Our previous NHLBI-supported study (HL 57232) showed that a combination treatment of """"""""Coaching"""""""" through follow-up phone calls 2 and 5 days following an index ED visit plus monetary incentive was highly effective in increasing the percentage of low-income urban children who received recommended primary care within 2 weeks of the ED visit for asthma, 44% in the intervention group vs 29% in usual care (p = 0.0004). However, the intervention was not associated with significant differences in morbidity (subsequent ED visits). We conclude that the intervention was effective in promoting the initial link to primary care, but was not effective in sustaining that link or management practices to minimize acuity of symptoms during exacerbation. Here we propose an expansion of the intervention initiated at the time of an ED visit for asthma to promote ongoing primary care and effective asthma management. Parents of low-income, urban, predominantly African American children, aged 2 - 12 years will be recruited at the time of their children's ED visits for acute wheezing. The experimental Intervention is designed to reduce morbidity from recurrent asthma through ongoing education and social support to encourage long-term primary care and adherence to recommended asthma management practices. It will include: 1) as in our previous study, monetary incentive to visit the PCP in order to start the process of ongoing care; 2) as in our previous study, contact by an asthma """"""""Coach,"""""""" but now extended through 12 months following the ED visit and focusing not only on attending primary care as recommended but also on parent adherence to asthma management strategies developed with the primary care provider (PCP); and 3) telemedicine provided by asthma nurses to reinforce asthma management strategies and assess the status of the child's asthma continued through 6 months following the index ED visit. After informed consent, cases will be randomly assigned to either Usual Care or Intervention, stratified by PCP clinic. All children will receive standardized/usual ED care to resolve wheezing and standardized discharge advice. Follow-up to assess study outcomes will be scheduled every 6 months from the time of randomization of each case and continue for 24 months following randomization. Intended impacts on patterns of care will be assessed by proportions of children who have a visit to their PCP for asthma planning within 2 weeks after the index ED visit and [3]1 subsequent PCP visit for regular care that includes asthma planning during the 24 months of follow-up. Primary outcome will be asthma morbidity, as indexed by the proportion of children who have at least one ED visit during the 24-month follow-up period. Additional outcomes will include the proportion of children who have at least 1 hospitalization, the proportion of participants with [3]1 visit to the PCP for acute asthma, and the net cost of asthma-related care, all through the 24 months of intervention and follow-up. Planned enrolment is 248 subjects (124 per group) to provide 80% power at p = .05 to detect a reduction of ED visits of 20%. Because the primary outcome can be obtained from medical records after consent even if phone contact cannot be maintained, intent to treat model will be used for analyses.
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