Asthma in America
The California Childhood
Asthma Initiative
David Núñ
ez, MD, MPH
Núñez,
California Department of Health Services
Academy Health Research Meeting
June 25, 2006
¾ Affects 9 million children &
adolescents
¾ Most common chronic childhood disease
¾ Among leading causes of pediatric
hospitalization and emergency (ED) visits
¾ Poor control associated with:
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z
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nocturnal symptoms
activity limitations/school absences
behavioral and school problems
Asthma Disparities
Impact Young Children
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¾
¾
Highest rates of asthma
hospitalization and ED
visits in children under
age 5
Effective secondary
prevention measures
underutilized (education,
controller meds,
environmental trigger
reduction)
Worst disparities affect
blacks and Latinos, low
SES, Medicaid and
uninsured
Effective Interventions?
CA 2004 Asthma Discharges
(per 10,000 Residents)
70
60
50
40
30
20
10
0
0 to 5
6 to 11
12 to 18
> 18
Age Group (yrs)
All race/ethnicity
¾ NCICAS: Care coordination by MSWs –
proven efficacy for schoolschool-aged, innerinner-city
children1
¾ No published interventions utilizing care
coordination in younger children
¾ Could asthma care coordination reduce
asthma morbidity and disparities in this
younger age group?
Blacks
1National
Intervention Design
Childhood Asthma Initiative (CAI)
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Target: children aged 00-5 years with asthma
Goal: reduce asthma morbidity & improve QOL
Eight rural & urban community projects selected
Multiple components of 3.53.5-year initiative:
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¾
Community coalition support
Clinical quality improvement collaboratives
Asthma Coordinator (AC) services
Funded by First 5 California – state tobacco tax
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$3.3 million for AC services ($2.5 million local
assistance)
Cooperative Inner-city Asthma Study. J Pediatr 1999; 35:332-338
¾ NonNon-experimental, public health service
program
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NonNon-research – no control group
No IRB/informed consent
¾ Open to all children aged 00-5 years with
asthma residing in CAI project county
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93% physician diagnosed asthma at enrollment
¾ Primary referral sources:
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Physicians
Community agencies
1
Asthma Coordinators
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ClinicClinic-based or community organization based
Varied professional backgrounds
NAEPP* based training to provide/reinforce:
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¾
Family asthma education
Use of asthma action plan
SelfSelf-management skills/medication use
Home environment assessment and advice
Coordinated care with health providers
Referrals (e.g. social services agencies, smoking
cessation, insurance)
2 ACs/site – all sites provided Spanish services
AC Parent/Caregiver Contacts
¾ Home
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z
visits – all 8 sites
Initial visit from 45 min. to 3 hrs.
2-4 followfollow-up visits from 45 min. to 2 hrs.
¾ ClinicClinic-based visits – 4 sites
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z
Initial visit from 45 min. to 2 hrs.
1-3 followfollow-up visits from 15 min. to 1 hr.
¾ Additional phone and written contacts
¾ Average total contacts/child
=6
¾ Average length of enrollment = 8 months
*National Asthma Education and Prevention Program, NIH
Measuring Effectiveness
¾
Parent/guardian interview conducted in English
and Spanish
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Enrollment
6-month intervals and/or graduation
Symptoms – prior 2 weeks
Management (tobacco smoke exp, AAP, meds)
ED/hosp/urgent care utilization – prior 6 months
Child missed preschool – prior 4 weeks
Parent missed school/work – prior 4 weeks
QOL – 5 caregiver questions* using Likert scale
Analysis
¾ Outcome variables compared between 1st
and last interviews (results not matched by
individual child)
¾ Chi square test for strength of association
¾ QOL items summed, normalized to
composite Likert scale
¾ Multivariate analyses (GEE) to compute
odds ratios and assess effect of individual
variables on measured outcomes
*Adapted from Juniper Paediatric Asthma Caregiver’s QOL Questionnaire
Evaluation Group
Characteristics
Participants
¾
Total enrollment 2,460 children
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¾
1,691 (69%) graduated
171 (7%) actively enrolled at program conclusion
297 (12%) discontinued services
301 (12%) lost to followfollow-up
Evaluation group
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1,920 (78%) completed 2 or more interviews*
Compared to unevaluated cohort:
• Higher percentage Hispanics: 74% vs. 66%
• Lower percentage blacks: 12% vs. 22%
Mean age
2.6 years
Male
64%
Hispanic
74%
Black
12%
Rural residents
66%
Insured
91% (67% Medicaid)
*2 interviews 54%; 3 interviews 23%; 4-5 interviews 1%
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Accomplishments: Changes in
Asthma Management*
Changes in Asthma Symptoms*
and Health Care Utilization*
80%
100%
80%
60%
60%
40%
40%
20%
20%
0%
ETS exposed
Asthma Plan
Frequent Use
Taking
Quick-relief Controller Med
Med
Enrollment interview
0%
Daytime
Symptoms
Enrollment interview
Final interview
*All changes significant at p <0.0001
z
4.0
z
3.0
40%
z
2.0
1.0
0.0
Enrollment interview
Improved care practices
Significant reductions in hospital and
ED/urgent care (potential cost savings)
Improved activity and QOL measures
¾ Asthma care coordination
20%
Parent Missed Work or
School
Final interview
Conclusions
60%
Child Missed
Preschool
Hospital
Care
¾ Regardless of individual race or ethnicity:
5.0
0%
ED Visits
*All changes significant at p <0.0001
Changes in Missed Activities* and
Quality of Life*
80%
Nighttime Urgent Care
Symptoms
Mean QOL Score
may be an
effective model for reducing early
childhood asthma disparities
Final interview
*All changes significant at p <0.0001
Implications for Policy and
Clinical Practice
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Culturally and linguistically appropriate services
are essential
Sustainability dependent upon:
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Standardized AC training
AC integration with medical home and quality
improvement process
Developing reimbursement strategies
Additional costcost-effectiveness data
Need timely, consistent quality and outcome
data that include race/ethnicity
Additional information available at: www.dhs.ca.gov/ps/cdic/caphi/CAI.htm
or via email to: dnunez@dhs.ca.gov
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