Using proven treatments consistently has been the key to successfully managing asthma, says Dr. Mona Mansour.
New Approaches – Inside and Outside the Hospital – Help Children Keep Severe Asthma in Check
Cincinnati is a city with many great features – beautiful neighborhoods, a reasonable cost of living, stable employment, a world-class symphony, zoo, and more.
Its geography, however, places it at the environmentally tricky confluence of low-lying valleys, smog-trapping hills and three heavily traveled interstate highways. That makes it an area ripe for asthma.
The region’s overall rate of pediatric asthma is more than twice the national average; in some urban-core neighborhoods, 10 times the national rate. Our doctors and nurses saw daily evidence of this as kids in asthma distress showed up in our Emergency Department.
They took action. And what they’ve done has allowed everyone to breathe a little easier.
Since 2008, our asthma-related hospital admission rate and emergency department visits for children covered by Medicaid have declined more than 30 percent. The improvement didn’t come from a breakthrough medication or genetic discovery. The city’s pollution levels did not drop significantly. The shift came by applying the science of quality improvement. Teams of caregivers started making small changes, and implementing them consistently over time.
“We’ve been working at this for several years. Most of our work has been about, ‘How do we change systems to deliver the interventions that we already know work?’” says Mona Mansour, MD, MS, director of Primary Care at Cincinnati Children’s.
Focus on Tough Cases
They assembled a medical team of people from every area in the hospital that works with kids who have asthma. The team focused first on children and families who made repeated hospital visits for the condition. Hospital staff also took a hard look at themselves and how they cared for those children.
“The goal was to get everybody on the same page when treating asthma,” says Carolyn Kercsmar, MD, director of the Asthma Center. The team examined every possible way they could improve outcomes for kids with asthma; the list of improvements they have made is long, and growing.
Taking It to the Streets
Outside the hospital, our researchers have been studying the impact of traffic and air pollution, and pollutants in the home environment, on asthma.
One environmental factor that’s worsening asthma rates is diesel exhaust. Diesel emissions produce tiny particles of harmful chemicals that can settle deep into the lungs.
“They are small, nasty particles,” says Patrick Ryan, PhD, an environmental epidemiologist in the Division of Biostatistics and Epidemiology. “They are worse than other pollutants because near the source, such as trucks and buses, most (of the particles) are ultra-fine.”
Ryan was one of six researchers who conducted the Traffic-Related Air Pollution (TRAP) study, published last March in The Journal of Pediatrics. Led by Nicholas Newman, DO, MS, and Robert Kahn, MD, in our Division of General and Community Pediatrics, the study included 758 Cincinnati children ages 1 to 16. It examined the effects on asthma rates and hospital readmissions on children exposed to factors such as tobacco smoke and traffic pollution; the study also factored in a child’s socioeconomic situation. The results showed that although the effects differed among black and white children, the factors contributed significantly to asthma in each group.
The TRAP study is just one of many explorations into the environmental and socioeconomic factors that contribute to asthma. Our doctors also have linked high rates of emergency room visits for asthma to kids who live in substandard housing conditions, where exposures to mold, dust mites and cockroach dander aggravate their health.
Their work is further evidence that improving children’s health must include improving the communities in which they live, says Newman. “Sometimes, the answer isn’t just a prescription, but a system. I cannot write a prescription for a new home or clean air.”