Montefiore issues passport to better outcomes
Partnership with primary care improves confidence
Managing asthma is never an easy task, but in the Bronx, which some clinicians say could have the highest prevalence of asthma in the United States, health care providers are particularly challenged to find ways to help their patients avoid symptoms of their disease.
Since 10% of the children living in New York City’s inner-city borough have asthma symptoms and the vast majority of them wind up in the clinic at Montefiore Medical Center, doctors there decided to look for ways to improve outcomes.
Preliminary results presented at the Pediatric Academic Societies’ annual meeting in San Francisco in May showed that Montefiore Asthma Passport Program works.
Karen Warman, MD, a pediatrician at Montefiore and assistant professor of pediatrics at Albert Einstein College of Medicine in the Bronx, found that patients in the intensive preventive care program had fewer hospitalizations than those under standard care and had a better understanding of appropriate asthma management at home.
In addition, participants had a better relationship with their doctors, which gave patients and their families higher confidence in their ability to manage their asthma and prevent acute exacerbations.
"I think what the program has taught us, so far, is how important it is for families to feel like they have a partnership with the entire health care team," Warman says. "We found that primary care-based interventions can improve some aspects of asthma care for inner-city children."
Continuity of care is key element
What is key to developing that sense of partnership, Warman says, is continuity of care. Unlike many managed care and inner-city clinic settings where patients have to take pot luck depending on which physician is on duty when they come in, Montefiore patients have one physician they see on a regular basis.
"What changed as a part of the intensive primary care component of the Passport program was that families were more likely to rely on a doctor to answer questions," Warman says. "They felt the doctors really cared and were there for them. They knew they were not alone."
She notes that he previous research showed that only about 5% of parents know when to start medications and fewer than 1% would use a peak flow meter to determine the child’s asthma status. "It’s so important that they know what to do when an attack begins," she says.
Warman and her colleagues began with 220 children ages 2 to 12 in January 1995 and randomized them — half to the Passport program and half to standard care. All children had at least one hospitalization in the previous year. Warman says they were pleasantly surprised when 90% of the children completed the year-long program.
The results: Passport program participants had:
• fewer hospitalizations (65.5% vs. 83%);
• more received flu shots (62% vs. 40%);
• more had written plans (66% vs. 44%);
• more reported using spacers (63% vs. 47%)
• more reported using peak flow meters (53% vs. 29%);
• more reported using mattress casings ( 49% vs. 35%);
• reported use of long-term control agents and responses to acute exacerbations did not differ, nor did symptom days, number of asthma attacks, ill visits, ED visits, or school absences.
At the beginning of the program, patients received a "passport," a heavy cardboard-type trifold document similar to an immunization record, that contained information necessary for prompt and effective emergency treatment: the name of the patient’s doctor, contact phone numbers, medications, and warning signs.
It also contains the patient’s individualized home management program and an asthma learning record that shows which asthma management educational modules they completed. "We found that a written plan signed by all parties, a contract, improves adherence," Warman says.
The passport plan relies on the green, yellow, and red zone concept, a simple road map to help parents determine when peak flows are diminishing to a point where medical intervention is necessary. (See box, p. 77.)
Those enrolled in the passport program received a strong educational component based on the National Asthma Education and Prevention Program’s (NAEPP) guidelines — with a few modifications.
"We modified the NAEPP teaching worksheets for our population by simplifying the language, streamlining the information, and creating a Spanish language version," Warman says.
For example, in discussing the use of anti-inflammatories, Warman thinks the word is a long one and the concept is complicated. "Instead, we bring home the idea of preventive medications or asthma controllers vs. rescue medicines," she says.
The team also re-designed the NAEPP worksheets to make them more culturally applicable and visually interesting using their own graphics and highlights of important concepts.
An asthma nurse educator met with each participating family to introduce the program, help devise a management program, and demonstrate the proper use of equipment. Families were encouraged to see their primary care providers to review the passport plan over the next 12 months.
"Our most recent data show that 55% of the passport plan kids’ visits to a primary care physician were preventive, as opposed to 38% for the control group," Warman says. "That is significant because it shows they are using the doctors as a resource, as they should."
Data were collected by telephone at baseline, six months, and 12 months into the program.
"We barraged them with letters, too. I think that helped," Warman says. Basically, Warman’s plan was to "get the message out" to patients in whatever ways they can. "There’s a lot of learning to do," she says. "We need to help them understand how important it is to prevent acute attacks. We need to increase their confidence and change medications when necessary."
Warman’s study won the Ambulatory Pediatric Association’s 1999 Ray E. Helfer award for innovation in pediatric education.
"Everybody is talking, and not much is helping so far to educate families and prevent kids from deteriorating," notes Tom Humphries, MD, MBA, chairman of the North Carolina Asthma Board and a practicing pediatric pulmonoligist and allergist in Charlotte, NC.
Humphries, whose practice follows 5,000 patients with asthma, says the guidelines are out there, but says he is frustrated because "something is not working" in terms of asthma education. He applauds the Passport program but says the intensive intervention and the large amount of time spent with primary care physicians is probably not practical in the everyday world of medical practice.
Humphries is working with fellow physicians and the American Lung Association to formulate standards for the certification of asthma educators, similar to those which govern certified diabetes educators.
"We’re trying to come up with something that will work in the real world. A nurse educator is less expensive and can be the asthma activist in a primary care office and can pick up warning signs early," says Humphries. "If it makes economic sense, then it will work."
[Contact Karen Warman at (718) 405-8090 and Tom Humphries at (704) 338-9818.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content