Asthma Program

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Article Citation(s):
Jowers JR, Schwartz AL, Tinkelman DG, Reed KE, Corsello PR, Mazzei AA, Bender DR, Lochhead RA. Disease management program improves asthma outcomes. American Journal of Managed Care 2000;6:585-92.

Intervention Setting:
Participants’ homes

Target Population:
High-risk patients of all ages with asthma-related hospitalizations or emergency visits during the preceding 12 months who received care through one single Medicaid managed care plan in western Pennsylvania.

Program Description:
The Disease Management Program: Asthma (DMP: Asthma) integrates traditional treatment methods with a disease management program that focuses on creating a partnership between the patient and the health care team. The program goal is to empower patients with the tools and resources they need to comply with their treatment protocol.

DMP: Asthma:

1. identifies and address patient’s educational needs;
2. reinforces the asthma action plan provided by the primary care provider;
3. provides asthma educational materials and peak flow meters to guide the patient in long-term monitoring; and
4. teaches patients in the home environmental control measures to reduce exposure to known triggers, and conduct regular telecommunication with patients to ensure an open exchange between patients, physicians, and nurses.

Patient data for the 12 months before the start of the program were gathered for all patients from the managed care plan. Patients provided information on previous health care use, work- or school-related absenteeism, symptom severity, and self-management skills. After enrollment in DMP: Asthma, all patient-specific hospitalization and emergency visit claims data were reported to the research center within 30 days. The data pool was updated with every nurse/patient interaction.

Patients received published educational materials written at either the fourth grade (for children) or tenth grade (for adults) literacy levels. These publications covered understanding asthma; identifying triggers of asthma; recognizing asthma signs; peak flow monitoring; managing medication and supplies; and allergic reactions to animals, dust mites, mold, and pollen. Specialized respiratory care nurses provided care management for patients with moderate and severe persistent asthma. With the use of a comprehensive entry questionnaire the nurse gathered information about the patient’s asthma history, symptoms, medical history, prescriptions, use of a spacer and peak flow meter, understanding of asthma, and family support system. The assessment allowed care managers to determine when patients needed moderate or more aggressive intervention. Depending on disease severity, patients received four to six proactive telephone calls annually from care management nurses. The nurses used these calls to assess the patient’s health status, review the asthma action plan, verify the patient had the resources at home needed to prevent an attack, and provide asthma education on an individual basis. Patients were encouraged to contact nurses when they were symptomatic. This allowed nurses to assist patients in implementing their asthma action plan. Physicians received reports from the care managers summarizing their patients’ status and providing health care utilization and productivity data as reported by the patient. This occurred after every contact between patient and care manager.

Local home healthcare companies provided two home health visits by a nurse for each enrolled patient. These visits were used to evaluate patients’ health status, assess their ability to manage their asthma, and conduct in-home education. The first home health visit took place within 4 weeks of enrollment. At this time, the home health nurse reviewed asthma physiology, early warning signs, and the asthma action plan, and discussed the patient’s medication. With the caregiver, the nurse conducted a home environmental assessment for asthma triggers. The nurse taught patients environmental control measures and demonstrated correct use of the peak flow meter and a metered dose inhaler (MDI). The second home visit consisted primarily of a review of asthma symptoms, the asthma action plan, peak flow meter and MDI technique, and environmental triggers, and determined the need for further education and home visits.

Evaluation Design:
A pre-post design was utilized.

Sample Size:
The sample included 317 patients who completed at least 6 months of the program.

Outcome Measures/Results:
Outcome measures included health care use, productivity, and cost of care based on the 6 months before enrollment compared with 6 months after enrollment. Emergency visits decreased 67%, (from 546 to 180), hospital days declined 61% (from 157 to 62), and unscheduled doctor visits decreased by 62% (from 1083 to 413). Adult days missed from work declined by over 85% (879 to 131). Caretaker days of missed work decreased 71% (312 to 90) and child days missed from school showed a 30% decline (719 to 505). The financial benefits of these reductions in use and missed days, both direct and indirect, totaled more than $400,000. After an average adjusted care rate of about $303 per patient for 6 months (total $96,051), benefits remained well ahead of costs. Sixty-two patients from the larger group completed 12 months in the program. Both adult and caretaker days of missed work declined by over 90%, emergency visits fell 77% (140 to 33), and unscheduled doctor visits decreased 66% (171 to 58).

Materials available:
The Disease Management Program: Asthma is available for purchase from the National Jewish Medical and Research Center, 1400 Jackson St., M305, Denver, CO 80206.

Article Citation(s):
Lin S, Gomez M, Hwang S-N, Franko EM, Bobier JK. An evaluation of the asthma intervention of the New York State Healthy Neighborhoods Program. J Asthma 2004;41(5):583–95.

Intervention Setting:
Interventions took place in homes of study participants in New York City and seven New York State counties. Various New York Departments of Health, from large central metropolitan to nonmetropolitan counties, were funded to implement this program.

Target Population:
The study involved people in neighborhoods with high levels of environmental risk factors that can lead to asthma morbidity and mortality. This included households with minorities, children younger than 14 years, and residents with less than a high school education or with an annual income less than $16,452. This also included neighborhoods with inadequate physical environments (substandard, older housing, or households in remote rural areas).

Program Description:
This evaluation assessed the affect of the Healthy Neighborhood Program (HNP) asthma intervention over a 4-year period, 1997–2000. Each program provides environmental and educational assistance unique to its population and geography. The HNP asthma interventions use home visits to identify people with asthma, assess asthma morbidity and management, and identify environmental asthma triggers. The programs provide a variety of controls for asthma triggers and education to change behavior and improve asthma management.

The HNP intervention funds outreach workers trained to assist people with asthma and to address the cultural and linguistic needs of the target households. Outreach workers first visited a targeted neighborhood and left door hangers announcing the program. The intervention visits began at a subsequent visit to the neighborhood. Once a household agreed to participate in the program, an adult resident was interviewed to determine the individual needs of the residents, including children, and the asthma status of each resident. A room-by-room visual inspection of the dwelling was conducted, which included identifying asthma triggers. Education about asthma management, community services, and reducing asthma triggers, including the risks of cigarette smoke, was conducted during the home visit with the residents who have asthma. Environmental controls were also provided, as needed, including mattress and pillow covers, furnace filters, rodent baits, and cleaning equipment and vacuums; and their proper use was demonstrated.

Children from low-income families who did not have a regular physician were referred to a private children’s health insurance program subsidized by the state government. The programs were required to revisit a sample of households at least 90 days after the initial HNP visit to ascertain the effectiveness of the home visits, educational materials, and environmental controls. Information was collected on the use of products to reduce household allergens and the results of any referrals made to other agencies. An assessment was made as to whether sources of allergens were reduced or eliminated in each dwelling. Residents were interviewed to determine if they read any of the education materials provided and if they changed their behavior as a result. In addition, attempts were made 1 year after the initial visit to revisit all households that had an asthmatic member. The purpose of these 1-year revisits was to determine if there was improvement in asthma morbidity and to assess the reduction in asthma triggers present in the home. Information was collected on the number of hospital admissions, emergency room visits, and school or work days lost due to asthma. Information was also collected on the number of persons with asthma who had a written management plan from their physician, who knew the early warning signs of an asthma attack, and who monitored their peak expiratory flow daily.

Evaluation Design:
This was a pre-post design study. Following the HNP intervention, 25% of households in the program were revisited within 90 days. During the 1997–1999 cycle the goal was to revisit 25% of all households. During the 2000–2002 cycle the homes of all asthmatics were visited with the goal of revisiting a total of 25% of the households seen in 1 fiscal quarter selected by the individual programs during each funding year. Data were maintained from the initial visits, 90-day revisits, and 1-year asthma revisits.

Sample Size:
801 people with asthma, of all ages, in the targeted HNP areas.

Outcome Measures/Results:
One final health outcome measure (the rate of self-reported hospitalizations [admissions and emergency room visits]); three intermediate outcome measures (the percent of homes with cockroaches, the percent of asthmatics with a written management plan, and the percent of asthmatics using a peak flow meter); and the estimated net savings resulting from a reduction in hospital admissions due to asthma.

Details:
Because of changes in reporting requirements across the funding cycles (1997–1999 and 2000–2002), the findings are reported separately. Hospitalization rates (hospitalizations per 100 diagnosed asthmatics) at the initial HNP visits and 1-year HNP revisits for 1997–1999 showed for all six programs combined 86.0 hospitalizations per 100 persons with asthma per year. At the 1-year asthma revisit, the average hospitalization rate was 44.5 per 100 people, a decrease of 48.3%. The average percent change for the six programs was –61.2%, a significant decrease after the HNP intervention. After accounting for the decrease in baseline rates of about 25% over this period, the decrease attributable to the program was about 23%.

In the second reporting cycle, 2000–2002, asthmatics in five counties (n=835) showed a combined hospitalization rate of 95.6 visits per 100 asthmatics. At the 1-year followup, the combined hospitalization rate was 24.9 (N=493). The average percent change for the five programs was –68.1%. The incidence of cockroach infestation, percentage of asthmatics with a written asthma plan and those using a peak flow meter were also calculated. Cockroaches were found in 10.2% of homes on average (range 21.7% to 0.8%) in 7 counties before the intervention and in 5.8% of homes in the 1-year followup (range 14.4 to 0.0). Researchers found 15.6 % of asthmatics used peak flow meters at the initial HNP visit. One year following the intervention, 43% of asthmatics were using a peak flow meter. The average percentage of participants in the HNP with a written asthma management plan increased by 48%.

Article Citation:
Ghosh CS, Ravindran P, Joshi M, Stearns SC. Reductions in hospital use from self management training for chronic asthmatics. Social Science & Medicine 1998;46(8): 1087-1093.

Intervention Setting:
The intervention setting was located at the asthma and allergy clinic in the Department of Respiratory Medicine at the Medical College in Trivandrum, India.

Target Population:
The target population was clinic patients, aged 10 to 45 years, who had chronic asthma. Patients visited the emergency room or hospital at least once in the past year because of their asthma, and they were on drug therapy at least 15 days each month. Patients who had chronic respiratory infections, bronchitis, emphysema, multi-system disorders, and a history of chronic smoking were excluded.

Program Description:
The objective of this study was to assess the effect of asthma self-management training (SMT) on the health status and medical care of patients who had chronic asthma. The purpose of SMT is to maintain function, to slow deterioration, and to minimize impact of the disease and its treatment on the health status of the patients. A social scientist conducted intervention sessions during the first month following the baseline interview. The patients were given precise, written instructions about drug administration. Patients were trained to adjust medications promptly and safely on the basis of their severity and peak expiratory flow rate (PEFR). Role models were used to help the patients develop skills for minimizing antigen exposure. Using focus group discussions and scenario descriptions, patients were trained to identify early symptoms and to take remedial actions to control acute attacks.

Evaluation Design:
The study utilized an individually randomized control design. The two groups were similar at baseline in terms of sex, age, health status, and health care utilization in the month prior to the study. Both groups received usual clinical care for asthma management (including bronchodilator and anti-inflammatory drugs). The intervention group received SMT along with usual care. Patients were monitored for 12 months. Health status data were recorded daily for four one-month periods. The PEFR was used to assess disease severity. The overall mean PEFR for each patient during the follow-up year was used to measure health status. Health service data were used to acquire information on emergency visits and hospitalizations. 

Sample Size:
The study initially included 153 patients enrolled in the intervention group and 150 in the control group. A total of 276 patients, 140 in the intervention group and 136 in the control group, completed the three follow-up periods. 

Outcome Measures and Results:
Outcome measures included daily asthma severity (as measured by PEFR), number and duration of hospitalizations, number of emergency visits, and cost. The intervention group’s mean PEFR improved by 14.5% over the 12-month follow-up. The intervention group had 48.5% fewer productive days lost and had 53.2% fewer days hospitalized compared with the control group. The likelihood that an intervention group participant would be hospitalized was reduced 26%. For patients hospitalized, the average number of days hospitalized during the year was 38 days for the control group and 22 days for the intervention group. The intervention group had a 46.7% reduction in emergency visits overall. The average total medical cost for the intervention group was 22% less than for the control group.

Availability of Protocol and Materials: 
The protocol and materials are not available for widespread distribution.

Case Study: None

Article Citation:
Hopman WM, Owen JG, Gagne E. Assessment of the effect of asthma education on outcomes. Managed Care Interface May 1999;89-93.

Intervention Setting:
Oakville Trafalgar Memorial Hospital in Ontario, Canada

The Oakville program is one of Canada’s Community Asthma Care Centers (CACC) whose objectives include decreasing hospital and ED utilization, assisting patients in achieving the best possible control of their asthma symptoms, eliminating duplication of services, supporting treatment prescribed by referring physicians, and improving consistency of asthma management in the community.

Target Population:
Asthma patients of all ages referred by the emergency department (ED), pediatricians, and family physicians were targeted for the study.

Program Description:
The study objective was to assess the effectiveness of a comprehensive assessment, treatment, and education program for referred patients with asthma. The program varied according to each patient’s needs. At an initial visit, standardized information was collected, and education and information were provided on the basis of patient responses on topics including medications, trigger avoidance, environmental control, self-monitoring skills, delivery systems and techniques, and basic spirometry. After 2 weeks, patients returned to the Asthma Education Centre for reassessment visits to build on the assessment and educational topics and to determine additional needs. Assessment visits continued until the patient’s asthma was under control. A personal action plan was developed, and the physician was contacted to provide information on patient’s condition, use of delivery devices, medications, and dosage. The physician also reviewed the action plan for approval. Patients were then seen at 3- and 6-month intervals.

Evaluation Design:
The study utilized a pre-post-intervention design. Initial data on patient history, symptoms, triggers, medications, environment, and actions taken during an asthma episode were collected via a validated questionnaire used by all CACCs. A one-year follow-up visit was used to collect post-intervention data; a 24-month follow-up also was carried out for a subset of 113 patients.

Sample Size:
In both the initial and a one-year follow-up visit, 121 patients were seen. The patient population assessed by age cohorts: 43 patients were aged 0–5 years, (2) 47 were aged 6–16 years, and (3) 31 were aged greater than 16 years.

Outcome Measures/Results:
Outcome measures included the number of nights awakened because of asthma-related symptoms, school or workdays missed in the past four weeks, and the number of ED visits and hospital admissions in the past 6 months (measured at baseline and at 12 and 24 months). Results include a decrease in night awakenings in the previous four weeks in all three age cohorts, a decrease in emergency visits in the previous 6 months in all age cohorts, a decrease in hospitalizations in the previous 6 months in all cohorts, and a decrease in days missed from school or work in the two older age cohorts. Days of work or school missed were not applicable to the youngest age cohort. All of these differences were statistically significant. Specific outcome measures comparing baseline (pre-) and 24-month follow-up (post-) are shown in Table 1. [opens in new window]

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None

Article Citation(s):
Griffiths C, Foster G, Barnes N, Eldridge S, Tate H, Begum S, et al. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA). Br Med J 2004;328(7432):144–7.

Intervention Setting:
44 general practices in two boroughs of east London, United Kingdom

Target Population:
People with acute asthma, aged 4–60 years, who sought emergency or after-hours treatment.

Program Description:
Patients were eligible for inclusion in the study if they had asthma diagnosed by a doctor, and had been admitted to or attended the emergency department at the Royal London Hospital or a general practitioner out-of-hours (after hours) service for acute asthma. Intervention included patient review in a nurse-led clinic and liaison with general practitioners and practice nurses comprising educational outreach, promotion of guidelines for high-risk asthma, and ongoing clinical support. Specifically, general practices randomized to the intervention group received two 1-hour visits by the specialist nurses at the start of the study to discuss guidelines for managing patients with acute asthma. Specialist nurses at the nurse-run clinic reviewed participants registered with the intervention practices for asthma control and drugs immediately after recruitment. They discussed a self-management plan. Patients with sufficient understanding received a peak flow meter and a written plan containing standard thresholds for peak flow and symptoms. Practices randomized to the control group received a single visit from the nurses to discuss standard guidelines for asthma. Control practice participants were checked for inhaler technique in the nurse-run clinic immediately after recruitment. Drugs were unaltered and participants continued with usual care.

Evaluation Design:
This was a randomized controlled trial. Randomization took place at the general practice level to either intervention or control groups

Sample Size:
324 individuals: 164 [51%] South Asian patients, 108 [33%] white patients, and 52 [16%] from other ethnicities, largely African and Afro-Caribbean. Only 45% of participants spoke English; 89% lived in rented housing and 55% were unemployed. Of the total, 63% were recruited prospectively after attendance with acute asthma.

Outcome Measures:
Percentage of participants receiving unscheduled care for acute asthma over 1 year and time to first unscheduled attendance

Results:
The specialist nurse intervention delayed time to first attendance with acute asthma (median of 194 days for the intervention group, 126 days median for the control group). The intervention also reduced the percentage of participants attending with acute asthma (58% for the intervention group, 68% for the control group). The overall rates of yearly attendance for unscheduled care for each participant were 1.98 for the intervention group and 2.36 for the control group.

Article Citation(s):
Hopman WM, Garvey N, Olajos-Clow J, White-Markham A, Lougheed MD. Outcomes of asthma education: results of a multi-site evaluation. Can Respir J 2004;11(4):291–7.

Intervention Setting:
Seven sites across Canada, including community asthma care centers (CACCs) in Nova Scotia, Newfoundland, and British Columbia, two from Ontario, plus a community hospital and an academic health sciences center in Ontario.

Target Population:
This study involved teens and adults, 16 years of age and older, with diagnosed asthma who were attending a participating asthma center or clinic. All participants were referred by family physicians, specialists, or emergency departments on the basis of poor asthma control or an exacerbation of asthma.

Program Description:
This study sought to determine the effectiveness of a standardized asthma education program, administered in a variety of settings, in improving a number of outcomes, and the factors associated with a change in outcome. The study hypothesis was that a standardized asthma education program would improve outcomes regardless of geographical site or physical setting.

Referred patients attended an initial visit and a 6-month follow-up visit to the education program. At the initial visit, spirometry was conducted and a detailed patient profile was concluded using a standardized questionnaire and software developed for this purpose. The questionnaire formed the basis of the needs assessment and contained items relating to patient history, contacts with the health care system, symptoms, triggers, medications, environment, action plans, and action taken during an asthma episode. Health-related quality of life was measured at baseline and again at a 6-month followup using the self-administered Medical Outcomes Study. (The Medical Outcomes Study 36-item Short Form 1.0 [SF-36] has been demonstrated to be reliable and valid for asthma. The SF-36 provides scores ranging from 0 [poor] to 100 [excellent] on eight domains; higher scores represent better function and lower pain levels).

The program was based on a model of education implemented in a large community hospital that had previously demonstrated statistically significant improvements in health outcomes. Trained asthma educators with a background in nursing or respiratory therapy provided the education. The program was standardized across the seven sites by means of a training workshop and the use of questionnaires. The education program included three levels of education available to the patient relative to their asthma severity and initial needs assessment. The education is based on the social cognitive theory of learning and behavior change. Curriculum content included trigger avoidance, environmental control, the role of medications, delivery systems, action plans, and self-monitoring skills. The education took about 2 hours to complete. A follow-up visit was scheduled for 2 weeks later to assess control and understanding and the instructional material was reviewed as necessary. A follow-up visit was scheduled for 6 months after the baseline visit, at which time the patients responded to a second standardized questionnaire that referenced the previous 6 months and assessed contact with the health care system, symptoms, triggers, medication, action plan use, and action taken during an episode.

Evaluation Design:
An uncontrolled, prospective, observational, comparative study with a pre-post design

Sample Size:
The final sample comprised 252 adults. The patients were predominantly middle-aged (mean average 42.0 years), with a long-standing history of asthma; 75% were female.

Outcome Measures:
Health care use (regular and unscheduled visits to general physicians and specialists, number of emergency room visits and hospitalizations, and length of stay), absenteeism, amount of leisure time missed, and health-related quality of life in a variety of settings.

Results:
Statistically significant improvements resulted in all health care use and absenteeism outcomes, except regular specialist visits. The following mean values are based on total number of visits or admissions divided by the sample size. Unscheduled physician visits fell from an average of 2.71 to 0.51. Unscheduled specialist visits fell from 0.14 to 0.06. The mean number of hospital admissions at baseline was 0.48; at followup this number had dropped to 0.13. The mean number of days in the hospital for the 63 patients admitted was 1.72 at baseline compared to 0.92 at follow-up. Mean number of emergency room visits fell over the same time from 0.95 to 0.27. The mean number of missed work or school days also fell, from 5.04 to 3.65. Finally, missed leisure time days fell from 2.14 to 1.81. Six months after asthma education, statistically significant improvements in all health-related quality of life domains had resulted, except for mental health. The change upward in five domains (physical function, role physical, role emotional, bodily pain, and vitality) exceeded 5 points. The developers considered that to be a clinically and socially meaningful change. The change in social function and general health fell just short of 5 points.

Article Citation:
Diamond SA, Chapman KR. The impact of a nationally-coordinated pharmacy-based asthma education intervention. Canadian Respiratory Journal 2001;8(4):261-5.

Intervention Setting:
A total of 536 community pharmacies across Canada held a “national asthma clinic day.”

Target Population:
Individuals of all ages whose asthma had been diagnosed by a physician (and parents of children with physician-diagnosed asthma) and who were self-referred for a counseling session with a pharmacist were part of the intervention.

Program Description:
The study objective was to assess the impact of a nationally coordinated, pharmacy-based educational intervention on self-management behavior and markers of asthma control in self-referred patients with asthma. An 8-hour train-the-trainer course prepared 55 pharmacists from across Canada, who in turn trained hundreds of pharmacists over a 3-month period. Trained pharmacists then implemented asthma education in their practices for several months before the nationally advertised asthma clinic day. A counseling room was provided at each pharmacy. On asthma clinic day, patients brought their medications and devices so they could be trained on their use. All the baseline data for the study were acquired by interview during this single day – March 5, 1997. The pharmacist used a questionnaire to guide a 20-minute discussion. A device checklist assessed patient technique. Pharmacists highlighted problems for each patient and suggested individual solutions. Arrangements were made regarding telephone follow-up.

Evaluation Design:
Pharmacists used a structured questionnaire to assess asthma control and self-management in the one-on-one counseling session using standard checklists and questions. A telephone follow-up 30 days later assessed the impact of the teaching. Data collected at the counseling session was compared with data provided at the time of the telephone interview.

Sample Size:
A total of 4,080 people with asthma participated in the study including parents of 255 pre-schoolers, 455 school-aged individuals, 1,324 adults ages 19-64, and 946 adults 65 years of age or older. The ages of 27% of participating patients were not recorded.

Outcome Measures/Results:
Outcome measures included the number of wheezing episodes and other symptoms per week, number of nighttime awakenings per week, and frequency of reliever and preventive medication use. The common problems identified included poor inhaler technique (22%), excessive use of a short acting beta2-agonist (16%), inconsistent use of an inhaled corticosteroid (22%), and manifestations of sub-optional asthma control beyond frequent beta2-agonist use (18%). Of participants, 60% were deemed to need follow-up with their doctors for re-assessment (72% of this group did follow-up). Following the intervention, frequency of reliever medication use and frequency of nighttime awakenings both decreased substantially. The percentage of patients using preventive medications daily rose slightly and the percentage of patients not using preventive medications or using them as needed decreased slightly. These changes were statistically significant.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None