Pediatric Asthma Alert Intervention for Minority Children With Asthma

Asthma is the number one cause of pediatric emergency department (ED) visits in young
children and results in a significant economic impact on society and use of health
resources. Reliance on the ED for asthma care is not only costly but it is also a dangerous
index of poorly controlled asthma. Recent updated national asthma guidelines recommend daily
inhaled corticosteroids (ICS) as the cornerstone of treatment for patients with persistent
asthma. When properly used ICS prevent exacerbations, ED visits and hospitalizations and
maintain asthma control. However, > 50% of inner city minority children with asthma do not
receive or use recommended anti-inflammatory preventive medications. In fact, many children
encounter repeated ED visits with no provision of appropriate preventive medications or
other components of guideline-based preventive care because of inconsistent follow-up with
their primary care provider (PCP). The overall goal of this study is to evaluate whether a
standardized caregiver and physician prompting intervention, Pediatric Asthma Alert Leader
(PAAL), can improve guideline-based preventive asthma care including increased
anti-inflammatory use and preventive PCP visits in children with frequent ED visits. This
study builds on the experience with our parent-child-PCP communication intervention
("Improving Asthma Communication in Minority Families", ACE) in which we found that teaching
parent and child asthma communication skills resulted in increased anti-inflammatory
medication use at 6 months for children with persistent asthma. However, the beneficial
effects of this intervention were seen primarily when caregivers and children were reminded
by the nurse interventionist to relay specific health information to the PCP. Furthermore,
the intervention was not associated with decreased ED visits or appropriate PCP follow-up to
sustain preventive care. The proposed PAAL intervention has the potential to substantially
improve care for children at highest risk for asthma morbidity and we propose to establish
(1) whether the positive effects of the ACE study can be replicated in a specific group of
high-risk children with repeat ED visits; 2) whether the effects of the intervention can be
enhanced by incorporating consistent clinician prompting to assure the provision of each
component of guideline-based asthma care (ICS use, asthma action plan, and sustaining
regular follow-up care to monitor asthma control); and 3)whether families not achieving
optimal care will respond to a more intensive tiered intervention. We propose a caregiver
and clinician prompting/feedback intervention using a pediatric asthma alert leader (PAAL)
nurse to 1) organize and relay critical, individualized child health information from the ED
and home setting to the PCP in a feedback letter, 2) ensure child and caregiver attendance
at the follow-up visit with the PCP and 3) empower the family and prompt the PCP for
guideline-based treatment decisions at the PCP visit. We hypothesize that the PAAL
intervention will improve preventive care and reduce morbidity and health care costs for
high-risk children with asthma compared to a Standard Asthma Education (SAE) control group.

Inclusion Criteria:

All 6 criteria must be met:

1. Physician-diagnosed asthma (based on caregiver report with validation from the
child's physician)

2. > 2 ED visits or > 1 hospitalization for asthma within past 12 months

3. Mild persistent to severe persistent asthma based on NHLBI guidelines criteria (7-9)
having any 1 of the following:

- An average of > 2 days per week of asthma symptoms

- > 2 days per week with rescue medication use (albuterol, xopenex) OR

- > 2 days per month of nighttime symptoms

4. Age > 3 and < 10 years

5. Reside in Baltimore Metropolitan area

6. Not currently participating in another asthma study or sibling enrolled in PAAL study

Exclusion Criteria:

1. Inability to speak and understand English

2. No access to a working phone or alternate phone for follow-up surveys

3. Co-morbid respiratory condition including cystic fibrosis, chronic lung disease
(BPD), lung cancer, tracheostomy that could interfere with the assessment of
asthma-related outcome measures.

4. Children residing in foster care or where consent cannot be obtained from a legal
guardian.