MADRID – Use of practice-based asthma navigators significantly reduced symptoms and emergency room and inpatient visits among inner-city children with moderate to severe asthma in a prospective, case-matched study.
"We’ve seen with our home-visit studies that we’re able to reduce asthma morbidity, but what we hear from the parents all the time is that they feel their communication with providers is lacking, and that they really needed someone to help them navigate the clinical system," Dr. Tyra Bryant-Stephens, founder and director of the Community Asthma Prevention Program at Children’s Hospital of Philadelphia (CHOP), said in an interview.
To overcome this hurdle, CHOP began integrating community health workers as asthma navigators into the clinical team at its inner-city asthma clinics. Key tasks are to teach caregivers about the Asthma Care Plan and proper use of controller medications, facilitate appointment scheduling and set up reminders, contact and share asthma care plans with school nurses, work with social workers to identify appropriate resources for families, and set care coordination goals.
Patrice Wendling/Frontline Medical News
Dr. Tyra Bryant-Stephens
The study enrolled children, aged 2-17 years, on at least two asthma control medications. The participants had been hospitalized or had at least two emergency department (ED) visits in the past year. Their average age was 4.6 years.
After 12 months in the navigator program, preliminary data on 99 children revealed a clear 2- to 3-day reduction over the past 14 days in days using rescue asthma medications (5.28 vs. 3.07; P less than .01), days with symptoms (6.93 to 3.8; P less than .01), and nights with symptoms (6.11 to 3.34; P less than .01), Dr. Bryant-Stephens reported at the world congress of the American College of Chest Physicians.
Compared with baseline, the number of days not taking asthma medications at 12 months was not significantly different (1.48 vs. 1.22) nor was the number of days during which activities had to be slowed (4.41 vs. 3.73).
Enrollment in the navigator program, however, lowered the number of school days missed (16 vs. 2; P less than .05), workdays missed (9.11 vs. 1.13; P less than .01), unscheduled visits to the doctor (2.5 vs. 0.5; P less than .05), ED visits (3.65 vs. 1.31; P less than .01), and hospitalizations (1.73 vs. 0.4; P less than .01).
Although the final analysis comparing participants with matched controls receiving usual care is not yet complete, the data so far show a definite reduction in health care utilization by participants, despite controls being less sick at baseline, Dr. Bryant-Stephens said. This is particularly encouraging because earlier studies at CHOP showed that roughly 50% of asthmatic children never made it back to their primary care physician for follow-up between ED visits.
Making appointments for and keeping follow-up visits were listed by 146 of 157 (93%) caregivers as one of the most important care coordination goals, and were achieved by 80% at 12 months with the assistance of phone calls from the asthma navigator, transportation tokens, and insurance cotransportation, according to the poster presentation.
Success among the other top five caregiver goals was 92% for learning how to properly use asthma medications (126/136 caregivers), 98% for reducing asthma triggers (154/157), 54% for stopping smoking in the house and car (23/42), and 94% for the surprising goal of losing weight in hopes it would reduce asthma symptoms (34/36).
There is no "magic bullet," or single component of the navigator program responsible for the results, but "I think what the navigators have been most effective at is bringing them back to the office. It’s unbelievable compared with the control group," Dr. Bryant-Stephens said at the meeting.
Ultimately, the goal is to make the program self-sufficient, with a pilot program currently underway in which Pennsylvania’s largest Medicaid provider, Keystone First, will pay CHOP to have their clients assigned an asthma navigator when they enroll at an asthma clinic.
Dr. Bryant-Stephens reported funding from the Merck Childhood Asthma Network.