Effectiveness of Community Based Interventions for Children with Asthma

1. Effectiveness of Community Based Interventions for Children with Asthma Noreen M. Clark, PhD Myron E. Wegman Distinguished University Professor Director, Center for Managing Chronic Disease University of Michigan

2. Improving Adherence in Pediatric Asthma: Where to from Here? Cynthia Rand, Ph.D. Johns Hopkins School of Medicine

3. 25+ Years Pediatric Adherence Research:What We�ve Learned Rates of pediatric nonadherence with therapy are comparable to adult nonadherence (i.e.~50%)

4. Percent of Children with Acute Severe Asthma Filling Systemic Corticosteroid Prescriptions Of 6035 tennesee children covered by Medicaid with an ED and 2102 children with a hospitalization less than half had a prescription filled with 7 days of discharge. Predictors of non-adherence were black race, older age and more rural county.Of 6035 tennesee children covered by Medicaid with an ED and 2102 children with a hospitalization less than half had a prescription filled with 7 days of discharge. Predictors of non-adherence were black race, older age and more rural county.

5. 25+ Years Pediatric Adherence Research:What We�ve Learned Pediatric self-reports of good adherence are as unreliable as adult reports Just as adult depression influences adherence with therapy, maternal depression influences pediatric adherence with asthma therapy Maternal health beliefs about asthma and controller therapy are strongly associated with adherence

7. 25+ Years Pediatric Adherence Research:What We�ve Learned Family structure and routines are predictive of better adherence Pediatrician communication skills can influence family/pediatric adherence While asthma education can significantly improve pediatric asthma adherence, improvements are often modest and transitory

8. Improving Patient Adherence with Chronic Therapies: What Does the Research Show? Changing adherence behavior is difficult Education in not enough Successful interventions are usually multi-factorial Recent intervention strategies that have shown some promise include: improved patient-provider communication simplifying therapy interventions to improve motivation monitoring and feedback of adherence Shared-decision-making

9. Improving Patient Adherence with Chronic Therapies: What Does the Research Show? Intensive provider/patient education and counseling strategies can be costly, complex and difficult to broadly implement New strategies to promote adherence are needed that are broadly generalizable, low-cost and sustainable

10. Compliance- �following doctors orders� Adherence-the extent to which a person�s behavior corresponds with recommendations from a health care provider� Concordance-shared decision-making a coming to an agreement that respects the patients beliefs and wishes

11. Where to from Here? Considering the whole patient and family: real world barriers to pediatric asthma treatment persistence and adherence Improving pediatric adherence with asthma therapy: Lessons from the most successful health behavior intervention ever conducted

15. Lessons learned from tobacco control initiatives Clear, unambiguous and reiterated public health messages can change health behavior Social institutions and public opinion are powerful agents for health behavior change Community and social institutions supported nonsmoking while penalizing and marginalizing smoking Simple, directive advice of health care providers can change health behaviors While intensive, high cost interventions can achieve moderate levels of change in select populations, low-cost, low-intensity interventions can achieve small changes in large populations. Even small health behavior changes over large populations can yield significant health benefits

16. Enhance use of the media and visible public health forums to promote, remind and reinforce adherence with chronic therapies Partner with social and community organizations to facilitate and support adherence with chronic therapies (e.g. schools, churches, workplaces, grocery stores, etc.) including resource to address barriers to adherence (e.g. cost) Incorporate simple adherence assessment and promotion into all health encounters, ideally with EMR and EPR support Explore the potential of technology-based support for adherence promotion �including web-based, email, IVR software. Consider low-cost, large scale interventions designed to achieve small changes in adherence over large populations

17. Summary Why should we consider asthma therapies in the context of the whole patient and family? Because even therapies with high efficacy will not be used if they don�t fit a family�s personal capacities, goals, and beliefs. What can we learn from the success of smoking cessation efforts in the US? While health behavior change is difficult, clear public health messages, social and institutional support, and simple, low-cost, broad-based interventions may have the potential to improve pediatric adherence with asthma therapies

18. Recommendations Develop innovative strategies to integrate adherence promotion and support into relevant health care delivery systems Develop provider, pharmacy and family support programs that reinforce and support adherence with therapy

19. Recommendations Integrate children�s adherence support into school-based asthma education and medical care via school-based clinics

20. Effectiveness of Community Based Interventions for Children with Asthma Noreen M. Clark, PhD Myron E. Wegman Distinguished University Professor Director, Center for Managing Chronic Disease University of Michigan