Health Care Providers

Creating a Medical Home for Asthma

Article Citation:
Evans D, Mellins R, Lobach K, Ramos-Bonoan C, Pinkett-Heller M, Wiesemann S, Klein I, Donahue C, Burke D, Levison M, Levin B, Zimmerman B, Clark N. Improving care of minority children with asthma: Professional education in public health clinics. Pediatrics. Feb 1997;99(2):157-164.

Intervention Setting:
Outpatient clinics

Target Population:
Twenty-two clinics administered by the Bureau of Child Health.

The clinics had an enrolled population 61,652 children.

Program Description:
In response to the lack of continuity of primary care for low-income children with asthma and of color in New York City, the Creating a Medical Home for Asthma program was established. The program utilized the principles of learner-centered teaching and theory-based approaches to organizational change. The training received by clinic staff was in accordance with NAEPP guidelines and sought the support and participation of not only the staff but also the administrators of pediatric clinics. The program consisted of three components: 1) five 3-hour sessions with staff members discussing the program and their roles in it; 2) three- hour tutorial sessions for each BCH physician; and 3) monthly visits to the clinics by a nurse educator.

Evaluation Design:
Clinics were randomly assigned to the intervention or control group. The control group received only copies of NAEPP guidelines and supplies of the same medications and devices used by the intervention group. The control groups received the training once the 2-yr intervention ceased.

Sample Size:
22 clinics

Outcome Measures/Results:
Outcome measures included identification and treatment of asthma patients, continuity of care, and the use of medication and patient education by physicians and nurses. Results reveal improvement in all areas.

Case Study:
None

Physician Asthma Education Program

Article Citation(s):
Brown R, Bratton SL, Cabana MD, Kaciroti N, Clark NM. Physician asthma education program improves outcomes for children of low-income families. Chest 2004;126(2):369–74.

This study is a subset of a larger intervention described in two earlier reports:

• Clark NM, Gong M, Schork MA, Evans D, Roloff D, Hurwitz M, et al. Impact of education for physicians on patient outcomes. Pediatrics 1998;101(5):831–6.
• Clark NM, Gong M, Schork A, Kaciroti N, Evans D, Roloff D, et al. Long-term effects of asthma education for physicians on patient satisfaction and use of health services. Eur Respir J 2000;16(1):15–21.

Intervention Setting:
Physicians in the New York, New York, and Ann Arbor, Michigan, areas were enrolled to receive two asthma seminars lasting 2–3 hours and spaced over a 2–3 week period.

Target Population:
Children with asthma from low-income families (income < $20,000) who were treated by physicians taking part in the study. (Note: The objective of this arm of the larger study was to determine if low-income child patients of physicians who participated in the intervention also benefited in health outcomes.)

Program Description:
The study hypothesis was that physicians participating in the seminars regarding asthma care would improve their patient health outcomes. Primary care pediatricians were randomized to the interactive seminars or to a control group. A random sample of patients (children) from each of the participating physicians was selected to assess the effectiveness of the program. Children qualified for the study if they had an asthma diagnosis by a physician, had no other chronic conditions, and had received emergency care at least once for asthma in the prior year. Children in the study had frequent asthma symptoms. Parents reported that 96.1% of all children had persistent symptoms and that 88.2% had moderate-to-severe persistent asthma during at least one season of the year.

The interactive seminar was based on a previously reported theory of physician self-regulation to enhance their therapeutic skills in treating childhood asthma and to develop their ability to educate and counsel families about asthma self-management. The two main components of the program included optimal clinical practice following National Asthma Education and prevention (NAEPP) guidelines and patient teaching and communication. The program included several activities and materials:

• brief lectures from a local asthma expert,
• a video showing effective clinician teaching and communication behavior,
• case studies that presented clinical problems,
• a protocol by which physicians could assess their oral communication behavior, and
• a review of messages to communicate and materials to distribute to patients and their families.

The first visit that the patient made to the physician within 22 months after the intervention was followed by an interview with the parent. The parent interview consisted of questions related to the children’s asthma symptoms, prescribed medications, use of health care services, and parental observations regarding physicians’ teaching and communication behaviors. The patient then was tracked and evaluated at 12 months and 24 months after the initial visit.

Evaluation Design:
Randomized controlled trial

Sample Size:
The sample included 23 pediatricians and 36 of their patients: children with asthma from low-income families, ages 1–12 years. This study is a subset of a larger study involving 74 pediatricians and 637 of their patients.

Outcome Measures:
Health care use for asthma: presenting at emergency departments and admission to the hospital

Results:
Low-income children in the treatment group were significantly less likely to be admitted to an emergency department (annual rate, 0.208 vs. 1.44, respectively) or to the hospital (annual rate, 0 vs. 0.029, respectively) for asthma care compared to low-income children in the control group during the 2-year assessment period. Low-income children in the treatment group tended to have higher levels of use of controller medications, to receive a written asthma action plan, and to miss fewer days of school. These differences were not statistically significant compared to low-income children in the control group. This study shows that the effectiveness of the physicians’ education program is not reserved merely to those patients with more resources. The greatest decline in emergency department use was in children from low-income families, when compared with children of middle- and upper-income families in the larger study.