Comprehensive case management by a specially trained nurse and home environmental evaluation and intervention by trained personnel have been proposed as interventions which can reduce childhood asthma morbidity. Both of these, however, are of unproven benefit among urban asthmatic children of low-income families. Furthermore, the impact if these interventions, which require an initial financial investment by health care organizations, on health care costs has not been established. The applicants propose to conduct a randomized, controlled trial of the effectiveness and cost impact of (a) case management by a specially trained nurse and (b) a home environment control intervention among four- to twelve-year-old children with moderate-to-severe asthma receiving care in five inner-city neighborhood health centers and in the Pediatric Clinic of Boston City Hospital (BCH). Using a factorial design, subjects will be randomized to receive one, both, or neither intervention. The following specific questions will be addressed: (1) Does case management by a nurse with special training in asthma care, working in concert with the primary care clinician, result in decreased utilization of acute care (i.e., hospitalization, emergency department care, and unscheduled clinic visits), decreased school absenteeism, and increased quality of life? (2) Does a home environment control intervention implemented by trained personnel visiting the patient's home result in the outcomes listed for Aim 1? (3) Does the combination of both interventions provide additional benefit beyond that provided by either intervention alone? (4) To what extent do these interventions lead to sustained reductions in the concentrations of important indoor allergens in house dust? To what extent are these reductions correlated with improvement in clinical outcomes? (5) What is the impact of these two interventions, alone or in combination, on direct health care costs?
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