NEW YORK - Intervention by a social worker can reduce morbidity in inner-city children with asthma. "By being innovative, we, as pediatricians, can have a greater impact on the rising morbidity in asthma," said Meyer Kattan, MD, of Mt. Sinai Medical Center, here.
A study of asthma intervention in inner-city children was conducted in eight sites: Baltimore, the Bronx, Chicago, Cleveland, Detroit, New York, St. Louis and Washington, DC. ß
More than 1,200 patients between the ages of 4 and 11 were enrolled. "We did a baseline interview, and we followed them for two years. Every two months, we called them and asked about symptoms in the previous two weeks and hospitalizations and emergency room visits during the previous 2 months," Kattan explained.
Interestingly, more than 90% of these inner-city patients had some form of health insurance, so insurance was not a barrier to access. "Additionally, they all had a regular place to go for care. But, more than 50% felt it was difficult to get care for their asthma," he said.
Another perception of the patients and their families was that their doctors' expertise regarding asthma was inadequate. "The medications that were given to these patients lend some credibility to this perception," he added.
More than 40% of the patients who were symptomatic within the past year were receiving ß-agonists only. Anti-inflammatory medications were used in fewer than 30% of the patients. "This is in direct contradiction to the current recommendations of the National Institutes of Health, which suggest that we should be using anti-inflammatory therapy as the primary therapy and adding ß-agonists," he said.
To determine patients' and caregivers' knowledge of asthma, they were given an asthma information quiz. For the questions regarding the triggers of asthma, the caregivers scored higher than 80%, and the children scored higher than 70%. However, when asked to put their knowledge into practice, they did not do as well.
Patients and their caregivers were given five asthma vignettes and were asked what they would do in each situation. "We scored the answers as helpful responses, neither helpful nor harmful responses or really harmful responses. While there were some helpful responses to these vignettes, on average, there were almost two potentially harmful answers across the five situations. Although knowledge may be good, behavior or reaction to a situation may not be optimal," Kattan said.
More than 600 of the patients' homes were analyzed for allergens to cats, dust mites and roaches. More than half of the homes had a significant amount of roach allergen. Then, the relationship between being exposed to cockroach allergen and being sensitized to the allergen was examined.
Patients who were exposed to cockroach allergen and were skin-test positive had the highest rate of hospitalization, emergency department (ED) visits and symptom days. "This rate was much higher than the other three groups," he said.
In addition to the high rate of cockroach allergen exposure, cigarette smoke exposure in the inner city is quite high. In this patient population, almost 60% had a smoker in the house. Approximately 35% had a primary caregiver who smoked. "We objectively measured cigarette smoke exposure - a cotinine level of greater than 30 is considered a significant exposure. More than 40% of these children with asthma had significant cigarette smoke exposure. We know from other studies that the higher the level of cotinine, the higher the number of acute exacerbations per year," he added.
However, this study found that exposure to an indoor allergen may be more important than exposure to cigarette smoke. Patients with no ED visits were compared with patients who had five or more ED visits per year. The percentage of patients who were exposed to cigarette smoke was the same in both groups. However, the patients who had five or more ED visits had a significantly higher number of positive skin tests to indoor allergens compared with those who did not have any ED visits.
Psychosocial factors are also a problem. During the baseline interview, patients underwent psychiatric and social assessment. More than one-third of the children, 35%, had scores that were more than two standard deviations from normal, and 50% of the parents had abnormal scores. "This was a test of stressful events: muggings, murders, divorces, etc.," Kattan explained.
Kattan and his colleagues developed an intervention to address access to care, environmental, psychosocial and medication adherence issues. "The aim of the intervention was to translate asthma knowledge into behavioral skills without a physician intervention," he said.
A risk assessment tool was developed and was given to a social worker who was trained in dealing with asthma issues. The social worker met with patients in the intervention group every two months, or more often if necessary, and called them once a month to deal with issues based on their risks. The control group did not meet with the social worker.
"One goal of the social worker was to teach patients and their caregivers how to communicate with physicians. If patients had psychiatric problems, they were referred, but the social worker could provide some support or counseling. To make sure that patients were taking their medications properly, the social worker discussed the use of spacers and inhalers. For environmental issues, such as roaches, the social worker discussed how to make the patient's house roach unfriendly," he said.
At the start of the intervention, both groups seemed to improve, except that there were significantly fewer symptoms in the group that had the asthma counselor. In the summer months, when the symptoms were lowest, there was no significant difference.
"However, in the fall, the groups separated again. This intervention can be used to reduce morbidity in the absence of a doctor. The successful approach needs to be innovative and go beyond the correct pharmacologic regimen, and the intervention needs to be tailored to the patients' needs," Kattan explained.
For more information:
- Kattan M. Successful Approach to chronic/severe asthma in inner-city children. Presented at the American Academy of Pediatrics 1998 Annual Meeting. Oct. 17-21,1998. San Francisco.
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