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PEDIATRICS Vol. 105 No. 5 May 2000, pp. 1029-1035
, §, 
,, §, ,, §, ,,, §, and, §
From the * Division of Pulmonary, Allergy and Immunology,
Department of Pediatrics, Eastern Virginia Medical School,
§ Children's Hospital of The King's Daughters, and Center for
Pediatric Research, Norfolk, Virginia.
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ABSTRACT |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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Objectives. To evaluate health care and financial outcomes in a population of Medicaid-insured asthmatic children after a comprehensive asthma intervention program.
Design. Controlled clinical trial.
Setting. Pediatric allergy clinic in an urban, tertiary care children's hospital.
Subjects. Eighty children, 2 to 16 years old, with a history of frequent use of emergent health care services for asthma.
Intervention. Children in the intervention group received asthma education and medical treatment in the setting of a tertiary care pediatric allergy clinic. An asthma outreach nurse maintained monthly contact with the families enrolled in the intervention group.
Outcome Measures. Emergency department (ED) visits, hospitalizations, and health care charges per patient in the year after enrollment.
Results. Baseline demographics did not differ significantly between the 2 groups. In the year before the study, there were no significant differences between intervention and control children in ED visits (mean, 3.5 per patient), hospitalizations (mean, .6 per patient) or health care charges ($2969 per patient). During the study year, ED visits decreased to a mean of 1.7 per patient in the intervention group and 2.4 in controls, while hospitalizations decreased to a mean of .2 per patient in the intervention group and .5 in the controls. Average asthma health care charges decreased by $721/child/year in the intervention group and by $178/patient/year in the control group.
Conclusions. A comprehensive asthma intervention program for Medicaid-insured asthmatic children can significantly improve health outcomes while reducing health care costs.asthma education, health care outcomes, Medicaid, asthma outreach, utilization.
Asthma is the most prevalent chronic disease in childhood
and the most common reason for absenteeism among children enrolled in
grade school.1,2 Low-income, minority children have a
higher prevalence of asthma than white children, and emergency department (ED) use, hospitalization and death from asthma are higher in this population.3-6 Effective outpatient care
is believed to prevent these adverse outcomes, however, inner-city,
minority children and their caretakers typically rely on acute episodic
care instead of routine preventive care for their
asthma.5-8
To address the needs of asthmatic children, previous investigators
developed and evaluated asthma education and outreach programs in a
variety of settings. These programs were associated with better control
of asthma symptoms, improved school attendance or performance, reduced
ED visits and hospitalizations, and reduced health care costs
among asthmatic children.9-21 However, few controlled
studies have been conducted in low-income, minority populations in
which morbidity from asthma is highest, and in which access to medical
care and psychosocial factors play a major role in the management of
chronic disease.22,23
The objective of this controlled clinical trial was to examine the
effect of a comprehensive education and outreach program designed to
decrease emergency department utilization and hospitalization for
Medicaid-insured asthmatic children.
Study Subjects
Between March and November of 1995, eligible asthmatic children
were identified by monthly review of ED visits and hospital admissions
to Children's Hospital of The King's Daughters (CHKD) in Norfolk,
Virginia, using computerized medical records. Children were considered
eligible for inclusion in the study if they met the following criteria:
1) seen in the CHKD ED 2 or more times or hospitalized for asthma at
least once in the previous year; 2) between 2 and 16 years old; 3)
insurance coverage through Medicaid; 4) primary care received in the
CHKD outpatient clinic; and 5) not evaluated by an asthma specialist in
the preceding 2 years. The criteria for hospitalization for status
asthmaticus during the study period included hypoxia (oxygen saturation
<94%), persistent wheezing despite 5 doses of albuterol and 2 doses
of ipratroprium bromide in the course of 2 hours, or a requirement for
albuterol more often than every 4 hours to maintain adequate
respiratory parameters.
At the time of recruitment, neither the interviewer nor the child's
family were aware of the group assignment. If the family agreed to
participate, children were alternately assigned to either the
intervention or the control group. Although a randomized assignment to
control or intervention group would have been ideal, alternate assignment did result in 2 similar groups of enrollees. No incentive was offered for participation beyond the opportunity to participate in
a program that might improve health outcomes for their asthmatic child.
Informed consent was obtained from parents and assent from children
older than 7 years of age. The study was approved by Eastern Virginia
Medical School's Institutional Review Board.
Intervention
The intervention program included clinical and educational
components that conformed to the current guidelines of the National Heart, Lung and Blood Institute (NHLBI)24 and have been endorsed by the American Academy of Pediatrics.
Clinical Care
Children in both the intervention and control groups continued
to receive usual care from their primary care provider (PCP) in the
children's clinic throughout the study. PCPs were aware that the study
was ongoing but were not specifically notified when one of their
patients was enrolled in the study. These physicians were not
restricted from referring children in their practice to the allergy
clinic or other educational interventions (ie, home health) during the
study period. Routine communication via letter between the PCP and the
allergist was maintained for children in the study as well as for
children who were referred outside the study. Most children continued
to receive the majority of their care at the children's clinic
throughout the study.
METHODS
Top
Abstract
Methods
Results
Discussion
Conclusion
References
Education and Outreach Intervention During the initial allergy clinic visit, intervention children and their caretakers participated in one-on-one asthma education in the clinic by the physician and the asthma outreach nurse. The teaching plan included recognition of asthma triggers, environmental control, symptoms and early warning signs, medication usage and side effects, use of spacer devices and peak flow meters if appropriate, and medical management of asthma exacerbations. Identification of specific triggers for each child was emphasized to the families, and use of holding chambers was reviewed at each visit. All patients were given a written action plan for exacerbations. Educational plans were tailored to the needs of each of the children and their families. During follow-up visits, asthma education was reinforced by both the physician and the asthma outreach nurse.
On a monthly basis, the asthma outreach nurse contacted each intervention family to inquire about the health status of the asthmatic child, review medication administration, refill prescriptions, schedule follow-up visits, and assist with transportation as needed. For those families without phones, messages were left with friends, neighbors, or other family members. The asthma outreach nurse worked closely with school personnel to pass information to and obtain information from the family and the child, particularly if phone access was difficult. Intervention families were encouraged to contact her with questions or concerns regarding asthma care. She also met patients during their clinic visits to answer questions and reinforce asthma education.Data Collection
Standardized monthly phone interviews were conducted for households in both intervention and control groups. Parental report of health care utilization was verified by data collection personnel with review of medical records. Hospital charges for all components of medical care provided during the outpatient visit (including provision of peak flow meters and spacers, skin testing, pulmonary function testing, influenza vaccination, etc) were obtained from computerized hospital financial records. For the 4% of ED visits and hospitalizations that occurred at an outside hospital, the average charge for a hospitalization or ED visit at CHKD was utilized. Records from the primary care clinic and the allergy clinic were reviewed to verify prescribed asthma medications and administration of the influenza vaccine.
During phone conversations with the control group families the asthma outreach nurse tracked health care utilization, but did not transmit information regarding asthma medications or management. If control families had questions regarding asthma symptoms or management during phone interviews, they were encouraged by the asthma outreach nurse to contact their PCP.
Health Outcomes
ED visits, hospitalizations, and hospital days during the study year were tracked for both groups. Physicians in the ED were aware that the asthma program was ongoing, but study patients were not specifically identified to them. All charges related to specialty care visits, except medication charges, were included. The asthma-related charges for all children in the year before enrollment were compared with charges for asthma care in the year after enrollment. The cost of the asthma outreach nurse's salary (approximately 12 hours per week, representing an annual cost of $15 000 in 1995) was added to the overall health care charges for the intervention group.
Statistical Analysis
Baseline demographics were compared using Fisher's Exact test
and 
2 analysis. Continuous variables,
including total charges, were tested for normality using the
Shapiro-Wilk test and a graphical display of the values. Because the
distribution of total charges per patient seriously deviated from
normality, study groups were compared using the 2-sample Wilcoxon
Rank-Sum test for equality of the median values of the 2 groups. The
effectiveness of the intervention for each outcome measure was assessed
using a generalized linear model that included history of the same
outcome in the previous year (total number of hospitalizations, ED
visits, or hospital days) as a covariate. In these models, the number
of ED visits and hospitalizations were assumed to have a Poisson distribution, while the total number of days in hospital was assumed to
have a binomial distribution (n = 365). A P
value of .05 or less was considered statistically significant.
Two-sided tests of hypothesis were used. Statistical analyses were
performed using STATA (Stata Corporation, College Station, TX)
statistical software.25
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RESULTS |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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Subject Enrollment and Follow-up
A total of 102 families were contacted for potential enrollment into the study. Of these, 80 agreed to participate in the study and were alternately assigned to either the intervention or control group. Two children in the intervention group were lost to follow up: 1 child in foster care was transferred out-of-state; the second was an adolescent female who withdrew herself from the study. All children in the control group completed the 1-year study period.
Baseline Characteristics
The baseline characteristics of the study population are shown in Table 1. There were no significant differences in age, sex, race, smoking exposure in the home, or phone access between the intervention and control groups. At the time of enrollment a higher proportion of control compared with intervention children were using an antiinflammatory medication.
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Use of Preventive Services
With encouragement from the asthma nurse, 32 children (84%) in the intervention group made at least 3 visits to the allergy clinic while 6 children (16%) had 2 or fewer visits to the allergy clinic during the study year. Of the 32 children in the intervention group who made at least 3 visits to the allergy clinic, 8 children made 4 visits, and 11 children made 5 or more visits. During the study year, visits to the PCP (including well-child as well as sick visits for asthma care) decreased by 20% in the intervention group (from 103 to 83) and increased by 4% (from 134 to 139) in the control group during that same time period. In the intervention group, 1 child was referred to home health for additional asthma instruction by the PCP. In the control group, 2 children were referred to home health for asthma instruction and 2 other children were seen in pulmonary clinic for asthma care.
During the study year, 36 children (95%) in the intervention group received the influenza vaccine compared with only 9 children (23%) in the control group (P < .001, Fisher's Exact test). By the end of the study year, the number of children who were prescribed antiinflammatory medication increased threefold. The number of children using antiinflammatory medication increased from 13 (34%) to 36 (95%) of children, while in the control group use of antiinflammatory medications was essentially unchanged (from 24 (60%) to 26 (65%)).
Preintervention and Postintervention Emergent Health Care Utilization
The mean number of ED visits, hospitalizations, and hospital days is shown in Fig 1. In the year before enrollment, there was no significant difference between intervention and control groups in the number of ED visits, hospitalizations, and hospital days per patient. When compared with the prior year the outcomes of interest in the intervention group decreased significantly: the number of ED visits decreased from 3.6 to 1.7 visits per child (P < .05), hospitalization decreased from .6 to .2 hospitalizations per child (P < .001), and average hospital days decreased from 2.4 to .9 hospital days per child (P < .001). In the control group, outcomes in the prior year were somewhat decreased in the study year, but these differences were not significant: ED visits decreased from 3.5 to 2.3 visits per child, hospitalization decreased from .53 to .48 hospitalizations per child, and average hospital days decreased from 1.8 to 1.7 hospital days per child.
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Most children in the intervention group had a decrease in their health care utilization. Nineteen children (50%) had a decrease in the number of hospitalizations, while 2 had an increase, and 17 remained unchanged (14 of the 17 had no prior hospitalization in the previous year). With regard to ED visits, 22 children (58%) had fewer visits to the ED in the study year, while 4 had an increase in number of visits and 12 had no change (6 of the 12 had no prior ED visits in the previous year).
Relative Risk of Asthma Events in Controls Versus Intervention Group
Using logistic regression analysis to control for individual history of asthma outcomes in the prior year, children in the control group compared with the intervention group were 1.4 (95% confidence interval [CI]: 1.02-1.91; P = .039) times more likely to have an ED visit and 2.4 (95% CI: 1.04-5.42; P = .040) times more likely to be hospitalized for asthma in the study year (Table 2). Although all sociodemographic and health care variables were examined as independent risk factors and for potential confounding or interaction effects, no independent variables were found to contribute significantly to the regression model other than study group and prior history of emergency services.
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Subgroup analysis suggested a trend toward greater effectiveness of the intervention program to decrease hospitalization among children residing in a smoke-free household than in households with smokers. A similar trend was observed in households with continuous telephone service rather than disconnected telephone service. These observed differences in intervention effectiveness by subgroup, however, were not statistically significant (Table 2).
Cost Analysis
The charges for asthma-related health care utilization are shown in Table 3. In the year before enrollment, mean total charges were very similar between intervention and control children: $2983 per child in the intervention group and $2955 per child in the control group. During the intervention year, mean total charges in the intervention group children decreased by $721 (from $2983 to $2262 per child per year) despite the additional cost of subspecialty care in the allergy clinic and salary support for the outreach nurse. This decrease is largely attributable to the decrease in hospitalizations and ED visits for children in the intervention group. In the control group, mean total charges decreased but to a much lesser extent, from $2955 to $2777 per child per year, a difference of $178.
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Quality of Life
Asthma-specific quality of life measurements, completed only in the intervention groups, were available in 15 of the intervention children and 36 of their adult caretakers. (The Pediatric Asthma Quality of Life Questionnaire is useful only for children at least 7 years of age.) A clinically important change (defined as .5 or greater by validation studies of the instrument) was noted in each domain tested and the overall quality of life score for both children and their caretakers (Table 4).26,27
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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With this comprehensive asthma intervention program we were able to demonstrate a decrease in the rate of hospitalization and use of ED services for a group of high-risk, low-income, minority children. Quality of life also improved for intervention families; however, the interpretation is somewhat limited by the inability to obtain quality of life data in the control group. Other studies have been published on the use of self-management programs to decrease asthma morbidity.9-21 Several reviews evaluating the current pediatric literature found positive results for some programs and inconclusive results for others, although study design and evaluation have not always withstood rigorous scientific scrutiny.22,2328-31 A recent meta-analysis of randomized, clinical trials of self-management teaching programs for children with asthma concluded that morbidity was not reduced as a result of these programs, and suggested that teaching programs be designed for target audiences with well-defined characteristics such as age, socioeconomic setting, and severity of disease.28 Our intervention was designed to target high-risk/Medicaid-insured asthmatic children with a prior history of hospitalization or multiple ED visits. It differs from those previously published in that it combines patient education and subspecialty medical management with an extensive outreach program that focused on improving the liaison between patient and provider.
Prior evaluations of asthma education programs for children and adults elucidate the need for control groups to be included in the study design.10,19,32,33 Oftentimes, a decrease in health care utilization can be seen in the control group as well as in the intervention group. During our intervention, the introduction of a Medicaid managed care program may have increased the amount of acute and preventive care provided by primary care physicians and subsequently decreased the number of ED visits for asthma exacerbations. In this study, control patients may have been more compliant with their asthma medications simply as a result of the monthly follow-up phone call from the asthma nurse (Hawthorne effect).
Experts who have reviewed the cost-effectiveness of asthma education programs identify the need for the use of standardized approaches to study design and cost-benefit analysis.34,35 Previous evaluations have documented cost savings from $180 to $543 per enrolled patient, although study design and costs included in the evaluation vary between studies.14,36 In our study, charges for health care services in the intervention group decreased by $721/patient/year despite the additional cost of allergy clinic visits, pulmonary function testing, skin testing, and the salary of the outreach nurse. Charges in the control group decreased by $178/patient/year, for a net difference in savings of $543 per patient. The majority of this savings is accounted for by the significant decrease in rate of hospitalization, which is the largest single component of direct expenditures related to the cost of asthma care in this country.37
Unfortunately, we did not have access to a pharmacy database for these children and therefore could not include the cost of outpatient medications in the overall cost analysis. Daily use of an antiinflammatory medication, which would be necessary for most children with moderate to severe asthma, can be expensive. However, one could estimate the cost attributable to daily use of these medications in the intervention group by adding the average wholesale price of 1 year's worth of beclomethasone to the charges in that group. Assuming that children in the intervention group used 1 canister per month of beclomethasone at an average cost of $30 per canister, a total of $360 per year would be added to the cost of care in the intervention group. The net difference in savings between the control and intervention groups would be reduced from $543 per child to $183 per child. This estimate does not account for use of any antiinflammatory medications in the control group, nor does it include the potential decrease in cost in the intervention group related to less frequent albuterol use as their asthma becomes better controlled. Thus, although this is only an estimate, it does not appear that the cost related to antiinflammatory medications would outweigh the savings realized by decreasing hospitalization rates with this intervention. Access to a pharmacy database would also have allowed investigators to track compliance with prescribed asthma medications and adherence to the asthma treatment plan. Prescription refill data, which is now computerized by most managed care organizations, should be included in future asthma intervention studies.
Children in the study were encouraged to continue seeing their primary care physician on a regular basis. Despite this, there was a decrease in the number of visits to the PCP in the intervention group, while the number of visits to the PCP in the control group remained constant. Children in the control group were most likely substituting a visit to the allergy clinic for a PCP visit. Overall, the number of outpatient visits during the study year did not differ between the 2 groups.
There are limitations to the generalizability of this study. Although children enrolled in the study were not specifically identified to their PCP, it is possible that the enrolled child or family member made their participation known to their PCP or a physician in the ED. The lack of perfect blinding may have affected a medical provider's decision to alter medications or admit an asthmatic child to the hospital. In addition, more children in the control group were using antiinflammatory medications at baseline than intervention children. Thus, although the 2 groups were matched for prior health care utilization as a measure of severity, control children may have had more severe asthma based on prescription of medications.
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CONCLUSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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In summary, we have shown that a comprehensive intervention program including education, medical management of asthma in accordance with NHLBI guidelines, and an effective outreach component that enhances the partnership between the asthmatic patient and the provider can decrease use of ED services and hospitalization rates for low-income children with asthma. Despite its limitations, this study provides evidence that asthma expenditures can be reduced by improving access to quality ambulatory care and outreach services for impoverished asthmatic children.
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FOOTNOTES |
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Received for publication Jul 24, 1998; accepted Jul 15, 1999.
Address correspondence and reprint requests to Cynthia S. Kelly, MD, Center for Pediatric Research, 855 W Brambleton Ave, Norfolk, VA 23510-1001. E-mail: ckelly{at}chkd.com
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ABBREVIATIONS |
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ED, emergency department; CHKD, Children's Hospital of The King's Daughters; NHLBI, National Heart, Lung and Blood Institute; PCP, primary care provider; CI, 95% confidence interval.
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REFERENCES |
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Abstract
Methods
Results
Discussion
Conclusion
References
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This article has been cited by other articles:
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