Asthma-related deaths, hospitalizations, and ED visits are more numerous among low-income and minority patients, including African Americans and among older adults who tend to suffer from other chronic diseases. Guidelines for asthma management have not met the unique needs of this older group with their socioeconomic burdens and frequent comorbidities. We recently demonstrated the feasibility, acceptability, and evidence of effectiveness of two separate interventions to improve access to care, patient-provider communication, and asthma outcomes: 1) CI: clinic intervention using a patient advocate to prepare for, attend, and confirm understanding of an office visit, and 2) HV: home visits for care coordination and informing clinicians of home barriers to managing asthma. This project explores whether these interventions can be combined for greater effectiveness and better delivery of guideline-based asthma care and outcomes in low-income minority patients. In addition, we explore whether giving clinicians real-time feedback on the patient?s health and home status structured in the framework of adherence to asthma guidelines is associated with subsequent improvement in asthma outcomes. In a randomized controlled factorial trial, 400 adults with uncontrolled asthma living in low-income urban neighborhoods will be offered 18-months participation: 12 months of clinical intervention and 6 months of evaluation to monitor sustainability of interventions and outcomes. Patients will be randomized to (1) patient advocate alone, (2) patient advocate with home visits, (3) patient advocate with real-time feedback to asthma provider (clinician) at each clinic visit of guidelines-relevant elements of a patient?s current care, and (4) both (2) and (3). The interventions will be delivered by a lay Community Health Navigator (CHN). The study will estimate:
Specific Aim 1 : improvement over time of within-group (before-after in four groups) asthma outcomes (asthma control, quality of life, ED visits, hospitalizations, prednisone bursts) Specific Aim 2: across group differences in improvement over time in asthma outcomes;
Specific Aim 3 : the costs associated with each of the interventions, and we will conduct a cost-offset analysis to determine which intervention costs are offset by savings attributable to reductions in ED, hospitalization or other visits for asthma control and other outcomes. Exploratory Aim: changes in behavior from the interventions using interviews of clinicians and patients. Hypothesis and Impact: We hypothesize improved outcomes in asthma patients through enhanced communication of patient and clinician, clinician attention to home environmental exposure, and clinician consideration of the guidelines, at a program cost offset by lower patient health care utilization.
Few interventions to improve asthma management have targeted low-income minority asthmatic adults, particularly older adults who often also have other health problems. National guidelines focus on children and young adults leaving asthma providers with little evidence-based data to guide clinical decisions for adult patients with multiple comorbidities. This project tests guideline-promoted interventions, delivered by community health navigators in clinical practices and in the home, with feedback to clinicians, to improve asthma control and quality of life for adults with uncontrolled asthma recruited from clinics serving low-income urban neighborhoods.
