Community Asthma Initiative Research Articles

Improved 10-year cost savings for patients served by the Boston Children’s Hospital Community Asthma Initiative

Objective To provide a 10-year follow-up of asthma cost-savings for patients served by the Community Asthma Initiative (CAI) group compared to a coarsely cost-matched comparison group from similar neighborhoods (comparison group). Methods CAI provided home visits and case management services for patients identified through emergency department (ED) visits and hospitalizations. Asthma costs for the two groups were extracted from the hospital administrative database for ED visits and hospitalizations for one year before and 10 years of follow-up. To eliminate cost differences at intake, a coarse cost-matching was implemented by randomly selecting comparison patients with similar costs to CAI patients (N = 208 pairs). The difference in cost-reduction between CAI and comparison patients was used to compute the adjusted Return on Investment (aROI). Results There were no significant differences between CAI and comparison groups, including baseline age (5.9 years [SD 2.9] v. 4.4 [SD 3.1]); Hispanic (46.2% v. 35.1%) and Black (43.9% v. 53.0%) race/ethnicity; and public insurance (71.2% v. 68.8%). The cost reduction difference for CAI was significant at one year (P = 0.0001) and two years (P = 0.03), but did not reach the level of significance for years 3-10. The CAI group had a greater cumulative cost reduction of $5,321 (P = 0.08, not significant). Average program cost per patient was $2,636. CAI broke-even after 3 years (aROI = 1.04) and yielded an adjusted ROI of 1.99 at 10 years. Conclusions The greater reduction in cumulative cost for CAI patients suggested a shift in trajectory at 10 years of follow-up, resulting in a positive aROI after three years.

Community Health Workers in Home Visits and Asthma Outcomes

The authors demonstrate that a Centers for Medicare and Medicaid Services (CMS) funded Community Asthma Initiative transition from a mixed nurse-community health worker model to a nurse supervised community health worker model could engender enhanced outcomes for hospitalizations and missed school and parent and/or guardian missed workdays.In the study, researchers included 389 patients were enrolled under the CMS grant from 2013–2015 at Boston Children’s Hospital and 733 Medicaid patients enrolled from 2005–2012 (comparison group).The 2 groups were compared at baseline, 6 months, and 12 months post enrollment for 5 asthma outcome measures: emergency department visits, hospitalizations, physical activity limitations, missed school days, and parent and/or guardian missed workdays. These measures were analyzed as dichotomous variables by using logistic regression, with the numbers of occurrences as continuous variables. A 13 question survey composed of activity and emotional health subscales was used to assess quality of life changes.The CMS group demonstrated more improvement in asthma outcomes, compared with the comparison group. They had a greater odds of decreased hospitalization (odds ratio: 3.13 [95% confidence interval: 1.49 to 6.59]), missed school days (odds ratio: 1.91 [95% confidence interval: 1.09 to 3.36]), and parent and/or guardian missed workdays (odds ratio: 2.72 [95% confidence interval: 1.15 to 6.41]). One year post enrollment, the CMS group experienced enhancement in all measured QoL parameters (all P values were <.01)The transition of the Community Asthma Initiative to a nurse supervised community health worker model for home visits resulted in positive impacts on asthma outcomes and quality of life.In the study, the authors highlight that home visits by nurse supervised community health workers can benefit pediatric asthma control and quality of life. The study is limited by fact that patient data were from 2 different time frames and the lack of spirometry testing to provide a more precise assessment of asthma control. The data supports that community engagement and home visits can be effective strategies to contain health care use and costs.

Community Health Workers in Home Visits and Asthma Outcomes.

The Community Asthma Initiative (CAI) was included in the New England Asthma Innovations Collaborative, which received a Centers for Medicare and Medicaid Services (CMS) Innovation grant. Under this grant, CAI transitioned from a mixed community health worker and nurse model to a nurse-supervised community health worker model. CMS limited enrollment to patients with Medicaid and encouraged 3 home visits per family. A total of 389 patients enrolled under the CMS grant at Boston Children's Hospital from 2013 to 2015 (CMS group) were compared with 733 CAI patients with Medicaid enrolled from 2005 to 2012 (comparison group). Changes in 5 asthma-related measures (emergency department visits, hospitalizations, physical activity limitations, missed school days, and parent and/or guardian missed workdays) were compared between baseline and 6 and 12 months postenrollment. Measures were analyzed as dichotomous variables using logistic regression. Numbers of occurrences were analyzed as continuous variables. Changes in quality of life (QoL) among the CMS group were examined through a 13-question survey with activity and emotional health subscales. Although patients in both groups exhibited improvement in all measures, the CMS group had greater odds of decreased hospitalizations (odds ratio 3.13 [95% confidence interval 1.49-6.59]), missed school days (1.91 [1.09-3.36]), and parent and/or guardian missed workdays (2.72 [1.15-6.41]) compared to the comparison group. Twelve months postenrollment, the CMS group experienced improvement in all QoL questions and subscales (all P values <.01). The CMS group showed improved outcomes for hospitalizations and missed school and workdays compared to the comparison group. The CMS group also exhibited significant improvement in QoL.

98. Improved 10-Year Health Trajectory for Patients Served by the Community Asthma Initiative

98. Improved 10-Year Health Trajectory for Patients Served by the Community Asthma Initiative

Community Asthma Initiative: Cost Analyses Using Claims Data from a Medicaid Managed Care Organization

Background Our objective was to examine the benefits from the Community Asthma Initiative (CAI) program using claims data from one Medicaid Managed Care Organization by comparing actual costs incurred for asthma treatment for CAI intervention patients with a cost-matched comparison group without CAI intervention from similar low-income neighborhoods. A number of randomized clinical trials have demonstrated the importance of culturally appropriate, individualized care coordination, asthma education and coaching for improvement in asthma outcomes through cost reduction, but the …

Community Asthma Initiative: Cost Analyses Using Claims Data from a Medicaid Managed Care Organization

Community Asthma Initiative: Cost Analyses Using Claims Data from a Medicaid Managed Care Organization

Community Asthma Initiative: Cost Analyses using Claims Data from a Medicaid Managed Care Organization

Objective: Use claims data to examine the cost benefit of the Community Asthma Initiative (CAI), a Boston area nurse-supervised community health worker (CHW) asthma home-visiting program. Methods: The reduction in asthma treatment costs was assessed using Massachusetts claims data from one Medicaid Managed Care Organization (MCO) in the north east that included all costs between January 1, 2011 and December 31, 2016. The data was used to determine asthma-related utilization cost reductions between 1 year pre- and 1, 2 and 3 years post-intervention. The cost reductions for 45 CAI patients and 45 cost-matched comparison patients were measured. Return on investment (ROI) was computed as the difference in cost reduction for CAI patients and a cost-matched comparison population divided by CAI program cost. Results: The excess reduction in per patient asthma-related utilization costs among CAI patients compared to the comparison population was $806 (p = 0.047), $1,253 (p = 0.01) and $1,549 (p = 0.005) between 1 year pre- and 1, 2 and 3 years post-intervention. These yielded adjusted ROI’s of 0.31, 0.78 and 1.37 after 1, 2 and 3 years post-CAI intervention. Conclusions: The reduction in asthma utilization costs of a home visit program by nurse-supervised CHWs exceeds program costs. The findings support the business case for the provision of secondary prevention of home-based asthma services through reimbursement from payers or integration into Accountable Care Organizations (ACOs).

Asthma in the USA: the good, the bad, and the disparity

Asthma in the USA: the good, the bad, and the disparity

Boston children's hospital community asthma initiative: Five-year cost analyses of a home visiting program

Objective: To evaluate the costs and benefits of the Boston Children's Hospital Community Asthma Initiative (CAI) through reduction of Emergency Department (ED) visits and hospitalizations for the full pilot-phase program participants. Methods: A cost-benefit analyses was conducted using hospital administrative data to determine an adjusted Return on Investment (ROI): on all 268 patients enrolled in the CAI program during the 33-month pilot program phase of CAI intervention between October 1, 2005 and June 30, 2008 using a comparison group of 818 patients from a similar cohort in neighboring ZIP codes without CAI intervention. Cost data through June 30, 2013 were used to examine cost changes and calculate an adjusted ROI over a 5-year post-intervention period. Results: CAI patients had a cost reduction greater than the comparison group of $1,216 in Year 1 (P = 0.001), $1,320 in Year 2 (P < 0.001), $1,132 (P = 0.002) in Year 3, $1,123 (P = 0.004) in Year 4, and $997 (P = 0.022) in Year 5. Adjusting for the cost savings for the comparison group, the cost savings from the intervention resulted in an adjusted ROI of 1.91 over 5 years. Conclusions: Community-based, multidisciplinary, coordinated disease management programs can decrease the incidence of costly hospitalizations and ED visits from asthma. An ROI of greater than one, as found in this cost analysis, supports the business case for the provision of community-based asthma services as part of patient-centered medical homes and Accountable Care Organizations.

Community Asthma Initiative to Improve Health Outcomes and Reduce Disparities Among Children with Asthma

Black and Hispanic children are hospitalized with complications of asthma at much higher rates than white children. The Boston Children's Hospital Community Asthma Initiative (CAI) provides asthma case management and home visits for children from low-income neighborhoods in Boston, Massachusetts, to address racial/ethnic health disparities in pediatric asthma outcomes. CAI objectives were to evaluate 1) case management data by parent/guardian report for health outcomes and 2) hospital administrative data for comparison between intervention and comparison groups. Data from parent/guardian reports indicate that CAI decreased the number of children with any (one or more) asthma-related hospitalizations (decrease of 79% at 12 months) and any asthma-related emergency department visits (decrease of 56% at 12 months) among children served, most of whom were non-Hispanic black or Hispanic. Hospital administrative data also indicate that the number of asthma-related hospitalizations per child significantly decreased among CAI participants compared with a comparison group. The CAI model has been replicated in other cities and states with adaptations to local cultural and systems variations. Health outcome and cost data have been used to contribute to a business case to educate legislators and insurers about outcomes and costs for this enhanced approach to care. Strong partnerships with public health, community, and housing agencies have allowed CAI to leverage its outcomes to expand systemic changes locally and statewide to reduce asthma morbidity.

Editorial introductions

Editorial introductions

A Cost Analysis for a Community-Based Case Management Intervention Program for Pediatric Asthma

Objective. Evaluate the costs and benefits of the Boston Children’s Hospital Community Asthma Initiative (CAI) program through reduction of Emergency Department (ED) visits and hospitalizations and quality of life (QOL) for patients and their families due to reduced missed school days and work days. Methods. Cost–benefit analysis was used to determine an adjusted Return on Investment (ROI) for all 102 patients enrolled in the CAI program in the calendar year 2006 after controlling for changes in a comparable population without CAI intervention. A societal ROI (SROI) was also computed by including additional indirect benefits due to reduced missed school days for patients and work days for caregivers. Results. Adjusted cost savings from fewer ED visits and hospitalizations resulted in an adjusted ROI of 1.33 (adjusted Net Present Value, (NPV) of savings = $83,863) during the first 3 years after controlling for factors other than the CAI intervention. When benefits due to reduced missed school days and missed work days were added to adjusted cost savings, the SROI increased to 1.85 (Societal NPV of savings = $215,100). Conclusions. Multidisciplinary, coordinated disease management programs offer the opportunity to prevent costly complications and hospitalizations for chronic diseases, while improving QOL for patients and families. This cost analysis supports the business case for the provision of proactive community-based asthma services that are traditionally not reimbursed by the fee-for-service health care system.

Considerations and challenges for eliminating asthma disparities in children

Evaluation of: Woods ER, Bhaumik U, Sommer SJ et al. Community asthma initiative: evaluation of a quality improvement program for comprehensive asthma care. Pediatrics 129(3), 465–472 (2012).The Community Asthma Initiative is an evidence-based asthma intervention that is effective in improving quality of life for inner-city African–American and Latino children, while showing a return on investment of US$1.46, due to lower asthma-related hospital costs. The program provides an example of a comprehensive asthma management model that could be disseminated nationally with the goal of reducing asthma disparities. The health of children disproportionately affected by asthma could also be improved by integrating a broad range of housing policies into evidence-based asthma interventions in communities with high-pediatric asthma morbidity. Such interventions will be costly, but are likely to achieve long-term sustainable health benefits for children with asthma.

Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

ER Woods, U Bhaumik, SJ Sommer. Pediatrics. 2012;129(3):465–472 To evaluate the cost-effectiveness of a quality improvement (QI) program in decreasing asthma emergency department (ED) visits, hospitalizations, limitation of physical activity, patient missed school, and parent lost work. Urban, low-income patients with asthma from 4 Boston-area zip codes were determined through records of ED visits or hospitalizations. The selected families were given the option of increased …

Editorial introductions

Editorial introductions

Community Asthma Initiative Improves Health Outcomes

Community Asthma Initiative Improves Health Outcomes

Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

The objective of this study was to assess the cost-effectiveness of a quality improvement (QI) program in reducing asthma emergency department (ED) visits, hospitalizations, limitation of physical activity, patient missed school, and parent missed work. Urban, low-income patients with asthma from 4 zip codes were identified through logs of ED visits or hospitalizations, and offered enhanced care including nurse case management and home visits. QI evaluation focused on parent-completed interviews at enrollment, and at 6- and 12-month contacts. Hospital administrative data were used to assess ED visits and hospitalizations at enrollment, and 1 and 2 years after enrollment. Hospital costs of the program were compared with the hospital costs of a neighboring community with similar demographics. The program provided services to 283 children. Participants were 55.1% male; 39.6% African American, 52.3% Latino; 72.7% had Medicaid; 70.8% had a household income <$25 000. Twelve-month data show a significant decrease in any (≥1) asthma ED visits (68.0%) and hospitalizations (84.8%), and any days of limitation of physical activity (42.6%), patient missed school (41.0%), and parent missed work (49.7%) (all P < .0001). Patients with greatest functional impairment from ED visits, limitation of activity, and missed school were more likely to have any nurse home visit and greater number of home visits. There was a significant reduction in hospital costs compared with the comparison community (P < .0001), and a return on investment of 1.46. The program showed improved health outcomes and cost-effectiveness and generated information to guide advocacy efforts to finance comprehensive asthma care.

Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care

146. Evaluation of the Community Asthma Initiative: Adolescent vs. Child Outcomes and GIS Mapping

146. Evaluation of the Community Asthma Initiative: Adolescent vs. Child Outcomes and GIS Mapping

Children’s Hospital Boston Community Asthma Initiative: Partnerships and Outcomes Advance Policy Change

Rates of poorly controlled asthma among low-income children, particularly racial and ethnic minorities, remain disproportionately high. Comprehensive asthma programs, including education, case management and home environmental interventions have reduced disparities. Few sustainable payment models exist. The Children's Hospital Boston's Community Asthma Initiative (CAI) demonstrated dramatic reductions in hospitalizations and emergency department (ED) visits among African American and Latino patients with a return on investment (ROI) of 1.46. A strong coalition focused on sustainability plus CAI outcomes contributed to the state legislature's approving a bundled payment pilot for high-risk pediatric asthma patients on Medicaid/MassHealth. Cost-effective, comprehensive asthma programs and policy makers' interest in new payment models created an opportunity for a new payment approach for pediatric asthma care. A community coalition that successfully addresses asthma health disparities with a strong business case and program outcomes can be leveraged to persuade policy makers of the value of innovative financing strategies for asthma care.