Few interventions to improve asthma management have targeted low-income minority adults and even fewer have focused on the real-world practice where care is provided for these patients. We adapted a patient navigator, here called a Patient Advocate (PA), a term preferred by patients, as a means of facilitating and maintaining access to chronic care for adults with moderate or severe asthma and prevalent chronic morbidities recruited from clinics serving low-income urban neighborhoods. The intervention, informed by focus groups of patients and providers, activates and empowers both groups, integrating activities with proven efficacy. Its feasibility and acceptability were demonstrated in RC1 HL099612 this project, implemented in a variety of practices, tests its comparative effectiveness and cost effectiveness. Our PA coaches, models, and assists with preparations for a visit with the asthma doctor attends the visit with permission of participant and provider and confirms understanding. The PA facilitates scheduling, obtaining insurance coverage, overcoming patients'unique social and administrative barriers to carrying out medical advice, and transfer of information between providers and patients. PA activities are individualized, multimodal, take account of comorbidities, and are generalizable to other chronic diseases. The PAs, highly valued by patients in RC1HL099612, are recent college graduates interested in health-related or education careers, research experience, working with patients, and generally having the same race/ethnicity distribution as potential subjects. We will enroll 300 adults wit moderate-severe asthma into a randomized clinical trial testing whether the PA intervention, compared to usual care, is associated with better and sustained asthma control (Specific Aim 1) and other asthma outcomes (prednisone bursts, ED visits, hospitalizations, quality of life, FEV1) (Specific Aim 2) relative to baseline. Secondary aims will assess mediators and moderators of the PA-asthma outcome relationship.
Specific Aim 3 evaluates the intervention's cost-effectiveness. We will explore intervention's impact on providers in post-study focus groups. This proposal is innovative and significant because it 1) compares the effectiveness of the PA to usual care, 2) focuses on inner-city low-income predominantly minority adults who experience high asthma morbidity, 3) uses a real-world behavioral intervention tested for sustainability in an RCT design, 4) tests a multi-faceted individualized intervention which considers comorbidities as it provides a model of chronic asthma management and is thus generalizable to patients with other chronic diseases and comorbidities, 5) examines patient-provider communication, 6) uses a unique PA, 7) considers both English- and Spanish-speaking patients, and 8) assesses the cost-effectiveness of the intervention relative to UC.

Public Health Relevance

Few interventions to improve asthma management have targeted low-income minority asthmatic adults and even fewer have focused on the real-world practice where care is provided for these patients. This project tests the effectiveness of a Patient Advocate as a practical and sustainable method of facilitating and maintaining communication between patient and provider and access to chronic care for adults with moderate or severe asthma recruited from clinics serving low-income urban neighborhoods. We compare the use of a Patient Advocate to current asthma care and test the Patient Advocate's cost-effectiveness.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Demonstration and Dissemination Projects (R18)
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Special Emphasis Panel (ZHL1-CSR-K (O1))
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Freemer, Michelle M,
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University of Pennsylvania
Internal Medicine/Medicine
Schools of Medicine
United States
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Localio, Anna M; Black, Heather L; Park, Hami et al. (2018) Filling the patient-provider knowledge gap: a patient advocate to address asthma care and self-management barriers. J Asthma :1-10
Korwin, Amy; Black, Heather; Perez, Luzmercy et al. (2017) Exploring Patient Engagement: A Qualitative Analysis of Low-Income Urban Participants in Asthma Research. J Allergy Clin Immunol Pract 5:1625-1631.e2
Apter, Andrea J; Morales, Knashawn H; Han, Xiaoyan et al. (2017) A patient advocate to facilitate access and improve communication, care, and outcomes in adults with moderate or severe asthma: Rationale, design, and methods of a randomized controlled trial. Contemp Clin Trials 56:34-45
Perez, Luzmercy; Morales, Knashawn H; Klusaritz, Heather et al. (2016) A health care navigation tool assesses asthma self-management and health literacy. J Allergy Clin Immunol 138:1593-1599.e3
Apter, Andrea J (2015) Understanding adherence requires pragmatic trials: lessons from pediatric asthma. JAMA Pediatr 169:310-1