SAN DIEGO - Asthma is a major problem in inner cities across the country, with access to medical care impairing many children's quality of life. Working around this and associated barriers is critical to improving asthma outcome.
"It's not simply access to care," said Craig A. Jones, MD, of the University of Southern California Medical Center in Los Angeles. "It's access to appropriate care. What happens when you get to the doctor? What happens when you go to a clinic?"
Jones described a program in Los Angeles that has improved asthma outcomes. Mobile clinics, staffed with a doctor, nurse, respiratory therapist and patient service worker, go to schools and county comprehensive medical centers. The program is aimed at early intervention, identifying those most at risk and helping them manage their asthma.
"The idea was if we had a predictable population at schools and clinics, and we connected that right team approach, that maybe that would change their health status," Jones said.
In the first year of the program, school nurses helped identify children who might benefit from mobile clinic services. Services included a full history evaluation, appropriate skin testing and pulmonary function testing. The program emphasized developing a treatment plan for patients, "teaching them an understanding of their controllers, their relievers, environmental interventions and making [patients] demonstrate an understanding," said Jones, who spoke here at the American Academy of Asthma, Allergy & Immunology 56th Annual Meeting.
Each team spent time making connections with children and parents and revisited schools and clinics every six weeks. If children required care between visits, they could go to another location where that mobile clinic was visiting.
The teams tried to integrate a patient's medical plan into the program by sending physicians copies of evaluations and making follow-up appointments with each patient's regular health care provider when possible.
"There's an attempt to integrate [the program] into what exists in the community," Jones said. "But what happens most of the time is that they are being provided a different standard of care than they have been provided before."
So far, that different standard of care has shown promising results. Of children who had uncontrollable asthma at baseline, 25% had improved asthma activity by their second visit, and 40% had achieved control within National Institutes of Health guidelines, Jones said. Overall results of two years of study showed that 55% of children who had more than one visit achieved control of their asthma and 12% showed symptom improvement.
Results of parental surveys also showed improvement. At baseline, 40% of parents reported that their children were coughing many times daily. However, "By the third visit, those populations are shifting down into the occasionally or never category," Jones said.
Pulmonary function tests showed improvements in asthma as well. "Pulmonary functions demonstrate consistent improvement that correlates with the other assessment," Jones said. "The longer we stay in the program, we tend to see more ... improvement."
School absenteeism was reduced as symptoms improved. Thirty-six percent fewer absenteeisms occurred among children with asthma in grade schools. In middle schools, absenteeism among patients in the program fell 22%.
During the program, 49% of patients were enrolled in MediCal, a California Medicare program. A survey of MediCal claim data for the year before and after the program started showed differences in asthma-related costs.
"If you look at their claim activity, they showed a drop in inpatient claims, a drop in emergency claims, a big drop in outpatient hospital claims and some increase in pharmaceutical claims," Jones said. "Shifting children into focused care has a greater impact on reduction of their acute care claim and maybe most importantly, shifts them into a different standard of care."
For more information:
- Jones CA. Practical management options for inner-city asthma care. Session 8503. Presented at the American Academy of Asthma, Allergy & Immunology 56th Annual Meeting. March 3-8, 2000. San Diego.
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