Translating an Efficacious Illness Management Intervention for African American Youth with Poorly Controlled Asthma to Real World Settings

迫切需要制定干预措施，以减少最佳哮喘管理的障碍， 减少少数群体儿童，特别是非洲儿童患哮喘相关疾病的重大风险， 美国青少年哮喘控制不佳很少有针对非裔美国人的临床试验 哮喘控制不佳的青少年，以及针对非裔美国青少年的干预研究 一般哮喘患者或非裔美国儿童哮喘控制不佳， 其特征在于方法上的局限性和/或对客观健康结果的影响有限。多系统 治疗保健（MST-HC）是一种密集的，多成分的，以家庭为基础的心理治疗， 在个人、家庭和社区系统中，青少年哮喘管理不良的多种原因。在 一项随机临床试验，我们发现MST-HC比以家庭为基础的家庭更有效 支持改善非洲人对控制药物的依从性和改善肺功能， 美国青少年中重度哮喘，哮喘控制不佳，完成后长达6个月 的干预。此外，MST-HC减少了哮喘相关的住院和相关的艾德就诊。 拟议研究的主要目的是调整MST-HC，使其适用于真实的世界公共医疗保健环境 并在T3转化试验中进行测试。新的干预措施，达到控制（RFC），将被安置在一个 儿科急诊科（艾德）在密歇根州儿童医院（CHM），并将适应交付 社区卫生工作者（CHW）。该设计是一种有效实施的“混合1”设计， 主要目的是确定在现实世界环境中循证干预的有效性， 次要目标是收集有关实施背景和障碍/促进因素的信息 执行。对于我们的有效性目标，我们将进行一项随机有效性试验， 在艾德因哮喘急性发作而就诊的哮喘控制不佳的高危青少年。RFC将 由韦恩儿童医疗保健访问计划提供，该计划是一个提供医疗保健的社区机构 服务不足的儿童在底特律地区，并将比较该机构的标准照顾 对哮喘控制不佳的青少年进行干预。为达致推行计划的目的，我们会评估 艾德临床工作人员通过临床路径识别、筛选和转介RFC的有效性。我们将 研究RFC实施的障碍和促进因素（包括其在艾德内的整合和 CHW）使用混合方法。我们还将开发和评估一种有效的方法， 测量CHW对RFC的忠诚度，并进行成本分析，为治疗等决策提供信息 剂量和CHW病例量。如果成功，这项研究有可能 提高弱势群体的生活质量，同时降低医疗保健费用。

There is a critical need to develop interventions to reduce barriers to optimal asthma management and reduce the significant risk for asthma-related morbidity experienced by minority children, especially African- American adolescents with poorly controlled asthma. There are few clinical trials focusing on African-American adolescents with poorly controlled asthma, and intervention studies targeting African-American adolescents with asthma in general or African-American children with poorly controlled asthma in particular are characterized by methodological limitations and/or limited effects on objective health outcomes. Multisystemic Therapy-Health Care (MST-HC) is an intensive, multi-component, home-based psychotherapy that targets the multiple causes of poor adolescent asthma management across individual, family and community systems. In a randomized clinical trial, we showed that MST-HC was significantly more effective than home-based family support in improving adherence to controller medications and improving lung functioning among African- American adolescents with moderate to severe, poorly controlled asthma up to six months after the completion of the intervention. In addition, MST-HC reduced asthma-related hospitalizations and associated ED visits. The primary purpose of the proposed study is to adapt MST-HC for use in real world, public healthcare settings and test it in a T3 translational trial. The new intervention, Reach for Control (RFC), will be housed in a pediatric emergency department (ED) at Children's Hospital of Michigan (CHM)and will be adapted for delivery by community health workers (CHWs). The design is an effectiveness-implementation “Hybrid 1” design where the primary aims are to determine the effectiveness of an evidence-based intervention in a real-world setting, and the secondary aims are to gather information about the context for implementation and barriers/ facilitators to implementation. For our effectiveness aim, we will conduct a randomized effectiveness trial with 170 high risk adolescents with poorly controlled asthma seen in the ED for an asthma exacerbation. RFC will be delivered by Wayne Children's Healthcare Access Program, a community agency providing health care services to underserved children in the Detroit area and will be compared to the agency's standard care intervention for youth with poorly controlled asthma. For our implementation aims, we will evaluate the effectiveness of identification, screening and referral to RFC by ED clinical staff via a clinical pathway. We will study barriers and facilitators to the implementation of RFC (both its integration within the ED and delivery by CHWs) using a mixed methods approach. We will also develop and evaluate an efficient and effective method of measuring CHW fidelity to RFC and conduct a cost analysis that will inform decisions such as treatment dose and CHW caseload in future real-world implementations. If successful, the study has the potential to improve quality of life for a vulnerable population while reducing healthcare costs.