Healthy Homes University: a home-based environmental intervention and education program for families with pediatric asthma in Michigan

Collaborative Integration of Community Health Workers in Hospitals and Health Centers to Reduce Pediatric Asthma Disparities: A Quality Improvement Program Evaluation

To address pediatric asthma disparities on the South Side of Chicago, a community health worker (CHW) home visiting intervention was implemented collaboratively by academic institutions and community based health centers. This evaluation assessed the effectiveness of this longitudinal quality improvement CHW intervention in reducing asthma morbidity and healthcare utilization. All patients aged 2-18 who met the high-risk clinical criteria in outpatient settings or those who visited the ED due to asthma were offered the program. A within-subject study design analyzed asthma morbidity and healthcare utilization at baseline and follow-up. Multivariable mixed-effects regression models, adjusted for baseline demographic and asthma characteristics, were used to assess changes over time. Among 123 patients, the average age was 8.8 (4.4) years, and 89.3% were non-Hispanic black. Significant reductions were observed in the average daytime symptoms days (baseline 4.1 days and follow-up 1.6 days), night-time symptoms days (3.0 days and 1.2 days), and days requiring rescue medication (4.1 days and 1.6 days) in the past two weeks (all p < 0.001). The average number of emergency department visits decreased from 0.92 one year before to 0.44 one year after program participation, a 52% reduction (p < 0.001). No significant difference was found in hospital admissions. These results support the use of a collaborative approach to implement the CHW home visiting program as part of standard care for pediatric asthma patients in urban settings. This approach has the potential to reduce asthma disparities and underscores the valuable role of CHWs within the clinical care team.

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

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CHECK: Multi-level Real-World Pediatric Asthma Care Coordination: Results and Lessons Learned

OBJECTIVE

Because asthma health disparities in children remain common, innovative approaches to obtain asthma health equity are essential. Comprehensive care coordination programs may address the social determinants of health that influence these disparities. This analysis aims to ascertain if receipt of Coordination of Healthcare for Complex Kids (CHECK) program services was associated with changes in school absence, cost, healthcare utilization, and controller prescription in children with asthma.

METHODS

The CHECK program ran from December 1^st, 2014 through August 31^st, 2017. Engagement with Community Health Workers (CHW) was rolling and targeted based on risk level (low, medium or high determined by healthcare utilization). This analysis included school-aged children with asthma (n = 2,629) and sufficient Chicago Public Schools attendance data (n = 430).

RESULTS

Children engaged in CHECK were more likely to be female (p = 0.046) and to identify as Black and/or Hispanic/Latino than enrolled-only children. School absence was not different between the groups. Average total cost for engaged children was 21.3% more than enrolled-only children the first year (p = 0.027) but did not differ by the second year (p = 0.948). At baseline, 68.1% of the cohort had at least one ED visit 12-months prior to CHECK, this reduced to 49.5% post-1 and 41.9% post-2. Engaged children were 21% more likely to visit an ED (p = 0.010) and 40% more likely to have a controller.

CONCLUSIONS

CHECK program receipt was associated with reduced costs and improved healthcare utilization, and controller prescriptions. School attendance did not change. The CHECK model offers potential pathways to support low-income children with asthma.

Effectiveness of a community-driven, asthma intervention: Project Asthma In-Home Response

Project Asthma In-home Response (AIR) is a multilevel, home-based intervention to address childhood asthma. This study aims to assess the effectiveness of the community-driven, multilevel Project AIR intervention. We hypothesize that children participating in the Project AIR intervention will have reduced asthma-related emergency room visits, hospitalizations, and asthma exacerbations. Seventy-Five participants of an in-home asthma intervention were surveyed at the onset of intervention and six months after the intervention. The mean age of clients in the sample population was ten years. Most clients in the sample population were 11 to 15 years old (34.7%), followed by 6 to 10 years old (29.3%) and 3 to 5 years (26.0%). Participation in the Project AIR intervention resulted in significant reductions in asthma attacks (p-value 0.0003), asthma-related emergency room visits (p-value >0.0001), and asthma-related hospitalizations (p-value 0.008). The results of this study support that in-home environmental asthma programs are an efficient method of treating asthma in a smaller metro area. Our findings reinforce prior studies in larger metropolitan areas such as New York and Boston (1).

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.

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.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding the potential of state-based public health genomics programs to mitigate disparities in access to clinical genetic services

Purpose

State Health Agencies (SHAs) have developed public health genomics (PHG) programs that play an instrumental role in advancing precision public health, but there is limited research on their approaches. This study examines how PHG programs attempt to mitigate or forestall health disparities and inequities in the utilization of genomic medicine.

Methods

We compared PHG programs in three states: Connecticut, Michigan, and Utah. We analyzed 85 in-depth interviews with SHA internal and external collaborators and program documents. We employed a qualitative coding process to capture themes relating to health disparities and inequities.

Results

Each SHA implemented population-level approaches to identify individuals who carry genetic variants that increase risk of hereditary cancers. However, each SHA developed a unique strategy—which we label public health action repertoires—to reach specific subgroups who faced barriers in accessing genetic services. These strategies varied across states given demographics of the state population, state-level partnerships, and availability of healthcare services.

Conclusion

Our findings illustrate the imperative of tailoring PHG programs to local demographic characteristics and existing community resources. Furthermore, our study highlights how integrating genomics into precision public health will require multilevel, multisector collaboration to optimize efficacy and equity.

Evidence-based pediatric asthma interventions and outcome measures in a healthy homes program: An integrative review

OBJECTIVE

Asthma disproportionately impacts and has poorer outcomes in low-income, minority, and inner-city children. The home environment has a profound impact on a child's asthma. Home-based asthma visits have the potential to positively impact a child's asthma, especially in targeted populations. The purpose of this integrative review is 1.) to explore the effectiveness of home-based education and environmental measures and 2.) to explore specific indicators and tools to measure pediatric asthma control and program effectiveness.

DATA SOURCES

Medline, CINHAL, and Ovid databases were searched from 2010 to 2017 utilizing the keywords healthy homes AND asthma and home based interventions AND asthma.

STUDY SELECTIONS

A total of 71 articles were retrieved of which 27 articles met the inclusion criteria of English language, human subjects, and the inclusion of pediatric populations. Three additional articles were hand-searched from previous references. In total, 30 articles were reviewed. A quality appraisal was conducted utilizing standardized appraisal tools.

RESULTS

Home-based asthma education and environmental interventions have proven to be effective. The programs reviewed varied in types of interventions, intensity and duration, the type of provider, length of follow-up, and outcome measures. Successful programs were patient-centered, included a home assessment and individualized education and interventions, and were collaborative. Multiple outcome indicators such as health care utilization, asthma control, missed days of school or productivity, asthma symptoms, and verification of environmental remediation have been utilized.

CONCLUSION

Home-based asthma programs can be beneficial to children with poorly controlled asthma and have the potential to be cost-effective.

Outcomes of the Montana Asthma Home Visiting Program: A home-based asthma education program

OBJECTIVE

Asthma is a common disease in children. Home-based, multi-trigger, multi-component interventions with an environmental focus have been shown to be effective to address asthma in children. The objective of this study was to assess the outcomes and feasibility of implementing a specific asthma home visiting (HV) program in a rural area.

METHODS

Children aged 0-17 years with uncontrolled asthma were enrolled in an asthma HV program that included six contacts over a 12-month period delivered by a registered nurse specifically trained in asthma education and trigger removal in eleven counties in the rural state of Montana. Between June 2010 and December 2016, data on asthma symptoms and asthma self-management skills were collected at baseline and throughout the program. In June 2017, they were analyzed to assess changes in asthma control and quality of life over time among participants completing all six contacts.

RESULTS

Since June 2010, 152 of 338 enrolled children completed all six contacts outlined in the program (45%). Participants who completed the program reported significant improvements in asthma control test scores, self-management skills, and self-efficacy related to asthma management. These results improved the longer participants remained in the program.

CONCLUSIONS

These findings suggest that it is feasible to implement a 12-month HV program using local public health resources in a rural area as outcomes improved over this time period.

Systematic review and content analysis of asthma knowledge questionnaires: A focus on the knowledge surrounding acute exacerbation management

OBJECTIVES

Asthma education is a key component of asthma management. Asthma education around the management of a person who is having an acute exacerbation of asthma (often referred to as asthma first aid (AFA) training) is important, particularly in a school setting. There is no gold standard assessment of asthma knowledge and also there is no specific tool to measure the knowledge of AFA. Our aim was to identify asthma knowledge questionnaires and perform a content analysis. We were interested in evaluating the number, the type and the format of AFA questions.

METHOD

A literature search was performed to identify the instruments which were able to assess asthma knowledge of people with asthma and/or caregivers of people with asthma. An electronic database search was performed in EMBASE, IPA, MEDLINE and PUBMED. Articles which described the development or psychometric testing of an asthma knowledge questionnaire were included. The content of questions in each instrument was analysed and categorised using the NVivo software, and a secondary analysis was performed to identify knowledge questions relevant to the management of an acute asthma exacerbation.

RESULTS

Forty-four papers with 37 different instruments met the inclusion criteria. The majority of the instruments contained a relatively low proportion of questions related to the management of acute asthma, i.e., only 162 of the 780 questions (21%). No questionnaire had sufficient specific emphasis on acute asthma management knowledge to test the impact of AFA training.

CONCLUSION

There is a scope to develop an up-to-date validated acute asthma management knowledge questionnaire for use in research and clinical settings.

Removing asthma triggers and improving children's health: The Asthma Partnership Demonstration project

BACKGROUND

Studies have revealed the efficacy of home-based environmental interventions on reduction of asthma symptoms as a strategy for managing asthma in children. A focus on education and behavior change alone is generally too limited to reduce exposure to asthma triggers that exist because of adverse housing conditions.

OBJECTIVE

To demonstrate that housing conditions as a focus of a health intervention should be considered more widely as an effective means of addressing serious health problems such as asthma.

METHODS

Residences of 41 families of children identified with some of the highest rates of asthma-related hospital visits were assessed for the presence of asthma triggers.

RESULTS

The intervention had a positive effect on lessening the effect of the child's asthma on the family's lives and activities. Reductions in frequency of negative effects of children's asthma on sleeping, job or work around the house, and family activity plans, fewer worries or concerns about children getting enough sleep and performing normal daily activities, and fewer adverse effects of children's asthma medications were reported. Reduced use of asthma medication, medication applications, and health visits were noted. Households with return visits had 50% lower hospital bills for childhood asthma treatment.

CONCLUSION

Home environment conditions that lead to or exacerbate asthma may be reduced or eliminated by making minor repairs and introducing reasonable cleaning regimens that address sources of asthma triggers. This can produce greater awareness on the part of families about the presence of asthma triggers and motivate future action to address the conditions associated with these triggers.

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

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

Home Environmental Interventions for the Prevention or Control of Allergic and Respiratory Diseases: What Really Works

Home health care workers interventions have been implemented in western countries to improve health status of patients with respiratory diseases especially asthma and allergic illnesses. Twenty-six controlled studies dealing with prevention and control of these diseases through home environmental interventions were reviewed. After a comprehensive description of the characteristics of these studies, the effectiveness of each intervention was then evaluated in terms of participants' compliance with the intervention program, improvement of quality of the indoor environment, and finally improvement of health outcomes, in detailed tables. Limitations and biases of the studies are also discussed. Overall, this review aims at giving a toolbox for home health care workers to target the most appropriate measures to improve health status of the patient depending on his and/or her environment and disease. Only a case-by-case approach with achievable measures will warrant the efficacy of home interventions. This review will also provide to the research community a tool to better identify targets to focus in future evaluation studies of home health care workers action.

The Determinants of Reported Personal and Household Hygiene Behaviour: A Multi-Country Study

A substantial proportion of the total infectious disease burden world-wide is due to person-to-person spread of pathogens within households. A questionnaire-based survey on the determinants of hand-washing with soap and cleaning of household surfaces was conducted in at least 1000 households in each of twelve countries across the world (N = 12,239). A structural equation model of hygiene behaviour and its consequences derived from theory was then estimated on this dataset for both behaviours, using a maximum likelihood procedure. The analysis showed that the frequency of handwashing with soap is significantly related to how automatically it is performed, and whether or not someone is busy, or tired. Surface cleaning was strongly linked to possessing a cleaning routine, the perception that one is living in a dirty environment and that others are doing the behaviour, whether one has a strong sense of contamination, as well as a felt need to keep one's surroundings tidy. Being concerned with good manners is also linked to the performance of both behaviours. This study is the first to identify the role of manners, orderliness and routine on hygiene behaviours globally. Such findings should prove helpful in designing programs to improve domestic hygiene practices.

Federal Enactment of Healthy Homes Legislation in the United States to Improve Public Health

Not all homes across America are “healthy” homes. This contributes to the poor health of Americans and exacerbates existing health conditions costing millions each year in health-care cost. Newer research is being conducted into strategies to alleviate biological, chemical, and physical hazards in the home, and various programs exist to assist the homeowner in making improvements in the quality of their home. Not every homeowner or renter nationwide or within community localities has access to these strategies or programs that could potentially improve their home environment and therefore the health of their family. The objective of this article is to propose elements of a policy to address this inconsistency and variation. This proposal centers around the federal enactment of a national policy demanding that each state implements a healthy homes program tailored to fit their specific state housing and health needs. Members of Congress from States that have successfully implemented healthy home programs should champion this policy. Organizations that recognize the impact of housing on health should support the development of a national healthy homes strategy. This article will discuss the need, outcomes, stakeholders, and minimum requirements of such a policy.

Effects of an Asthma Training and Monitoring Program on Children's Disease Management and Quality of Life

OBJECTIVES

To determine the effects of an asthma training and monitoring program on children's disease management and quality of life.

MATERIAL AND METHODS

The sample consisted of 120 children and their parents. Data were collected during, at the beginning, and at the end of the 3-month monitoring period using four forms and a quality of life scale. After an initial evaluation, approaches to control symptoms and asthma triggers and measures that might be taken for them were taught to the children and parents. The children recorded the conditions of trigger exposure, experience of disease symptoms, their effects on daily activities, and therapeutic implementations on a daily basis.

RESULTS

During the 3-month monitoring period, the number of days when the children were exposed to triggers (p=0.000) and experienced disease symptoms decreased to a statistically significant level (p=0.006). Majority of domestic triggers disappeared, but those stemming from the structure of the house and non-domestic triggers indicated no change (p>0.05). Moreover, 30.8% of the children applied to a physician/hospital/emergency service, 4.2% of the children were hospitalized, and 30% of them could not go to school. The number of times when the children applied to a physician/hospital/emergency (p=0.013), the number of times they used medicines (p=0.050), and the number of days they could not go to school (p=0.002) decreased at a statistically significant level, and their quality of life increased (p=0.001).

CONCLUSION

Asthma training and monitoring program decreased children's rate of experiencing asthma symptoms and implementations of therapeutic purposes and increased their life quality.

Impact of student pharmacist-delivered asthma education on child and caregiver knowledge

OBJECTIVE

To evaluate the effectiveness of asthma education delivered by student pharmacists and to assess the impact of child and caregiver baseline asthma knowledge on asthma control in children.

DESIGN

Student pharmacists developed and implemented asthma self-management education interventions for children and their caregivers and performed asthma screenings for children at a series of asthma camps.

ASSESSMENT

Eighty-seven children, ages 5-17 years, and their caregivers were enrolled in this study. A previously validated asthma questionnaire was modified to assess asthma knowledge among children and adults. Asthma knowledge increased significantly in children following participation in the education intervention (p<0.001). The education intervention, however, did not increase caregiver knowledge of asthma. A significant association was observed between caregiver baseline asthma knowledge and better asthma control in their children (p=0.019).

CONCLUSION

The results of this study demonstrate that student pharmacist-delivered asthma education can positively impact asthma knowledge in children, and that caregivers' knowledge of asthma is strongly correlated with better asthma control in their children.

Assessing the effectiveness of a healthy homes training

This pilot study assessed the effectiveness of a National Center for Healthy Housing training model on understanding common hazards. An additional objective was to look at local interest in establishing a healthy homes training program in Arkansas. The study involved an intensive 2-day training model with the use of pre- and post-surveys of 69 participants from various invited public health fields. These surveys were administered before and after the training to test for significant change in understanding of healthy home concepts. Proficiency skill level ratings showed significant improvement (all p < 0.0001) in perceived learning across all topic areas. Participants showed post-training improvement in knowledge-based questions in most, but not all topic areas. Study results show improvements are needed in specific training areas addressing skills to keep the home dry and ventilated. The current training model is effective as a potential healthy homes training program; however, some areas of training could be improved and targeted to specific professions.

Strategies, actions, and outcomes of pilot state programs in public health genomics, 2003-2008

State health departments in Michigan, Minnesota, Oregon, and Utah explored the use of genomic information, including family health history, in chronic disease prevention programs. To support these explorations, the Office of Public Health Genomics at the Centers for Disease Control and Prevention provided cooperative agreement funds from 2003 through 2008. The 4 states' chronic disease programs identified advocates, formed partnerships, and assessed public data; they integrated genomics into existing state plans for genetics and chronic disease prevention; they developed projects focused on prevention of asthma, cancer, cardiovascular disease, diabetes, and other chronic conditions; and they created educational curricula and materials for health workers, policymakers, and the public. Each state's program was different because of the need to adapt to existing culture, infrastructure, and resources, yet all were able to enhance their chronic disease prevention programs with the use of family health history, a low-tech "genomic tool." Additional states are drawing on the experience of these 4 states to develop their own approaches.

Associations between environmental exposures and asthma control and exacerbations in young children: a systematic review

OBJECTIVE

To complete a systematic review of the literature describing associations between all environmental exposures and asthma symptoms and exacerbations in children up to mean age of 9 years.

DESIGN

Systematic review.

SETTING

Reference lists of identified studies and reviews were searched for all articles published until November 2013 in electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Controls Trials Register).

PARTICIPANTS

Studies were selected which examined a link between exposure to environmental factors and asthma symptoms and exacerbations where the study participants were children with a mean age of ≤9 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Indices of asthma symptoms, control and exacerbations.

RESULTS

A total of 27 studies were identified including eight where inhaled allergens and four where environmental tobacco smoke (ETS) were the exposures of interest. There was evidence that exposure to allergen, ETS, poor air quality and unflued heaters had a modest magnitude of effect (ORs between 2 and 3). There was also evidence of interactions observed between exposures such as allergen and ETS.

CONCLUSIONS

Exposure to inhaled allergens, ETS, unflued heaters and poor air quality has an important effect on exacerbations in young children with asthma and should be minimised or, ideally, avoided. Better understanding of the effect of exposure to damp housing, air conditioning and dietary factors plus interactions between environmental exposures associated with exacerbations is required.

Connecting at-risk inpatient asthmatics to a community-based program to reduce home environmental risks: care system redesign using quality improvement methods

INTRODUCTION

Connecting patients admitted with asthma to community-based services could improve care and more efficiently allocate resources. We sought to develop and evaluate an intervention to mitigate in-home environmental hazards (eg, pests, mold) for such children.

METHODS

This was a controlled, quality improvement study on the inpatient units of an urban, academic children's hospital. Clinicians and public health officials co-developed processes to identify children with in-home risks and refer them for assessment and remediation. Processes assessed were the rate at which those identified as eligible were offered referrals, those referred received inspections, and primary care physicians (PCPs) were notified of risks and referrals. Consecutively occurring and seasonally matched intervention (n = 30) and historical control (n = 38) subcohorts were compared with respect to postdischarge mitigating actions (eg, discussions with landlords, PCPs), remaining risks, and morbidity (symptom-free days in previous 2 weeks and Child Asthma Control Test scores).

RESULTS

In the first year, the percentage of eligible children offered referrals increased to a sustained rate of ∼90%; ∼65% of referrals led to in-home inspections (n = 50); and hazards were abated in 30 homes. PCP notification increased from 50% to ∼80%. After discharge, referred parents were more likely to discuss concerns with landlords, the health department, attorneys, and PCPs than patients admitted preimplementation (all P < .05). Referred households were more likely to report reduced presence of ≥2 exposures (P < .05). No differences in asthma morbidity were observed.

CONCLUSIONS

We integrated environmental hazard mitigation into inpatient care. Community-engaged care delivery that reduces risks for poor asthma outcomes can be initiated within the hospital.

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 impact of asthma health education for parents of children attending head start centers

Parents of children who attend Head Start Centers are key participants in the health promotion and care of their own children. This non-randomized, longitudinal study aimed to test the effectiveness of an educational intervention based on the asthma and healthy homes curriculum targeting parents of Head Start children with or without an asthma diagnosis. One hundred and fifteen parents of children in Head Start Centers received an educational intervention at their corresponding sites, additionally pre- and post-test surveys were administered to measure educational intervention outcomes. A follow-up survey was conducted 6 months after the educational intervention was offered. Results showed a statistically significant increase in asthma and healthy home-knowledge (p < 0.001) in several areas. At 6 months post-intervention (54.4 %) (61 participants) were contacted and 98.4 % of made changes in their households as a result of their training. This study suggests that education can improve knowledge and change behaviors for the well-being of the residents of that household.

Management of pediatric asthma at home and in school

The incidence of pediatric asthma in the United States creates a huge financial burden to the economy as well as a negative impact on child health. Identification and elimination of asthma triggers are helpful in reducing asthma exacerbations. The incidence of asthma is higher in African American and underserved populations. Improved management of pediatric asthma leads to improved school performance, improved mental health, and general well-being.

History of symptom triggers in patients presenting to the emergency department for asthma

OBJECTIVES

Understanding triggers is important for managing asthma particularly for patients who seek emergency department (ED) care for exacerbations. The objectives of this analysis were to delineate self-reported triggers in ED patients and to assess associations between triggers and asthma knowledge, severity, and quality of life.

METHODS

At the time of an ED visit, 296 patients were asked what were their usual asthma triggers based on a checklist of 25 potential items, and what they thought specifically precipitated their current ED visit. Using standardized scales, patients also were asked about asthma knowledge, severity, and quality of life.

RESULTS

The mean age was 44 years and 72% were women. Patients cited a mean of 12 triggers; most patients had diverse triggers spanning respiratory infections, environmental irritants, emotions, allergens, weather, and exercise. Patients with more triggers were more likely to be women (odds ratio (OR) = 2.0, confidence interval (CI) = 1.3, 3.2, p = .002), obese (OR = 1.7, CI = 1.1, 2.5, p = .01), and to not have a smoking history (OR = 1.9, CI = 1.3, 2.9, p = .001). There were no associations between number of triggers and current age, age at diagnosis, education, socioeconomic status, or race/ethnicity. Patients who cited more triggers had more frequent flares (OR = 1.1, CI = 1.1, 1.2, p < .0001), worse quality of life scores (OR 1.6, CI = 1.1, 2.4, p = .02), and were more likely to have been previously hospitalized for asthma (OR = 1.9, CI = 1.3, 2.9, p = .003) and to have previously required oral corticosteroids (OR = 2.9, CI = 1.6, 5.1, p = .003). There was little clustering of specific triggers according to the variables we considered except for more frequent animal allergy in patients diagnosed at a younger age (OR = 2.8, CI = 1.7, 4.5, p < .0001) and worse quality of life in patients citing emotional stress as a trigger (OR = 2.5, CI = 1.5, 4.0, p = .0002). Patients attributed their current ED visit to multiple precipitants, particularly respiratory infections and weather, and these were concordant with what they reported were known triggers.

CONCLUSIONS

Patients presenting to the ED for asthma reported multiple triggers spanning diverse classes of precipitants and having more triggers was associated with worse clinical status. ED patients should be instructed that although it may not be possible to eliminate all triggers, mitigating even some triggers can be helpful.