A Randomized Controlled Trial of Parental Asthma Coaching to Improve Outcomes Among Urban Minority Children

1. A Randomized Controlled Trial of Parental Asthma Coaching to Improve Outcomes Among Urban Minority Children Nelson KA, Highstein GR, Garbutt J, et al. A randomized controlled trial of parental asthma coaching to improve outcomes among urban minority children. Arch Pediatr Adolesc Med. 2011;165(6):520-526.

3. Introduction Study Aims Primary Decrease proportion per group with =1 ED visit for acute asthma over 2 years. Secondary Decrease proportion with =1 hospitalization over 2 years. Increase proportion with =1 outpatient visit for asthma management. Increase partnership with PCP, use of controller medications, and use of asthma action plan.

4. Methods Study Design Randomized controlled trial of peer asthma coaching for 18 months vs usual care (discharge sheet serving as an asthma action plan). Coaching was designed to help participants (parents) adopt and maintain asthma management strategies: Acute asthma care using action plan. Complete outpatient visits for asthma monitoring. Foster collaborative partnership with PCP to comanage asthma. Use controller medications as prescribed. Avoid known environmental triggers.

5. Methods Study Design Coaching was based on the transtheoretical model of behavior change. Coaches empowered parents to identify motivators, understand barriers, and seek solutions to barriers regarding these asthma management strategies. Coaches recorded stage of change of parents after each management strategy was discussed. Outcomes (health care visits in different settings for each child) were measured through medical record audit.

6. Methods Sample/Participants Parents were the subjects, enrolled during their children�s ED visits. Parent eligibility: Attested to being primary care giver for eligible child. Spoke English. Reported having working telephone. Agreed to study procedures. Child eligibility: Had prior asthma diagnosis (parental report). Reported =1 acute asthma visit (ED or PCP) during last 15 months. Lived in specified urban zip codes. Medicaid insurance. Received acute asthma treatment during index ED visit.

7. Methods Data Analysis Target sample size = 210 To detect 20% difference in primary outcome (proportion with =1 ED visit in 2 years) between groups; a = .05 and power = 80%. Overenrolled, assuming a potential 15% dropout rate (n = 247 total). Relative risk of health care visits compared between groups using Cochran-Mantel-Haenszel methods. Analysis of primary outcome was adjusted for PCP practice strata and prior-year asthma-related ED visit.

8. Methods Limitations Enrolled convenience sample and did not collect information on those not enrolled. In a previous coaching study with similar enrollment methods in the same ED, no evidence of selection bias was found. Only records from the study hospital were reviewed, and the city has another children�s hospital with an ED. Another previous study found that <5% of children admitted to our hospital had admission at other hospital. Did not measure PCP care beyond medical record review.

9. Results Characteristics of Asthmatic Children in the Study Characteristic Intervention Control

10. Results Coaching Effect on Health Care Visits

11. Comment Implications for Future Clinical Work Asthma management for children involves a complex system of care. Asthma morbidity remains high for urban, Medicaid-insured children. Visits for asthma monitoring and partnership between parents and PCPs are important aspects of effective care. In our study, coaching increased visits for asthma monitoring but did not decrease ED visits or hospitalizations. Asthma monitoring visits may have remained too infrequent to have a significant effect on hospital-based visits. More effective programs are needed to improve outcomes for this population. Such programs should include strategies targeting both parents and PCPs to accomplish the goals of a collaborative model of chronic disease management.

12. Comment Implications for Future Research in This Area Future research should include development and testing of interventions targeting medical care providers as well as children and parents. Establishment and maintenance of a collaborative partnership between PCPs and parents to comanage asthma are understudied and underpromoted. Implications for Health Policy Health insurance coverage for children and families must continue to improve. Support for the medical home concept of care must be strengthened. Asthma coaching may be an effective part of care in a medical home.

13. Contact Information If you have questions, please contact the corresponding author: Kyle A. Nelson, MD, MPH, Pediatric Emergency Medicine, The Children�s Hospital of Boston, Harvard Medical School, 300 Longwood Ave, Boston MA 02115 (kyle.nelson@childrens.harvard.edu). Funding/Support This study was funded by grant HL 072919 from the National Heart, Lung, and Blood Institute.