The impact of health education on frequency and cost of health care use by low income children with asthma. Home-based asthma education of young low-income children and their families. Randomized trial of a comprehensive asthma education program after an emergency department visit. A randomized controlled trial of a pediatric asthma outreach program. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Effect of a structured asthma education program on hospitalized asthmatic children: a randomized controlled study. Asthma education by community child health nurses. Delivering tailored asthma family education in a pediatric emergency department setting: a pilot study. The pediatric asthma intervention: a comprehensive cost-effective approach to asthma management in a disadvantaged inner-city community. Self-management education of children with asthma: AIR WISE. A randomized clinical trial to reduce asthma morbidity among inner-city children: results of the National Cooperative Inner-City Asthma Study. Asthma at the interface: bridging the gap between general practice and a district general hospital. Efficacy of an individualized written home-management plan in the control of moderate persistent asthma: a randomized, controlled trial. Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice. Breaking the access barrier: evaluating an asthma center's efforts to provide education to children with asthma in schools. Outcomes evaluation of a comprehensive intervention program for asthmatic children enrolled in medicaid. Reductions in hospital use from self management training for chronic asthmatics. An evaluation of an innovative multimedia educational software program for asthma management: report of a randomized, controlled trial. Improved asthma outcomes in a high-morbidity pediatric population: results of an emergency department-based randomized clinical trial. A comprehensive inner-city asthma program reduces hospital and emergency room utilization. Emergency department allies: a controlled trial of two emergency department-based follow-up interventions to improve asthma outcomes in children. Prospective controlled evaluation of the effect of a community based asthma education centre in a multiracial working class neighbourhood. Effectiveness of a multicomponent self-management program in at-risk, school-aged children with asthma. An educational program for parents of asthmatic preschool children: short- and medium-term effects. A controlled trial of an environmental tobacco smoke reduction intervention in low-income children with asthma. Asthma in adolescents: a randomized, controlled trial of an asthma program for adolescents and young adults with severe asthma. Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma. Asthma coaching in the pediatric emergency department. Improving follow-up for children with asthma after an acute Emergency Department visit. Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial. Effectiveness of a nurse-managed program for children with chronic asthma. An interdisciplinary intervention for undertreated pediatric asthma.
A sample of 310 low income urban children with asthma from 290 families was randomized into a control group and an experimental group that received health education to improve asthma management at home. No significant decreases in subsequent health care use were observed when the experimental group was compared to the control group without regard to previous hospitalization. When the comparison was restricted to children who had been hospitalized during the preceding year, however, the experimental group was found to have decreased its use of the emergency room significantly more than the control group (p less than 0.05) and to have experienced a significantly greater reduction in the mean number of hospitalizations (p less than 0.05) during the year of follow-up. The program reduced health care costs for children with one or more hospitalizations, saving $11.22 for every $1.00 spent to deliver health education. To conduct a controlled trial of a home-based education program for low-income caregivers of young children with asthma.
                Participants were randomized to treatment-eight weekly asthma education sessions adapted from the Wee Wheezers program (n = 49)-or usual care (n = 46). Baseline and 3- and 12-month follow-up data were gathered from caregivers and from children's medical records.
                Treatment was associated with less bother from asthma symptoms, more symptom-free days, and better caregiver quality of life at follow-up for children 1-3, but not those 4-6, years of age. Treatment and control groups did not differ in caregiver asthma management behavior or children's acute care utilization.
                This home-based asthma education program was most effective with younger children; perhaps their caregivers were more motivated to learn about asthma management. Targeting psychosocial factors associated with asthma morbidity might also enhance the efficacy of asthma education for these families. Patients with asthma who visit the emergency department (ED) may benefit from education that optimizes self-management and treatment.
                To conduct a randomized trial of asthma education (AE) after an ED visit.
                Patients who present with acute asthma and history consistent with moderate to severe persistent asthma or recent ED visits were stratified by age (adult, child) and randomly assigned to intervention or usual care during the ED visit. The intervention was conducted by trained asthma educators and included a facilitated office visit with the primary care physician followed by a home visit. Intention-to-treat analysis was conducted, with time to first asthma relapse (either ED or unscheduled urgent office visit) during the 6-month follow-up period used as the primary outcome.
                Of the 239 patients analyzed, 46% were adults, 46% were male, 30% were African American, and 56% had moderate to severe persistent asthma. Follow-up information was obtained on 191 patients (80%) at 6 months; 23.1% of the intervention group vs 31.1% of the usual care group had an urgent asthma visit (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.48-1.29). Overall, 39% of the 117 patients assigned to the intervention group did not comply with any of the post-ED activities. Subgroup analysis suggested greater benefit among children (HR, 0.62; 95% CI, 0.33-1.19) than adults (HR, 1.08; 95% CI, 0.50-2.33).
                Delivery of a comprehensive AE program after an ED visit was ineffective in adult patients; however, it may be effective in children. Further research on alternative AE delivery strategies appears warranted to reduce the burden of asthma visits to the ED. Previous studies have shown that asthma education and case management may reduce asthma emergency care, hospitalizations, and expenditures.
                We sought to study the effect of an asthma outreach program (AOP), a team-based, case-management intervention, on emergency ward (EW) and hospital use.
                Fifty-seven patients aged 1 to 15 years with the diagnosis of asthma based on the usual clinical practice criteria who were continuously enrolled in a staff-model health maintenance organization for a period of at least 2 consecutive years were randomized into 2 intervention groups. The control group received a single intensive asthma education intervention, and the AOP group received the same initial education but then was followed-up by an asthma case management nurse throughout the intervention period.
                EW visits, hospitalizations, and total outside-of-health-plan expenditures (consisting of EW and hospital expenses, as well as miscellaneous costs, such as ambulance, durable medical equipment, tertiary referrals, and home care) were assessed from claims filed for a year before and after enrollment. Control group patients experienced significant reductions in EW visits (39%), hospitalizations (43%), and outside-of-health-plan costs (28%), possibly as a result of the baseline educational intervention received by all enrolled patients, in conjunction with regression to the mean. AOP group patients experienced significant reductions in EW visits, (73%, P =.0002), hospitalizations (84%, P =.0012), and outside-of-health-plan use (82%, P <.0001). When compared with the control group, AOP group patients demonstrated additional significant reductions in EW visits (57%, P <.05), hospitalizations (75%, P <.05), and outside-of-health-plan use (71%, P <.001). Estimates of direct savings to the health plan ranged from $7.69 to $11.67 for every dollar spent on the AOP nurse's salary, depending on assumptions.
                Asthma patients in a staff-model health maintenance organization decreased their resource use between 57% to 75% by participation in an AOP as compared with a randomized control group receiving only an educational intervention. Substantial savings were achieved compared with the cost of the AOP nurse. Re-admissions to hospital in childhood asthma are common with studies reporting that 25% or more of children will be re-admitted within a year. There is a need for strategies to reduce re-admissions.
                A prospective randomised control study of an asthma home management training programme was performed in children aged two years or over admitted with acute asthma. Two hundred and one children were randomised at admission to either an intervention group (n = 96) which received the teaching programme or a control group (n = 105). A nurse-led teaching programme used the current attack as a model for the management of future attacks and included discussion, written information, subsequent follow up and telephone advice aimed at developing and reinforcing individualised asthma management plans. Parents were also provided with a course of oral steroids and guidance on when to start them.
                The groups were similar in degree of social deprivation, length of stay, number of previous admissions, acute asthma treatment, and asthma treatment at discharge. Subsequent re-admissions were significantly reduced in the intervention group from 25% to 8% in individual follow up periods that ranged from two to 14 months (chi 2 = 9.63; p = 0.002). This reduction was not accompanied by any increase in subsequent emergency room attendances nor, in the short term, by any increase in urgent community asthma treatment. The intervention group also showed significant reductions in day and night morbidity 3-4 weeks after admission to hospital.
                A nurse-led asthma home management training programme administered during a hospital admission can significantly reduce subsequent admissions to hospital for asthma. Acute hospitalisation may be a particularly effective time to deliver home management training. The aim of this study was to compare the effectiveness of an intensive asthma education program (group B) with that of a standard asthma education program (group A).
                A prospective randomized single blinded study was conducted in the pediatric department of a public hospital in Hong Kong. Children aged 2-15 years admitted to the pediatric department with an acute attack of asthma were recruited. A standard asthma education program (group A) or an intensive asthma education program (group B) for children were offered. The main outcome measures include the number of visits to the emergency department and the number of hospitalization for asthma during the 3 month follow-up period.
                A total of 45 children were in group A and 55 in group B. Group B had statistically significant reductions in the number of visits to the emergency department and the number of hospitalizations. Drug compliance was also significantly improved in group B. Parents' satisfaction rate was also higher in group B.
                The intensive asthma education program might be more cost effective than the standard asthma education program in the management of asthmatic children admitted to hospital in Hong Kong. A randomised controlled study of an educational programme for children with asthma and their families was carried out by community child health nurses. Three hundred and sixty eight children aged 2 to 14 years were enrolled in the study after admission to hospital for asthma. The intervention group was visited monthly by a nurse for six months. The subjects were assessed six months later by a postal, self administered questionnaire. European children in the intervention group were taking significantly more drugs for the treatment of asthma six months after the index admission to hospital than those in the control group (mean (SD) intake 2.7 (1.1) v 2.1 (1.0), respectively). In particular, they were using more theophylline (56.6% v 37.0%) and inhaled steroids (34.9% v 21.0%). There was no difference between the groups for parental reports of improvement, of missed schooling, and in severe attacks of asthma of not responding to the usual treatment at home. European children in the intervention group used the hospital services for severe attacks of asthma more than controls (34.2% v 10.5%). There were more re-admissions in the European intervention group in the subsequent six months after the index admission than in the control group (mean (SD) 0.51 (0.97) v 0.29 (0.65). Re-admission continued to be higher in the 12 months after the nurse had stopped visiting (0.81 (1.65) v 0.25 (0.65]. There was no difference in the duration of hospital stay between the intervention and control groups. For Polynesian children there was no difference between the groups for any outcome measures. Many children are brought to the pediatric emergency department (ED) with acute asthma symptoms. Emergency asthma care is costly, and many ED visits may be preventable. Families often do not have written asthma action plans and lack asthma self-management skills. This study tests a tailored self-management intervention delivered in the ED for families of children with asthma. The primary hypotheses were that the intervention group would have greater confidence to manage asthma 14 days postintervention and more well-asthma visits and fewer urgent care/ED visits at 9 and 12 months.
                This randomized intervention/usual-care study was part of a larger ED asthma surveillance project in 4 urban pediatric ED sites. Asthma educators used a computer-based resource to tailor the intervention messages and provide a customized asthma action plan and educational summary. Children with acute asthma were enrolled during an ED visit, and follow-up telephone interviews were conducted during the next 9 months. The ED clinician classified the child's acute and chronic severity.
                To date, 464 subjects aged 1 to 18 years have been enrolled. The ED clinicians reported that 46% had intermittent and 54% had persistent chronic severity with 51% having mild acute severity episodes. The confidence level to prevent asthma episodes and keep them from getting worse was significantly higher in the intervention group at 14 days postintervention. More subjects in the intervention group reported well-asthma visits by 9 months. Return ED visits were significantly lower in the intervention group in those with intermittent asthma. Twelve-month follow-up is in process.
                The tailored ED self-management intervention demonstrates significant effects on caregiver self-confidence and well-visit follow-up. Additional evaluation is needed to determine what impact this intervention has long-term. To compare three pediatric asthma interventions for their impact on improving the health status of inner-city asthmatic children and in achieving cost savings.
                A total of 212 children 1 to 16 years of age were randomized into three groups: group 1 (n = 74) received one individualized asthma education session; group 2 (n = 68) received reinforced asthma education; group 3 (n = 70) received reinforced asthma education plus case management. Asthma-related health resource utilization and cost were primary outcomes. The cost-benefit analysis sought to estimate the expected cost savings to the Illinois Department of Healthcare and Family Services (Medicaid administrator) associated with the intervention.
                Participants in all three groups used significantly fewer emergency health care services in the follow-up year. Averaged across all three groups, the magnitudes of declines were substantial: 81% for hospitalizations, 69% for hospital days, 64% for emergency department visits, and 58% for clinic visits. Although there were no statistically significant differences between study groups for three of the four main outcome measures, group 3 participants consistently improved to the greatest degree. All three interventions were associated with considerable cost savings ranging from $4,021/child/year for group 1 to $4,503/child/year for group 3.
                Asthma education with or without case management services enhances the health of children with asthma thereby reducing associated costs. This study was conducted to test the efficacy of AIR WISE, an individually administered asthma self-management program. Subjects were paired and randomly assigned to either an experimental group (N = 7) or a control group (N = 7). The frequency of experimental group emergency visits, analyzed over a 12-month posttreatment period, was substantially less than those of the control group, supporting the hypothesis that AIR WISE is effective in high-utilizer children through improved self-management. To evaluate a family-focused asthma intervention designed for inner-city children 5 to 11 years old with moderate to severe asthma.
                Randomized, multisite, controlled trial to minimize symptom days (wheeze, loss of sleep, reduction in play activity) measured by a 2-week recall assessed at 2-month intervals over a 2-year follow-up period. The intervention was tailored to each family's individual asthma risk profile assessed at baseline.
                Averaged over the first 12 months, participants in the intervention group (n = 515) reported 3.51 symptom days in the 2 weeks before each follow-up interview compared with 4.06 symptom days for the control group (n = 518), a difference of 0.55 (95% CI, 0.18 to 0.92, P =.004). The reduction among children with severe asthma was approximately 3 times greater (1.54 d/2 wk). More children in the control group (18.9%) were hospitalized during the intervention compared with children in the intervention group (14. 8%), a decrease of 4.19% (CI, -8.75 to 0.36, P =.071). These improvements were maintained in the intervention group during the second year of follow-up, during which they did not have access to the asthma counselor.
                We demonstrated that an individually tailored, multifaceted intervention carried out by Masters-level social workers trained in asthma management can reduce asthma symptoms among children in the inner city. A clinic supervised by a nurse, using principles originally developed in general practice, was established in the paediatric department of a district general hospital. A randomised controlled study was conducted comparing children admitted with asthma or attending outpatients who were given a patient education programme and self management plan (intervention group) with a control group. The study comprised 91 patients aged 3-14 years admitted for asthma or attending a hospital outpatient department from November 1989 to November 1990. Seventy seven patients completed the study and kept diaries for a median of 283 days. Patients in the intervention group had significantly less restriction of activity (95% confidence interval (CI) -0.27 to -0.01) and fewer episodes of peak flow below 30% of best (95% CI 0.03 to 1.17). Patients in the intervention group were more likely to make the correct response to an acute exacerbation of their asthma than the control group (71% v 47%, 95% CI 9.51 to 39.1). The intervention group had fewer school absences and fewer home visits by a general practitioner. There was an increase in the readmission rate for the intervention group. A subgroup of patients who self managed by doubling their use of inhaled steroids during an exacerbation performed better than those patients who only increased their bronchodilator or were managed on salbutamol or sodium cromoglycate alone. Improvements in patient follow up and the structure of the self management plans used, particularly changing the peak flow level at which inhaled steroids are doubled, may further improve the outcome of patients attending the asthma clinic. The management of childhood asthma necessitates a comprehensive approach including pharmacological treatment as well as education about self-evaluation and home management of the condition.
                To evaluate the efficacy of adding an individualized written home-management plan in the control of moderate persistent asthma.
                Children with moderate persistent asthma were randomized to receive either an individualized written home-management plan or no plan, in addition to standard asthma therapy including education. They were followed up with serial measurement of outcome variables.
                Children receiving an individualized written home-management plan had fewer acute asthma events, fewer lost school days, lower symptom score and less nocturnal awakening than those who did not receive a written plan.
                The addition of a written individualized home-management plan improves overall control in children with moderate persistent asthma. Discharge planning is becoming an important part of the management of childhood asthma in hospital. Readmission to hospital, although often inevitable, might represent a failure of the opportunity for intervention presented by a brief period of supervised care in hospital.
                To examine the impact of a structured, nurse-led discharge package for children admitted to hospital with acute asthma on readmission to hospital, reattendance at the accident and emergency (A&E) department, and general practitioner consultations for asthma.
                A structured nurse-led discharge package, consisting of a 20 minute patient education programme and self management plan for children with asthma was developed on the wards of a busy children's hospital. A randomised controlled trial was conducted involving 160 children aged 2-16 years admitted for asthma over a 12 month period. Readmission and A&E reattendance's over the six months after discharge from hospital were obtained from the hospital computerised information system and general practitioner consultations from practice records.
                Children in the intervention group were significantly less likely to be readmitted to hospital in the next six months than those in the control group (12 of 80 v 30 of 80 patients), and significantly less likely to attend the A&E department (6 of 80 v 31 of 80). Significantly fewer children in the intervention group had visits to their general practitioner for problematic asthma (31 of 78 v 72 of 77 for whom data were available).
                By delivering the simplest form of education and support during a child's stay in hospital, readmissions over a six month period were reduced. The programme was designed to be suitable for administration by nursing staff on the children's wards after a brief period of training. To evaluate an asthma education program for children with asthma that is delivered in their school by certified asthma educators from a local hospital-based asthma center.
                Randomized controlled trial.
                Twenty-six elementary schools located in a suburb of Toronto.
                A total of 256 children in grades 2 to 5 with asthma and their parents were randomized to control and experimental groups.
                Children in the experimental group received the "Roaring Adventures of Puff" asthma education program over the course of six weekly 1-h sessions. Those in the control group continued receiving usual care.
                Data collection involved measuring asthma quality of life, self-efficacy for managing asthma, school absenteeism, days of interrupted activity, health services use, and parental loss of time from work. Quality of life and self-efficacy data were collected from the children at baseline and 2 months. Telephone parental interviews conducted over 1 year were used to collect data on the remaining variables. Unpaired t test, analysis of variance, and chi2 test were used to determine whether differences existed between the groups. The results are reported as the mean +/- SD. The experimental group demonstrated higher scores than the control group for self-efficacy (3.6 +/- 0.7 vs 3.8 +/- 0.9, respectively; p < 0.05) and quality of life (5.0 +/- 1.4 vs 5.5 +/- 1.4, respectively; p < 0.05). At 1 year, the experimental group demonstrated fewer mean urgent health-care visits (2.5 +/- 2.5 vs 1.7 +/- 1.9 visits per year, respectively; p < 0.01), days of missed school (4.3 +/- 5.7 vs 3.0 +/- 4.4 days per year, respectively; p > 0.05), and days of interrupted activity (9.1 +/- 10.5 vs 6.2 +/- 7.3 days per year; p < 0.01) related to asthma than the control group. There were no differences between the groups for parental work absenteeism or scheduled asthma visits.
                Providing an asthma education program to children in their school can significantly improve quality of life and reduce the burden of childhood asthma. To evaluate health care and financial outcomes in a population of Medicaid-insured asthmatic children after a comprehensive asthma intervention program.
                Controlled clinical trial.
                Pediatric allergy clinic in an urban, tertiary care children's hospital.
                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.
                Emergency department (ED) visits, hospitalizations, and health care charges per patient in the year after enrollment.
                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.
                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. The purpose of this study was to assess the impact of asthma Self Management Training on the health status and resource use of patients with chronic asthma. The study consisted of a randomized control design of chronic asthmatic patients in a tertiary care center in India. The intervention group (153 patients) received four training sessions in addition to the regular care provided to the control group (150 patients). Health status and resource use were measured at baseline and over a one year follow-up period. The intervention group had significantly better health status (measured by breathing ability), fewer productive days lost, and lower resource use (hospitalizations and emergency room visits) than the control group. Total annual costs (direct and indirect) were also lower, though physician costs were not included in the assessment. Therefore, incorporation of asthma Self Management Training as part of clinical management of asthma can result in improvements in health status and reductions in hospital use. Asthma continues to be a substantial cause of morbidity in pediatric populations. New strategies are needed to provide cost-effective educational interventions for children with asthma, particularly those in the inner city.
                To assess the effectiveness of a multimedia educational software program about asthma.
                A hospital-based primary care clinic and an affiliated neighborhood health center.
                Randomized, controlled trial.
                Children 3 to 12 years old with physician-diagnosed asthma.
                An interactive educational computer program, Asthma Control, designed to teach children about asthma and its management. Using a graphic display of a child going through simulated daily events, the game emphasizes: 1) monitoring; 2) allergen identification; 3) use of medications; 4) use of health services; and 5) maintenance of normal activity. Control group participants reviewed printed educational materials with a research assistant.
                Acute health care use (emergency department and outpatient) was the primary outcome. Secondary outcome measures included maternal report of asthma symptom severity, child functional status and school absences, satisfaction with care, and parental and child knowledge of asthma.
                A total of 137 families were enrolled in the study (76 intervention, 61 control). Both intervention and control groups showed substantial improvement in all outcomes during the 12-month follow-up period. Aside from improvement in knowledge after use of the computer program, no differences were demonstrated between the 2 groups in primary or secondary outcome measures. Children reported enjoyment of program use.
                This trial of an educational software program found that it did not produce greater improvement than occurred with review of traditional written materials. Because both groups showed substantial improvement over baseline, computer-based education may be more cost-effective. Alternatively, improvements in illness severity over time may overshadow the effects of such interventions. Rigorous comprehensive evaluations such as this are necessary to assess new interventions intended to improve management and outcomes of asthma. To determine if an emergency department-based asthma follow-up clinic could improve outcomes within a high-morbidity pediatric population.
                Prospective, randomized clinical trial with 6 months of follow-up.
                Emergency department of an urban pediatric medical center.
                Convenience sample of 488 patients aged 12 months to 17 years, inclusive, with prior physician-diagnosed asthma and 1 or more other unscheduled visits in the previous 6 months and/or 1 or more hospitalizations in the prior 12 months.
                Single follow-up clinic visit focusing on 3 domains: asthma self-monitoring and management, environmental modification and trigger control, and linkages and referrals to ongoing care.
                The primary outcome measure was unscheduled visits for acute asthma care. Secondary outcomes included compliance with a medical plan and asthma quality of life. Analysis was by intention to treat with adjustment for baseline differences.
                Of those randomized to the clinic visit, 172 (70.5%) of 244 attended. The intervention group had significantly fewer mean unscheduled visits for asthma care during follow-up (1.39 vs 2.34; relative risk [RR] = 0.60 [95% confidence interval (CI), 0.46-0.77]). At 6 months, significantly more patients in the intervention group reported use of inhaled corticosteroids in the prior 2 days (49.3% vs 26.5%; RR = 2.03 [95% CI, 1.57-2.62]), no limitation in daytime quality of life (43.8% vs 34.4%; RR = 1.36 [95% CI, 1.06-1.73]), and no functional limitations in quality of life (49.8% vs 40.8%; RR = 1.33 [95% CI, 1.08-1.63]).
                Attendance in the follow-up clinic was high. The intervention decreased subsequent unscheduled health care use while improving compliance and quality of life. To evaluate the efficacy of a comprehensive asthma program on emergency department (ED) visits and hospital admission rates in an inner-city pediatric population.
                A12-month prospective randomized trial.
                Three hundred asthma patients, ages 2 to 17 years, were recruited and randomized in an inner-city pediatric ED, to obtain asthma care in a specialty clinic or to continue receiving care by other health resources. The specialty clinic provided intensive medical and environmental control, education, close monitoring, and 24-hour availability. For the prospective study, monthly questionnaires were sent to the caregivers of these children to evaluate use of hospital facilities for asthma care. For the retrospective study, use of hospital resources by the study participants was analyzed using a hospital database.
                One hundred twenty-nine patients (60 in the treatment group and 69 in the control group) were included in the final analysis. Asthma severity index was significantly higher for the patients in the treatment versus the control group (35% versus 16.2%, P = .05). Fewer patients in the treatment group visited the ED at least once during the first study year, 32 versus 46, (P = .11), and they made fewer visits, 73 versus 269. The mean number of ED visits of the patients who used the ED was 0.1 versus 0.326 for the control group (P = .01). There were also fewer admissions in the treatment group, 22 versus 29 (P < .59). The 53 patients remaining in the treatment group in the second study year made fewer visits to the ED versus the control group (P < .03). In comparison to the first year, fewer patients in the treatment group visited the ED or were hospitalized in the second year (P = .007 and P = .04, respectively).
                A comprehensive asthma care program is efficacious in reducing hospital utilization. We sought to study the impact of emergency department (ED)-based intensive primary care linkage and initiation of asthma case management on long-term, patient-oriented outcomes for children with an asthma exacerbation.
                Our study was a randomized, 3-arm, parallel-group, single-blind clinical trial. Children aged 2 through 17 years treated in a pediatric ED for acute asthma were randomly assigned to standard care (group 1), including patient education, a written care plan, and instructions to follow up with the primary care provider within 7 days, or 1 of 2 interventions. Group 2 received standard care plus assistance with scheduling follow-up, while group 3 received the above interventions, plus enrollment in a case management program.
                The primary outcome was the proportion of children having an ED visit for asthma within 6 months. Other outcomes included change in quality-of-life score and controller-medication use.
                Three hundred fifty-two children were enrolled; 78% completed follow-up, 69% were black, and 70% had persistent asthma. Of the children, 37.8% had a subsequent ED visit for asthma, with no difference among the treatment groups (group 1: 38.4%; group 2, 39.2%; group 3, 35.8%). Children in all groups had a substantial, but similar, increase in their quality-of-life score. Controller-medication use increased from 69.4% to 81.4%, with no difference among the groups.
                ED-based attempts to improve primary care linkage or initiate case management are no more effective than our standard ED care in improving subsequent asthma outcomes over a 6-month period. Previous work has indicated a high rate of non-attendance at hospital based clinics among young, multiracial asthmatic patients of lower socioeconomic class. The efficacy of delivering asthma education from a community health centre established in a multiracial working class neighbourhood was evaluated.
                A prospective controlled study was performed in which asthmatic subjects aged between two and 55 years attending a hospital emergency room with acute asthma and living within a defined geographical area of high emergency room users were randomised to the usual follow up or the education centre plus usual follow up. Measurements were taken at entry into the study and again nine months later.
                At nine months patients randomised to the education centre had more preventive medications, more peak expiratory flow meters and better flow meter technique, more self-management plans, better knowledge of appropriate action to take when confronted with worsening asthma, less nocturnal awakening, and better self-reported asthma control than the control group. There was no difference between the study groups in measurements of compliance, hospital admission, days lost from school or work, or emergency room use.
                The main effects of education were on asthma knowledge and self-management skills, whilst improvements in asthma morbidity were small. Potential reasons for this include heterogeneous study population (in terms of baseline self-management skills, asthma severity, ethnicity and age), pragmatic study design, insensitivity of many of the measurements of morbidity, the modest effectiveness of a single time limited education programme, and inability to limit the effects of such a large community based study to the intervention group (there was a 67% reduction in asthma admissions during the study period from the geographical area targeted compared with a 22% reduction for the rest of Auckland). Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care.
                To determine the effectiveness of an asthma education video game in reducing morbidity among high-risk, school-aged children with asthma.
                We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study.
                Compared with controls, the intervention group had significant improvements in the physical domain (P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain (P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child (P = .02 at 8 weeks) and parent (P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables.
                A multicomponent educational, behavioral, and medical intervention targeted at high-risk, inner-city children with asthma can improve asthma knowledge and quality of life. Parent education has proven to be effective in improving parents coping with their child's asthma. Little is known about its effectiveness neither during inpatient rehabilitation nor about the different effectiveness of different approaches. A controlled clinical trial was conducted with 242 parents of asthmatic children aged less than 8 years. The aims were to develop a cognitive-behavioral training program for parents and compare its differential effectiveness with an information-centered standard-program as part of rehabilitation. Both groups reported a highly significant increase in their knowledge, self-efficacy and quality of life over time in a follow-up just after the end of their inpatient stay. There was a further increase from discharge to the 6-month follow-up for self-efficacy and quality of life. In respect to the functional severity of asthma, children of both groups showed a significant improvement. Whether these effects have long-term stability and which parents benefit from which type of intervention will be the objective of an ongoing 12-month follow-up. To determine the effectiveness of a cotinine-feedback, behaviorally based education intervention in reducing environmental tobacco smoke (ETS) exposure and health-care utilization of children with asthma.
                Randomized controlled trial of educational intervention vs usual care.
                The pediatric pulmonary service of a regional pediatric hospital.
                ETS-exposed, Medicaid/Medi-Cal-eligible, predominantly minority children who were 3 to 12 years old and who were seen for asthma in the hospital's emergency, inpatient, and outpatient services departments (n = 87).
                Three nurse-led sessions employing behavior-changing strategies and basic asthma education and that incorporated repeated feedback on the child's urinary cotinine level.
                The primary measurements were the urinary cotinine/creatinine ratio (CCR) and the number of acute asthma medical visits. The secondary measurements were number of hospitalizations, smoking restrictions in home, amount smoked, reported exposures of children, and asthma control.
                The intervention was associated with a significantly lower odds ratio (OR) for more than one acute asthma medical visit in the follow-up year, after adjusting for baseline visits (total visits, 87; OR, 0.32; p = 0.03), and a comparably sized but nonsignificant OR for one or more hospitalization (OR, 0.34; p = 0.14). The follow-up CCR measurement and the determination of whether smoking was prohibited inside the home strongly favored the intervention group (n = 51) (mean difference in CCR adjusted for baseline, -0.38; p = 0.26; n = 51) (60; OR [for proportion of subjects prohibiting smoking], 0.24; p = 0.11; n = 60).
                This intervention significantly reduced asthma health-care utilization in ETS-exposed, low-income, minority children. Effects sizes for urine cotinine and proportion prohibiting smoking were moderate to large but not statistically significant, possibly the result of reduced precision due to the loss of patients to active follow-up. Improving ETS reduction interventions and understanding their mechanism of action on asthma outcomes requires further controlled trials that measure ETS exposure and behavioral and disease outcomes concurrently. Asthma is common and is often poorly controlled in adolescent subjects.
                To determine the impact of an age-specific asthma program on asthma control, particularly on exacerbations of asthma requiring emergency department treatment, and on the quality of life of adolescents with asthma.
                The present randomized, controlled trial included patients who were 15 to 20 years of age and had visited emergency departments for management of their asthma. The interventional group attended an age-specific asthma program that included assessment, education and management by a team of asthma educators, respiratory therapists and respiratory physicians. In the control group, spirometry was performed, and the patients continued to receive usual care from their regular physicians. The outcomes were assessed by a questionnaire six months after entry into the study.
                Ninety-three subjects entered the study and were randomly assigned to the intervention or control group. Of these, only 62 patients were available for review after six months. Subjects in both the control and the intervention groups showed a marked improvement in their level of asthma control, reflected primarily by a 73% reduction in the rate of emergency department attendance for asthma. Other indexes of disease control, including disease-specific quality of life, as assessed by questionnaires, were improved. There was, however, no discernible difference between the subjects in the two groups, with the exception of an improvement in favour of the intervention group in the symptom (actual difference 0.7, P=0.048) and emotional (actual difference 0.8, P=0.028) domains of the asthma quality of life questionnaire. The overall quality of life score favoured the intervention group by a clinically relevant difference of 0.6, but this difference did not reach statistical significance (P=0.06).
                Although all subjects demonstrated a significant improvement in asthma control and quality of life, the improvement attributable to this intervention was limited to two domains in disease-specific quality of life. To determine the effectiveness of a home-based asthma education intervention in increasing appropriate nebulizer use and reducing symptom frequency, emergency department (ED) visits, and hospitalizations over 12 months.
                A randomized clinical trial. Settings Pediatric primary care, pulmonary/allergy, and ED practices associated with the University of Maryland Medical System and The Johns Hopkins Hospital, Baltimore.
                Children with persistent asthma, aged 2 to 9 years, with regular nebulizer use and an ED visit or hospitalization within the past 12 months. Children were randomized into the intervention (n = 110) or control (n = 111) group. Follow-up data were available for 95 intervention and 86 control children.
                Home-based asthma education, including symptom recognition, home treatment of acute symptoms, appropriate asthma medication, and nebulizer practice.
                Estimates of mean differences in asthma symptom frequency, number of ED visits and hospitalizations and appropriate quick relief, controller medication, and nebulizer practice over 12 months.
                Of the 221 children, 181 (81.9%) completed the study. There were no significant differences in home nebulizer practice, asthma morbidity, ED visits, or hospitalizations between groups (P range, .11-.79). Although most children received appropriate nonurgent asthma care (mean, 2 visits per 6 months), more than one third of all children received at least 6 quick-relief medication prescriptions during 12 months, with no difference by group.
                A nebulizer education intervention had no effect on asthma severity or health care use. Of concern is the high quick-relief and low controller medication use in young children with asthma seen nearly every 3 months for nonurgent care. Coaching and monetary incentives have been used to modify medical behavior of individuals with several chronic diseases, including asthma. The authors performed a randomized, controlled trial of an intervention combining asthma coaching during an emergency department (ED) visit for asthma, and monetary incentive to improve follow-up with primary care providers (PCP).
                Subjects were parents of children 2-12 years of age, with Medicaid or no medical insurance, receiving treatment for asthma in the ED. The primary outcome was a verified PCP visit for asthma within two weeks of the index ED visit. All parents received 15 dollars for their time in the ED. Parents in the intervention group were told that they would receive an additional 15 dollars monetary incentive if a PCP visit was completed. The coach engaged in a dialogue with the parent during the ED visit, and discussed the importance and advantages of seeking follow-up care with the child's PCP. All parents received the usual discharge instructions, including advice to see the PCP within three days.
                The authors enrolled 92 parents; outcome data were available for 86 (42 controls, 50 intervention). Demographic characteristics were similar in both groups. There was no significant difference in the proportion of patients who had follow-up PCP visits between the intervention (22.0%; 95% confidence interval [95% CI] = 11.5% to 36.0%) and control (23.8%; 95% CI = 12.0% to 39.4%) groups (p = 0.99).
                An intervention combining asthma coaching during acute ED visits and a monetary incentive to return for a PCP visit does not appear to increase follow-up with the PCP. To improve follow-up with primary care providers after acute Emergency Department (ED) asthma visits for children from low-income urban families.
                A prospective, randomized, controlled trial evaluated combined telephone asthma coaching and monetary incentive. The primary outcome was asthma-planning visits with primary care providers within 15 days of index ED visits. The subjects were urban parents whose children were treated for asthma in the ED and had Medicaid or no insurance.
                We enrolled 527 parents (264 control and 263 intervention). There was a significant difference ( P < .0001) between the intervention (35.7%) and control (18.9%) groups in the proportion of children who had asthma-planning visits and decreased mean nights/days with asthma symptoms by 4.36 intervention and 3.31 control at 2 weeks. The proportions of children with asthma-planning visits and acute asthma care visits during the 16-day to 6-month period were similar for both groups.
                Telephone coaching and a monetary incentive significantly increased the proportion of low-income urban parents who brought their children for asthma-planning visits, and decreased asthma symptoms shortly after asthma ED visits. The intervention did not increase subsequent asthma-planning visits or decrease ED visits or hospitalizations. The effects on morbidity were examined of providing an educational intervention and a written guided self-management plan to the parents of pre-school children following a recent attendance at hospital for asthma or wheeze.
                A prospective, randomised, partially blinded, controlled trial was designed at two secondary care centres. Over a 13 month period 200 children aged 18 months to 5 years at the time of admission to a children's ward or attendance at an accident and emergency department or children's (emergency) assessment unit (A&E/CAU) with a primary diagnosis of acute severe asthma or wheezing were recruited. 101 children were randomised into the control group and received usual care and 99 were assigned to the intervention group and received: (1) a pre-school asthma booklet; (2) a written guided self-management plan; and (3) two 20 minute structured educational sessions between a specialist respiratory nurse and the parent(s) and child. Subjects were assessed at 3, 6, and 12 months. The main outcomes were GP consultation rates, hospital re-admissions, and attendances at A&E/CAU. Secondary outcomes included disability score, caregivers' quality of life, and parental knowledge of asthma.
                There were no statistically significant differences between the two groups during the 12 month follow up period for any of the main or secondary outcome measures.
                These results do not support the hypothesis that the introduction of an educational package and a written guided self-management plan to the parents of pre-school children with asthma who had recently attended hospital for troublesome asthma or wheeze reduces morbidity over the subsequent 12 months. nan To examine the effectiveness of an interdisciplinary intervention for pediatric asthma.
                Randomized, controlled study.
                Urban tertiary-referral pediatric hospital.
                One hundred seventy-five patients with asthma lacking written treatment plans and presenting with asthma-related emergency department visits (two or more) and/or hospitalizations (one or more) in the past year were randomized to a comparison group receiving medical care alone (n = 86) or to an interdisciplinary intervention group receiving medical care, asthma education, and problem-solving therapy (n = 89)
                All participants received written asthma management plans, peak flow meters, and spacer devices. The intervention group also received asthma education, an asthma risk profile assessment, brief problem-solving therapy, and access to a 24-h nurse advice line. The primary outcome measure was change in asthma symptoms, and secondary outcomes included health-care utilization and asthma-related quality of life.
                Both groups demonstrated significant reductions in asthma symptoms and improvements in quality of life without any between-group differences identified over the course of follow-up. In contrast, the intervention group demonstrated less frequent health-care utilization than the comparison group, with 28% of the intervention group requiring emergency department or inpatient services for asthma compared to 41% of the comparison group (adjusted odds ratio, 1.92; 95% confidence interval, 1.00 to 3.69) over the 12-month follow-up period.
                This study examined the effectiveness of an interdisciplinary intervention for undertreated asthma. The intervention did not result in improvements in asthma symptoms, but accomplished modest reductions in the utilization of acute medical care.
Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.