Pediatric Asthma Alert Intervention in Minority Children

描述(申请人提供)：哮喘是幼儿儿科急诊科就诊的头号原因。依赖ED进行哮喘治疗成本高昂，也是哮喘控制不佳的危险指标。吸入性皮质类固醇(ICS)是持续哮喘患者治疗的基石，可以防止病情恶化和急诊。然而，许多市中心的儿童没有接受或使用推荐的抗炎预防药物，往往是因为急诊科就诊后不一致的随访。这项随机试验的总体目标是评估与标准哮喘教育(SAE)对照组的儿童相比，标准化照顾者和医生提示干预的儿科哮喘警报领导者(PAAL)是否可以改善经常去急诊室就诊的儿童的基于指南的预防性哮喘护理。这项研究建立在我们的父母-孩子-初级保健提供者(PCP)沟通干预(哮喘沟通教育，ACE)的经验基础上，表明教授父母和孩子哮喘沟通技能的护士在6个月时增加了持续性哮喘儿童抗炎药物的使用。然而，干预与维持预防性护理的适当的PCP后续行动无关。拟议的干预措施使用PAAL护士1)确保儿童和家长在哮喘急诊科就诊后4周内参加后续的PCP就诊，2)组织并在PCP就诊时将来自急诊部和家庭的关键健康信息传达给儿童的PCP，以及3)授权家庭并促使PCP提供以指南为基础的哮喘护理(包括ICS处方、签署的哮喘行动计划和安排重复的PCP就诊)。PAAL干预措施的目标是改善适当的预防性哮喘护理(每年2次PCP就诊)和抗炎药物的适当使用(AIM 1)，改善哮喘结果(症状日夜、生活质量)(AIM2)，并确定干预措施的成本效益(AIM 3)。过去一年中，300名3-10岁患有轻度持续性哮喘和严重持续性哮喘的儿童的家庭将从两个大型城市儿科急诊室招募，随机进入PAAL或SAE，并进行12个月的跟踪调查。主要结果是非紧急哮喘就诊次数和消炎处方补充率。数据分析将包括卡方检验、t检验、方差分析和多元线性回归模型，以比较两组之间的结果。双变量和多变量参数技术将被用来比较PAAL和SAE组之间的护理成本和有效性。如果成功，这种相对简单且可报销的干预措施可能会广泛适用于城市实践中的哮喘护理。公共卫生相关性：患有哮喘的年轻市中心儿童急诊科就诊率最高。依赖急诊科的哮喘治疗可能是哮喘控制不佳的危险迹象。这项研究的重点将是，在哮喘急诊室就诊后，让专门的哮喘护士加入到儿童医生的家庭中，以确保孩子和父母遵守随访预约，并让护士提醒孩子的医生开预防哮喘药物，以及为家庭制定哮喘行动计划是否会减少哮喘儿童喘息和咳嗽的时间。

DESCRIPTION (provided by applicant): Asthma is the number one cause of pediatric emergency department (ED) visits in young children. Reliance on the ED for asthma care is costly and also is a dangerous index of poorly controlled asthma. Inhaled corticosteroids (ICS) are the cornerstone of treatment for patients with persistent asthma and can prevent exacerbations and ED visits. However, many inner city children do not receive or use recommended anti- inflammatory preventive medication often due to inconsistent follow-up after an ED visit. The overall goal of this randomized trial is to evaluate whether a standardized caregiver and physician prompting intervention, the Pediatric Asthma Alert Leader (PAAL), can improve guideline-based preventive asthma care in children with frequent ED visits as compared to children in a standard asthma education (SAE) control group. This study builds on the experience with our parent-child-primary care provider (PCP) communication intervention (Asthma Communication Education, ACE) demonstrating that nurses teaching parent and child asthma communication skills resulted in increased anti-inflammatory medication use at 6 months for children with persistent asthma. However, the intervention was not associated with appropriate PCP follow-up to sustain preventive care. The proposed intervention uses a PAAL nurse to 1) ensure child and parent attendance at the follow-up PCP visit within 4 weeks after an asthma ED visit, 2) organize and relay critical health information from the ED and home to the child's PCP at the PCP visit and 3) empower the family and prompt the PCP to provide guideline based asthma care (including ICS prescription, signed asthma action plan and scheduling a repeat PCP visit). The goals of the PAAL intervention are to improve receipt of appropriate preventive asthma care (> 2 PCP visits/yr) and appropriate use of anti-inflammatory medication (> 6 anti-inflammatory refills/yr) (AIM 1), improve asthma outcomes (symptom days and nights, quality of life) (AIM2), and establish the cost effectiveness of the intervention (AIM 3). Families of 300 children ages 3-10 years with mild persistent to severe persistent asthma and > 2 ED visits or > 1 hospitalization for asthma over the past year will be recruited from two large urban pediatric EDs, enrolled, randomized into the PAAL or SAE and followed for 12 months. Primary outcomes are number of non-urgent asthma visits and anti-inflammatory prescription refill rates. Data analysis will include chi-square, t-tests, ANOVA and multivariate linear regression models to compare outcomes between the two groups. Bivariate and multivariate parametric techniques will be used to compare costs and effectiveness of care between the PAAL and SAE groups. If successful, this relatively simple and reimbursable intervention could be widely applicable for asthma care in urban practices. PUBLIC HEALTH RELEVANCE: Young inner-city children with asthma have the highest emergency department (ED) visit rates. Relying on the emergency department for asthma care can be a dangerous sign of poorly controlled asthma. This research will focus on whether having a specialized asthma nurse join the family at a child's doctor visit after an ED visit for asthma to make sure the child and parent keep the follow-up appointment and have the nurse remind the child's doctor to prescribe preventive asthma medicines and an asthma action plan for home will result in young children with asthma having fewer days with wheezing and cough.