In the US, children from minority ethnic and racial backgrounds suffer disproportionately from asthma and account for substantially more emergency department (ED) visits and hospitalizations than non-minority children. While NHLBI guidelines recommend daily preventive medications for all children with persistent asthma to prevent morbidity as well as ED visits and hospitalizations, many children who should receive preventive medications are not receiving them. This is in part because children presenting to the ED for an acute asthma exacerbation rarely receive preventive asthma care, due to the ED's focus on acute, episodic care. In order to provide optimal preventive care and prevent ED recidivism, the NHLBI guidelines recommend that children follow-up with a primary care provider (PCP) within 1-4 weeks of the ED visit. The post-ED follow- up visit is an opportunity for the PCP to prescribe effective preventive asthma medications, step-up medication for children who demonstrate poor control, promote adherence, and provide education on asthma self- management and trigger control. However, rates for follow-up after an asthma-related ED visit are extremely low, and preventive care is delivered inconsistently even when children are seen in follow-up, resulting in substantial preventable morbidity. Our prior work has demonstrated that a provider prompting intervention can enhance the delivery of guideline-based preventive asthma treatments at the time of a primary care office visit and ultimately reduce morbidity for high-risk children with asthma. We have also found that telemedicine, a mobile medical system that allows clinicians to provide assessment through remote audiovisual technology; can link children with persistent asthma to a provider for optimal chronic illness management. The overall goal of this project is to use a novel telemedicine-based program to facilitate primary care follow-up and promote the delivery of guideline-based preventive care for high-risk children presenting to the ED for an asthma exacerbation. We propose a 2-group randomized trial to test the TEAM-ED (Telemedicine Enhanced Asthma Management through the Emergency Department) intervention. The intervention includes: 1) a telemedicine assessment initiated by a clinical tele-health assistant (CTA) at the child's school within one week of discharge from the ED and completed by a PCP, 2) `point-of-care' prompting to promote the provision of guideline-based preventive care during the telemedicine visit, and 3) two additional telemedicine-assisted follow-up assessments to assure optimal response to treatment and tailor the care regimen as needed. We plan to enroll 430 children (ages 4-12 years) over four years from two EDs in urban Rochester, NY. We will assess the effectiveness of the program in reducing respiratory morbidity (e.g. symptom severity, quality of life, repeat unscheduled asthma visits) and improving preventive asthma care, with follow-up assessments at 3, 6, 9, and 12 months. At the study's completion, the effectiveness of this novel system of care will be better defined as a sustainable means to improve preventive care and reduce morbidity for high-risk urban children with asthma.
Poor and minority children suffer disproportionately from asthma and account for substantially more emergency department visits than non-minority children. This project may have a profound impact on public health because it proposes an innovative intervention to link children to primary care following an emergency visit for asthma, in order to promote the delivery of effective guideline-based asthma care. It is specifically designed to promote optimal care within an existing infrastructure. Should it prove successful in improving the health of urban children with asthma and preventing subsequent acute visits, it has the potential to serve as a sustainable model for improved asthma care in this population.
