Children with Asthma

Medical Clinics/Physicians Offices

Asthma Care Training (ACT) for Kids

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
1233 20th St. NW
Washington, DC 20036
phone: 1-800-7-ASTHMA

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

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Asthma Education Program for Pediatric Medicaid Patients

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

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Asthma Outreach Program (AOP)

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

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Bedouin Primary Care Clinic Asthma Program

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.

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Children’s Hospital Asthma Management Program

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

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Decreasing Smoke Exposure for Children with Asthma

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

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Family-to-Family Network

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 secondary mental health problems (e.g., anxiety and depression). The objective of this study was to evaluate potential changes in maternal mental health, anxiety, and depression following participation in an intervention for families of children with selected chronic illnesses, including asthma. Participants were recruited through clinic directors or pediatricians. Network Mothers (mothers of older children with similar conditions as the intervention mother’s child) were assigned one to seven of the intervention mothers. The Network Mothers made bi-weekly phone contacts, seven face-to-face visits (usually at the subject’s home), and three special family events.

Evaluation Design:
The study design was a randomized controlled clinical trial with repeated measures one year apart. A 45-90 minute interview was conducted at baseline and at 12 months post-baseline. Interim interviews of 15-20 minutes were conducted by phone at 4, 8, and 16 months post-baseline for each participant. Mothers were compensated for their time and effort. Control children received standard clinical care, and the mother received contact information for an experienced parent whom they could call if they chose to do so.

Outcome Measures/Results:
Participants in the experimental group reported lower levels of anxiety post-intervention compared with their baseline scores. By contrast, participants in the control group reported higher levels of anxiety 1 year after baseline. Analyses suggested that the intervention’s effect was especially pronounced for mothers who were highly anxious at baseline. The mean anxiety score for experimental group mothers who reported that they were in good, fair, or poor health at baseline decreased from 26.4 to 23.9 during the intervention period. By contrast, the mean anxiety score for the control group mothers who reported being in good, fair, or poor health at baseline increased from 24.8 at baseline to 26.5 twelve months later. The intervention had no demonstrable effect on symptoms of depression, perhaps because baseline levels were low. However, after controlling for baseline anxiety, there was a substantial decrease in anxiety among the experimental group. The study demonstrated that a family support intervention can have positive effects on maternal anxiety.

Using a cut-off score that indicated a measure of adjustment and maladjustment, 19% in the experimental group and 15% of the control group fell below this cutoff point, i.e., were in the maladjustment category, at baseline. At follow-up, 10% of the experimental group children and 21% of the control group scored below this cut-off point. The study demonstrated that the family-support intervention had modest, positive effects on the adjustment of children with selected chronic illnesses. Investigators found no effect of the intervention on measures of children’s anxiety, depression, or self-esteem.

Sample Size:
A total of 161 families participated in the study. Of these, 73 in the experimental group and 66 in the control group completed the trial.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution. However, an intervention implementation manual can be requested from Dr. Henry Ireys, the principal investigator for this study, at hireys@mathematica-mpr.com.

Case Study:
None

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Interactive Multimedia Program for Asthma Control and Tracking (IMPACT)

Article Citation(s):
Krishna S, Francisco BD, Balas EA, Konig P, Graff GR, Madsen RW. Internet-enabled interactive multimedia asthma education program: A randomized trial. Pediatrics 2003;111:503-511.

Intervention Setting:
Asthma clinic

Target Population:
Children under 18 years of age with confirmed diagnosis of asthma at all severity levels

Program Description:
The program was designed to determine 1) whether the addition of an interactive multimedia asthma education program would significantly increase asthma knowledge of children and caregivers and 2) whether this increase in asthma knowledge would be significantly related to disease outcomes and healthcare resource use among the children with asthma when compared with a control group. At enrollment, participants completed the Asthma Summary since Last Visit, Pediatric Asthma Care Knowledge Survey, and Pediatric Asthma Caregiver’s Quality of Life Questionnaire. Data were collected at two subsequent visits scheduled about 3 months and 12 months after enrollment. The intervention and control groups both received instruction from a nurse practitioner using printed and verbal approaches to education. This instruction followed the Caring for Kids with Asthma series, using 26 instructional sheets that focused on understanding asthma, selected devices, medication and environmental factors. During the clinic visits, each child or caregiver took part in one-on-one training to ensure correct use of devices and medications. All families received an individualized, computer-generated asthma action plan with detailed instructions for daily self-management and guidelines for handling exacerbations and emergencies.

In addition to receiving conventional patient education, intervention group children and families used the Interactive Multimedia Program for Asthma Control and Tracking (IMPACT) during routine office visits. The IMPACT Kids CD consists of vignettes covering basic pathophysiology of asthma, environmental triggers, quick-relief and control medications, and strategies to control and manage asthma. The program incorporates self-management principles in an interactive format comprising animated lessons, each averaging a minute in length. Ten of the lessons present real-life scenarios and require decisions about alternative behaviors that would be likely to affect asthma. Other lessons involve activities in which children learn to more accurately describe their symptoms and medication use. IMPACT used the Internet and a Web-based server to respond to individual learning needs (based on how participants responded to questions posed in the lessons). The program was made available to children and families only during clinic visits. The program tracked educational progress of individual children and generated standardized reports to help children, families, and schools record current symptom level and medication use. The program was completed in about 1.3 hours, although actual time varied by individual reading level and comprehension. The program was used during waiting times within the flow of clinic activities between recording patient vital signs, spirometry, physical exam, discussions of therapeutic options and discharge teaching. It used participants’ time effectively while not incurring additional staffing overhead.

If the child was under 7 years of age, the parent used the program, and his/her knowledge was assessed. Children aged 7–17 used the program while their parents observed. At each tutorial session, IMPACT first presented review lessons previously viewed from which incorrect answers were entered, followed by new content. Users progressed in linear manner through the 44 lessons. IMPACT interspersed several types of lessons, including traditional instructional vignettes, decision-making scenarios, and exercises to improve the child’s ability to report symptoms and medication use.

Evaluation Design:
A randomized controlled study approach was used.

Sample Size:
The study comprised 238 children with asthma visiting the Pediatric Pulmonary and Allergy Clinic of the University of Missouri — Columbia Health Care referred by their primary care physicians for asthma.

Outcome Measures/Results:
Outcome measures included changes in asthma knowledge, use of quick rescue relief medicine, asthma symptoms, lost school days and emergency visits. Asthma knowledge improved significantly in the intervention subgroups: caregivers of children aged 0–6 years, caregivers of children aged 7–17 years, and children aged 7–17 years. At 12 months asthma symptom days decreased from 81 days to 51 days per year. The rate of school absences, decreased significantly: 5.4 days per child per school year for the intervention children compared with just a 1.6-day reduction for control children. The number of emergency visits among the intervention group participants also decreased significantly from 1.93 per year to 0.62. The intervention group children used a significantly lower average daily dose of inhaled corticosteroids following the third visit.

Materials available:
Dr. Santosh Krishna, School of Public Health, St. Louis University, 3545 Lafayette Ave., Suite 300, St. Louis, M0 63104; phone (314) 977-8280; krishnas@slu.edu

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Managing Asthma

Article Citation:
Clark NM, Feldman CH, Evans D, Duzey O, Levison MJ, Wasilewski Y, Kaplan DL, Rips JL, Mellins RB. Managing better: Children, parents and asthma. Patient Education and Counseling 1986;8:27-38.

Intervention Setting:
Pediatric allergy clinics in Harlem, St. Luke’s-Roosevelt and Presbyterian Hospitals in New York, NY

Target Population:
Predominantly African American and Hispanic children, 4-17 years old, diagnosed with asthma by a physician, and their caregivers

The children had at least one clinic visit and one wheezing episode in the past year.

Program Description:
A health education program based on the idea of family management of asthma.

This concept explicitly recognizes that pediatric self-management of asthma often involves the participation and guidance of parents and other family members. Based on previous interviews with asthmatic children, their parents and physicians, the program was designed to give families a better understanding of the medical aspects of asthma and what they can do as a unit to help the child better manage his/her asthma. The program is grounded in self-efficacy theory and Friere’s idea that shared dialogue can lead to more effective problem-solving skills among adults. The program, which was taught in six weekly sessions, was also designed to be developmentally appropriate for the children who participated. It was delivered in both Spanish and English.

Evaluation Design:
Children were randomly assigned to the control and experimental groups. All sibling groups were kept together. Children and parents were interviewed prior to the start of the study and one year following completion. From the interview data, pre- and post-asthma management indices were constructed for each child. Medical and school records were also reviewed. ANOVA and chi-squared statistics were used to analyze the data.

Sample Size:
600 participants

310 children with asthma and 290 parents were assigned to either the intervention or control group. 207 children were in the intervention group, and 103 were in the control group.

Outcome Measures/Results:
Data was collected to determine how well the program met its goals of teaching families how to set realistic guidelines for children’s activities; how to prevent, monitor and treat attacks; how to administer medication; how to get useful information from physicians; and how to improve the child’s performance is school. Parents in the experimental group improved significantly in their ability to prevent and manage children’s attacks as well as set more reasonable limits on physical activity. Children demonstrated improvement in their use of several asthma self-management techniques. It also appeared that parents were more confident in their child’s ability to manage his/her asthma.

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

Case Study:
None

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National Cooperative Inner-City Asthma Study (NCICAS)

Article Citation:
Evans R, Gergen P, Mitchell H, Kattan M, Kercsmar C, Crain E, Anderson J, Eggleston P, Malveaux FJ, Wedner HJ. A randomized clinical trial to reduce asthma morbidity among inner-city children: Results of the National Cooperative Inner-City Asthma Study. Journal of Pediatrics 1999;135(3): 332-338.

Intervention Setting:
Clinics

Target Population:
Children diagnosed by physicians with moderate to severe asthma, 5- to 11-years old, English or Spanish-speaking, and living in selected inner-city census tracts of one of eight metro areas served by the study

Program Description:
A comprehensive community-based initiative designed to reduce asthma symptoms and improving the quality of life for inner-city children

The initiative focused on asthma education, self-management techniques and improving physician interaction with patients. The program utilized Asthma Counselors (ACs) to educate and support families in their efforts to manage the child’s asthma. ACs were responsible for developing asthma management plans based on oral instructions from physicians, helping families improve their communication with physicians, encouraging caretakers to attend adult group asthma education sessions, and referring families to community resources for assistance with psychological/social issues and smoking cessation. The initiative also provided families with pillow and mattress covers and instructed families on way to minimize children’s exposure to tobacco smoke and pets.

Evaluation Design:
A randomized, multi-site, controlled trial

Participants completed a comprehensive baseline assessment on hospitalizations, doctor visits, symptoms, home environment and medical care. After the group sessions were completed, data were collected during bimonthly, in-person caretaker interviews and telephone conversations during the alternate months. Parents were asked to recall how well their child was doing in the previous two weeks. Baseline and outcome data were compared using ANOVA or the Mantel-Haenszel chi-square tests.

Sample Size:
1033 children with asthma - 515 in the intervention group, and 518 in the control group

Outcome Measures/Results:
Outcomes included self-reported maximum number of symptom days, hospitalizations, and unscheduled visits. For the first year, participants in the intervention group reported fewer symptom days than did the control group. The reduction among children with severe asthma was 3 times greater for the intervention group. More control group children were hospitalized than intervention group children. These results were similar in the second year of the follow-up during which time they did not have access to the AC. The results indicate that a community-based approach is an effective method for inner city children and may be transportable to other settings.

Availability of Protocol/Materials:
The Guide for Helping Children with Asthma, one of the primary intervention materials, is available from the National Institute of Allergy and Infectious Diseases by calling 301-496-7353. Other materials are not available at this time.

Case Study:
The Inner-city Asthma Intervention, El Rio Santa Cruz Community Health Center, Tucson, Arizona

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Outpatient Clinic Asthma Management Program

Article Citation:
Hui SHL, Jeung TF, Ha G, Wong E, Li AM, Fok TF. Evaluation of an asthma management program for Chinese children with mild-to-moderate asthma in Hong Kong. Pediatric Pulmonology 2002;33:22-9.

Intervention Setting:
Outpatient clinic of a university teaching hospital in Hong Kong

Target Population:
Children with mild to moderate asthma

Program Description:
This intervention is based on the hypothesis that an asthma management program conducted by a pediatric nurse specialist and focused on key symptoms could improve outcome measures of asthma in children living in Hong Kong. The intervention consisted of an interactive 2-hour group session with follow-up visits at 3-month intervals with the nurse specialist. The asthma management program addressed asthma symptoms and pathophysiology; trigger factors, potential allergens, and importance of environmental control; principles and techniques of using asthma medications; and use of an asthma diary. All patients and their parents attended an interactive program session that consisted of a video display summarizing the major issues related to asthma pathogenesis and management. This session included a presentation on appropriate contingency plans in case of acute asthma attacks. A final 30-minute group discussion allowed patients and parents to ask questions, and the nurse specialist evaluated each patient’s inhaler use technique. Educational pamphlets that reinforced the program session were distributed to each family, and patients were asked to keep an asthma diary on asthma symptoms and the use of anti-asthma drugs. Children were then followed up in the clinic at 3-month intervals during which patient knowledge and emergency action plans for acute asthma attacks were reviewed and a check on drug compliance was checked. The frequency of nocturnal cough and wheezing attacks, as well as subjective evaluation of asthma severity, asthma-related quality of life, and asthma knowledge scores were obtained from each patient at baseline and 6 and 12 months after the educational session. Information also was collected about the number and duration of hospitalizations, unscheduled outpatient visits to any medical practitioners, unscheduled emergency department visits, and number of school or daycare days missed for the year before and after the asthma management program.

Evaluation Design:
A prospective cohort study design

Sample Size:
A total of 106 children aged 0–18 years with asthma who had no previous formal education on contingency plans to help during acute asthma attacks

Outcome Measures and Results:
Outcome measures included asthma symptoms, unscheduled outpatient attendance, emergency department visits, school absenteeism, number and duration of hospitalizations, and use of inhaled corticosteroids. Nocturnal cough, wheezing attacks, and asthma severity decreased significantly while asthma-related quality of life, and knowledge scores regarding asthma increased at 6 and 12 months after the asthma management program from those at baseline. Additionally, acute asthma attacks, unscheduled outpatient visits, emergency department visits, school absenteeism, total number of hospitalizations, and duration of stay in hospitals because of asthma were significantly reduced during the same period. Approximately 53% of patients used inhaled corticosteroids (ICS) at baseline, which increased to 74% over the study period. This increased use of appropriate medication accounted for much of the beneficial effect associated with the asthma management program. Nonetheless, some additional improvement in asthma symptoms attributable to this program could be detected after adjustment for steroid use.

At baseline 7% of families reported having taken avoidance measures against house dust mites. Six months after the asthma management program, 92% of families reported avoidance measures, and 12 months after the program, 93% reported taking avoidance measures. This behavioral modification may have resulted in reduced exposure of patients to this important aeroallergen and probably contributed to improvement in asthma outcomes.

Availability of Protocol and Materials:
The educational materials used in this study were based on an asthma course from the New Zealand Asthma Foundation. The nurse specialist used an education plan in conjunction with the asthma management program that is not copyrighted and can be requested from the authors (see the published article referenced above).

Case Study:

None

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Pediatric Asthma Care Patient Outcomes Research Team II Study

Article Citation(s):
Lozano P, Finkelstein JA, Carey VJ, Wagner EH, Inui TS, Fuhlbrigge AL, et al. A multisite randomized trial of the effects of physician education and organizational change in chronic asthma care. Arch Pediatr Adolesc Med 2004;158:875–83.

Intervention Setting:
This study involved 42 primary care pediatric practices affiliated with four managed care organizations. These included 15 practices in Seattle, Washington; 11 Chicago, Illinois, area practices; and 16 practices in eastern Massachusetts.

Target Population:
Children aged 3–17 years with mild-to-moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations (MCO)

Program Description:
Researchers incorporated—a “peer leader” physician education program and a physician education program with a nurse-run intervention (to better organize chronic asthma care in the primary care practice). They hypothesized that the two interventions would reduce asthma symptom days as compared with usual care.

Subjects for the study were identified from automated claims and pharmacy data from MCOs for children with any asthma-related use in 1 year. That included hospitalizations, emergency department visits, or ambulatory care treatment that required two or more asthma medications during the same period.

The peer leader education intervention consisted of training one physician in each practice site to serve as an asthma “champion” who would share asthma care guidelines and other information with colleagues and encourage their use. Peer leaders received training in asthma pharmacotherapy and physician behavior change strategies. They also received ongoing support in their role as change agents.

The interventions included two workshops, central support by an educational coordinator, and an ongoing learning network for peer leaders via national and local teleconferences. Each peer leader received a physician tool kit. The kit included the National Asthma Education and Prevention Program/Expert Panel Report 2 (NAEPP/EPR2) guidelines and laminated pocket cards summarizing the EPR2 approach to diagnosis and treatment, among other resources. Each practice also received a tool kit of patient education materials.

The educational coordinator contacted each peer leader every 1–2 months to provide ideas, materials, and support; identify and resolve barriers to change; and encourage less active peer leaders to become more involved. All practices randomized to the second intervention, called Planned Asthma Care (PAC), also received the peer leader education intervention. In addition, PAC set up visits with a trained asthma nurse.

Asthma nurses were trained in EPR2 and in self-management support techniques. Nurses attended a full day of training to learn motivational enhancement and problem-solving techniques. They also met weekly or every other week for 10 weeks for 1-hour conference calls to review written materials with one of the investigators. The asthma nurse scheduled four or five PAC visits during the 2 years of the study in conjunction with visits to the primary care physician. At each visit the asthma nurse aimed to

1. conduct a standardized assessment of asthma symptoms, medication use, environmental control, and self-management skills (and share a computer-generated report of findings with the child’s physician),
2. support and participate in care planning (including medication and environmental measures) in conjunction with the primary care physician, using the EPR2, with emphasis on the use of controllers for persistent disease, and
3. provide self-management support to families (regarding medication adherence, technical skills, and environmental triggers) using problem-solving and motivational techniques.

In between PAC visits, asthma nurses made standardized telephone follow-up calls and worked with patients and parents who were reluctant to attend PAC visits. Other asthma nurse activities included reviewing quarterly registry-based asthma panel reports on medication use and emergency department visits with physicians. They also arranged for allergists to visit the primary care site for case discussions. The peer leader education coordinator documented peer leader reports of asthma-related activities through telephone contacts attempted every 1 to 2 months. Asthma nurses tracked PAC visits and telephone calls and used a laptop database to record the data. Peer leaders performed an average of 9.5 group sessions in their practices in 2 years. Planned care intervention subjects had on average three PAC visits and 4.7 telephone follow-up calls by the asthma nurse during the 2 years. PAC visits averaged 65 minutes (including the physician visit) and telephone sessions averaged 20 minutes.

Evaluation Design:
This randomized controlled clinical trial compared two National Asthma Education and Prevention Program guideline-based strategies to improve asthma care for children in the primary care setting against usual care. Practices were randomized within each geographic site to two intervention arms and usual care.

Sample Size:
638 children with an average age of 9.4 years. Of those, 60% were boys. According to parent reports, the sample included 421 white subjects, 108 African American subjects, and 108 subjects of other races. [Ed Note: 421 + 108 + 108 = 637, but these are the numbers reported in the journal article]

Outcome Measures:
Annualized asthma symptom days and frequency of brief oral steroid courses (bursts)

Results:
Researchers followed asthma symptom days across a 2-week period every 8 weeks. This allowed them to assess 25% of the actual time on study and to measure the effect of the intervention on long-term health status. Evaluation of oral steroid bursts allowed researchers to detect exacerbations that might not result in an emergency department visit or health care encounter.

Details:
The pre-intervention mean (+/– standard deviation) annualized asthma symptom days was 107.4 (+/– 122) days. Children in the planned care group had 13.3 fewer symptom days annually (–12% from baseline; P=0.02) than the usual care children. Children in the peer leader group had 6.5 fewer symptom days per year than the usual care children, a nonsignificant difference. The planned care children had a 39% lower oral steroid burst rate per year relative to usual care children. Children in the peer leader group had a 35% lower oral steroid burst rate per year compared with children in the usual care group.

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Pediatric Asthma Episodes of Care Disease Management Program

Article Citation:
Marosi A, Stiesmeyer J. Improving pediatric asthma patient outcomes by incorporation of effective interventions. Journal of Asthma 2001;38(8):681-90.

Intervention Setting:
Health clinic office

Target Population:
Children who had uncontrolled asthma or those who did not adhere to prescribed medication therapy

Program Description:
This study tested the use of objective home pulmonary function monitoring in conjunction with the use of long-term control medications and comprehensive patient education to improve treatment adherence and asthma control and decrease asthma severity. At the initial clinic appointment, a pediatric allergist completed a comprehensive patient evaluation comprising an extensive medical history, physical exam, allergy testing, pulmonary function studies, radiographs (if indicated), and disease severity assessment. An asthma management plan was then designed and explained to the patient and caregiver. At the initial visit, the nurse specialist provided an individualized educational plan and one-on-one instructions to each patient and family. Major topics included introduction to asthma, trigger identification and control, asthma medications, asthma equipment skills and asthma self-management. During follow-up visits the nurse specialist evaluated the patient’s asthma-related knowledge and skills and provided additional information. Adherence to prescribed therapy, response to medications, and symptom control also were evaluated at follow-up visits. Adherence strategies were designed with patients to promote regular use of long-term control medications and routine monitoring of pulmonary function. Between clinic visits, the nurse specialist contacted patients by phone to answer questions and resolve adherence difficulties. Each patient was given an AirWatch monitor and taught how to use it. The AirWatch electronic airway monitoring system (ENACT Health Management Systems, Mountain View, California) comprises a hand-held, pager-sized electronic device that measures peak expiratory flow (PEF) and forced expiratory volume in 1 second (FEV1). Once a week, the patient connected the AirWatch monitor to a phone line and sent lung function data to AirWatch Central. AirWatch Central then faxed the patient status report, consisting of graphs of the patient’s PEF and FEV1 values for the previous 30 days and 6 months, to the allergist for evaluation. Patients received a monthly report card summarizing pulmonary function values and compliance information for the previous 30 days. During follow-up visits at 1, 3, and 6 months, the allergist assessed changes in the patient’s health status and asthma severity.

Evaluation Design:
An observational cohort design

Sample Size:
A total of 80 children with uncontrolled asthma enrolled with the Lovelace Health Systems in Albuquerque, New Mexico. Patients were enrolled in the study if they chose to use the AirWatch computerized peak flow meter instead of the conventional peak flow model.

Outcome Measures and Results:
Outcome measures included adherence to medications, adherence to AirWatch, asthma control, and asthma severity. Prestudy adherence to medication was 40% of their combined prescribed medication therapy, and after 6 months of intervention, the patients increased their combined adherence to 75% of their total prescribed doses. Collective adherence to AirWatch decreased from 56% of their prescribed readings at 1 month following initial visit to 40% at 3 months and to 23% at 6 months. The number of patients with optimal control increased by more than threefold from 12 to 42 (15% to 52%), and patients with only occasional symptoms almost doubled from 17 to 33 (21% to 41%). The number of patients with frequent symptoms decreased from 32 to 3 (40% to 4%), and patients with daily symptoms decreased from 19 to 2 (24% to 33%). Asthma severity improvements also resulted from the intervention. At baseline, only 10 patients had mild persistent asthma; at follow-up this number rose to 21 patients. At baseline 70 patients presented with moderate and severe persistent asthma. At follow-up this number had decreased to 58. Initially 59 had moderate persistent asthma; this number decreased to 50 following the intervention, and the 11 diagnosed with severe persistent disease decreased to eight at follow-up.

Availability of Protocol and Materials:
The Pediatric Asthma Episodes of Care Disease Management Program is copyrighted by Lovelace Health Innovations, an organization supported by Greenstone Healthcare Solutions, a subsidiary of Pharmacia and Johnson & Johnson. Lovelace was dissolved in 1999. The protocol and materials are not available for widespread distribution.

Case Study:
None

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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.

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Tobacco Smoke Reduction Program

Article Citation:
Wilson SR, Yamada EG, Sudhakar R, Roberto L, Mannino D, Mejia C, Huss N. A controlled trial of an environmental tobacco smoke reduction intervention in low-income children with asthma. Chest 2001;20:1709-22.

Intervention Setting:
The pediatric pulmonary service of a regional pediatric hospital in central California

Target Population:
Low-income minority children with asthma exposed to environmental tobacco smoke (ETS) who were Medicaid/Medi-Cal-eligible and were at risk of having been seen for acute asthma in an urgent-care setting, hospital emergency department, or impatient hospital setting in the previous year

Program Description:
The study objective was to determine the effectiveness of a cotinine-feedback, behaviorally-based education intervention in reducing ETS exposure and health-care utilization of children with asthma. The intervention consisted of three one-on-one, behaviorally-based counseling sessions provided by a nurse-educator spaced over 5 weeks. The protocol included instruction about asthma and its treatment, environmental controls, the inflammatory nature of asthma, and the role of ETS in exacerbating and sustaining inflammation. Behavior-changing strategies were used to gain cooperation. ETS exposure recall was reported at each session for the 3 days preceding the session. A key feature of the intervention was repeated feedback to parents over a 5-week period regarding the results of four successive urine cotinine measures to inform them of the level of exposure to the child and the success of their efforts to reduce this exposure.

Evaluation Design:
The study was a randomized controlled trial of an educational intervention compared with usual care. Assays for urine cotinine and creatinine were completed for intervention and control children at enrollment and at 6 and 12 months after enrollment. Intervention children provided urine samples at each intervention session. All children’s asthma drugs were adjusted as needed following enrollment. Medical records were reviewed at the end of the follow-up year.

Sample Size:
A total of 87 children aged 3–12 years, 44 in the intervention group and 43 in the control group, participated in the study.

Outcome Measures/Results:
The primary outcome measures investigated were emergency and urgent health utilization for asthma and ETS exposure as indexed by the child’s urine cotinine/creatinine ratio (CCR). The proportion of children with more than one asthma-related medical visit decreased substantially in the intervention group from 50% in baseline year to 29.6% in follow-up year, contrasted by a substantial increase of 37.2 % to 46.5% in the control group. The odds of having more than one medical visit were reduced by about two thirds in the intervention group compared with the control group. Cotinine-level differences correspond to a 46% greater reduction in the CCR in the intervention group than in the control group, a difference that is not statistically significant. A trend toward relatively low odds of hospitalization in the intervention group was observed, but the differences were not statistically significant.

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

Case Study:
None

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Wee Weezers

Article Citation:
Wilson SR, Latini D, Starr NJ, Fish L, Loes LM, Page A, Kubic P. Education of parents of infants and very young children with asthma: a developmental evaluation of the Wee Wheezer’s program. J Asthma 1996;33(4):239-254.

Intervention Setting:
Outpatient clinic

Target Population:
Children with asthma and less than seven years of age and their families

Program Description:
An asthma education program in English and Spanish, based on social learning theory, designed specifically for parents of young children under the age of seven

The program helps parents gain the knowledge, skills and motivation necessary to recognize, prevent, and/or appropriately manage asthma symptoms; to use medical, educational, and interpersonal resources for information and support; communicate effectively with other adult caretakers and physicians; and promote general well-being of the family unit. The program consists of four small group sessions that last approximately 2 hours each. Nurses familiar with asthma management facilitate the sessions.

Evaluation Design:
Unavailable

Sample Size:
76 families, 41 in the intervention and 35 controls

The control families received the program after the intervention was completed.

Outcome Measures/Results:
Outcome measures included symptom-free asthma days as reported by parents, parental sleep interruption, degree to which child was bothered by asthma symptoms, and the number of days the child was sick due to asthma. ANOVA was used to analyze the data. Children in the treatment group experienced improvement on all five outcomes and statistically significant improvement in two outcomes: symptom-free days and sleep interruption. There were also significant gains in parental knowledge about asthma and asthma management.

Availability of Protocol/Materials:
The Wee Wheezers Program kits available from:

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

Case Study:
Wee Wheezers Asthma Education Program,Darnell Army Community Hospital, Fort Hood, Texas

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