A Multicomponent, Multi-Trigger Intervention to Enhance Asthma Control in High-Risk African American Children

Mark H. Ebell, MD, MS; Stephanie Patrice Hall, PhD, MPH; R. Chris Rustin, DrPH; Kia Powell-Threets, MS; Luis Munoz; Kia Toodle; (Mary) Lu Meng, PhD; Jean O'Connor, JD, MPH, DrPH

Disclosures

Prev Chronic Dis. 2019;16(5):e69 

In This Article

Discussion

This pilot project provided a MCMT intervention to 23 children who were dually enrolled in CMS and Medicaid in a single public health district and who had asthma that was either not well controlled or very poorly controlled. Compared with the baseline assessment, the follow-up assessment of the MCMT intervention found that parents reported clinically and statistically significant improvements in asthma control, frequency of nighttime awakenings, and activity limitations. In addition, they reported significantly fewer days of school missed (1.4 vs 3.3) and fewer emergency department visits (0.27 vs 0.95) at follow-up. While fewer hospitalizations were reported at 12 months follow-up, this finding was not significant. These findings are consistent with those in a previous systematic review,[9] and are notable for having been implemented in a real world setting without research staff and in a very high-risk population.

The study had several limitations. First, it is a small and nonrepresentative sample of all children with asthma. However, we believe it does reflect a critical population that experiences a substantial burden of disease, namely African American children with poorly controlled asthma who live in poverty. Second, the reliance on parental self-report is another limitation and is subject to optimistic bias (parents may wish to please the interviewers by reporting positive results). Third, the absence of a control or comparison group is an important limitation. Finally, we had missing data, which is the result of doing a pragmatic study in a real-world setting executed by a staff without extensive research training.

To address these limitations, a larger trial is warranted, perhaps using a stepped-wedge design to compare results in treated and untreated homes. Additional study in the Medicaid managed care population is also needed, and a larger pilot project with 100 children is under way at the Georgia Department of Public Health. Longer term studies are also needed to evaluate the persistence of the intervention and whether changes in medication use and environmental improvements persist over time.

There is a gap between what is effective to control asthma and what is routine practice in community and clinical settings. MCMT interventions are multisectoral by definition, presenting challenges for implementation in real-world settings. Public health departments, while theoretically well positioned to lead the charge of bringing together clinical, environmental, housing, and educational supports with payors to promote the control of chronic conditions at the community level, often face the realities of limited resources, high staff turnover, limited leadership capacity, and hard-to-reach populations with severe health conditions. Our study team found that despite extremely limited resources, state and local health departments can collaborate together and with the Medicaid program to not only implement the program but to achieve what appear to be promising outcomes. In a state where pediatric asthma mortality is a considerable concern, and where outcomes for pediatric asthma are strongly divided along racial and economic lines,[8] the modest success of this project should serve as an important lesson learned for other states, regardless of Medicaid expansion status. Furthermore, the project demonstrated that collaboration between nursing, chronic disease prevention, and environmental health professionals was feasible to jointly address pediatric asthma. However, considerable resources were expended on developing the methodology for the project to be applied in a real-world setting, and more practical guidance for state and local health departments on the implementation of MCMT interventions in real-world settings is needed. Adequate resources for further testing of widespread implementation of MCMT interventions for appropriate populations is needed, as is reimbursement for the interventions through Medicaid of the service delivery providers, including public health departments, if the efforts are to be sustainable.

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