Community Health Worker Asthma Interventions for Children: Results From a Clinically Integrated Randomized Comparative Effectiveness Trial (2016‒2019).

Objectives. To compare asthma control for children receiving either community health worker (CHW) or certified asthma educator (AE-C) services. Methods. The Asthma Action at Erie Trial is a comparative effectiveness trial that ran from 2016 to 2019 in Cook County, Illinois. Participants (aged 5‒16 years with uncontrolled asthma) were randomized to 10 home visits from clinically integrated asthma CHWs or 2 in-clinic sessions from an AE-C. Results. Participants (n = 223) were mainly Hispanic (85%) and low-income. Both intervention groups showed significant improvement in asthma control scores over time. Asthma control was maintained after interventions ended. The CHW group experienced a greater improvement in asthma control scores. One year after intervention cessation, the CHW group had a 42% reduction in days of activity limitation relative to the AE-C group (b = 0.58; 95% confidence interval = 0.35, 0.96). Conclusions. Both interventions were associated with meaningful improvements in asthma control. Improvements continued for 1 year after intervention cessation and were stronger with the CHW intervention. Public Health Implications. Clinically integrated asthma CHW and AE-C services that do not provide home environmental remediation equipment may improve and sustain asthma control.

Implementation Lessons From a Randomized Trial Integrating Community Asthma Education for Children.

This study characterized and compared the implementation of clinically integrated community health workers (CHWs) to a certified asthma educator (AE-C) for low-income children with asthma. In the AE-C arm (N = 115), 51.3% completed at least one in-clinic education session. In the CHW arm (N = 108), 722 home visits were completed. The median number of visits was 7 (range, 0-17). Scheduled in-clinic asthma education may not be the optimal intervention for this patient population. CHW visit completion rates suggest that the schedule, location, and content of CHW asthma services better met patients' needs. Seven to 10 visits seemed to be the preferred CHW dose.

Variables Associated with Emergency Department Utilization by Pediatric Patients with Asthma in a Federally Qualified Health Center.

To study variables associated with Emergency Department (ED) utilization among pediatric patients with asthma in a Federally Qualified Health Center (FQHC). We analyzed Electronic Health Record (EHR) data in a retrospective cohort study of patients with asthma between ages 2 and 18 who received primary care at a FQHC. The primary outcome studied was a visit to the ED at Ann and Robert Lurie's Children's Hospital (LCH) for an acute visit related to asthma. Univariate analyses and a multiple logistic regression were performed to study the effect of demographic and clinical variables on ED utilization. Of the 286 patients in the initial EHR query, 200 were included in the final analysis. The median age of subjects in the study cohort was 8.73 years. Patients in the cohort with ED visits averaged 1.32 ED visits in the 15-month period of analysis. The multivariable logistic regression model demonstrated the significant predictors of ED utilization were (1) younger age (OR 0.977, 0.968-0.984, P < 0.001), (2) proximity of patient residence to the hospital when compared with their primary care medical home (OR 0.907, 95% CI 0.828-0.992, P < 0.05), and (3) absence of an asthma action plan (OR 0.079, 95% CI, 0.016-0.283, P < 0.001). Younger age, closer relative proximity of the patient's home to the hospital compared with the clinic, and absence of an asthma action plan were all identified as significant predictors of ED utilization. Sex, ethnicity, language, passive smoke exposure, and insurance status were not statistically significant predictors of ED utilization.

Design and baseline characteristics of a low-income urban cohort of children with asthma: The Asthma Action at Erie Trial.

OBJECTIVE: To describe the methodology of a randomized controlled trial comparing the efficacy of integrated asthma community health workers (CHW) and a certified asthma educator (AE-C) to improve asthma outcomes in low-income minority children in Chicago. METHODS: Child/caregiver dyads were randomized to CHW home visits or education in the clinic from an AE-C. Intervention was delivered in the first year after enrollment. Data collection occured at baseline, 6-, 12-, 18, and 24-months. The co-primary outcomes included asthma control using the Asthma Control Test/childhood Asthma Control Test (ACT/cACT) and activity limitation over the past 14 days. RESULTS: A total of 223 participants ages 5-16 years were randomized. The majority of children were in the 5-11 year old range (78.9%). Most caregivers (96.9%) and 44% of children were female. Approximately 85% of caregivers and children reported Hispanic ethnicity and 62.3% reported a household income of ≤ $59,000. Over half (55.7%) had uncontrolled asthma as measured by ACT/cACT; 13.9% had a normal ACT/cACT score but were uncontrolled using the Asthma Control Questionnaire and 20.2% were controlled on both measures but had received oral steroids in the past year for asthma. CONCLUSION: The Asthma Action at Erie Trial successfully recruited a largely Hispanic cohort of children with uncontrolled or high-risk asthma to study the differential effects of clinic-based AE-C and home-based CHW interventions. Strengths of the trial include its comparative effectivness design that integrates interventionists and intervention delivery into a clinical setting. Categorizing asthma control in community settings for research purposes presents unique challenges. CLINICAL TRIAL REGISTRATION: University of Illinois at Chicago Protocol Record R01HL123797, Asthma Action at Erie TrialClinicalTrials.gov Identifier: NCT02481986 "ClinicalTrials.gov Registration" register@clinicaltrials.gov.

Metered dose inhaler technique among inner-city asthmatics and its association with asthma medication adherence.

INTRODUCTION: Inhaled medications, critical for asthma treatment, are self-administered through metered dose inhalers (MDI). Asthma self-management hinges on adherence to these medications and to proper MDI technique. OBJECTIVE: To assess predictors of proper MDI technique, and MDI technique as a tool to identify patients with low adherence to inhaled medications. METHODS: Prospective cohort of asthmatics from clinics in New York, NY and New Brunswick, NJ. MDI technique was assessed using a standardized checklist. Adherence to inhaled asthma controller medication was evaluated with the Medication Adherence Report Scale. Predictors of MDI technique were evaluated using regression analyses. The distribution of number of MDI technique steps missed was compared in adherent vs. non-adherent asthmatics. RESULTS: Overall, 326 patients were included (55% Hispanic, 27% Black). In adjusted analyses, age < 55 years was significantly associated with MDI technique (P = 0.03). Overall, 12%, 34%, 40% of asthmatics missed 5-6, 3-4, or 1-2 MDI steps; 16% received a perfect MDI technique score. Adherence rates were 20%, 39%, 48%, and 62% among those who missed 5-6, 3-4, 1-2, or none of the steps in the MDI technique checklist (P < 0.001). CONCLUSION: Poor MDI technique is common among inner-city patients with asthma and is associated with poor adherence to controller medications. Older patients with asthma are at higher risk of improper MDI technique. Assessment of MDI technique may be a simple clinical aid to identify patients with low adherence to controller medications.

Exploring prenatal outdoor air pollution, birth outcomes and neonatal health care utilization in a nationally representative sample.

The impact of air pollution on fetal growth remains controversial, in part, because studies have been limited to sub-regions of the United States with limited variability. No study has examined air pollution impacts on neonatal health care utilization. We performed descriptive, univariate and multivariable analyses on administrative hospital record data from 222,359 births in the 2000, 2003 and 2006 Kids Inpatient Database linked to air pollution data drawn from the US Environmental Protection Agency's Aerometric Information Retrieval System. In this study, air pollution exposure during the birth month was estimated based on birth hospital address. Although air pollutants were not individually associated with mean birth weight, a three-pollutant model controlling for hospital characteristics, demographics, and birth month identified 9.3% and 7.2% increases in odds of low birth weight and very low birth weight for each µg/m(3) increase in PM(2.5) (both P<0.0001). PM(2.5) and NO(2) were associated with -3.0% odds/p.p.m. and +2.5% odds/p.p.b. of preterm birth, respectively (both P<0.0001). A four-pollutant multivariable model indicated a 0.05 days/p.p.m. NO(2) decrease in length of the birth hospitalization (P=0.0061) and a 0.13 days increase/p.p.m. CO (P=0.0416). A $1166 increase in per child costs was estimated for the birth hospitalization per p.p.m. CO (P=0.0002) and $964 per unit increase in O(3) (P=0.0448). A reduction from the 75th to the 25th percentile in the highest CO quartile for births predicts annual savings of $134.7 million in direct health care costs. In a national, predominantly urban, sample, air pollutant exposures during the month of birth are associated with increased low birth weight and neonatal health care utilization. Further study of this database, with enhanced control for confounding, improved exposure assessment, examination of exposures across multiple time windows in pregnancy, and in the entire national sample, is supported by these initial investigations.

Fine particulate matter pollution linked to respiratory illness in infants and increased hospital costs.

There has been little research to date on the linkages between air pollution and infectious respiratory illness in children, and the resulting health care costs. In this study we used data on air pollutants and national hospitalizations to study the relationship between fine particulate air pollution and health care charges and costs for the treatment of bronchiolitis, an acute viral infection of the lungs. We found that as the average exposure to fine particulate matter over the lifetime of an infant increased, so did costs for the child's health care. If the United States were to reduce levels of fine particulate matter to 7 percent below the current annual standard, the nation could save $15 million annually in reduced health care costs from hospitalizations of children with bronchiolitis living in urban areas. These findings reinforce the need for ongoing efforts to reduce levels of air pollutants. They should trigger additional investigation to determine if the current standards for fine-particulate matter are sufficiently protective of children's health.

Comprehensive environmental management of asthma and pediatric preventive care.

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

Inhaler device, administration technique, and adherence to inhaled corticosteroids in patients with asthma.

AIM: To compare inhaled corticosteroid (ICS) inhaler type with user technique and ICS medication adherence among adults with asthma. METHODS: We classified 270 adults into two groups by ICS device type: metered-dose inhaler (MDI) or dry powder inhaler (DPI). Inhaler technique was assessed using standardised checklists. Medication adherence was evaluated using the Medication Adherence Report Scale (MARS). Differences in inhaler technique and MARS score among patients using MDIs versus DPIs were evaluated. RESULTS: Univariate analysis showed no difference in technique scores between the groups (p=0.46), but better ICS adherence among DPI users (p=0.001). In multivariable analysis, DPI use remained significantly associated with higher rates of adherence (OR 2.2; 95% CI 1.2 to 3.8) but not with inhaler technique (-0.2; 95% CI -0.5 to 0.1) after adjusting for potential confounders. CONCLUSIONS: Type of inhaler device appears to be associated with adherence to asthma controller medications. Prospective studies are needed to elucidate further the potential effect of the type of ICS delivery device on asthma self-management.

The effects of outdoor air pollutants on the costs of pediatric asthma hospitalizations in the United States, 1999 to 2007.

BACKGROUND: Acute exposure to outdoor air pollutants has been associated with increased pediatric asthma morbidity. However, the impact of subchronic exposures is largely unknown. OBJECTIVE: To examine the association between subchronic exposure to 6 outdoor air pollutants (PM2.5, PM10, ozone, nitrogen oxides, sulfur oxides, carbon monoxide) and pediatric asthma hospitalization length of stay, charges, and costs. METHODS: We linked pediatric asthma hospitalization discharge data from a nationally representative dataset, the 1999-2007 Nationwide Inpatient Sample, with outdoor air pollution data from the Environmental Protection Agency. Hospitals with no air quality data within 10 miles were excluded. Our predictor was the average concentration of 6 pollutants near the hospital during the month of admission. We conducted bivariate analyses using Spearman correlations and multivariable analyses using Poisson regression for length of stay and linear regression for log-transformed charges and costs, controlling for patient demographics, hospital characteristics, and month of admission. RESULTS: In unadjusted analyses, all 6 pollutants had minimal correlation with the 3 outcomes (ρ<0.1, P<0.001). In multivariable analyses, a 1-unit (µg/m) increase in monthly PM2.5 led to a $123 increase in charges (95% confidence interval $40-249) and a $47 increase in costs (95% confidence interval $15-93). No other pollutants were significant predictors of charges or costs or length of stay. CONCLUSION: Subchronic PM2.5 exposure is associated with increased costs for pediatric asthma hospitalizations. Policy changes to reduce outdoor subchronic pollutant exposure may lead to improved asthma outcomes and substantial savings in healthcare spending.

Comprehensive use of environmental control practices among adults with asthma.

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

Factors associated with furry pet ownership among patients with asthma.

BACKGROUND: Exposure to indoor allergens is an established risk factor for poor asthma control. Current guidelines recommend removing pets from the home of patients with asthma. OBJECTIVES: This cross-sectional study was conducted to determine the prevalence of furry pet ownership in asthmatics compared to non-asthmatics and to identify factors associated with furry pet ownership among those with asthma. Secondary analysis assessed characteristics among asthmatics that might be associated with allowing a furry pet into the bedroom. METHODS: Using data from The National Asthma Survey collected from 2003 to 2004, we carried out univariate and multiple regression analyses, in 2009, to identify independent predictors of furry pet ownership in asthma sufferers after controlling for potential confounders. RESULTS: Overall, asthmatics were more likely to own a furry pet than nonasthmatic individuals in the general population (49.9% versus 44.8%, p < .001). Multivariate analysis showed that female sex, older age, white race, and high income were independent predictors of furry pet ownership among asthmatics. Additionally, 68.7% of patients with asthma who own a furry pet allowed them into their bedroom. Higher income and carrying out < or =2 environmental control practices in the home were associated with increased likelihood of allowing a furry pet into the bedroom. CONCLUSIONS: Furry pet ownership is equally or more common among asthmatics compared to those without asthma. The majority of asthmatics with furry pets allow them into the bedroom. Recognizing and addressing these problems may help decrease asthma morbidity.

Racial and ethnic differences in the use of environmental control practices among children with asthma.

OBJECTIVE: Minority children with asthma suffer a disproportionate burden of asthma morbidity. National asthma guidelines recommend use of environmental control practices (ECPs) as part of a comprehensive approach to asthma management. The purpose of this study was to examine use of ECPs among minority and nonminority children with asthma. METHODS: The authors used data from the four state sample of the National Asthma Survey, a telephone survey conducted in 2003. The sample included Alabama, California, Illinois, and Texas. Parents provided responses for 2003 children < or =17 years of age with a diagnosis of asthma. The outcomes of interest were use of mattress covers, use of pillow covers, smoke avoidance, pet avoidance, and carpet removal. Univariate and multiple regression analyses were conducted to examine the rates of use of these ECPs among minority and nonminority children. RESULTS: Black and Hispanic children with asthma were less likely to use mattress covers and pillow covers compared to white children in these four states. Smoking avoidance was less likely among black children but more likely among Hispanic children compared to white children. Both black and Hispanic children were more likely to live in a home without pets and without carpets compared to white children. CONCLUSIONS: These data illustrate that there are differences in the patterns of ECP use among minority and nonminority children with asthma in these four states. This information can help target physician counseling regarding ECP use in asthmatic children and should inform interventions to improve asthma management among minority children.

Use of herbal remedies and adherence to inhaled corticosteroids among inner-city asthmatic patients.

BACKGROUND: Complementary and alternative medicines (CAM), such as herbal remedies, are widely used by patients with chronic diseases, such as asthma. However, it is unclear whether use of the herbal remedies is associated with decreased adherence to inhaled corticosteroids (ICSs), a key component of asthma management. OBJECTIVE: To examine the association among use of herbal remedies, adherence to prescribed ICSs, and medication and disease beliefs. METHODS: We surveyed 326 adults with persistent asthma who received care at 2 inner-city outpatient clinics. Patients were asked about CAM use (teas, herbs, and rubs) for the treatment of asthma in the prior 6 months. Medication adherence was assessed using the Medication Adherence Report Scale, a validated self-report measure. Univariate and multiple regression analyses were used to assess the relationship among herbal remedy use, adherence to ICSs, and medication and disease beliefs. RESULTS: Overall, 25.4% (95% confidence interval, 20%-30%) of patients reported herbal remedy use. Univariate analyses showed that herbal remedy use was associated with decreased ICS adherence and increased asthma morbidity. In multivariable analysis, herbal remedy use was associated with lower ICS adherence (odds ratio, 0.4; 95% confidence interval, 0.2-0.8) after adjusting for confounders. Herbal remedy users were also more likely to worry about the adverse effects of ICSs (P = .01). CONCLUSIONS: The use of herbal remedies was associated with lower adherence to ICSs and worse outcomes among inner-city asthmatic patients. Medication beliefs, such as worry about ICS adverse effects, may in part mediate this relationship. Physicians should routinely ask patients with asthma about CAM use, especially those whose asthma is poorly controlled.