Environmental Measure Aides Asthma Interventions

Delaney Gracy, MD, MPH

A newly developed Environmental Scoring System (ESS) proved useful in a variety of home-based asthma intervention programs despite differences in settings, staffing, populations, and administration.

The ESS was developed by the Massachusetts Department of Public Health to help address the highest asthma prevalence in adults among US states. Massachusetts is also confronting one of the highest percentage of children with uncontrolled asthma and the associated high rates of emergency department visits, hospital admissions and school absenteeism, according to rankings by the Centers for Disease Control and Prevention (CDC).

Zhao Dong, MS, ScD, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, and colleagues who tested the ESS in several community-based programs considered these healthcare challenges, and the efforts to address them.

"There is evidence that asthma disparities can be substantially reduced by comprehensive care, both through the health care system and through home-based intervention programs," they wrote.

The ESS yields a composite score ranging from 0 to 6 from a binary score of 0 or 1 for each of 6 asthma triggers: dust, mold, pests, smoke, pets, and chemicals. In preliminary assessments, the ESS was reduced at the end of a series of home visit interventions. The questions remained as to whether the ESS could be incorporated into various and differing intervention programs and relate to clinical outcomes.

"Given the large variability in the implementation of specific asthma programs and design of survey questions to collect information on asthma triggers, it is unclear whether ESS would be a good approach for measuring environmental triggers and predicting asthma outcomes across different programs and populations," Dong and colleagues wrote.

In an editorial accompanying the evaluation of the ESS, Delaney Gracy, MD, MPH, Chief Medical Officer, Children's Health Fund, New York, NY, emphasized the importance of developing and validating such tools.

"In a time when our health system is increasingly focused on quality measures, value-based care incentive models, and quantitative impact assessment, well-designed tools, methods and comparative values are keys to meaningful data and the assimilation of information that can drive change,” Gracy wrote.

Dong and colleagues evaluated the ESS in 6 community asthma intervention programs, including the Boston Public Health Commission Asthma Home Visit Program (BPHC), the Boston Children's Hospital Community Asthma Initiative (CAI), and Tufts Medical Center Floating Hospital for Children Asthma Prevention and Asthma Initiative (Tufts).

Among all participants, the completion of intervention visits was marked by an increase in the average of total scores on the Asthma Control Test, corresponding to reduction in symptoms, and a reduction in the number of emergency department visits and in ESS scores. The magnitude and statistical significance of the changes varied between programs, however.

Dong and colleagues found that statistically significant reduction in total ESS was primarily driven by reduction in the mold score in the BPHC and CAI programs.

"Nevertheless, total ES was able to capture the overall variability in environmental triggers over visits regardless of the performance of each individual score," they wrote.

All the studied programs improved asthma outcomes to varying degrees, and the ESS tool appeared to be widely implementable, without much variation of program and survey designs, Dong and colleagues indicated.

Gracy welcomed evidence that the measure could be useful to the intervention programs.

"This type of tool has the potential to be very important in creating needed cross-program comparisons, setting benchmarks of success, accumulating impact data to support intervention reimbursement, and facilitating the impact assessment of individual programs," Gracy wrote.

The study, "Evaluation of the Environmental Scoring System in Multiple Child Asthma Intervention Programs in Boston, Massachusetts," was published online in the American Journal of Public Health.

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