Transcript Children`s Hospital Boston`s Community Asthma Initiative

Children’s Hospital Boston’s
Community Asthma Initiative (CAI):
An Innovative Community-based
Intervention Leading to Policy Changes
Elizabeth R. Woods, MD, MPH,
Urmi Bhaumik, MBBS, MS, DSc,
Susan J. Sommer, MSN, RNC
Amy B. Burack, RN, MA, AE-C,
Lauren K. Ebe, BA
Alaina J. Kessler, BS, BA
Lisa M. Mannix, BA
Elizabeth M. Klements, MS, APRN, BC,
Shari Nethersole, MD
Funding in Part From
• BANK OF AMERICA
• Anonymous Individual Donor
• Healthy Tomorrows, HRSA grant
#H17MC06705
• CDC REACH U.S. #1U58DP001055-01
• Office of Child Advocacy
• Children’s Hospital Boston’s Program for
Patient Safety and Quality
Asthma Hospitalization Rates
in Boston
• Leading cause of hospitalization at
Children’s Hospital Boston
• 70% of children hospitalized for asthma at
CHB come from Roxbury, Dorchester,
Jamaica Plain, Roslindale and Hyde Park
• Rate of asthma hospitalizations for
children in Boston in 2003 increased 25%
from the previous year
(Health of Boston 2005, BPHC,
www.bphc.org/reports/pdfs/report_205.pdf)
Race/ethnic Disparities
• Asthma hospitalization rates for Latino and
Black children in 2003 were 5 times the
rate for white children (Health of Boston,
2005)
• Of CHB asthma admissions (1/04-6/04)
23% were Black/African American, and
20% Hispanic, whereas of total CHB
patients 11% were Black/African American
and 13% were Hispanic
School prevalence
• Average prevalence of asthma in
the Boston Public Schools was
16% in 2003-2004 school year
• 5 Boston Schools reported
prevalence rates >24%, highest
at 39%
Children’s Hospital Boston
Community Asthma Initiative
The Program Model
• Nurse case management, individualized asthma
plan
- Asthma education, medication management
- Connection to PCP, Allergy evaluation,
insurance, housing, community resources
• Boston Asthma Initiative (BAI) and nurse home
visits, environmental assessment, asthma
teaching, assistance with environmental triggers
• Integrated Pest Management
• Linkage with community agencies, activities,
and schools
Access to Care, Connection to Primary Care,
Medication Management, Asthma Action Plan
Homesafe Kit:
Boston Public Health Commission
• Plastic trash can/cleaning
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•
•
•
•
•
•
supplies
Plastic food containers
Foam/Copper gauze
Non-toxic insect traps
Mouse (sticky) traps
Weather stripping
Bedding encasements
Bilingual information cards
Additional Collaboration:
Boston Inspectional Services
Breathe Easy Program
• www.cityofboston.gov/isd/bmc
Asthma Health Project/ BPHC:
Combines physical activity with asthma
education to improve health and well being
of Boston children living with asthma
• Boston Asthma Games
• Boston Asthma Swim
• Boston Asthma Summer
Program
Boston Public Schools
• Asthma Action Plan
Acquisitions
• Resources and support to
BPS nurses:
- Albuterol
- Nebulizers
- Spacers
- Instructional booklets
and videos
- Scholarships to CHB
conferences
- Parent/Student/Staff
Education Workshops
Target Population:
• Four zip codes for Roxbury, Jamaica
Plain and Mission Hill
• Patients identified for CAI by CHB
Emergency room visits, Admissions,
provider referral
• Patients were identified by active
visit logs and summaries from billing
codes from hospital data bases
Methods
• Data were collected as part of
patient care and parental clinical
interviews at baseline, 6 months and
12 months
• Data were compared from baseline
to 6 or 12 months by McNemar’s
test for dichotomous variables,
paired t-tests and Wilcoxen sign
ranked test for continuous variables.
QI Indicators Monitored every 6
months (summed to 12 months)
• Number of emergency department visits
• Number of hospitalizations
• Number missed school days
• Number of missed work days
• Number of days with limitation of physical
activity
• Number of children with an up to date
Asthma Action Plan
• Average monthly cost of medications (or
co-pays)
Data to Date
• As of July 1, 2007
- 186 patients out of 370 identified (50%)
• Received Case management
• 54.3% are boys,
• Mean age 8.1 years (SD ± 4.5 years)
- 113 families home visits (61%)
• 56 outreach and 95 nurse visits
• 18 families Intensive IPM (25 visits)
- Cost for asthma $1-500/month (mean $92.82)
self- or co-pay
- Mean days to follow up with primary care 11.8
+ 17.0 SD
62% Reduction in Emergency Room Visits due to Asthma
6 months
64.5
70
60
% of patients
50
40
24.7
30
20
10
0
Baseline (95 pts)
p<0.001
6 months (95 pts)
76% Reduction in Hospital Admissions due to Asthma
6 months
52.6
60
% of patients
50
40
12.6
30
20
10
0
Baseline (95 pts)
6 months (95 pts)
p<0.001
56% Reduction in Any Days with Limitation of Physical Activity
6 months
67.4
70
60
% of patients
50
29.3
40
30
20
10
0
Baseline (95 pts)
6 months (95 pts)
p<0.001
41% Reduction in Any Missed School Days
6 months
96.2
100
90
80
57
% of patients
70
60
50
40
30
20
10
0
Baseline (95 pts)
6 months (95 pts)
p<0.001
62% Reduction in Parent/Guardian Missed Any Work Days
6 months
75.0
80
70
% of care givers
60
50
28.8
40
30
20
10
0
Baseline (95 pts)
6 months (95 pts)
p<0.001
124% Increase in having an Asthma Action Plan
6 months
87.5
90
80
% of patients
70
60
39.1
50
40
30
20
10
0
Baseline (95 pts)
6 months (95 pts)
p<0.001
59% Decrease in Emergeny Room Visits due to Asthma
1 Year
68.1
70
60
% of patients
50
27.7
40
30
20
10
0
Baseline (48 pts)
1 year (48 pts)
p=0.001
86% Decrease in Hospital Admission due to Asthma
1 Year
58.3
60
% of patients
50
40
30
8.3
20
10
0
Baseline (48 pts)
1 year (48 pts)
p<0.001
57% Decrease in any Limitation of Physical Activity
1 year
78.7
80
70
% of patients
60
34
50
40
30
20
10
0
Baseline (48 pts)
1 year (48 pts)
p<0.001
48% Decrease in Any Missed School Days
1 Year
97.6
100
90
80
51.2
% of patients
70
60
50
40
30
20
10
0
Baseline (48 pts)
1 year (48 pts)
p<0.001
52% Decrease in Any Parent/Guardian Missed Work days
1 Year
76.7
80
70
% of caregives
60
50
36.7
40
30
20
10
0
Baseline (48 pts)
1 year (48 pts)
p<0.001
Paired T-tests, 6 and 12 months
Mean Diff SD
P-value
ER Visits, 6mo.
ER Visits, 12 mo.
Admissions, 6 mo.
0.56
0.58
0.55
1.04
1.20
0.78
0.0008
0.003
<0.001
Admissions, 12 mo.
0.62
0.77
0.001
Missed School days,
6 mo.
1.39
2.81
5.10
5.00
0.079
0.001
Missed School Days,
12 mo.
Public Policy Advocacy Efforts:
• Boston Urban Asthma Coalition (BUAC)
- An Act to Improve Asthma Management
(2007-08 legislative session)
• Asthma Regional Council (ARC)
- Business case for investing in asthma
education and environmental interventions
- Insurance benefits guides for providers
Conclusions
• Community Asthma Initiative significantly
decreased emergency room visits,
admissions, missed school days, missed
work days
• Program improves access to care
• Successful model of enhanced asthma
care and education that can be replicated
nationally
• Policy changes are in process to support
asthma care, home visits, and affordable
medications