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Article Citation(s):
Halken S, Host A, Niklassen U, Hansen LG, Nielson F, Pedersen S, Osterballe O, Veggerby C, Poulsen LK. Effect of mattress and pillow encasings on children with asthma and house dust mite allergy. Journal of Allergy and Clinical Immunology. 2003;111:169-76.

Intervention Setting:
Participants’ homes

Target Population:
Children aged 6–15 years with well managed asthma and house dust mite (HDM) allergy.

Program Description:
This investigation aimed to determine whether use of mattress and pillow encasings resulted in effective long-term control of HDM allergen levels, thereby reducing the need for asthma medication in the children. Children were randomized to either an active treatment group that was provided mattress and pillow encasings coated with semipermeable polyurethane or a control group that received specially constructed cotton placebo mattress and pillow covers that resembled the active treatment covers. All encasings were delivered directly from the manufacturer to the patients. During the study, the encasings were to remain unwashed, and changes in the child’s mattress, bed and bedroom, as well as structural changes in the residence, were not allowed. Three children in the active group and four children in the placebo group were excluded during the study when their families could not comply with these controls or when the child did not take the medications as prescribed. A clinical evaluation with lung function measurement, adjustment of the pharmacologic treatment, and dust sampling from the child’s mattress occurred at baseline and every 3 months during the 12-month study period. At inclusion and during baseline and treatment periods, asthma medication was titrated to the lowest effective dose of inhaled steroids and B₂-agonists on the basis of symptoms, need for B₂-agonists, and peak flow recorded in diaries. Lung function measurements were determined using spirometry. Diaries were used to record morning and evening peak expiratory flow symptoms (symptom scores of 0–3 with 0 being no symptoms and 3 being worst case) during night and day. The number of doses of B₂-agonist used on demand were recorded for 2 weeks before the visits. Forty of the 47 children using inhaled steroids used the same product during the entire study period. All children used short-acting B₂-agonist as needed during the study period.

Evaluation Design:
A randomized controlled study approach was used.

Sample Size:
The study comprised 60 children with physican-diagnosed asthma, a positive skin-prick test response to HDM, a positive bronchial provocation test result with HDM allergen extract, and a measured amount of dust from the child’s mattress.

Outcome Measures/Results:
Outcome measures included reduction in HDM allergen concentrations and reductions in use of inhaled steroids. Concentrations of total HDM allergens on mattresses in the active group significantly decreased but not in the placebo group after 6 and 12 months. The daily dose of inhaled steroids (budesonide or fluticasone) was reduced by at least 50% in significantly more children in the active group than in the placebo group (73% vs. 24%, p<.01) after 12 months. The approximate 50% reduction in inhaled steroid use among the children in the active treatment group occurred without worsening in symptoms or lung function or need for rescue medication. Encasing mattresses and pillows resulted in a significant long-term reduction in both HDM allergen concentrations on mattresses and in the need for inhaled steroids in children with asthma and HDM allergy.

Materials available:
None

Article Citation(s):
Tsitoura S, Nestoridou K, Botis P, Karmaus W, Botezan C, Bojarskas J, Arshad H, Kuehr J, Forster J. Randomized trial to prevent sensitization to mite allergens in toddlers and preschoolers by allergen reduction and education. Archives of Pediatric Adolescent Medicine 2002;156:1021-27.

Associated citations:
Arshad SH, Bojarskas J, Tsitoura S, et.al. Prevention of sensitization to house dust mite by allergen avoidance in school age children: A randomized controlled study. Clinical and Experimental Allergy 2002;32(6):843-49).

Halmerbauer G, Gartner C, Schirl M, et al. Study on the prevention of allergy in children in Europe [SPACE]: allergic sensitization at 1 year of age in a controlled trial of allergen avoidance from birth. Pediatric Allergy and Immunology 2003;14:10-17.

Intervention Setting:
This multi-site community-based study was conducted in homes in four countries: England, Germany, Greece, and Lithuania.

Target Population:
Toddlers and preschoolers who initially were not sensitized to mite allergens and had at least one parent with atopic symptoms and sensitization were targeted for this study.

Program Description:
The objective of this study was to determine the effects of the reduction of mite allergen exposure on prevention of sensitization to house dust mites and development of allergic disease in toddlers and preschoolers age 1.5–5 years who were at high risk for atopy. All parents received an educational program. All were given background information about allergies and the higher risk for their child to develop an allergy. Booklets on environmental influences on children’s health and preventive recommendations were provided to the intervention group, along with additional oral explanations. A similar booklet, without information about mattress covers, was distributed to parents of the children in the control group. The intervention included providing a special dust mite-impermeable encasement for all beds in the room at home where the children in the intervention slept. Intervention group parents received extensive advice about measures to reduce dust mite allergens in the child’s room (carpet removal; hot washing of sheets, pillow, blankets, and toys; cleaning tips; ventilation; elimination of pets in the room; and avoidance of cigarette smoking). A healthcare worker visited participants’ homes at 6 months to ensure the encasements were in place and to repeat instructions for reducing house dust mite allergens. Information about the child’s atopic symptoms was obtained at 6 months in health centers. All the families in the control group in all four locations received the following common recommendations: avoid exposure to pets in bedrooms, ensure good ventilation of rooms, and avoid cigarette smoking. Likewise, information about the child’s atopic symptoms was obtained at the 6-month follow-up. After 12 months, all parents and their children were invited to participate in a follow-up examination that included a skin-prick test or immunoglobulin E (IgE) determination and a questionnaire on symptoms.

Evaluation Design:
A randomized controlled study approach was used.

Sample Size:
The study comprised 636 children with a mean age of 3.1 years. Inclusion criteria included: 1) local residence; 2) a positive parental screening questionnaire result (history of asthma, atopic eczema, or hay fever) and positive parental skin-prick test or IgE; 3) no sensitization to mite allergens at the beginning of the study; and 4) atopic manifestations, such as bronchial asthma, hay fever, or atopic eczema. Because investigators were interested in new cases of sensitization to mite allergens, they excluded all children whose skin prick tests were positive for D pteronyssinus or D farinae in the initial screening.

Outcome Measures/Results:
The primary outcome measure was sensitization to mite allergens as indicated by skin prick test or specific Ig E. Of the 330 children in the intervention group, 10 (3%) had sensitization to mite allergens compared with 20 (6.5%), in the control group, a statistically significant difference. The finding suggests that a simple program of prevention measures in childhood may reduce the risk for later development of asthma. The prevalence of atopic clinical manifestations was available for the 566 children who participated in the 12-month follow-up. Children with sensitization had a higher prevalence of symptoms of asthma and eczema (two to three times more common) and a higher prevalence of reported physicians’ diagnoses of food allergy and asthma than non-sensitized children.

Materials available:
Dr. Wilfried Karmaus, Associate Professor, Department of Epidemiology, Michigan State University, 4660 S Hagadorn Rd., Suite 600, East Lansing, MI 48823; Telephone (517) 353-8623 ext. 115; fax (517) 432-1130; www.epi.msu.edu/faculty/directory/karmaus.htm. [external link]

Article Citation:
Guendelman S, Meade K, Benson M, Chen YQ, Samuels S. Improving asthma outcomes and self-management behaviors of inner-city children: A randomized trial of the Health Buddy interactive device and an asthma diary. Archives of Pediatric and Adolescent Medicine 2002;156(2):114-20.

Intervention Setting:
Participants’ homes and an outpatient clinic at Children’s Hospital Oakland, Oakland, California

Target Population:
Inner-city children aged 8–16 years with persistent physician-diagnosed asthma. The child’s caregiver had to speak English, and the home had to have telephone.

Program Description:
The objective of this study was to assess the effectiveness of an interactive health communications device programmed for the management of pediatric asthma. This approach departs from conventionally delivered asthma education programs or interactive computer-based educational programs that do not rely on the interaction between the child and a health professional, educator, social worker, or other instructor. Health Buddy, programmed for the care of inner-city children with asthma, monitors asthma symptoms, quality of life, and self-care and sends information through a secured Web site to the health-care provider. The hypothesis was that by allowing children an opportunity to acquire knowledge about asthma and symptom recognition and receive immediate feedback on their decisions and behaviors, asthma symptoms among Health Buddy users would decrease. Continued use of the Health Buddy would help to increase self-care behaviors, which in turn would reduce symptoms.

All children were prescribed daily prevention medication and a quick-relief medication to use as needed. A nurse conducted a kickoff standardized teaching session. Each child received a peak flow measuring device and instruction on its use to establish personal best. They were instructed to take daily peak flow measurements and to record them in their diary. Children were then randomized and instructed how to use the assigned tracking method to record their peak flow readings and symptoms. The intervention children assigned to Health Buddy were given a demonstration on how to use the device and explained how to install it at home. The control group used an asthma diary. Each day the nurse coordinator queried to the intervention children using a standard Internet browser. The children answered the queries by pressing buttons on the device. The device automatically telephoned a data processing center at night, which processed the responses and published them to a secure website the next day. The nurse coordinator then reviewed the information. Each answer to a question received immediate feedback from the device: praise for a correct answer or encouragement to try again. Additionally, asthma facts and trivia questions that changed daily were included on Health Buddy program to pique children’s curiosity and enhance learning. The dialogs were designed for a third-grade reading level. By protocol, children had to access the device once a day. All children were asked to return for two follow-up visits at 6 and 12 weeks during which the nurse interviewed the child and delivered a standardized teaching session that reinforced peak-flow measurement compliance with meds and tracking symptoms. A physician examined each child during these follow-up visits.

Editor’s Note:
Health Buddy was developed by Health Hero Network, Mountain View, California. The device, connected to a home telephone, can be programmed to present questions and information on a screen and to record responses. Example of exchange between the child and Health Buddy: “Hi! Thanks for hanging out with your Health Buddy today. Your questions are now ready for you. Have you had any coughing or wheezing in the last day?” If the child answers “Yes”: “This could be a sign that your asthma is acting up. You may need to take your Albuterol as directed by your doctor when you are coughing and wheezing.” If the answer is “No”: “That’s great! You must be taking your preventor [sic] medicine. Did you miss out on any sports, exercise, or play yesterday because of your asthma?” If child answers “Yes”: “Sorry to hear you missed out on some fun. If your asthma acts up while doing sports, exercise, or play, please talk to your doctor about this. It is important to know what activities might trigger your asthma.” If the answer is “no”: “That is fantastic! Sports and exercise are fun and healthy.”

Evaluation Design:
A randomized controlled trial design

Sample Size:
Sixty-six participants in the intervention group, and 68 in the control group

Outcome Measures and Results:
Outcome measures included limitation to activity, peak flow reading in the red zone (<50% of the personal best) or yellow zone (50%-80% of the personal best) in the 2 weeks before the interviews, missed school days, and use of health services because of asthma in the preceding 6 weeks. Children in both arms of the study reported a decrease in asthma symptoms and decrease in peak flow readings in the yellow or red zone at 6 weeks and 12 weeks compared with baseline. Fewer children in the intervention group had peak flow readings in the yellow or red zone during the 2 weeks before the 6-week follow-up visit compared with control group children. Children in the intervention group were less likely to report limitation in activities. The odds of an urgent call for health services with Health Buddy were 0.43 of the odds of an urgent call with the asthma diary.

Availability of Protocol and Materials:
The principal investigator of the study plans to replicate this first trial in a different setting using a health-care plan and local physicians. The protocol and materials are not available for widespread distribution.

Case Study:
None

Article Citation:
Harish ZH, Bregante AC, Morgan C, Fann CSJ, Callaghan CM, Witt MA, Levinson KA, Caspe WB. A comprehensive inner-city asthma program reduces hospital and emergency room utilization. Annals of Allergy and Asthma Immunology 2001;86:185-189.

Intervention Setting:
Pediatric asthma center in New York City

Target Population:
This research targets inner-city, pediatric asthma patients ages 2–17 and their parents/caregivers recruited from the pediatric emergency department (ED) of the Bronx Lebanon Hospital in South Bronx. The hospital serves a predominantly Hispanic (58%) and African-American (37%) population.

Program Description:
The study objective was to evaluate the efficacy of a comprehensive asthma program on ED visits and hospital admission rates in an inner-city pediatric population. The intervention consisted of three 1-hour visits conducted 2 weeks apart. The activities in the first visit included review of patient history, asthma regimen with adjustment to the National Asthma Education and Prevention Program (NAEPP) guidelines as needed, proper use of a metered dose inhaler and spacer, and a review of clinical signs of asthma. A computerized asthma education program was used to present information on asthma pathogenesis and medications. The second visit included teaching the use of a peak flow meter for patients over age 5 and instructing the children and caregivers on use of an asthma emergency plan. Visit three included skin testing for common perennial and seasonal aeroallergens. Atopic patients received detailed training in environmental control measures. Mattress and pillow encasements were provided to patients allergic to dust mites. Caregivers were encouraged to call program staff any time if symptoms did not respond to one treatment of inhaled bronchodilators. Patients were given inhaled and oral corticosteroids to be used only when instructed by the provider on call.

Evaluation Design:
The evaluation consisted of a prospective randomized controlled trial. A visiting nurse reviewed medication use and environmental allergens at home. Questionnaires were sent to each patient’s home each month asking a) “Has your child visited the ED for asthma in the last month?” – if ‘yes’ the number of times, b) “Was your child admitted to the hospital for asthma in the last month?” – if ‘yes’ the number of days, c) “Did your child miss any school days because of asthma?” Participants were awarded a lottery ticket for each completed questionnaire.

Sample Size:
Sixty children were in the treatment group, and 69 were in the control group.

Outcome Measures/Results:
Outcome measures include ED attendance and hospitalizations. In the first study year, 32 patients in the treatment group visited the ED 73 times; 46 patients in the control group visited the ED 269 times. The mean number of ED visits per patient per month was 0.1 in the treatment group and 0.326 for the control group. The decrease in ED use by treatment patients was statistically significant for 6 months of the year including the last 4 months. There were fewer admissions in the treatment group (22) than in the control group (29). In the second year of the study, the mean number of ED visits per patient per year was 0.396 for treatment group and 1.0 for the control group, a statistically significant difference. Also, in the second year, 14 (26%) of the 53 patients in the treatment group visited the ED at least once, compared with 32 (53%) of the 60 patients in the first year. In first year, 53% of the treatment group visited the ED compared with 26% in the second year, and 27% of the treatment group was admitted to the hospital in the first year compared with 11% in year 2.

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

Case Study:
None

Article Citation(s):
Becker A, Watson W, Ferguson A, Dimich-Ward H, Chan-Yeung M. The Canadian Asthma Primary Prevention Study: outcomes at 2 years of age. J Allergy Clin Immunol 2004;113(4):651–6.

Intervention Setting:
Homes of study participants

Target Population:
This study focused on a cohort of infants at high-risk for development of asthma on the basis of an immediate family history of asthma. High-risk infants were defined as those with at least one first-degree relative with asthma or two first-degree relatives with other classic IgE-mediated allergic diseases as identified during the mother’s third trimester of pregnancy.

Program Description:
This study sought to determine the effectiveness of a multifaceted intervention program in the primary prevention of asthma in high-risk infants. The hypothesis was that there existed a potential for long-term modification of the infant’s risk for asthma during this small window of opportunity. After baseline assessment, a sealed envelope was opened that determined the family’s allocation to the intervention or control group. The control group did not receive specific information about intervention measures but followed the usual care recommended by their primary care physicians. Home visits were carried out during the third trimester of pregnancy, at 2 weeks, and at 4, 8, 12, 18, and 24 months after the birth of the child. Demographic and health characteristics were gathered through use of a standardized questionnaire. Home characteristics were assessed using a questionnaire and a walk-through survey.

The intervention program included the following:

1. The infant’s mattress and all mattresses and box springs in the parent’s bedroom were encased to limit exposure to house dust mites. Families were instructed to wash all bedding weekly using the hot cycle of their washing machines. Benzyl benzoate powder was applied to carpets in the infant’s bedroom, the parent’s bedroom, and the most commonly used room. Benzyl benzoate foam was applied to upholstered furniture in the most commonly used room before birth and at 4 and 8 months after birth.
2. Families were counseled to remove cats, dogs, or both from the home, or to keep pets outside the home, or at least outside the infant’s bedroom.
3. For environmental tobacco smoke (ETS), parents were counseled on smoking cessation and families were instructed to keep homes smoke free.
4. Families were encouraged to avoid daycare until after the first year of life. Nurses reinforced various avoidance measures at each home visit.
5. Mothers were encouraged to breast feed their infant for at least 4 months and for the first year if possible. Where breast-feeding was not possible, partially hydrolyzed whey formula was supplied until 12 months of age.

During each home visit dust samples were collected from the infant’s and parent’s bedroom floors and mattress and the floor and upholstered furniture in the most commonly used room. Samples were analyzed in duplicate for house dust mite and cat allergens. Allergens from these sites at each time were averaged. Each child was seen by a pediatric asthma specialist blinded to the study group and to compliance with intervention and who did not provide health care to the families. They examined the child and conducted a structured interview to record symptoms and physical findings. Allergy skin tests were conducted using house dust mite (HDM), cat, dog, cockroach, Alternaria species (fungi), cow’s milk, egg white, wheat, soy, and peanut allergens.

The intervention successfully decreased HDM exposure in the first and second year. There was significantly less cat allergen exposure in intervention homes at 2 weeks and 4 months. Mothers in the intervention group breast-fed longer and delayed introduction of solid food longer than mothers in the control group. Significantly fewer intervention group children were in daycare by 1 year of age. Finally, there was less ETS exposure in intervention homes.

Evaluation Design:
This was a prospective, prenatal, randomized, controlled clinical trial. Mothers of infants were randomized to an intervention group or a control group. The study included infants born between October 1994 and August 1996.

Sample Size:
Participants included 545 mothers of 549 high-risk infants for asthma

Outcome Measures:
Prevalence of asthma* and atopy at age 2 years in high-risk infants

Results:
At age 2 years, 19.5% of children in this high-risk cohort satisfied the criteria of having asthma, and 14.5% had positive skin test responses to at least one common allergen. At age 2 years, 16.3% of intervention group children and 23.0% of control children had asthma; 15.6% of children in the intervention group and 13.7% of control children were atopic. The intervention had a significant effect on the prevalence of asthma at age 2 years, decreasing the number of children given a diagnosis of possible and probable asthma in the intervention group (16.3%) compared with the control group (23.0%).

The main difference between the control and intervention groups was in the substantial reduction of persistent asthma, defined as asthma present at both year 1 and 2, in the intervention group (4.9%) vs. 11.3% for the control group, a 60% decrease in the intervention group. Recurrent wheeze was defined as three or more episodes of wheezing, each lasting 1 week or more. At 2 years of age, significantly fewer children had recurrent wheeze in the intervention group (1.0%) compared with control group (3.5%). The intervention had its greatest effect on recurrent wheeze with a 90% reduction in the intervention group compared with that seen in the control group at 2 years.

*Asthma was defined as the sum of children with a diagnosis of both possible asthma and probable asthma. Possible asthma was defined as at least two distinct episodes of cough each lasting for 2 or more weeks; at least two distinct episodes of wheeze, each lasting 2 or more weeks; or in the absence of a cold, at least one of the following: nocturnal cough (at least once a week) and hyperpnea-induced cough or wheeze. Probable asthma was defined as at least two distinct episodes of cough, each lasting 2 or more weeks, or at least two distinct episodes of wheeze, each lasting 1 or more weeks and one of the following: nocturnal cough lasting a week in the absence of cold, hyperpnea-induced cough or wheeze, response to treatment with B-agonist, anti-inflammatory drugs, or both.

Article Citation(s):
Morgan WJ, Crain EF, Gruchalla RS, O’Connor GT, Kattan M, Evans III R, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med 2004;351:1068–80.

Intervention Setting:
Study participants’ homes

Target Population:
Inner-city children with atopic asthma

Program Description:
The objective of this study was to determine whether an environmental intervention tailored to each child’s allergic sensitization and environmental risk factors could improve asthma-related outcomes. Previous studies of environmental interventions for patients with asthma have focused on a single allergen, such as dust mites or environmental tobacco smoke, rather than on the multiple exposures encountered by many urban children with asthma.

Eligibility was limited to residents of census tracts in which at least 20% of households had incomes below the federal poverty level. Eligibility criteria included at least one asthma-related hospitalization or two unscheduled, asthma-related visits to the clinic or emergency department during the previous 6 months and a positive skin test in response to at least 1 of 11 indoor allergens. A baseline clinical evaluation included questionnaires on complications related to asthma and the home environment, and skin testing was performed. A baseline home evaluation involved direct visual inspection and dust collection from the child’s bedroom. The home evaluation team collected separate, vacuumed dust samples from the child’s bedroom floor and bed. Samples were tested for dust mite, cockroach, cat, and dog allergens.

Children were randomly assigned to the control group or the intervention group by blocked randomization within a site. Families in the control group received visits only for evaluation at 6-month intervals throughout the study. The goal of the intervention was to provide the child’s caretaker with the knowledge, skills, motivation, equipment, and supplies to perform comprehensive environmental remediation. Researchers educated the family regarding the importance of the mitigation behavior and its effectiveness and modeled the targeted behavior. Caretakers performed the mitigation behavior while the environmental counselors provided feedback and encouragement.

The intervention was organized into six modules that focused on remediation of exposure to dust mites, passive smoking, cockroaches, pets, rodents, and mold. Intervention activities were tailored to each child’s skin-test-sensitization profile and environmental exposures on the basis of the caretaker’s report and the study staff’s observations during the baseline home evaluation. During the 12-month intervention, two research assistants conducted five mandatory and two optional home visits. All visits were followed by a telephone call to address any barriers to implementing the remediation plan.

During the first visit, the intervention teams taught the caretaker about the role of allergens and irritants in the child’s asthma. They also introduced the environmental intervention plan, which included the creation of an environmentally safe sleeping zone. Allergen-impermeable covers were placed on the mattress, box spring, and pillows of the child’s bed at the first visit. The teams gave families a vacuum cleaner equipped with a high-efficiency particulate air (HEPA) filter and instructed them on its use. A HEPA air purifier was set up in the child’s bedroom if the child was exposed to passive smoking, sensitized and exposed to cat or dog allergens, or sensitized to mold. Professional pest control was provided for children sensitized and exposed to cockroach allergen. Follow-up surveys of the home environment and collection of dust allergens were repeated at 6, 12, 18, and 24 months to assess changes in the home environment.

Evaluation Design:
This randomized controlled trial lasted 1 year. It included education and remediation of exposure to both allergens and environmental tobacco smoke. Home environmental exposures were assessed every 6 months and asthma-related complications were assessed every 2 months during the intervention and for 1 year after the intervention. Interviewers conducted standardized telephone interviews with each child’s primary caretaker every 2 months during the year of the intervention and the year after the intervention. They collected data on asthma symptoms, medication use, and health care use.

Sample Size:
The sample included 937 children, ages 5–11 years (mean age 7.7 years), in six major U.S. cities (Boston, Chicago, Dallas, New York City, Seattle-Tacoma, and Tucson), whose asthma had been diagnosed by a physician at research centers in those cities. Most of the children were black or of Hispanic descent, as reported by each child’s caretaker.

Outcome Measures/Results:
Children in both groups had a high prevalence of allergic sensitization to cockroach and dust-mite allergens. Exposure to tobacco smoke and airborne allergens was common. Detectable levels of cockroach allergens were found in 68.4% of bedrooms. Dust-mite allergens were found in 84.1% of bedrooms. Additionally, 76.8% of children sensitive to cockroach and 86.7% of those sensitive to dust-mite allergen had detectable levels of these allergens in their bedrooms. Home environmental interventions resulted in significantly fewer dust-mite allergens in the bed and cockroach and dust-mite allergens on the child’s bedroom floor. Those improvements remained significantly higher for the intervention group in the second year.

The primary health outcome was the maximal number of days with asthma symptoms in the 2 weeks before the telephone interview (conducted every 2 months for 2 years). Symptom days were defined as the largest value among the following three variables:

1. number of days with wheezing, tightness in the chest, or cough;
2. number of nights with disturbed sleep as a result of asthma; and
3. number of days on which the child had to slow down or discontinue play activities because of asthma.

The intervention group reported significantly fewer symptoms of asthma during the intervention year and the follow-up year. The maximal number of days with symptoms was lower in the intervention group by 0.82 day per 2-week period in the first year and 0.60 day per 2-week period in the second year. This observed reduction in symptoms translates into 34 fewer days with reported wheeze during the 2 years of the study among children in the intervention group compared with those in the control group. The interventions also helped significantly reduce disruptions of caretakers’ plans, caretakers’ and children’s lost sleep, and school days missed by the children in the intervention group. The intervention resulted in 13.6% fewer unscheduled visits for asthma per year, 19.3 fewer days with symptoms per year, and 20.7% fewer missed school days per year.

Article Citation(s):
Georgiou A, Buchner D, Ershoff DH, Blasko KM, Goodman LV, Feigin J. The impact of a large-scale population-based asthma management program on pediatric asthma patients and their caregivers. Annals of Allergy, Asthma, and Immunology. 2003;90:308-15.

Intervention Setting:
Participants’ homes

Target Population:
Children aged 5–3 years with asthma in the United States whose families were covered by the United Health Plans were eligible for this study.

Program Description:
The objective of this study was to determine the impact of an asthma management program on pediatric patients with asthma and their caregivers over a 12-month period. In this longitudinal study, 401 randomly selected households with children with asthma completed a survey questionnaire before and after 12 months of participation in the Asthma Management Program. Information collected included daytime and nighttime asthma symptoms, functional impact of the disease, interference attributable to treatment, and impact on family activities. In addition to seeking information from caregivers on process measures (such as the use of written action plans, knowledge about asthma triggers, attack management, use of a peak flow meter), caregivers were questioned about lost work and lost school days related to their child’s asthma. Additional information about participants was supplemented by asthma-related medical care use obtained from the computerized claims database.

The Asthma Management Program interventions were tailored to each child’s asthma health risk and need as determined from medical records, filled prescriptions, and the self-reported survey. The interventions for all participants consisted of an educational booklet, asthma treatment guides and seasonal and quarterly mailings about asthma-related issues (called "educational touches"), and an asthma control kit that included a peak flow meter and an educational video. All "high-needs" asthma patients were offered one-on-one asthma education and intensive "telephonic care management" conducted by registered nurses and respiratory therapists. Telephonic care managers provided feedback to patients’ physicians when appropriate. Additionally, all high-risk members received an asthma control kit that included a peak flow meter and an educational video. All physicians were given a list of their identified asthma patients, including a medication and utilization history, and were provided copies of the NAEPP guidelines. Physicians of high-risk members were sent a letter regarding their patients’ involvement in the program and were encouraged to provide these patients with asthma action plans.

Evaluation Design:
A one-group pretest-posttest design was used with a comparison of responses to questionnaire items before and after exposure to the asthma health management program.

Sample Size:
A total of 1,003 patients were randomly sampled from a group of 3,585 patients in 17 regional health-care districts. Only 401 patients’ families completed the study.

Outcome Measures/Results:
Outcome measures related to the child’s health included daytime symptoms, nighttime symptoms, functional limitation, life interruptions resulting from treatment, impact on family activity, emergency or inpatient care for asthma, and missed school days. Caregiver measures included missed workdays because of the child’s asthma. Data indicated higher post intervention scores on all of the child’s quality of life parameters. The largest improvement was detected for nighttime symptoms (a gain of 5.8 points), the smallest change was detected for daytime symptoms (2.4 points). The proportion of children classified as having mild symptoms based on frequency of reported symptoms increased from 66.9% at baseline to 75.3% at follow-up. The percentage of patients requiring inpatient admission or emergency care decreased significantly, (9.7% vs. 5.5%) according to claims data from the baseline year and the 12-month period of intervention preceding the follow-up. The percentage of children who missed one or more school days because of asthma decreased significantly from 36% to 23%. Forty-eight (17.1%) working caregivers reported having missed 1 or more days from work during the previous 4-week period because of the child’s asthma in the preintervention period; this figure decreased to 27 (9.6%) at follow-up. Of the 48 respondents reporting 1 or more missed workdays at baseline, 38 reported no missed days at follow-up. The mean annualized number of caregiver workdays missed because of asthma care fell from 3.8 days at baseline to 1.8 days at follow-up. This computed to a baseline annual mean of 30.5 missed hours per employed primary caregiver of an child with asthma, compared with 14.4 hours per year at follow-up. The estimated indirect costs related to lost caregiver work time suggested a savings of $327.00 per employed caregiver resulting from the reduction in lost work hours.

In 2003, this program was implemented in over 30 United Healthcare Plans.

Materials available:
Materials are not available for widespread distribution.

Article Citation:
Jones PK, Jones SL, Katz J. Improving compliance for asthmatic patients visiting the emergency department using a health belief model intervention. J Asthma 1987; 24(4):199-206.

Intervention Setting:
The emergency department or discussion via telephone

Target Population:
Children and adults with asthma presenting to an emergency department with an acute attack

Program Description:
An asthma education program, based on the Health Belief Model, designed to increase the likelihood participants will make and keep follow-up appointments after a visit to the emergency room. 

An initial assessment of the role of demographic and situational factors on patients’ compliance rates with appointment referrals was conducted. In response, an asthma education program was developed to increase how patients perceived their susceptibility to acute asthma episodes, the seriousness of an episode, the risks associated with an episode and the benefits of preventing an episode by making and keeping referral appointments. The program was tailored for participants based on individual assessments of perceived risk and benefits. A shorter version of the education program was also conducted via telephone 1-2 days after discharge from the emergency room.

Evaluation Design:
A randomized control study

Patients were randomly assigned to three treatment groups and one control group. The extent of compliance was assessed by calling the agency to which patients were referred to find out if appointments were made and kept. All patients were subsequently contacted via phone by a nurse. Data were also collected on individual demographic and situational factors that might influence compliance.

Sample Size:
74 asthmatic patients randomly assigned to four groups: (1) routine nursing care, (2) routine care in the ER with a follow up phone intervention, (3) education during ER visit with no follow up intervention, and (4) education during the ER visit and a follow up phone intervention.

Outcome Measures/Results:
The primary outcome measures were the number of follow-up referral appointments made and kept. Patients receiving any of the interventions were more likely to make (91% vs. 43%) and keep appointments (75% vs. 10%) than the control group. Other findings suggest that females were more likely to make appointments, and people over age 30 were more likely to make and keep appointments. In addition, patients whose primary health problem was rated as serious were more likely to make and keep appointments, as were those patients with low need for childcare. The telephone intervention was almost as effective as the education program in the ER; consequently, it may be the more effective approach in terms of cost-benefit.

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

Case Study:
None

Article Citation:
Wesseldine LJ, McCarthy P, Silverman M. Structured discharge procedure for children admitted to hospital with acute asthma. Archives of Disabled Children 1999;80:110-4.

*Editor’s note: This program is very similar to the study by Madge, McColl, and Paton carried out in Glasgow, United Kingdom (UK) and described in Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: A randomized controlled study. Thorax 1997;52:223-8.

Intervention Setting:
A pediatric hospital in the UK

Target Population:
Children with acute asthma admitted to the hospital in Leicester, UK during 1996

Program Description:
The study objective was to examine the impact of a structured, nurse-led discharge intervention for children admitted to the hospital with acute asthma upon readmission to the hospital, re-attendance at the emergency department (ED), and general practitioner consultation for asthma. The intervention consisted of a 20-minute patient education program and self-management plan. A knowledgeable pediatric nurse provided Instruction. The intervention included provision of information on the nature of asthma, risk factors and their avoidance, and appropriate use of medications and devices. The educational component emphasized guided disease self-management. An individualized written management plan was provided for each child. The booklet At Home with Asthma was provided to reinforce verbal information. Contact numbers for help-lines were also provided.

Evaluation Design:
The study was a randomized controlled trial with follow-up after 6 months of being discharged from the hospital for asthma treatment. Baseline data were collected via questionnaire on the day of discharge from the hospital. Data were collected regarding medications used, admissions to the hospital, emergency-care received, and physician visits. The pattern and severity of asthma symptoms, atopy and allergy, and causal factors also were recorded.

Sample Size:
A total of 160 children aged 2–16 years of age participated (80 in each of the intervention and control groups) who previously had been admitted to the hospital for asthma and were readmitted to the hospital, re-visited an ED, or had a general practitioner consultation for asthma during a 12-month period.

Outcome Measures/Results:
Outcome measures included re-admission (with overnight stay) to the hospital within 6 months after discharge. Secondary outcome measures included re-attendance without admission either in the ED or the children’s admission unit. The proportion of children re-admitted to hospital was substantially lower in the intervention group (15%) than in the control group (37%), a statistically significant difference. The total number of re-admissions in the intervention group was 18 compared with 69 in the control group (in which multiple re-admissions occurred). Emergency department attendance was substantially lower for the intervention group, at 8% compared with 38% for the control group. Of the children in the intervention group, 39% visited physicians compared with 90% of children in the control group.

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

Case Study:
None

Article Citation(s):
Ebbinghaus S, Bahrainwala AH. Asthma management by an inpatient asthma care team. Pediatric Nursing 2003; 29:177-83.

Intervention Setting:
Children’s Hospital of Michigan in Detroit

Target Population:
Children admitted to the hospital with an asthma exacerbation

Program Description:
Administrators at Detroit’s Children’s Hospital of Michigan initiated an Inpatient Asthma Service program to address glaring discrepancies in treatment plans for the care of patients not admitted by private primary care physicians but, instead, through channels such as the emergency department. Treatment plan discrepancies applied to asthma exacerbations, asthma education, and length of stay in the hospital. Objectives of the new Inpatient Asthma Service included 1) standardized asthma care by a specialist team in accordance with National Asthma Education and Prevention Program (NAEPP) guidelines, 2) comprehensive asthma education to patients and their families; and 3) referral to the outpatient asthma clinic for further follow-up, management, and reinforcement of asthma education. The Inpatient Asthma Service consists of physicians specializing in asthma and allergy and pediatric asthma nurse specialists trained in inpatient asthma management and education. The nurse specialist independently assessed and monitored asthma patients, conducted asthma education (customizing instruction according to learner needs), developed new educational materials as standards of asthma management change, and facilitated coordination of resources for inner-city families. The nurse specialist’s activities included:

• Obtaining a detailed family history, a detailed asthma history, and clinical assessment of the exacerbation;
• Helping families with social needs (language barrier, insurance coverage, access to a nebulizer and medications, transportation);
• Informing the asthma specialist of changes in clinical status of the patient that required modifications in management; and
• Providing asthma education to inpatients and families during the hospital stay.
  Asthma education discussion topics included
  • asthma as a chronic disease with airway changes
  • symptom recognition
  • asthma action plan
  • differentiation between rescue and controller medication and their use and effects
  • environmental control measures
  • importance of regular physician monitoring and follow-up after hospital discharge
  • demonstrating proper inhaler technique and medication use with placebo inhalers, spacers, masks, nebulizer tubing, and peak flow meters
  • reviewing written home instructions before discharge about medication use, time, and dosing with the family; verifying correct inhaler use; scheduling follow-up appointments with the allergy-asthma clinic; arranging for a visiting nurse agency referral to assist with ongoing asthma education and environmental assessments; and reinforcing appropriate medication use.

A number of teaching tools have been developed to support the inpatient asthma education that are culturally sensitive and reflect patients’ needs. An animated metered dose inhaler named Peter Puffer® is depicted in an animated live action video, comic book, and educational handouts with African-American children living in the Detroit community who attend school and take asthma medication. Commercially available pocket-sized flipcharts and pamphlets depicting asthma airway changes and common asthma medications complemented information discussed in the patient handouts.

Evaluation Design:
A pre-post design was used.

Sample Size:
An average of 4,500 children are treated each year in the Children’s Hospital of Michigan emergency department for asthma exacerbation. Roughly 1,500 of these children are hospitalized each year. The actual number of children included in this evaluation was not provided.

Outcome Measures/Results:
Outcome measures included the length of stay in the hospital and cost savings. Before 1996, the average length of stay in the hospital was 2.2 days. Since 1996, an average of 55% of pediatric patients with asthma have been admitted to the Inpatient Asthma Service program, and the length of stay for this group of patients decreased to an average of 1.7 days. The length of stay for patients admitted under the care of hospital staff or private primary care physicians since 1996 continued to average 2.2 days. This 0.5 day (or 12 hours) average shorter stay per patient reduced costs for the hospital and costs incurred by the family related to meals, parking, transportation, sibling child care, and missed days from work and school. Since 1996, the cost of patient admission to the inpatient asthma service averaged $420 less than the cost of an admission to hospital staff or private physicians. The annual difference in care costs per patient multiplied by the number of patients admitted to the Inpatient Asthma Service program each year yielded an average annual cost savings of $300,000 per year.

Materials available:
None

Article Citation:
Taggart VS, Zuckerman AE, Lucas S, Acty-Lindsey A, Bellanti JA. Adapting a self-management education program for asthma use in an outpatient clinic. Ann Allergy March 1987;58(3):173-178.

Taggert VS, Zuckerman AE, Sly RM. You can control asthma: Evaluation of an asthma education program for hospitalized inner-city children. Patient Education and Counseling 1991;17:35-47.

Intervention Setting:
Inner city hospital

Target Population:
Hospitalized asthmatic children between the ages of 4 and 12

Program Description:
A nurse-administered pediatric asthma program for hospitalized children.

Several theories were used to guide the development of the program: self-learning, self-regulation, and health locus of control. An environmental assessment of the hospital setting in which the program was to be delivered was conducted using the PRECEDE model. The program consists of five lessons and was developed to demonstrate the feasibility of teaching children about asthma and self-management techniques as part of their standard medical care. The program was adapted from a successful earlier version, set in the emergency room, which taught parents and children how to successfully manage acute attacks. The program used a combination of written materials, games, videotape and one-on-one discussions with the nurse.

Evaluation Design:
Pre- and post questionnaires were given to children and, whenever possible, parents to test knowledge and their health locus of control. Nurses were also asked to keep logs to determine how many eligible patients actually received the program. Nurses were also asked to complete a questionnaire on the perceived feasibility of the program. Medical records were reviewed for fifteen months prior to and after enrollment into the program.

Sample Size: 
40 children

Pre-test data were collected on all 40; however, post-test data were available for only 30 children

Outcome Measures/Results:
The goal of the program was to improve children’s management of asthma, decrease emergency room visits and hospitalizations and increase follow through on routine asthma clinic appointments. Results indicate that nurses felt the program was feasible. Despite the large percentage of parents who did not participate in any of the sessions, it appears that children were able to transfer the knowledge and skills they learned. Hospitalization and parent’s report of frequency of symptoms did not decrease; however, rate of emergency room use decreased. The program’s impact on health locus of control and self-efficacy was unclear.

Evolution of the Program:
In 1991, the educational materials from this intervention were published as You Can Control Asthma: A Book for the Family and You Can Control Asthma: A Book for Kids. These materials have served as the core of multiple interventions in varied settings over time. Over the following decade, the books have been periodically updated and are distributed by the Allergy and Asthma Foundation of America (AAFA).

Availability of Materials:
You Can Control Asthma: A Book for the Family and You Can Control Asthma: A Book for Kids are available by mail or phone, or can be ordered on line from:

Asthma and Allergy Foundation of America [external link]
1233 20^th St. NW
Washington, DC 20036
phone: 1-800-7-ASTHMA

Case Study:
None

Article Citation:
Lewis CE, Rachelefsky G, Lewis MA, de la Sota A, Kaplan M. A randomized trial of A.C.T. (Asthma Care Training) for Kids. Pediatrics October 1984;74(4):478-486.

Rachelefsky GS, Lewis CE, de la Sota, A, Lewis MA. ACT (Asthma Care Training) for Kids. A childhood asthma self-management program. Chest January 1985;(suppl to no.1):98S-100S.

Intervention Setting:
Kaiser-Permanente facilities

Target Population:
Children identified with severe asthma between the ages of 7 and 12 and their parents

Severe asthma was defined as requiring medication at least 24% of the days of a month. All participants were members of the Kaiser Permanente health care system.

Program Description:
An asthma education and self-management program designed to give children and their parents the knowledge, confidence, and skills to reduce the frequency and severity of asthma attacks.

The program was developed as a supplement to existing medical care. Children and parents are taught to recognize symptoms, triggers and how to decide when to use medication and when to get additional help. The five, 1-hour educational sessions are held separately for parents and children; however, they come together for the last 15 minutes of each session to practice what they have learned. The program utilizes principles of social learning theory to reinforce the message that children are in control of their asthma.  To convince children they have the ability to manage their asthma, a driving analogy (“You are in the driver’s seat”) is used throughout the interactive group educational sessions.

Evaluation Design:
Children and their parents were randomly assigned to either the intervention or the control group. The control group received 3-½  hours of lecture presentations whereas the intervention group received 5 hours of interactive activities in a smaller group setting.  Data were collected via a structured telephone interview at baseline, 3, 6, and 12 months after the study.  Medical records were also reviewed to ascertain if there were any changes in emergency room visits and hospitalizations. ANOVA and non-parametric contingent analyses were used to analyze the data.

Sample Size:
76 children and their parents including 48 in the intervention group and 28 in the control group.

Outcome Measures/Results:
Outcome measures included the number of emergency room visits and hospitalizations, knowledge of asthma symptoms, triggers and treatments; parental and child’s perceptions of child’s health status and ability to control attacks; and steps taken during an attack.  Although the intervention and control groups had equivalent increases in knowledge and changes in beliefs, the intervention groups increased their use of compliance behaviors and reduced emergency room visits and days of hospitalizations. Qualitative data indicated there were improvement in father/child relationships and less smoking around children in the home.

Availability of Protocol/Materials:
The ACT for Kids Program kit is available by mail or phone, or it can be ordered on line.

Asthma and Allergy Foundation of America [external link]
1233 20^th St.  NW
Washington, DC 20036
phone: 1-800-7-ASTHMA

Case Study:
Asthma Care Training (ACT), Providence Alaska Medical Center, Anchorage, Alaska

Article Citation:
Kelly CS, Morrow AL, Shults J, Nakas N, Strope GL, Adelman RD. Outcome evaluation of a comprehensive intervention program for asthmatic children enrolled in Medicaid. Pediatrics 2000;105(5):1029-35.

Intervention Setting:
The intervention took place at a pediatric allergy clinic in a Norfolk, Virginia tertiary-care children’s hospital.

Target Population:
Low-income minority children enrolled in Medicaid who had two or more emergency department (ED) visits or a hospitalization in the previous year were targeted for the intervention.

Program Description:
The study objective was to evaluate the use of ED and hospitalization outcomes for Medicaid-insured asthmatic children after the comprehensive asthma intervention program. Children in the intervention group received asthma education and medical treatment at the child’s pediatric allergy clinic. Education was tailored to the needs of each family by providing one-on-one contact between child and family and a physician and asthma nurse. Education included recognition of asthma triggers, environmental controls, symptoms and warning signs, medication use and side effects, use of spacers and peak flow meters, and management of exacerbations. Written action plans were provided. An asthma outreach nurse maintained monthly contact with the intervention group families to review the health status of the child, medicine administration, to refill prescriptions, and to reinforce liaison between patient and provider.

Evaluation Design:
Children were alternately assigned in this controlled clinical trial, resulting in similar intervention and control groups. Children were identified for the study by computerized medical records. No incentive was offered for participation. Skin testing was used where indoor allergen sensitivity was apparent and avoidance techniques based on results were possible. Immunotherapy was not started. ED and hospital records were used to assess medical services use for the study year.

Sample Size:
A total of 80 children aged 2–16 years were included in the study.

Outcome Measures/Results:
Outcome measures included ED visits and hospitalizations. The mean number of ED visits at baseline and 1 year for the intervention group was 3.6 and 1.7 per child. Hospital visits decreased from 0.6 to 0.2 per child and hospital days decreased from an average of 2.4 to 0.9 per child. In the control group, ED visits decreased from 3.5 to 2.3 visits per child whereas hospitalizations decreased from 0.53 to 0.48 and average hospital days decreased from 1.8 to 1.7 per child. Logistic regression analysis was used to control for individual history of asthma outcomes in the prior year. Children in the control group compared with those in the intervention group were 1.4 times more likely to have an ED visit and 2.4 times more likely to be hospitalized, a statistically significant difference.

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

Case Study:
None

Article Citation:
Greineder, DK, Loane KC, Parks P.  A randomized controlled pediatric asthma outreach program. J Allergy Clin Immunol March 1999;103(pt 1):436-440.

Intervention Setting:
The Health Centers Division of Harvard Pilgrim Health Care, a large HMO in New England

Target Population:
Children with asthma ages 1-15 and their families

Program Description:
An asthma education program developed in accordance with the NHLBI Guidelines for diagnosis and management for pediatric asthma.  The program is a team-based intervention using an allergy nurse, nurse practitioner, and allergist to help patients gain knowledge about controlling their asthma.  The program components include a doctor’s visit to assess a family’s knowledge base, and education in the following seven areas: 1) asthma definition/ pathogenesis, 2) triggers and warning signs, 3) asthma medications, 4) inhaler, spacer, and nebulizer training, 5) peak flow meter and zoning instruction, 6) environmental control and adherence to medication schedules, and 7) importance of doctor visits. The patient and family receive 1 one-on-one education session led by the AOP nurse.

Evaluation Design:
Patients continuously enrolled in a HMO for at least 2 consecutive years were randomized into two groups.  The control group received a single-intensive asthma education intervention and the intervention group received the same initial education but followed by asthma case management through the intervention.  The Wilcoxon matched pair signed rank and Chi-square tests were used to analyze the data.

Sample Size:
A total of 57 patients participated, of whom 9 were recruited during hospitalization and randomized into the “control group” and another 9 into the intervention group.  Thirty-nine other patients recruited by referral were randomized independently into the control and intervention groups.

Outcome Measures/Results:
Data were collected on three key outcome variables: (1) ER visits, (2) hospitalizations, and (3) health plan expenditures. Control patients had significant reductions in ER visits (39%), hospitalizations (43%) and health plan costs (28%), likely resulting from baseline educational intervention for all enrolled patients.  Intervention patients had significant reductions in ER visits (73%), hospitalizations (84%) and health plan costs (82%).  Compared to the control group, intervention patients demonstrated additional reductions in ER visits, hospitalizations, and outside of health plan use.

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

Case Study:
None

Article Citation(s):
Peleg R, Gehtman P, Blancovich I, Aburabia R, Allush R, Hazut S, Shvartzman P. Outcomes of an intervention programme for treatment of asthma in a primary care clinic for Bedouins in Southern Israel. Family Practice 2002;19:448-51

Intervention Setting:
A rural primary care clinic for Muslim Bedouins in southern Israel

Target Population:
Bedouin children aged <14 years with asthma attending a health clinic.

Program Description:
Many Bedouin children with asthma in southern Israel exhibited severe symptoms even following medical treatment. A new Arabic clinical intervention was developed that included numerous elements designed to optimize the treatment of asthma at the clinic to improve children’s health. The program included:

1. in-service instruction to the clinic staff on new asthma guidelines;
2. health education for the clinic population that focused on improving living conditions, cleanliness, and hygiene;
3. instruction on the proper use of medications;
4. ongoing instruction to asthma patients;
5. provision of free spacers for those eligible; and
6. an invitation to an asthma health fair at which participants heard general information about asthma, viewed a 20-minute videotape on allergens and asthma, saw a demonstration and practiced using nebulizers and space chambers, and had an individual review of their medications.

Evaluation Design:
A pre-post study design was utilized.

Sample Size:
The study comprised 267 children (preintervention) and 276 children (postintervention) who had been diagnosed with asthma.

Outcome Measures/Results:
Outcome measures included nebulizer treatments received by asthma patients in the clinic, referrals to the emergency department, hospitalizations, and availability of electric nebulizer equipment or space chambers in the homes of children with asthma. Data on these parameters were collected over the course of 3 months (November – January) before the intervention. These data were again collected a year later (following the intervention) during the same three-month period. Results included:

1. a 30.2% reduction in nebulizer treatments from 9.89 per 100 children per month in the preintervention period to 6.9 in the postintervention period;
2. a decrease in hospitalizations for asthma from 6 in the preintervention period to none in the postintervention period;
3. a decrease in referrals for emergency treatment from 61 in the preintervention period to 6 in the postintervention period; and
4. an increase in the number of homes with inhalation equipment from 73 in the preintervention period to 150 in the postintervention timeframe.

Materials available:
The educational material used in this study included simulators and air spacers donated by TEVA, an Israeli pharmaceutical company. CHS health promotion and marketing unit provided posters and videos on asthma management used in patient education. Materials are not available for widespread distribution.

Article Citation(s):
Miller K, Ward-Smith P, Cox K, Jones EM, Portnoy JM. Development of an asthma disease management program in a children’s hospital. Current Allergy and Asthma Reports 2003;3:491-500.

Intervention Setting:
Children’s Mercy Hospital (CMH) in Kansas City, Kansas. CMH serves a large metropolitan area and surrounding region. It is a regional Medicaid health facility.

Target Population:
Children who had an emergency visit or hospitalization for asthma

Program Description:
In 1996, a small audit on the quality of CMH care for asthma patients revealed that asthma care was deficient. The emergency department served as a primary source for the children’s asthma care. A more extensive audit showed that, in 1995, 2,738 children had emergency visits, and 472 were hospitalized for asthma. These numbers represented about 6% of all emergency visits and hospital admissions – a considerable impact on the hospital’s health care system. This discovery prompted development of a comprehensive asthma disease management program at CMH with the goal of providing high-quality interventions for children in whom asthma was diagnosed. Specific program aims were to 1) reduce the frequency of admissions, 2) provide more cost-effective care to patients who were admitted to the hospital, and 3) develop clinical practice guidelines that encourage providers to use the best-known treatments and thus improve the quality of care. The hospital developed a database to merge clinical information from different hospital-based sources into a central registry. The database was expanded to include encounter information from a health plan mainframe, thereby creating a comprehensive registry of all members with asthma in the health plan. This information, along with prescription fill data, permitted the identification of all health plan members who had asthma, regardless of whether they were seen at CMH, and to fully track them through patterns of prescription use.

Stratification of patients by clinical severity and hospital use was carried out to provide the most cost-effective asthma care and assign hospital resources where they would produce the greatest benefit. Asthma severity also was used to establish performance outcomes; e.g., providers prescribing practices for patients with persistent asthma. Interventions included education and use of clinical practice guidelines. An asthma educator was hired to work in the primary care clinic 2 days a week to deliver standardized asthma education, to foster awareness of proper asthma management and inspire desirable changes in provider behavior. The hospital asthma educator taught asthma self-management skills. Providers were encouraged to prepare asthma action plans for the patients. Easy-to-read and color-coded Asthma Action Cards were developed for use in teaching self-management.

The staff developed an Asthma Clinical Practice Guide (CPG) to standardize management of asthma. An algorithm was developed that described an entire hospital-based asthma encounter from presentation in the emergency setting through an inpatient stay and, finally, to discharge planning. The CPG was available to all hospital providers on an internal website linked to an electronic order entry system to help minimize errors. Outcomes were imbedded directly into the CPG so clinical outcomes and performance of providers could be monitored.

Evaluation Design:
Cohort study comparing outcomes between two groups of asthma patients treated at the hospital: managed patients (Family Health Partners)(FHP) and unmanaged Medicaid patients (non-FHP).

Sample Size:
The sample size varied depending on the measure (emergency use or hospitalization). The exact number is not clear.

Outcome Measures/Results:
Outcome measures included hospital admissions, costs, and quality of life (QoL). Most hospital admissions for asthma occurred during the fall, with a baseline admission rate throughout all seasons. During 1997 and 1998, asthma admissions peaked in the fall both for the FHP group patients and the non-FHP group patients. In 1999 and subsequent years, the peak was present only for non-FHP patients. The main effect of the hospital intervention was that it reduced peak use for FHP-insured patients. Costs per patient per admission for inpatient asthma care in 1997–98 averaged $6,422.00 for FHP members and $6,402.00 for non-FHP members. Per admission inpatient asthma care for FHP members fell in 1998–1999 to an average of $4,266.00, while asthma care for non-FHP members stayed nearly the same at $6,398.00 per admission. Data on QoL were obtained from a randomly selected group of unmanaged and managed patients. Data were collected at the initial visit, when the participants in the managed group received asthma education and an asthma action plan, and at the new two subsequent visits. The baseline QoL score for both patients and caregivers in both groups was 4.5. In the managed population, caregiver QoL scores rose to 5.2 by visit two (a 0.5 point change is considered clinically significant). The patient’s QoL remaining unchanged. By the subsequent visits, the patients also reported an improved QoL. The QoL of unmanaged patients did not improve. The CMH Asthma Disease Management Program led to fewer hospitalizations, improved QoL for children and their caretakers, and a 37.5% decrease in care costs.

Materials available:
None

Article Citation:
Hovell MF, Meltzer SB, Zakarian JM, Wahlgren DR, Emerson JA, Hofstetter CR, Leaderer BP, Meltzer EO, Zeiger RS, OConnor RD, et al. Reduction of environmental tobacco smoke exposure among asthmatic children: a controlled trial. Chest Aug 1994;106(2):440-446.

Wahlgren DR, Hovell MF, Meltzer SB, Hofstetter R, Zakarian JM. Reduction of environmental tobacco smoke exposure in asthmatic children. Chest Jan 1997; 111(1):81-88.

Intervention Setting:
Pediatric medical clinic

Target Population:
Children aged 6-17 years with asthma and at least one parent who smoked cigarettes

Program Description:
A behavioral medicine program designed to reduce asthmatic children’s exposure to environmental tobacco smoke (ETS) at home.

The program consisted of (1) a six-month series of counseling sessions designed to decrease ETS exposure attended by target parents and children, (2) regular clinic visits, (3) two-week monitoring intervals preceding clinic visits (with session diaries), and (4) standard medical care. Between counseling sessions patients used diaries to record peak flow meter readings and symptoms.  Behavior modification techniques such as stimulus control, shaping, and personal feedback were incorporated into programs tailored for each families.

Evaluation Design:  
A randomized clinical trial using a three-group repeated measures design.

The design assigned families to (1) an experimental group that received counseling, monitored patients’ exposure to smoke and monitored patients’ asthma symptoms, (2) a group that did not receive counseling but engaged in the same monitoring activities, or (3) a control group that received the usual care. Families were measured six times in twelve months. ANOVA was employed to identify differences among groups.

Sample Size:
91 families recruited from four large pediatric allergy clinics in San Diego. 

Data were collected and final analyses conducted with 79 families.

Outcome Measures/Results:
Data were collected on children’s exposure to ETS, and an environmental monitor was used to validate parents' reported exposure and smoking rates.  Exposure to parents’ cigarettes at home decreased for all groups.  The experimental group attained a 79% decrease in children’s ETS exposure, the monitoring group had a 42% decrease, and the control group had a 34% decrease.  ANOVA revealed a significant (p<.05) effect of the program over time.  After 1 year, only the experimental group had a decrease in ETS exposure at home for all smokers.  The monitoring group increased exposure 14% and the usual treatment group increased 22% over time.

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

Case Study:
None

Article Citation:
Ireys HT, Chernoff R, DeVet KA, Dim Y. Maternal outcomes of a randomized controlled trial of a community-based support program for families of children with chronic illnesses. Archives of Pediatric and Adolescent Medicine 2001;155(7):771-7.

Chernoff RG, Ireys HT, DeVet KA, Kim YJ. A randomized controlled trial of a community-based support program for families of children with chronic illness. Pediatric outcomes. Archives of Pediatric and Adolescent Medicine 2002;156(6):533-9.

Intervention Setting:
A community-based family support intervention and the referring sub-specialty and general pediatric clinics and practices in the metropolitan Baltimore, Maryland area.

Target Population:
The study targeted mothers of children aged 7–11 years who had been diagnosed as having diabetes, sickle cell anemia, cystic fibrosis, or asthma. Each child had been treated at a clinic or a pediatrician’s office. Eligible participants lived within a 50-mile radius of Baltimore, their household had a telephone, and the primary care giver was a woman and English-speaking. To be included in the study as an asthma patient, the child had to have moderate to severe disease, receive daily medication, and wheeze 2-3 times a week or had at least one hospital or emergency department visit in the previous 6 months.

Program Description:
Parents of children with chronic illnesses are at high risk for seconda