Using the Telephone to Improve Care in Childhood Asthma
Condition: Asthma
MeSH terms: Asthma
Study type: Interventional

Summary: 
      Asthma is the most common chronic disease of childhood and a major cause of morbidity in the
      United States. If asthma symptoms are controlled, a child with asthma can stay well and lead
      a normal life. Daily use of inhaled steroids controls symptoms and reduces morbidity and
      emergent health care utilization in children with persistent asthma, and is safe for
      long-term use. However, inhaled steroids are underused in community asthma care.

      The Telephone Asthma Program (TAP) is a series of brief, telephone calls with a trained coach
      to help the parent manage the child's asthma care. The coach will teach self-management
      skills, help the parent to use the child's asthma medicines effectively, provide support and
      remind the parent to go for follow-up care with the pediatrician. We hypothesized that the
      Telephone Asthma Program will reduce the incidence of acute exacerbations of asthma that
      require emergent care, improve the quality of life of children with asthma and their parents,
      and increase the daily use of inhaled steroids in children with persistent asthma. We
      evaluated the Telephone Asthma Program in a randomized controlled trial involving 362
      children aged 5 to 12 years old cared for by community pediatricians. Eligible children were
      randomized to the TAP program or usual care by their pediatrician.
    

Detailed description: 
      Asthma morbidity is largely preventable with effective maintenance care. National guidelines
      recommend 1) daily treatment with inhaled corticosteroids (ICS) to prevent asthma symptoms
      and activity limitations, minimize acute exacerbations and maintain normal lung function; 2)
      early intervention guided by a written Asthma Action Plan for worsening symptoms;3) a
      partnership between the primary care provider, the patient and their family to develop shared
      treatment goals, select an appropriate treatment plan, resolve asthma-related concerns, and
      provide support for day-to-day care, and 4) periodic assessments (every 1 to 6 months) by the
      physician to monitor asthma control and assess if the goals of therapy are being met, with
      asthma self-management education provided at diagnosis and reinforced at every opportunity.
      Despite widespread dissemination of these guidelines, under-use of controller medications is
      pervasive, home management of an acute exacerbation is often delayed and inadequate, and only
      50% of asthmatic children report maintenance care visits twice a year. Most primary care
      pediatricians do not provide education about use of preventive treatments or self-management
      behaviors citing lack of confidence in their ability to effect change, logistical issues such
      as lack of time, educational materials, support staff, and inadequate reimbursement as
      significant barriers to these activities. Practical, efficient interventions to improve
      maintenance asthma care in office-practice are needed.

      In response to complaints from community pediatricians in our practice-based research network
      that few children with persistent asthma used their controller medications as prescribed we
      collaborated with local asthma experts and the telephone triage service at our children's
      hospital to develop and evaluate a 12-month telephone-coaching program to provide education
      and support to parents to improve asthma self-management for their children. The Telephone
      Asthma Program (TAP) was provided in addition to usual care, and was evaluated in a
      randomized controlled trial (RCT).

      The TAP program was based on the Transtheoretical Model of Behavior Change developed by James
      Prochaska. This model postulates a series of 5 ordered stages of readiness to change to a
      desired behavior (Precontemplation, Contemplation, Preparation, Action and Maintenance). The
      desired behaviors for TAP were: 1) using controller medications as prescribed, 2)
      administering rescue medications at the child's first signs of an asthma exacerbation, 3)
      having an up-to-date asthma action plan readily available for all who may need it, and 4)
      having a collaborative relationship with the child's PCP that included regular asthma
      check-up visits at least every 6 months. Our goal was that all 4 behaviors would be addressed
      by the coach for each parent throughout the 12-month program period. Guided by computerized
      telephone protocols the coach provided tailored care advice appropriate for the parent's
      stage of readiness for behavior change. In this way, the coach could provide education and
      support to help the parent to provide effective asthma care at home for their child, and
      supplement the care provided by the physician.
    

Intervention name(s): Telephone Asthma Program
Intervention type(s): Behavioral
Intervention description(s): The parent will have access to a trained asthma coach for 12 months. The coach will call the parents at mutually convenient times (up to 12 times a year) to work on 4 targeted asthma behaviors:
Using asthma controller medications as prescribed
Having and Asthma Action Plan available to all who may need it.
Using asthma rescue medications with the child's first symptoms.
Having a collaborative relationship with the child's primary care provider that includes asthma check-ups at least twice a year.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Supportive Care
Keywords: Asthma; Telemedicine; Randomized controlled trial