Reducing Asthma Disparities in Children: A Model Program with Promising Results QA
04
October

By Adem Lewis / in , , /


SPEAKER 1: 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 DIETTE: It’s
a great question. And do I need to repeat
it for people online? SPEAKER 1: No, because
she had the mic. GREGORY DIETTE: You 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. And the other is what should the
components of Integrative 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, the 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. I’ll just give you an example,
that the NIEHS had just 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. And so they’d look for the
trails for the cockroaches, and then monitor what happened. So putting new
baits after they’d been eliminated to see if
they’d 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 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, but 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 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’re 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 improvements, especially with the roaches. And they would come
back two weeks later, and there would be a
significant change, that they were sold on it. 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 the natural natural
history of asthma is towards improvement
as the kid gets older, how can we tell that
their improvements are quantified, the
magnitude of the benefit of this intervention? That is, how can
we say that this is because of the intervention
versus if the kid is improving? And do we have any
case-controlled study? Or would it be before
and after, probably? It’s a little bit more difficult
to make those assumptions. KATE SCOTT: Well, I know you
can answer really well to that. GREGORY DIETTE: Well, yeah,
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 going to do. And I think that
part of the reason that we present it
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, 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
control 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 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. Your point is a great one. AUDIENCE: Following up
on that but I think also when she is doing the Medicaid
analysis when you’re actually getting the real-cost data. At that point, she could go
ahead and find matched controls in the community. That’s one thing we’ve done. KATE SCOTT: And that’s
exactly what we plan on doing, that we’ll have a match
control group, yes. SPEAKER 1: Yeah,
right down here. AUDIENCE: Kate, you
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 based out of a
patient-centered medical home, where a child is
already being seen. And there’s a possibility
that you might actually see a great improvement
in asthma management, when they’re locked into a
medical home, possibly. But I could 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. At least, I hope. GREGORY DIETTE: I just want
to follow up too, if I could. Because I think
that’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 [? NCICAS ?] 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, people get excited. And they say, whoa,
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. You know, if the parent’s
smoking around them. Air cleaners use a little
bit of 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. SPEAKER 1: OK. 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 too,
for all asthmatic children? GREGORY DIETTE: Yeah. The second part first,
maybe, 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 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 or
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 is an issue of, always, who do you select for a trial? And I think the people who
were 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 I showed
of Peyton Eggleston 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, | mean, we’re talking about
cigarette smoking. So there’s a massive
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 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. SPEAKER 1: OK 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-aged 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. 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 home visits,
Community Health Worker model, with nursing supervision. And that actually does
see children aged 2 to 18, so Head Start kids
actually can enroll. AUDIENCE: OK. This other question, it’s
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 Breathmobile see patients who
are already seeing a consistent medical
provider at Johns Hopkins? GREGORY DIETTE: Well, those
are very different questions. 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 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 would 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 flora 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. Breastfeeding is a big issue. There are observational studies
that seem to show an advantage and some 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 somebody’s got a
good idea how to do it. But you know, a lot
of this gets driven by a randomized
controlled trial evidence on what to do, not just
what might make sense or what an observation
might have shown. Are you familiar with
the Breathmobile? KATE SCOTT: Yeah. 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. I’m not sure exactly the
question that the person presents online. Because the Breathmobile,
when I think of them, it is a specialty
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 NP’s with background
in 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 RAD
home-visiting program is that when we worked
with the families and we tried to really find out
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
have Breathmobile. It’s going to have
Mercy Medical. If the kid is seeing
two different people. If they’ve seeing
a GI specialist, it also goes to them. So we’re trying to kind of
break through that barrier and coordinate care. AUDIENCE: 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 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 there, they have something called
an innovation website, and so that they’ll
feature programs that are up and running,
and so they can disseminate information to others. Because 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. SPEAKER 1: OK. 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 DIETTE: So
a couple things. I mean, in Peyton
Eggleston’s study, the air cleaners 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 adhere to something do other things better as well. And so I think
that’s a fair point. But I don’t 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, 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 control trial that shows
that if you take it out of the drinking water, that
a community doesn’t get cancer. We just say, it’s a
carcinogen. It’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. 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
it does, in fact, reduce the pollutant
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 in
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, 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 change somewhat. We’ll learn from the data. SPEAKER 1: OK, we do have
a couple 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. SPEAKER 1: OK. 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
PCP/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.” So did we have another
question in the back? AUDIENCE: Well, kind of a
larger [INAUDIBLE] 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 socio-economically 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 costs? GREGORY DIETTE: I’ll answer him. KATE SCOTT: That’s a good one. GREGORY 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, the role
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’s 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 the 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 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. SPEAKER 1: OK. 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
just going to fix one problem, but going into the
house and trying to provide as many
services as possible through integrated
delivery of services. SPEAKER 1: OK. 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. OK, thank you very much. [APPLAUSE]


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