4.9-5.4, P < 0.001), and reduced urgent physician visits for asthma (1.3-0.2 visits per person, P = 0.04). The study lacked sufficient power to perform intergroup comparisons.

CONCLUSIONS

Findings from this pilot study indicate that vigorous (swimming) and moderate-intensity (golf) physical activity programs are well-tolerated, safe, and achieve high parental satisfaction. Participants and parents reported reduced childhood asthma symptoms and physician office visits and improved parental QOL. These findings suggest a potentially beneficial role for moderate to vigorous physical activity in childhood asthma.

Selective provision of asthma self-management tools to families

OBJECTIVE

Providing asthma education in a primary care setting can be challenging because of time and resource constraints. The purpose of this work was to determine factors associated with the provision of different asthma self-management tools.

METHODS

We conducted a cross-sectional survey with 896 parents of children with asthma (age 2-12 years). We collected information regarding demographics and asthma care, including parent receipt of an asthma action plan, a symptom diary, and asthma information materials; whether an asthma management plan was sent to the child's school; and whether the physician reviewed written instructions on use of a metered-dose inhaler. We used multivariate logistic regression methods to determine factors associated with receipt of different asthma self-management tools controlling for demographic factors.

RESULTS

For families where parents only completed high school, there was greater likelihood of receipt of an asthma action plan and physician review of written instructions about how to use an inhaler. For families with a household income less than twice the poverty line, there was greater likelihood of receipt of an asthma action plan, the physician sending a letter to the child's school regarding the child's asthma, and receipt of an asthma symptom diary.

CONCLUSIONS

In our sample, primary care pediatricians do not routinely provide asthma education in accordance with National Heart, Lung, and Blood Institute asthma guidelines and "triage" which families receive additional asthma education. We believe that the use of targeted asthma education is a symptom of the limited time and competing demands during a typical visit. As a result, those involved in quality improvement need to help physicians become more efficient and effective at providing asthma education within such time constraints or develop alternative systems of providing asthma education.

The Inner-City Asthma Intervention asthma counselor program: a collaborative model between physician and social worker to help empower families

BACKGROUND

The Inner-City Asthma Intervention (ICAI) asthma counselor program was modeled after interventions proven to be effective by the National Cooperative Inner-City Asthma Study (NCICAS) with inner-city children with asthma. The objective of the ICAI program was to translate and implement the NCICAS intervention into the real-world setting.

OBJECTIVE

To describe the unique pairing of a master's degree-level social worker asthma counselor (AC) and physician program manager (PM) as they collaborate to implement a successful chronic disease intervention program.

METHODS

A case-study design was used to describe the asthma counselor program collaboration at our site. This information was supplemented by additional qualitative data from the final report submitted by the Alliance of Community Health Plans to the Centers for Disease Control and Prevention and from questionnaire data and enrollment and retention data compiled by Wood et al.

RESULTS

A master's degree level trained social worker functioned as an AC and successfully collaborated with a physician PM to help combat one of the most common chronic diseases of childhood. This is evident when evaluating administration, recruitment, education and system issues, and community outreach.

CONCLUSIONS

The AC/PM partnership is a blueprint of how a successful collaboration may be duplicated by future social worker-physician teams. An effective program needs to address administrative issues, patient recruitment, ongoing team education, patient retention, and community outreach. Practical examples of each element are described.

The Inner-City Asthma Intervention: description of a community-based implementation of an evidence-based approach to asthma management

BACKGROUND

In 2000, the Centers for Disease Control and Prevention funded a 4-year project to implement the Inner-City Asthma Intervention (ICAI)-an asthma treatment and management project based on the protocol developed for the National Cooperative Inner-City Asthma Study (NCICAS) funded by the National Institutes of Health, National Institute of Allergy and Infectious Disease.

OBJECTIVE

To describe the ICAI's major components and implementation issues.

METHODS

Information contained in this article is based on project activity and management reports, site client tracking and data collection reports, site visit and other program oversight activity, and general subject matter knowledge. The site client tracking data collection process varied among sites during the intervention. Common definitions and processes were developed and implemented as needed.

RESULTS

Three of the 24 original sites discontinued participation. The remaining sites enrolled 4,174 children into the intervention. Although the project ended earlier than originally scheduled, 1,035 children completed the entire intervention. Of the 3,139 children who did not complete the entire protocol, 1,355 children and their families completed the core activities or the core activities plus one or more follow-up activities.

CONCLUSION

The ICAI project demonstrated that although there were a number of implementation issues to overcome, it is possible to implement effectively a proven National Institutes of Health protocol in the community setting.

From research to reality: from the National Cooperative Inner-City Asthma Study to the inner-city asthma implementation

Several themes emerged from the information provided in this supplement. 1. Implementation of the protocol was feasible, although retention of participants was challenging and customization at each site was essential. 2. Master's degree level social workers were well suited to partnering with health care professionals to address the many issues involved in caring for children with asthma and their families. 3. Collaboration between team members and community partners was critical to successful implementation. 4. Sustainability beyond external funding is attainable if local funding is sought and outcome measures that are considered important to the community are measured and reported.