Managing Pediatric Asthma: Emergency Department Demonstration

Published: December 10, 2006

Program Results Report

Grant ID: PAE

Managing Pediatric Asthma: Emergency Department Demonstration Program

An RWJF national program

SUMMARY

The Managing Pediatric Asthma: Emergency Department Demonstration Program, a

national program of the Robert Wood Johnson Foundation (RWJF), developed and tested

emergency department-based systems to improve pediatric asthma care.

During 2001–2005, project teams at four sites—Honolulu, Houston, Milwaukee and

Washington—implemented the following:

● Data systems to track emergency department pediatric asthma patients.

● Educational interventions to help patients and parents manage the disease.

The project teams reported their findings in the April 2006 supplement to Pediatrics.

Key Results

● Although results were not uniform, the projects as a group demonstrated that

emergency departments can deliver effective asthma education and management

programs to pediatric asthma patients and their families.

● The projects demonstrated that emergency department-based patient tracking systems

can produce data to enhance understanding of the local pediatric asthma population

and inform clinical and educational interventions.

● The projects found that children with the mildest chronic asthma severity

classification—mild intermittent—constituted an unexpectedly large proportion of

emergency department pediatric asthma patients.

Funding and Management

The RWJF Board of Trustees authorized the program in July 1999 for up to $3.5 million

as part of a major effort to improve management of pediatric asthma in high-risk

populations (see Context).

RWJF Program Results Report – Managing Pediatric Asthma: Emergency Department Demonstration Program 2

The American Academy of Allergy, Asthma & Immunology (AAAAI) in Milwaukee

managed the program and provided technical assistance to the project staffs.

THE PROBLEM

Asthma, a chronic inflammatory disease of the airways, is a major public health problem

of growing concern to government officials and the medical community.

From 1980 to 1996, the number of Americans with asthma more than doubled to almost

15 million, according to the federal Centers for Disease Control and Prevention (CDC).

By 2002, an estimated 20 million Americans had asthma. Almost a third of those—6

million—were under 18 years of age.

The American Lung Association calls asthma the most common chronic disorder of

childhood. The cost of treating pediatric asthma totals $3.2 billion a year, according to

research published in 2000 in the Journal of Allergy and Clinical Immunology.

In 2000, asthma accounted for about 465,000 hospitalizations, and of those, 214,000 (46

percent) involved patients under 18 years of age. Four million children experience at least

one asthma attack or wheezing episode a year, according to CDC survey data.

Asthma is characterized by recurrent episodes of breathlessness, wheezing, coughing, a

tightness of the chest and other breathing difficulties. These conditions take a heavy toll

on the ability of young patients to lead active, normal lives. One measure of this is that

the disease is a leading cause of school absenteeism. In 2002, asthma was responsible for

an estimated 14.7 million missed school days, according to CDC.

An acute exacerbation of asthma, commonly called an asthma attack, can be life

threatening. Between 1979 and 1996, the number of children dying annually from asthma

increased almost threefold—from 93 to 266, the CDC reported.

Asthma affects all populations but has a disproportionate impact on economically

disadvantaged, urban and minority groups. African-Americans experience asthma-related

hospitalizations and death at almost triple the rate of whites, according to the CDC.

The Role of Emergency Departments

When an asthmatic child has difficulty breathing, the hospital emergency department

(ED) is a common source of treatment. At night, when physician offices are closed, the

ED is likely to be the parent's only option. For families without insurance coverage, it

may be their only known source of care, day or night.

One out of every three children with asthma visits an ED in a 12-month period, according

to a 1998 national survey ("Asthma in America") funded by the pharmaceutical company


GlaxoSmithKline. Asthma was the cause of more than 727,000 ED visits by patients 17

and under in 2002.

Treatment and Management Tools

Although there is no known cure for asthma, advances in scientific understanding of the

disease's underlying mechanisms have produced treatment tools and management

strategies that can improve the health of asthma patients.

In addition to short-acting medications for quick relief once an exacerbation starts, there

are long-term control medications, such as inhaled corticosteroids, that providers can

prescribe to lessen the number and severity of attacks.

Prescribing the appropriate medication requires an accurate assessment of the patient's

condition. Physicians generally classify asthma according to a four-level chronic severity

scale developed by the National Asthma Education and Prevention Program of the

National Heart, Lung, and Blood Institute to guide management of the disease, including

medication.

The four levels are:

● Mild intermittent.

● Mild persistent.

● Moderate persistent.

● Severe persistent.

A patient's severity level depends on symptom frequency and other clinical features.

Guidelines recommend daily use of long-term control medication for patients in the

persistent categories.

Primary care providers can also help patients and their parents by developing a written,

individualized asthma action plan that outlines how to manage the disease and respond to

worsening symptoms, including what medication to take and when to seek help from a

doctor.

Another critical step is to identify and mitigate environmental conditions in the home that

can cause the child's airways to the lungs to become inflamed, swollen and clogged.

These conditions are called triggers, and commonly include secondhand tobacco smoke,

dust mites, cockroaches, mold and family pets.

Mitigation can be as simple as removing stuffed toys from a child's room, installing

mattress and pillow covers and eliminating clutter that sustains roaches and other pests.


Non-environmental conditions, such as upper respiratory viral infections, also can be a

factor in asthma attacks.

Despite the knowledge and resources available to control asthma, many people with the

disease and even some health care professionals do not take advantage of the tools.

Public health authorities agree that education of asthma patients and their parents in

management strategies is an important need.

● The story of "JH," a five-year-old boy living in southeast Washington with his

mother, two sisters and a cat, illustrates the challenge. Their home is more than 50

years old and in poor repair. His mother smokes and burns incense in the home.

More…

Another need is to accurately track the dimensions of the disease. Asthma surveillance

systems frequently depend on large sets of retrospective data collected from national

samples. These data typically produce measurements three to four years out of date.

Getting real-time, local information can provide a more accurate understanding of the

disease and effective intervention at the community level, experts believe.

Reference Sources

For a more comprehensive explanation of national asthma care guidelines, see:

● Pediatric Asthma: Promoting Best Practice Guide for Managing Asthma in Children,

published by the American Academy of Allergy, Asthma & Immunology (AAAAI).

● "Key Clinical Activities for Quality Asthma Care" in the March 28, 2003, issue of

CDC's Morbidity and Mortality Weekly Report, available on the CDC website.

CONTEXT

Improving the quality of care of people suffering from chronic health conditions is a key

goal of RWJF. In 1998, RWJF program staff considered how the Foundation might more

productively focus its efforts on that objective.

One recommendation was to explore a few chronic diseases in depth and develop

interventions that improved clinical care management of patients with those conditions. A

set of disease-specific initiatives would not only help those patients but could potentially

produce models of care applicable to other chronic illnesses, the staff reasoned.

Influenced by the growing prevalence of asthma and its status as the most common

chronic disease of childhood, RWJF program staff recommended pediatric asthma as the

focus of the Foundation's first disease-specific effort. Programs focused on diabetes and

depression followed.

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http://www.cdc.gov/mmwr/PDF/rr/rr5206.pdf


In 1999, following a scan of asthma literature and activities to identify gaps and

opportunities in the field, RWJF funded a spectrum of initiatives in asthma treatment,

management and policy:

● Allies Against Asthma, a $12.5-million, four-year program to support public-private

coalitions working to improve the control of pediatric asthma in eight communities

across the nation. The University of Michigan School of Public Health managed the

program.

● A $228,000 RAND study of policy options for improving childhood asthma

outcomes. (See Program Results Report on ID# 037143.)

● Four initiatives aimed at improving management of pediatric asthma in high-risk

populations. The overall goal was to reduce ED visits, hospital admissions and costs

caused by poorly managed asthma and to increase the health-related quality of life for

children with asthma:

— Managing Pediatric Asthma: Emergency Department Demonstration Program—

the subject of this report.

— Improving Asthma Care for Children, a $3.2-million program to test new

approaches to managing pediatric asthma by Medicaid managed care

organizations. The Center for Health Care Strategies managed the program. (See

Program Results Report on the program.)

— A $2.4-million grant (ID# 037658) to the University of Michigan School of

Public Health, which developed the Patient Education Material Assessment Tool

to help physicians improve their management of pediatric asthma patients.

— A $495,689 grant (ID# 037659) to the Center for Health Care Strategies to

identify barriers to managing pediatric asthma and to develop new financing

models for improved management.

The initiatives, with different objectives, activities and staffs, met regularly as the

Pediatric Asthma Steering Committee to coordinate efforts. It was the first time that

RWJF had attempted to coordinate related but separate programs in this manner.

PROGRAM DESIGN

The Managing Pediatric Asthma: Emergency Department Demonstration Program

aimed to develop and test ED-based systems to improve pediatric asthma care and reduce

ED visits by—and hospitalizations of—asthmatic children.

RWJF program staff viewed the hospital ED as a potential resource in chronic asthma

management—a role that would go beyond just providing episodic treatment for

attacks—the traditional function of emergency medicine.

http://www.asthma.umich.edu/

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http://www.rwjf.org/en/research-publications/find-rwjf-research/2006/06/improving-asthma-care-for-children.html

http://www.asthma.umich.edu/media/resources_autogen/ToolkitPDF_FINAL072705.pdf


The RWJF program staff reasoned that not only do ED physicians see large numbers of

children with asthma, they typically see them when an attack is underway. In this acute

moment of need, might patients and parents be especially receptive to asthma education

and recommendations for follow-up primary or specialty care?

That was the key proposition RWJF wanted to test: Does the ED visit offer "a teachable

moment" that the staff can exploit to make a lasting impact on the health of the pediatric

asthma patient?

The RWJF Board of Trustees authorized spending $3.5 million over three years to

support four emergency department demonstration projects with grants of up to $875,000

each. The projects were to implement and evaluate:

● ED-based interventions to improve the delivery of clinical care to children with

asthma and provide patient, family and caregiver education in asthma management.

● Surveillance systems to track pediatric asthma patients and measure the impact of the

interventions.

The expectation was that the models demonstrated by the grantees, if successful, would

be replicable at other hospitals. The models were set up to:

● Reduce hospital admissions and ED visits for pediatric asthma.

● Improve patients' health outcomes and quality of life.

● Improve environmental control measures in the patients' homes, including increasing

dust and pest control and reducing exposure to secondhand tobacco smoke.

● Improve skills of the patients, their families and their caregivers to manage the

disease.

● Provide real-time information from the tracking system for use in improving the

interventions.

Program Evolution

Initially, RWJF program staff planned to support a similar set of emergency department

demonstration projects developed by CDC's National Center for Environmental Health.

However, because of administrative hurdles to accepting outside funding, CDC decided

to proceed without RWJF, using its own resources.

The CDC program (Asthma Surveillance and Interventions in Hospital Emergency

Departments) differed in several respects from the RWJF initiative. Most importantly, it

focused on adult as well as pediatric asthma patients and emphasized surveillance, that is,

the systematic collection, evaluation and dissemination of data to track the occurrence

and severity of the disease.


Nevertheless, the two program staffs collaborated closely throughout and brought the two

sets of grantees together periodically to exchange information. RWJF program funds

helped pay CDC travel expenses related to these joint meetings (see The Program).

The three recipients of CDC funding were Michigan State University, Northwestern

University (Illinois) and the University of South Carolina. The projects began September

2001 and were completed by September 2005. See Appendix 1 for an outline of the

projects' objectives.

THE PROGRAM

To manage the demonstration program and provide technical assistance to the grantees,

RWJF established a national program office at the American Academy of Allergy,

Asthma & Immunology (AAAAI), a 6,300-member professional medical specialty

organization headquartered in Milwaukee.

The program director was Gary S. Rachelefsky, M.D., clinical professor and allergy

clinic co-director at the medical school of the University of California at Los Angeles and

a past president of AAAAI. Assisting him were Amy Stone, the program's deputy

director, and Suzanne Kennedy, Ph.D., research associate.

Previously, RWJF supported Rachelefsky and AAAAI in developing Pediatric Asthma:

Promoting Best Practice Guide for Managing Asthma in Children. (See Program Results

Report on ID# 033546.) RWJF senior program officer Seth Emont, Ph.D., chief architect

of the Foundation's asthma-specific initiatives, also was involved in that project.

To select and help guide the grantees, RWJF appointed a nine-member national advisory

committee chaired by Gail G. Shapiro, M.D., clinical professor of pediatrics at the

University of Washington School of Medicine and AAAAI president in 2001.

Asthma specialists, an ED physician and nurse and a CDC official were among the

members. (See Appendix 2 for the list of members.)

The Planning Phase

In collaboration with RWJF personnel, the national program staff drafted a Call for

Proposals and disseminated it to 66 hospitals with EDs that served children. Only those

pediatric care centers or associated organizations were permitted to apply.

To be eligible, an organization had to involve at least three other hospitals in the

proposed project, in addition to the lead hospital. It also was to target a pediatric patient

population that had at least 25 percent at high risk for severe asthma and suboptimal care.

The national program office received 17 proposals. In October 2001, RWJF provided

grants to support four projects recommended by the national advisory committee:

http://www.rwjf.org/en/research-publications/find-rwjf-research/2002/04/breathing-easier.html

http://www.rwjf.org/en/research-publications/find-rwjf-research/2002/04/breathing-easier.html


Hawaii CARES (Child Asthma Research to Elevate Standards)

Grantee: Kapi'olani Health Foundation, Honolulu, Hawaii

Funding: $260,941 (ID# 043505) and $610,939 (ID# 047512)

Lead Institution: Kapi'olani Medical Center for Women and Children

Partners: Castle Medical Center

Waianae Coast Comprehensive Health Center

Kaiser Permanente Medical Center

Principal Investigator: Rodney Boychuk, M.D.

Texas Emergency Department Asthma Surveillance

Grantee: Baylor College of Medicine, Houston, Texas

Funding: $862,492 (ID# 043506)

Lead Institution: Texas Children's Hospital

Partners: Ben Taub General Hospital

Lyndon B. Johnson General Hospital

University of Texas Medical Branch - Galveston

Principal Investigator: Charles G. Macias, M.D., M.P.H.

Emergency Department Allies

Grantee: Children's Hospital and Health System, Milwaukee, Wis.

Funding: $875,000 (ID# 043507)

Lead Institution: Children's Hospital of Wisconsin

Partners: St. Mary's Hospital - Milwaukee

St. Mary's Hospital - Ozaukee

St. Joseph's Community Hospital of West Bend

Community Memorial Hospital - Menomonee Falls

Kenosha Hospital and Medical Center

Principal Investigator: Kevin J. Kelly, M.D.

Improving Pediatric Asthma Care in the District of Columbia

Grantee: Children's Research Institute, Washington, D.C.

Funding: $874,837 (ID# 043508)

Lead Institution: Children's National Medical Center

Partners: Howard University Hospital

Providence Hospital

George Washington University Hospital

Georgetown University Hospital


Greater Southeast Community Hospital

Principal Investigator: Stephen J. Teach, M.D., M.P.H.

The Implementation Phase: National Program Office

The national program staff advised the project teams on various technical matters,

including implementation of common data-gathering methodologies, and provided a

consulting epidemiologist to assist with research issues.

The consultant—Herman Mitchell, Ph.D., senior research scientist with Rho, a research

organization based in Chapel Hill, N.C.—helped with tasks such as designing a

randomization process to divide ED patients evenly into intervention groups according to

asthma severity.

In addition, he investigated whether project data established a correlation between local

outdoor air quality and ED asthma visits.

The national staff also:

● Sponsored three annual meetings (in Chicago, Las Vegas and San Francisco) at which

the project teams shared experiences and conferred with advisory committee

members and outside experts. The CDC grantees also attended.

● Held quarterly teleconferences with the project directors and conducted annual site

visits. Advisory committee members—two were responsible for each site—

participated in the visits.

● Developed a program website with a password-protected section where project

directors filed quarterly progress reports, and advisory committee members offered

suggestions. A public section of the website provided information on asthma

resources.

● Participated with leaders of RWJF's other asthma programs in twice-a-year meetings

of the Pediatric Asthma Steering Committee. RWJF program officers helped plan the

meeting agendas and facilitated some sessions.

Implementation Phase: Communications

Near the end of the program, the national staff collaborated with CDC to organize an

invitational meeting in Atlanta on the appropriate role of EDs in managing pediatric

asthma. Rachelefsky, the program director, conceived of the meeting as a means to affect

asthma management policy and practices nationally.

The January 21–23, 2005, meeting—entitled "Doing the Most to Ensure the Least: ED

Asthma Visits"—drew approximately 50 asthma and ED clinicians, researchers, public

http://www.rhoworld.com/rho/clinical-research-services

http://www.pediatricasthma.org/


health experts and policy-makers in addition to directors of the RWJF and CDC

demonstration projects.

After reports on the preliminary results of the demonstrations, meeting participants

developed policy recommendations on the role of EDs in pediatric asthma care. The

recommendations—based in part on results of the demonstrations—called for ED staffs

to go beyond treatment of acute exacerbations and provide some elements of ongoing

care. See Appendix 3 for details.

The national program staff emphasized that the recommendations reflected the views of

the individual participants and should not be construed as endorsed by the participants'

affiliated organizations.

The program staff edited the recommendations for publication and also oversaw

preparation of articles by teams from RWJF- and CDC-funded projects on the

methodologies and outcomes of the demonstrations. The program director, deputy

director, research associate and Stephen Redd, M.D., chief of the CDC's Air Pollution

and Respiratory Health Branch, formed an editorial board that reviewed article outlines

and drafts and then edited the articles for publication.

The national program office staff arranged for publication of the articles and the January

2005 meeting recommendations as a supplement to the April 2006 issue of Pediatrics, the

journal of the American Academy of Pediatrics.

RWJF paid the cost of the supplement, about $70,000, from separate funds reserved for

special communications opportunities. Abstracts are free, and the full texts are available

for a fee, on the journal's website.

Implementation Phase: Individual Projects

At the four sites, project staff:

● Collected data that tracked ED pediatric asthma patients.

● Implemented and evaluated ED-based interventions aimed at improving asthma

management by patients and parents.

● Improved ED pediatric asthma care procedures and practices.

In Washington, for example, the project team at Children's National Medical Center

(Children's) instituted a special clinic—called the IMPACT DC Asthma Clinic—that

provided individualized asthma care and education to selected pediatric asthma patients.

The staff compared their outcomes over six months with a randomized control group.

"We're not delivering rocket science medicine," Stephen J. Teach, M.D., M.P.H., the

project director, says of the clinic. In other words, there is nothing novel about the asthma

http://pediatrics.aappublications.org/content/vol117/issue4/index.dtl


care and education that he and his staff deliver. What is novel, says Teach, is that they are

reaching families who never before had this information. More…

For descriptions of the specific site activities and objectives, see the separate reports on:

● Hawaii CARES (Honolulu).

● Texas Emergency Department Asthma Surveillance (Houston).

● Emergency Department Allies (Milwaukee).

● Improving Pediatric Asthma Care in the District of Columbia (Washington).

ASSESSMENT OF RWJF'S THREE PEDIATRIC ASTHMA INITIATIVES

In April 2002, RWJF contracted with Patricia Patrizi, an evaluation consultant based in

Wyncote, Pa., to assess the extent to which the Foundation's cluster of pediatric asthma

initiatives (Improving Asthma Care for Children, Managing Pediatric Asthma and Allies

Against Asthma: A Program to Combine Clinical and Public Health Approaches to

Chronic Illness) was beginning to influence the field (ID# 045001).

Her assessment focused on the grantmaking strategy and the degree of synergy resulting

from it, not on individual program components. Patrizi's team interviewed 40 individuals,

including asthma experts, RWJF personnel and staff of the asthma initiatives.

In a May 2003 report to RWJF (Grantmaking in Pediatric Asthma: An Experiment in

Field-Building), Patrizi and co-author Avalie Saperstein concluded that the asthma

initiatives had strong, effective leaders but so far had been unable "to forge collective

goals or a cohesive campaign for change."

The report indicated that the departure of Emont, the chief architect of the asthma

programs, from RWJF in March 2001 was a significant reason for that. In his absence, no

one within the Foundation was championing the asthma effort and taking responsibility

for the steering committee, whose meetings were "perfunctory and focused on reporting

individual programs," the report said.

Commenting on the assessment, Robin E. Mockenhaupt, Ph.D., a senior RWJF program

officer involved in the asthma initiatives and later associate chief of staff, suggested that

a change of direction within RWJF had a greater impact than the departure of any one

staff member.

She noted that after the asthma initiatives got underway, RWJF's interest shifted from

specific chronic diseases to improving the quality of chronic care in general. As a result,

the asthma programs became less important to the strategic objectives of the Foundation

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and, consequently, to the specific management team responsible for overseeing the

asthma programs.

OVERALL PROGRAM RESULTS

The following were the principal results of the program according to interviews, findings

reported in the Pediatrics supplement, the national program staff's final report to RWJF

and other documents:

● Although results were not uniform, the projects as a group demonstrated that

emergency departments can deliver effective asthma education and management

programs to pediatric asthma patients and their families.

— Three of the four sites (Honolulu, Houston and Washington) reported at least

some improved outcomes among patients who participated in ED-based

interventions. The fourth site (Milwaukee) found no important benefits from the

two interventions tested.

● The projects demonstrated that emergency department-based patient tracking

systems can produce data to enhance understanding of the local pediatric

asthma population and inform clinical and educational interventions.

— The four sites implemented a variety of systems that used prospective and

retrospective information sources to identify characteristics of children with

asthma, including chronic severity classifications, medication usage and ED

revisit rates.

● The projects found that children with the mildest chronic asthma severity

classification-mild intermittent-constituted an unexpectedly large proportion of

emergency department pediatric asthma patients.

— Project researchers suggested that the large "mild intermittent" share of

emergency pediatric asthma encounters—almost 60 percent in Houston—raises

questions about the current national classification and treatment guidelines for

pediatric asthma. See Intermittent Asthma Patients: Why So Many?

● The program, in collaboration with CDC, produced and disseminated to the

medical community recommendations for the appropriate role to be played by

emergency departments in pediatric asthma care.

— Although issued without endorsement by any specific organization, the

recommendations developed at the January 2005 Atlanta meeting and published

in Pediatrics have the potential to influence pediatric asthma care by EDs and

primary care providers. See Appendix 3 for details of the recommendations.


KEY SITE RESULTS

The following were among the key results and findings reported by the project teams in

the Pediatrics supplement:

● Hawaii CARES, Honolulu

— Use of controller medications increased after an educational intervention.

— The project demonstrated that "ED-based interventions are possible and

effective."

● Texas Emergency Department Asthma Surveillance, Houston

— The project captured data on 6,222 pediatric asthma encounters in a two-

year period. A majority of the children had mild asthma by both chronic and

acute severity classifications.

— Patients with mild intermittent asthma who received an educational

intervention had significantly fewer urgent care/emergency department visits

in the nine months following the intervention compared to similar patients in

the control group.

● Emergency Department Allies, Milwaukee

— The project implemented a Web-based, password-protected system that

collected data on 3,302 ED pediatric asthma patients in its first 18 months of

operation and remained ongoing at the end of the grant period.

— The clinical trial demonstrated no important benefits for patients in either of

the two intervention groups.

● Improving Pediatric Asthma Care in the District of Columbia, Washington

— The project established an ongoing clinic at Children's National Medical

Center that provides individualized asthma care and education to ED

pediatric asthma patients and their parents.

— A randomized clinical trial found that after six months clinic participants

reported greater use of asthma control medicine and fewer ED visits than

members of a control group.

An Example. The experience of 16-month-old Suni provides a glimpse at how

one intervention—the IMPACT DC Asthma Clinic—works and the benefit it

provides.

"She's a very good example of what we're all about," says Teach, the project

director, as the cute little girl runs around the brightly lit hospital clinic, a pacifier

in her mouth and a sniffling noise coming from her head or chest or maybe both.

More…


For detailed results and findings at each site, see the separate project reports:

● Hawaii CARES (Honolulu)

● Texas Emergency Department Asthma Surveillance (Houston)

● Emergency Department Allies (Milwaukee)

● Improving Pediatric Asthma Care in the District of Columbia (Washington).

CHALLENGES

● The effort to determine if a correlation exists between emergency department

asthma visits and outdoor air pollutants was unsuccessful.

Mitchell, the consultant from Rho, an epidemiologist experienced in asthma research,

worked with the Houston, Milwaukee and Washington project teams to compare

asthma patient tracking data with local air-quality readings.

The Houston and Milwaukee data showed no significant relationships, and the

Washington results were sufficiently inconsistent that Mitchell believed there was an

error in the data or the analysis programming. Mitchell was unable to discover the

source of the problem before the program ended, the national program office staff

reported.

● Enrolling and tracking enough patients to meet study goals was a challenge for

some sites.

One difficulty was devising a randomization scheme to produce a study population

with enough severe asthmatics. The sites experienced more mild intermittent

asthmatics than expected, complicating the effort to focus on children with more

severe classifications. See Key Site Results.

Also, asthma admissions at some of the partner hospitals turned out to be lower than

anticipated. Still another problem was parental fatigue; the Milwaukee project team

found that the more intense and time-consuming the intervention—home visits being

the most intense—the less willing parents were to participate in the study. The

multiplicity of consent forms required of participants also was a discouraging

influence. See the separate report on Emergency Department Allies.

● Efforts to ensure follow-up care of ED patients by primary care providers had

varying levels of success.

The project staffs used a variety of strategies to try to "build a bridge" with primary

care providers. These included faxing asthma action plans to the patient's usual

provider and making presentations to groups of community physicians.







The Honolulu project had the most success in this regard. Project staff conducted a

series of courses and meetings aimed at engaging primary care providers in asthma

management. See the separate report on Hawaii CARES.

LESSONS LEARNED

1. Don't underestimate the importance and value of having "champions" in

partnering institutions. Housed at the lead institutions, the principal investigators

for all four projects had trouble building relationships with their outlying partner

hospitals. The situation improved if the project director identified supporters at the

other hospitals and communicated clearly with them.

Research efforts need leaders who understand why the project is important and have

the ability and vision to inspire other people. (Deputy Director/Stone)

2. Don't forget to address the needs of patients with mild asthma when designing

an emergency department program. All four projects had higher than anticipated

numbers of patients with mild intermittent asthma. The staffs learned that planning

for the infrequent but severe exacerbations that some mild asthmatics experience is

more difficult than controlling a more severe form of asthma.

They also found that it is important for educational interventions to teach mild

asthmatics and their parents to focus on particular triggers, such as viruses, and to

contact their primary care provider at the onset of an attack. (National Program Office

Report to RWJF)

3. Make sure emergency department personnel receive ongoing training in asthma

assessment. At the program's outset, some physicians and asthma experts argued that

an ED staff does not have the time, expertise or inclination to correctly diagnose

chronic asthma severity.

All four projects implemented processes that successfully taught ED staff to diagnose,

treat and manage pediatric asthma. The Houston project staff performed a validation

study that showed that trained staff was able to assess asthma accurately. (National

Program Office Report to RWJF)

AFTERWARD

Funding

In the fall of 2005, the pharmaceutical company Sanofi-Aventis, which produces inhaled

corticosteroids for asthma treatment, provided AAAAI with funding to continue data

collection for one year at three of the sites: Houston, Milwaukee and Washington.

The company viewed the data generated by the projects as an opportunity to discern

relationships between drug treatments and clinical outcomes.



Communications About All Three Asthma Initiatives

In 2005, RWJF initiated a two-phased communications project to develop and

disseminate a set of lessons and recommendations stemming from its asthma-specific

programs: Improving Asthma Care for Children, Allies Against Asthma and the

emergency department demonstrations described here.

In the first phase, RWJF awarded a six-month, $69,700 contract (ID# 046062) to a

Philadelphia firm, Steege/Thomson Communications, to create evidence-based messages

on asthma care aimed at the health care community and policy-makers.

In addition to interviewing staff of the asthma programs and their grantee organizations,

the Steege/Thomson team developed and tested potential messages in four focus groups

composed of pediatric practitioners, ED physicians, managed care medical directors and

members of a hospital asthma steering committee.

In August 2005, the firm submitted a 33-page communications plan—Robert Wood

Johnson Foundation Pediatric Asthma Initiative Communications Findings and Plan—

that identified three "summary themes" common to successful pediatric asthma

management: (1) education, (2) collaboration and (3) a continuum of care.

Based on those themes, the document recommended a set of messages and strategies that

included:

● Create a print presentation of the programs' key findings and most replicable projects

and disseminating the material to government leaders and hospital groups.

● Develop at least one continuing medical education course aimed at spotlighting a

program initiative, such as tying reimbursement to patient and physician education.

● Implement national, local and specialty media outreach to showcase the programs'

success stories and replicable models.

RWJF has funded the communication project's second phase—implementation—under

ID# 052807, through October 2007. Under this contract, Steege/Thomson

Communications is working with the three national program offices to:

● Package and distribute key program lessons to targeted providers and community

groups.

● Secure media coverage of results, particularly in the specialty media; promotes policy

lessons to federal and state officials.

● Produce a website that houses all tools, resources and results from the program. A

renewal of this project is not anticipated.


RWJF viewed the communication project as the culmination of its effort to build the

asthma field. In recent years, RWJF has increased its focus on improving the quality of

chronic care generally, and has no plans to target asthma or other single diseases with a

major new initiative.

Prepared by: Michael H. Brown

Reviewed by: Kelsey Menehan and Molly McKaughan

Program Officers: Seth Emont, Robin E. Mockenhaupt and Anne Weiss


APPENDIX 1

Three Emergency Department Projects Funded by the Centers for

Disease Control and Prevention

The three projects in the CDC program entitled Asthma Surveillance and Interventions in

Hospital Emergency Departments had the following objectives, according to information

provided by CDC:

Lead Institution: Michigan State University

Project Title: Development and Implementation of an ED Surveillance and

Intervention System for Asthma Care in Grand Rapids, Michigan

Partners: Spectrum Health Downtown (Butterworth, Mich.), Spectrum Health East

Campus (Blodgett, Mich.) and Gerber Memorial Hospital (Fremont, Mich.)

Principal Investigator: Mathew J. Reeves, Ph.D.

Objectives:

— Assess feasibility of using emergency department electronic billing data for

asthma surveillance.

— Evaluate three asthma management approaches, using a combination of usual

emergency department care, inhaled corticosteroids and asthma management

plans.

— Assess reasons for seeking asthma care in the emergency department.

For additional information, see two articles by project team members published in the

supplement to the April 2006 issue of Pediatrics: (Abstracts are free, and full-text

versions of articles are available for a fee, on the journal's website.)

— Reeves MJ, Bohm SR, Korzeniewski SJ and Brown MD. "Asthma Care and

Management Before an Emergency Department Visit in Children in Western

Michigan: How Well Does Care Adhere to Guidelines?" Pediatrics, 117(4)

Supplement: 118–126, 2006.

— Reeves MJ, Lyon-Callo S, Brown MD, Rosenman K, Wasilevich E and Williams

SG. "Using Billing Data to Describe Patterns in Asthma-Related Emergency

Department Visits in Children." Pediatrics, 117(4 Supplement): 106–117, 2006.

Lead Institution: Northwestern University

Project Title: Illinois ED Asthma Collaborative Study

Partners: Rush University Medical Center, Christ Hospital, John J. Stroger Jr.

Hospital of Cook County, Rockford Memorial Hospital, St. John's Hospital and

University of Chicago Hospitals

http://pediatrics.aappublications.org/content/vol117/issue4/index.shtml


Principal Investigator: Kevin Weiss, M.D.

Objectives:

— Test and refine emergency department survey instruments and mode of

administration of a surveillance system.

— Conduct 18-month feasibility and responsiveness trial of the system.

— Refine system, transfer to the Internet and disseminate findings.

For additional information, see the article by project team members published in the

supplement to the April 2006 issue of Pediatrics: (An abstract is free, and the full text

is available for a fee, on the journal's website.)

— Lenhardt RO, Catrambone CD, McDermott MF, Walter J, Williams SG and

Weiss KB. "Improving Pediatric Asthma Care through Surveillance: The Illinois

Emergency Department Asthma Collaborative. Pediatrics, 117(4 Supplement):

96–105, 2006.

Lead Institution: University of South Carolina School of Public Health

Project Title: Carolina Asthma Surveillance and ED-Based Intervention

Partners: Richland Memorial Hospital, Fairfield Memorial Hospital and Piedmont

Medical Center

Principal Investigator: Tim E. Aldrich, Ph.D., M.P.H.

Objectives:

— Use emergency department electronic data to characterize children who receive

care for asthma.

— Call families to identify triggers.

— Conduct home assessments and interviews with a sample of children.

— Offer educational interventions to adults in hospitals.



APPENDIX 2

National Advisory Committee for the Emergency Department

Demonstration Program

Gail G. Shapiro, M.D., Chair

Allergist/Immunologist

Northwest Asthma and Allergy Center

Seattle, Wash.

Edwin D. Boudreaux, Ph.D.

Psychologist/Researcher

University of Medicine and Dentistry of New

Jersey and Cooper Hospital

Department of Emergency Medicine

Camden, N.J.

Lesley Anne Brabyn, M.A.

Executive Director

Asthma Education and Research Council

Larkspur, Calif.

Jean G. Ford, M.D.

Pulmonologist/Asthma Researcher

Bloomberg School of Public Health

Department of Epidemiology

Baltimore, Md.

Mitch Goldman, D.O.

Emergency Department Physician

St. Vincent Hospital of Indianapolis

Carmel, Ind.

Anthony J. Killian, R.N.

Emergency Department Nurse/Researcher

University of Pennsylvania

Sicklerville, N.J.

Mary Ann Lewis, R.N., Dr. P.H.

Nurse/Asthma Researcher and Educator

School of Nursing

University of California, Los Angeles

Los Angeles, Calif.

Milton D. Schwarz, M.D.

Regional Quality Medical Director

Pacific Region

Aetna U.S. Healthcare

San Ramon, Calif.

Seymour Williams, M.D.

Centers for Disease Control and Prevention

National Center for Environmental Health

Atlanta, Ga.

APPENDIX 3

Key Elements of the Recommendations Developed by Participants at the Meeting in Atlanta on January 21-23, 2005

Meeting participants—who included clinicians, researchers, public health experts,

insurers and policy-makers—considered:

● Whether the emergency department should expand its role beyond episodic treatment

of asthma exacerbations and,

● If so, in what ways.

The following are among the participants' recommendations as "fleshed out" and edited

by staff of the RWJF and CDC demonstration programs and published in the supplement

to the April 2006 issue of Pediatrics.


The Pediatrics article, "Commentary: Doing the Most to Ensure the Least ED Asthma

Visits: Asthma Experts Consider Preliminary Project Findings." (Pediatrics 117(4

Supplement): 159–166, 2006) emphasizes that the recommendations reflect the opinions

of the individual meeting participants and were not endorsed by their affiliated

organizations. An extract of the article is free, and the full text is available for a fee, on

the journal's website.)

"Commentary and recommendations were made in hope that a number of audiences

would find them thought provoking and useful," the unsigned article says.

● Appropriate role of the emergency department in managing childhood asthma.

— Because evidence indicates that many children with asthma are "not connected

with a system that provides all the elements of effective treatment, it is important

that the ED expand its childhood asthma management role beyond treatment of

the acute exacerbation."

— "Initiating some of the elements of long-term care for children who have

persistent asthma or recurrent exacerbations can allow the ED to serve as a bridge

between the acute and long-term comprehensive care settings."

— It is "necessary for the ED to assess or characterize the child's chronic asthma

severity level."

— The ED should "provide limited patient and family asthma education."

— For patients with persistent asthma or recurrent asthma exacerbations, the ED

should "initiate a referral to a long-term care system that can provide all of the

elements of asthma care." Follow-up visits for evaluation and care by a primary

provider should be reimbursed by health insurers.

— When possible, the ED should make the follow-up appointment "during the ED

visit or as soon as possible thereafter" and fax the ED visit information to the

provider.

— Depending on circumstances, the ED "should consider making chronic-care

therapeutic recommendations at discharge," tailoring prescriptions and therapeutic

devices to the patient's asthma severity level.

— Children with wheezing symptoms should be referred to the child's usual provider

for follow-up care.

● The emergency department as educational venue.

— "Asthma ED visits offer teachable moments that need to be recognized and used

for providing appropriate asthma education."



— The best staff-training models "(1) include training for everyone who sees the

patient, including reception staff, triage nurses, nurses, respiratory therapists and

physicians and (2) are supported by hospital administrators."

— "Educational messages need to be simple, straightforward, culturally and

linguistically appropriate, and primarily visual."

— "A multifaceted, automated system that includes reminders, incentives and

positive feedback seems promising."

— Identifying a champion for the ED effort, such as a physician or nurse leader "can

help ensure success."

— The ED's education role is distinct from the "broader, long-term educational role"

of the primary care provider. To maintain that distinction, "ED-based education

should focus on the basic or initial elements of asthma education, such as how to

recognize symptoms and when and how to use medications."

● ED-based asthma surveillance.

— "Tracking ED asthma patients offers a valuable opportunity for detecting asthma

trends as well as a chance to intervene."

— Billing data, real-time tracking data and other information sources have different

strengths and limitations. (The recommendations examine several types of

surveillance, but—while calling the Houston and Milwaukee systems "effective

models" for prospective tracking—endorse no specific approach to data

collection.)

APPENDIX 4

Glossary

Acute exacerbation of asthma: An asthma attack in which build up of mucus, swelling

of air tubes and tightening of muscles around air tubes results in breathing difficulty.

Asthma attacks may be mild, moderate or severe.

Albuterol—typically delivered with an inhaler—is a commonly used reliever. Relievers

are not effective in controlling the underlying disease itself.

Asthma action plan: A plan developed jointly by the health care provider and the

asthma patient to help manage the disease. Plans identify early warnings signs of an

attack, outline recommended doses and frequencies of medication for quick relief and

long-term control and provide emergency contact information.

Bronchospasm: Difficulty breathing caused by sudden constriction of the muscles in the

walls of the bronchioles, the small air tubes that branch off from the bronchi.


Frequent flyer: A person who has severe asthma and utilizes emergency department

services and other health care resources on a frequent basis.

Inhaled corticosteroids are generally considered the most effective anti-inflammatory

medication available for long-term control. Once an attack has started, controllers are not

effective in bringing relief.

Long-term control medications: Drugs, also called controllers, used daily to prevent

the symptoms of asthma and reduce the frequency and severity of attacks.

Nebulizer: A device that turns liquid medication into a fine spray.

Peak Flow Meter: A portable, handheld device that measures airflow from the lungs.

Reactive airway disease: A non-clinical term often used to describe hyper-reactivity of

the airways to various stimuli. Someone with reactive airways may or may not have

asthma.

Severity: The degree to which asthma affects a patient and/or the level of medication

needed to control the disease. Practitioners generally categorize chronic asthma by four

severity classifications defined by National Heart, Lung, and Blood Institute guidelines:

mild intermittent, mild persistent, moderate persistent and severe persistent.

Short-acting medications, also known as relievers and rescue medicine. Drugs that act

rapidly to open the breathing passages and relieve acute asthma symptoms once an attack

occurs.

Spacer: A device that attaches to an inhaler and captures the right amount of medication,

making it easier to administer an effective dose. Often used to help children, the elderly

and others who have trouble holding their breath, as required for effective inhaler

treatment.

Spatial accessibility: The term used by the Washington project staff in analyzing

patients' proximity to pediatric primary services. The staff calculated spatial accessibility

as the ratio of full-time equivalent pediatric primary care providers to child population in

the immediate vicinity of the patient's residence.

Spirometer: A diagnostic tool that tests lung function. Spirometry refers to the test that

measures airflow in and out of the lungs.

Trigger: An environmental exposure that can set off an asthma attack, causing airways to

become inflamed, swollen and clogged. Common triggers include secondhand tobacco

smoke, dust mites, cockroaches, mold, family pets and outdoor air pollution, such as

industrial emissions and automobile exhaust.

Wheezing: A high-pitched whistling sound associated with breathing difficulty.


APPENDIX 5

''JH'': A Case Study

The Division of Emergency Medicine of Children's National Medical Center in

Washington reported the following case study to illustrate the barriers to successful

management of pediatric asthma:

JH is a five-year-old, African-American boy living in southeast Washington with his

mother, two sisters and a cat. Their home is more than 50 years old and in poor repair.

His mother smokes and burns incense in the home.

JH has asthma. He coughs or wheezes four days out of every seven and at least six to

seven nights a month. The family has Medicaid managed care insurance and goes to a

large clinic for primary care. JH's asthma medication is albuterol delivered by nebulizer

on an as-needed basis. He has no written asthma action plan.

In the last 12 months, JH has made four visits to the ED at Children's National Medical

Center and has been admitted once. When his mother was asked who provides her son's

asthma care, she replied: "You guys at Children's do."

What is wrong here? Three things, according to the Children's staff:

● JH's home environment contained multiple potential triggers.

● He was not taking a long-term control medication and did not have a written asthma

plan, contrary to national guidelines for control of moderate persistent asthma.

● A primary care provider was not managing his asthma.

Research

Although not specifically related to the story of JH, a study published in 2000 in the

Journal of Allergy and Clinical Immunology concluded that asthma management of

inner-city children relied on episodic and emergency care and that medication

management did not conform to guidelines.

A Johns Hopkins University research team interviewed parents of 392 urban, low-

income, African-American children with asthma and found that in the previous six

months, 43.6 percent of the children had visited an ED for asthma care (and were not

hospitalized).

Almost three-quarters of the parents (73.2 percent) were able to identify a specific

physician or nurse who provided primary asthma care to their child. However, of those

families without an identified primary provider, 39.3 percent got their usual asthma care

from an ED.


[Rand CS, Butz AM, Kolodner K, Huss K, Eggleston P and Malveaux F. "Emergency

Department Visits by Urban African American Children with Asthma." Journal of

Allergy and Clinical Immunology, 105(January): 83–90, 2000.]

APPENDIX 6

Not Rocket Science

"We're not delivering rocket science medicine," Stephen J. Teach, M.D., M.P.H., says of

the IMPACT DC Asthma Clinic, which he runs at Children's National Medical Center.

In other words, there is nothing novel about the asthma care that he and his staff are

providing. What is novel is that they are providing it to families who never before had it,

says Teach.

Teach's main objective is to make the parents of asthmatic children understand that the

disease is not episodic but an ongoing condition that must be managed every single day.

The Straw Analogy

When he meets with a family, he uses the analogy of a straw and coffee stirrer. The

healthy human airway, he tells the parents, is like a fat straw—the kind you get at a

convenience store to suck a mushy, icy drink out of a paper cup. It is easy to blow

through.

But try blowing through a plastic coffee stirrer. You can do it but not easily. That is what

an inflamed, constricted airway is like, Teach tells the parents. The daily use of controller

medication treats the underlying cause of asthma and keeps the child's airways open—

like the fat straw.

"You can see the light bulb go off," says Teach. "No one has ever sat down with them

and explained this before." He and his staff also show the families a color diagram of the

lungs with cutouts that can be rotated between healthy airways and inflamed ones.

Hunger for Information

Parents are anxious to avoid the disruption that an ED visit causes the family, says Teach.

That, he suggests, explains why more than 70 percent selected for clinic participation

showed up for their session. "I think these families are generally hungry" for information.

In addition to being hard on the families, ED visits are expensive for the health care

system, says Teach. Repeat visits are the "canary in the coal mine," he says. They mean

something is wrong.


The IMPACT DC Asthma Clinic is based on two assumptions, Teach explains. One is

that the emergency department can no longer sit on the sidelines of the pediatric asthma

problem. It must do something to improve longitudinal care of children with the disease.

The second assumption is that the emergency department should not become the primary

care provider. Its role is, rather, to reinforce the primary care provider's role and improve

the relationship between the provider and family.

APPENDIX 7

Intermittent Asthma Patients: Why So Many?

The RWJF demonstration program found an unexpectedly high proportion of the children

receiving ED treatment for asthma had mild intermittent asthma—the least severe of the

four chronic severity levels defined by National Heart, Lung, and Blood Institute

guidelines.

In Milwaukee, 32 percent of the pediatric asthma patients were classified mild

intermittent and in Houston 58.7 percent, according to ED tracking data for those two

projects. (For more about the Milwaukee and Houston projects, see the Program Results

reports on, respectively, Emergency Department Allies (ED Allies) and Texas

Emergency Department Asthma Surveillance (TEDAS).)

Percentages that high raise questions about the national classification and treatment

guidelines for pediatric asthma, according to project staff.

The common wisdom is that ED asthma cases represent a failure of the primary health

care system says Kevin J. Kelly, M.D., director of the ED Allies demonstration If a child

with asthma has good care and is on long-term control medication, trips to the ED should

not be necessary—at least that has been the general thinking.

However, national asthma guidelines recommend controller medications only for children

with persistent asthma—not for those in the intermittent category, Kelly notes. So the

intermittent asthma children tracked in Milwaukee should not have been on controller

drugs, he says. And yet, they were coming to the ED for help.

What does it mean? In Kelly's view, the finding shows that the health care profession

does not know all it needs to know about pediatric asthma. Specifically, what is needed is

a study focused on intermittent asthma, he says.





APPENDIX 8

The IMPACT DC Asthma Clinic: One Family's Experience

Suni, a cute 16-month-old, runs around the brightly lit hospital clinic, a pacifier in her

mouth and a sniffling noise coming from her head or chest or maybe both.

"She's a very good example of what we're all about," says Stephen J. Teach, associate

chief of emergency medicine at Children's National Medical Center (Children's) and

founder of the IMPACT DC Asthma Clinic.

Suni, he explains, is a frequent flier: an asthmatic child whose troubled breathing brings

her repeatedly to the ED for relief. Like the majority of pediatric asthma patients he sees,

she is young. In layman's terms, Teach explains that small children have small windpipes

and are more affected by the disease.

Already in her short life, Suni has made five visits to the ED at Children's, the major

pediatric hospital in Washington. The attacks can be scary for her mother, Vanessa

Mason, a computer specialist who lives a short drive from the hospital and works in

suburban Virginia. Some nights her daughter coughs non-stop. Is she having trouble

breathing, Mason worries?

Suni's most recent flare-up began with a cold and fever. Her mother took her to the ED at

Children's, where the staff administered albuterol with a nebulizer and gave her a liquid

steroid. That did the trick—temporarily.

Two days later Mason got a call from Suni's day care center saying the cough and fever

had returned. Mason telephoned her daughter's primary care provider and was told,

according to the mother, that treatment facilities were unavailable and that the little girl

should go to the ED.

So it was back once again to the large, dark-glassed hospital building located two and a

half miles north of the U.S. Capitol. This time, in addition to administering medications,

the physician recommended that Suni and her mother attend the IMPACT DC clinic.

(The clinic had recently opened its asthma intervention program to all children treated for

acute exacerbations of asthma—after a clinical trial found greater use of asthma control

medicine and fewer emergency visits among clinic participants than those in a control

group.)

So on this bright September morning, two weeks later, mother and child have returned to

the ED complex of rooms at Children's for an hour-and-half session with Teach and

Deborah Quint, an educator and the IMPACT DC project director.

Along with instructions about how to eliminate asthma triggers in her home and the

importance of follow up visits with a primary care provider, Mason gets a written asthma


action plan outlining the type, frequency and quantity of medication that Suni should take

depending on the severity of her symptoms and peak-flow readings at the time.

The plan is a one-page sheet color coded like a traffic signal to three levels or zones of

health:

● Green ("Go Zone") for no symptoms: Suni is to take a prescribed controller

medication daily.

● Yellow ("Caution Zone") for mild wheezing and other early signs of difficulty: Suni

gets a reliever medication in addition to the daily controller, and her mother calls the

primary care provider.

● Red ("Stop Zone") for worsening conditions that are unresponsive to medication: Her

mother is to get immediate help from the primary care provider.

For an asthma action plan similar in approach, see the form published by the New York

City Department of Health and Mental Hygiene and the New York City Asthma

Initiative.

It is Suni's first asthma action plan. It means nothing to her, of course, but her mother

immediately sees the benefit. "It's very helpful, especially to know when to administer

what," she says. "Hopefully by implementing the plan, we won't be having to make a lot

more visits here."

http://www.nyc.gov/html/doh/downloads/pdf/asthma/plan1.pdf




BIBLIOGRAPHY

(Current as of date of the report; as provided by the grantee organization; not verified by RWJF; items not

available from RWJF.)

National Program Office Bibliography

Articles

Kennedy SM, Stone A and Rachelefsky GR. "Asthma Interventions in the Emergency

Department." Unpublished.

Kennedy SM, Stone A and Rachelefsky GR. "Factors Associated with ED Use in

Asthma: Acute Care Interventions Improving Chronic Disease Outcomes." Annals of

Allergy, Asthma & Immunology, 90: 45–50 (with accompanying guest editorial 8–9),

2003.

Rachelefsky GR, Kennedy S. and Stone A. "Introduction: Enhancing the Role of the

Emergency Department in the Identification and Management of Childhood Asthma."

Pediatrics, 117(4 Suppl.): 57–62, 2006. Available online.

"Commentary: Doing the Most to Ensure the Least ED Asthma Visits: Asthma Experts

Consider Preliminary Project Findings." Pediatrics, 117(4 Suppl.): 159–166, 2006.

Available online.

Reports

Robert Wood Johnson Foundation Pediatric Asthma Initiative Communications Findings

and Plan. Philadelphia: Steege/Thomson Communications, 2005.

Grantee Websites

www.pediatricasthma.org. Website of the Robert Wood Johnson Foundation national

program Managing Pediatric Asthma: Emergency Department Demonstration Program;

includes background of the program and links to resources on asthma. Milwaukee:

American Academy of Allergy, Asthma and Immunology.

Evaluator's Bibliography

Reports

Patrizi P and Saperstein A. Grantmaking in Pediatric Asthma: An Experiment in Field-

Building. Wyncote, PA: May 2003.

http://pediatrics.aappublications.org/cgi/reprint/117/Supplement_2/S57

http://pediatrics.aappublications.org/cgi/reprint/117/Supplement_2/S159

http://www.pediatricasthma.org/


PROJECT LIST

Reports on the projects managed under this National Program are listed below. Click on a

project's title to see the complete report, which typically includes a summary, description

of the project's objectives, its results or findings, post grant activities and a list of key

products.

● Honolulu's Emergency Department-Based Education Program Improves Asthma

Management in Children (Grant ID# 47512, etc., December 2006)

● Milwaukee Hospital Develops Web-Based Pediatric Asthma Tracking System and

Educational Program for Emergency Department Visits (Grant ID# 43507, December

2006)

● Texas Hospitals Reduce Emergency Department Visits by Educating Families of

Pediatric Asthma Patients (Grant ID# 43506, December 2006)

● Washington Hospital Opens Asthma Clinic That Reduces Emergency Department

Visits, Improves Care (Grant ID# 43508, December 2006)









Managing Pediatric Asthma: Emergency Department Demonstration

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