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Objectives: To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children., Methods: We prospectively enrolled 2-10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP "Acute Asthma" visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP., Results: One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5 ± 2.3 (standard deviation), range 0-10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2 ± 2.8; range 1-18. The mean number of PCP Acute Asthma visits/child was 0.7 ± 1.6; range 0-11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI -0.018, 0.06)., Conclusions: Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.

Purpose: To examine parent and child characteristics associated with engagement in a coaching intervention to improve pediatric asthma care and factors associated with readiness to adopt and maintain targeted asthma management behaviors., Methods: Using methods based on the Transtheoretical Model, trained lay coaches worked with 120 parents of children with asthma promoting adoption and maintenance of asthma management strategies (behaviors). Coaches assigned stage-of-change (on continuum: pre-contemplation, contemplation, preparation, action, maintenance) for each behavior every time it was discussed. Improvement in stage-of-change was analyzed for association with characteristics of the participants (parents and children) and coaching processes., Results: Having more coach contacts was associated with earlier first contact (p<0.001), fewer attempts per successful contact (p<0.001), prior asthma hospitalization (p=0.021), more intruding events (p<0.001), and less social support (p=0.048). In univariable models, three factors were associated with forward movement at least one stage for all three behaviors: more coach contacts overall, fewer attempts per successful contact, and more discussion/staging episodes for the particular behavior. In multivariable models adjusting for characteristics of participants and coaching process, the strongest predictor of any forward stage movement for each behavior was having more contacts (p<0.05)., Conclusions: Improvement in readiness to adopt and maintain asthma management behaviors was mostly associated with factors reflecting more engagement of participants in the program. Similar coaching interventions should focus on early and frequent contacts to achieve intervention goals, recognizing that parents of children with less severe disease and who have more social support may be more difficult to engage., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: To investigate whether asthma coaching decreases emergency department (ED) visits and hospitalizations and increases outpatient asthma monitoring visits., Design: Randomized controlled trial., Setting: Urban tertiary care children's hospital., Participants: Primary caregivers (hereafter referred to as parents) of children aged 2 to 10 years with asthma who have Medicaid insurance coverage and are urban residents who were attending the ED for acute asthma care., Intervention: Eighteen months of participating in usual care (control group) vs receiving coaching focused on asthma home management, completion of periodic outpatient asthma monitoring visits, and development of a collaborative relationship with a primary care provider (intervention group)., Main Outcome Measures: The primary outcome was ED visits. Secondary outcomes were hospitalizations and asthma monitoring visits (nonacute visits focused on asthma care). Outcomes were measured during the year before and 2 years after enrollment., Results: We included 120 intervention parents and 121 control parents. More children of coached parents had at least 1 asthma monitoring visit after enrollment (relative risk [RR], 1.21; 95% confidence interval [CI], 1.04-1.41), but proportions with at least 4 asthma monitoring visits during 2 years were low (20.0% in the intervention group vs 9.9% in the control group). Similar proportions of children in both study groups had at least 1 ED visit (59.2% in the intervention group vs 62.8% in the control group; RR, 0.94; 95% CI, 0.77-1.15) and at least 1 hospitalization (24.2% in the intervention group vs 26.4% in the control group; 0.91; 0.59-1.41) after enrollment. An ED visit after enrollment was more likely if an ED visit had occurred before enrollment (RR, 1.46; 95% CI, 1.16-1.86; adjusted for study group), but risk was similar in both study groups when adjusted for previous ED visits (1.02; 0.82-1.27)., Conclusion: This parental asthma coaching intervention increased outpatient asthma monitoring visits (although infrequent) but did not decrease ED visits., Trial Registration: clinicaltrials.gov Identifier: NCT00149500.

Objectives: To examine how exhaled nitric oxide (eNO) levels measured before and after treatment of asthma exacerbations relate to emergency department (ED) disposition., Methods: We enrolled children 6 to 17 years old treated for asthma exacerbations in a pediatric ED. Using an offline single-breath eNO sampling technique, we collected replicate initial samples before treatment and replicate final samples when disposition was decided. We determined correlations and coefficients of variability of eNO values (parts per billion, ppb) of samples and compared by disposition (hospitalization or discharge) mean initial and final eNO levels and initial-to-final change., Results: Eighty-one subjects had initial and final eNO values; 24 subjects with more severe presentations had final values only. Replicate eNO samples were correlated (initial r = 0.98, final r = 0.99) and had low coefficients of variability (initial, 0.059 ± 0.057; final, 0.061 ± 0.070). For subjects with initial and final values, initial eNO levels were similar by disposition (mean difference, -8.0 ppb; 95% confidence interval [CI], -24.8 to 8.9 ppb), as were final levels (mean difference, -2.8 ppb; 95% CI, -23.8 to 18.2 ppb). Overall, final eNO was higher than initial (36.3 ± 29.7 vs 31.5 ± 23.9 ppb), but only 63% of subjects had any increase. Change in eNO was similar by disposition (mean difference, 4.6 ppb; 95% CI, -3.4 to 12.6). For more severe subjects with final eNO only, eNO was similar by disposition (P = 0.47)., Conclusions: For children aged 6 to 17 years with asthma exacerbations, eNO levels can be reliably measured. However, eNO levels measured before treatment or when disposition was determined did not distinguish children needing hospitalization., (Copyright © 2011 by Lippincott Williams & Wilkins)

To describe an asthma management protocol used in a nurse-staffed pediatric After-Hours Call Center (AHCC) that incorporates severity-based home treatment recommendations and follow-up call assessments. Call records for asthma advice from January 1, 2004 to June 30, 2004 were identified retrospectively and reviewed. Descriptive statistics were used to report patient demographics, frequencies of symptom severity zones (Red, Yellow, or Green) at initial calls, frequencies of call dispositions designating care advice provided (including home treatment recommendations and seeking emergency department [ED] care), and changes in severity zones between initial calls and follow-up calls when nurses reassessed patients after recommended home treatment. During the study period, 3,632 asthma calls (2,439 initial; 1,193 follow-up) were managed by AHCC nurses. Initial calls were classified mostly as Red (28%) or Yellow (42%) severity zones; 27% were Green zone and 3% could not be categorized. Fifty-two percent of initial calls with Red or Yellow severity zones involved home treatment recommendations; 50% of those Red zone and 63% of those Yellow zone calls had improved severity zones at follow-up call assessments. Twenty-eight percent of patients with home treatment recommendations were referred to the ED at the time of follow-up call nurse reassessment. This telephone-based nurse-staffed pediatric acute asthma management protocol includes provision of severity-based home treatment recommendations and follow-up assessments, and improved symptoms for many children with acute exacerbations. This protocol may also be successful in other locations and may improve outcomes, such as reduction in ED visits.

Objective: To test whether community health workers are able to reach low-income parents of African American children hospitalized for asthma and to reduce rehospitalization among them., Design: A randomized controlled evaluation of usual care vs 2-year asthma coach intervention., Setting: An urban children's hospital and the surrounding community., Participants: A population-based sample of 306 children hospitalized for asthma met the inclusion criteria of being 2 to 8 years of age, of African American ethnicity, and having Medicaid coverage. Of these, 200 were contacted and 191 recruited with commitment to evaluation activities but, in order to assess reach, no commitment to participating in intervention., Interventions: Coaches reinforced basic asthma education and encouraged key management behaviors through home visits and phone calls tailored to parent's readiness to adopt management practices and emphasizing a nondirective supportive style (cooperative and accepting of feelings and choices)., Outcome Measures: The reach of intervention to parents, contacts with coaches, and rehospitalization over 2 years based on hospital records., Results: Within 3 months of randomization to the asthma coach group, 89.6% of parents had at least 1 substantive contact with the coach, with an average of 21.1 contacts per parent over the 24-month intervention. The proportion of children rehospitalized was 35 of 96 (36.5%) in the asthma coach group and 55 of 93 (59.1%) in the usual care group (P < .01), controlling for parental education and child age, sex, and hospitalization in the year prior to the index hospitalization. In surveys, parents indicated the importance of the nondirective approach to support., Conclusions: An asthma coach can reach low-income parents of African American children hospitalized for asthma and reduce rehospitalization among the children.

Objective: We hypothesized that children with moderate acute asthma exacerbations receiving oral montelukast with standard therapy will have at least 12% greater forced expiratory volume in 1 second (FEV1) improvement in 3 hours than those receiving standard therapy alone., Methods: In this randomized, double-blind, placebo-controlled study, we enrolled emergency patients aged 6 to 14 years with moderate acute asthma exacerbations (peak expiratory flow rate, 40%-70% predicted). Subjects received montelukast 5 mg or placebo orally then standard therapy. We measured FEV1 before study medication administration and hourly for 3 hours. The primary outcome was FEV1% predicted change at 3 hours., Results: At the time of the planned interim analysis, we had enrolled 27 subjects; 23 (11 montelukast, 12 placebo) had a complete FEV1 data. Both groups had similar mean FEV1 increases at 3 hours (mean [SD]: montelukast = 16.8% [11.4%], placebo = 19.9% [12.1%]; 95% confidence interval for difference = -12.22% to 5.95%). Based on further analysis, we determined that enrollment of the planned sample was unlikely to significantly change the results. If our study hypothesis were true, the montelukast group mean FEV1 increase should be 32% or greater. The probabilities were low that the montelukast sample could be drawn from a normally distributed population with a mean of 32% and that subsequently enrolled montelukast subjects would have sufficient FEV1 improvements to attain a mean of greater than 32%., Conclusion: Based on these results, for children aged 6 to 14 years with moderate acute asthma exacerbations, oral montelukast (5 mg) added to standard therapy as in this design is unlikely to result in additional FEV1 improvements in 3 hours.

Objectives: Coaching and monetary incentives have been used to modify medical behavior of individuals with several chronic diseases, including asthma. The authors performed a randomized, controlled trial of an intervention combining asthma coaching during an emergency department (ED) visit for asthma, and monetary incentive to improve follow-up with primary care providers (PCP)., Methods: Subjects were parents of children 2-12 years of age, with Medicaid or no medical insurance, receiving treatment for asthma in the ED. The primary outcome was a verified PCP visit for asthma within two weeks of the index ED visit. All parents received 15 dollars for their time in the ED. Parents in the intervention group were told that they would receive an additional 15 dollars monetary incentive if a PCP visit was completed. The coach engaged in a dialogue with the parent during the ED visit, and discussed the importance and advantages of seeking follow-up care with the child's PCP. All parents received the usual discharge instructions, including advice to see the PCP within three days., Results: The authors enrolled 92 parents; outcome data were available for 86 (42 controls, 50 intervention). Demographic characteristics were similar in both groups. There was no significant difference in the proportion of patients who had follow-up PCP visits between the intervention (22.0%; 95% confidence interval [95% CI] = 11.5% to 36.0%) and control (23.8%; 95% CI = 12.0% to 39.4%) groups (p = 0.99)., Conclusions: An intervention combining asthma coaching during acute ED visits and a monetary incentive to return for a PCP visit does not appear to increase follow-up with the PCP.

Objective: To improve follow-up with primary care providers after acute Emergency Department (ED) asthma visits for children from low-income urban families., Study Design: A prospective, randomized, controlled trial evaluated combined telephone asthma coaching and monetary incentive. The primary outcome was asthma-planning visits with primary care providers within 15 days of index ED visits. The subjects were urban parents whose children were treated for asthma in the ED and had Medicaid or no insurance., Results: We enrolled 527 parents (264 control and 263 intervention). There was a significant difference ( P < .0001) between the intervention (35.7%) and control (18.9%) groups in the proportion of children who had asthma-planning visits and decreased mean nights/days with asthma symptoms by 4.36 intervention and 3.31 control at 2 weeks. The proportions of children with asthma-planning visits and acute asthma care visits during the 16-day to 6-month period were similar for both groups., Conclusions: Telephone coaching and a monetary incentive significantly increased the proportion of low-income urban parents who brought their children for asthma-planning visits, and decreased asthma symptoms shortly after asthma ED visits. The intervention did not increase subsequent asthma-planning visits or decrease ED visits or hospitalizations.

Studies of asthma admissions in the St. Louis metropolitan area have disclosed substantial numbers of children with readmissions. To determine the magnitude of readmissions and attributes of children with readmissions, a retrospective analysis of 8,761 children with 14,905 asthma hospitalizations for January 1, 1990 through December 31, 1999 at the two university affiliated children's hospitals in St. Louis was undertaken. Patient attributes of age, sex, race/ethnicity, residence, payor status, length of stay, and month of admission were compared between patients admitted once during that period and patients admitted multiple times. Main outcome measures were the total number of admissions and time to readmission during the study interval. A Lin, Wei, Yang, and Ying model of time to readmission showed that African-American children with Medicaid or no insurance are at higher risk of readmission (risk ratio 1.28) than are African-American patients with commercial insurance or white/other race/ethnicity patients regardless of insurance. Probability of readmission increased from 30% after a first admission, 46% after a second, and 59% after a third. Prior admission was a more specific indicator of readmission with greater positive predictive value than ethnicity or insurance status or their combination.