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CHS Research News
Vol 17, Issue 3, Fall 2005

Feature Article

Childhood asthma: Innovations in service design can help kids breathe easier

By Katie Saunders

Group Health Center for Health Studies Associate Investigator and pediatrician Paula Lozano, MD, MPH, was drawn to study asthma 11 years ago for two reasons. One, she saw the disease’s impact on kids and their families. And two, she saw the potential for medical care to make a difference.

Asthma is the most common chronic condition in childhood. It impairs breathing by obstructing air coming out of the lungs. Attacks can lead to emergency room visits, hospitalizations, and even death—not to mention lost school days, parents’ work absences, and high rates of health care utilization. Although the consequences can be dire, there’s a lot the medical profession can do to help patients successfully manage their condition, as outlined in guidelines issued by the National Institutes of Health in 1991 and 1997.

"If you waved a magic wand and implemented these guidelines immediately, there’s reason to believe that asthma care would be improved for lots of kids," says Lozano. Unfortunately, there is no magic wand and, as with other conditions, issuing of the guidelines for asthma did not translate into widespread adoption.

In recent years however, Lozano and her colleagues have shown that medical practices that use "a planned-care model" (aka "the Chronic Care Model") to treat childhood asthma can make significant progress toward following evidence-based guidelines. And this, in turn, makes a big difference in the well-being of the children these practices care for.

Planned-care model helps families learn to control inflammation

One key guideline recommendation is that kids suffering from moderate to severe asthma use inhaled anti-inflammatory medications daily to prevent and combat inflammation in the lungs. This understanding that asthma is a disease of chronic inflammation evolved over time, according to Lozano. In the distant past, the disease was thought to be caused primarily by emotional or hysterical reactions. While emotions are still recognized as triggers (Lozano is currently working on a grant examining the comorbidity of asthma and anxiety), this simplistic explanatory model has been replaced by a view of asthma as a complex illness involving many factors.

The dominant therapy in the 1960s through the mid-1980s consisted of various medications—"relievers"—that eased symptoms such as wheezing by relaxing the smooth muscles in the lungs. Although some of these medications are still used for quick relief, scientific breakthroughs in the 1970s and early 1980s exposed asthma as primarily a disease of chronic inflammation. That is, the lining of the airways becomes inflamed, causing swelling that radically reduces the size of the breathing tube. In addition, asthma generates a large amount of mucous, further restricting the breathing passage. According to Lozano, the "reliever" medications are only partially effective because they do not treat the underlying inflammation. In contrast, inhaled anti-inflammatory medications—"controllers"—target the root cause of asthma and have been found (in studies by Lozano and others) to reduce emergency room visits and hospitalizations caused by the condition.

Despite their efficacy, "controller" medications are used regularly by only a fraction of the target population of kids with moderate to severe asthma. Why? Providers’ prescribing habits and patient adherence both play a role. Lozano points out that "controller" medications, unlike "reliever" medications, do not provide instant relief, since reversing the inflammation takes longer than simply easing symptoms. This lack of "instant feedback" may cause people to doubt the medication’s effectiveness, and consequently, to stop using the drug. Other potential reasons for patient non-compliance include fears of adverse events and, as revealed in an analysis by Lozano and colleagues, parents’ misunderstanding of the preventive nature of these medications (e.g., some think they’re for symptom relief).

Providers are also a factor in the under-use of "controller" medications. Although a survey by Lozano and colleagues revealed that a majority of providers are familiar with the guideline recommendations, implementing them is easier said than done. Lozano explains that providers must place patients into one of four categories, which, in turn, dictate the appropriate treatment. Such assessments require both time and a specific skill set—attributes that might be in short supply in a busy primary care practice. According to Lozano, this situation exemplifies the underlying premise of the Chronic Care Model developed by CHS Senior Investigator Ed Wagner, MD, MPH, and his colleagues at CHS’ MacColl Institute. That is, simple knowledge of a guideline is not sufficient. Rather, systems must also be in place to support providers in complying with guideline recommendations.

Other aspects of the Chronic Care Model—including patient registries, clinical information systems, decision support, and practice reorganization—are potential tools available to a health care system to support the proactive treatment of chronic conditions such as asthma. Lozano and colleagues put some of these methods to the test in a randomized trial designed to evaluate a "planned-care method" of providing primary care for children with asthma. The method involved regularly scheduled visits with specially trained nurses to help families learn how to manage symptoms. Specifically, at each visit the nurse:

• Assessed asthma symptoms, medication use, environmental triggers and self management skills;

• Supported and assisted with care planning (including medication and environmental control measures); and

• Provided self-management support such as problem-solving and motivational techniques to encourage medication adherence and reducing environmental triggers. (Indoor allergens and irritants such as tobacco smoke, furry pets, household pests such as cockroaches, and dust mites have been found to exacerbate asthma. A survey of parents of children with asthma conducted by Lozano and colleagues found that exposure to environmental triggers was common and that few families received written instructions on how to reduce their exposure. )

The asthma nurse shared her assessment with the primary care physician, who also received extra education in asthma management. After two years, the researchers found that compared to children in usual care, the children in the planned-care practices: 

• had 13 fewer days of symptoms per year; 

• needed a third less rescue medication; and 

• used their medication as prescribed, according to parent’s reports.

Summarizes Lozano: "Our profession has developed some great evidence-based guidelines for asthma care and we know that if we follow them, children have improved outcomes. But the fact is, a busy primary care doctor cannot possibly provide all the guidance that’s needed. But if we reorganize our practice teams, we can do it."

Research addresses racial/ethnic disparities in care

Using the planned-care model is just one way to improve asthma care for children. Another perplexing issue that has attracted Lozano’s attention is the racial/ethnic disparities in processes of care and outcomes. Lower income and minority children are disproportionately affected by asthma, and lower financial access to health care is not the only explanation, according key findings of the Asthma Care Quality Assessment (ACQA) Project, a collaborative effort involving Lozano, and Tracy Lieu and Jonathan Finkelstein of Harvard Pilgrim Health Plan, and others. ACQA consisted of a telephone survey of parents of children aged 2 to 16 years with asthma who are insured by Medicaid at one of five managed care plans, including Group Health. Overall, 73 percent of kids with persistent asthma were under-users of controller therapy, with blacks and Latinos significantly more likely to under-use than whites. Thus, even with equal financial access to health care, minorities were less likely to use preventive therapy.

Lozano and colleagues offered several possible explanations for this finding, including racial/ethnic differences in health beliefs and concepts of disease, difference in beliefs about the value of prevention, fears about steroids, and/or lack of regularity in the life of the family. Communication barriers between patients and providers, due to a lack of awareness of patients’ health beliefs and/or language difficulties, were another potential explanation for racial/ethnic disparities in asthma care.

The ACQA researchers explored some of these explanations empirically through survey data provided by the children’s primary care providers and practice site administrators. They were particularly interested in the relationship between asthma quality of care and practice site (clinic) policies regarding chronic care, primary care, and low-income populations. Examples of the latter, also referred to as policies to promote cultural competence, included: recruiting ethnically diverse or bilingual nurses and providers; offering cross-cultural or diversity training to staff; and offering training to providers to develop communication skills. Chronic-care policies referred to activities promoted by the Chronic Care Model, such as providing feedback reports to providers and offering patients self-management tools such as low-cost peak-flow meters and written asthma care plans. To assess primary care policies, the researchers asked about access and continuity (e.g., telephone advice and same-day appointments are always available; acute visits in urgent care are followed up in primary care) and case-management and care coordination (e.g., asthma nurses are available to provide case management).

Low-income children in practice sites with the strongest policies to encourage cultural competence were less likely to under-use preventive asthma medications, as were kids in sites with policies to promote access and continuity of care. Further, clinicians were less likely to under-prescribe controller medications if they received asthma reports. Based on these encouraging findings, the researchers argue that these health plan policies, especially those related to cultural competence, should be further evaluated in future interventional studies.

Lessons may apply to other pediatric issues

Asked about future research, Lozano describes her interest in developing self-management strategies that can be applied to all kinds of child health issues—not just asthma care. She explains that most of the available self-care strategies—care planning, peer support, problem-solving strategies—have not been explored in pediatric settings. "It’s a leap to say that strategies proven successful in adults will work in kids," says Lozano. "Kids are developing along a continuum. At what point can you ask them to take responsibility for their adherence to medications, avoiding tobacco smoke, eating healthily, or exercising? That, for me, is a really exciting frontier."

Lozano is equally animated when talking about her collaborators, emphasizing that her work on asthma would not be possible without a multi-disciplinary team. She singles out Ed Wagner, Kevin Weiss (Northwestern University), Jon Finkelstein and Tracy Lieu (Harvard Pilgrim Health Plan), CHS Biostatistician Lou Grothaus, and Vince Carey (Harvard University).

Lozano is gratified that her team’s work was so prominently featured in a June 2005 publication from the Agency for Healthcare Research and Quality titled, "Chronic Care for Low Income Children with Asthma: Strategies for Improvement."

"On a good day, research is incremental," says Lozano. "What most of us hope for is to contribute information to a body of knowledge and help to improve care. I feel that the team that I’ve been a part of has done that," she says.

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