AJPH RESEARCH

Pediatric Asthma Care Coordination

in Underserved Communities: A
Quasiexperimental Study
Mary R. Janevic, PhD, MPH, Shelley Stoll, MPH, Margaret Wilkin, MPH, Peter X. K. Song, PhD, Alan Baptist, MD, Marielena Lara, MD, MPH,
Gilberto Ramos-Valencia, DrPH, Tyra Bryant-Stephens, MD, Victoria Persky, MD, Kimberly Uyeda, MD, MPH, Julie Kennedy Lesch, MPA,
Wen Wang, MS, and Floyd J. Malveaux, MD, PhD

Objectives. To assess the effect of care coordination on asthma outcomes among Care coordination is a promising strategy
children in underserved urban communities. to address these barriers. As defined by
Methods. We enrolled children, most of whom had very poorly or not well-controlled Brown, care coordination is
asthma, in medical–social care coordination programs in Los Angeles, California; Chicago,
a client-centered, assessment-based
Illinois; Philadelphia, Pennsylvania; and San Juan, Puerto Rico in 2011 to 2014. Partici- interdisciplinary approach to integrating health
pants (n = 805; mean age = 7 years) were 60% male, 50% African American, and 42% care and social support services in which an
Latino. We assessed asthma symptoms and health care utilization via parent interview at individual’s needs and preferences are assessed,
a comprehensive care plan is developed, and
baseline and 12 months. To prevent overestimation of intervention effects, we con-
services are managed and monitored by a care
structed a comparison group using bootstrap resampling of matched control cases from coordinator following evidence-based standards
previous pediatric asthma trials. of care.6(p1)
Results. At follow-up, intervention participants had 2.2 fewer symptom days per
month (SD = 0.3; P < .01) and 1.9 fewer symptom nights per month (SD = 0.35; P < .01) Previous quasiexperimental studies have
suggested that care coordination results in re-
than did the comparison group. The relative risk in the past year associated with the
duced asthma symptoms and reduced urgent
intervention was 0.63 (95% confidence interval [CI] = 0.45, 0.89) for an emergency de-
health care utilization.7–10 For example, 13%
partment visit and 0.69 (95% CI = 0.47, 1.01) for hospitalization.
of high-risk children with asthma in the Link
Conclusions. Care coordination may improve pediatric asthma symptom control and
Line intervention group (Philadelphia) had
reduce emergency department visits.
follow-up hospitalizations over a 1-year period
Policy Implications. Expanding third-party reimbursement for care coordination ser- compared with 33% in a matched sample
vices may help reduce pediatric asthma disparities. (Am J Public Health. 2016;106:2012– comparison group.9 In the Community
2018. doi:10.2105/AJPH.2016.303373) Asthma Initiative (Boston), participants expe-
rienced a 68% decrease in ED visits over 12
months.10 Care coordination appears to be cost

A sthma affects more than 6.1 million

children younger than 18 years in the
United States1 and results in millions of doctor
visits and missed school days annually, hun-
dreds of thousands of emergency department
(ED) visits and hospitalizations, and thousands
of deaths.2,3 Despite widespread attention to
disparities in pediatric asthma, significant
gaps persist.2,3 Non-Latino Black children
(13.4%) are nearly twice as likely to have
asthma as are non-Latino White children
(7.5%) or Latino children (7.4%), with the
exception of Puerto Rican children (20.7%).1
Black and Latino children with asthma visit
the ED more frequently than do White
children and are more likely to die from
asthma.3 Barriers to asthma management,
such as lack of consistent, appropriate medical
care and increased exposure to environ-
mental triggers, disproportionately affect
children living in low socioeconomic,
effective, with the return on investment cal-
culated at 1.46 dollars saved per dollar spent.10
Policy developments related to the Patient
urban areas.4,5 Protection and Affordable Care Act increase
ABOUT THE AUTHORS
At the time of the study, Mary R. Janevic, Shelley Stoll, and Margaret Wilkin were with the Department of Health Behavior
and Health Education, University of Michigan School of Public Health, Ann Arbor. Peter X. K. Song and Wen Wang are
with the Department of Epidemiology, University of Michigan School of Public Health. Alan Baptist is with the Division
of Allergy and Clinical Immunology, University of Michigan Medical School, Ann Arbor. Marielena Lara was with the
Children’s Hospital of Los Angeles, University of Southern California, Los Angeles. Gilberto Ramos-Valencia is with
the Department of Biostatistics and Epidemiology, Graduate School of Public Health, University of Puerto Rico, San Juan,
Puerto Rico. Tyra Bryant-Stephens is with the Children’s Hospital of Philadelphia, Philadelphia, PA. Victoria Persky is
with the Division of Epidemiology and Biostatistics, University of Illinois, Chicago School of Public Health, Chicago, IL.
Kimberly Uyeda is with the Los Angeles Unified School District, Los Angeles. Julie Kennedy Lesch and Floyd J. Malveaux were
with the Merck Childhood Asthma Network, Inc., Washington, DC.
Correspondence should be sent to Mary R. Janevic, PhD, MPH, University of Michigan School of Public Health, 1425
Washington Heights, Ann Arbor, MI 48109-2029 (e-mail: mjanevic@umich.edu). Reprints can be ordered at http://www.ajph.org
by clicking the “Reprints” link.
This article was accepted July 7, 2016.
doi: 10.2105/AJPH.2016.303373

2012 Research Peer Reviewed Janevic et al. AJPH November 2016, Vol 106, No. 11

the feasibility of care coordination models.
Medicaid reimbursement is now permitted
for preventive services (including chronic
disease management)11 that are delivered by
certified, nonlicensed health care providers
if they are recommended by a licensed health
care practitioner. This facilitates the provision
of asthma care coordination elements such
as education and home visits by community
health workers or certified asthma educators.
The Affordable Care Act also permits state
Medicaid programs to form health homes
for patients with chronic illness, of which
care coordination is 1 of 6 core services.11
The Merck Childhood Asthma Network,
Inc. (MCAN) funded a 4-year project to
assess the effectiveness of pediatric asthma
care coordination in 4 urban settings. These
sites were the Los Angeles Unified School
District (LAUSD) Asthma Program (Los
Angeles, CA), the Children’s Hospital of
Philadelphia Asthma Care Navigator Pro-
gram (Philadelphia, PA), the federally quali-
fied health center–based La Red de Asma
Infantil de Puerto Rico (San Juan, PR),
and the neighborhood-based Addressing
Asthma in Englewood Project (Chicago,
IL).12 We have reported 1-year changes in
participants’ daytime and nighttime symp-
toms and frequency of ED visits and
hospitalizations.
METHODS
From 2005 to 2015, the MCAN Care
Coordination Programs, phases I and II,
funded diverse sites to reduce pediatric
asthma morbidity in vulnerable populations.
In phase I (2005–2009), 5 sites implemented
evidence-based interventions to improve
outcomes, explore the factors that led to
successful evidence-based intervention
adoption, and understand program adapta-
tions.13,14 In phase II (2010–2015), 4 sites
implemented evidence-based pediatric
asthma care coordination activities. All
phase II sites adapted Yes We Can, a medical–
social model of care that deploys health
workers to provide asthma education, link
families to health and social services, and
facilitate patient–clinician communication.7
Details about the settings and content of
the 4 programs are presented in Table 1
and are also found elsewhere.12 Broadly, all
November 2016, Vol 106, No. 11 AJPH
4 sites included intervention components in
which an asthma care coordinator provided
families with asthma education, including use
of an asthma action plan and trigger re-
mediation. Staff with varied professional
backgrounds, including nurses, health edu-
cators, and community health workers, who
were trained in delivering culturally relevant
care performed the asthma care coordinator
role.
Asthma care coordinators typically made 1
or more home visits to assess triggers and
helped the family address social barriers to
asthma management. Participants received
remediation materials such as pillow covers
and pest management supplies. Importantly,
at each site, asthma care coordinators formed
links with clinical care providers, although the
extent and nature of clinical integration varied
across sites.12
Participants and Data Collection
Eligibility criteria and recruitment pro-
cedures varied by site (Table 1). Programs
recruited primarily, but not exclusively,
children with poorly controlled, persistent
asthma. A total of 1223 children were en-
rolled, exceeding the target sample size
(determined by feasibility) of 800.
We administered a survey to parents
or caregivers upon enrollment at baseline
and 12 months later to collect data on
primary intervention outcomes, asthma self-
management, and satisfaction with asthma
care. Across sites, we collected baseline data
between January 2011 and June 2013; we
collected follow-up data between January
2012 and November 2014.
Asthma care coordinators, who received
training in this task and were given a detailed
reference manual, administered surveys, in
English or Spanish, primarily in the clinic or in
the caregiver’s home. Occasionally, they
conducted interviews by telephone. No
incentives for survey completion were
provided.
Outcomes
We assessed daytime and nighttime
symptoms with 2 items adapted from the
Childhood Asthma Control Test15: “During
the last 4 weeks, how many days did [child’s
name] have any daytime asthma symptoms
(like wheezing, shortness of breath, tightness
AJPH RESEARCH
in the chest, or cough)?” and “During the last 4
weeks, how many nights did [child’s name]
wake up during the night because of asthma?”
We asked parents how many times in the
past 12 months their child had been “treated
in the emergency department or ER for
asthma” and “been admitted to a hospital for
asthma and had to stay overnight for one or
more nights.”
Analysis Plan
We conducted all analyses using SAS
version 9.3 (SAS Institute Inc., Cary, NC).
We examined all survey variables for con-
sistency and completeness before analysis.
We calculated descriptive statistics on
the demographic and health characteristics
and compared those who completed the
study (n = 805) with those lost to follow-up
(n = 418) using the c2 test of homogeneity for
categorical variables and the t test for con-
tinuous variables. We assessed changes from
baseline to 12-month follow-up in mean
symptom days, symptom nights, number of
ED visits, and number of hospitalizations
using generalized mixed-effects models with
a Poisson distribution (SAS PROC
GLIMMIX). We treated the family as the
cluster of analysis and adjusted for age, race/
ethnicity, gender, and site as fixed effects. Be-
cause the sample included children living in the
same household, we used a family identifier as
a random intercept to account for correlation
within the 68 sets of siblings in the sample.
To enhance the rigor of the study design,
we use a novel statistical technique, the Clark
adjustment (named after pioneering asthma
researcher Noreen Clark16), in which
a comparison group is constructed using
matched control group data from previous
trials.17 This simulated control group is used
to estimate the usual improvement over time
that occurs in asthma symptoms as children
age.18 Ko et al. estimate that children younger
than 10 years experience an 18% per-year
decrease in symptoms, with more modest
decreases in older children.17 Moreover,
many children enter asthma studies following
exacerbations of the illness, yet symptoms
naturally fluctuate over time.
Failure to account for this expected im-
provement over time could lead to an
overestimation of the intervention effect. We
used bootstrap resampling with replacement
Janevic et al. Peer Reviewed Research 2013
AJPH RESEARCH

TABLE 1—Intervention: Merck Childhood Asthma Network Care Coordination Programs, Phase II, 2010–2015

Variable Los Angeles, CA Chicago, IL Philadelphia, PA San Juan, Puerto Rico

Content (delivered in-person Asthma education Asthma education Asthma education Asthma education
1-on-1 to parent or caregiver) Home environmental assessment Home environmental assessment Home environmental assessment Home environmental assessment
Mitigation suppliesa and education Mitigation suppliesa and education Mitigation suppliesa and education (received by half of participants)
provided provided provided Mitigation suppliesa and education
Referrals provided Referrals provided Needs assessment of caregiver provided
AAP given and explained AAP given and explained Goal setting for care coordination
ACT administered Follow-up reports sent to Education and links provided to
physicians meet goals
Goals assessed
Interventionist Asthma program nurses (RNs) Community health educators Asthma care navigators (clinic- In clinic: health educator
based community health workers) In home: community health worker
Setting Home Home Clinic and home Clinic and home
Occasionally at school or over
telephone
Contacts 3–4 home visits plus telephone calls ‡ 1 home visit plus at least 2 3 home visits plus ‡ 4 clinic visits 2 clinic and, for half of the
2 wk after each visit additional home, clinic, or (if possible) participants, 2 home visits
telephone contacts
Eligibility criteria
Asthma morbidity Diagnosed asthma or symptoms Diagnosis of intermittent or Diagnosis of persistent asthma Diagnosis of asthma
persistent asthma
Age, y 4–18 0–18 0–17 0–17
Location or provider Reside in LAUSD boundaries Reside in Englewood, West PCP in 1 of 3 urban CHOP clinics Patient of HealthProMed FQHC
Englewood, or in the 10
blocks surrounding
Other ACT < 20 and any of the following: All of the following: Any of the following:
‡ 10 missed school days ‡ 1 hospitalization or 2 ED visits in Daily asthma symptoms in last 2 wk
Recent ED visit or hospitalization last year ‡ 2 nights of asthma symptoms
Recent diagnosis Prescribed controller medication last 2 wk
Parent, nurse, or doctor request Medical assistance as primary ‡ 1 asthma hospitalizations last
insurance year
English or Spanish is primary ‡ 2 ED asthma visits last year
language of caregiver Control medication use every day
last wk or rescue medicine ‡ 2
times/wk
Recruitment Existing school district health Community health educators ED and hospitalization records Study staff recruited in FQHC
information recruited at local clinics Chart review in participating clinics waiting room
Referrals from school nurses, Referrals from physicians, schools, Provider referral Community recruitment
doctors, and other staff, parents, community-based organizations;
Breathmobile doctors community recruitment

Note. AAP = Asthma Action Plan; ACT = asthma control test; CHOP = Children’s Hospital of Philadelphia; ED = emergency department; FQHC = federally qualified
health center; LAUSD = Los Angeles Unified School District; PCP = primary care provider; RN = registered nurse.
a
Mitigation supplies include items such as roach gel and mattress covers.

to match intervention to control cases on
race/ethnicity, gender, and the dichotomized
baseline value of the variable of interest to
compare children at similar levels of asthma
severity. We repeated this sampling 1000
times to reduce selection bias. Regression
models were fit within each of the 1000
matched samples, averaging results across
models to determine final estimates of the
treatment group effect. A more detailed de-
scription of this technique can be found in
Appendix A (available as a supplement to the
online version of this article at http://www.
ajph.org) and Ko et al.17
We estimated models with the following 4
outcomes: pre–post change in symptom days
and symptom nights and the probability
of reporting 1 or more ED visits and hospi-
talizations. For each model, the main pre-
dictor variable was group (treatment or
control), with age and baseline value of the
outcome as covariates. We obtained control
cases from control group data from 4 previous
randomized controlled trials of pediatric

2014 Research Peer Reviewed Janevic et al. AJPH November 2016, Vol 106, No. 11
 AJPH RESEARCH

asthma interventions from 2001 or later: participants were either African American TABLE 2—Baseline Demographic
the Detroit Middle School Asthma Project,19 (50.4%) or Latino (42.1%), including those Characteristics of Final Sample (n = 805):
the Physician Asthma Care Education pro- of Puerto Rican, Mexican American, and Merck Childhood Asthma Network Care
gram,20 the Inner City Asthma Consortium,21,22 Central American origin, and recruited from Coordination Programs, Phase II, 2010–2014
and the Study of Adherence Monitoring the San Juan and Los Angeles sites, re-
with Feedback and Asthma Basic Care in- spectively. About one third of respondents Characteristic No. (%)
terventions.23 Details on control cohort char- reported speaking Spanish at home. More Site (n = 805)
acteristics are found in Table A (available as than 90% of the sample was insured by Chicago, IL 134 (16.6)
a supplement to the online version of this article Medicaid. Los Angeles, CA 232 (28.8)
at http://www.ajph.org). Philadelphia, PA 254 (31.6)
In the 2 symptom models, we estimated San Juan, Puerto Rico 185 (23.0)
general linear models with change in symp- Pre–Post Results
Age, y (n = 803)
toms (daytime or nighttime) from baseline As shown in Table 3, at baseline, parents
0–4 259 (32.2)
to follow-up as the dependent variable. reported adjusted means of 5.0 and 3.8 daytime
5–8 270 (33.5)
For the 2 health care use models (probability and nighttime symptom days per month, re-
9–11 137 (17.0)
of having at least 1 ED visit or hospitalization spectively; at follow-up, these decreased to
12–18 137 (17.0)
at follow-up, if this event was reported at 2.1 and 1.2. Parents reported an adjusted mean
Male (n = 802) 479 (59.5)
baseline), we fit zero-inflated log-linear of 3.2 ED visits and 2.0 hospitalizations in the
models. We excluded Latino participants past year at baseline; the adjusted means at Child’s race or ethnicity (n = 802)
(n = 339) from these 2 models only because follow-up were 1.2 and 0.6, respectively. African American 406 (50.4)
of a lack of comparable health care use data The pre–post changes (ratio of adjusted Latino 339 (42.1)
(i.e., events not reported in the same recall means) were all statistically significant. White 14 (1.7)
period) for Latino children in the control The intraclass correlation coefficient (ICC), Other 43 (5.3)
cohorts. Analytic samples for these 2 models a correlation measure available in the Language spoken at home (n = 801)
also excluded non-Latino participants who normal linear mixed-effects model, is not English 481 (59.8)
did not have at least 1 baseline ED visit well defined in the Poisson generalized Spanish 239 (29.7)
(n = 143 excluded) or hospitalization (n = 224 mixed-effects model we used in the analysis, Other 81 (10.1)
excluded) at baseline. and thus we did not include the ICC for Level of asthma control (n = 797)
family-level clustering in the table. Coefficients Well controlled 182 (23.0)
for all model variables are presented in Table B Not well controlled 390 (49.0)
(available as a supplement to the online version Very poorly controlled 225 (28.0)
RESULTS of this article at http://www.ajph.org).
Caregiver’s relationship to child (n = 804)
A total of 1223 parents or caregivers
Mother 733 (91.1)
completed a baseline interview, and 805
Father 26 (3.2)
(66%) completed a follow-up interview. Site-Specific Results
Other 45 (5.6)
Most (67%) of the participants who were We sought to examine the effect of
lost to follow-up came from the LAUSD site care coordination across sites. However, Highest level of school caregiver attended
owing to the transient nature of this school because we found significant pre–post (n = 796)
population. Compared with study com- changes in all 4 primary outcomes in the Less than high school 121 (15.0)
pleters, participants lost to follow-up were pooled sample, as a post hoc analysis we High school 498 (61.9)
older (8.7 vs 7.0 years; P < .001); more ran models including a “site · time” in- College 164 (20.4)
likely to be Latino (65% vs 42%; P < .001); teraction to determine whether the pre–post Postcollege 13 (1.6)
less likely to have medical insurance (88% changes varied significantly by site. This Other
vs 96%; P < .001); and less likely to have coefficient was significant in the models Child has health or medical insurance 776 (96.4)
Medicaid (74% vs 92%; P < .001). for symptom days and hospitalizations, in- (n = 794)
Children lost to follow-up also reported dicating differential change by site for these Child’s insurance is Medicaid (n = 791) 742 (92.2)
more baseline symptom days (8.5 vs 7.4; 2 outcomes.
P = .02) than did completers; however, We next examined change in symptom
symptom nights were similar between the days within each site and found that all Clark Adjustment Results
2 groups. Across sites, the final analytic sites showed a statistically significant im- Table 4 shows that compared with the
sample was approximately equally distributed provement in this outcome (P < .001). control group, the intervention group ex-
among children aged 0 to 4 years, 5 to 8 years, For hospitalizations, pre–post improve- perienced a 2.2-day (SD = 0.43) greater re-
and 9 years or older (Table 2). Slightly ments were significant (P < .001) within duction in symptom days and a 1.9-day
more than half of participating children all sites except LAUSD. (Results not (SD = 0.35) greater reduction in symptom
were male (59.5%). The vast majority of shown.) nights. Without the Clark adjustment, as

November 2016, Vol 106, No. 11 AJPH Janevic et al. Peer Reviewed Research 2015
AJPH RESEARCH
TABLE 3—Self-Reported Outcomes at Baseline and 12-Month Follow-Up: Merck Childhood Asthma Network Care Coordination Programs,
Phase II, 2010–2014
Outcome
During the past 4 wk
No. d child had any daytime asthma symptoms
No. d child woke up during the night because of asthma
During the past 12 mo
No. emergency department visits
No. hospitalizations
Note. CI = confidence interval. We used the Poisson version of generalized linear mixed-effects models with the following specifications: family as the cluster of
analysis; canonical link function; gender, baseline age, time, and site as fixed effects; a random intercept for each family as a random effect; and no R-side
(marginal) correlation.
a
Means of variables of interest are for a Hispanic boy aged 7.05 years in Philadelphia, as an example case, with the mean and mode characteristics in the data set.
shown in the example case in Table 3,
participants reported 2.9 fewer symptom
days and 2.6 fewer symptom nights over
the project period; these represent over-
estimations of program effect of 130% and
136%, respectively.
The relative risk (RR) associated with
participation in the intervention of having
1 or more ED visits in the past 12 months,
considering at least 1 baseline ED visit, was
0.63 (95% confidence interval [CI] = 0.45,
0.89) and of having 1 or more hospitalizations,
considering at least 1 baseline hospitalization,
was 0.69 (95% CI = 0.47, 1.01).
DISCUSSION
Overcoming persistent race/ethnicity and
socioeconomic-based disparities in asthma
outcomes is widely viewed as a top priority
in respiratory health.24 We found support
for our hypothesis that structured asthma care
coordination programs—which provided
education and resources to families and in-
tegrated these services with clinical care—
would improve key outcomes among
children from low-income, urban African
American and Latino communities. We
found that over a 1-year period, children who
participated in the care coordination pro-
grams experienced marked improvement
in both daytime and nighttime symptoms
and reduced their risk of reporting
asthma-related ED visits.
Importantly, we were able to compare
changes in program participants with matched
2016 Research Peer Reviewed Janevic et al.
Baseline (n = 805), Adjusted Follow-Up (n = 805), Adjusted Ratio of Adjusted Meansa
Meana (95% CI) Meana (95% CI) Between Baseline and Follow-Up (95% CI)
5.0 (3.7, 6.8) 2.1 (1.6, 2.9) 2.4 (2.3, 2.5)
3.8 (2.6, 5.4) 1.2 (0.8, 1.7) 3.2 (3.0, 3.4)
3.2 (2.3, 4.5) 1.2 (0.9, 1.7) 2.6 (2.4, 2.8)
2.0 (1.2, 3.2) 0.6 (0.4, 1.0) 3.1 (2.7, 3.5)
cases in a control group derived from past magnitude to those we observed are likely to
trials to better isolate the effects of the in- result when this care coordination model is
terventions. This approach reduces the used in similar community or care settings.
possibility that the observed program effect Symptoms are a core outcome measure in
stems from typical age-related improvements asthma research, although evidence is lacking
in asthma symptoms or regression to the to identify the minimally important clinical
mean. difference in longitudinal studies.26 Children
Our findings have a high degree of external who have well-controlled asthma according
validity, because our study design followed to National Asthma Education and Pre-
many of the principles of pragmatic trials,25 vention Program guidelines have symptoms
for example, there were no health-related on 2 or fewer days per week and nighttime
selection criteria, apart from level of asthma symptoms (awakenings) 1 or fewer days per
control at some sites; a range of practitioners, month.27 National Asthma Education and
who were given flexibility in adhering to the Prevention Program recommendations for
details of implementation, applied the in- asthma severity assessment specify that 2 or
tervention in a variety of settings; and patient more ED visits or hospitalizations for asthma
and provider adherence were minimally in the past year are associated with a higher
monitored. In other words, because the in- risk of exacerbations or death. Therefore,
terventions were deployed under real-world reductions in daytime and nighttime symp-
conditions, improvements of a similar toms and ED visits, as we observed, increase
TABLE 4—Outcomes From Clark Adjustment Analyses Comparing Participants to
Standardized Comparison Group: Merck Childhood Asthma Network Care Coordination
Programs, Phase II, 2010–2014
Treatment Effect Difference (95% CI) or RR (95% CI)
a
No. d of daytime symptoms in past 4 wk (n = 779) –2.20 (–3.05, –1.35)
No. d of nighttime symptoms in past 4 wka (n = 782) –1.92 (–2.61, –1.23)
No. ED visits in past 12 mob (n = 315) 0.63 (0.45, 0.89)
b
No. hospitalizations in past 12 mo (n = 233) 0.69 (0.47, 1.01)
Note. CI = confidence interval; ED = emergency department; RR = risk ratio. For ED visit and hospitali-
zation analyses, results were from a zero-inflated log-linear model.
a
Samples were matched on gender, race, and whether number of baseline days or nights were £ 14 for
the respective model.
b
Samples were matched on gender and race, including only those with a baseline event; Hispanic/Latino
participants were excluded from our analysis because of the absence of comparable health care use data
from matched control cases.
AJPH November 2016, Vol 106, No. 11

children’s likelihood of having a favorable
clinical profile of being in the well-controlled
category and at lower risk.
At the population level, reductions in
expensive urgent care use will result in sub-
stantial decreases in health care costs. Dem-
onstrating the favorable impact on costs of
asthma care models may assist in advocating
coverage by private health insurers.28
Our results are consistent with previous
research on asthma care coordination and
therefore add to a growing evidence base
for the effectiveness of this approach. The
cross-site evaluation of the MCAN phase I
sites, which employed many of the elements
of care coordination that were employed in
phase II, also used a pre–post comparison
to assess the impact of the communities’
initiatives on asthma outcomes.8 Phase I sites
saw a 56.1% decrease in participants’ mean
symptom days over 2 weeks (compared with
57.9% in phase II sites over 4 weeks) and
a 55.2% decrease in mean symptom nights
over 2 weeks (compared with a decrease of
68.9% in phase II sites over 4 weeks).
An evaluation of Yes We Can also showed
significant decreases in daytime and night-
time symptom days over 2 weeks (decreases
of 45.1% and 46.0%, respectively).7 Our
outcomes related to ED visits and hospitali-
zations were consistent with this previous
work.8,29 For example, participants in the
phase I sites reported 1.1 fewer ED visits over
12 months (compared with 2.0 among
phase II participants).8
In addition to our quantitative analysis,
a comprehensive cross-site qualitative eval-
uation assessed the implementation process,
the sustainability of these programs, and their
links to key policy and systems changes.12 The
ability to demonstrate positive outcomes of
the programs, such as those we have reported,
also played a role in promoting program
sustainment at all sites.30
Our results demonstrate the value of the
Clark adjustment methodology for creating
a control group using matched cases from
existing control cohorts. When we compared
pre–post changes in daytime and nighttime
asthma symptoms with the results with the
Clark adjustment, we saw that the program’s
effects on these 2 outcomes had been over-
estimated in the simpler analysis. The Clark
adjustment may be useful in future evalua-
tions of community-based studies, as well
November 2016, Vol 106, No. 11 AJPH
as implementation research, and pragmatic
studies when randomization to a usual care
condition is not feasible or acceptable.
A randomized design remains the gold
standard for isolating an intervention effect;
however, the Clark adjustment represents
a valid, quasiexperimental alternative that can
enhance the rigor of studies at little added
cost, while allowing studies to be conducted
under usual conditions that maximize ex-
ternal validity.25,31 In addition, evaluations
of community-based, asthma management
support programs that employ the Clark
adjustment may build a more compelling
case for reimbursement for asthma educator–
provided services.32
To maximize the value of this novel
methodology, we urge collaborative devel-
opment and maintenance of a mechanism by
which researchers and evaluators can easily
access relevant control group data, for example,
in a central online repository that offers an easy
to use process for using the data to form
a matched control group for a particular study
or evaluation. This control group data should
necessarily be regularly updated to reflect
changes in usual care for pediatric asthma.
Control cases should be demographically
and geographically representative of the
entire US population of children with asthma
and should represent typical settings (in-
cluding community clinics, academic
centers, and schools) in which children re-
ceive asthma care. Additionally, we recom-
mend that available control group data
align with the outcome measures for
asthma studies recommended by the Na-
tional Institutes of Health and the Agency
for Healthcare Research and Quality.33
Limitations
Several study limitations are noteworthy.
First, because the control cohorts that in-
cluded Latino children did not have data
on ED visits and hospitalizations reported in
a timeframe like ours (in the past year), we
excluded Latino participants from the Clark
adjustment analysis of the program’s effect
on these particular outcomes. Although our
analysis of the program’s effect on asthma
symptoms included all sites and participants,
excluding Latino participants from the 2
models of health care utilization meant that
all participants at the Puerto Rico site and
AJPH RESEARCH
nearly 70% at the LAUSD site (data not
shown) were not represented in the Clark
adjustment analysis for ED use and hospital-
izations. However, we found that within
the MCAN group, non-Latino children
had greater odds of reporting an ED visit at
follow-up than did Latino children in the study
(odds ratio [OR] = 1.44; 95% CI = 1.07, 1.94)
and similar odds for reporting a hospitalization
(OR = 1.08; 95% CI = 0.75, 1.54; data not
shown), suggesting that the program was at
least as effective among Latino children.
Second, loss to follow-up may have in-
troduced bias; however, the children who
dropped out had health characteristics that
were similar to the symptoms of those who
remained in the sample, and most dropouts
occurred in the LAUSD, where children
frequently switched schools. Third, we used
control group data collected as early as 2001,
when standard clinical management of asthma
may have been different; for example, the use
of long-term controller medications has in-
creased over time.34 Control group data from
an earlier time may, therefore, be different
from control group data collected contem-
poraneously with the MCAN interventions.
Similarly, control group data did not
represent the cities included in our trial,
and therefore any regional differences in
asthma morbidity or treatment are not
accounted for. In sum, our quasiexperimental
design did not eliminate all threats to internal
validity. Nonetheless, simulations with
Clark adjustment methodology demon-
strated that the estimates of program effects
it produces are within 2.4% of those using the
gold standard of a true control group.17
Last, our pre–post analysis accounted
for within-family correlation but ignored
within-site correlation. The small number
of sites made the estimation of the intersite
correlation either imprecise or not possible
for each outcome. The assumption of zero
intersite correlation does not affect estimates
but may slightly reduce the statistical power.
Public Health Implications
We conducted an evaluation of a pediatric
asthma care coordination model in 4 distinct
settings—neighborhoods, schools, outpatient
clinics, and a federally qualified health center—
in communities strongly affected by disparities
in asthma morbidity and mortality.
Janevic et al. Peer Reviewed Research 2017
AJPH RESEARCH
Using a novel statistical technique—a sim-
ulated control group made up of matched cases
from previous trials—to increase the internal
validity of this community-based effectiveness
study, we have provided compelling evidence
that this model can significantly reduce asthma
symptoms and ED visits. Expanding access
to care coordination services, for example, by
expanding third-party reimbursement, may
help reduce asthma disparities at the population
level.
CONTRIBUTORS
M. R. Janevic led the writing of the article. S. Stoll,
M. Wilkin, P. Song, A. Baptist, M. Lara, G. Ramos-
Valencia, T. Bryant-Stephens, V. Persky, K. Uyeda,
J. Kennedy Lesch, W. Wang, and F. Malveaux con-
ceptualized the article, contributed to the writing,
conducted the analysis, and interpreted the results. All
authors approved the final submitted version.
ACKNOWLEDGMENTS
Funding for this study came from the Merck Childhood
Asthma Network, Inc. (MCAN), a nonprofit 501(c)(3)
organization funded by the Merck Foundation.
A version of this study was presented at the American
Thoracic Society’s 2015 International Conference,
Denver, CO.
We would like to thank Kelsey Thome, Elizabeth
Tullis, and Ye Yang for their assistance with this article.
Note. Two authors (J. K. L., MCAN programs
manager, and F. J. M., MCAN executive director)
were Merck employees and played a role in the study
design; the interpretation of data; the writing of the article;
and the decision to submit the article for publication.
They do not, and are not permitted to, promote the
commercial products of Merck.
HUMAN PARTICIPANT PROTECTION
The University of Michigan institutional review board
designated the cross-site evaluation “not regulated”
(HUM00043931). Site-specific study procedures were
approved by review boards at the Los Angeles Unified
School District; University of Illinois, Chicago; Children’s
Hospital of Philadelphia; and the University of Puerto
Rico.
REFERENCES
1. Centers for Disease Control and Prevention. 2013
National Health Interview Survey (NHIS) data [2013
current asthma population estimates, current asthma
prevalence percents]. 2013. Available at: http://www.
cdc.gov/asthma/nhis/2013/data.htm. Accessed June 9,
2015.
2. Akinbami LJ, Moorman JE, Liu X. Asthma prevalence,
health care use, and mortality: United States, 2005–2009.
Natl Health Stat Report. 2011;(32):1–14.
3. Moorman JE, Akinbami LJ, Bailey CM, et al.
National surveillance of asthma: United States, 2001–
2010. Vital Health Stat 3. 2012;(35):1–58.
4. Alicea-Alvarez N, Swanson-Biearman B, Kelsen SG.
A review of barriers to effective asthma management in
Puerto Ricans: cultural, healthcare system and pharma-
cogenomic issues. J Asthma. 2014;51(1):97–105.
5. Basch CE. Asthma and the achievement gap among
urban minority youth. J Sch Health. 2011;81(10):606–613.
2018 Research Peer Reviewed Janevic et al.
6. Brown RS, Peikes D, Peterson P, Schore J. The
Promise of Care Coordination: Models That Decrease Hospi-
talizations and Improve Outcomes for Beneficiaries With
Chronic Illnesses. New York: National Coalition on
Care Coordination; 2009.
7. Thyne SM, Rising JP, Legion V, Love MB. The Yes
We Can Urban Asthma Partnership: a medical/social
model for childhood asthma management. J Asthma.
2006;43(9):667–673.
8. Mansfield C, Viswanathan M, Woodell C, et al.
Outcomes from a cross-site evaluation of a comprehensive
pediatric asthma initiative incorporating translation of
evidence-based interventions. Health Promot Pract. 2011;
12(6 suppl 1):34S–51S.
9. Coughey K, Klein G, West C, et al. The Child Asthma
Link Line: a coalition-initiated, telephone-based, care
coordination intervention for childhood asthma. J Asthma.
2010;47(3):303–309.
10. Woods ER, Bhaumik U, Sommer SJ, et al.
Community asthma initiative: evaluation of a qual-
ity improvement program for comprehensive asthma
care. Pediatrics. 2012;129(3):465–472.
11. Katzen A, Morgan M. Affordable Care Act oppor-
tunities for community health workers. Available at:
http://www.chlpi.org/wp-content/uploads/2013/12/
ACA-Opportunities-for-CHWsFINAL-8-12.pdf.
Accessed July 23, 2015.
12. Kelly RP, Stoll SC, Bryant-Stephens T, et al.
The influence of setting on care coordination for
childhood asthma. Health Promot Pract. 2015;16(6):
867–877.
13. Viswanathan M, Lux L, Lohr KN, et al. Translating
evidence-based interventions into practice: the design
and development of the Merck Childhood Asthma
Network, Inc. (MCAN). Health Promot Pract. 2011;
12(6 suppl 1):9S–19S.
14. Lara M, Bryant-Stephens T, Damitz M, et al.
Balancing “fidelity” and community context in the ad-
aptation of asthma evidence-based interventions in the
“real world.” Health Promot Pract. 2011;12(6 suppl 1):
63S–72S.
15. Liu AH, Zeiger R, Sorkness C, et al. Development
and cross-sectional validation of the Childhood Asthma
Control Test. J Allergy Clin Immunol. 2007;119(4):
817–825.
16. Allegrante JP. A tribute to Noreen M. Clark, 1943–
2013. Health Educ Behav. 2014;41(5):466.
17. Ko YA, Song PX, Clark NM. Declines with age in
childhood asthma symptoms and health care use. An
adjustment for evaluations. Ann Am Thorac Soc. 2014;
11(1):54–62.
18. To T, Gershon A, Wang C, Dell S, Cicutto L.
Persistence and remission in childhood asthma:
a population-based asthma birth cohort study.
Arch Pediatr Adolesc Med. 2007;161(12):
1197–1204.
19. Clark NM, Shah S, Dodge JA, Thomas LJ,
Andridge RR, Little RJ. An evaluation of asthma in-
terventions for preteen students. J Sch Health. 2010;80(2):
80–87.
20. Cabana MD, Slish KK, Evans D, et al. Impact of
physician asthma care education on patient outcomes.
Pediatrics. 2006;117(6):2149–2157.
21. Szefler SJ, Mitchell H, Sorkness CA, et al. Manage-
ment of asthma based on exhaled nitric oxide in addition
to guideline-based treatment for inner-city adolescents
and young adults: a randomised controlled trial. Lancet.
2008;372(9643):1065–1072.
22. Busse WW, Morgan WJ, Gergen PJ, et al. Ran-
domized trial of omalizumab (anti-IgE) for asthma in
inner-city children. N Engl J Med. 2011;364(11):
1005–1015.
23. Otsuki M, Eakin MN, Rand CS, et al. Adherence
feedback to improve asthma outcomes among inner-city
children: a randomized trial. Pediatrics. 2009;124(6):
1513–1521.
24. Schraufnagel DE, Blasi F, Kraft M, Gaga M, Finn PW,
Rabe KF. An official American Thoracic Society/
European Respiratory Society policy statement: dispar-
ities in respiratory health. Am J Respir Crit Care Med. 2013;
188(7):865–871.
25. Thorpe KE, Zwarenstein M, Oxman AD, et al. A
pragmatic–explanatory continuum indicator summary
(PRECIS): a tool to help trial designers. J Clin Epidemiol.
2009;62(5):464–475.
26. Krishnan JA, Lemanske RF Jr, Canino GJ, et al.
Asthma outcomes: symptoms. J Allergy Clin Immunol.
2012;129(3 suppl):S124–S135.
27. National Asthma Education and Prevention
Program. Expert Panel Report 3 (EPR-3): guidelines
for the diagnosis and management of asthma-summary
report 2007. J Allergy Clin Immunol. 2007;120(5 suppl):
S94–S138. [Erratum in J Allergy Clin Immunol.
2008;121(6):1330]http://dx.doi.org/10.1016/j.jaci.
2007.09.029
28. Isasi F, Tewarson H, Pandit S. Health Investments That
Pay Off: Strategies for Addressing Asthma in Children.
Washington, DC: National Governors Association
Center for Best Practices; 2015.
29. Centers for Disease Control and Prevention.
Table 5: asthma morbidity outcomes from the SFGH
YES WE CAN program pre- and post-intervention
design (n = 65). Available at: http://www.cdc.gov/
asthma/interventions/ywc_tbl5.htm. Accessed July
23, 2015.
30. Stoll S, Janevic M, Lara M, et al. A mixed-method
application of the program sustainability assessment
tool to evaluate the sustainability of 4 pediatric asthma
care coordination programs. Prev Chronic Dis. 2015;12:
E214.
31. West SG, Duan N, Pequegnat W, et al. Alternatives to
the randomized controlled trial. Am J Public Health. 2008;
98(8):1359–1366.
32. Centers for Disease Control and Prevention. Asthma
self-management education and environmental man-
agement: approaches to enhancing reimbursement.
Available at: http://www.cdc.gov/asthma/pdfs/
Asthma_Reimbursement_Report.pdf. Accessed July 21,
2015.
33. Busse WW, Morgan WJ, Taggart V, Togias A. Asthma
outcomes workshop: overview. J Allergy Clin Immunol.
2012;129(3 suppl):S1–S8.
34. Kit BK, Simon AE, Ogden CL, Akinbami LJ.
Trends in preventive asthma medication use among
children and adolescents, 1988–2008. Pediatrics. 2012;
129(1):62–69.
AJPH November 2016, Vol 106, No. 11
Copyright of American Journal of Public Health is the property of American Public Health
Association and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.