# Abstract

 

## Background Asthma is the most common chronic condition of childhood and disproportionately affects inner-city minority children. Low rates of asthma preventer medication adherence is a major contributor to poor asthma control in these patients. Web-based methods have potential to improve patient knowledge and medication adherence by providing interactive patient education, monitoring of symptoms and medication use, and by facilitation of communication and teamwork among patients and health care providers. Few studies have evaluated web-based asthma support environments using all of these potentially beneficial interventions. The multidimensional website created for this study, BostonBreathes, was designed to intervene on multiple levels, and was evaluated in a pilot trial. 

## Methods An interactive, engaging website for children with asthma was developed to promote adherence to asthma medications, provide a platform for teamwork between caregivers and patients, and to provide primary care providers with up-to-date symptom information and data on medication use. Fifty-eight (58) children primarily from inner city Boston with persistent-level asthma were randomised to either usual care or use of BostonBreathes. Subjects completed asthma education activities, and reported their symptoms and medication use. Primary care providers used a separate interface to monitor their patients' website use, their reported symptoms and medication use, and were able to communicate online via a discussion board with their patients and with an asthma specialist. 

## Results After 6-months, reported wheezing improved significantly in both intervention and control groups, and there were significant improvements in the intervention group only in night-time awakening and parental loss of sleep, but there were no significant differences between intervention and control groups in these measures. Emergency room or acute visits to a physician for asthma did not significantly change in either group. Among the subgroup of subjects with low controller medication adherence at baseline, adherence improved significantly only in the intervention group. Knowledge of the purpose of controller medicine increased significantly in the intervention group, a statistically significant improvement over the control group. 

## Conclusions This pilot study suggests that a multidimensional web-based educational, monitoring, and communication platform may have positive influences on pediatric patients' asthma-related knowledge and use of asthma preventer medications. # Results 983 children with asthma were identified through automated medical record review. Of these, 520 (52.9%) were able to be reached and had an eligible physician, 391 (75.2%) completed a phone screening, and 89 (22.8%) were deemed eligible for the study. Of the 89 eligible subjects, 31 declined to participate leaving 58 (65%) enrolled with 21 randomized to the control group, and 37 randomized to the intervention group. See Figure  [2](#) for Consort diagram. <figure> <p><img src="" /></p> <figcaption><strong>Consort Diagram.</strong></figcaption> </figure> At the 6 month end-point, the control group retained 14 (66.7%) of enrolled subjects, and intervention group retained 28 (75.7%) of subjects. The other subjects were lost to follow-up before the 6 month end point. Analysis of the randomness of missing data for days of wheeze, days had to slow down, nights woke-up, days limited activity, days parent lose sleep and days missed school for asthma using the permutation test indicated no significant dependence of drop out on the outcome values. Thirteen \[ [13](#) \] physicians and 1 NP participated in the study of whom 61% were female, the mean age was 45 years old, 95% were located in an urban practice area, 22% were family physicians and 78% were pediatricians or pediatric NP. Characteristics of the subjects are described in Table  [1](#) . Overall, 58.6% of subjects were African-American, and 32.6% of household reported earning less than $15,000 per year. Most subjects (87.5%) had some form of health insurance. Parents of control subjects were slightly more likely to report high school education or above (78.4% of intervention subject parents, versus 100% of control parents, P = 0.041). ::::table-wrap

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**Sample Characteristics**
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**Characteristic** **Intervention, (N = 37)** **Control, (N = 21)** **P**

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**Demographics**\
Age (years)\
Mean 11.9 ± 2.0 12.9 ± 3.0 0.13
Median and Range 12 (8--16) 14 (7--17)\
Male gender 22 (59.5%) 12 (57.1%) 1.0
Race\
Hispanic 4 (10.8%) 2 (9.5%) 0.70
Black 20 (54.1%) 14 (66.7%)\
White 8 (21.6%) 2 (9.5%)\
Other 5 (13.5%) 3 (14.3%)\
Parental Education: at least High School completion 29 (78.4%) 20 (100%) 0.041
Employed caregiver in household 29 (78.4%) 13 (61.9%) 0.23
Total family Income under $15,000 9 (28.1%) 6 (42.9%) 0.50
Child covered by health insurance 32 (91.4%) 17 (81%) 0.41
**Home Environment**\
Cockroaches at home 8 (22.9%) 7 (33.3%) 0.53
Dog at home 6 (17.1%) 3 (14.3%) 1.0
Cat at home 6 (17.1%) 9 (42.9%) 0.06
Pet rodent at home 3 (8.6%) 2 (9.5%) 1.0
Smokers at home 8 (22.9%) 9 (42.9%) 0.14
**Computer Use**\
Computer Competence Score, self reported (1--5), Mean (SD) 4.3 ± 0.6 4.6 ± 0.5 0.07
Hours/day on computer, Mean (SD) 2.0 + 1.8 1.6 + 1.6 0.51
Type of Internet Connection\
Dial-Up 10 (32.3%) 2 (13.3%) 0.29
Broadband 21 (67.7%) 13 (86.7%)\
Able to log onto Boston Breathes website\
With assistance 2 (7.1%) 2 (11.1%) 0.64
Without assistance 26 (92.9%) 16 (88.9%):::: Intervention subjects accessed the BostonBreathes site on average 7 times per month in the first month of the study, with decrease over time (Figure  [3](#) ). <figure> <p><img src="" /></p> <figcaption><strong>Subject Logins to BostonBreathes Website, by Month.</strong></figcaption> </figure> 

## Clinical outcomes Reported days of wheezing improved in both groups at the 6- month endpoint (−1.4 days of wheezing per 2 weeks in intervention subjects, and −4.2 days in control subjects), and patient awakening and parental loss of sleep improved significantly only in the intervention group (−0.8 and −0.6 days change per 2 weeks respectively at 6 months). However, there were no significant differences between groups in the changes of these measures (Table  [2](#) ). Emergency room or acute visits to a physician for asthma also did not significantly change in either group over the study period. ::::table-wrap
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**Changes in Clinical Outcomes, Intervention vs. Control Group**
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```
                                                                            **Intervention, N = 28**   **Control, N = 14**                                                                                           
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**Symptoms over previous 2 weeks** **Mean at baseline** **Mean change at 6 months** **P-value** **Mean at baseline** **Mean change at 6 month** **P-value** **P-value for differences in changes**
Days of wheeze 2.9 −1.4 0.03 5.1 −4.2 0.004 0.10
Days had to slow down 2.5 −1.4 0.07 1.1 −0.4 0.48 0.79
Nights woke-up 1.2 −0.8 0.04 1.9 −1.0 0.06 0.66
Days limited activity from asthma 0.6 −0.2 0.99 2.0 −1.8 0.13 0.14
Days parent lose sleep 0.9 −0.6 0.01 0.9 −0.6 0.13 0.71
Days missed school for asthma 0.2 −0.2 0.38 0.4 −0.4 0.25 0.31
Baseline N(%) 6-Month N (%) p-value Baseline N(%) 6-Month N (%) P-value P-value for differences in changes
Acute asthma-related PCP or ER visit in prior 2 months 5 (19.2) 1 (3.9) 0.18 1 (7.1) 1 (7.1) 0.99 0.64
**Primary controller compliance (%)** Mean at baseline Mean Change at 6 months P-value Mean at baseline Mean Change at 6 month P-value P-value for differences in changes
All subjects (I = 21, C = 9) 38.0 +11.2 0.30 45.9 −4.4 0.81 0.46
High risk subjects\* (I = 15, C = 8) 16.3 +29.8 0.01 39.2 −5.0 0.81 0.10
**Asthma Knowledge** Baseline N(%) 6-Month N (%) P-value Baseline N(%) 6-Month N (%) P-value P-value for differences in changes
Correctly Described Purpose of Personal Controller Medicine (I = 12, C = 8) 4 (33.3) 9 (75.0) 0.03 4 (50.0) 3 (37.5) 0.25 0.03

\*Those subjects with a baseline controller adherence of \<75%.:::: Among the subgroup of subjects with low (\<75%) controller medication adherence at baseline, controller medication adherence at 6 months improved significantly only in the intervention group. Knowledge of the purpose of controller medicine increased significantly in the intervention group subset, but not in the control subset, a statistically significant difference favoring the intervention group. 

## Communication, teamwork, and messaging outcomes The most frequent messaging activity was between patients and the asthma nurse specialist, with less activity by the PCP (Table  [3](#) ). The most frequent message content was encouragement of medication adherence and website use (Table  [4](#) ), followed by discussion of asthma educational content, discussion of asthma symptoms, or issues regarding peak flow readings or measurement. Socializing on non-medical topics was very common. Explicit coordination of care represented about 5% of posting. ::::table-wrap
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**Summary by Sender of Private Chat Messages**
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**Originator of message** **Total # of messages sent, N (%)**

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Asthma nurse 235 (38.7)
Asthma specialist 4 (7.0)
PCP 100 (16.5)
Patient 216 (35.6)
BB team 36 (5.9)
Parent 12 (2.0)
Blank/None 4 (7.0):::: ::::table-wrap
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**Summary by Content of Message**
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**Primary Message Content** **Total # of postings, N (%)**

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Medication adherence encouraged or inquired by MD or RN 82 (13.5)
Encouraged patient to use BostonBreathes 78 (12.9)
Asthma education for patient 74 (12.2)
Asthma symptom or Peak Flow- addressed or asked by MD/RN 68 (11.2)
Socializing 61 (10.1)
Subject telling progress- asthma mentioned 42 (6.9)
Doctor/nurse providing general encouragement- positive feedback 38 (6.3)
Team review summary 29 (4.8)
Medication adherence issue addressed by patient 28 (4.6)
Coordination of care 21 (3.5)
Asthma symptoms or peak flow reported by patient 20 (3.3)
Non asthma illness posting 11 (1.8)
Socializing (doctor posting) 11 (1.8)
Appointment reminder for patient or patient asked to make appointment 10 (1.7)
Acknowledgement of a team posting by PCP or patient 7 (1.2)
Discussion of incentive points 7 (1.2)
Issue with Peak Flow meter 4 (0.7)
Blank message 4 (0.7)
Medicine dose change or medicine change discussed 2 (0.3)
All other 10 (1.7):::: Subjects reported an average BB session duration of 19 minutes. They reported strong satisfaction with BB with all domains generating mean agreement ratings of 8.5 or higher, on a Likert scale of 0 (strongly disagree) to 10 (strongly agree), including: the ease of use of the website (8.4), good looking appearance (8.5), usefulness of information (9.2), and ease of learning the system (8.5). Twenty-four percent (24%) of subjects reported never using the website with a parent, 48% reported sometimes doing so, and 28% reported often or always using the website with a parent. Results of the provider survey on experience with BB are shown in Table  [5](#) . Providers tended toward agreement that BB provided useful information; was easy to use; that their patients benefited from using BB; and that the asthma specialist feedback was useful. Responses were neutral on effectiveness of the discussion board for communication with patients, and on average, expressed neutral to slight disagreement on adequacy of time available to use BB, and if they had changed management based on BB data. Open-ended comments grouped into three consistent themes: the observation that BB improved communication with patients, the advantages of having access to information on patient asthma status on a more immediate, day to day, basis; and that the time commitment to use the system was a concern. ::::table-wrap
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**Post-project Provider Attitudes Towards BostonBreathes**
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**Attitude statement** **Mean*, N = 14*\*

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BostonBreathes provided me with useful information about my patient(s) that I would not have had otherwise. 6.5
The BostonBreathes website was easy to use. 6.9
I had enough time in my schedule to use BostonBreathes. 4.6
I changed the asthma management of my patient(s) based on data from the site. 4.6
It was easy to remember to login to BostonBreathes. 5.0
I would recommend that other MDs use BostonBreathes for their asthma patients 5.6
BostonBreathes is best for severe asthmatics only. 5.0
I trusted the information being entered by my patient(s). 5.7
I believe my patient(s) benefited from using the BostonBreathes website. 6.6
I would recommend BostonBreathes for my asthmatic patients. 6.2
The discussion board was an effective way to communicate with my patient(s). 5.6
The feedback from Asthma Specialist posted to the discussion board was useful in helping me to manage my asthma patient(s). 6.3

\*All answers rated on Likert scale 0-10 (0=Strongly Disagree to
10=Strongly Agree).:::: On average, subjects earned $6 (range, $0-$40) in incentive payments for website use over the 6 month participation period, plus $15.00 total in payments for completing pre and post study surveys.


Extracted trial result:
Outcome: School days missed for asthma (continuous)
Intervention: BostonBreathes system
Comparator: Control
Intervention group size: 28
Intervention mean: -0.2
Comparator group size: 14
Comparator mean: -0.4
Notes: standard deviations not given, means are mean change