Primary care provider perceptions of an asthma home visiting program.

INTRODUCTION: Pediatric asthma home visiting programs have improved clinical outcomes, but little is known about how providers perceive these programs. The purpose of this study was to understand how primary care providers and their colleagues in a medical home perceive an asthma home visiting program that is available at no cost to their patients. METHODS: After several years of running an asthma home visiting program using community health workers (CHW) in 10 pediatric primary care offices in the South Coast of Massachusetts, we surveyed the providers of patients who had enrolled in the program. An anonymous online survey was developed by the program leaders, the program analytics team, and the CHWs for quality improvement purposes. Survey domains included the perceived utility of various aspects of the program, impact on patients, and interaction with CHWs, as well as demographic information about the providers. RESULTS: Of the 24 providers asked to complete the survey from eight primary care practices, 21 completed the survey (88%). Respondents perceived that the most beneficial aspects were environmental assessment (95%), asthma education (91%), and addressing environmental issues (86%). In addition to numerous positive free-text responses, suggestions for improvement were in the areas of referral completion, post-visit communication, and patient identification in the medical record. All respondents would continue to refer to the program. CONCLUSIONS: Primary care providers and medical home staff perceived an asthma home visiting program to have high utility, particularly the environmental assessment, asthma education, and mitigation of environmental issues. Additional opportunities for improvement were identified.

Improved 10-year cost savings for patients served by the Boston Children's Hospital Community Asthma Initiative.

OBJECTIVE: To provide a 10-year follow-up of asthma cost-savings for patients served by the Community Asthma Initiative (CAI) group compared to a coarsely cost-matched comparison group from similar neighborhoods (comparison group). METHODS: CAI provided home visits and case management services for patients identified through emergency department (ED) visits and hospitalizations. Asthma costs for the two groups were extracted from the hospital administrative database for ED visits and hospitalizations for one year before and 10 years of follow-up. To eliminate cost differences at intake, a coarse cost-matching was implemented by randomly selecting comparison patients with similar costs to CAI patients (N = 208 pairs). The difference in cost-reduction between CAI and comparison patients was used to compute the adjusted Return on Investment (aROI). RESULTS: There were no significant differences between CAI and comparison groups, including baseline age (5.9 years [SD 2.9] v. 4.4 [SD 3.1]); Hispanic (46.2% v. 35.1%) and Black (43.9% v. 53.0%) race/ethnicity; and public insurance (71.2% v. 68.8%). The cost reduction difference for CAI was significant at one year (P = 0.0001) and two years (P = 0.03), but did not reach the level of significance for years 3-10. The CAI group had a greater cumulative cost reduction of $5,321 (P = 0.08, not significant). Average program cost per patient was $2,636. CAI broke-even after 3 years (aROI = 1.04) and yielded an adjusted ROI of 1.99 at 10 years. CONCLUSIONS: The greater reduction in cumulative cost for CAI patients suggested a shift in trajectory at 10 years of follow-up, resulting in a positive aROI after three years.

Community Asthma Initiative: Cost Analyses using Claims Data from a Medicaid Managed Care Organization.

Objective: Use claims data to examine the cost benefit of the Community Asthma Initiative (CAI), a Boston area nurse-supervised community health worker (CHW) asthma home-visiting program. Methods: The reduction in asthma treatment costs was assessed using Massachusetts claims data from one Medicaid Managed Care Organization (MCO) in the north east that included all costs between January 1, 2011 and December 31, 2016. The data was used to determine asthma-related utilization cost reductions between 1 year pre- and 1, 2 and 3 years post-intervention. The cost reductions for 45 CAI patients and 45 cost-matched comparison patients were measured. Return on investment (ROI) was computed as the difference in cost reduction for CAI patients and a cost-matched comparison population divided by CAI program cost. Results: The excess reduction in per patient asthma-related utilization costs among CAI patients compared to the comparison population was $806 (p = 0.047), $1,253 (p = 0.01) and $1,549 (p = 0.005) between 1 year pre- and 1, 2 and 3 years post-intervention. These yielded adjusted ROI's of 0.31, 0.78 and 1.37 after 1, 2 and 3 years post-CAI intervention. Conclusions: The reduction in asthma utilization costs of a home visit program by nurse-supervised CHWs exceeds program costs. The findings support the business case for the provision of secondary prevention of home-based asthma services through reimbursement from payers or integration into Accountable Care Organizations (ACOs).

How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians.

OBJECTIVE: Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians. METHOD: We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston Children's Hospital, University of Michigan C. S. Mott Children's Hospital, and Penn State Hershey Children's Hospital. In-depth, semi-structured, qualitative interviews explored participants' definitions of recovery. Interviews were analyzed using inductive data-driven thematic analysis. Statistical analyses followed to examine the distribution within each theme by respondent type. RESULTS: Qualitative analysis resulted in the emergence of four overarching themes of ED recovery: (a) psychological well-being, (b) eating-related behaviors/attitudes, (c) physical markers, and (d) self-acceptance of body image. Endorsement of themes two and four did not significantly differ between patients, parents, and clinicians. Clinicians were significantly more likely to endorse theme one (χ2 = 9.90, df = 2, p = .007, φc = 0.356) and theme three (χ2 = 6.42, df = 2, p = .04, φc = 0.287) than patients and parents. DISCUSSION: Our study demonstrates overwhelming support for psychological markers as indicators of ED recovery by all three groups. Clinicians should remain open to additional markers of recovery such as body acceptance and eating-related behaviors/emotions that may be of critical importance to patients and their caregivers.

Parent experiences with a nurse-supervised community health worker asthma home-visiting program.

Objective: This study seeks to identify helpful components of a nurse-supervised Community Health Worker (CHW) asthma home-visiting program, obtain feedback from parents and families about their experiences, and receive suggestions for new services that the program could provide. Methods: Likert scale ratings and semi-structured qualitative interviews were conducted with parents who were selected from a representative sample and previously participated in the program. Five-point Likert scale ratings from 1 (not helpful) to 5 (very helpful) were obtained for 11 program components. Interviews were analyzed using a grounded theory participatory approach. Data were analyzed and themes were identified by two different coders using Dedoose software. Results: A total of 22 participants were enrolled and 20 participants completed Likert scale ratings and qualitative interviews. Likert scale ratings (mean standard deviation [SD]) show that program strengths include asthma education (4.75 [0.55]), supplies (4.65 [0.99]), help with housing conditions (3.94 [1.56], pest management (3.79 [1.69]) and greater access to community resources (3.70 [1.30]). The ratings suggest that families need more help with other social determinants of health, such as school, lack of enough money or food, and mental health and behavioral concerns (3.05 [1.78]). Interviews echoed these ratings and revealed several themes about family and parental stress, children's activity limitations, desire for outreach after the 12-month intervention, a need for help with other social determinants and more emotional support. Conclusions: This study shows that the program was well received and reveals the importance of addressing social determinants of health and behavioral health concerns.

Evaluation of the Environmental Scoring System in Multiple Child Asthma Intervention Programs in Boston, Massachusetts.

OBJECTIVES: To test the applicability of the Environmental Scoring System, a quick and simple approach for quantitatively measuring environmental triggers collected during home visits, and to evaluate its contribution to improving asthma outcomes among various child asthma programs. METHODS: We pooled and analyzed data from multiple child asthma programs in the Greater Boston Area, Massachusetts, collected in 2011 to 2016, to examine the association of environmental scores (ES) with measures of asthma outcomes and compare the results across programs. RESULTS: Our analysis showed that demographics were important contributors to variability in asthma outcomes and total ES, and largely explained the differences among programs at baseline. Among all programs in general, we found that asthma outcomes were significantly improved and total ES significantly reduced over visits, with the total Asthma Control Test score negatively associated with total ES. CONCLUSIONS: Our study demonstrated that the Environmental Scoring System is a useful tool for measuring home asthma triggers and can be applied regardless of program and survey designs, and that demographics of the target population may influence the improvement in asthma outcomes.

Boston children's hospital community asthma initiative: Five-year cost analyses of a home visiting program.

OBJECTIVE: To evaluate the costs and benefits of the Boston Children's Hospital Community Asthma Initiative (CAI) through reduction of Emergency Department (ED) visits and hospitalizations for the full pilot-phase program participants. METHODS: A cost-benefit analyses was conducted using hospital administrative data to determine an adjusted Return on Investment (ROI): on all 268 patients enrolled in the CAI program during the 33-month pilot program phase of CAI intervention between October 1, 2005 and June 30, 2008 using a comparison group of 818 patients from a similar cohort in neighboring ZIP codes without CAI intervention. Cost data through June 30, 2013 were used to examine cost changes and calculate an adjusted ROI over a 5-year post-intervention period. RESULTS: CAI patients had a cost reduction greater than the comparison group of $1,216 in Year 1 (P = 0.001), $1,320 in Year 2 (P < 0.001), $1,132 (P = 0.002) in Year 3, $1,123 (P = 0.004) in Year 4, and $997 (P = 0.022) in Year 5. Adjusting for the cost savings for the comparison group, the cost savings from the intervention resulted in an adjusted ROI of 1.91 over 5 years. CONCLUSIONS: Community-based, multidisciplinary, coordinated disease management programs can decrease the incidence of costly hospitalizations and ED visits from asthma. An ROI of greater than one, as found in this cost analysis, supports the business case for the provision of community-based asthma services as part of patient-centered medical homes and Accountable Care Organizations.

Redesign of chronic illness care in children and adolescents: evidence for the chronic care model.

PURPOSE OF REVIEW: This article provides an overview of the chronic care model (CCM), examines the evidence for its utility in pediatric and adolescent chronic illness, and discusses practical steps for improving chronic illness care in the pediatric medical home. RECENT FINDINGS: Few studies have used the CCM as an improvement framework in pediatrics. However, in recent years, several quality improvement efforts based on the CCM have demonstrated improvement in important process measures or clinical outcomes in pediatric or adolescent obesity, inflammatory bowel disease, attention-deficit/hyperactivity disorder, depression, and asthma. SUMMARY: The CCM is an improvement framework that has demonstrated success in improving the care of children and adolescents with chronic disease. More research is needed to identify priority conditions for improvement efforts, to better understand the mediators of health outcomes in pediatric chronic disease, and to rigorously demonstrate the effectiveness of new models of chronic illness care. The evidence to date suggests that the CCM may be useful in guiding the redesign of care delivery systems to improve the health outcomes of young people with chronic disease.

Gastrointestinal Manifestations of Eating Disorders.

Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.

Factors Associated With HIV Testing in Adolescent and Young Adult Females With a History of STI.

To determine the percentage of female adolescent patients (13-26 years old) who had HIV testing ordered within 90 days of incident sexually transmitted infection (STI) diagnosis during an outpatient clinic visit. This was a retrospective chart review study evaluating 830 visits among 589 female patients 13 to 26 years who had an incident STI diagnosed in outpatient Adolescent Medicine or Pediatric Practices in an urban, nonprofit, academic, free-standing children's hospital at the main campus and a community site in the Northeast United States. Odds of HIV screening was greater at the community-based adolescent medicine practice (odds ratio [OR] = 3.17; 95% confidence interval [CI]: [1.92, 5.24]) and when seen by an adolescent medicine provider (OR = 1.44; 95% CI: [1.02, 2.03]). Only 33.5% (n = 283) of 844 clinical encounters had HIV screening obtained within 90 days of incident STI diagnosis. Overall, HIV screening rates within 90 days of STI diagnosis was low, and there is much room for improvement.