Improving Pediatric Asthma Care in the District of Columbia (IMPACT DC)
Where They Are
“For many children, especially those in major cities, the emergency department is the primary source of asthma care,” says Stephen Teach, M.D., medical director of IMPACT DC, a pediatric asthma surveillance, research and intervention project located at Children’s National Medical Center. “We are attempting to break this cycle of dependence.”
“Repeat visits to the emergency department are the ‘canary in the coal mine,’” says Dr. Teach. “They mean something’s wrong.” In southeast Washington, D.C., Dr. Teach could see that something was wrong. Each year, he and his colleagues saw more than 6,000 asthma-related visits in the ED. That’s nearly 1 percent of all pediatric asthma emergency visits nationwide.
With support from the Robert Wood Johnson Foundation through the Emergency Department Demonstration Program, Dr. Teach designed a clinic based on two strongly held convictions. The first is that emergency departments must acknowledge their long-term role in combating chronic diseases such as asthma, particularly among children. The second is that emergency departments should not take the place of primary care, but should reinforce the role of primary care and strengthen ties between families and their physicians.
By leveraging families’ familiarity and comfort with the urban ED, and by supporting timely follow-up care, IMPACT DC capitalized on the “teachable moment” available during the ED visit to the patients’ ultimate benefit.
Mapping Geospatial Access
In Washington, as in many other American cities, numerous factors come together to make life difficult for people with asthma: humid climate, poor housing and inadequate access to primary care. Surveillance data from IMPACT DC clearly shows how poor access to primary pediatric care in Washington, D.C., is associated with fewer scheduled asthma visits. “Our mapping demonstrates strong local racial, ethnic and economic disparities in asthma care and outcomes. ED visits are most common among children from areas marked by poverty, high concentrations of minority residents and poor spatial access to primary care,” says Dr. Teach.
The vast majority of ED visits are made by children in the most disadvantaged areas of the District.
In response, Dr. Teach created a model that meets parents and their children with asthma where they are—in the emergency department. Though he and his team emphasized linking to primary care providers, they also encouraged children and families to return to the emergency department two to 15 days after an acute visit for asthma for a single, 90-minute educational session aimed at helping them take charge of asthma. Seventy percent of 488 children followed through with their appointments. At six months, significantly more children in the intervention group reported use of asthma controller medications and no functional limitations on their quality of life due to asthma. In addition, they made 40 percent fewer ED visits for asthma during the follow-up period. The study was published in the May 2006 issue of Archives of Pediatrics & Adolescent Medicine. “Our study was designed to capitalize on the ‘teachable moment,’” says Dr. Teach, “It was also comprehensive and highly family- and patient-centered, an approach that has been shown to be especially important to inner-city families.”
Strengthening the Continuum
During the follow-up visits to the IMPACT DC Asthma Clinic, educators try to work within the scope of families’ limited resources. Understanding medications and their proper use is key, and sessions cover use of metered dose inhalers (MDIs) and spacers, dry powder inhalers, nebulizers and peak flow meters. While extensive environmental remediation is often out of reach for these families, says Deborah Quint, IMPACT DC’s project director, the clinic helps parents focus on creating trigger-free “safe sleep zones.” The clinic sees 40 to 50 families a month, with higher numbers in the winter months.
While highly individualized, each session includes helping patients set up additional visits with their primary care provider. After each clinic visit, the IMPACT DC staff generates a highly individualized letter addressed to the child’s primary care provider that includes an updated asthma action plan. The staff also schedules a follow-up appointment for each patient with their primary care provider. “We see coordination with primary care as among the most crucial things we do,” says Quint. “We help families see their primary care doctor as their ‘asthma provider,’ and provide them with tools to strengthen that relationship. The bottom line is that we want each child to have a medical home.” The program has also been able to provide each child’s school nurse with an individualized asthma action plan.
For many families long crippled by school and work days missed due to asthma, the control offered by the clinic’s education is life-changing. “People really do feel that their lives are changed by this intervention,” says Quint. “In many cases, they’ve never received this basic asthma education. Suddenly, they know what to do to keep their kids healthy, and it’s very empowering.”
In only a few short years, the IMPACT DC Asthma Clinic has become an institution at Children’s National Medical Center. Residents seek it out. Colleagues refer to it. Consistently, Dr. Teach and his ED team have reached out and educated hospital staff about the program’s impressive outcomes. “Having validated the efficacy of our model,” says Dr. Teach, “our next goal is to refine and expand it, bringing even more partners into the process of reducing asthma morbidity among disadvantaged children.”
IMPACT DC at Children’s National Medical Center uses families’ familiarity with the emergency department (ED) as a site of care to recruit them into a program that provides asthma education and encourages families to seek a long-term relationship with their primary care provider. Within two weeks after an asthma-related ED visit, patients return to the IMPACT DC Asthma Clinic where they are taught both medical and environmental management of asthma. The follow-up clinic operates within the ED itself and also at a community site within an area of high pediatric asthma prevalence. IMPACT DC also works with school nurses and local organizations to provide necessary equipment, smoking cessation education, tenant advocacy, outreach and home visits.
The program originated in the emergency department at Children’s National Medical Center, and has become a fully institutionalized program there. IMPACT DC also works closely with the National Capital Asthma Coalition.
Strategies and Programs
- ED-based asthma clinic
- Patient and family education and medical care
- Referrals to primary care
Children and Families Served
The initial study followed 488 children for six months; today, an average of 40 to 50 new families per month receive asthma education in the IMPACT DC Asthma Clinic.
A randomized clinical trial showed significant improvements in the IMPACT DC group over the control group. Perhaps most importantly, more than 70 percent of patients randomized to the intervention group attended the IMPACT DC Asthma Clinic.
At a one-month follow-up (by intention-to-treat analysis):
- Use of a hypoallergenic mattress pad or pillow cover increased from 23 percent (control group) to 75 percent (intervention group).
- Daily smoking in the home reduced from 9.9 percent to 4.4 percent.
- Use of a written asthma action plan increased from 40 percent to 62 percent.
- Always using a spacer when taking medications by metered-dose inhaler increased from 27 percent to 49 percent.
At a six-month follow-up, improvements persisted:
- Unscheduled visits to urgent care or ED decreased (1.4 visits in intervention group vs. 2.3 visits in control group).
- Daily use of inhaled corticosteroids increased (49 percent in intervention group vs. 27 percent in control group).
- Search for and then capitalize on previously untapped opportunities for effective intervention.
- Develop asthma care interventions that are appropriate to the patient’s situation, can adjust to the patient’s unique needs and can be implemented by the patient’s family.
- Conduct a pilot to prove the concept and make the case for institutionalizing the intervention.
- Consider forming a consortium of hospitals to collect uniform health care data.
- Honor each hospital’s unique needs when conducting multi-hospital surveillance.
- When conducting an emergency department-based intervention study, expect busy periods to be challenging.
- Be prepared to conduct extensive outreach to primary care providers when undertaking an emergency department-based care intervention.
- Know that convincing managed care organizations to support a clinical service is not an easy sell.
The program has become a fully institutionalized program of Children’s National Medical Center. In 2006, the program won a National Environmental Leadership Award in Asthma Management from the EPA.