Patient Advocates for Low-Income Adults with Moderate to Severe Asthma: A Randomized Clinical Trial

Abstract

Background: Few interventions have targeted low-income adults with moderate to severe asthma despite their high mortality.

Objective: To assess whether a patient advocate (PA) intervention improves asthma outcomes over usual care (UC).

Methods: This 2-armed randomized clinical trial recruited adults with moderate to severe asthma from primary care and asthma-specialty practices serving low-income neighborhoods. Patients were randomized to 6 months of a PA intervention or UC. PAs were recent college graduates anticipating health care careers, who coached, modeled, and assisted participants with preparations for asthma-related medical visits, attended visits, and confirmed participants' understanding of provider recommendations. Participants were followed for at least a year for patient-centered asthma outcomes: asthma control (primary outcome), quality of life, prednisone requirements, emergency department visits, and hospitalizations.

Results: There were 312 participants. Their mean age was 51 years (range, 19-93 years), 69% were women, 66% African American, 8% Hispanic/Latino, 62% reported hospitalization for asthma in the year before randomization, 21% had diabetes, and 61% had a body mass index of 30 or more. Asthma control improved over 12 months, more in the intervention group (-0.45 [95% CI, -0.67 to -0.21]) than in the UC group (-0.26 [95% CI, -0.53 to -0.01]), and was sustained at 24 months but with no statistical difference between groups. The 6-month rate of emergency department visits decreased in the intervention (-0.90 [95% CI, -1.56 to -0.42]) and UC (-0.42 [95% CI, -0.72 to -0.06]) groups over 12 months. The cost of the PA program was $1521 per patient. Only 64% of those assigned had a PA visit.

Conclusions: A PA may be a promising intervention to improve and sustain outcomes in this high-risk population if expanded to address factors that make keeping appointments difficult.

Keywords: Asthma; Asthma control; Asthma-related quality of life; Health literacy; Inner-city asthma; Patient advocate.

Conflict of interest statement

Conflicts of interest: A. J. Apter is a consultant for UpToDate and an associate editor of the Journal of Allergy and Clinical Immunology. K. H. Morales owns stock in Altria Group Inc, British American Tobacco PLC, and Phillip Morris International Inc. The rest of the authors declare that they have no relevant conflicts of interest.

Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Figures

FIGURE 1.

Participant flow diagram (Consolidated Standards of Reporting Trials). *Attendance at participating clinics was reviewed daily. Thus, some patients’ records were reviewed multiple times. †Contacting patients was time-consuming; we scanned clinic records to meet patients when they came for an appointment and could be approached.

FIGURE 2.

Time from randomization to data collection by treatment group. There were 5 data collection sessions scheduled for months 0, 3, 6, 9, and 12 and represented by vertical lines. In the figure we have labeled with numbers when the collection actually took place, indicating a spread of time when collection occurred. For example, the third data collection was to occur at month 6 but actually occurred between months 3 and 21 (for 1 outlier) for those assigned a PA.