Preventive Asthma Care Research Articles

Impact of Rural School-Based Health Centers on Asthma Management

To test the hypothesis that students with asthma who have access to school-based health centers (SBHCs) receive more recommended preventive care and use less emergency care, we compared patterns of health care utilization among rural students with asthma by SBHC access. Using a cross-sectional design, we analyzed encounters for all patients ages 4 through 19 living in 4 counties covered by a healthcare system that sponsors a network of SBHCs in rural upstate New York. Patient addresses for each encounter were geocoded to school districts, allowing us to determine whether students lived in districts with (n=15) or without (n=23) a SBHC. We measured utilization among students with asthma in 2016 and 2017, comparing measures by SBHC access. Students with asthma were identified using ICD diagnosis codes from visits in the two calendar years prior to each analysis year. Students in districts with SBHCs had greater odds of 2 or more asthma-related office visits (OR=2.23; 95% CI: 1.66-2.99) and 1 or more well-child visits (OR=1.24; 95% CI: 1.03-1.50) than their peers in districts without SBHCs. Students in districts with SBHCs had lower odds of a respiratory-related convenient care or emergency department visit (OR=0.45; 95% CI: 0.30-0.67). Across outcomes, differences were greatest when comparing students who utilized the SBHC in their district with students in districts who did not have access to a SBHC. Rural students with asthma who have access to SBHCs have greater opportunities for preventive asthma care per national guidelines and use emergency departments and convenient care less.

Evaluating barriers and facilitators to healthcare providers’ use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework

Objective Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services. Methods The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis. Results Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers. Conclusions Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.

Hospital-Initiated Care Bundle, Posthospitalization Care, and Outcomes in Adults with Asthma Exacerbation

Hospitalization for asthma exacerbation is an opportune setting for initiating preventive efforts. However, hospital-initiated preventive asthma care remains underdeveloped and its effectiveness is uncertain. To examine the effectiveness of a hospital-initiated asthma care bundle on posthospitalization asthma care and clinical outcomes. Prospective multicenter study of adults (18-54 years) hospitalized for asthma exacerbation in 2017 to 2019. During the hospitalization, we implemented an asthma-care bundle (inpatient laboratory testing, asthma education, and discharge care), and prospectively measured chronic asthma care (eg, immunoglobulin E testing, specialist care) and asthma exacerbation (ie, systemic corticosteroid use, emergency department [ED] visit, hospitalizations) outcomes. By applying a self-controlled case series method, we examined within-person changes in these outcomes before (2-year period) and after (1-year period) the bundle implementation. Of 103 adults hospitalized for asthma exacerbation, the median age was 40 years and 72% were female. Compared with the preimplementation period, the postimplementation period had improved posthospitalized asthma care, including serum specific immunoglobulin E testing (rate ratio [RR] 2.18; 95% confidence interval [95% CI] 0.99-4.84; P= .051) and evaluation by asthma specialist (RR 2.66; 95% CI 1.77-4.04; P<.001). Likewise, after care bundle implementation, patients had significantly lower annual rates of systemic corticosteroid use (4.2 vs 2.9 per person-year; RR 0.70; 95% CI 0.61-0.80; P<.001), ED visits (3.2 vs 2.7 per person-year; RR 0.83; 95% CI 0.72-0.95; P= .008), and hospitalizations (2.1 vs 1.8 per person-year; RR 0.82; 95% CI 0.69-0.97; P= .02). Stratified analyses by sex, race and ethnicity, and health insurance yielded consistent results. After hospital-initiated care bundle implementation, patients had improved posthospitalization care and reduced rates of asthma exacerbation.

Preventive care for asthma and multidisciplinary team social work: art and education experience

Objective: The purpose of this article is to describe the experience in art education of Social Work in a multiprofessional team, in the preventive care for asthma, and the changes felt by the participants of the "Choir Voices in Overcoming", through the (inter) experiences and experiences of singing and living with asthma. Methods: Qualitative, empirical, bibliographical and phenomenological research. Using field diary, semi-structured interview and content analysis. A total of 14 women and a man between the ages of 23 and 75 participated in the Asthma Reference Center. Results: Art education, through music, is a resource for the social worker to enhance the self-esteem of people in asthma treatment. Conclusion: People with asthma socializing while engaged in art education, influences their quality of life.

Psychosocial Associations with Life-Threatening Asthma in Inner City Children

RationaleInner city children have high asthma related morbidity and mortality. Previous studies suggest that psychosocial issues may increase the risk of near-fatal and fatal asthma, but detailed analyses of specific factors in high risk inner city children are scarce.MethodsBaseline survey data including measures of caregiver depression (CES-D), quality of life, social support and neighborhood stress were collected from caregivers of inner city children with uncontrolled asthma. All child subjects (N=150) were enrolled in a study evaluating the impact of a multifaceted preventive asthma care intervention. Comparison of children with and without a prior intensive care (ICU) admission for asthma was conducted using chi-square and logistic regression.ResultsSubjects were primarily African American (95.3%) and young (mean age 6.4yrs; 64% male); 31% of whom had a prior ICU admission. Caregivers were primarily mothers (92.7%), single (85.2%), employed (53.3%) and very poor (34.6% income <$10,000). Most caregivers reported asthma related daily stress (64.7%), 29.3% had CES-D scores >16, consistent with depression. Most reported some neighborhood related stress with low social embeddedness most commonly reported. There was a trend for children from very poor households (<$10,000/yr vs >$10,000/yr) to have had a prior ICU admission (OR 1.96 (0.92, 4.17) p=0.081). For caregivers reporting extremely high neighborhood stress, each unit increase in depression (CES-D score) increased the odds of prior ICU admission by 20%, p=0.031.ConclusionsIdentifying and addressing caregiver depression and stress may help to decrease the high morbidity and mortality seen in inner city children with poorly controlled asthma. RationaleInner city children have high asthma related morbidity and mortality. Previous studies suggest that psychosocial issues may increase the risk of near-fatal and fatal asthma, but detailed analyses of specific factors in high risk inner city children are scarce. Inner city children have high asthma related morbidity and mortality. Previous studies suggest that psychosocial issues may increase the risk of near-fatal and fatal asthma, but detailed analyses of specific factors in high risk inner city children are scarce. MethodsBaseline survey data including measures of caregiver depression (CES-D), quality of life, social support and neighborhood stress were collected from caregivers of inner city children with uncontrolled asthma. All child subjects (N=150) were enrolled in a study evaluating the impact of a multifaceted preventive asthma care intervention. Comparison of children with and without a prior intensive care (ICU) admission for asthma was conducted using chi-square and logistic regression. Baseline survey data including measures of caregiver depression (CES-D), quality of life, social support and neighborhood stress were collected from caregivers of inner city children with uncontrolled asthma. All child subjects (N=150) were enrolled in a study evaluating the impact of a multifaceted preventive asthma care intervention. Comparison of children with and without a prior intensive care (ICU) admission for asthma was conducted using chi-square and logistic regression. ResultsSubjects were primarily African American (95.3%) and young (mean age 6.4yrs; 64% male); 31% of whom had a prior ICU admission. Caregivers were primarily mothers (92.7%), single (85.2%), employed (53.3%) and very poor (34.6% income <$10,000). Most caregivers reported asthma related daily stress (64.7%), 29.3% had CES-D scores >16, consistent with depression. Most reported some neighborhood related stress with low social embeddedness most commonly reported. There was a trend for children from very poor households (<$10,000/yr vs >$10,000/yr) to have had a prior ICU admission (OR 1.96 (0.92, 4.17) p=0.081). For caregivers reporting extremely high neighborhood stress, each unit increase in depression (CES-D score) increased the odds of prior ICU admission by 20%, p=0.031. Subjects were primarily African American (95.3%) and young (mean age 6.4yrs; 64% male); 31% of whom had a prior ICU admission. Caregivers were primarily mothers (92.7%), single (85.2%), employed (53.3%) and very poor (34.6% income <$10,000). Most caregivers reported asthma related daily stress (64.7%), 29.3% had CES-D scores >16, consistent with depression. Most reported some neighborhood related stress with low social embeddedness most commonly reported. There was a trend for children from very poor households (<$10,000/yr vs >$10,000/yr) to have had a prior ICU admission (OR 1.96 (0.92, 4.17) p=0.081). For caregivers reporting extremely high neighborhood stress, each unit increase in depression (CES-D score) increased the odds of prior ICU admission by 20%, p=0.031. ConclusionsIdentifying and addressing caregiver depression and stress may help to decrease the high morbidity and mortality seen in inner city children with poorly controlled asthma. Identifying and addressing caregiver depression and stress may help to decrease the high morbidity and mortality seen in inner city children with poorly controlled asthma.

Practice Variation in Management of Childhood Asthma Is Associated with Outcome Differences

Although specialist asthma care improves children's asthma outcomes, the impact of primary care management is unknown. To determine whether variation in preventive and acute care for asthma in pediatric practices affects patients' outcomes. For 22 practices, we aggregated 12-month patient data obtained by chart review and parent telephone interviews for 948 children, 3 to 12 years old, diagnosed with asthma to obtain practice-level measures of preventive (≥1 asthma maintenance visit/year) and acute (≥1 acute asthma visit/year) asthma care. Relationships between practice-level measures and individual asthma outcomes (symptom-free days, parental quality of life, emergency department [ED] visits, and hospitalizations) were explored using generalized estimating equations, adjusting for seasonality, specialist care, Medicaid insurance, single-family status, and race. For every 10% increase in the proportion of children in the practice receiving preventive care, symptom-free days per child increased by 7.6 days (P= .02) and ED visits per child decreased by 16.5% (P= .002), with no difference in parental quality of life or hospitalizations. Only the association between more preventive care and fewer ED visits persisted in adjusted analysis (12.2% reduction; P= .03). For every 10% increase in acute care provision, ED visits per child and hospitalizations per child decreased by 18.1% (P= .02) and 16.5% (P < .001), respectively, persisting in adjusted analyses (ED visits 8.6% reduction, P= .02; hospitalizations 13.9%, P= .03). Children cared for in practices providing more preventive and acute asthma care had improved outcomes, both impairment and risk. Persistence of improved risk outcomes in the adjusted analyses suggests that practice-level interventions to increase asthma care may reduce childhood asthma disparities.

Prompting asthma intervention in Rochester-uniting parents and providers (PAIR-UP): a randomized trial.

A disproportionate number of impoverished and minority children have asthma and receive suboptimal preventive care. To evaluate whether the Prompting Asthma Intervention in Rochester-Uniting Parents and Providers (PAIR-UP) intervention, administered in primary care offices, improves the delivery of preventive care and reduces morbidity for urban children with asthma. Cluster randomized trial in which 12 urban primary care practices were matched based on size and type and randomly allocated to the PAIR-UP intervention or usual care (UC). We enrolled 638 children aged 2 to 12 years with persistent or poorly controlled asthma in the waiting room prior to a visit with a clinician for any reason from October 2009 to January 2013. Blinded interviewers called caregivers within 2 weeks to inquire about preventive measures taken at the visit and called them 2 and 6 months later to assess symptoms. Children enrolled at PAIR-UP practices received prompts for the caregiver and clinician at the time of the visit that outlined the child's asthma severity or control as well as specific guideline-based recommendations to enhance preventive care. These practices also received educational resources and periodic feedback on their asthma care performance. The UC practices received copies of the asthma guidelines. The primary outcome was symptom-free days (SFDs) per 2 weeks at the 2-month follow-up. We enrolled 638 children (participation rate of 80%; 36% were black, 36% were Hispanic, and 68% had Medicaid insurance). Groups were similar in demographic characteristics and asthma severity at baseline. At the index visit, more children in the PAIR-UP group received a preventive medication action (new medication, increased dose, recommendation to restart preventive medication) than in the UC group (58% vs 33%; odds ratio [OR] = 2.8; 95% CI, 1.9 to 3.9). More children in the PAIR-UP group than in the UC group received an asthma action plan (61% vs 23%; OR = 8.3; 95% CI, 3.7 to 18.7), discussions regarding asthma (93% vs 78%; OR = 4.5; 95% CI, 2.8 to 7.2), and secondhand smoke counseling (80% vs 63%; OR = 2.6; 95% CI, 1.2 to 5.5). At the 2-month follow-up, children in the PAIR-UP group had more SFDs per 2 weeks than those in the UC group (mean difference, 0.78 days; 95% CI, 0.29 to 1.27). At 6 months, the improvement in SFDs was no longer statistically significant (mean difference, 0.56; 95% CI, -0.14 to 1.25). The PAIR-UP intervention improved the delivery of preventive asthma care and reduced asthma morbidity for high-risk urban children with persistent asthma at 2 months, but the improvement in SFDs was no longer significant at 6 months. clinicaltrials.gov Identifier: NCT01105754.

Quality improvement methods improve inhaled corticosteroid prescribing in the emergency department

Objective: Inhaled corticosteroids (ICS) are underutilized among persistent asthmatics. Because of low outpatient follow-up rates after Emergency Department (ED) visits, children are unlikely to be prescribed ICS by their primary care physician after an acute exacerbation. ED physicians have the opportunity to contribute to the delivery of preventive care in the acute care setting. Our objective was to evaluate if quality improvement (QI) methods could improve the rate of ICS initiation at ED discharge. Methods: Within the Pediatric ED (PED) at a tertiary children’s hospital, QI methods were used to encourage ICS prescribing at the time of ED discharge. Interventions focused on education at both the attending physician and resident level, process improvements designed to streamline prescribing, and directed provider feedback. This involved multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed monthly to determine ICS prescribing rates. The effect of our interventions on prescribing rate was tracked over time using a run chart. Results: Following our interventions, the ICS initiation rate for children seen in and discharged home from the ED with an acute asthma exacerbation increased from a baseline median rate of 11.25% to a median rate of 79% representing a significant, non-random improvement. The ICS initiation rate has been sustained for 8 months over our goal rate of 75%. Conclusions: This study demonstrates that QI methods can be used to increase inhaled corticosteroid initiation rate at the time of ED discharge and, thus, improve the delivery of preventive asthma care in the acute care setting.

Improving preventive care in high risk children with asthma: lessons learned

Objectives: Rates of preventive asthma care after an asthma emergency department (ED) visit are low among inner-city children. The objective of this study was to test the efficacy of a clinician and caregiver feedback intervention (INT) on improving preventive asthma care following an asthma ED visit compared to an attention control group (CON). Methods: Children with persistent asthma and recent asthma ED visits (N = 300) were enrolled and randomized into a feedback intervention or an attention control group and followed for 12 months. All children received nurse visits. Data were obtained from interviews, child salivary cotinine levels and pharmacy records. Standard t-test, chi-square and multiple logistic regression tests were used to test for differences between the groups for reporting greater than or equal to two primary care provider (PCP) preventive care visits for asthma over 12 months. Results: Children were primarily male, young (3–5 years), African American and Medicaid insured. Mean ED visits over 12 months was high (2.29 visits). No difference by group was noted for attending two or more PCP visits/12 months or having an asthma action plan (AAP). Children having an AAP at baseline were almost twice as likely to attend two or more PCP visits over 12 months while controlling for asthma control, group status, child age and number of asthma ED visits. Conclusions: A clinician and caregiver feedback intervention was unsuccessful in increasing asthma preventive care compared to an attention control group. Further research is needed to develop interventions to effectively prevent morbidity in high risk inner-city children with frequent ED utilization.

Racial disparities at the point of care for urban children with persistent asthma.

Little is known about disparities in preventive asthma care delivery at the time of an office visit. Our objective was to better understand what treatments are delivered at the point of care for urban children with asthma, and whether there are racial disparities. We enrolled 100 Black and 77 White children (2-12 years) with persistent asthma from 6 primary care practices. We evaluated how frequently providers delivered guideline-based asthma actions at the index visit. We also assessed asthma morbidity prior to the index visit and again at 2 month follow-up. Black children had greater symptom severity and were less likely to report having a preventive medication at baseline, but were no more likely to report a preventive medication action at the time of an office visit. Symptoms persisted for Black children at follow-up, suggesting additional preventive actions were needed. Further efforts to promote consistent guideline-based preventive asthma care are critical.

The School-Based Preventative Asthma Care Trial: Results of a Pilot Study

JS Halterman, M Fagnano, G Montes. J Pediatr. 2012;161(6):1109–1115 To test the feasibility and preliminary effectiveness of the School-Based Preventive Asthma Care Technology (SB-PACT) program, which included directly observing therapy of preventive asthma medications in school facilitated by Web-based technology for systemic symptom screening, electronic report generation, and medication authorization from providers. The study included 100 children (aged 3–10 years) with physician-diagnosed asthma with persistent symptoms based on National Heart, Lung, and Blood Institute guidelines from 19 inner-city schools in Rochester, New York. The investigators conducted a pilot, randomized trial of SB-PACT versus usual care. Outcomes were …

Medicaid Payment Innovations to Financially Sustain Comprehensive Childhood Asthma Management Programs at Federally Qualified Health Centers

Background. One in 7 children in the United States is diagnosed with asthma, the leading cause of chronic childhood disease. Although a manageable condition when recommended medication regimens are followed and environmental control measures implemented, asthma remains the third most common reason for hospitalization among non-newborn hospital stays. As the primary health care home to a fifth of all low-income children who are especially vulnerable to asthma, federally qualified health centers play a critical role in providing comprehensive and preventive asthma care to their pediatric patients. Many health centers rely on the asthma education and counseling services of traditional and nontraditional providers, such as clinicians and community health workers, who may or may not be certified as asthma educators, as essential elements of asthma management and control. Asthma counselors are particularly valuable for patient home assessments and tailored education and counseling that are recommended components of evidence-based asthma care. Yet sustainable reimbursement for their services is a frequent challenge. Methods. We conducted an environmental scan of innovative approaches to securing adequate Medicaid reimbursement for asthma educator services provided as part of asthma management and control. Results. We identified a number of models at the individual health center, Medicaid health plan, and Medicaid state program level for securing sustainable reimbursement for asthma educators. Whereas state-based approaches are preferable to more incremental options at the health center and health plan level, local approaches may be more feasible for some health centers. Conclusion. Asthma educators provide essential, cost-effective services as part of childhood asthma care management. This analysis identifies creative solutions for health centers and other health care organizations to consider as mechanisms for sustaining the important services of these providers.

Preventive Asthma Care Delivery in the Primary Care Office: Missed Opportunities for Children With Persistent Asthma Symptoms

ObjectiveTo describe which National Heart Lung and Blood Institute preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery varies by asthma symptom severity. MethodsWe approached children (2 to 12 years old) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit. ResultsWe identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009 to January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs non-asthma-related visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14–0.84), trigger reduction discussion (OR 0.39, 95% CI 0.19–0.82), recommendation of follow-up (OR 0.40, 95% CI 0.19–0.87), and receipt of action plan (OR 0.37, 95% CI 0.16–0.86). ConclusionsMany children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.

Factors Associated with Completion of a Behavioral Intervention for Caregivers of Urban Children with Asthma

Background. Rates of preventive follow-up asthma care after an acute emergency department (ED) visit are low among inner-city children. We implemented a novel behavioral asthma intervention, Pediatric Asthma Alert (PAAL) intervention, to improve outpatient follow-up and preventive care for urban children with a recent ED visit for asthma. Objective. The objective of this article is to describe the PAAL intervention and examine factors associated with intervention completers and noncompleters. Methods. Children with persistent asthma and recurrent ED visits (N = 300) were enrolled in a randomized controlled trial of the PAAL intervention that included two home visits and a facilitated follow-up visit with the child’s primary care provider (PCP). Children were categorized as intervention completers, that is, completed home and PCP visits compared with noncompleters, who completed at least one home visit but did not complete the PCP visit. Using chi-square test of independence, analysis of variance, and multiple logistic regression, the intervention completion status was examined by several sociodemographic, health, and caregiver psychological variables. Results. Children were African-American (95%), Medicaid insured (91%), and young (aged 3–5 years, 56%). Overall, 71% of children randomized to the intervention successfully completed all home and PCP visits (completers). Factors significantly associated with completing the intervention included younger age (age 3–5 years: completers, 65.4%; noncompleters, 34.1%; p < .001) and having an asthma action plan in the home at baseline (completers: 40%; noncompleters: 21%; p = .02). In a logistic regression model, younger child age, having an asthma action plan, and lower caregiver daily asthma stress were significantly associated with successful completion of the intervention. Conclusions. The majority of caregivers of high-risk children with asthma were successfully engaged in this home and PCP-based intervention. Caregivers of older children with asthma and those with high stress may need additional support for program completion. Further, the lack of an asthma action plan may be a marker of preexisting barriers to preventive care.

Does Using an Asthma Prompting Form Improve Asthma Care in a Pediatric Office?

An asthma exacerbation can be a life-threatening experience. This project tested the effectiveness of using a prompting form to improve childhood asthma care. Thirty randomly selected charts without a prompt form in a pediatric practice were compared for differences with thirty randomly selected charts with a completed prompting form. The number of medications reviewed (p=.001) and the frequency of refills written (p=.024) were significantly higher in the prompt group. Education was higher (p=.000) and triggers were more frequently discussed in the prompt group. The use of a prompting form facilitates discussion and improves preventive asthma care.

The School-Based Preventive Asthma Care Trial: Results of a Pilot Study

To test the feasibility and preliminary effectiveness of the School-Based Preventive Asthma Care Technology (SB-PACT) program, which includes directly observed therapy of preventive asthma medications in school facilitated by Web-based technology for systematic symptom screening, electronic report generation, and medication authorization from providers. We conducted a pilot randomized trial of SB-PACT versus usual care with 100 children (aged 3-10 years) from 19 inner-city schools in Rochester, New York. Outcomes were assessed longitudinally by blinded interviewers. Analyses included bivariate statistics and linear regression models, adjusting for baseline symptoms. There were data for 99 subjects for analysis. We screened all children using the Web-based system, and 44 of 49 treatment group children received directly observed therapy as authorized by their providers. Treatment group children received preventive medications 98% of the time they were in school. Over the school year, children in the treatment group experienced nearly 1 additional symptom-free day over 2 weeks versus the usual care group (11.33 vs 10.40, P = .13). Treatment children also experienced fewer nights with symptoms (1.68 vs 2.20, P = .02), days requiring rescue medications (1.66 vs 2.44, P = .01), and days absent from school due to asthma (0.37 vs 0.85, P = .03) compared with usual care. Further, treatment children had a greater decrease in exhaled nitric oxide (-9.62 vs -0.39, P = .03), suggesting reduction in airway inflammation. The SB-PACT intervention demonstrated feasibility and improved outcomes across multiple measures in this pilot study. Future work will focus on further integration of preventive care delivery across community and primary care systems.

Working Toward a Sustainable System of Asthma Care: Development of the School-Based Preventive Asthma Care Technology (SB-PACT) Trial

Objective. We previously conducted the School-Based Asthma Therapy trial to improve adherence to national asthma guidelines for urban children through directly observed administration of preventive asthma medications in school. The trial successfully improved outcomes among these children; however, several factors limit its potential for dissemination. To enhance sustainability, we subsequently developed a new model of care using web-based guides for efficient communications and integration within school and community systems. This article describes the development of the School-Based Preventive Asthma Care Technology (SB-PACT) trial. Method. We developed the SB-PACT web-based system based on stakeholder feedback, and conducted a pilot randomized trial with 100 children to establish its feasibility in facilitating preventive asthma care for high-risk children. The SB-PACT system represents a new model of care using web-based guides for asthma symptom screening, follow-up control assessments, and electronic communications with providers. Result. We enrolled and successfully screened all children using the web-based system. Most providers used the electronic communication system without difficulty, and the majority of children in the intervention group received preventive medications through school as planned and dose adjustments as needed. Several challenges to implementation also were encountered. Conclusions. This program is designed to promote sustainability of school-based asthma care, reduce program costs, and ultimately succeed in a real-world setting. With further refinements, it has the potential to be implemented nationally in schools.

A Pilot Study to Enhance Preventive Asthma Care among Urban Adolescents with Asthma

Background. Low-income, minority teens have disproportionately high rates of asthma morbidity and are at high risk for nonadherence to preventive medications. Objective. To assess the feasibility and preliminary effectiveness of an innovative school-based asthma program to enhance the delivery of preventive care for 12–15 year olds with persistent asthma. We hypothesized that this intervention would () be feasible and acceptable among this population and () yield reduced asthma morbidity. Design/methods. Subjects/setting: Teens with persistent asthma and a current preventive medication prescription in Rochester, NY. Design: Single group pre-post pilot study during the 2009–2010 school year. Intervention: Teens visited the school nurse daily for 6–8 weeks at the start of the school year to receive directly observed therapy (DOT) of preventive asthma medications; 2–4 weeks following DOT initiation, they received three counseling sessions (one in-home and two via telephone) using motivational interviewing (MI) to explore attitudes about asthma management, build motivation for medication adherence, and support transition to independent preventive medication use. Primary outcome: Number of symptom-free days (SFDs)/2 weeks; outcome data were collected 2 months after baseline and at the end of school year. Results. We enrolled 30 teens; 28 participated in the intervention. All teens initiated a trial of school-based DOT. All in-home MI visits were completed successfully, and 89% completed both follow-up sessions. Teens experienced an overall reduction of symptoms with more SFDs/2 weeks from baseline to 2-month and final (end of school year) assessments (8.71 vs. 10.79 vs. 12.89, respectively, p = .046 and p = .004). Teens also reported fewer days with symptoms, less activity limitation, and less rescue medication use (all p < .05). Exhaled nitric oxide levels decreased (p = .012), suggesting less airway inflammation. At the final assessment, teens reported significantly higher motivation to take their preventive medication every day (p = .043). At the end of the study, 79% of teens stated that they were better at managing asthma on their own, and 93% said they would participate in a similar program again. Conclusions. This pilot study provides preliminary evidence of the feasibility and effectiveness of a novel school-based intervention to promote independence in asthma management and improve asthma outcomes in urban teens.

Comprehensive environmental management of asthma and pediatric preventive care

Indoor environmental triggers can increase asthma morbidity. National guidelines recommend comprehensive use of environmental control practices (ECPs) as a component of asthma management. The purpose of this study was to examine the association between preventive asthma care and comprehensive ECP use among children with asthma. We used data from the National Asthma Survey, including 1,921 children with asthma. Comprehensive use was defined as using at least five of eight ECPs: (i) air filter, (ii) dehumidifier, (iii) mattress cover, (iv) pillow cover, (v) pet avoidance, (vi) smoke avoidance, (vii) removing carpets, and (viii) washing sheets in hot water. Univariate and multiple regression analyses were conducted to examine the association between comprehensive use of ECPs and receipt of preventive asthma care, as measured by number of routine asthma visits in the prior year and physician advice to modify the environment. Overall, 17% (95% CI: 14-19%) of participants had comprehensive ECP use. The most commonly used practices were 'smoke avoidance' (85%), 'pet avoidance' (59%), and 'washing sheets in hot water' (46%). Comprehensive use of ECPs was associated with having received physician advice [odds ratio (OR) 3.1, 95% CI: 2.2-4.4] and increased asthma visits (1-2 visits: OR 1.5, 95% CI: 1.0-2.4; 3-4 visits: OR 2.2, 95% CI: 1.3-3.8; ≥5 visits: OR 2.7, 95% CI: 1.5-4.8). Only a minority of parents implement comprehensive ECPs, and receipt of preventive asthma care is associated with comprehensive use. Further research is needed to determine the factors mediating these associations in order to inform more effective asthma counseling.

Comprehensive use of environmental control practices among adults with asthma

Asthma is a common chronic illness among adults. National guidelines recommend comprehensive implementation of environmental control practices (ECP) for asthma management. The purpose of this study was to examine the association between preventive asthma care and comprehensive ECP use among adults with asthma. We used data from the Four-State National Asthma Survey, including 3727 adults with asthma. Comprehensive management was defined as implementing at least five of eight ECP: (1) air filter, (2) dehumidifier, (3) mattress cover, (4) pillow cover, (5) no pets, (6) no smoking, (7) no carpets, and (8) washing sheets in hot water. We examined the association between comprehensive implementation of ECP and receipt of preventive asthma care, as measured by number of routine asthma visits in the prior year and physician advice to modify the environment. Overall, 13.3% (95% confidence interval [CI], 11.8-14.8%) of participants reported comprehensive ECP use. The most frequently implemented ECP were no smoking (80%), no pets (54%), and washing sheets in hot water (43%). Comprehensive ECP use was associated with having received physician advice (odds ratio [OR], 2.3; 95% CI, 1.6-3.4) and increased number of routine asthma visits (1-2 visits: OR, 2.4, and 95% CI, 1.5-4.0; 3-4 visits: OR, 2.4, and 95% CI, 1.3-4.5; 5 or more visits: OR, 3.4, and 95% CI, 1.9-6.4). Receipt of preventive asthma care is associated with comprehensive implementation of ECP. Further research is needed to determine the factors mediating these associations to develop more effective asthma counseling.