Puerto Rican children have the highest rates of asthma morbidity of any etnic group and are more likely to die because of their asthma as compared with other children. In Puerto Rico gross disparities exist in the quality of asthma care received by poor asthmatic children compared to higher income children. As described by the Institute of Medicine, such health disparities likely result from multi-level barriers to appropriate care. Based on a conceptual model of health disparities developed by this investigative group, we propose to evaluate the effectiveness of the Pediatric Asthma Community- Based Program (PACBP), a novel, multi-level intervention designed to eliminate asthma disparities in treatment by intervening at the health policy, provider, and family level.
Aim 1 will use a non-experimental pre-post comparison design to assess a historic change in medication policy (i.e., the state assuming responsibility for the cost of medication) in a pilot health region in Puerto Rico. We will use automated claims and pharmacy data one year prior to and one-and-a-half years post policy change to compare pharmacy dispensing of antiinflammatory controller medications (ACMs), oral steroids and beta agonists (primary outcome), as well as rates of Emergency Department (ED) visits and hospital admissions (secondary outcomes) in children with persistent asthma.To examine the impact of change at the provider level, Aim 2 will use a randomized control trial (RCT) design nested within the pilot region to study the impact of a culturally-adapted version of the Easy Breather Program ( EBP), a provider-focused educational intervention designed to increase guideline-based care. Using claims data, we will compare rates of ACM dispensing (primary outcome), as well as beta-agonist and oral steroid dispensing. We will also compare chart audits of guideline-based care, and provider surveys of asthma management practices. To examine the impact of change at the family level, Aim 3 will use a RCT to test a family-based asthma management intervention (FAMI), nested in clinics of the Pilot region that received the EBP. This intervention is designed to increase family knowledge, skills and self-efficacy for asthma management. The primary outcome variable for the FAMI study is symptomfree days. Secondary outcomes include ACM use and quality of life, as well ED visits and hospital admissions, beta agonist and oral steroids use, and functional disability. Finally, Aim 4 will evaluate the costeffectiveness of each level of the Pediatric Asthma Community-Based Program (PACBP). The proposed study will be the first to test a culturally-adapted, community-based intervention that addresses the elimination of health disparities by intervening at the provider, family and health policy level.
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