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«Reducing Environmental Triggers of Asthma in Homes of Minnesota Children Assistance Agreement Number CH-96541501 United States Environmental ...»

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Reducing Environmental Triggers of Asthma in

Homes of Minnesota Children

Assistance Agreement Number CH-96541501

United States Environmental Protection Agency

Asthma Program

Chronic Disease and Environmental Epidemiology

Health Promotion and Chronic Disease

Minnesota Department of Health

September 2007

Acknowledgements

This research was supported by Assistance Agreement CH-96541501 from the United

States Environmental Protection Agency (EPA). Its contents are solely the

responsibility of the authors and do not necessarily represent the official views of the EPA.

For more information or to obtain additional copies of this report contact:

Laura Oatman, MS Asthma Program Minnesota Department of Health 85 East Seventh Place PO Box 64882 St. Paul, MN 55164-0882 651-201-5914 laura.oatman@health.state.mn.us Suggested citation: Reducing Environmental Triggers of Asthma in Homes of Minnesota Children. Minnesota Department of Health. St. Paul, MN. September 2007.

For more information about the Minnesota Department of Health Asthma Program

call:

651-201-5909 1-877-925-4189 (toll free) Website: www.health.state.mn.us/asthma i Table of Contents Page List of Tables

List of Figures

Executive Summary

Introduction

Research Methods

Results

Baseline Descriptive Results

Age and Gender

Asthma Severity

Family History of Asthma

Asthma Action Plan

Use of Peak Flow Meter

Ownership and Residence Type

Pets

Other Environmental Concerns

Allergies

Asthma Triggers

Health Service Utilization

Asthma Medications

School Absences

Asthma Symptoms (ITG Child Asthma Short-Form)

Products and Project Costs

3-, 6-, 9-, and 12-month Follow-up Results

Statistical Analysis and Limitations

Health Service Utilization

School Absences

Asthma Symptoms (ITG Child Asthma Short-Form)

Discussion

Next Steps / Sustainability

References

Appendix A: Pediatric Home Service Data Collection Form

–  –  –

Table 1: “Quality of Life” Questions

Table 2: Environmental Interventions Available

Table 3: NHLBI Classification of Asthma Severity

Table 4: Allergies

Table 5: Asthma Triggers

Table 6: Mean Health Service Utilization—Baseline

Table 7: Asthma Medication Use—Baseline

Table 8: ITG Child Asthma Short Form—Baseline Scores

Table 9: ITG Child Asthma Short Form—Baseline Scores by Asthma Severity....... 13 Table 10: Products

Table 11: Follow-up Visits

Table 12: Mean Health Service Utilization by Follow-up Visit

Table 13: Paired t-tests—Health Service Utilization at 12 months

Table 14: School Absences by Follow-up Visit

Table 15: Paired t-tests—School Absences

Table 16: Mean ITG Child Asthma Short-Form Scores

Table 17: Paired t-tests

–  –  –

Figure 1: Age Distribution of Enrolled Children

Figure 2: Severity Classification

Figure 3: Residence Classification

Figure 4: Health Service Utilization—Baseline

iiiEXECUTIVE SUMMARY

Asthma is a common chronic disease in the United States affecting more than 20 million Americans including an estimated 6.3 million children under the age of 18.

Environmental exposures to allergens and irritants may cause or exacerbate asthma, and controlling these exposures is an important component in managing asthma.

The Minnesota Department of Health Asthma Program partnered with Pediatric Home Service to conduct a demonstration project Reducing Environmental Triggers of Asthma (RETA) in homes of children with asthma. This study addressed environmental factors in the home using inexpensive, uncomplicated interventions. The most common interventions were HEPA air cleaners, pillow and mattress dust encasements, and HEPA vacuum cleaners.

Sixty four families received both family-specific education and appropriate materials to minimize or eliminate exposures to environmental allergens and irritant triggers of asthma. During the initial home visit, information was collected regarding the number of emergency department visits, hospitalizations, missed school days, and unscheduled clinic visits that occurred in the previous 3 months. Quality of life improvement was measured by responses to a short form completed by the child’s parent or guardian regarding how the child’s life was affected by asthma by asthma during the past 4 weeks.

RETA KEY FINDINGS

Findings from the RETA data At baseline more than three-fourths of the children referred to the EPA asthma housing program were children with moderate persistent or severe asthma.

The ITG Child Asthma Short-Form results support the finding related to severity in that the mean scores on the Daytime Symptom, Nighttime Symptom and Functional Limitation scales would be considered scores found generally among children with moderate to severe asthma symptom impact.

Utilization of health care services for children with these severity levels of asthma is substantial.





On average there was 1 hospital visit, 1 emergency department visit, 2 unscheduled office visits and 1 use of oral prednisone during a 3-month recall period.

Children with these severity levels of asthma miss an appreciable amount of school. During a 3 month period of time, the average number of days missed is the equivalent of 1 week. Several children missed a considerably greater amount of school—in 3 cases the equivalent of more than 4 weeks during a 3 month period.

The most commonly identified asthma trigger was viral infections (98%) followed by weather (80%), exercise (69%), secondhand smoke (67%) and allergies (66%).

The most common environmental concern was secondhand smoke. Nearly half of the children (48%) were regularly exposed to secondhand smoke.

The average cost of products provided to families of children with asthma was $204 with a range of $48 to $470. Added to this is the average cost of the initial home assessment of $132 and a product delivery visit in the amount of $132, for an average initial project visit cost of $468.

Several outcomes demonstrated statistically significant changes over time. At the 12-month follow-up visit there were on average reported declines in unscheduled office visits (approximately 2 office visits) and use of oral prednisone (approximately 1 therapy regimen). These changes were statistically significant (p ≤0.05). Hospital visits also declined by approximately 1 visit, though this difference was not at the significance level designated for significance.

The number of school days missed significantly declined from 7 days to less than 1 day on average 12 months later. The change was statistically significant (p ≤0.05).

There were improvements in daytime symptom and functional limitation scores.

The resultant scores were dramatically closer to values generally viewed as moderate to no symptom impact on quality of life. These changes were statistically significant (p ≤0.050).

Pediatric Home Service staff observations and actions The product interventions were still in homes after 12 months. To date, there have been no products reported missing from the homes.

The products are still being used.

The products are “moving” if the family relocates to a different residence.

The focus has been on the child’s bedroom to provide at least one location were asthma triggers are minimized.

Home visits helped the families “work the system” by empowering people to tell their landlord about problems.

Many children were on the wrong medication. For example, one child was using a reliever medication 6 times a day; the child needed a daily controller medication.

Asthma Action Plans are a powerful tool but often were not prominently displayed in the home. Pediatric Home Service developed a refrigerator magnet for staff to write child-specific information on asthma management.

PHS also developed colorful “tip cards” for low literacy families. The tip cards include information on asthma medications, steps to take when asthma symptoms occur and triggers of asthma.

PHS purchased plastic boxes with covers to store the children’s asthma medications and materials.

Cost Savings of RETA Intervention The average cost of the initial visit and product interventions was $468.

Unscheduled office visits (urgent care) costs per pediatric asthma visit is $84 (average).

Hospitalization costs per pediatric asthma visit is $2,260 (average).

At the 12-month follow-up visit there were on average reported declines in hospital visits (approximately 1 visit), and unscheduled office visits (approximately 2 office visits).

Assuming the costs of health service utilization are $2,428 (1 hospital visit and 2 unscheduled office visits) and the average cost of an intervention was $468, the costs saved by implementing these interventions are estimated to be approximately $1,960 per child.

INTRODUCTION

Asthma is a common chronic disease in the United States affecting more than 20 million Americans including an estimated 6.3 million children under the age of 18 (ALA 2003).

Environmental exposures to allergens and irritants may cause or exacerbate asthma (IOM 2000), and controlling these exposures is an important component in managing asthma (Crain et al. 2002, Morgan et al. 2004, Takaro et al. 2004). The Minnesota Department of Health Asthma Program (MDH) conducted a demonstration project Reducing Environmental Triggers of Asthma (RETA) in homes of children with asthma.

The MDH environmental intervention program used a Certified Asthma Educator / respiratory therapist to teach the family about specific environmental triggers of asthma.

This study explored the hypothesis that by addressing environmental factors at home through inexpensive, uncomplicated interventions, the quality of children’s lives through fewer hospitalizations, fewer emergency department visits, and fewer missed school days - can be enhanced. MDH also sought to demonstrate potential cost savings to health plans by providing these in-home environmental interventions.

RESEARCH METHODS

The Minnesota Department of Health (MDH) Asthma Program partnered with Pediatric Home Service (PHS), a durable medical equipment and supply company. Since 1995, PHS has provided over 1,900 pediatric asthma home visits to educate family members regarding medical and environmental management of asthma. A Certified Asthma Educator / respiratory therapist provides this in-home asthma education. The clientele of PHS is almost exclusively disproportionately impacted children. Over 90 percent of their clients reside in the inner cities of Minneapolis or St. Paul, and 80 percent come from minority populations. Approximately 85 percent of their clients live in rental housing. Client referrals come from Hennepin County Medical Center, Partners in Pediatrics, and Children’s Respiratory and Critical Care, and Children’s Hospitals and Clinics. PHS also has an ongoing working relationship with the Minneapolis Public School District (kindergarten through grade 12).

RETA explored the hypothesis that if environmental asthma triggers in the home can be eliminated or reduced, the quality of children’s lives is enhanced. Criteria for a family’s inclusion included the child being 18 years of age or younger, a physician diagnosis of persistent asthma, under a physician’s care, and on daily preventative medications. In most cases the child also had documented allergies (RAST or skin tested). The results of the first home visit, along with the child’s allergies, determined the recommended interventions. Sixty seven children were enrolled in the study; three dropped out before the initial visit. Sixty four families received both the family-specific education and appropriate materials to minimize or eliminate exposures to environmental allergens and irritant triggers of asthma. Families also received an asthma brochure developed by the Hennepin County Medical Center (2004).

During the initial home visit, information was collected regarding the number of emergency department visits, hospitalizations, missed school days, and unscheduled clinic visits that occurred in the previous 3 months (Appendix A). The Quality of Life improvement was measured by responses to a short form completed by the parent or guardian regarding how the child’s life was affected by asthma during the past 4 weeks (Bukstein et al. 2000). Table 1 lists the Quality of Life questions asked during the study.

After the intervention, this same information was collected at intervals of 3 months (telephone interview), 6 months (home visit), 9 months (telephone interview), and 12 months (home visit). The total cost of the intervention, including the cost of the home visit by the certified asthma educator, was recorded. The sustainability of the interventions was evaluated for the 3, 6, 9 and 12-month intervals.

Table 1: “Quality of Life” Questions

Has your child complained of being short of breath?

Has exertion, such as running, made your child breathless?

Has your child coughed at night?

Has your child been woken up by wheezing or coughing?

Has your child stayed indoors because of wheeze/cough?

Has your child’s education suffered due to asthma?

Has your child’s asthma interfered with his/her life?

Has asthma limited your child’s activities?

Has taking his/her inhaler or other treatments interrupted your child’s life?

Have you had to make adjustments to family life because of your child’s asthma?

Enrollment in RETA began in December 2004 and ended about one year later. Table 2 lists the most common environmental interventions used during this study. The most common interventions used were HEPA air cleaners, pillow and bed dust encasements, and HEPA vacuum cleaners.



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