Asthma Express: Bridging the Emergency to Primary Care in Underserved

Asthma, the leading chronic disorder in childhood, is the number one cause of pediatric
emergency department (ED) visits in young children and is responsible for a substantial
impact on healthcare costs. The ED is often the point of contact for low-income children and
many families view the ED as their primary source of asthma care. Poor and minority
children have the highest asthma morbidity, are the least likely to receive adequate
preventive therapy or specialty care and more frequently exposed to environmental triggers
than non-poor children. However, prior studies, including our pilot, indicate that children
with frequent asthma ED visits will attend a one-time ED-based follow-up clinic for an
asthma "check-up" and education. The goal of this randomized controlled trial is to test the
efficacy of a multifaceted, ED + primary care provider (PCP) and home-based intervention,
Asthma Express (AEx), for children with > 2 asthma ED visits or 1 hospitalization/year that
provides tailored guideline based asthma care. Allergy and cotinine biomarkers, collected
during the ED visit, are used to target the home environmental control component of the
intervention. The AEx intervention (n=132) will be compared to an attention control (CON)
group (n=132) for the specific aims: (1) to reduce asthma morbidity (increase symptom free
days and nights) and decrease ED visits and hospitalizations and increase asthma control and
caregiver quality of life, (2) to improve the use of appropriate preventive
anti-inflammatory medication based on child pharmacy refill records and (3) to compare the
economic cost and effects of this intervention. Children aged 3-12 years with > 2 asthma ED
visits or 1 hospitalization within the past 12 months and a current ED visit for asthma will
be recruited from the Johns Hopkins Pediatric-ED and followed for 12 months. Symptom
frequency, health care utilization, caregiver quality of life and cotinine measures will be
collected at baseline, 6 and 12 months and pharmacy data collected at baseline and 12
months. Data analysis includes initial cross tabulations of health outcomes by group (AEx
vs. CON) and multivariate generalized linear regression models to study the effects of the
AEx treatment on mean symptom free days/nights, repeat ED visits, hospitalizations and
caregiver quality of life scores and anti-inflammatory medication refills. Mean total costs
of ED, PCP visits, hospital days and medication costs will be compared between groups (AEx
and CON) for the economic analysis. The AEx model is designed to be accessible,
guideline-based, easily replicated and incorporated into ED care. If successful, this study
will fill critical gaps in the ED transition to preventive care asthma interventional
research.

Inclusion Criteria:

Physician-diagnosed asthma (based on caregiver report with validation from the child's ED
attending physician or Pediatric Nurse Practitioner)

- Age > 3 and < 18 years

- Reside in Baltimore Metropolitan area

- Not currently participating in another asthma study or sibling enrolled in Asthma
Express Follow-up Clinic study

Exclusion Criteria:

- Inability to speak and understand English

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

- 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.

- Children/adolescents residing in foster care or where consent cannot be obtained from
a legal Guardian

- Severe respiratory distress based on NHLBI Guideline criteria for evaluation of
asthma exacerbation severity in the emergency care setting