Asthma: Home-Based Multi-Trigger, Multicomponent Environmental Interventions Children and Adolescents with Asthma

• Asthma symptom days: median decrease of 21 days per year (6 studies)
• School days missed: median decrease of 12 days per year (5 studies)
• Acute healthcare visits: combined median decrease of 0.57 visits per year (10 studies)
  • Hospitalizations: median decrease of 0.4 hospitalizations per year
  • Emergency department visits: median decrease of 0.2 visits per year
  • Unscheduled office visits: median decrease of 0.5 visits per year
• Pulmonary function: overall, no significant improvement (7 studies)

• Improvement in symptom free days
• Savings from averted costs of asthma care and improvement in productivity

Thirteen studies described in fourteen papers qualified for the economic review. All numbers are in $2007 US dollars.

• Program cost per participant: $231 to $14,858 (13 studies)
  • Interventions with major environmental remediation: $3,796 to $14,858 (3 studies)
  • Interventions with minor to moderate remediation and an educational component: $231 to $1,720 (10 studies)
• Six studies with minor to moderate remediation demonstrated that these interventions provide good value for money invested based on substantial returns for money invested and a cost per symptom free day that is below the standard cut-off for what is considered cost-effective in the literature.
  • Cost-benefit studies show a return of $5.3 to $14.0 for each dollar invested (3 studies)
  • Cost-effectiveness studies show a cost of $12 to $57 per additional symptom free day (3 studies)
• The majority of studies in the economic review were interventions for children with asthma, and studies that included adults also included children.

Reviewed interventions were conducted:

• Mostly in the homes of U.S. urban minority children
• By a wide range of organizations including:
  • State and local health departments
  • Health care systems
  • Community organizations
• By a wide range of trained personnel including:
  • Community health workers (most common)
  • Nurses
  • Respiratory therapists
  • Social workers
  • Physicians

The following outlines evidence gaps for home-based multi-trigger, multicomponent environmental interventions for adults and for children and adolescents.

Effectiveness. The effectiveness of home-based multi-trigger, multi-component interventions has been established. Important questions still remain regarding the intervention composition and intensity as well as effectiveness in different settings and populations. Some of these questions include:

• What are the independent contributions of particular intervention components to overall intervention effectiveness? Which components are the most important for inclusion in this intervention?
• What is the required intensity (number of home visits, intensity of remediation, intensity of education) needed for an effective home intervention program?
• How does household member smoking impact the effects of this intervention? Should smoking cessation counseling be a necessary component of all home-based environmental interventions for asthma?

Applicability. This intervention has been studied most in low-income, urban minority populations but is most likely effective in most settings and populations. The following questions remain about the applicability of this intervention in various settings and populations:

• How effective is this intervention in adult populations?
• Are there differences in intervention effectiveness between children and adolescents?
• How effective is this intervention in rural populations?
• Is this intervention more effective in participants with more severe asthma symptoms?
• How does the type of dwelling (apartment, duplex, single family home) impact the effectiveness of the intervention?

Implementation. This intervention has been implemented in a variety of ways. However, questions still remain as to what is the most effective and cost-effective way to implement this intervention in a “real-world setting.” These questions include:

• How should this intervention be integrated in the health care system to insure appropriate access and sustainability?
• Which asthma patients should this intervention target?
• Who are the most effective intervention implementers (community health workers, nurses, respiratory therapists, etc.) and does this change depending on intervention setting?

• Of the 23 included studies, 20 studies evaluated interventions targeting homes in which only children or adolescents had asthma; one study exclusively targeted adults; and two studies targeted children and adults (results of these last two studies were included both in the child and adult analyses).
• The number of participants in the studies ranged from 18 to 1033, with a median number of 104 participants (interquartile interval [IQI]: 64 274).
• Follow-up periods ranged from 1 month to 48 months, with a median follow-up period of 12 months (IQI: 12 18 months).
• Education focus ranged from primarily environmental education to primarily asthma self-management education, including monitoring asthma symptoms and the use of asthma management plans.
• Most studies focused equally on both environmental and self-management education.
• Two studies (9%) focused only on remediation and did not have an educational component.
• Fourteen studies were tailored based on exposure to asthma triggers in the home; of these, seven also included specific allergen sensitivities in tailoring the intervention.
• Number of home visits was one (3 studies), two to seven (15 studies), and eight or more (5 studies).
• Home visits were made exclusively by community health workers (6 studies), nurses (5 studies), respiratory therapists (2 studies), physicians (2 studies), social workers (1 study), housing officers (1 study), environmental educators (1 study), and trained sanitarians (1 study). Or they were conducted by mixed teams of community health workers and nurses (2 studies), social worker, nurse, and respiratory therapist (1 study), and research assistant and pest control professional (1 study).

Crocker DD, Kinyota S, Dumitru GG, et al. Effectiveness of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity: a Community Guide systematic review. American Journal of Preventive Medicine. 2011;41(2S1):S5-32.

Nurmagambetov TA, Barnett SBL, Jacob V, et al. Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity: a Community Guide systematic review. American Journal of Preventive Medicine. 2011;41(2S1):S33-47.

Task Force on Community Services. Recommendations from the Task Force on Community Preventive Services to decrease asthma morbidity through home-based, multi-trigger, multicomponent interventions. American Journal of Preventive Medicine. 2011;41(2S1):S1-4.

Crocker DD, Hopkins D, Kinyota S, Dumitru G, Herman E, Ligon C. A systematic review of home-based multi-trigger multi-component environmental interventions to reduce asthma morbidity. Journal of Allergy and Clinical Immunology. 2009;123(S20). Available at: http://www.jacionline.org/article/S0091-6749(08)02513-X/abstract.

Atherly AJ. The economic value of home asthma interventions. 2011;41(2S1):S59-61.

Krieger JW, Philby ML, Brooks MZ. Better home visits for asthma: lessons learned from the Seattle–King County asthma program. American Journal of Preventive Medicine. 2011;41(2S1):S48.

Murphy JS, Sandel MT. Asthma and social justice: how to get remediation done. American Journal of Preventive Medicine. 2011;41(2S1):S57–8.

Sever ML, Salo PM, Haynes AK, Zeldin DC. Inner-city environments and mitigation of cockroach allergen. American Journal of Preventive Medicine. 2011;41(2S1):S55–6.

Wilce MA, Garbe PL. Evaluating home-based, multicomponent, multi-trigger interventions: your results may vary. American Journal of Preventive Medicine. 2011;41(2S1):S52–4.

Effectiveness Review

Analytic Framework see Figure 1 on page S10

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table Effectiveness Review
Contains evidence from reviews of home-based multi-trigger, multicomponent environmental interventions for adults and for children and adolescents

Economic Review

Summary Evidence Table Economic Review
Contains economic evidence from reviews of home-based multi-trigger, multicomponent environmental interventions for adults and for children and adolescents

Effectiveness Review

Barton A, Basham M, Foy C, Buckingham K, Somerville M. The Watcombe Housing Study: the short term effect of improving housing conditions on the health of residents. Journal of Epidemiology and Community Health 2007;61(9):771-7.

Brown MD, Reeves MJ, Meyerson K, Korzeniewski SJ. Randomized trial of a comprehensive asthma education program after an emergency department visit. Annals of Allergy, Asthma, & Immunology 2006;97(1):44-51.

Carter MC, Perzanowski M, Raymond A, Platts-Mills T. Home intervention in the treatment of asthma among inner-city children. The Journal of Allergy and Clinical Immunology 2001;108(5):732-7.

Eggleston PA, Butz A, Rand C, Curtin-Brosnan J, Kanchanaraksa S, Swartz L, et al. Home environmental intervention in inner-city asthma: a randomized controlled clinical trial. Annals of Allergy, Asthma, & Immunology 2005;95(6):518-24.

Evans III R, Gergen PJ, Mitchell H, Kattan M, Kercsmar C, Crain E, et al. A randomized clinical trial to reduce asthma morbidity among inner-city children: results of the National Cooperative Inner-City Asthma Study. The Journal of Pediatrics 1999;135(3):332-8.

Hasan RA, Zureikat GY, Camp J, Duff J, Nolan BM. The positive impact of a disease management program on asthma morbidity in inner-city children. Pediatric Asthma, Allergy & Immunology 2003;16(3):147-53.

Hughes DM, McLeod M, Garner B, Goldbloom RB. Controlled trial of a home and ambulatory program for asthmatic children. Pediatrics 1991;87(1):54-61.

Kercsmar CM, Dearborn DG, Schluchter M, Xue L, Kirchner HL, Sobolewski J, et al. Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environmental Health Perspectives 2006;114 (10):1574-80.

Klinnert MD, Liu AH, Pearson MR, Ellison MC, Budhiraja N, Robinson JL. Short-term impact of a randomized multifaceted intervention for wheezing infants in low-income families. Archives of Pediatrics & Adolescent Medicine 2005;159:75-82.

Krieger J, Takaro TK, Song L, Beaudet N, Edwards K. A randomized controlled trial of asthma self-management support comparing clinic-based nurses and in-home community health workers: the Seattle-King County Healthy Homes II Project. Archives of Pediatrics & Adolescent Medicine 2009;163(2):141-9.

Krieger JW, Takaro T, Song L, Weaver M. The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. American Journal of Public Health 2005;95(4):652-9.

Levy JI, Brugge D, Peters JL, Clougherty JE, Saddler SS. A community-based participatory research study of multifaceted in-home environmental interventions for pediatric asthmatics in public housing. Social Science & Medicine 2006; 63(8):2191-203.

Morgan WJ, Crain EF, Gruchalla RS, O’Connor GT, Kattan M, Evans III R, et al. Results of a home-based environmental intervention among urban children with asthma [see comment]. New England Journal of Medicine 2004;351(11):1068-80.

Nicholas S, Hutchinson VE, Ortiz B, Klihr-Beall S, Jean-Louis B. Reducing childhood asthma through community-based service delivery–New York City, 2001-2004. Morbidity and Mortality Weekly Report 2005;54(1):11-4.

Nishioka K, Saito A, Akiyama K, Yasueda H. Effect of home environment control on children with atopic or non-atopic asthma. Allergology International 2006;55(2):141-8.

Oatman L. Reducing environmental triggers of asthma in homes of Minnesota children (Evaluation report: not published). Minnesota Department of Health; St. Paul (MN):2007.

Parker EA, Israel BA, Robins TG, Mentz G, Xihong L, Brakefield-Caldwell W, et al. Evaluation of community action against asthma: a community health worker intervention to improve children’s asthma-related health by reducing household environmental triggers for asthma.Health Education & Behavior 2008; 35(3):376-395.

Primomo J, Johnston S, DiBiase F, Nodolf J, Noren L. Evaluation of a community-based outreach worker program for children with asthma [References]. Public Health Nursing 2006;23(3):234-41.

Shelledy DC, McCormick SR, LeGrand TS, Cardenas J, Peters JI. The effect of a pediatric asthma management program provided by respiratory therapists on patient outcomes and cost. Heart & Lung 2005;34(6):423-8.

Somerville M, Mackenzie I, Owen P, Miles D. Housing and health: does installing heating in their homes improve the health of children with asthma? Public Health 2000;114(6):434-9.

Stout JW, White LC, Rogers LT, McRorie T, Morray B. The Asthma Outreach Project: a promising approach to comprehensive asthma management. The Journal of Asthma 1998;35(1):119-27.

Thyne SM, Rising JP, Legion V, Love MB. The ‘Yes We Can’ Urban Asthma Partnership: a medical/social model for childhood asthma management. Journal of Asthma 2006;43(9):667-73.

Economic Review

Barton A, Basham M, Foy C, Buckingham K, Somerville M, on behalf of the Torbay Healthy Housing Group. The Watcombe Housing Study: the short term effect of improving housing conditions on the health of residents. J Epidemiol Community Health 2007;61(9):771 7.

Bryant-Stephens T, Li Y. Outcomes of a home-based environmental remediation for urban children with asthma. J Natl Med Assoc 2008;100(3):306 16.

Eggleston PA. Home environmental intervention in inner-city asthma: a randomized controlled clinical trial. Ann Allergy Asthma Immunol 2005;95(6):518 24.

Jowers JR, Schwartz AL, Tinkelman DG, et al. Disease management program improves asthma outcomes. Am J Manage Care 2000;6(5): 585 92.

Kattan M, Stearns SC, Crain EF, et al. Cost-effectiveness of a home-based environmental intervention for inner-city children with asthma. J Allergy Clin Imunol 2005;116(5):1058 63.

Kercsmar CM, Dearborn DG, Schluchter M, et al. Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environ Health Perspect 2006;114(10):1574 80.

Krieger JW, Takaro TK, Song L, Weaver M. The Seattle King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health 2005;95(4):652 9.

Lin S, Gomez MI, Hwang SA, Franko EM, Bobier JK. An evaluation of the asthma intervention of the New York State Healthy Neighborhoods Program. J Asthma 2004;41(5):583 95.

Oatman L. Reducing environmental triggers of asthma in homes of Minnesota children. St. Paul MN: Minnesota Department of Health, 2007.

Primomo J, Johnston S, DiBiase F, Nodolf J, Noren L. Evaluation of a community-based outreach worker program for children with asthma. Public Health Nurs 2006;23(3):234 41.

Shelledy DC. The effect of a pediatric asthma management program provided by respiratory therapists on patient outcomes and cost. Heart Lung 2005;34(6):423 8.

Somerville M, Mackenzie I, Owen P, Miles D. Housing and health: does installing heating in their homes improve the health of children with asthma? Public Health 2000;114(6):434 9.

Sullivan SD, Weiss KB, Lynn H, et al. The cost-effectiveness of an inner-city asthma intervention for children. J Allergy Clin Immunol 2002;110(4):576 81.

With the assistance of a CDC librarian, the team searched for published studies in the following databases: MEDLINE, Cochrane Library, CINAHL, PsychINFO, Web of Science, EMBASE, ERIC, and Sociological Abstracts. The team also searched bibliographic reference lists and accepted suggestions of studies from members of the team.

The team considered studies for inclusion if they:

• Were primary research published in a journal or a technical or government report
• Were published in English
• Met minimum research quality criteria for study design and execution specifically, using designs with before-and-after comparisons in the intervention group at least or comparisons across two groups receiving different levels of intervention
• Were community-based
• Evaluated one of nine identified asthma interventions
• Addressed secondary or tertiary prevention

Studies for home-based environmental interventions were considered if they also:

• Included at least one home visit
• Were multicomponent
• Were multi-trigger
• Evaluated one or more outcomes of interest

The team searched for and accepted for possible inclusion studies published from 1966 to February 2008.

Search Terms (Medline)

Database: MEDLINE (OVID) 722 results

Note: Search was the same for the other databases with the exception of terminology (such as use of exp, and Boolean terms) which was adapted according to database requirements.

General Asthma

1. (exp asthma/ or asthma.mp)
2. exp Bronchial Hyperreactivity/mo, nu, pc, ec, ep, th
3. *Respiratory sounds/nu, pc, ep, th
4. (wheeze or reactive airway$).mp.
5. or/1-4

Home Interventions to Reduce Environmental Triggers

1. (trigger and (reduce or reduction$)).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
2. exp dust/ or exp allergens/
3. (reduce or reduction$).mp. [mp=title, original title, abstract, name of substance word, subject heading word]
4. 7 and 8
5. 6 or 9
6. exp air pollution, indoor/lj, ec, pc, sn or *dust mites/
7. allergen level$.mp.
8. exp Patient Education/ or exp Health Education/mt, ec, og, ed, st, sn, lj, ut or exp “Patient Acceptance of Health Care”/sn
9. remediation.mp.
10. exp Environmental Remediation/ae, an, lj, ec, mt, st
11. exp intervention studies/
12. 14 or 15
13. 16 and 17
14. environmental control.mp.
15. exp Inhalation exposure/
16. exposure reduction$.mp.
17. 10 or 11 or 12 or 13 or 18 or 19 or 20 or 21
18. 5 and 9
19. 5 and 10
20. 23 or 24

Study Designs/Evaluations

1. Randomized Controlled Trials/ or randomized trial$.mp. or program$.mp.
2. controlled trial$.mp.
3. impact$.mp. or exp Sickness Impact Profile/
4. study effectiveness.mp.
5. effectiveness of study.mp.
6. effectiveness of stud$.mp.
7. exp Program Evaluation/ or evaluation$.ab.
8. trial$.mp. or “Randomized Controlled Trial [Publication Type]”/
9. or/86-93

Exclusions

1. case report$.mp. or exp “Case Reports [Publication Type]”/
2. comment$.mp. or exp “Comment [Publication Type]”/
3. letter$.mp. or exp “Letter [Publication Type]”/
4. newspaper article$.mp. or exp “Newspaper Article [Publication Type]”/
5. news.mp. or exp “News [Publication Type]”/
6. drug approval/ or drug evaluation/ or neurotic disorders/ or antibodies, monoclonal/ or randomized controlled trials/ or “United States Food and Drug Administration”/ or research design/ or clinical trials/
7. drug$ trial$.mp. or placebos/
8. or/35-41

Asthma and included study designs/evaluations

1. 5 and 34

Asthma + Home Interventions

1. 5 and 25

Asthma + Home Interventions

Asthma + any of the above interventions or study designs-excluded study designs

Economic Review

The economic review team adjusted the search strategy used in the effectiveness review by adding keywords specif c to economic evaluation, such as economic(s), cost, benef t, cost benef t, benef t cost, utility, cost utility, QALY, cost effectiveness, and eff ciency. In addition to the databases searched in the effectiveness review (i.e., MEDLINE, EMBASE, ERIC, PsycINFO, Web of Science, Cochrane Library, Sociological Abstracts, and CINAHL), social science databases such as EconLit, Social Sciences Citations Index, and JSTOR; databases of the Centre for Reviews and Dissemination at the University of York; and Google were also used. These searches were conducted for 1950 through July 2008.

• Home-based environmental interventions in the community may combine asthma-related interventions with other health interventions, such as teaching lead-poisoning prevention and offering vaccinations during the home visit. It is not known, however, whether taking the focus away from asthma would make the primary intervention objective less effective.
• These interventions provide an effective way to target two of the four components considered essential to effective asthma management, according to the NAEPP Expert Panel Report Guidelines for the Diagnosis and Management of Asthma (EPR-3): (1) provision of self-management education for a partnership in asthma care; and (2) reduced exposure to indoor environmental triggers.
• Other organizations, such as the Center for Managing Chronic Disease with the Asthma Health Outcomes Project (AHOP), the Global Initiative for Asthma with the GINA report, and the National Center for Healthy Housing with the Housing Interventions and Health Outcomes review have published guidelines stating that multifaceted home-based environmental interventions are effective and ready for implementation.
• The literature indicates that it is beneficial to hire and train community health workers to implement this intervention for the purpose of reaching out to primarily low-income, ethnic minority populations.
  • Community health workers play an essential role in the implementation of interventions, bridging the gaps between underserved populations and researchers. Because they are usually from the same community, community health workers can connect culturally with local populations and build trusting relationships with clients and their families. This trust often allows clients to disclose more health needs to community health workers.
  • Community health workers may also be more economical than other trained personnel such as nurses or respiratory therapists. However, nurses and other healthcare professionals may be able to address health needs in more detail and greater depth.
• The literature strongly suggests that environmental tobacco smoke be considered at the same level of importance as other asthma triggers and be an integral part of the standard environmental assessment, education, and evaluation components in home-based environmental interventions.
• The review team noted that remediation, particularly major remediation, can be very expensive for either the study or the participant. In addition, remodeling may increase triggers such as dust and volatile organic compounds and worsen asthma and allergies.
• The review team questioned whether it might be dangerous for healthcare workers going into homes, though this has not been the case in the field (as evidenced by assorted studies and personal communication).
• Included studies noted the following barriers to implementation: reluctance of families to accept home visits, inability to maintain follow-up due to a transient population, difficulty scheduling appointments, and poor compliance with recommendations.
• Included studies cited the following additional benefits of these interventions: improved caregiver support, quality of life, family relationships, energy efficiency, communication between caregivers and physicians, and relationships between healthcare providers and the community.
• The review team also postulated additional benefits such as smoking cessation for the caregiver, which would reduce triggers in the home for parents and siblings of children in the study, and identification of additional health concerns, such as lead paint, as part of the home assessment.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce emergency department visits for people aged 5 years and over with asthma — RD-03
• Reduce asthma attacks — RD-04