Introduction

Many children with asthma do not get the care they need,

despite the existence of asthma care guidelines and evidence

about effective treatments. For example, the appropriate use

of controller medications is very important in the treatment

of asthma. By helping to reduce the underlying

inflammation of the airways in a person with asthma,

controller medications diminish asthma symptoms and

prevent attacks. However, among children and adults with

persistent asthma, approximately 29 percent are not

receiving appropriate controller medications from providers,

and some patients are not using the medications

appropriately.1 Among Medicaid-enrolled children with

persistent asthma, the underuse of controller medications is

widespread, reaching as high as 73 percent.2 As a result,

there are more acute episodes, greater use of emergency

rooms and hospitals, and increased treatment costs. 

Research has shown that reorganizing the way chronic care

is delivered can increase the appropriate use of controller

medications among children with asthma and have other

positive results. Preliminary evidence also suggests that

disparities in asthma care can be decreased through the use

of strategies sensitive to the needs of racial and ethnic

minorities.

This report provides promising strategies that could help

policymakers and purchasers of health care and health

insurance improve care for children with asthma. Other

related topics discussed are: 

• Patterns of use/underuse of controller medications.

• Effects of proper use of controller medications. 

• Practices and policies used by managed care

organizations (MCOs) and clinics and their effects on

quality of care.

It is addressed to:

• Administrators of State Medicaid programs. 

• Executives of Medicaid managed care organizations.

• Managers of provider organizations.

• Health plan executives.

• Employers who purchase health care for their

employees.

Chronic Care for Low-Income Children with Asthma: 

Strategies for Improvement

Making a Difference

• Controller medications are underused by children with

asthma, especially low-income and minority

children...Page 2

• Increasing use of controller medications improves

outcomes ...Page 3

• Processes of asthma care for children enrolled in

Medicaid managed care vary more by practice site than

by health plan...Page 4

• Cultural competence policies are associated with better

quality asthma care for Medicaid-insured

children...Page 4

• Clinic-based organizational changes can help to

improve asthma care for children...Page 5

Issue #18 June 2005

RESEARCH

IN ACTION

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality

Authors: Mark W. Stanton, M.A., and Denise Dougherty, Ph.D.

Managing Editor: Margaret Rutherford

Design and Production: Frances Eisel

Suggested citation: Stanton MW, Dougherty D, Rutherford MK. Chronic care

for low-income children with asthma: strategies for improvement. Rockville

(MD): Agency for Healthcare Research and Quality; 2005. Research in

Action Issue 18. AHRQ Pub. No. 05-0073.

Note: Bernard Friedman, Ph.D., made a significant contribution

to this report.
They may want to consider the strategies outlined in this

report as they seek ways of providing higher quality care for

children with asthma. Health care purchasers in the public

and private sectors have the ability to use the contracting

process to alter benefits or to add performance measures and

set goals. Purchasers may want to consider modifying their

benefit designs to cover an expanded emphasis on patient

education strategies. Chronic care for low-income children

with asthma can be improved if the information in this

report is acted on. 

Background

Approximately 9 million children (12 percent of children

under age 18) have been diagnosed with asthma, according

to the 2002 National Health Interview Survey.3 In 2002,

health care costs for children with asthma in the United

States totaled more than $6 billion.4 Hospital stays are

usually the most expensive form of medical care, and

children age 17 and under are much more likely to be

admitted to a hospital for asthma than are adults (27.5 per

10,000 vs. 12.7 per 10,000).5 In fact, asthma admissions

accounted for 7.4 percent (152,000) of all hospital

admissions for children and adolescents in 2000.6 Almost

half of hospitalizations for asthma among children are billed

to Medicaid.6

States are increasingly contracting with Medicaid managed

care programs in various forms and giving them the

responsibility for providing care to many Medicaid-enrolled

children. Managed care, with its emphasis on the

organization and coordination of care, has increased

expectations about the quality of care that can be provided

for those with asthma and other chronic conditions. At the

same time, another feature of managed care, fixed prepaid

budgets, has raised questions about the ability of these

organizations to deliver on their promise.7

Data on asthma care show gaps in quality 

Asthma care guidelines and evidence about effective

treatments are available. The National Asthma Education

and Prevention Program (NAEPP) Expert Panel issued its

revised Guidelines for Diagnosis and Management of

Asthma (EPR-2) in 1997 and an Update in 2002.8 However,

many children with asthma do not get the care they need. 

In addition, even when providers deliver appropriate care,

children may not be using controller medications correctly

because their parents do not understand the purpose of the

medication.9 According to the 2004 survey on the quality of

care in commercial managed care plans from the National

Committee for Quality Assurance, about 29 percent of

children and adults (ages 5-56) with persistent asthma are

not receiving inhaled corticosteroids to control their

condition.1 The problem of underuse was even more serious

among children with persistent asthma enrolled in Medicaid

managed care, according to researchers from the Asthma

Care Quality Assessment (ACQA) Study (Box 1). In 1999,

these children experienced a very high rate (73 percent) of

underuse of controller therapy, with 49 percent of parents

reporting no controller use and 24 percent reporting less

than daily use.a,2

A related issue is the significant racial/ethnic disparities in

asthma status and home management practices. For

example, African-American and Hispanic children with

similar insurance and sociodemographic characteristics have

more severe asthma than white children based on number of

symptom days, school days missed, and health status scores.

Also, compared to white children, in 1999 AfricanAmerican and Hispanic children were 31 percent and 42

percent less likely, respectively, to be using controller

medications (including inhaled corticosteroids).10 Finally,

African-American children are about three times as likely to

be admitted to a hospital for asthma as white children.11

2 www.ahrq.gov

Box 1. Asthma Care Quality Assessment Study (ACQA) 

Asthma Care Quality in Varying Managed Care Medicaid

Plans. Harvard Medical School. Grant No. U01-HS09935.

1998-2003. ACQA, a project jointly funded by the

Agency for Healthcare Research and Quality, the American

Association of Health Plans Foundation, and the Health

Resources and Services Administration, investigated

patterns of asthma-related health care for Medicaid-insured

children in five geographically dispersed not-for-profit

managed health care plans, including three group-model

health maintenance organizations and two Medicaid

managed care organizations. A series of papers have been

published based on the findings of this study.

a The statistics, based on reports by parents not confirmed by review of

medical records, do not separate the effects of inadequate prescribing of

controller medications from inadequate patient adherence to prescribed

preventive regimens. 
Successful asthma management

Successful management of asthma has four basic

components: 

1. Reducing or controlling exposure to environmental

triggers. 

2. Objective monitoring of the condition by patient and

provider. 

3. Taking appropriate medications as indicated.

4. Active involvement of the patient in managing the

disease. 

The last component—patient self-management (and, in the

case of children, family management)—is critical to the

other three. People with persistent asthma need long-term

controller medications. The treatment of choice for the most

effective long-term control of asthma is inhaled

corticosteroids. This may be supplemented by long-acting

beta-agonists in cases of moderate to severe persistent

asthma. Other controller medications include leukotrine

modifiers, cromolyn, nedocromil, and theophylline. Longterm controller medications are taken every day, usually

over long periods of time, to control chronic symptoms and

to prevent asthma episodes or attacks.8

Increasing use of controller medications improves

outcomes 

In its systematic review of research on the management of

chronic asthma, an Evidence-based Practice Center (EPC)

reported that the regular use of inhaled corticosteroids

improves long-term outcomes for children with mild to

moderate asthma .b ,12 This systematic review also found

that regular use of controller medications reduced

hospitalizations. A similar effect was observed in a study

conducted among children enrolled in three MCOs.13 This

study found that children receiving controller medications

were only 40 percent as likely to have emergency

department visits or hospitalizations compared with

children who did not receive such medications. 

Specialist and followup visits are linked to controller

medication use

The ACQA study mentioned earlier found that Medicaidinsured children with asthma who received specialist visits

or followup appointments were more likely to use

appropriate controller medications.2 One possible reason

for this is that specialists may be more likely to have

systems allowing for more effective patient education.

Other reasons are that patients seeing specialists may have

more severe disease or be more motivated to follow their

physician’s guidance.

Patient education and self-management are related

to organization of care 

Given the complex and chronic nature of asthma and the

importance of routine patient self-management (e.g.,

appropriate use of controller medications, identification of

symptoms of an exacerbation, avoidance of environmental

triggers), patient education for self-management has been

strongly recommended. However, the evidence for specific

measures can be unclear. For example, the EPC report

mentioned earlier12 determined that the evidence on the

effectiveness of written asthma treatment plans distributed

to the patient was inconclusive. Positive results may

depend on how the education is delivered.c Patient

education is linked to the way in which asthma care is

organized within each practice. 

The Pediatric Asthma Care Patient Outcomes Research

Team (PAC PORT) study (Box 2) used a Planned Care

Model to better organize asthma care by combining nursemediated organizational change and physician peer leader

education. This model was found to be effective in

improving asthma care in the primary care setting within

managed care. 

The Planned Care Model in this study was based on the

Chronic Care Model developed by Wagner and

colleagues.14,15 The core of the Planned Care Model

consisted of visits with an asthma nurse trained in the

NAEPP guidelines and in self-management support. Part

of this training involved learning how to use techniques

www.ahrq.gov 3

b Under AHRQ’s Evidence-based Practice Centers (EPC) Program, 5-

year contracts are awarded to institutions in the United States and Canada

to serve as EPCs. The EPCs review all relevant scientific literature on

clinical, behavioral, and organization and financing topics to produce

evidence reports and technology assessments. These reports are used for

informing and developing coverage decisions, quality measures,

educational materials and tools, guidelines, and research agendas. 

c The NAEPP continues to recommend the use of written treatment plans

as part of the treatment protocol.
drawn from motivational interviewing and problem-solving

therapy to improve self-management in pediatric chronic

illness care.d The nurse provided standardized assessments,

care planning, coordination with the primary care provider,

and self-management tools for the patients and their

families.

The peer leader education component consisted of training

one pediatrician per practice in asthma guidelines and peer

teaching methods. This pediatrician served as an asthma

expert who provided support, education, and feedback to

other members of the practice related to their asthma

management. This component was more effective when

combined with the asthma nurse visits. Children receiving

care through practices relying on both peer leader education

and visits with a trained asthma nurse had 13 fewer

symptom days annually and a 39-percent lower oral steroid

burst rate per year relative to usual care.e,16 In a followup

cost-effectiveness study, the researchers found that the

additional incremental cost for each of the 13 symptom-free

days was $68.17

Care is affected more by practice site than MCO

The ACQA study investigated the extent to which MCOs

and their affiliated practice sites consistently used 27

different processes of asthma care. These processes of care

included promoting self-management support by teaching

spacer techniquef and strengthening delivery systems by

using asthma nurses or other managers. The policies and

practices selected for study were adapted from the

Assessment of Chronic Illness Care, a tool for assessing

processes of chronic illness care that is based on the

Chronic Care Model.18 These processes have been shown

to be associated with high-quality asthma care or in a more

general sense, high-quality chronic illness care.14 Many of

them are included as components of quality care in the

NAEPP Expert Panel Report cited earlier.8

Clinicians at 73 practice sites (including community health

centers, solo and specialty practices, multispecialty group

practices, and academic health centers) completed a survey

to assess how frequently their practices were using these

processes of asthma care for poor populations. After

analyzing the results of the survey, ACQA researchers

found that Medicaid MCOs do not consistently influence

the processes of asthma care used by their associated

practice sites.19 The practice sites overall scored well on

some processes of care. For example, 84 percent facilitated

specialist referral for difficult cases and 90 percent ensured

primary care followup after an urgent care visit. However,

the researchers found wide variability among most

processes of care from practice site to practice site.g

MCOs appeared to exert a moderate to strong influence on

their affiliated practice sites with respect to only five

processes of care, three of them related to information

systems (Table 1). For example, a strong relationship was

found between MCOs and affiliated practice sites for the

use of registries and reports. Two processes of care were

strongly related to the MCOs: ensuring primary care

followup after an urgent care visit and use of asthma nurses

or other case managers. In general, sites were less likely to

emphasize processes of care related to self-management

support and information systems and more likely to

emphasize processes of care related to delivery system

design and decision support. 

Cultural competence and reports to physicians can

improve care

The ACQA researchers also surveyed practice sites to

determine the prevalence of certain practices and policies

especially associated with quality care for poor and

minority children. Their objective was to examine

associations between those practices and policies and the

quality of care for Medicaid-insured children with asthma.20

4 www.ahrq.gov

d Motivational interviewing is designed to strengthen a person’s

commitment to changing behavior by focusing on such factors as desire,

self-efficacy, need, readiness, and reasons.

e When a patient has an acute attack that does not respond to the usual

asthma medications, an oral corticosteroid may be prescribed in a high

dose for a few days. This treatment is known as steroid burst.

f A spacer is a long tube that slows the delivery of medication from

pressurized metered dose inhalers. Some instruction in its proper use is

required.

g Another study found that there were significant differences across three

MCOs in the proportions of patients dispensed controller medications. It

did not relate these differences to differences in processes of care,

structures of care, or patient outcomes.13
www.ahrq.gov 5

Cultural and linguistic competence is the ability of health

care providers and health care organizations to understand

and respond effectively to the cultural and linguistic needs

brought by the patient to the health care encounter.

Cultural competence policies included:

• Recruiting ethnically diverse nurses and providers (71

percent of practices).

• Attempts to minimize cultural barriers through printed

materials (48 percent).

• Offers of cross-cultural or diversity training (39

percent).

• Offers to providers of training to develop

communication skills (24 percent). 

• Evaluation of the level of cultural competence among

providers (15 percent). 

Also included in the survey were different types of reports

to physicians such as:

• Lists of asthma patients (15 percent).

• Asthma registries to prompt physicians about

appropriate medications or services (22 percent).

• Reminders about asthma guideline adherence for

individual patient encounters (34 percent). 

• Feedback reports to improve performance in asthma

care (30 percent). 

The researchers found that both cultural competence

practices and the use of reports to physicians were

associated with less underuse of controller medications,

better asthma physical status at followup, and better parent

ratings of care. In addition, access to and continuity of care

were also associated with better outcomes. 

What can be done to improve care?

The ACQA study concluded that MCOs participating in

Medicaid could play a greater role in improving asthma

care processes at practice sites if they placed greater

emphasis on improving information systems and selfmanagement support services. In addition to the

organizational changes discussed earlier in the Planned

Care Model intervention, other interventions to improve

professional and patient education and control of

environmental asthma triggers might also have positive

impacts. Several examples of successful interventions

reported on in recent studies are discussed below: 

• A social-worker-based program involving asthma

education and control of environmental asthma triggers

(Box 3).

• An interactive seminar for physicians based on selfregulation theory (Box 4).

• A training program for intervention staff in public

health clinics (Box 5).

The National Cooperative Inner-City Asthma Study

(NCICAS) shows that a multifaceted program that includes

social-worker-based asthma education, case management,

and home-based interventions to control environmental

asthma triggers can reduce asthma symptoms among innercity children, especially those with more severe asthma.

The increase in costs was modest: when compared with

usual care, the intervention improved outcomes at an

average individual cost of $9.20 per symptom-free day. In

this intervention, social workers functioned as case

managers.21

Self-regulation theory focuses on the ways in which people

direct and monitor their activities and emotions in order to

attain their goals. Studies found that a two-session

interactive seminar for physicians using this theory to assist

Table 1. Asthma processes of care moderately to

strongly correlated within the managed care

organization and their frequency of use in Medicaid

managed care practice sites

Percent usually or 

Care process always using process

Delivery System Design

Ensure primary care followup after 

urgent care visit 90

Use asthma nurses or other case 

managers 42

Information Systems

Give feedback reports to providers to 

improve asthma care 30

Provide registries to clinicians 14

Use registries to prompt clinicians 

regarding guidelines 21

Source: Lozano P, Grothaus LC, Finkelstein JA, et al. Variability in asthma care and services for low-income populations among practice sites in managed Medicaid systems.

Health Serv Res 2003; 38 (6 Pt I):1563-78.
6 www.ahrq.gov

in altering physician treatment practices resulted in more

children being placed on inhaled corticosteroids. This

regimen, coupled with physician education in

communication and education techniques, resulted in

significantly fewer symptoms and fewer followup office

visits, non-emergency physician office visits, emergency

department visits, and hospitalizations in the treatment

group compared to controls. The effects of the physician

education persisted over 2 years, and treatment group

physicians expended no more time with their patients than

controls. Children of younger single mothers reaped the

greatest benefit from the physician education.22, 23

A study focused on professional education in public health

clinics found that improvements could be obtained only by

combining the provision of sufficient equipment and

prescription drugs with seminars for providers, all other

clinic staff, and administrators. As a result, clinics were

able to substantially increase the percentage of patients

receiving both inhaled anti-inflammatory and beta-agonist

medications over a 2-year period.24

Ongoing research 

Other approaches to asthma care improvement for children

funded by the Agency for Healthcare Research and Quality

(AHRQ), some of which focus on low-income children, are

being tested in community health centers and in Head Start

programs.

Better Pediatric Outcomes Through Chronic Care.

University of Connecticut. Grant No. U18 HS11068-01.

This study, focusing on poor, minority, inner-city children

with asthma, is developing and testing the use of provider

prompts on guideline recommendations at the point of care

using affordable information technology. It also provides

and tests a family-focused supportive educational

intervention delivered by a community health worker. 

Managed Care Organization Use of a Pediatric Asthma

Management Program. University of Connecticut. Grant

No. U18 HS11147. This study, also focusing on inner-city

children, tests an asthma management program for its

reproducibility, effectiveness in adherence to guidelines, and

cost burden on an MCO. 

Developing an Asthma Management Model for Head Start

Children. Arkansas Children’s Hospital, Little Rock. Grant

No. U18 HS11062-01. This study is testing a multifaceted

case-management model implemented by Head Start

personnel for its effects on school absence, acute care

utilization, and asthma management practices of children,

parents, and staff. 

Developing an Asthma APGAR. Olmsted Medical Group.

Grant No. R03-HS14476. This project collaborates with

rural practice-based research network physicians using

participatory action research to modify and validate the

asthma APGAR, an asthma severity index developed by the

principal investigator. The practice asthma APGAR is used

to provide targeted feedback to physicians and practices to

guide activities oriented toward translating research into

practice. After assuring face validity, the study will assess

the effectiveness of the practice asthma APGAR in helping

providers identify gaps in asthma care and develop simple

implementable solutions for those gaps. Finally, the

researchers will evaluate the potential of spreading use of

the tool to other rural practices.

Telephone-Linked Communications for Asthma. Boston

Medical Center. Grant No. R01-HS10630-01. The goal of

this project is to develop and evaluate an education and

monitoring system for children with asthma. TLC-Asthma

is a computer-based telecommunications system that will

give guidance on asthma management to families and

collect information to share with each family’s primary care

provider on the problems and successes the family is having

managing the child’s asthma. 

Conclusion

Studies show underuse of controller medications among

children with asthma and higher rates of negative patient

outcomes associated with such underuse. In addition,

significant disparities in asthma care exist among minority

children. Higher quality asthma care for Medicaid-insured

children is associated with practice-site policies to support

cultural competence, reports to clinicians, and access and

continuity of care. Research also shows that processes of

asthma care for children enrolled in Medicaid managed care

vary more by practice site than by health plan. MCOs

participating in managed Medicaid could play a greater role

in improving asthma care processes at practice sites if they

placed greater emphasis on improving information systems

and self-management support services. Also, some of the

intervention strategies found to be successful in studies

could be helpful in improving asthma care. Public and
private payers such as State Medicaid programs might want

to consider encouraging MCOs and patients to implement

one or more of these interventions. 

References 

1. National Committee for Quality Assurance. The State of

Health Care Quality: 2004. Washington; 2004. Web site:

http://www.ncqa.org/Communications/News/sohc2004.htm.

Accessed March 14, 2005.

*2. Finkelstein JA, Lozano P, Farber HJ, et al. Underuse of

controller medications among Medicaid-insured children

with asthma. Arch Pediatr Adolesc Med 2002; 156(6):

562-7.

3. National Center for Health Statistics. Nine million U.S.

children diagnosed with asthma, new report finds. Fact

Sheet. March 31, 2004. Web site: http://www.cdc.gov/nchs/

pressroom/04news/childasthma.htm. Accessed July 29,

2004.

4. Wise PH. The transformation of child health in the United

States. Health Aff 2004; 23(5):9-25.

5. National Center for Health Statistics. Hospital discharge

rates by age, gender, race, and region, 1998-2002. Asthma

Data on Demand. Web site: http://209.217.72.34/asthma/

ReportFolders/reportfolders.aspx. Accessed March 11,

2005.

*6. Owens PL, Thompson J, Elixhauser A, et al. Care of

children and adolescents in U.S. hospitals. Rockville

(MD): Agency for Healthcare Research and Quality; 2003.

HCUP Fact Book No. 4. AHRQ Pub. No. 04-0004.

7. Ware JE, Bayliss MS, Rogers WH, et al. Differences in 4-

year health outcomes for elderly and poor, chronically ill

patients treated in HMO and fee-for-service systems.

JAMA 1996; 276(13):1039-47.

8. National Asthma Education and Prevention Program

(NAEPP) Expert Panel. Expert Panel Report 2: Guidelines

for the diagnosis and management of asthma. Bethesda

(MD): National Institutes of Health; 1997. NIH Pub. No.

97-4051. Web site for the 1997 Guidelines and 2002

Update: http://www.nhlbi.nih.gov/guidelines/

asthma/asthgdln.htm. Accessed March 9, 2005.

*9. Farber HJ, Capra AM, Finkelstein JA, et al.

Misunderstanding of asthma controller medications:

association with nonadherence. J Asthma 2003; 40(1):

17-25.

*10. Lieu TA, Lozano P, Finkelstein JA, et al. Racial/ethnic

variation in asthma status and management among children

in managed Medicaid. Pediatrics 2002; 109(5):857-65.

*11. Agency for Healthcare Research and Quality. 2004

National Healthcare Disparities Report. Rockville (MD):

Department of Health and Human Services, Agency for

Healthcare Research and Quality; Dec 2004. AHRQ Pub.

No. 05-0014.

*12. Aronson N, Lefevre F, Piper M, et al. Management of

chronic asthma. Evidence Report/Technology Assessment

Number 44. (Prepared by Blue Cross and Blue Shield

Association Technology Evaluation Center under Contract

No. 290-97-0015.) AHRQ Pub. No. 01-E044. Rockville

(MD): Agency for Healthcare Research and Quality; Sept

2001. Web site: http://www.ahrq.gov/clinic/epcsums/

asthmasum.htm.

*13. Adams RJ, Fuhlbrigge A, Finkelstein JA, et al. Impact of

inhaled antiinflammatory therapy on hospitalization and

emergency department visits for children with asthma.

Pediatrics 2001; 107(4):706-11.

14. Wagner EH, Austin BT, Von Korff M. Improving outcomes

in chronic illness. Managed Care Q 1996; 4(2):1-14. 

15. Wagner EH, Austin BT, Von Korff M. Organizing care for

patients with chronic illness. Milbank Q 1996; 74(4):

511-44.

*16. Lozano P, Finkelstein JA, Carey VJ, et al. A multi-site

randomized trial of the effects of physician education and

organizational change in chronic asthma care. Health

outcomes of the Pediatric Asthma Care PORT study. Arch

Pediatr Adolesc Med 2004 Sep; 158(9):875-83.

*17. Sullivan SD, Lee TA, Blough DK, et al. A multi-site trial

of physician education and organizational change in

chronic asthma care: cost-effectiveness analysis of the

Pediatric Asthma Care PORT. Arch Pediatr Adolesc Med

2005; 159(5).

18. Bonomi AE, Wagner EH, Glasgow R, et al. Assessment of

Chronic Illness Care (ACIC): a practical tool to measure

quality improvement. Health Serv Res 2002; 37(3):

791-820. 

*19. Lozano P, Grothaus LC, Finkelstein JA, et al. Variability in

asthma care and services for low-income populations

among practice sites in managed Medicaid systems.

Health Serv Res 2003; 38(6 Pt 1):1563-78.

* AHRQ-funded/supported research 

www.ahrq.gov 7
*20. Lieu TA, Finkelstein JA, Lozano P, et al. Cultural

competence policies and other predictors of asthma care

quality for Medicaid-insured children. Pediatrics 2004;

114(1):e102-10.

*21. Sullivan SD, Weiss K, Lynn H, et al. The cost-effectiveness

of an inner-city asthma intervention for children. J Allergy

Clin Immunol 2002; 110(4):576-81. 

22. Clark NM, Gong M, Schork MA, et al. Impact of

education for physicians on patient outcomes. Pediatrics

1998; 101(5):831-6.

23. Clark NM, Gong M, Schork MA, et al. Long-term effects

of asthma education for physicians on patient satisfaction

and use of health services. Eur Respir J 2000; 16:15-21.

24. Evans D, Mellins R, Lobach K, et al. Improving care for

minority children with asthma: professional education in

public health clinics. Pediatrics 1997; 99(2):157-64.

* AHRQ-funded/supported research 

8 www.ahrq.gov
Box 2. PAC PORT Planned Care Model

Nurse-mediated change

Four or five visits per year with a trained asthma nurse who conducts

assessments are planned for asthma patients and family members.

Nurse activities (patient visits, etc.) include:

• Assessment of asthma symptoms, medication use, environmental

control, and self-management skills. (The nurse shares a computergenerated report of findings with the child’s physician.)

• Self-management support to families regarding medication

adherence, technical skills, and environmental triggers, using

problem-solving and motivational techniques.

• Proactive standardized telephone followup between visits.

• Support and participation in care planning (including medication

and environmental measures) in conjunction with primary care

providers, using the Expert Panel Report-2 (EPR-2), with emphasis

on the use of controllers for persistent disease. 

• Arranging for allergists to visit the primary care site for case

discussions.

• Other activities including reviewing with physicians quarterly

registry-based asthma panel reports (on medication use and

emergency department visits).

Asthma nurse training includes: 

• Training in NAEPP’s EPR-2 and in self-management support

techniques.

• Full-day training session to learn motivational enhancement and

problem-solving techniques.

• Meetings weekly or every other week for 10 weeks for 1-hour

conference calls to review written materials. 

Peer leader education 

One primary care provider per practice is trained in asthma guidelines and

peer teaching methods.

Training emphasizes asthma pharmacotherapy and physician behavior

change strategies.

Training includes two workshops, central support by an educational

coordinator, and an ongoing learning network for peer leaders via national

and local teleconferences.

Peer leader education provides ongoing support for physicians in their role

as change agents.

Note: PAC PORT is Pediatric Asthma Care Patient Outcomes Research

Team. NAEPP is the National Asthma Education and Prevention

Program. 

Source: Lozano P, Finkelstein JA, Carey VJ, et al. A multi-site

randomized trial of the effects of physician education and organizational

change in chronic asthma care. Health outcomes of the Pediatric Asthma

Care PORT study. Arch Pediatr Adolesc Med 2004 Sep; 158(9):875-83.

For additional information, contact Dr. Paula Lozano at: Center for

Health Studies, Group Health Cooperative. E-mail: Lozano.p@ghc.org.

Box 3. National Cooperative Inner-City Asthma Study Intervention

This is a comprehensive social-worker-based education program combined

with environmental control. 

• Social workers were trained as asthma counselors (ACs) over a 3-

month period.

• Training included three separate 21/2-day sessions plus attending local

asthma clinics for at least 2 weeks. 

• ACs worked with child’s caretaker to improve communications

between family and physician.

• Primary care physicians were sent a blank asthma care plan, a spacer, a

peak flow meter, and National Heart, Lung, and Blood Institute’s

asthma treatment guidelines.

• Caretakers attended two adult group asthma education sessions and

one individual meeting with their AC during the 2 months after

baseline assessments. 

• Group sessions covered asthma triggers, environmental controls,

asthma physiology, strategies for problem solving, and communicating

with their child’s physician.

• Two group sessions for children were conducted during the next 2-

month period. 

• ACs met with caretakers in person every 2 months and spoke with

them on the telephone on alternate months. 

• Families were given pillow and mattress covers and were encouraged

to minimize exposure to tobacco smoke and pets. 

• All children participating were given comprehensive 2-hour baseline

assessments regarding health status, asthma symptoms, use of health

care services, and psychological status. 

Source: Sullivan SD, Weiss K, Lynn H, et al. The cost-effectiveness of an

inner-city asthma intervention for children. J Allergy Clin Immunol 2002;

110(4):576-81.

For additional information, contact Dr. Sean Sullivan at the University of

Washington. E-mail: sdsull@u.washington.edu; telephone: 206-685-8153.

www.ahrq.gov 9
10 www.ahrq.gov

Box 5. Creating a Medical Home for Asthma: Professional education

in public health clinics

The purposes of the program are:

• To help staff link the goals of continuing care for asthma to the

preventive care mission of the clinics.

• To help staff resolve organizational problems blocking acceptance of

the new approach to asthma care.

• To build teamwork and a sense of owning the program by involving

staff in planning how to implement the program in each clinic.

The program has three main components:

1. Training sessions for all clinic staff.

• Five 3-hour sessions over a 5-month period were attended by all

clinic staff. Emphasis was placed on defining the roles of clerks,

public health assistants, and lab technicians and teaching them to

answer questions and encourage compliance.

- Session 1 introduced the Creating a Medical Home for Asthma

Program and asked clinic staff to assess assets and barriers to

implementing the program.

- Session 2 used a skit written by faculty and performed by staff

showing how the program would work and also introduced an

interactive exercise called “force field analysis” to help clinic teams

plan how to start the program in each clinic.

- Session 3 introduced prevention and treatment protocols based on

the National Asthma Education and Prevention Program

Guidelines.

- Session 4 modeled optimal communication skills for medical

interviews and family education using videotapes showing a

faculty doctor and nurse conducting an initial visit for asthma

with a patient.

- Session 5 introduced a screening process to identify children with

asthma and invite them to receive treatment in the clinic.

• Two additional 3-hour sessions were held at the end of the first

followup year to reinforce communication skills and discuss patients

they had worked with.

2. Tutorial session for each clinic physician. Each clinic physician spent 3

hours observing a Columbia University faculty physician treating

children with asthma in a hospital setting.

3. Visits by a full-time nurse educator. Once a month, a nurse educator

visited to help solve problems and continue the educational process. 

In addition to this training, all clinics received appropriate medications

and delivery devices. 

Source: Evans D, Mellins R, Lobach K, et al. Improving care for minority

children with asthma: professional education in public health clinics.

Pediatrics 1997; 99(2):157-64.

The program can be accessed on the New York City Department of

Health Web site at: http://www.nyc.gov/html/doh/html/

cmha/index.html. Accessed on March 9, 2005. 

Box 4. Interactive seminar for physicians based on self-regulation

theory (Physician Asthma Care Education: PACE)

Physicians were helped to observe, evaluate, and react to their own efforts

to treat and educate their patients. The purposes of the seminar were to:

• Help physicians create interactive conversation with patients to derive

information for making therapeutic decisions.

• Create a congenial and supportive atmosphere so that patients would

be candid.

• Reinforce positive efforts of families to self-manage.

• Provide a supportive climate for mutual problem-solving.

• Strengthen patients’ skills in using medicines.

• Provide the patient with a view of the long-term therapeutic plan.

• Build patients’ confidence to control symptoms.

The program had two components: optimal clinical practice based on

National Asthma Education and Prevention Program guidelines, and

patient teaching and communications. 

There were two 21/2-hour seminars 2-3 weeks apart. The seminars

included:

• Brief lectures on clinical practice by respected asthma specialists.

• A video depicting effective clinical teaching and communication

behavior.

• Case studies presenting troublesome clinical problems.

• A protocol by which physicians could assess their own behavior

regarding patient communications. 

• A review of messages to communicate and materials to use when

teaching patients.

The topics included: 

• What happens in an asthma attack.

• How medicines work.

• Responding to changes in asthma severity.

• How to take medicines.

• Safety of medicines.

• Goals of therapy.

• Criteria of successful treatment.

• Managing asthma at school.

• Identifying and avoiding triggers.

• A long-term treatment plan showing patients at home how to adjust

medications. 

Source: Clark NM, Gong M, Schork A, et al. Impact of education for

physicians on patient outcomes. Pediatrics 1998; 101(5):831-6.

For additional information, contact Amy Friedman at the University of

Michigan. E-mail: arfried@umich.edu; telephone: 734-647-3179.
www.ahrq.gov 11

Previous issues of Research in Action are available for free from the AHRQ Publications Clearinghouse: 1-800-358-9295.

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Issue Title Publication Number

17 Employer-Sponsored Health Insurance: Trends in Cost and Access AHRQ 04-0085

16 Programs and Tools to Improve the Quality of Mental

Health Services AHRQ 04-0061

15 Women and Domestic Violence: Programs and Tools That Improve 

Care for Victims AHRQ 04-0055

14 Hospital Nurse Staffing and Quality of Care AHRQ 04-0029

13 Dental Care: Improving Access and Quality AHRQ 03-0040

12 Advance Care Planning: Preferences for Care at the End of Life AHRQ 03-0018

11 AHRQ Tools for Managed Care AHRQ 03-0016

10 AHRQ Tools and Resources for Better Health Care AHRQ 03-0008

9 Reducing Costs in the Health Care System: Learning From 

What Has Been Done AHRQ 02-0046

8 Prescription Drug Therapies: Reducing Costs and Improving AHRQ 02-0045

Outcomes

7 Improving Treatment Decisions for Patients with Community- AHRQ 02-0033

Acquired Pneumonia

6 Medical Informatics for Better and Safer Health Care AHRQ 02-0031

5 Expanding Patient-Centered Care to Empower Patients and AHRQ 02-0024

Assist Providers

4 Managing Osteoarthritis: Helping the Elderly Maintain Function AHRQ 02-0023

and Mobility

3 Preventing Disability in the Elderly With Chronic Disease AHRQ 02-0018

2 Improving Care for Diabetes Patients Through Intensive AHRQ 02-0005

Therapy and a Team Approach

1 Reducing and Preventing Adverse Drug Events To Decrease AHRQ 01-0020

Hospital Costs
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June 2005