Can patient education, outreach, and follow-up improve treatment and outcomes for low-income children with asthma?
A comprehensive asthma intervention that provided Medicaid-insured children with education, treatment, and regular follow-up in an inner-city hospital-based specialty care clinic improved quality of care and outcomes.
Why is this important?
Many children with asthma and their families do not practice effective asthma management, including the regular use of anti-inflammatory medication when indicated to control asthma symptoms.
Poor and minority children suffer disproportionately from asthma and its consequences (Akinbami et al. 2002); hence, they may have even greater need for improvement in care and outcomes. Passive education alone is not enough to bring about change, but more intensive programs can be effective (Guevara et al. 2003).
Interventions
A specialty clinic at an inner-city hospital, Children's Hospital of the King's Daughters, Norfolk, Va., tested the effect of an intensive asthma education and outreach program (Kelly et al. 2000). Medicaid-insured children and adolescents (ages 2 to 16 years) who had visited the emergency room twice or been hospitalized once in the past year, and who consented to participate, were alternately assigned to an intervention or control group. There were no baseline differences between the groups.
- The intervention group children and their caregivers received individual asthma self-management education and a written action plan for exacerbations.
- An outreach nurse contacted these children once per month to monitor their status, review medications, refill prescriptions, schedule follow-up care, and assist with transportation needs. The nurse worked with school personnel on behalf of school-age children.
- Intervention group children could use the specialty clinic for care, but control group children were referred to their primary care physician for treatment.
Findings
During the intervention year, children in the intervention group received better quality of care and had better outcomes compared with the control group children.
- Nearly all children in the intervention group (95%) received an influenza immunization, compared with 23 percent of children in the control group.
- Use of anti-inflammatory medication increased nearly threefold (from 34% to 95%) among intervention children but did not change greatly in the control group (60% to 65%).
- Adverse outcomes declined significantly in the intervention group (half as many emergency room visits and two-thirds fewer days in the hospital on average compared with the baseline year) but not in the control group.
- Intervention group children had a clinically meaningful improvement in their quality-of-life scores (data not shown).
- Annual average health care charges declined $543 more per child in the intervention group than in the control group in the intervention year (Kelly 2000).
Implications
An intensive education program combined with a series of outreach activities conducted by a nurse substantially improved quality of care and patient outcomes while also reducing treatment costs at an asthma specialty clinic.
Improvement Ideas and Resources
The Agency for Healthcare Research and Quality and the Council of StateGovernments have developed a resource guide to help states assess and improve the quality of asthma care.
Measure:
Participants in this controlled before-and-after study included Medicaid-insured children and adolescents (ages 2 to 16) who had visited an inner-city hospital emergency room two or more times or been hospitalized one or more times for asthma in the past year, had received primary care in the hospital's outpatient clinic, had not been evaluated by an asthma specialist in the past two years, and whose family consented to participate. Participants were alternately assigned to intervention or control groups, which were demographically similar at baseline. Most children continued to receive the majority of their care from the hospital's outpatient clinic during the intervention. Quality of care was measured using clinical and educational interventions recommended by the National Asthma Education and Prevention Program.
Utilization data were collected through monthly telephone interviews with parents of children and verified by comparison to medical records. Data were obtained from hospital financial records on charges for outpatient medical care of study patients; charges for hospitalizations and emergency department visits that occurred in other institutions were imputed based on the study hospital's average charges. The cost of the outreach nurse (12 hours per week or $15,000/year) was included in the cost of the intervention. In logistic regression analyses controlling for individual history of asthma outcomes in the prior year, children in the control group were significantly more likely than those in the intervention group to have an emergency department visit and to be hospitalized for asthma in the study year (Kelly et al. 2000).
Limitations:
The study involved a small number of patients in an urban tertiary care hospital and may not be generalizable to other settings.
Source:
The study was based on parent interviews and medical records and was conducted by researchers at Eastern Virginia Medical School and Children's Hospital of the King's Daughters, and the Center for Pediatric Research, Norfolk, Va. (Kelly et al. 2000).
References:
* Indicates source of data used in the chart(s).Akinbami, L. J., B. J. LaFleur, and K. C. Schoendorf. 2002. Racial and Income Disparities in Childhood Asthma in the United States. Ambulatory Pediatrics 2 (5): 3827.
Guevara, J. P., F. M. Wolf, C. M. Grum et al. 2003. Effects of Educational Interventions for Self Management of Asthma in Children and Adolescents: Systematic Review and Meta-Analysis. BMJ 326 (7402): 13089.
* Kelly, C. S., A. L. Morrow, J. Shults et al. 2000. Outcomes Evaluation of a Comprehensive Iintervention Program for Asthmatic Children Enrolled in Medicaid. Pediatrics 105 (5): 102935.