Reducing Asthma Disparities in Children: A Model Program with Promising Results Full
11
October

By Adem Lewis / in , , /


MOLLY MITCHELL: Good
afternoon, everyone. It’s a pleasure to
see you all here. My name’s Molly Mitchell and
I’m with the Mid-Atlantic Public Health Training Center. And on behalf of
the Training Center and the Maryland Department
of Health and Mental Hygiene, I’d like to welcome you all here
for our June 2012 public health practice grand rounds. And today’s topic is on
reducing asthma disparities in children, a model program
with promising results. And before we get started
with our two presenters, I just want to make
a few announcements about some of our trainings
that are coming up. And for those of you who
are watching us online, if you would, please, click
on the link for signing in. That’ll give us a
better count for us to report to our federal
funders of how many people were training today. And also, for those
watching online, you can also just
click, at any point, on the link on the
screen if you have a question for either
one of our presenters. That way you can send an
email question in for them. And we’ll have Q&A at
the end of the session. And while you’re
on our website, you can also look at some of our
upcoming trainings, which include public health nursing
and achieving outcomes through best process program
design and evaluation. And we also have a
new course I want to just draw your
attention to, Leading Change Through Communication;
Strategic Use of Old and New Media. It’s taught by faculty
at the Hopkins Center for Communications programs. And it’s meant for anyone
who’s engaged in communication to try to change behavior. It’s going to have
four live talks. There are 10 modules. It’s going through
July and August. So please, for more information,
check that out on our website as well. And so with that, I think I’m
going go ahead and introduce our two presenters today. First, we have Dr. Greg Diette. Dr. Diette is
professor of medicine and epidemiology at the
Johns Hopkins University School of Medicine where he is
a director of clinical research in the division of pulmonary
and critical care medicine. Dr. Diette received his
undergraduate degree in economics from Wharton
School of the University of Pennsylvania, his M.D.
From Temple University and a master’s in epidemiology
from the Johns Hopkins Bloomberg School
of Public Health. He’s a pulmonologist
and has a practice devoted to the care of adults
with obstructive lung diseases, including asthma and COPD. He has an extensive portfolio
of patient-based research in asthma and COPD supported
by the NIH and other sponsors. His current research
focuses on identifying factors that cause
or provoke asthma, especially air pollutants
and allergens that are problematic in intercity homes. He has also begun examining
how dietary patterns may increase susceptibility
to inhalable pollutants in allergens. And we also have Kate Scott. Ms. Scott is an asthma program
director for the Baltimore City Health Department. She oversees clinical
asthma programs, including a CDC-funded
translational research grant for asthma
home-visiting services. She has presented project
findings at conferences nationwide and is
a frequent resource for agencies seeking to initiate
effective asthma programs. She represents the
health department on the Department
of Health and Mental Hygiene Maryland Asthma
Control program executive committee and the Greater
Baltimore Asthma Alliance. Prior to coming to
the health department, Ms. Scott was an HIV aids
clinic and inpatient nurse at Johns Hopkins Hospital. She started her career in public
health serving as a Peace Corps volunteer in Central America
and received her RN and MPH from Johns Hopkins. And with that, I’m going to hand
the floor over to Dr. Diette. Thank you. GREGORY B DIETTE:
Thanks very much. And thanks for joining us
online and here in person. I’m going to go
first before Kate to try to give you an
idea of some of the work that we’ve done at
Hopkins that sets up the kind of intervention
that Kate’s working on and give you an idea of why
we’ve been working together on that. And I’m going to
focus on findings that come from our own center,
the Center for Childhood Asthma in the Urban Environment. I want to start by telling
you about a boy that is in one of our studies. And when we met him,
he was 10 years old. He’s African-American and
lives in East Baltimore, which is where Hopkins is located,
household income was low. And he’s very symptomatic,
so in a two-week period, he’d had four days
with symptoms, he’d woken up two nights,
and in the past three months, he’d had four unscheduled
doctor visits for his asthma. He’s on a whole
host of medications and most of the ones that
we know to prescribe, albuterol, an inhaled steroid,
a leukotriene modifier, and then also systemic steroids. And in his home he had,
among other things, an active smoker,
cockroaches, and mice. And so he, in a lot of ways,
is typical of the people we have in mind for our studies. I’ll point out here, this
is a graph from the CDC. And the circle is 1998, because
that’s when he was born. So we met him in 2008. And he was born in the
midst of an epidemic that’s been increasing and
continues to increase beyond the length
of this figure. The figure’s split because
the CDC changed the questions that they asked in
1998, coincidentally when he was born. But what you can see is
both for children and adults that there’s been a rise over
time, and in a relatively short amount of time. What’s important also is that we
see this is about the same time scale as the prior
slide, and one of the things we can
see here, too, this shows mortality
over a time scale. And there’s been some
attenuation of mortality, which is good over the
last several years, but the gap between mortality
for whites and blacks has actually increased,
even though there’s attenuation overall. And this is true for other
outcomes too, hospitalizations, symptoms, and other
things that are important. So this has been
our focus is to try to identify factors that
contribute to this disparity and also to try
to eliminate them. And I’m representing
a group called the Center for Childhood Asthma
in the Urban Environment, which is funded by NIH, the
Environmental Health Sciences branch and EPA jointly. We’re in our third
five-year funding period. So we’ve had the Center
for more than 12 years, initially led by
Peyton Eggleston and now led by Pat Breysse
of School of Public Health and myself from the
School of Medicine. This is a model that
started the Center and it still guides
us now, which is that we’re really looking
at complex interactions between factors that can bring
on asthma or make it worse. We focused on
pollutants in allergens. And we focused on ones that
originate or congregate inside the house. We look at the steps that lead
to immunologic sensitization that lead to symptoms. And what you see on the
bottom there also is that– and for you online,
I’ll just show you if I can get this down here– that we don’t look
at this in a vacuum. We look at it in the
context of where people live and how they live
and recognizing that asthma, as with
most chronic conditions, is not just the
disease, but also related to the susceptibility
factors that are contextual. This is a picture
of our laboratory. Some people have an actual
laboratory to study. I don’t. And this is what we consider
to be our laboratory, which is a picture of a typical
block in East Baltimore. And what you can see is that
although the housing structure differs from neighborhood
to neighborhood, that what’s very typical
is two or three story row homes that are turn of the prior
century in terms of when they were built, and that
there are many that are occupied that are also
adjacent to unoccupied houses as well. So I’m going to address
just three of the points that I think we make
with our center, just to give you some highlights
of things that we’ve worked on that I think set up,
I hope, nicely for Kate the intervention that
she’s working on, and one finding
about whether or not domestic mouse allergen
causes asthma morbidity. So do mice in the house
make asthma worse? Do the pollutants particulate
matter and nitrogen dioxide, do they make asthma worse? And then the third point
is can we intervene? What’s available
to do right now? So with this first point
about mouse allergen, so that’s not a mouse, right? That’s a cockroach. And before I talk
about mice, I just want to bring us
back for a second. We’ve known more about
cockroaches longer than we have about mice in terms
of what they do in the house. And it’s a story that’s
been known for a while. This is a poster made by
our community advisory board in connection with the Maryland
Institute College of Art. And there’s a few
posters they made which I think are really nice,
but illustrating some factors that affect asthma. The reason I’m
showing the cockroach, though, is I just want
to explain the working model for what an allergen
does and why it makes sense to study it the way we do. So this is a little bit of a
complicated slide, but not too bad if you take a moment here. The point I want to make
here is that there’s two steps to becoming a person
who’s allergic to an allergen. And the first step is
illustrated at the top here, where the allergens, which
are those little green dots, they come in and they
meet certain kinds of white blood cells. Those white blood
cells communicate. And you see over on
the right-hand side of the slide that b-cells,
which are a lymphocyte, they put out antibodies
as a response. And those antibodies
are those little upside down Y things, the yellow,
and they go and attach to other cells, in
this case mast cells. Once they’ve attached,
that’s now a sensitized cell. So that step has to occur first. First the cells
become sensitized. And then the second step is
now your re-exposed to that allergen, and that
causes symptoms. So two steps have to occur,
first sensitisation and then second, re-exposure
to the allergen. The reason that’s
important is because this is a cockroach finding. And this is a study
that was published over a decade ago from the National
Cooperative Inner City Asthma Study. And this showed
very convincingly that cockroaches matter in
terms of asthma and morbidity. So this illustrates
hospitalizations in kids with asthma. And there’s four bars there. And the first two, blue
bars, are non-sensitized. So these are kids who have
not had that first step of sensitisation to cockroach. And the first bar
is low exposure. And the second bar is high
exposure to cockroach. And you can see they
have a similar amount of hospitalization. The next bar is sensitized,
but not highly exposed, and that also is
similar, so they don’t have that second
condition of high exposure. But when the two are
together, there’s been both sensitization
and exposure, that’s when you get the morbidity. So this is sort of
the working model for allergen provoking asthma. And it’s the same model that
we use to look at for mice. So in one of our studies,
we recruited preschool age children, so two
to six years old. They were all in nine contiguous
zip codes in Baltimore City. They had to have health care,
doctor-diagnosed asthma, and have active asthma
within the last 12 months. We also recruited controls
who were very similar, except they didn’t have
doctor-diagnosed asthma or symptoms. This is a map of Baltimore City. And it’s a partial map,
but there’s some things you can see on here. I’ll use the cursor. But this is where
we are right now. This is Johns Hopkins
Hospital and Johns Hopkins School of Public Health
are on this intersection. My cursor disappeared–
but this green plus. And you can see that the red
dots are people with asthma and the triangles are controls,
people without asthma. And we use this Northeast
quadrant, if you will, of what’s defined as East
Baltimore to do our studies. We spend a fair amount
of time assessing what their indoor
environment was like. So we sampled
particulate matter, which I’ll talk more
about in a little bit. We sampled dust
from the bedroom, and the kitchen, and
the family and TV room to look for allergens. We had a home inspection. And we also asked
parents or caregivers about the life history of the
child in terms of exposures that they might have had. And I’m only going to show just
a couple of findings on here that are relevant
to mouse, but one I thought was very
interesting is just in terms of
self-reported exposure. There’s a lot of
awareness of mice. You can see the majority
of parents or caregivers said, yes, indeed, we have
mouse exposure in our home. It’s a higher bar
than cockroach. So cockroach is high. And those are both
higher than pets. So mice and cockroaches
matter a lot. Smoking is on there,
too, and it’s about 58%, which is remarkable
and startling, given that the average in the country
is about 21% for all comers. So in our city, in
homes with asthmatics, we have more than
half with a smoker. So one of the things that
we assayed from the dust was a protein that
comes from mice. It’s found in their urine. So anywhere that
mice go, you can find this particular protein. And it’s thought to be a
pheromone-binding protein, so some way to attract a mate. And it’s a light
enough particle, unlike some, that it can
become aerosolized or airborne. So it can float around and
be in the breathing zone whether or not it’s in the
settled dust or in the air. And what we found was a parallel
story to what has already been shown for
cockroach, which is, this is looking at
rescue medication use, so the number of
days of medication, three particular time points. And the first two bars in each
of those three collections of bars are the
non-sensitized kids with low and high exposure. The right-hand two are
sensitized low and high. And you can see that the most
prominent bar in each case is those that are both
sensitized and highly exposed to mouse. And we found this for a
variety of symptoms as well. This illustrates using
albuterol as a rescue. We also, in a
longitudinal model, where we looked
over time, we could find that unscheduled
doctor visits, ED visits, and hospitalizations were all
importantly and significantly associated with being both
highly exposed and sensitized to mouse. And in this case, the
hospitalization odds ratio was nearly 70. I mean, it was just a
remarkably strong risk factor. And this is after
adjustment for other things, including cockroach. So we found this to be a very
important finding for us, which is, at least in Baltimore City,
that there’s a lot of mice, and that there’s a very
important impact of them. So this other issue
I want to address is whether or not
certain pollutants that are inside the home
can aggravate asthma. And many of you may be familiar
with particulate matter, but in any case
you’re not, I just want to show you that
particulate matter is basically dust, and it’s dust that’s
small enough, in the case where we study it, small enough to
enter the respiratory tract. It can come from
natural things, so it’s part of just dust that’s
from dirt and things out in the world that come in. It includes viruses and
bacteria, animal debris. And then there’s
man-made sources too, so mostly from combustion, so
trucks, buses, cars, factories, and then inside, tobacco smoke. And anything that burns
produces particulate matter. I want to give you an idea of
what particulate matter looks like, because you can’t
really see it up close. We’re talking about
something that’s a tiny fraction of the
width of a human hair. So you can’t see it
up close, but you can see what it looks
like from a distance. And this is a slide from a
camera that’s mounted near Boston and it shows what
the PM2.5 concentration was in about the 10 range, and
it’s micrograms per meter cube. But the thing just to
keep in mind as I talk is just that number
10, because I’m going to use the same units
in a couple of other slides. So that’s the
skyline when it’s 10. This is the skyline
when it’s about 60. It’s couple of days apart. It’s the same vantage point. But what you can see is if
you step back from pollution, you can see it better. So remember those
numbers 10 and 60. So this is what we
found in our homes. And this is the distribution
of particulate matter in children’s bedrooms
in East Baltimore. And the first two
box and whisker plots here I’ll spend most
of that time on, this is fine particulate
matter, which is what I illustrated
in the preceding slides. You can see the range
here is from 0 to 100. And we’ve excluded the outliers. Remember, I showed
you 10 and 60. The range I’m showing
you here goes up to 100, but our outliers go up into the
hundreds, so about 300 or so. And what you can see is
that the median value for indoor fine PM, that
first box and whisker, is about 35 or so. So it’s sort of midway
between those two slides that I showed you. And what’s really remarkable
is that it’s much, much higher than the outside air. So if you have an impression
about what outside air is in a city like Baltimore, it
may not be ideal on most days, but you can see that
that red line is the EPA standard in place at the
time that we did the study, and because it’s
a box and whisker, that heavy horizontal bar is
the median, the box around it. I’ll see if I can make
my cursor show you. I can’t get the
cursor to come on. But the box around it shows
the inter-quartile range. So what you can see
is the ambient air would only fail the EPA
standard about 1/4 of the time, but the homes, if there
were such a standard, would fail about 3/4 of the
time, so much, much worse inside than outside in
terms of particulate matter. Nitrogen dioxide’s another
pollutant we’re interested in. And this is a gas that’s
produced by combustion. And a lot of those
sources are the same. So if you burn something inside
or if you use natural gas for cooking or a gas
heater, things of that sort will produce it. It also comes from smoke and
from exhaust from cars, trucks, and buses. The problem with it is it can
damage the airway epithelium. There’s evidence that it
can increase susceptibility to infections. And it can promote sensitization
to allergens as well. So this is another figure
that I want to show you, and it shows a couple of things,
so the ambient values of NO2 on the vertical axis or
the y-axis and indoor NO2 on the x-axis. And two things to
notice about this, one is that there is no
relationship between the indoor and the outdoor. And this was important for us. This is a swirl of dots
that seem to have no– it’s not a straight line,
it’s a swirl of dots. And I do know that
sometimes people will produce a swirl of dots and
they’ll shoot a line through it and try to convince you
there’s a relationship. I’m hoping you don’t see one. The r-squared is 0.015, which
is really no association. The reason this is
important is because you could say that maybe the NO2
you measure inside a home just came in through the
window, and some certainly does, but it’s not mostly that. There’s an indoor
contribution that matters. If you look at the
range, also the ambient range that we had goes up
to 50 and the indoor range goes up to 300. So it’s another example
of where we actually have a higher pollutant
concentration inside than we do outside. So what’s the impact? A couple of things
here, so we looked at it a bunch of different
ways and adjusted for a variety of things. But in most of our models,
we adjusted the indoor for ambient or outdoor values. And what we can find is, for
most of the common asthma symptoms, that there’s
a significant increase in those symptoms for every
10 micrograms per meter cubed. So remember in my slide, the
range I showed you was 100. Our actual range goes up to 300. And the difference in the
skyline’s was about a 50 point difference. So for every 10 micrograms
per meter cubed, we could find an important
and significant increase in symptoms and
rescue medication use. And the same story for NO2. And this is after adjustment
for particulate matter. So the two contribute in some
way separately to the symptoms. And we can find significant
symptoms in either case. So the last thing I want to
talk about before handing over to Kate is can we intervene? And here, this is
an emerging story that we’re trying
to contribute to. And one of the things
I want to mention first is what’s already known
about this in terms of what the guidelines recommend. So this is a slide that
reproduces recommendations for asthma health
care practitioners from National Heart,
Lung, and Blood Institute. And this is consensus and
evidence-based guidelines based on what’s known. And so we know that
for allergens it says that if a patient has
asthma, we should reduce, if possible, exposure
to the allergens. But the second bullet
point’s especially important, that to know that you
can’t just pick one. You have to have a multimodal
intervention for it to work and the evidence
grade is A, which means that there’s been a number
of randomized controlled trials in the appropriate population
to support that evidence. So we know that. That’s one thing. And that comes from
studies like this. This is one of the
NIH-funded multisite studies that was done,
published in 2004, where they targeted allergens
and secondhand smoke in a one-year intervention. They dropped cockroach
by 70%, the allergen, and also had a drop in
dust mite concentration. What I want to share
with the figure, though, which is really
important, is that– this vertical bar
here that you see at 12 months, that’s the end
of the intervention time. And so to the left
of that dotted line is the year of
the intervention. And the blue line is
the control group. The intervention
group’s the orange line. And what you can
see is that there’s a separation between
the lines and a lower number of symptoms in the
people in the intervention. So the magnitude
of that difference is about the exact
same magnitude as what you see in a typical
inhaled corticosteroid trial. So medications that
we use regularly produce about the same effect
as does this intervention. That’s one important point. The other is that
unlike medications, the time to the
right of that bar is the follow-up year when
there was no more intervention. And you can see
that the separation remains for the entire year. So there’s really good prolonged
effect of an intervention that takes one year to put in
place, but it has a tail to it, which is quite good. This is multimodal
and it worked. But talking about the
irritants in particular, which I think are an issue,
tobacco smoke and then the pollutants that I mentioned,
the particulate matter, and NO2, and some
of the others, this is another of the slides
from our community advisory board thinking
about tobacco smoke. I want to show you
what the guidelines say about these sorts of things. So this I think is remarkable
each time I see it. So in terms of
tobacco, it would seem to be a pretty
easy recommendation to say anybody who has asthma,
or especially a kid who has asthma, don’t
smoke around them. And it makes good logical sense. But if you look at the evidence
grade from the guidelines, it says clinicians
should advise persons who have asthma not
to smoke or be exposed to environmental tobacco smoke,
evidence grade C. So it only comes from
observational studies, not from clinical trials. So that’s a pretty weak
recommendation for something that I think would
have seemed obvious. And then, consider referring
to smoking cessation, a little better evidence
grade, but that’s for adults who smoke and
have young children, so not the strongest evidence
grade for that. Also, in terms of devices
that you might think about, these are almost all
labeled as opinion-based because there weren’t
trials to support them. Air conditioning gets
an evidence grade C because there’s an
observational study that showed that people who
live in neighborhoods where there are more air conditioners
seem to have less asthma. That’s the standard of evidence. If you look at the bottom
one, air cleaners, which can strain the air of
particles and perhaps of gases, they said at the time of the
most recent guidelines there’s insufficient evidence
to recommend them, but they might reduce
some allergens. They don’t comment on whether
they reduce pollutants. So that’s a pretty weak
standard of evidence. And this one especially
makes me wonder where we are in terms of the progress. It says for indoor
and outdoor pollution, clinicians should advise
patients to avoid, if possible– so not definitely,
but if possible– exposure to gas stoves and
appliances that are not vented to the outside, fumes
from wood burning appliances or fireplaces, sprays,
or strong odors. So there’s a lumping together
of these exposures that might aggravate asthma, but
we don’t have strong evidence to say that if you intervene
that it’s going to work. The guidelines also
say, by the way, to come inside when
it’s polluted outside. And that might not
work if you remember the slide I showed a
few ago, because there’s more pollution of some sorts
inside than there is outside. So what’s been done for this? I wanted to highlight some of
the findings from my colleagues in the center. This is Peyton Eggleston
was the lead investigator in this study. And this was a 100
children in Baltimore, randomized controlled
trial of two groups. And it was, again, a
multimodal intervention where it targeted
allergens and pollutants. But there were only
two things that could have affected particulate
matter in this case, one was the use of a HEPA
containing air cleaner and the other was trying
to get people to not smoke. The latter didn’t work. People smoked just as
much before and after. So the only really thing that
happened during the trial was that people had a HEPA air
cleaner in the active group. And then the control
group was maintained the way they were,
but then treated at the end of the year the
same way as the active group. And they were
followed over time. And so one of the things
that Peyton was able to show is that the two lines
in the lower part show between a 30% and 40%
reduction in particulate matter from having an air
cleaner in the child’s bedroom. And that was sustained. The timeline goes
to 6 and 12 months. The control group, it looks like
it goes up a little teeny bit, but it’s pretty much
no change for the most part in the control group. So it showed that an
air cleaner intervention as part of a
multimodal intervention can reduce particulate matter. And this is the change in
the proportion with symptoms. And you see that
there’s a good change. Going down is good
on this figure, so that in the treatment
group, symptoms were less. Although, by the end of
a year, the effect was attenuated somewhat. It was still significant
though, and so showing there’s some
correspondence between PM going down in a multimodal
trial and getting better. This is a picture of one of the
air cleaners from the study. And I think I like
it a lot because I think it’s naive to think
that the answer to asthma is to go plug an air cleaner in. There’s a lot going
on in someone’s home. And it’s not just
that, but it can be a valuable contributor to it. Then, one other study, which
was just very recently completed and reported with Arlene Butts
who’s in the School of Nursing as the lead, this was
focused on tobacco smoke. This has three study groups. And there’s a control group,
which had asthma education, and then two that
included air cleaners, one was with air cleaners
to put in the house and the other was an air cleaner
intervention plus a health coach to see if a
coach that goes in to help get people to quit
smoking or smoke outside could work as well. And I’ll just tell you a
couple of things about this, one is that the health
coach didn’t help. So there really was
no impact of that. But the air cleaners did work. And this is one figure
showing the control group, where you see PM2.5
concentration. That median bar on the
left in the control group is at about 0, meaning that in
the ones without air cleaners, their particulate matter
stayed about the same. The air cleaner groups,
though, it did go down, and it went down
significantly and importantly. And I’ll show you the actual
numbers on that on this slide. So if we look at this,
there’s baseline, and then follow-up, and
then difference here. But this value here,
3.5, the PM 2.5 went up by 3.5 micrograms per
meter cubed in the control group and it went down by
about 20 and 16 in the two air cleaner groups, which was
statistically significant. So 20 micrograms per meter cubed
is an important difference. And this is coarse particles
in the lower part of the table, and that also there was
an important difference. One thing I do want
to point out here is if we look at air nicotine– I can’t get this cursor to work. But in the control
group, the difference is minus 0.4 micrograms
per meter cubed, air cleaner minus 0.3,
air cleaner and health coach minus 0.6, not
statistically significant, so meaning that although
we could reduce particles, we couldn’t necessarily
reduce everything that comes from tobacco smoke. So I think the
important message here is if there’s a parent
of a child with asthma, getting an air cleaner
could well be good. Symptom days improved
in this trial in the people who
got the air cleaners. But it’s not as
good as not smoking. And so it’s not a
substitute for not smoking. It’s sort of the best
intermediate thing you could do if you can’t get
the parent to quit smoking. One last one I’m
going to show you is just another approach
that we’re taking and something that we’ve
called the STOVE study. My colleague Nadia
Hansel is running this. This is a HUD-funded study. And this we’re
looking to see if we can target NO2 in particular. It turns out that gas stoves in
Baltimore City are very common. They’re almost never
vented to the outside. So they produce the fumes
and particles in the home. And so we have a trial
going on right now where we’re looking at homes
with an unvented gas stove and they’re being
randomly assigned to get a substitute stove,
which is an electric stove, or put in a vent that
vents the gases outside, or to use two air cleaners. And the study will
finish December. So I don’t have the
final results yet. But it looks like at
least for the one week, the immediate effect is
that swapping the stove out makes good sense, that
it’s a source control. But there might be an
advantage to the air purifiers because that also
might mop up NO2 that isn’t just produced
by the gas stove but from other sources as well. Those aren’t final
results yet, but it’s sort of the early peak at
what happens immediately. So these are
approaches we’re taking to sort of thinking about
interventions and ways to improve the environment. So I’m going to finish there. I think we do questions, which
I hope you’ll send in if you’re online after Kate goes. And so I’ll turn
this over to Kate. KATE SCOTT: You said it was F5? SPEAKER: Yeah. KATE SCOTT: Shift F5. Thank you. All right. Thank you, everyone. I really appreciate
this opportunity to tell you a little bit about
our Reducing Asthma Disparities program. We call it RAD. It’s an asthma
home-visiting program that we started in 2008. And so there’s three
things that I really hope that you get out
of today’s presentation. The first one is that asthma
home-visiting programs like the one I’m
about to describe can make a difference
in childhood asthma. The second is that
this program is based in sound science and
good asthma management. And finally, I hope to
persuade and encourage you to follow in this
endeavor and that you too could have an
asthma home visiting program in your community. I would like to acknowledge
that this project was funded by the CDC. And again, we started in 2008. The Department of Health and
Mental Hygiene was our IRB. We had two principal
investigators and we had five
co-investigators, each of who brought a set of
skills and experience that made this
program successful. So let’s talk a little bit about
asthma prevalence in Baltimore. So as you can see
on the slide here, 20% of children in
Baltimore have asthma. This is current prevalence. This is much higher than the
Maryland and the national rate. Let’s take a look
at ED visits then. So when we compare it
to Maryland ED visits, we see that Baltimore City
children are going to the ED 2.5 times more frequently
than statewide. You look at asthma
hospitalizations, you see something very similar,
is that Baltimore City kids are being hospitalized for asthma
more frequently than our state counterparts. Now, these two
indicators are really important to look at, ED
rates and hospitalizations due to asthma,
because it’s a sign that a child’s asthma
is not well controlled. So as you can see on this
slide, Baltimore City is not unique to the rest of
the state, but what’s alarming is the disparity between
blacks and whites when it comes to
urgent care visits. So if you look closely
at the far right, you’ll see Baltimore
City and you’ll see the number of
African-Americans, the rate, and how much higher that
is compared to whites. So we know there’s
something going on. So what other disparities
exist in Baltimore that can have an impact on asthma? Children living in poverty, this
is an astounding number, 37.3% percent of Baltimore children
actually live in poverty. That is much higher
than the Maryland rate and higher than the US rate. Adult smoking rates, we
just heard from Dr. Diette that smoking can have
an impact on asthma. And so what’s going
on in Baltimore? This survey showed that adults
in Baltimore, 28% of them smoke. But what’s even more
alarming is when you look at household
income, when you see that a family earns
less than $15,000 a year, that that goes up to 36%. And that will become
significant when you look at our RAD’s study results. Housing statistics,
let’s talk about mice. Dr. Diette did. We know that it’s important. It is an asthma trigger. So nationally, it
doesn’t look like it’s that much of a problem. We’ve got 6.3%. Let’s take a look at Baltimore. We’re looking at 34% on average. Median age of housing
stock, in Baltimore, we realize that we
live in an older city, and the average age of
a home is from 1947. So you wonder why
this is important. The reason why this is important
is because in older homes, it’s more likely to have leaks,
drips, entry points for pests, and make it hard to maintain. When you compare this to the
national age, it’s around 1974. So to address asthma
disparities in Baltimore, what did we decide to do? We went for funding. We received funding through
the CDC Translational Research grant. And we decided to translate the
work of Seattle-King County’s asthma home-visiting program. It’s an evidence-based program. Like Seattle, we
focused on reducing home environmental triggers and
asthma medical case management. Now, when we started,
we thought that we would spend most of our
time on the home environment and working with
triggers and families. But what we found
that was equally important was the amount of
time we spent with families to go over medication,
understanding the difference between a
controller and a rescue med, having medications
that are up to date, understanding when to take
them, how to take them, asthma action plans, and
follow-up appointments. Our target population, children
with moderate to severe asthma. How did we determine this? So this was determined
by a questionnaire that was completed by Study
Staff prior to enrollment. Those questions included
symptomology in the last two weeks, so looking at daytime,
nighttime rescue medication use. We also asked about ED
visits and hospitalizations in the last year. And we chose children
between the ages of 4 and 18 who were Baltimore City
Public School students. So one of the most
important aspects to making this program a success
were the partnerships that we developed, set
while we set up RAD and while we were running RAD. So in the health department,
we know that we’re good at certain things. So we’re good at
community organizing. We’re involved in the community. We know the resources
that are available. We’re tapped into internal
and external groups that can help families in need. But where we needed
strengthening was in our partnerships
and our clinical expertise. So we reached out to our asthma
clinicians here at Hopkins. We had allergists,
pulmonologists, and general pediatricians who
were working in the trenches with families of
children with asthma. And that made a huge impact
on the direction that we went. Asthma champions, also
able to share information with us in the community
about their own experiences so that we
could learn from that, but that they could also
advertise and promote our program. Area hospitals and universities,
where this came into play was that with the backing
of Hopkins and University of Maryland, what
we were able to do was it gave us the credibility
and the ability to do research, which otherwise might
have been more challenging. And we also wanted to coordinate
with area resources so the Greater Baltimore Asthma
Alliance, otherwise known as GABAA, that’s an asthma
advocacy group locally here. And they spend their time
with asthma education and disseminating information. So what we did is that
throughout the study period we would go back to GABAA and
we would ask for feedback. We’d share with
them are findings, some of our challenges,
some of our successes, and ask for feedback, because
not only was this a study, but it really was a program,
an implementation of science, and that we really wanted
to have a good service for children in Baltimore. And finally, local
area researchers, so we knew other
people in Baltimore were doing asthma
home-visiting studies so we wanted to make sure
that we weren’t soliciting participants from
other studies and we wanted to share information. So what were the goals? We wanted to decrease asthma
morbidity, asthma symptom days, use of urgent health
services, and exposure to asthma triggers. We also wanted to increase
provider knowledge of the home environment and
communication with families. So what did we do? So this was a six-home
visit intervention over six months with
a one-year follow-up. And in between the six
months and the one year, we had follow-up phone calls
that the community health worker did. So many topics were covered
in each of those home visits, but highlights is what
I’ve included here, medication and
technique, identification of asthma triggers, trigger
reduction education, and coordination with providers. So what did we use for
our data collection? So what we did is
we collected data at the beginning of the study
and then at the very end, one year later. We used two instruments. The first one was a
baseline interview. It was an extensive
form and it was about the medical management
of a child with asthma. So it included symptomology,
ER visits, hospitalization, episodes, asthma
action plans, quality, caregiver quality of
life, medications, medication technique,
allergy testing, you name it, it was in there, very
comprehensive form. And then the second
instrument we used was the Home
Environmental Assessment. So this was key to the program
because the community health worker, at this point, would do
a walk-through with the family. And what they would do is they
would walk through the living room, the kitchen, the bedroom,
the bathroom, and the basement if there was one. And they’d do it
with the families, looking for asthma triggers,
opening up cabinets, looking for holes between pipes where
pests can move in and out, looking for evidence
of mice and roaches, which are extensive in Baltimore
City housing in this study that we found, and also
to educate families. And what happened is that based
on this baseline and this Home Environmental
Assessment, that really geared the direction
of the education that the family received. So the final piece was
the encounter form. So this was a two or
three page document that went to the medical
provider or providers of the child that
we were seeing. And what that did
is that it was kind of this little snapshot of what
a community health worker did in the home, which was
really nice, because we looked at symptomology,
daytime/nighttime rescue medication use. We looked at
medication technique and what meds were in the home. We looked at ER visits,
hospitalizations. We also recorded what
we had discussed, our protocols, our problems
that we identified in the home. And those problems
include everything from med adherence, med
technique, mice, roaches, smoking, et cetera. So we also did goals. So the community health worker
sat down with the family and said, OK, we
got this, and we got this, all these things
that we can work on. What do you want to do first? Set tiny goals so that
when they come back, they have some success. And if they didn’t meet those
goals, then talk about why and try and come
up with new goals. It also included a date and
time for the next visit. So the beauty in this
tiny form is that it went to the medical provider. And often we got feedback
from the medical provider that included things like I had
no idea there was a mouse infestation, I need to
add this to the regimen, or I haven’t seen this child
in two years, very helpful. We would go back, then, to
that family and say, OK, is there another provider
that your child is seeing? If not, let’s make a
follow-up appointment. So what did our
baseline data look like? So we were looking at
102 kids, the majority are African-American,
mostly boys, average age around nine, family
size about four, about two people
in the household had asthma, and significantly,
looking at this, almost 97% of the kids were Medicaid. So we didn’t select for
Medicaid kids or low income, but it’s just kind
of what happened. So this mirrors a Little bit of what Greg was
reporting in his studies, that on this
initial assessment– and this is what we found– that almost 59% of
families had mice, 42% had roaches,
38% had a furry pet, and that 31% of the
primary caregivers smoked. So after the intervention,
pre-post data is what we’re looking at now. So what were the reported
changes in the child’s health? This is over a two-week period. So we saw a decrease
in symptoms, a decrease in nights awakened, a decrease
with having to stop their play, a decrease in rescue
medication use, and happily, an increase
in controller meds. What else did we see? Well, so at that
initial visit, we asked about hospitalizations,
how many times had that child
been hospitalized? So out of our
study participants, they had said that a child had
been hospitalized 44 times. At one year, it was 32– 12, not a big difference, right? Until you look at the cost
of an average hospitalization in Baltimore City. So the average cost
is around $7,900. And depending on the
institution that they go to, it can be higher or lower. So that number will become
important in the next slide. The other is the
number of ED visits. So pre-intervention,
240 ED visits is what families had reported. So then when you looked
at it one year later, it’s still a high number,
139, but it’s 101 fewer. So if an average ED visit
in Baltimore is $772, that begins to add up. And the mean number of ED
visits in the past year actually did decrease. That was significant. Costs averted, so we look at the
hospitalization and ED visits, and that total cost
is around $172,000, so we’re looking at
almost $1,700 per child is what they’re
costing the system. Home-visiting program
costs, about $141,000– and you’re wondering,
what does that include? It includes the community health
workers, nursing supervision, a referral coordinator that
I’m going to talk about soon, and supplies. And those supplies included
mattress and pillow encasements, pest management
supplies, like baits, gels, copper mesh to plug holes. It also included a mop, a
bucket, and green cleaning supplies like baking soda,
baking soda bonamy, vinegar, so nontoxic, and a vacuum cleaner. So the average cost for
a child in the program was about $1,400. So the difference
is around $304. That’s the potential
cost-savings. So how does this compare
to our counterparts who we were translating the research
from, Seattle-King County? Their program costs are
similar, about the same, $1,300. Now, their direct medical
costs averted is a little less, $124 to $147, compared to RAD. But there’s some subtleties
here in this slide that I’d like to point out. The first is that
Seattle-King County, their data is coming
from 2001-2002 cost data, versus ours, we’re
looking at Medicaid cost data from 2011. The other is that the
RAD data is self-report, and in Seattle-King County,
they had medical records. And so what we’re doing
now is that we’re actually examining our Medicaid
kids, and we’re looking at Medicaid
claims data, and we’re doing a pre-post
intervention analysis to determine if our
self-report data does actually mirror the actual cost data. Lessons learned–
infrastructure, so if you’re going to undertake
this, know your institution’s strengths and identify
where you need assistance. So like I said
earlier, the health department, great with
partners, great with community, and they know the resources. And also we have a
very holistic approach to working with families, so we
have a community health worker model. So for example, if Brandy,
one of our community health workers, goes in to see a
family and mom is stressed out and she’s all worried about her
gas and electric being cut off, so the first thing
that she’s going to do is not to be
talking about asthma and how many days a
child has had symptoms, and did they sleep
well last night, she’s going to pull out
her resource book and say, have you called
blah, blah, blah? Have you called this resource? Is your phone working? Let’s use mine– actually,
connect that family to those resources
right then and there. And then, that provides that
gateway, that entry point, and also that confidence
in this person who’s now entered their home to say,
hey, they’re here to help me. Program database, so we didn’t
have one when we started. It took about six
months to get something up that was just a skeleton. It took a year for
us to get something that really we could
pull information out of, that we could look for lost to
follow-up, overdue visits, et cetera, run reports on
the community health workers and their caseloads. So just knowing what
your strengths are and knowing where you
need to build in more time is important. Staffing, I’m a firm believer
in the community health worker model. I feel like they have this
unique connection with families in Baltimore, that they’re
able to communicate important information in a
way that families understand. And the beauty of
this is that we have a nurse manager who is
the support for the community health worker. And so that encounter form
that I was talking about that the community health worker
fills out, that actually goes to the nurse manager,
every encounter form, she reviews it, sends
back feedback to the community health worker and says,
what about this, fix this. The community health
worker fixes it and then sends it off to the physicians. Referral coordinator, so what’s
the referral coordinator? So basically, we currently get
between 40 and 60 referrals on a weekly basis, especially
in the high season for asthma, in the spring and the fall. So we found out early on
that we needed referrals to be funneled
through one person. So this referral
coordinator, she gets every referral that
comes into the program. She enters it into the database. She screens every call. So that means that she
completes the questionnaire to determine eligibility. And then she assigns the case
to a community health worker, makes the chart, puts it on
the calendar of the community health worker, sends out
a letter to the family, et cetera, extremely important
part of the program for us. And the other is to
recognize the training that’s involved when you are
working with staff. So you make sure you have
to build in the time for it. And what we did here is that we
looked at our asthma partners, and we had the community
health workers actually go into the clinic setting where
they could observe clinicians working with families
with children with asthma, so they could kind of see
and learn a little bit more about what happened in
that kind of exchange. And it also gave
us the opportunity for the clinicians to get
to know us a little bit, so that is Brandy or that
is Tyra who I’ve just spent the day with
and she’s going to be sending me encounter
forms on this kid. So it’s always nice to
put a name with a face. The asthma training
was extensive. And it’s something
that’s always ongoing. So it’s not just
that one-time thing. It’s the weekly meetings
that the nurse manager has with her staff. It’s the monthly updates that
are a little bit more in-depth that makes sure that the
community health worker is confident in their knowledge
and how they’re presenting this to families. Healthy homes, so we know
that the environment where we live, where we
work, where we play has a huge impact on our health. So what we did is we
used the National Center for Healthy Housing, and
the community health workers and staff actually took the
Healthy Homes Practitioner course. It was a multi-day course. And then they did refreshers. And one of the nice
thing is that in-house we actually had an IPM expert. So for those who don’t know,
IPM stands for Integrative Pest Management. So it’s a green way
of managing pests, a very important
part when you’re looking at a healthy home. So we did a lot of internal
training also to refresh and so that the community
health workers were comfortable when they were actually
looking in the home and looking for asthma triggers. And finally, we used
motivational interviewing. So we had an expert come
in, do multiple trainings with the community health
workers and the staff to– because the community
health worker already has this really nice
relationship with the family. But sometimes you need just
a little bit more knowledge to identify where a family
is in the stages of change. And so when you’re
able to do that and you know where a
family is, then you know how to target
your teaching. And that’s what the
motivational interviewing did. Other lessons
learned, referrals. Initially, we
thought we were only going to be getting
them from school health. We had planned on that,
because we were thinking that those would be
the children that were not in a medical home. What we found was that when
our IRB finally came through it was in late spring and
so school was almost out, we had a ton of referrals
from school health, but we knew that
summer was coming and we needed to branch out
so we went to our clinicians, we went to area
hospitals and EDs. And as a result of that and the
partnerships that developed, we were integrated
into two systems. And so in those two systems,
we now get weekly updates from one of them. And the other, it’s built into
their electronic medical record so that when a physician is
seeing a child for asthma, not only are they
checking did I give the child an inhaled
corticosteroid, have I sent them for
allergy testing, what was their ACT test
score, and they can also check for home-visiting. So what that does is that
makes it easy on the clinician, it makes it easy on us
because we get the referrals and then we can act
on them quickly. What we also found
was that the ratio of number of referrals
to actually kids enrolled was about
a 1 to 5 ratio. It varied a little
bit depending on where the referral was coming
from, but about a 1 to 5. And I talked to some other area
researchers here in Baltimore and they said that
they’d found the same, so it was about right. And then, the partnerships
and coordination of care, so that clinician buy-in,
extremely important. So what we did is in some
of the clinics in the area we did brown bag lunches
or early morning breakfasts and we tagged on to
their monthly meeting, and basically said, this
is what we’re doing, this is our program, this is how
we hope to be helpful to you, this is how you do a referral. Asthma champions became a
huge kind of advocate for us, and that included school
health nurses and actually local and state government. And then, database
management, so what we did was that we got
our database up and running, but then for our baseline
and one-year data, we moved that with
the program evaluator to the University of Maryland,
where she could actually analyze it using
statistical modeling and all that fancy statistics to
show our results, which is very helpful. So conclusions, so going
back to the beginning, I was hoping that you would
see that asthma home-visiting programs can make a difference
in childhood asthma. So in this study/program,
we saw that we decreased triggers and
symptoms, decreased ED visits and hospitalizations, and
increased med adherence. There was a cost savings
of about $304 per child. And the most important
part is that this actually confirms the other
research that’s already out there, that asthma
home-visiting programs work and they should be incorporated
into comprehensive asthma management. Greg’s slide showed it. Seattle’s showed it. I was recently in
Chicago and they also had the same CDC grant, they
have very similar results. So it’s time now to move
the research into practice and to have these kinds
of programs integrated. And that’s it. Thank you. [APPLAUSE] Great. Thank you so much, Ms,
Scott and Dr. Diette. At this time, we do
have time for questions both from the live audience
here and from those of you who are watching online
for both of our presenters. Again, if you’re
watching online, just simply click on
that link on your screen and you can send a question to
either one of our presenters. And if you’re here
in our live audience and you have a question,
if you could just please wait for the microphone
to come around. And that way, everybody
who is watching online can benefit from your
question as well. So with that, we can get
started with questions. Yeah, right here. AUDIENCE: Hello. So it sounds like you guys
have integrated IPM as part of the asthma management. My question is, is there
data showing specifically that the pesticides
are contributing to symptom severity
or symptom frequency and/or the development of asthma
in kids who don’t have it? GREGORY B DIETTE:
That’s a great question. And do I need to repeat
it for people online? MOLLY MITCHELL: No,
because she had the mic. GREGORY B DIETTE:
She had the mic. OK, great. So there’s a lot of great
questions in that one question. So one is whether or not
pesticides contribute. Trigger And then
the other is, what should the components of
integrated pest management be? And I think the second one’s
easier to handle in terms of whether you think about a
pesticide-free approach to it or not, I think the better
programs include bait and then elimination of pests
that way, and that even within the use of baits,
that there are better and worse approaches, I think. And I’ll just give
you an example. The NIEHS conducted a study
looking at cockroaches and they compared
an entomologist, so a bug expert-driven approach
to hiring the companies that are pest management companies. And what they found was
that there was actually a very good logical
approach, which was to put these
baits along the places where entomologists
see the trails. So they look for the
trails for the cockroaches and then monitor what
happens, so put in new baits after they’ve been eliminated
to see if they’ve come back, and use the monitoring
program to then decide when you need to redo your program. The professional companies,
so far, what they tend to do is spray in spots that just
happen to be maybe typical, like corners or holes,
or things of that sort, but not literally driven by
where the critters are seen. And then they also come
back on a schedule, by a time schedule not based
on what the results are. So they might come back in six
months or a year or something. So even within that,
there’s a good approach. I think the ones that
don’t spray insecticides are better because of the
concern that you bring up, which is whether or not
they can provoke asthma. And virtually any
spray of any sort, whether it’s an insecticide,
or a cleaner, or something else can provoke an asthma
attack in an asthmatic. So I think the ones that
don’t involve sprays are the better approach. KATE SCOTT: And just to add
on to that, when we started, I had to actually sell the
community health workers on integrative pest management. They were more in tune
with using the Raid sprays, one even had told me about using
anti-freeze on a cotton ball and that would kill mice. So when we started, I
was like, all right, that’s one way to
do it, but when we’re working with our families,
we’re going to use IPM. And they followed along with me. They were like, OK, Kate,
yes, we’re going to do it. But it wasn’t until they
actually implemented it in the home setting where
they saw the improvements, especially with the roaches,
and they would come back two weeks later and it would
be a significant change, that they were sold on it. And so they became
really good advocates for this type of an
intervention, which also helped with buy-in for the
family too because they saw an immediate improvement. AUDIENCE: I have a question. When there is, in the
natural history of asthma towards an improvement
as the kids get older, how can we tell that
the improvements are quantified to the
magnitude of the benefit of these interventions? That is, how can
we say that it’s because of the intervention
versus the kid is improving? And do we have any
case control study? Or because the before
and after, probably, it’s a little more difficult
to make those assumptions. MOLLY MITCHELL: I
know you can answer. GREGORY B DIETTE:
It’s a great question. I mean, it’s an
issue of study design and what standard of evidence
you need in order to guide what you’re trying to do. And I think that part of
the reason that we presented together is that I was
presenting more clinical trials evidence that had
a control group . And the good thing
about clinical trials is that by having
a control group is you can be confident
that the signal you see is from the intervention. The bad thing is, is
that we highly select people to get the intervention. And it also doesn’t prove
that you can just roll it out in a community. So I think the two kinds of
research are complementary. I think you have to do NIH-style
controlled trials to prove that an intervention can
work, but that’s not really feasible on a mass scale. And to ask a city, or
a state, or a country to roll it out in a
controlled way is difficult. So I think some of
it’s program evaluation after having proven
that an intervention can work in certain circumstances. I mean, point is a great one. AUDIENCE: Following up
on that, but I think also when she’s doing the
Medicaid analysis, when you’re actually getting the
real cost data, at that point, she could go ahead and
find match controls in the community. That’s one thing we’ve done. KATE SCOTT: And that’s
exactly what we plan on doing. We’ll have a match
control group, yes. SPEAKER: Right down here. AUDIENCE: Kate, you’ve
mentioned that now that you have data from
Baltimore as well as Seattle, what are your thoughts
in terms of moving these studies into a
research to practice mode? KATE SCOTT: So I’m more
than ready to move this into practice. And I can see it in a
variety of settings. So I can see it in
the health department, and there’s positives to that. I can also see it based out of
a patient-centered medical home, so where a child is
already being seen. And there’s a possibility
that you might actually see a greater improvement
in asthma management when they’re locked into
a medical home, possibly. But I can see it
in both settings. And I think that with
the Affordable Care Act, if it moves forward
like we hope it does, that you’ll see more of these
preventive services in place, I hope. GREGORY B DIETTE: I just
want to follow-up too if I could because I think
it’s a great point, which is the what to do next. And I think part of
it’s a matter of people who care about the issue to try
to articulate some of the cost and benefit issues of
the programs as well. The slide that I showed that
was done by the NIKA study, where there was a one-year
follow-up period showing that it still worked even after
the intervention was gone, is enormously
important because we accept, without even
thinking that hard, that it’s OK to use
asthma medications that have a temporary effect. And we pay hundreds of dollars
per month for each medication. And that’s a no-brainer. We just do it. But then when we talk
about a program that might average over a year $100
a month, then people get excited and say, well, that’s an
expensive thing, how are you going to sustain it? And so I think making
some case that costs are worth it in some cases. The other is that medications,
for example, have side effects. Most, but not all
of the interventions that target the environment
don’t really have side effects. Getting somebody to quit smoking
doesn’t cause health problems for the most part for the child
if the parent’s smoking around them. Air cleaners use a
little bit electricity, but they don’t harm you. And so there’s other ways to
think about the trade-offs too in terms of costs and
benefits that I think we all collectively
have to articulate to the people who are in
charge of allocating dollars for health care. AUDIENCE: I had a
couple of questions. One, the data on your
smoking counselor were not significant in terms
of the effectiveness of that. And I’m wondering if
there are alternatives that you might recommend
for programs that might be implemented in other cities? And then the second
question, your interventions were focused on children
who had severe asthma, moderate to severe
asthma, and yet the guidelines recommend that
these kinds of interventions be considered for all
asthmatic children. So I’m wondering
if you have plans to expand the intervention
for all asthmatic children? GREGORY B DIETTE: Yeah, I mean,
so the second part first maybe, so about where you
should go with it, I think that the guidelines
are a little soft in terms of the recommendations about who
should get the interventions. And I highlighted
in a couple of cases where they’ll say if
possible, for example. It doesn’t designate
a severity level, but it’s kind of a
soft prompt as opposed to saying that all
asthmatics of all types should get these interventions. There’s a feasibility
part that’s implied there. In terms of even
allergen reduction, the guidelines say
that for people whose asthma is at least
at the persistent level, that they should have
allergen testing done, allergy testing done through
either blood or skin tests. And so there’s a
little hesitation, I feel, in the guidelines in
terms of who should get it. From a trial standpoint,
there’s an issue always of who do you
select for a trial. And I think the people who
are sicker to begin with have a better chance
of showing a signal. And so that’s the place
to start in some cases, and then see if you
can replicate that same magnitude of
benefit in somebody who’s not as sick to begin with. The study that showed of Peyton
Eggleston’s was the first of those air cleaner
studies, not the one that had the health
coach, and his actually was at the mild range. So his were not very
symptomatic to begin with. The second one was
a little sicker, and that was deliberate
in order to try to be able to find a signal. As far as the health
coach goes, I mean, we’re talking about
cigarette smoking. So there’s a mass of
literature on what it takes to get people to quit smoking. And it’s partially successful. There’s evidence for
counseling working, there’s evidence for
pharmacology working, and the two together
working even better yet. This particular model was
built around the notion that if you could
have a smoke-free home and enforce that, what
would that look like? And this was one
more trial where I think we found that smoking
behavior is very stubborn and that it’s very hard to get
people to change their smoking behavior. So I honestly don’t
know what to do. I mean, it’s not enough
just to tell somebody that you might be
harming your child. It’s not enough to tell
them to smoke outside because we know that the smoke
comes back in if somebody is on the porch, for example. So it’s very hard. I don’t know the answer. This particular
trial only showed that an air cleaner
could contribute, although not be a
complete solution. MOLLY MITCHELL: Well, we
do have some questions from our audience
online so I want to take a minute to take some
of those questions right now. And this first one
comes from Tiffany, who works in a Head Start program. She says, I work with families
of preschool age children and asthma is an increasing
problem for our families and young children. What would be your
recommendations for how I can use this
information learned in this training to
help our families? KATE SCOTT: So at least
in Baltimore, we’ve spent some time actually trying
to reach out to Head Starts. And we do it in two ways. We offer education
at the actual site. So we’ll work with the
workers, people that actually work at Head Starts. And we’ll provide
education to parents, so we can do group education
classes to share insight. We also have a smaller
asthma home-visiting program that’s not a study, but
it’s mirrored after RAD. And it’s smaller. It’s three visits,
community health worker model with nursing supervision. And that actually does
see children aged 2 to 18. And so that Head Start
kids actually can enroll. MOLLY MITCHELL:
This other question is really two questions. We’re now in the second
generation of children since these home efforts began. And have you
considered addressing the prevention of
asthma and allergies through breastfeeding, or
provided by breastfeeding? And then, also, part two is,
does inconsistent medical care affect asthma management? Why does the Maryland
breath mobile see patients who
are already seen a consistent medical
provider at Johns Hopkins? GREGORY B DIETTE: Well, those
are very different question. So I mean, the first one
about asthma prevention is a very important
topic and one a lot of us who work in
asthma think hard about. And there have been NIH
and other federal agencies that have convened
groups of people to try to figure out where or
if there is low hanging fruit in terms of prevention. There really isn’t a
leading major single target for reduction of
incident to asthma. And there are different
attempts that are going on. For example, there’s
a study looking at vitamin D supplementation
in pregnant moms to see if the
children who were born will be less likely to
wheeze and then eventually be diagnosed with asthma. That’s one approach. There’s people who are
thinking about the microbiome and whether or not the
gut bacteria of children, if it’s manipulated on purpose
by a supplement of some sort or through other strategies,
like preferring vaginal over c-section birth, where
the floor that the child gets are different in that case. There’s a lot of different
potential strategies. But at the moment, there isn’t
a single way to prevent it and there’s not a
single best candidate, I don’t think, for prevention. And breastfeeding
is a big issue. There are observational studies
that seem to show an advantage and some of that don’t, I
think, in terms of at least asthma health or allergy. I think the evidence
is tilted definitely in favor of there being
a protective effect. Trials, I don’t work in
that particular realm, so I don’t know, but trials
seem a little daunting to me. I mean, thinking about the
idea of assigning someone to breastfeed or not
would be difficult. But I don’t do
that sort of work. Maybe someone’s got a
good idea of how to do it. But a lot of this gets driven
by randomized controlled trial evidence on what to do, not
just what might make sense or what an observation
might have shown. Do you do treatment
with the breath mobile? KATE SCOTT: So one
thing that we did find is that
coordination of care was extremely important when
managing children with asthma. And so there were
times when you saw that a child was seeing
a specialist and also a primary care. And I’m not sure exactly
the question that the person presents online because
the breath mobile, when I think of them, it is
especially clinic for children. It’s a clinic on wheels. It’s mostly stationed at schools
throughout the school year. And that’s staffed by
NP pulmonologists or NPs with background to pulmonology. So depending on who
they see at Hopkins, they could be seeing just
a general pediatric doctor or they could be
seeing a specialist. But the point of the
random visiting program is that when we worked
with the families and we tried to
really find out, OK, who else does your child
see for medical care. And so when that encounter
form was faxed to providers, it actually has all the
physicians on the cover sheet. So it’s going to
breath mobile, it’s going to have mercy
medical, if the kid has seen two different people. If they’re seeing
a GI specialist, it also goes to them. So we’re trying to kind of
break through that barrier and coordinate care. MOLLY MITCHELL:
Here’s another one. What does the state
Medicaid program think about funding the
program in the future? KATE SCOTT: So we had the
opportunity to present, do a small presentation to the
state a couple of months ago. They were really interested
in our program results and suggested that
we move forward with the economic evaluation of
the RAD Medicaid claims data, while at the same time
moving forward on their– they have something called
an innovation website, and so that they’ll
feature programs that are up and running, and so that
you can disseminate information to others. Because the whole point of– there’s many points
to RAD, one of them is to improve children’s
health, but it’s also to share what we’ve
learned with others. So we want to be
able to do that. And with that, we hope
it will open more doors to actually work with
managed care organizations who have a vested
interest in lowering their costs for children
who use urgent care services such as
EDs and hospitals. MOLLY MITCHELL: Yeah,
right over here. AUDIENCE: On the evaluation
of the air cleaner, are you able to look at
the lasting benefit based on the behavioral change of
the parent who presumably has to turn it on and use it? Can you distinguish between
well-used air cleaners and ones that are not being used? And secondly, is it
strong enough evidence of its effectiveness to entrust
the insurance companies? GREGORY B DIETTE: So
a couple of things, I mean, in Peyton
Eggleston’s study, 50% of the air cleaners
were on 50% of the time. So it actually was not
anywhere near close to 100% 100% of the time. So those figures I
showed you, though, aren’t selected for the
people who used it more or used it at all. So that’s despite
non-adherence, if you will. So I don’t know. That was an intention
to treat design and I don’t think
he broke it out by looking at people who did
or didn’t use it very well. But it allowed for
some non-adherence. You could wonder if people
who adhered to something do other things better as well. And so I think
that’s a fair point. But I don’t know how to
address that from that trial. In terms of whether
people should be incented to pay
for these things, I think that’s an
important issue. If we look at
things– if we think there’s a carcinogen
in the drinking water, you know, I know a lot
of people get together and they yell about it and argue
about whether to take it out, but we don’t insist
that there be a randomized controlled trial
that shows if you take it out of the drinking water that a
community doesn’t get cancer. We just say it’s a
carcinogen that’s in there. And if we know a way to get
it out, we should do it. I think there’s an
abundance of evidence that particulate matter and
nitrogen dioxide as just two examples of
pollutants harm people with respiratory disease. And so I don’t
think we necessarily need to insist on the
same level of evidence that we do to bring a drug to
market, to say that something that’s logical, that
does in fact reduce the pollution that we know
is harmful ought to be used. And so I think we’re at a point
where we have enough evidence to say, gee, these things
aren’t that expensive. They cost hundreds of dollars. They don’t have a lot
in terms of maintenance. They use electricity at the
rate of about a 60-watt bulb. And so we’re not talking about
something that’s over the top expensive that actually doesn’t
wear out very fast either, and that there is clinical
trials evidence of efficacy both reducing pollutants
and improving symptoms. So I think we’re at the point
where people should want to do this and spend several
hundred dollars which might be two months worth of medication
equivalent on one more thing that doesn’t
harm people either. AUDIENCE: I have a question. How do we decide an
optimal number of visits? And do you think that more
visits means more better results, or the opposite? That could affect the
cost effectiveness of the intervention. KATE SCOTT: Yeah, so we actually
want to look at that because we know that a six-home
visiting model is expensive, it’s time consuming, you
need a lot of admin support to continue to
follow-up with families. And part of our Medicaid
claims data analysis is actually going to look at
where did we get the biggest bang for the buck. And so was it at four
visits when we really saw adherence kick
in and ED visits and hospitalizations drop? I have a feeling it’s
going to be somewhere between three and four. And I know that other
asthma home-visiting programs have not always
using a six-home visiting model anymore. They’ve dropped that
number somewhere between four and five,
depending on the program. So I expect that we’ll
see, we’ll change somewhat. We’ll learn from the data. MOLLY MITCHELL: We do have
a couple of more comments and questions online. One is whether the Baltimore
City Sanitation department plays a role in
cleaning up communities to minimize rodents, if
they’ve been involved at all. KATE SCOTT: So we didn’t
coordinate services directly with DPW, but there are
services in the city that are related to trash
removal and rat rub-out. But we didn’t directly
coordinate with them. MOLLY MITCHELL: And this
is a comment from an asthma and allergy sinus center. The cost savings are impressive. I just want to comment that I’m
confident that longitudinally the cost savings would be even
greater as the families become more comfortable with the use
of daily controller medications, develop greater trust and
bonds with their health care providers, and ultimately
more appropriate utilization of health
care resources, seeing PCPs/specialists in
outpatient setting versus ED visits. I find that often it is trust in
the system and personal comfort with their
understanding of asthma, in addition to better
symptom recognition, that leads to better medication
compliance and use of daily controller meds. Education is key. Did we have another
question in the back? AUDIENCE: Would
you say it’s kind of a larger contextual issue? I know you’re working in a
specific and very important field. What I’m concerned
about is that we have, particularly among the
socioeconomically deprived communities, other epidemics
of diabetes and obesity. And I’m wondering if there’s
anybody in public health or related fields who’s taking
a look at whether or not there’s any connection
between what you’re doing and these other
epidemics which are plaguing these communities
at a great human cost and social cost. GREGORY B DIETTE: Yeah,
that’s a great question. Our current center,
the third iteration of our Center for Childhood
Asthma in the Urban Environment is actually funded to
look at dietary issues, and dietary issues as the role
that they play in developing allergy and asthma. And it’s for reasons
that you say. There’s a concordance of
epidemics in populations of people like we’re studying,
so like African-Americans in the inner city that diabetes
is higher, obesity is higher. And the time trends are
very temptingly overlapping, so that the obesity
epidemic took off at about the same point when
the asthma epidemic took off. And where there is a
change in the inflection point of the epidemic curves. And what we’re looking
at, at least in our center is, how the composition of
diet has changed over time and how that composition may
both provoke allergy and asthma and also fail to protect against
it, so with a general notion that there’s a pro-inflammatory
component to diet with things especially like processed
meats and foods of that sort, and a lack of antioxidant
capacity through less fruit and vegetable, less fatty
fish and things of that sort. So we’re taking both
an observational and an experimental
approach to looking to see if we can change
the trajectory of asthma and allergy with
things like diet. I think they’re all intertwined. And I think that they’re
very hard to separate, but it’s really where
there’s a lot of value. It’s not just one factor. AUDIENCE: I’d just like
to comment on that. Because I think what Kate
was saying before about also offering other
resources to families is a way that you
can also combat some of the other problems by
going in with not just we’re going to fix one problem,
but going into the house and trying to provide as
many services as possible through an integrated
delivery of services. MOLLY MITCHELL: I think
we have time for one more question if we have one. Or maybe not. I think that wraps up our
presentation for today. So I really want to thank
again, Ms. Scott and Dr. Diette for coming today for
this great presentation. And thank you all for coming. And we hope to see
you again next month on the third Wednesday
for our next grand rounds. Thank you very much. [APPLAUSE]


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