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Disclosure: Pappalardo reports that he serves on the Chicago Asthma Consortium Board of Directors and the Sanofi and Takeda Medical Advisory Boards; as a consultant for OptumRx/United Health Group; and travel support from the Asthma and Allergy Foundation of America for speaking engagement at the 2019 US Asthma Summit. Please see the study for relevant financial disclosures by all other authors.
The central theses:
- Community health services have been associated with improvements in inhaler technique, inhaled corticosteroid ownership, and adherence compared to certified asthma education services.
- Improvements in inhalation technique were sustained through 24 months in children receiving services from community health workers.
- Systemic and policy changes in health care are needed to improve outcomes related to environmental exposures that trigger asthma.
Visits from a community health worker were associated with improved medication use and inhaler technique among urban children with asthma, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
However, changes in health policy are needed to support sustained improved outcomes for these children, the researchers wrote.
“This study was designed to try to reduce health disparities in asthma,” Andrea A Pappalardo, MD, FAAAAI, FACAAI, Assistant Professor of Medicine and Pediatrics at the University of Illinois at Chicago, Healio said.
Andrea A Pappalardo
“Many factors contribute to asthma health inequalities, making low-income urban children less likely to receive guideline-based asthma treatment,” she continued. “We know that self-management support can help, but how to implement self-management support in real-world environments wasn’t clear.”
Study design and methods
The Asthma Action at Erie study recruited 223 children aged 5 to 16 years (mean age 9.4 years; standard deviation 3) with uncontrolled asthma attending a Federally Qualified Health Center in the Chicago area. In addition, 85.2% of these patients were Hispanic and 44% were girls.
During the baseline assessment, researchers collected information about each child’s demographics, asthma symptoms and history, medication, inhaler technique, triggers, psychosocial factors, and other data.
Data collection was repeated in each patient at home after 6, 12 and 24 months and by telephone after 18 months. Monthly phone calls collected updates on hospitalizations, ED and ER visits, and oral corticosteroid breakouts.
The researchers also hired and trained a certified asthma educator (AE-C) and two community health workers (CHWs), all of whom were bilingual in English and Spanish.
“The practical value of both CHWs and AE-Cs is well known to those who have worked in the community asthma and allergy field for years,” said Pappalardo.
Within a month of enrollment and again at 6 months, the 108 children in the AE-C arm were offered a 1-hour health center session that addressed asthma symptoms, control, medications, compliance, technique, triggers, action plans and many more concerns of the caregiver or the child, with telephone follow-up 2 weeks after each session.
The 115 children in the CHW arm were offered 10 visits over a 12-month period, mostly at home. These visits focused on the same asthma issues, the researchers said, but were flexible to cover specific needs and to include behavior change plans, in addition to identifying triggers in the home and discussing how to change them.
Families in the CHW group had a median of seven visits (interquartile range, 4), while 49% of the AE-C group received no interventions, 29% had one session, and 22% had two sessions. Costs included $74 per CHW visit and $135 per AE-C session.
Previous analysis of the study’s results showed that the CHW and AE-C groups achieved similar results in asthma control, which Pappalardo said was surprising given that the CHWs had much more contact with families. The current analysis examined the impact of the intervention on adherence, inhalation technique, and trigger reduction at home.
At 6 months, the CHW group had a 9.8% improvement in inhalation technique (95% CI, 4.2% – 15.32%) that persisted after the end of the intervention. But the medication technique in the AE-C deteriorated (P = 0.013), resulting in a difference of 13.4% (95% CI, 7.8% – 18.9%) between the groups at 12 months. At 24 months, the difference was 10% (95% CI, 4.7% – 15.3%), which the researchers called significant.
While 44.4% of the children received an inhaled corticosteroid (ICS) at home at baseline, 56% of the CHW group and 35% of the AE-C group had an ICS at home at 12 months (OR = 2.39; 95 %CI, 0.99-5.79), although this effect did not persist at 24 months (OR=1.52; 95%CI, 0.59-3.92).
In an adjusted model, the CHS group had improved ICS adherence at 12 months, but the AE-C group did not, with a 16% (95% CI, 2.3%-29.7%) difference between the groups, although both arms were similar again at 24 months.
“This secondary analysis showed, as we expected, that the CHW intervention was associated with improved asthma therapy adherence and better inhaler technique,” said Pappalardo.
“When we ended the intervention, behavior worsened, suggesting that further CHW services are needed to maintain medication adherence and correct inhalation technique,” she continued.
Aside from improvements in exposure to strong odors in both the CHW group (OR=0.25; 95% CI, 0.13-0.47) and the AE-C group (OR=0.38; 95% CI, 0.19-0.78) At 24 months, the researchers continued, there were no meaningful changes in trigger exposures in either group.
Although families change triggers that they can control, the researchers found that many triggers are related to housing, infrastructure, and other factors beyond their control that require public health changes at the systemic and policy levels.
Still, the researchers said that CHW interventions directly linked to a medical system can improve the presence and adherence to ICS treatment in children with asthma living in urban settings. However, replicating these results can be difficult.
“Many states do not have formal certification for CHWs, making it difficult to standardize,” Pappalardo said. “Clinical groups should follow best practices for training and recruiting CHW as outlined in the CHW Core Consensus Project.”
For more informations:
Andrea A Pappalardo, MD, FAAAAI, FACAAI, can be reached at [email protected]