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Apter AJ, Perez L, Han X, Ndicu G, Localio A, Park H, Mullen AN, Klusaritz H, Rogers M, Cidav Z, Bryant-Stephens T, Bender BG, Reisine ST, Morales KH. Patient Advocates for Low-Income Adults with Moderate to Severe Asthma: A Randomized Clinical Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3466-3473.e11. [PMID: 32673877 DOI: 10.1016/j.jaip.2020.06.058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/20/2020] [Accepted: 06/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Few interventions have targeted low-income adults with moderate to severe asthma despite their high mortality. OBJECTIVE To assess whether a patient advocate (PA) intervention improves asthma outcomes over usual care (UC). METHODS This 2-armed randomized clinical trial recruited adults with moderate to severe asthma from primary care and asthma-specialty practices serving low-income neighborhoods. Patients were randomized to 6 months of a PA intervention or UC. PAs were recent college graduates anticipating health care careers, who coached, modeled, and assisted participants with preparations for asthma-related medical visits, attended visits, and confirmed participants' understanding of provider recommendations. Participants were followed for at least a year for patient-centered asthma outcomes: asthma control (primary outcome), quality of life, prednisone requirements, emergency department visits, and hospitalizations. RESULTS There were 312 participants. Their mean age was 51 years (range, 19-93 years), 69% were women, 66% African American, 8% Hispanic/Latino, 62% reported hospitalization for asthma in the year before randomization, 21% had diabetes, and 61% had a body mass index of 30 or more. Asthma control improved over 12 months, more in the intervention group (-0.45 [95% CI, -0.67 to -0.21]) than in the UC group (-0.26 [95% CI, -0.53 to -0.01]), and was sustained at 24 months but with no statistical difference between groups. The 6-month rate of emergency department visits decreased in the intervention (-0.90 [95% CI, -1.56 to -0.42]) and UC (-0.42 [95% CI, -0.72 to -0.06]) groups over 12 months. The cost of the PA program was $1521 per patient. Only 64% of those assigned had a PA visit. CONCLUSIONS A PA may be a promising intervention to improve and sustain outcomes in this high-risk population if expanded to address factors that make keeping appointments difficult.
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Affiliation(s)
- Andrea J Apter
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Luzmercy Perez
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Xiaoyan Han
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Grace Ndicu
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Anna Localio
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Hami Park
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Alyssa N Mullen
- Temple Physicians, Inc, Temple University Health System, Philadelphia, Pa
| | - Heather Klusaritz
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Marisa Rogers
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Zuleyha Cidav
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pa
| | | | | | | | - Knashawn H Morales
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Bruhl RJ, Perkison WB, Hanania NA, McNeill LH, Oluyomi AO, Fiesinger EB, Minard CG, Solomon A, Hamilton WJ, Butler B, Caldwell J, Crosby E, Davis C, Galvan H, Harris R, Lacour-Chestnut F, Martin C, Pannell S, Phipps K, Richardson G, Solomon A, White W, Boles J, Rangel A, Virk R, Brock M, Guffey D, Ramamurthy U, Persse D, Maffei S, Chan W, Reyes B. Design of a home-based intervention for Houston-area African-American adults with asthma: Methods and lessons learned from a pragmatic randomized trial. Contemp Clin Trials 2020; 91:105977. [PMID: 32151753 DOI: 10.1016/j.cct.2020.105977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/24/2020] [Accepted: 03/02/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Rebecca Jensen Bruhl
- Environmental Health Service, Department of Family & Community Medicine, Baylor College of Medicine, Houston, TX, United States.
| | - William Brett Perkison
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, United States
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Lorna H McNeill
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Abiodun O Oluyomi
- Section of Epidemiology and Population Science, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Ellen Baskin Fiesinger
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, United States
| | - Charles G Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, United States
| | - Abida Solomon
- College of Nursing, Prairie View A&M University, Houston, TX, United States
| | - Winifred J Hamilton
- Environmental Health Service, Department of Family & Community Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Brian Butler
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | - James Caldwell
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | - Eunice Crosby
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | - Cellie Davis
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | - Hope Galvan
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | - Rachel Harris
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | | | - Carol Martin
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | - Shereda Pannell
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | - Kathy Phipps
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | | | - Adriene Solomon
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | - William White
- HIITBAC Patient/Stakeholder Advisory Board, Houston, TX, United States
| | - Jamie Boles
- Environmental Health Service, Department of Family & Community Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Adriana Rangel
- Environmental Health Service, Department of Family & Community Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Ritupreet Virk
- Environmental Health Service, Department of Family & Community Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Melissa Brock
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Danielle Guffey
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, United States
| | - Uma Ramamurthy
- Office of Research Information Technology, Baylor College of Medicine, Houston, TX, United States
| | - David Persse
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, United States; Emergency Medical Services, Houston Fire Department, City of Houston, TX, United States
| | - Salvador Maffei
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Wenyaw Chan
- Department of Biostatistics, The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, United States
| | - Brenda Reyes
- U.S. Department of Housing & Urban Development, Washington, DC, United States
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Localio AM, Black HL, Park H, Perez L, Ndicu G, Klusaritz H, Rogers M, Han X, Apter AJ. Filling the patient-provider knowledge gap: a patient advocate to address asthma care and self-management barriers. J Asthma 2018; 56:1027-1036. [PMID: 30285499 DOI: 10.1080/02770903.2018.1520864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Introduction: In an ongoing study, a new clinical role adapted from a patient navigator called the patient advocate (PA) met with patients before medical visits, attended appointments and afterwards reviewed provider instructions. This qualitative analysis examines the perspectives of PAs and providers regarding their experiences with patients to understand how a PA can help patients and providers achieve better asthma control. Methods: PAs recorded journal entries about their experiences with patients. Provider focus groups and interviews were conducted by researchers and transcribed. Analysis was based on the Grounded Theory approach for qualitative research, using open and then focused coding. Two researchers independently coded these sources until intercoder agreement was achieved. Results: Upon review of 31 journal entries on PA experiences with 24 patients and transcripts from 2 provider focus groups and 12 provider interviews, 5 themes emerged surrounding asthma care and self-management: medication adherence, follow-up, communication, social determinants of health and time. While patients shared with PAs specific socioeconomic barriers to medication adherence and follow-up, providers often did not know about these problems and cited barriers to communication. Time restrictions on medical visits further limited communication. Conclusions: Perspectives reported here illustrate a gap in knowledge and understanding between patients and providers. The PA's unique relationship with patients and presence inside and outside of medical visits allowed them to learn contextual patient information unknown to providers. PAs and providers cited numerous ways PAs can help to improve patient-provider mutual understanding.
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Affiliation(s)
- Anna M Localio
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heather L Black
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hami Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luzmercy Perez
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Grace Ndicu
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heather Klusaritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Rogers
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xiaoyan Han
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrea J Apter
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Apter AJ, Morales KH, Han X, Perez L, Huang J, Ndicu G, Localio A, Nardi A, Klusaritz H, Rogers M, Phillips A, Cidav Z, Schwartz JS. A patient advocate to facilitate access and improve communication, care, and outcomes in adults with moderate or severe asthma: Rationale, design, and methods of a randomized controlled trial. Contemp Clin Trials 2017; 56:34-45. [PMID: 28315481 PMCID: PMC5503302 DOI: 10.1016/j.cct.2017.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 11/24/2022]
Abstract
Few interventions to improve asthma outcomes have targeted low-income minority adults. Even fewer have focused on the real-world practice where care is delivered. We adapted a patient navigator, here called a Patient Advocate (PA), a term preferred by patients, to facilitate and maintain access to chronic care for adults with moderate or severe asthma and prevalent co-morbidities recruited from clinics serving low-income urban neighborhoods. We describe the planning, design, methodology (informed by patient and provider focus groups), baseline results, and challenges of an ongoing randomized controlled trial of 312 adults of a PA intervention implemented in a variety of practices. The PA coaches, models, and assists participants with preparations for a visit with the asthma clinician; attends the visit with permission of participant and provider; and confirms participants' understanding of what transpired at the visit. The PA facilitates scheduling, obtaining insurance coverage, overcoming patients' unique social and administrative barriers to carrying out medical advice and transfer of information between providers and patients. PA activities are individualized, take account of comorbidities, and are generalizable to other chronic diseases. PAs are recent college graduates interested in health-related careers, research experience, working with patients, and generally have the same race/ethnicity distribution as potential participants. We test whether the PA intervention, compared to usual care, is associated with improved and sustained asthma control and other asthma outcomes (prednisone bursts, ED visits, hospitalizations, quality of life, FEV1) relative to baseline. Mediators and moderators of the PA-asthma outcome relationship are examined along with the intervention's cost-effectiveness.
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Affiliation(s)
- Andrea J Apter
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Knashawn H Morales
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Xiaoyan Han
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Luzmercy Perez
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jingru Huang
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Grace Ndicu
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna Localio
- Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alyssa Nardi
- Temple Physicians, Inc., Temple University Health System, Philadelphia, PA 19129, USA
| | - Heather Klusaritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Marisa Rogers
- Department of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alexis Phillips
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Zuleyha Cidav
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - J Sanford Schwartz
- Department of Medicine, 3400 Spruce St, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Wharton School of Business, University of Pennsylvania, Philadelphia, PA, USA
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