Achieving and Maintaining Asthma Control in an Urban Pediatric Disease Management Program: The Breathmobile Program

Abstract

Jones CA, Clement LT, Morphew T, et al. J Allergy Clin Immunol. 2007;119(6):1445–1453 PURPOSE OF THE STUDY. This observational study evaluated the asthma control achieved in children from a lower socioeconomic urban setting with regular participation in a disease-management guideline-based program. STUDY POPULATION. Patients aged 3 to 18 years with asthma were a self-selected, predominately Hispanic group recruited from lower socioeconomic areas of Los Angeles, California, served by the Pediatric Asthma Disease Management Program. Enrollment was from January 1, 1998, through June 30, 2006. METHODS. The primary measure was physician-assessed asthma control based on National Heart, Lung, and Blood Institute guidelines from parent and/or patient recall. This included symptom frequency of <2 days per week and <2 nights per month for the 4-week period before the visit, no severe flare-ups of asthma since the last visit, normal lung function, and no reported limitations on the patient's activities or exercise. Other data collected included physician estimate of compliance with the management plan, indicators of asthma morbidity, and severity assessments based on guideline criteria. Cox regression analysis was conducted to determine the cumulative probability that a new patient will achieve asthma control with each subsequent visit. RESULTS. A total of 2185 patients were eligible for evaluation of time to first achieve control, and 1591 patients were eligible to evaluate subsequent control maintenance. Of these patients, 70% to 87% achieved control by visit 3, and 89% to 98% achieved control by visit 6. Subsequent control maintenance was variable. Thirty-nine percent displayed well-controlled asthma (control at >90% of subsequent visits), and 13% had difficult-to-control asthma (control at <50% of subsequent visits). Maintenance of control was influenced by physician-estimated compliance with the treatment plan, baseline severity, and the interval between clinic visits. CONCLUSIONS. Asthma control can be achieved in the majority of children in an urban setting if they participate in a structured disease-management program. Long-term maintenance of asthma control was variable, and physician-rated compliance was the factor most closely associated with the probability of controlled asthma in all severity groups. REVIEWER COMMENTS. This study reported remarkably similar rates of initial asthma control across a broad severity spectrum in a lower socioeconomic urban setting. Equally noteworthy is the observation that maintaining such control was challenging across the severity spectrum, too. These findings reinforce the importance of routine monitoring of patients with persistent asthma, which is the cornerstone of recent revisions in the National Heart, Lung, and Blood Institute guidelines. This self-selected group of patients was more likely to be motivated and compliant with asthma-management plans. Nonetheless, this study shows what can be achieved, often with some difficulty, with a systematic approach in this patient population.