The effects of combining Web-based eHealth with telephone nurse case management for pediatric asthma control: a randomized controlled trial

David Gustafson, Meg Wise, Abhik Bhattacharya, Alice Pulvermacher, Kathleen Shanovich, Brenda Phillips, Erik Lehman, Vernon Chinchilli, Robert Hawkins, Jee-Seon Kim, David Gustafson, Meg Wise, Abhik Bhattacharya, Alice Pulvermacher, Kathleen Shanovich, Brenda Phillips, Erik Lehman, Vernon Chinchilli, Robert Hawkins, Jee-Seon Kim

Abstract

Background: Asthma is the most common pediatric illness in the United States, burdening low-income and minority families disproportionately and contributing to high health care costs. Clinic-based asthma education and telephone case management have had mixed results on asthma control, as have eHealth programs and online games.

Objectives: To test the effects of (1) CHESS+CM, a system for parents and children ages 4-12 years with poorly controlled asthma, on asthma control and medication adherence, and (2) competence, self-efficacy, and social support as mediators. CHESS+CM included a fully automated eHealth component (Comprehensive Health Enhancement Support System [CHESS]) plus monthly nurse case management (CM) via phone. CHESS, based on self-determination theory, was designed to improve competence, social support, and intrinsic motivation of parents and children.

Methods: We identified eligible parent-child dyads from files of managed care organizations in Madison and Milwaukee, Wisconsin, USA, sent them recruitment letters, and randomly assigned them (unblinded) to a control group of treatment as usual plus asthma information or to CHESS+CM. Asthma control was measured by the Asthma Control Questionnaire (ACQ) and self-reported symptom-free days. Medication adherence was a composite of pharmacy refill data and medication taking. Social support, information competence, and self-efficacy were self-assessed in questionnaires. All data were collected at 0, 3, 6, 9, and 12 months. Asthma diaries kept during a 3-week run-in period before randomization provided baseline data.

Results: Of 305 parent-child dyads enrolled, 301 were randomly assigned, 153 to the control group and 148 to CHESS+CM. Most parents were female (283/301, 94%), African American (150/301, 49.8%), and had a low income as indicated by child's Medicaid status (154/301, 51.2%); 146 (48.5%) were single and 96 of 301 (31.9%) had a high school education or less. Completion rates were 127 of 153 control group dyads (83.0%) and 132 of 148 CHESS+CM group dyads (89.2%). CHESS+CM group children had significantly better asthma control on the ACQ (d = -0.31, 95% confidence limits [CL] -0.56, -0.06, P = .011), but not as measured by symptom-free days (d = 0.18, 95% CL -0.88, 1.60, P = 1.00). The composite adherence scores did not differ significantly between groups (d = 1.48%, 95% CL -8.15, 11.11, P = .76). Social support was a significant mediator for CHESS+CM's effect on asthma control (alpha = .200, P = .01; beta = .210, P = .03). Self-efficacy was not significant (alpha = .080, P = .14; beta = .476, P = .01); neither was information competence (alpha = .079, P = .09; beta = .063, P = .64).

Conclusions: Integrating telephone case management with eHealth benefited pediatric asthma control, though not medication adherence. Improved methods of measuring medication adherence are needed. Social support appears to be more effective than information in improving pediatric asthma control.

Trial registration: Clinicaltrials.gov NCT00214383; https://ichgcp.net/clinical-trials-registry/NCT00214383 (Archived by WebCite at http://www.webcitation.org/68OVwqMPz).

Conflict of interest statement

The authors have no financial interests in the eHealth system evaluated here, although Gustafson, Wise, and Hawkins were lead members of the development team.

Figures

Figure 1
Figure 1
Comprehensive Health Enhancement Support System (CHESS) services for parent, case manager, and child. CM = case management.
Figure 2
Figure 2
Parent’s home page of the Comprehensive Health Enhancement Support System (CHESS) asthma module.
Figure 3
Figure 3
CONSORT diagram of sample pool, recruitment, and participation.
Figure 4
Figure 4
Mediational analyses. CHESS+CM = Comprehensive Health Enhancement Support System plus monthly nurse case management.
Figure 5
Figure 5
Percentage of active Comprehensive Health Enhancement Support System (CHESS) users by month.

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