Puerto Rican children have the highest rates of asthma morbidity of any etnic group and are more likely todie because of their asthma as compared with other children. In Puerto Rico gross disparities exist in thequality of asthma care received by poor asthmatic children compared to higher income children. Asdescribed by the Institute of Medicine, such health disparities likely result from multi-level barriers toappropriate 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), anovel, multi-level intervention designed to eliminate asthma disparities in treatment by intervening at thehealth policy, provider, and family level.
Aim 1 will use a non-experimental pre-post comparison design toassess a historic change in medication policy (i.e., the state assuming responsibility for the cost ofmedication) in a pilot health region in Puerto Rico. We will use automated claims and pharmacy data oneyear prior to and one-and-a-half years post policy change to compare pharmacy dispensing of antiinflammatorycontroller medications (ACMs), oral steroids and beta agonists (primary outcome), as well asrates of Emergency Department (ED) visits and hospital admissions (secondary outcomes) in children withpersistent asthma.To examine the impact of change at the provider level, Aim 2 will use a randomizedcontrol trial (RCT) design nested within the pilot region to study the impact of a culturally-adapted version ofthe Easy Breather Program ( EBP), a provider-focused educational intervention designed to increaseguideline-based care. Using claims data, we will compare rates of ACM dispensing (primary outcome), aswell 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 familylevel, Aim 3 will use a RCT to test a family-based asthma management intervention (FAMI), nested in clinicsof the Pilot region that received the EBP. This intervention is designed to increase family knowledge, skillsand self-efficacy for asthma management. The primary outcome variable for the FAMI study is symptomfreedays. Secondary outcomes include ACM use and quality of life, as well ED visits and hospitaladmissions, beta agonist and oral steroids use, and functional disability. Finally, Aim 4 will evaluate the costeffectivenessof each level of the Pediatric Asthma Community-Based Program (PACBP). The proposedstudy will be the first to test a culturally-adapted, community-based intervention that addresses theelimination of health disparities by intervening at the provider, family and health policy level.
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