Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED)

 描述(申请人提供)：在美国，来自少数族裔和种族背景的儿童患有哮喘的比例不成比例，与非少数族裔儿童相比，他们在急诊科(ED)就诊和住院的人数要多得多。虽然NHLBI指南建议所有患有持续性哮喘的儿童每天服用预防性药物，以防止发病率以及急诊和住院，但许多应该接受预防性药物治疗的儿童没有得到这些药物。部分原因是，因哮喘急性加重而向教育署求诊的儿童，很少获得预防性哮喘治疗，因为教育署注重急性、间歇性的治疗。为了提供最佳的预防性护理和防止ED复发，NHLBI指南建议儿童在急诊室就诊后1-4周内向初级保健提供者(PCP)进行随访。教育署后的后续访问是一个机会 儿科医生将开出有效的预防哮喘药物，对控制不良的儿童加强用药，促进坚持，并提供哮喘自我管理和触发控制的教育。然而，哮喘相关急诊室就诊后的随访率极低，即使在随访中看到儿童，预防性护理的提供也不一致，导致了相当大的可预防的发病率。我们之前的工作已经证明，在初级保健办公室就诊时，提供者提示干预可以加强基于指南的预防性哮喘治疗的提供，并最终降低哮喘高危儿童的发病率。我们还发现，远程医疗是一种移动医疗系统，允许临床医生通过远程视听技术提供评估；可以将患有持续性哮喘的儿童与提供者联系起来，以实现最佳的慢性病管理。这个项目的总体目标是使用一种基于远程医疗的新计划来促进初级保健的后续工作，并促进为向急诊室提出哮喘恶化的高危儿童提供基于指南的预防性护理。我们提出了一项两组随机试验来测试Team-ED(通过急诊科远程医疗增强哮喘管理)干预。干预措施包括：1)在儿童学校，由临床远程保健助理(CTA)在急诊室出院后一周内发起并由初级保健医生完成远程医疗评估；2)在远程医疗访问期间促进提供基于指导方针的预防性护理的“看护点”；以及3)另外两项远程医疗辅助后续评估，以确保对治疗作出最佳反应，并根据需要调整护理方案。我们计划在四年内从纽约州罗切斯特市区的两所急诊室招收430名儿童(4-12岁)。我们将评估该计划在降低呼吸道发病率(如症状严重程度、生活质量、重复非计划的哮喘就诊)和改善预防性哮喘护理方面的有效性，并在3、6、9和12个月进行跟踪评估。在这项研究完成后，这一新型护理系统的有效性将被更好地定义为一种可持续的手段，以改善预防护理并降低患有哮喘的高危城市儿童的发病率。

 DESCRIPTION (provided by applicant): In the US, children from minority ethnic and racial backgrounds suffer disproportionately from asthma and account for substantially more emergency department (ED) visits and hospitalizations than non-minority children. While NHLBI guidelines recommend daily preventive medications for all children with persistent asthma to prevent morbidity as well as ED visits and hospitalizations, many children who should receive preventive medications are not receiving them. This is in part because children presenting to the ED for an acute asthma exacerbation rarely receive preventive asthma care, due to the ED's focus on acute, episodic care. In order to provide optimal preventive care and prevent ED recidivism, the NHLBI guidelines recommend that children follow-up with a primary care provider (PCP) within 1-4 weeks of the ED visit. The post-ED follow- up visit is an opportunity for the PCP to prescribe effective preventive asthma medications, step-up medication for children who demonstrate poor control, promote adherence, and provide education on asthma self- management and trigger control. However, rates for follow-up after an asthma-related ED visit are extremely low, and preventive care is delivered inconsistently even when children are seen in follow-up, resulting in substantial preventable morbidity. Our prior work has demonstrated that a provider prompting intervention can enhance the delivery of guideline-based preventive asthma treatments at the time of a primary care office visit and ultimately reduce morbidity for high-risk children with asthma. We have also found that telemedicine, a mobile medical system that allows clinicians to provide assessment through remote audiovisual technology; can link children with persistent asthma to a provider for optimal chronic illness management. The overall goal of this project is to use a novel telemedicine-based program to facilitate primary care follow-up and promote the delivery of guideline-based preventive care for high-risk children presenting to the ED for an asthma exacerbation. We propose a 2-group randomized trial to test the TEAM-ED (Telemedicine Enhanced Asthma Management through the Emergency Department) intervention. The intervention includes: 1) a telemedicine assessment initiated by a clinical tele-health assistant (CTA) at the child's school within one week of discharge from the ED and completed by a PCP, 2) `point-of-care' prompting to promote the provision of guideline-based preventive care during the telemedicine visit, and 3) two additional telemedicine-assisted follow-up assessments to assure optimal response to treatment and tailor the care regimen as needed. We plan to enroll 430 children (ages 4-12 years) over four years from two EDs in urban Rochester, NY. We will assess the effectiveness of the program in reducing respiratory morbidity (e.g. symptom severity, quality of life, repeat unscheduled asthma visits) and improving preventive asthma care, with follow-up assessments at 3, 6, 9, and 12 months. At the study's completion, the effectiveness of this novel system of care will be better defined as a sustainable means to improve preventive care and reduce morbidity for high-risk urban children with asthma.