Asthma is the number one cause of pediatric emergency department (ED) visits in young children. Reliance on the ED for asthma care is costly and also is a dangerous index of poorly controlled asthma. Inhaled corticosteroids (ICS) are the cornerstone of treatment for patients with persistent asthma and can prevent exacerbations and ED visits. However, many inner city children do not receive or use recommended anti- inflammatory preventive medication often due to inconsistent follow-up after an ED visit. The overall goal of this randomized trial is to evaluate whether a standardized caregiver and physician prompting intervention, the Pediatric Asthma Alert Leader (PAAL), can improve guideline-based preventive asthma care in children with frequent ED visits as compared to children in a standard asthma education (SAE) control group. This study builds on the experience with our parent-child-primary care provider (PCP) communication intervention (Asthma Communication Education, ACE) demonstrating that nurses teaching parent and child asthma communication skills resulted in increased anti-inflammatory medication use at 6 months for children with persistent asthma. However, the intervention was not associated with appropriate PCP follow-up to sustain preventive care. The proposed intervention uses a PAAL nurse to 1) ensure child and parent attendance at the follow-up PCP visit within 4 weeks after an asthma ED visit, 2) organize and relay critical health information from the ED and home to the child's PCP at the PCP visit and 3) empower the family and prompt the PCP to provide guideline based asthma care (including ICS prescription, signed asthma action plan and scheduling a repeat PCP visit). The goals of the PAAL intervention are to improve receipt of appropriate preventive asthma care (>2 PCP visits/yr) and appropriate use of anti-inflammatory medication (>6 anti-inflammatory refills/yr) (AIM 1), improve asthma outcomes (symptom days and nights, quality of life) (AIM2), and establish the cost effectiveness of the intervention (AIM 3). Families of 300 children ages 3-10 years with mild persistent to severe persistent asthma and >2 ED visits or >1 hospitalization for asthma over the past year will be recruited from two large urban pediatric EDs, enrolled, randomized into the PAAL or SAE and followed for 12 months. Primary outcomes are number of non-urgent asthma visits and anti-inflammatory prescription refill rates. Data analysis will include chi-square, t-tests, ANOVA and multivariate linear regression models to compare outcomes between the two groups. Bivariate and multivariate parametric techniques will be used to compare costs and effectiveness of care between the PAAL and SAE groups. If successful, this relatively simple and reimbursable intervention could be widely applicable for asthma care in urban practices.

Public Health Relevance

Young inner-city children with asthma have the highest emergency department (ED) visit rates. Relying on the emergency department for asthma care can be a dangerous sign of poorly controlled asthma. This research will focus on whether having a specialized asthma nurse join the family at a child's doctor visit after an ED visit for asthma to make sure the child and parent keep the follow-up appointment and have the nurse remind the child's doctor to prescribe preventive asthma medicines and an asthma action plan for home will result in young children with asthma having fewer days with wheezing and cough.

National Institute of Health (NIH)
National Institute of Nursing Research (NINR)
Research Project (R01)
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Nursing Science: Children and Families Study Section (NSCF)
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Hardy, Lynda R
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Johns Hopkins University
Schools of Medicine
United States
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