Health care education, delivery, and quality
Achieving and maintaining asthma control in an urban pediatric disease management program: The Breathmobile Program

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Background

National guidelines suggest that, with appropriate care, most patients can control their asthma. The probabilities of children achieving and maintaining control with ongoing care are unknown.

Objective

We sought to evaluate the degree to which children in a lower socioeconomic urban setting achieve and maintain control of asthma with regular participation in a disease management program that provides guideline-based care.

Methods

Interdisciplinary teams of asthma specialists use mobile clinics to offer ongoing care at schools and county clinics. A guideline-derived construct of asthma control is recorded at each visit.

Results

Two thousand one hundred eighty-five enrollees were eligible to evaluate the time to first achieve control, and 1591 patients were eligible to evaluate subsequent control maintenance. Depending on severity, 70% to 87% of patients with persistent asthma achieved control by visit 3, and 89% to 98% achieved control by visit 6. Subsequent control maintenance was highly variable. Thirty-nine percent of patients displayed well-controlled asthma (control at >90% of subsequent visits), whereas 13% displayed difficult-to-control asthma (<50% of subsequent visits). Patients from each baseline severity category were found in each group. Maintenance of control was influenced by physician-estimated compliance with the treatment plan, baseline severity, and the interval between clinic visits.

Conclusions

Many children can achieve asthma control with regular visit intervals and guideline-based care; however, long-term control can be highly variable among patients in all severity categories.

Clinical implications

These findings highlight the need and feasibility for systematically tracking each patient's clinical response to individualize therapy and guide the use of population management strategies.

Section snippets

Study population

This observational study evaluates patterns of asthma control in a treated population of pediatric patients whose families follow-up with ongoing care in a guideline-based disease management program. The treated population reflects a self-selected group that participates when (1) ongoing specialty care is offered to the general population of children at many sites across an urban lower socioeconomic community, (2) financial and logistical barriers are minimized, and (3) systematic approaches

Patient population

Ages ranged from 3 to 18 years (mean, 9 years; SD, 3.4 years) at the time of the first visit and included a predominately Hispanic (self-described) population with patients in all guideline severity classifications. The characteristics of the patients considered for the time-to-control and maintenance-of-control analyses are described in Table I.

Patient visit intervals

Seventy percent of visits occurred within 71 days of the previous visit. The average interval between patient visits to the program was a median of 56

Discussion

This study reports patterns of asthma control observed in the context of a systematic approach to regularly scheduled care for a large, lower socioeconomic, urban pediatric population. The results provide a novel view of the ability to achieve and maintain control of asthma (as determined by an asthma specialist) when families in this setting elect to participate in readily accessible guideline-based care. Although the number of visits required to achieve control was greater for children

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    The Los Angeles County Department of Health Services provides ongoing support for all clinical operations. The Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA) has provided start-up funds for each Breathmobile, ongoing technical support for the Asma-Trax clinical tracking system, and ongoing support for data management and data analysis. AAFA has received funds to support the data management and analysis from Genentech and Merck, Inc. Schools as sites for ongoing care, nursing services as part of the health care team, and electrical power to support Breathmobile operations are provided by the Los Angeles Unified School District and the Montebello Unified School District. Development of the first-generation clinical tracking software was supported in part by the Southern California AAFA, GlaxoSmithKline, and Merck, Inc. Support for development of the current clinical tracking system, Asma-Trax, was provided in part by the Southern California AAFA.

    Disclosure of potential conflict of interest: C. A. Jones has consulting arrangements with AstraZeneca, Genentech, Merck, and Sanofi-Aventis; has received grant support from Genentech, GlaxoSmithKline, and Merck; and is on the speakers' bureau for AstraZeneca, Genentech, Merck, and Sanofi-Aventis. K. Y. C. Kwong has received grant support from GlaxoSmithKline and is on the speakers' bureau for Novartis, Genentech, and AstraZeneca. The rest of the authors have declared that they have no conflict of interest.

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