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Innovations : reducingasthmadisparities

Clinical Innovations

Title: Reducing Asthma Disparities (RAD)

 

Organization: Baltimore City Health Department 

Innovation Type: Community Based Chronic Disease Management 

What we’re doing: Providing an evidence-based 6-session home visiting program for persistent asthmatic children in Baltimore to reduce home environmental asthma triggers and increase medication adherence.

Clinical innovation: The Reducing Asthma Disparities (RAD) Program targeted over 200 Baltimore school aged persistent asthmatics, identified by school nurses, health care providers and emergency departments for home based, individualized assessments and interventions.  The CDC-funded program was modeled on the successful Seattle King County Asthma Program[i]  and included six Baltimore specific adaptations.   After an initial interview and room-by-room asthma trigger assessment of the family’s home, staff and caregivers developed an individualized plan to reduce/eliminate home asthma triggers and to improve the child’s adherence to asthma medication and medical follow-up.  Information from observations and individualized plans were faxed to the child’s primary care provider following every visit.  The program provided families with bedding and pillow covers, cleaning supplies, and a vacuum cleaner.  Staff worked with providers to ensure that each child had an Asthma Action Plan, appropriate medication (controller and rescue) at home and school, and knew how to properly administer the medication. The program included six home visits in a one year period, ending with another interview and room-by-room assessment of the home at one-year.  

Evaluation Type:  Quasi-experimental

Evaluation Plan: Compare initial and one year medical histories, visual assessments, and Emergency Department and hospitalization costs. 

Outcomes:   

For 102 children who completed the program there were statistically significant (p=0.0001) decreases in asthma symptoms and Emergency Department (ED) visits:

·         days with asthma symptoms in past 14 days - ↓ 1.9 days

·         nights with asthma symptoms in past 14 days - ↓ 2.0 days

·         days had to stop usual activity in past 14 days - ↓ 2.0 days

·         days using rescue medication in past 14 days - ↓ 2.6 days

·         ED visits in past year - ↓ 1.0 visit

There was also an increase in use of controller medication by 1.3 days in the past 2 weeks but it was not statically significant (p=0.09).

There was a significant decrease in the number of hospitalizations (p=0.02).

Potential for cost savings

Using average Maryland Medicaid costs for hospitalizations and ED visits (2011), and comparing the costs for one year prior to enrollment to one year post enrollment for 102 children with the costs for Baltimore’s asthma home visiting program, we estimate:

Costs averted (hospitalizations & ED visits) = $172,364  ($1,690/child)

Home visiting program costs = $141,372 ($1,386/child)

Potential cost-savings for third-party payers = $30,992 ($304/child)

These results are consistent with other studies showing the cost effectiveness of asthma home visiting programs [2,3].  Krieger et al (2005)1 in a randomized clinical trial reported program costs of $1,316 per participant and direct medical costs averted were $124-$147 per participant. In the RAD program outcome measures are based on patient reports rather than medical records.  We will investigate outcomes for program participants and a selection of matched controls using Medicaid claims data later in 2012.

RAD enrollment closed in 2011.  Additional resources are needed to provide effective home-based, multi-trigger, multi-component interventions, such as this home-visiting program, to communities with high childhood asthma burdens [4, 5]. Securing funding for asthma home visiting services in Maryland would be a good first step in ensuring adequate community resources to address health disparities in childhood asthma for Maryland’s children.[vi]  The RAD program might be a good fit for patient-centered medical homes, particularly those serving large populations of children with asthma. 

Population Served:  Baltimore City public school children, aged 4-18 (95% African American, 63% male, average age at enrollment 8.7 years).  Average family size 4.4 persons (SD = 1.5), with an average of 2 persons with asthma (SD = 1.2).

Date of Implementation:  2009 - 2012

Contact:  Kate Scott, Asthma Program Director, Baltimore City Health Department kate.scott@baltimorecity.gov



[1] Krieger JW, Takaro TK, Song L, Weaver M. The Seattle–King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health 2005; 95(4):652–9.

[2] Crocker DD, Kinyota S, Dumitru GG, et al. Effectiveness of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity: a Community Guide systematic review. Am J Prev Med 2011;41(2S1): S5–S32.

[3] Nurmagambetov TA, Barnett SBL, Jacob V, et al. Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity: a Community Guide systematic review. Am J Prev Med 2011;41(2S1):S33–S47.

[4] Task Force on Community Preventive Services. Recommendations from the Task Force on Community Preventive Services to decrease asthma morbidity through home-based, multi-trigger, multicomponent interventions. Am J Prev Med 2011;41(2S1):S1–S4.

[5] Krieger J. Home visits for asthma: we cannot afford to wait any longer. Arch Pediatr Adolesc Med 2009;163(3):279–81.

[6] Krieger JW, Philby ML, Brooks, MZ.  Better home visits for asthma; lessons learned from the Seattle-King County Asthma Program. Am J Prev Med 2011;41(2S1):S48–S51.