Community Collaboration Improves Asthma Control

Tara Haelle

April 04, 2018

A community-level intervention for patients with asthma led to substantially reduced short-acting beta agonist (SABA) inhaler use and increased participants' symptom-free days, according to a pragmatic single-group study published April 2 in Health Affairs.

The study assessed a citywide digital health intervention developed through a private–public–nonprofit collaborative to reduce asthma morbidity in Louisville, Kentucky. The intervention involved analyzing aggregated inhaler use data for participating patients with asthma, determining environmental triggers, using findings to guide policy recommendations, and implementing interventions at a city level.

"Among participants with twelve months of follow-up, there was a 78 percent reduction in SABA use, an 84 percent reduction in nighttime SABA use, and a 48 percent improvement in symptom-free days from baseline to month 12," report Meredith Barrett, PhD, vice president of research at Propeller Health, San Francisco, California, and associates with the AIR Louisville Collaborative.

"This study demonstrates how digital technology can quantify some of the factors that trigger asthma," Len Horovitz, MD, a pulmonary specialist at Lenox Hill Hospital in New York City, who was not involved with the study, told Medscape Medical News. For example, "traffic routes that produced pollution in greater amount could be correlated with increased inhaler use."

Both self-awareness and self-efficacy likely contributed to the improved outcomes, while also providing stronger patient–provider communication and an opportunity for early intervention before a severe asthma attack.

"When you collaborate and bring in the right stakeholders, who can properly collect data and interpret [them] in a way that is meaningful for patients, give patients tools that are appropriate for managing their condition, and measure all that and what it means, you can have good outcomes," said Albert Rizzo, MD section chief of Christiana Care Health System's Division of Pulmonary and Critical Care Medicine, Wilmington, Delaware, and senior medical advisor the American Lung Association.

But that's no small task, said Rizzo, who was not involved in the study.

"It shows what you can do when you put a lot of resources into it," Rizzo told Medscape Medical News. But the requirement for a lot of parts and resources will likely make it difficult to replicate elsewhere. "It's a lot of moving parts. It's a good study, a big study, with good results, but a lot of work went into it."

Patients' use of an asthma management app were also key to providing them with ongoing education and reeducation that isn't easily achievable in the current healthcare system.

"Patients don't always have the resources to get the access to care, get the right medications, and be told how to use those medications appropriately," contributing to problems with compliance and appropriate medication use, Rizzo said. "Patients feel good in between treatments, so they don't use the control medication as often as they should."

Louisville frequently falls short of national air quality standards for sulfur dioxide and fine particulate matter, largely because of the combination of nearby coal power plants, temperature inversions that trap pollution near ground level, and use of cars as primary transportation in the city, Barrett and colleagues note.

Countywide asthma hospitalizations cost $26 million in 2015, and Louisville "is consistently ranked among the most challenging US cities in which to live with asthma," they add.

However, the 2010 election of a mayor whose platform emphasized "innovation" led to a collaboration involving the city government; the local nonprofit Healthy Air, Water, and Soil; and Propeller Health, a digital health business based in Madison, Wisconsin. The AIR Louisville collaboration began with a pilot study from 2012 to 2014 that resulted in improved outcomes among city residents with asthma. That success then led to a larger 2.5-year study funded by the Robert Wood Johnson Foundation.

"[The foundation] challenged the collaborative team to make AIR Louisville more inclusive and more relevant to local business leaders and municipal stakeholders by bringing to the table diverse partners with a vested financial and social interest in Louisville," the authors write. "AIR Louisville's objectives were to help people control their symptoms, identify hot spots of respiratory disease symptoms and their environmental correlates, use the collected data to guide policy decisions, increase community awareness of air quality and health, and engage diverse local partners to make the collaboration sustainable."

Each partner in the initiative had a specific role. A municipal office managed city department coordination for the collaborative, whereas Propeller Health managed and analyzed data from the digital health platform. The nonprofit's role involved both community outreach and the recruitment and communication coordination among program partners, including seven local employers, a Medicaid insurer, and three provider practices.

To determine neighborhoods likely to benefit most from a targeted intervention, the collaborators looked at areas with the greatest asthma prevalence and severity, highest air pollution, lowest tree density, highest impervious surface, and highest temperature. Participants were recruited between March 2015 and September 2016 through clinics, community events, print and digital media, employers, and social media. They needed to reside or work in Jefferson County, be at least 4 years old, have a self-reported asthma diagnosis, and have a current SABA prescription.

Each participant received sensors that paired with their inhalers, monitored the time and date of their use, and then transmitted this information over a Bluetooth connection to their smartphone. The smartphone identified the location and sent all the data to HIPAA-compliant servers. (Those without smartphones were given wireless hub devices.)

Meanwhile, the app patients used encouraged "self-management by providing information about their level of asthma control and adherence, learning about potential environmental triggers, and receiving guidelines-based education," the authors explain. "Participants could authorize health care providers to view their data and summary reports through a secure web dashboard to inform clinical treatment, such as medication adjustments or early intervention at the sign of acutely increasing SABA use."

Among the 497 participants who used the inhaler sensors for at least 60 days, mean age was 38 years, with a range from 4 to 90 years. Eighty percent were adults, 61% were white, 25% were black, and 63% were female. More than half the participants' asthma was poorly controlled, with a 14.7 mean adult control score on the Asthma Control Test. During the study, participants used their rescue inhalers 34,870 times.

Both daytime and nighttime use of SABA gradually declined, from an average 0.76 daytime events and 0.29 nighttime events per person per day in the first week to 0.18 and 0.05, respectively, after a year. The proportion of symptom-free days increased from 62% the first week to 90% after a year.

In addition, feedback from 57 participants revealed that 80% were satisfied with the sensor, 86% said they understood their asthma better, 81% felt more confident about avoiding a severe asthma attack, and 56% said they spoke with their healthcare provider about the data their inhaler sensor collected.

"Those outcomes tell you that you're doing quality care," Rizzo told Medscape News. "If a patient isn't waking up in the night with cough and shortness of breath, that's good asthma control. If they're able to participate in tennis or swimming or things they want to do without being hampered by wheezing or an asthma attack, that's good asthma control."

Identifying High-Risk Areas

AIR Louisville then used the spatial distribution data of inhaler use to create a density map showing hot spots with the greatest use of SABA. Each data point included the location's weather and air quality conditions so the researchers could analyze environmental predictors of SABA use, accounting for weather, participants' age and sex, and a "neighborhood-level social vulnerability" index score.

The three densest hot spots of SABA use were areas with industrial activity, high pollution, and high road traffic. Because the hot spots had greater urban heat and pollution than elsewhere in the city, AIR Louisville decided planting more trees in those areas could reduce heat and filter air pollution.

The city held two summits with city officials, program stakeholders, public school health representatives, local university researchers, and representatives from other cities with similar challenges (Knoxville, Tennessee; Pittsburgh, Pennsylvania; and Portland, Oregon) to incorporate feedback into eventual policy recommendations. Those recommendations included requiring 45% replacement of trees removed during land development and updated zoning rules that create buffers between emission sources and housing, schools, and daycares. Further follow-up projects are planned as well.

"The connections built with city agency leaders through AIR Louisville have enabled other conversations with nonprofits, local businesses, and health systems about innovative solutions to stubborn health problems," paving the way toward potential cooperation with other initiatives, the authors report.

"At a time of growing government mistrust, collaborative efforts such as AIR Louisville may help repair relationships."

The benefits of AIR Louisville would likely extend to those with other chronic lung disease, such as chronic obstructive pulmonary disease, Rizzo told Medscape Medical News, but its success does not mean it would work anywhere.

"It shows if you identify a trigger and mitigate that trigger, you get better asthma results for asthma control. But what's the ability to do all those things?" Rizzo said. Planting trees may not be an adequate solution elsewhere, or the best solutions may not be feasible.

In addition to being resource-intensive, other communities may not see benefits as substantial as those in Louisville if they already have less pollution and cleaner air, unlike the poor air quality in Louisville that had more room for improvement.

"Some of these factors could be replicated in other cities, although it is unclear the degree of benefit that would be obtained," Horovitz told Medscape Medical News.

Still, the authors perceive opportunities for replicating aspects of this model in other cities and at the federal level.

"There is growing interest in this type of model, and we plan to replicate this model in other regions to strengthen the evidence for local and national policy making," the authors write.

The success of such models will necessarily rely on the enthusiasm and dedication of key people involved, Rizzo told Medscape Medical News.

"Each of these aspects of this in Louisville had to have a couple champions in key areas that pushed this forward," Rizzo said. "You can collaborate and coordinate, but unless someone ties it together, makes it meaningful, and takes on the responsibility to move it forward, you're not going to get the results you want.

The research was funded by the Robert Wood Johnson Foundation, American Lung Association, Foundation for a Healthy Kentucky, Norton Healthcare Foundation, and Owsley Brown II Family Foundation. However, the collaboration involved a range of community and business partners. Three of the five named authors are paid employees of Propeller Health. The other authors have disclosed no relevant financial relationships.

Health Aff. 2018;37:525-534. Abstract

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