Pediatric Asthma Alert Intervention in Minority Children

描述（由申请人提供）：哮喘是幼儿儿科急诊科（ED）就诊的头号原因。依赖急诊科治疗哮喘是昂贵的，也是哮喘控制不良的危险指标。吸入皮质类固醇（ICS）是治疗持续性哮喘患者的基础，可以预防急性发作和ED就诊。然而，许多内城儿童没有接受或使用推荐的抗炎预防药物，往往是由于在急诊科就诊后随访不一致。本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，标准化的护理人员和医生提示干预（儿科哮喘警报领导者（PAAL））是否可以改善频繁急诊科就诊儿童基于指南的预防性哮喘护理。本研究建立在我们的父母-儿童初级保健提供者（PCP）沟通干预（哮喘沟通教育，ACE）的经验基础上，表明护士教授父母和儿童哮喘沟通技巧导致6个月时持续性哮喘儿童使用抗炎药物增加。然而，干预与适当的PCP随访没有关联，以维持预防性护理。建议的干预使用一名PAAL护士来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)组织和传递来自急诊科和家庭的关键健康信息给儿童的PCP就诊，3)授权家庭并促使PCP提供基于指南的哮喘护理（包括ICS处方，签署哮喘行动计划和安排重复的PCP就诊）。PAAL干预的目标是改善接受适当的预防性哮喘护理（每年PCP就诊2次）和适当使用抗炎药物（每年PCP就诊6次）（AIM 1），改善哮喘结局（症状昼夜、生活质量）（AIM2），并建立干预的成本效益（AIM 3）。将从两个大型城市儿科急诊科招募300名年龄在3-10岁的儿童家庭，这些儿童在过去一年中患有轻度持续性至重度持续性哮喘，并因哮喘就诊2次或住院1次，随机分为PAAL或SAE，并随访12个月。主要结局是非紧急哮喘就诊次数和抗炎处方补充率。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来比较两组之间的结果。双变量和多变量参数技术将用于比较PAAL组和SAE组之间的护理成本和效果。如果成功，这种相对简单且可报销的干预措施可能广泛适用于城市实践中的哮喘护理。公共卫生相关性：市中心患有哮喘的儿童急诊科（ED）就诊率最高。依赖急诊部门的哮喘护理可能是哮喘控制不良的危险迹象。这项研究的重点是，是否有一名专门的哮喘护士在孩子去急诊室看医生后加入家庭，以确保孩子和父母遵守后续预约，并让护士提醒孩子的医生开预防性哮喘药物和家庭哮喘行动计划，这将导致患有哮喘的幼儿减少喘息和咳嗽的天数。

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.