Low-income adults with uncontrolled asthma saw both their asthma control and quality of life improve with the help of an in-home, self-management asthma support program delivered by community health workers (CHWs), according to a report published online by JAMA Internal Medicine.
Asthma affects 24.6 million American, including 17.5 million adults. Control of asthma is inadequate despite the availability of effective methods to manage it. Home-based self-management support to improve asthma control among children is well established. However, the effectiveness of home visits for adults has not been well studied.
James Krieger, M.D., M.P.H., of Public Health-Seattle and King County, Washington, and co-authors report on the Home-Based Asthma Support and Education trial (HomeBASE). The study enrolled 366 participants with uncontrolled asthma: 189 to usual care and 177 to the intervention, which included CHWs who provided education, support and service coordination during home visits. The CHWs provided an average of 4.9 home visits during a one-year period.
The intervention group had greater increases in the average number of symptom-free days over two weeks (2.02 days per two weeks more) and quality of life as measured on a questionnaire increased an average of 0.50 points. However, average urgent health care use episodes in the past 12 months decreased similarly in both groups from an average of 3.46 to 1.99 episodes in the intervention group and from an average of 3.30 to 1.96 episodes in the usual care group.
"We anticipate that this intervention could be readily replicated by health organizations serving diverse, low-income clients, suggesting that it could reduce asthma-related health inequities. Intervention protocols can be implemented without specialized training or resources. The cost per participant was approximately $1,300 (2013 U.S. dollars), substantially less than one year's supply of an inhaled corticosteroid," the study concludes.
Commentary: Finding Value in Medicine
In a related commentary, Harrison J. Alter, M.D., M.S., of the Alameda Health System, Oakland, Calif., writes: "Using a combination of motivational interviewing, home-based education, environmental modification and social support, the intervention succeeded in increasing symptom-free days, asthma-related quality of life scores, general physical function and other patient-centered outcomes, when compared with like controls. What the intervention did not show was a comparative decrease in urgent medical care use, including emergency department visits, unscheduled physician visits and hospitalizations, which declined among both intervention and control participants, or use of steroid pulses."
"Doubtless, many readers will view this as a negative trial result; each intervention participant cost the program approximately $1,800, with no return to be found in concomitant medical savings. But it may be time to pry ourselves loose from such a strict definition of success," the author notes.
"The main purpose of our care should not be to reduce medical care use. Sometimes, in daily practice, it can feel as though certain actors in our system wish it were so. We cannot, as clinicians, investigators, teachers, healers, ignore the reality of the importance of this goal. But if in every medical effort we turn to check its effect on the system, we may find ourselves turning away from the patient," the author concludes.