In-Home Asthma Treatment Improves Adults' Control

Marcia Frellick

November 26, 2014

Low-income adults with uncontrolled asthma had improved control and quality of life when they received five home visits per year by community health workers, according to study results published online November 24 in JAMA Internal Medicine.

James Krieger, MD, MPH, from Public Health–Seattle and King County in Washington, and colleagues studied 366 participants from King County with uncontrolled asthma: 177 who received the intervention, which included education, service, and care coordination by community health workers, and 189 who received usual care.

The intervention group had significantly greater increases in symptom-free days (2.02 days [95% confidence interval, 0.94 - 3.09 days; P < .001] more for every 2 weeks) and quality of life, as measured by the Mini Asthma Quality of Life Questionnaire, which increased an average of 0.50 points (95% confidence interval, 0.28 - 0.71 points; P < .001).

However, the intervention did not result in a significant decrease in use of urgent care. Urgent care episodes during the last 12 months decreased similarly in both groups from 3.46 to 1.99 episodes, on average, in the intervention group and from 3.30 to 1.96 episodes in the control group. The intervention cost about $1300 (in 2013 US dollars) per participant, which is substantially less than a 1-year supply of an inhaled corticosteroid, the researchers note.

In an invited commentary, Harrison J. Alter, MD, from the Alameda Health System in Oakland, California, writes that he was impressed with the results, especially considering that the target population of working-poor patients who have moderate to severe asthma is typically hard to help achieve control.

He writes that the lack of a reduction in urgent medical care to offset the intervention cost should not overshadow the benefits.

"[I]t may be time to pry ourselves loose from such a strict definition of success," he writes.

"The main purpose of our care should not be to reduce medical care use. Sometimes, in daily practice, it can feel as though certain actors in our system wish it were so. We cannot, as clinicians, investigators, teachers, healers, ignore the reality of the importance of this goal. But if in every medical effort we turn to check its effect on the system, we may find ourselves turning away from the patient," Dr Alter concludes.

The community health workers provided education and support and coordinated services during their visits. They were full-time employees recruited from the area served and had high school or equivalent (general education development) degrees. They were native Spanish-speakers and had personal experience with asthma. They received 80 hours of classroom training, followed by biweekly training.

In addition to their enhanced care and follow-up communications, intervention participants received tools such as allergen-impermeable bed casements and a low-emission vacuum cleaner. Those with furry and/or feathered pets and nonsmokers who were exposed to second-hand smoke received high-efficiency particulate air filters.

"We anticipate that this intervention could be readily replicated by health organizations serving diverse, low-income clients, suggesting that it could reduce asthma-related health inequities," study authors conclude.

This study was supported by the National Institutes of Health/National Institute of Environmental Health Sciences and the National Center for Advancing Translational Sciences. The authors have disclosed no relevant financial relationships. Dr Alter owns less than $50,000 stock in Gilead Sciences.

JAMA Intern Med. Published online November 24, 2014. Abstract

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