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292 Establishment of a telemedicine program for bronchial asthma in a correctional population
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Abstracts
291
The Children’s Health Survey for Asthma-Teen Version (CHSAT): Development and Testing of a Self-Report Measure for Adolescents L Asmussen*. L Olson*, EN Grantt, K Weiss? *Center for Child Health Research, American Academy of Pediatrics tCenter for Health Services Research, Rush-Presbyterian-St Luke’s Medical Center The past decade has witnessed an increase in the development and use of parent-report health status instruments for conditions like pediatric asthma. Fewer instruments exist to obtain information directly from the child or adolescent. The CHSA-T was developed in response to this gap. Based on a parent-report version of the CHSA, the CHSAT was revised for content and ease of administration for the younger participant. This report summarizes results of the first pilot test of the CHSA-T conducted with a sample of 47 urban and suburban youth with asthma in the Chicago area. Respondents ranged in age from 8 16 (M=ll.l) and were evenly divided by gender (47% male). Most respondents were African American (49%) or White (47%). Participants independently completed the CHSA-T followed by a short debriefing interview to obtain feedback about the instrument and gauge understanding of various terms and concepts. Qualitative data were examined for common themes and issues. Quantitative data from the CHSA-T were analyzed at the individual item level for missing data and descriptive statistics. Analyses were conducted at the scale level for reliability, construct validity, and differences by demographic characteristics. Three scales (Physical Health, Activities and Emotional Health) were computed from 34 core items. Scores range from O-100 with higher scores indicating better health or more positive outcomes. Mean scale scores ranged from 62. I - 7 I .3 with the lowest mean score observed for the Physical Health scale. A lack of floor and ceiling effects suggests that response choices are appropriate and tap a wide range of experiences. Internal consistency reliability was high (Cronbach’s alphas .90) for all three scales. No statistically significant differences emerged by child age in mean scale scores, missing data or length of time required for questionnaire completion. However, qualitative commentary suggests that the measure is most suitable for youth ages 12+. While there is general consensus that obtaining health-related, quality of life information from the patient’s perspective is valuable, when the patient is a child, issues of cognitive development and conceptual appropriateness as well as practicality and feasibility are important considerations. The initial psychometric findings of this pilot are promising. To further instrument development, the CHSA-T is currently in testing in 3 large clinical trials across the country.
292
Establishment of a Telemedicine Program for Bronchial Asthma in a Correctional Population J A Grant*. D Cheesman*f. H Jones*t. W Givens*t, T Eapen*. 0 Murray+f. B Virrcent*f. H Wu+. K Dunn* *University of Texas Medical Branch at Galveston tTexas Department of Criminal Justice Despite their established efficacy, the National Asthma Education and Prevention Program (NAEPP) guidelines are being underutilized in treatment of many groups. Among inmates incarcerated in the Texas Department of Criminal Justice (TDCJ), asthma is a major illness and a chief cause of expensive care: emergency room visits and hospitalizations. Medical care for 120,000 inmates is provided through a managed care contract by faculty and staff of the University of Texas Medical Branch at Galveston (UTMB). Because of the great distance from TDCJ units to UTMB, a network for telemedicine has been developed. This report describes the initiation of a telemedicine program for patients with asthma in TDCJ. The Estelle Unit in Huntsville, Texas, is a regional medical facility located 160 miles north of Galveston. 3,000 inmates are housed at this unit. The staff includes physicians, physicians’ assistants, physical therapists, nurses and respiratory therapists. Respiratory therapists provide long-term care in a chronic care clinic for inmates with respiratory disorders, and inmates are seen every l-3 months. In this new
J ALLERGY CLIN IMMUNOL JANUARY 2000
program, patients with moderate to severe persistent asthma at the Estelle Unit have been referred for specialty evaluation via telemeditine. The telemedicine clinic is held weekly, and patients are presented by the respiratory therapists to university allergy faculty. Peripheral equipment available for telemedicine examination include otorhinoscopes and stethoscopes. Unique features of the program are evaluation of objective data: resource utilization (drug usage, hospital. and emergency room visits), pulmonary function, daily peak flow measurement, and quality of life measurements. If necessary, in-person clinic visits are scheduled. Finally. most emergent care is provided at the university hospital, In a year, 28 patients have been enrolled in the program and 3 were dropped for noncompliance. Patients are seen every l-6 months via telemedicine. The principal observations were underutilization of medication recommend by NEAPP for long-term control of asthma and overutilization of bronchodilators. A second observation was the diagnosis of multiple comorbid conditions that had not been previously identified or treated: allergic rhinitis (N=2 I), gastroesophageal reflux disorder (14). chronic sinusitis (9). nasal polyposis (8). chronic obstructive pulmonary disease (8). adrenal suppression (7) vocal cord dysfunction (6), bronchitis (4) allergic bronchopulmonary aspergillosis (I), and emphysema (I). There were 24 hospitalizations for asthma in two years before starting this program, and 3 after patients were evaluated. Periodic spirometry has proved the most reliable factor to judge improvement. Traditional measures of daily peak flow and quality of life have been less reliable, reflecting the motives of an incarcerated population. Telemedicine is an appropriate means of providing specialty care for groups in underserved populations, including prisons and rural areas. The preliminary success of our program has been due to a close collaboration between senior clinical consultants and experienced respiratory therapists. It is critical that the personnel on both ends of a telemedicine system are carefully chosen and trained to effect the most positive results. 2%
Two Year Outcome and Cost Savings Following Attendance of a Multidisciplinary Day Program for Pediatric Patients with Severe Asthma DL Bratton, MR Price, LA Gavin, MD Klinnert National Jewish Medical and Research Center, Denver CO The National Jewish Pediatric Day Program uses a multidisciplinary care model to address the needs of children with severe asthma unresponsive to traditional outpatient management. Families of 98 children (aged 9 months to 18 years) were enrolled and participated an average of 15.6 days in the program. Medical (oral steroid bursts and functional severity (Rosier, 1994)) and psychosocial data (perceived competence in managing illness and quality of life (Juniper, 1996)) were collected at admission. discharge and at one and two years post discharge. Medical care utilization (hospitalizations, emergency room visits, sick and well clinic visits). and costs of these services were compared for the year prior to. and one and two years following participation in the program. RESULTS: Questionnaire data was available for 98 subjects at admission. 87 at 1 year and 7 1 at two years follow up. Medical record data was available for 94,82 and 75 subjects at each time point, respectively. Using ANOVA comparing data on admission, and at one and two years post discharge, significant improvements in oral steroid bursts, functional severity, caregiver and patient quality of life, and perceived competence in managing illness were demonstrated (p <.OOOl for each variable). For all outcome variables, the gains were significant in the first year and maintained in the second year. Importantly, significant reductions in hospital days (p c.0001) and for medical care utilization were noted. Assigning costs to each medical encounter, a median total utilization cost/patient of $16,250 ($6,972$25,714 IQR) for the year prior to program participation was reduced to $1,902 ($505.$6,524 IQR) at one year and $690 ($185~$3,550 IQR) at two year follow up (p <.OOOI). Together, both medical and econom-
Abstracts
291
The Children’s Health Survey for Asthma-Teen Version (CHSAT): Development and Testing of a Self-Report Measure for Adolescents L Asmussen*. L Olson*, EN Grantt, K Weiss? *Center for Child Health Research, American Academy of Pediatrics tCenter for Health Services Research, Rush-Presbyterian-St Luke’s Medical Center The past decade has witnessed an increase in the development and use of parent-report health status instruments for conditions like pediatric asthma. Fewer instruments exist to obtain information directly from the child or adolescent. The CHSA-T was developed in response to this gap. Based on a parent-report version of the CHSA, the CHSAT was revised for content and ease of administration for the younger participant. This report summarizes results of the first pilot test of the CHSA-T conducted with a sample of 47 urban and suburban youth with asthma in the Chicago area. Respondents ranged in age from 8 16 (M=ll.l) and were evenly divided by gender (47% male). Most respondents were African American (49%) or White (47%). Participants independently completed the CHSA-T followed by a short debriefing interview to obtain feedback about the instrument and gauge understanding of various terms and concepts. Qualitative data were examined for common themes and issues. Quantitative data from the CHSA-T were analyzed at the individual item level for missing data and descriptive statistics. Analyses were conducted at the scale level for reliability, construct validity, and differences by demographic characteristics. Three scales (Physical Health, Activities and Emotional Health) were computed from 34 core items. Scores range from O-100 with higher scores indicating better health or more positive outcomes. Mean scale scores ranged from 62. I - 7 I .3 with the lowest mean score observed for the Physical Health scale. A lack of floor and ceiling effects suggests that response choices are appropriate and tap a wide range of experiences. Internal consistency reliability was high (Cronbach’s alphas .90) for all three scales. No statistically significant differences emerged by child age in mean scale scores, missing data or length of time required for questionnaire completion. However, qualitative commentary suggests that the measure is most suitable for youth ages 12+. While there is general consensus that obtaining health-related, quality of life information from the patient’s perspective is valuable, when the patient is a child, issues of cognitive development and conceptual appropriateness as well as practicality and feasibility are important considerations. The initial psychometric findings of this pilot are promising. To further instrument development, the CHSA-T is currently in testing in 3 large clinical trials across the country.
292
Establishment of a Telemedicine Program for Bronchial Asthma in a Correctional Population J A Grant*. D Cheesman*f. H Jones*t. W Givens*t, T Eapen*. 0 Murray+f. B Virrcent*f. H Wu+. K Dunn* *University of Texas Medical Branch at Galveston tTexas Department of Criminal Justice Despite their established efficacy, the National Asthma Education and Prevention Program (NAEPP) guidelines are being underutilized in treatment of many groups. Among inmates incarcerated in the Texas Department of Criminal Justice (TDCJ), asthma is a major illness and a chief cause of expensive care: emergency room visits and hospitalizations. Medical care for 120,000 inmates is provided through a managed care contract by faculty and staff of the University of Texas Medical Branch at Galveston (UTMB). Because of the great distance from TDCJ units to UTMB, a network for telemedicine has been developed. This report describes the initiation of a telemedicine program for patients with asthma in TDCJ. The Estelle Unit in Huntsville, Texas, is a regional medical facility located 160 miles north of Galveston. 3,000 inmates are housed at this unit. The staff includes physicians, physicians’ assistants, physical therapists, nurses and respiratory therapists. Respiratory therapists provide long-term care in a chronic care clinic for inmates with respiratory disorders, and inmates are seen every l-3 months. In this new
J ALLERGY CLIN IMMUNOL JANUARY 2000
program, patients with moderate to severe persistent asthma at the Estelle Unit have been referred for specialty evaluation via telemeditine. The telemedicine clinic is held weekly, and patients are presented by the respiratory therapists to university allergy faculty. Peripheral equipment available for telemedicine examination include otorhinoscopes and stethoscopes. Unique features of the program are evaluation of objective data: resource utilization (drug usage, hospital. and emergency room visits), pulmonary function, daily peak flow measurement, and quality of life measurements. If necessary, in-person clinic visits are scheduled. Finally. most emergent care is provided at the university hospital, In a year, 28 patients have been enrolled in the program and 3 were dropped for noncompliance. Patients are seen every l-6 months via telemedicine. The principal observations were underutilization of medication recommend by NEAPP for long-term control of asthma and overutilization of bronchodilators. A second observation was the diagnosis of multiple comorbid conditions that had not been previously identified or treated: allergic rhinitis (N=2 I), gastroesophageal reflux disorder (14). chronic sinusitis (9). nasal polyposis (8). chronic obstructive pulmonary disease (8). adrenal suppression (7) vocal cord dysfunction (6), bronchitis (4) allergic bronchopulmonary aspergillosis (I), and emphysema (I). There were 24 hospitalizations for asthma in two years before starting this program, and 3 after patients were evaluated. Periodic spirometry has proved the most reliable factor to judge improvement. Traditional measures of daily peak flow and quality of life have been less reliable, reflecting the motives of an incarcerated population. Telemedicine is an appropriate means of providing specialty care for groups in underserved populations, including prisons and rural areas. The preliminary success of our program has been due to a close collaboration between senior clinical consultants and experienced respiratory therapists. It is critical that the personnel on both ends of a telemedicine system are carefully chosen and trained to effect the most positive results. 2%
Two Year Outcome and Cost Savings Following Attendance of a Multidisciplinary Day Program for Pediatric Patients with Severe Asthma DL Bratton, MR Price, LA Gavin, MD Klinnert National Jewish Medical and Research Center, Denver CO The National Jewish Pediatric Day Program uses a multidisciplinary care model to address the needs of children with severe asthma unresponsive to traditional outpatient management. Families of 98 children (aged 9 months to 18 years) were enrolled and participated an average of 15.6 days in the program. Medical (oral steroid bursts and functional severity (Rosier, 1994)) and psychosocial data (perceived competence in managing illness and quality of life (Juniper, 1996)) were collected at admission. discharge and at one and two years post discharge. Medical care utilization (hospitalizations, emergency room visits, sick and well clinic visits). and costs of these services were compared for the year prior to. and one and two years following participation in the program. RESULTS: Questionnaire data was available for 98 subjects at admission. 87 at 1 year and 7 1 at two years follow up. Medical record data was available for 94,82 and 75 subjects at each time point, respectively. Using ANOVA comparing data on admission, and at one and two years post discharge, significant improvements in oral steroid bursts, functional severity, caregiver and patient quality of life, and perceived competence in managing illness were demonstrated (p <.OOOl for each variable). For all outcome variables, the gains were significant in the first year and maintained in the second year. Importantly, significant reductions in hospital days (p c.0001) and for medical care utilization were noted. Assigning costs to each medical encounter, a median total utilization cost/patient of $16,250 ($6,972$25,714 IQR) for the year prior to program participation was reduced to $1,902 ($505.$6,524 IQR) at one year and $690 ($185~$3,550 IQR) at two year follow up (p <.OOOI). Together, both medical and econom-