The P&S Journal: Spring 1998, Vol.18, No.2
Harlem Lung Center
New York City has the dubious distinction of having the highest asthma mortality rate in the United States, and Harlem is one of the city's asthma hot spots, with a hospitalization rate for asthma triple that of the rest of New York City. Now, the Harlem Lung Center, based at Harlem Hospital Center, is developing strategies to control asthma, including a clinical intervention that uses community health workers and peer educators to help asthma patients better manage their disease.
"Our program of research aims to understand risk factors of asthma and to test intervention strategies to address those factors," says Dr. Jean Ford, assistant professor of medicine and public health and chief of pulmonary medicine at Harlem Hospital.
To help develop appropriate clinical interventions, researchers from the Harlem Lung Center conducted a study of the risk factors for asthma in Harlem. Dr. Sally Findley, principal investigator, relied on data from the Harlem Health Survey, which looked at risk factors for morbidity and mortality in a random sample of Harlem's adult residents. They found that the prevalence of a lifetime diagnosis of asthma among adult Harlem residents was 13.9 percent, almost 2.96 times higher than in the general population of African-Americans. In Harlem and the United States, the strongest predictor of asthma was a low to moderate income level, especially among the working poor. In Harlem, asthma is also associated with exposure to rats and mice, environmental tobacco smoke, experience of chronic depression, and traumatic events in the family or community.
Another study, headed by Dr. Ford, attempted to identify the risk factors for emergency room visits for asthma in Harlem by surveying patients visiting the emergency room for asthma and physicians who take care of asthmatic patients from Harlem. "We found that there are significant operational problems in our clinics, as well as social problems that get in the way of the management of asthma," says Dr. Ford. For instance, the study found that most patients do not expect to be able to reach a health care provider when they are sick from asthma, and most do not call a health care provider before visiting the emergency room. Under treatment also appears to be an issue: Only 24 percent of patients coming to the emergency department said they used corticosteroids to manage their asthma (including 7 percent who were on inhaled steroids). The study also found that a large number of asthmatic patients are receiving therapies for asthma that are not consistent with current guidelines for practice-a problem that other studies have also identified in other communities. "We have to develop a system that is user-friendly, where patients have access to providers and where the most effective asthma control strategies are employed," says Dr. Ford, who is also a member of the National Heart, Lung, and Blood Institute's expert panel on asthma management. "This includes listening to our patients, making sure that their concerns are addressed, and ensuring that they receive the information necessary to make informed decisions about their asthma. But the resources for effective asthma education largely do not exist in the clinics that serve urban populations of color."
Based on the results of these studies, investigators at the Harlem Lung Center designed the REACH (Reducing Emergency Asthma Care in Harlem) program. The study will enroll 350 adult patients who come to the Harlem Hospital emergency department with acute asthma more than once during a one-year period (as of late December, 287 patients were enrolled). The patients are randomly assigned into one of two groups: One group receives the "usual" care for asthma, according to NIH guidelines, and the other receives the same care plus support from community health workers and volunteer peer educators. The peer educators-all of whom have asthma and live in the community-receive training in skills needed for effective asthma management. They participate in patient support groups, where they share their knowledge and skills (for example, techniques for the use of metered dose inhalers, spacers, and peak flow meters) with other asthmatic patients in the intervention group of the study. The United Hospital Fund of New York supports the training of the volunteer peer educators.
The community health workers are Harlem Hospital employees who are specially trained to identify and address barriers to care for patients with asthma and to contact patients within days following their visit to the emergency department. Thereafter, the community health workers collaborate with the clinical staff and peer educators to maintain ongoing therapeutic relationships with the patients in the intervention group of the study. This may include a home visit to reinforce the educational message received during the clinical encounter. The community health workers also assess social barriers, including the need for referrals to Medicaid and housing services.
Additional studies at the Harlem Lung Center are focusing on other aspects of asthma. For instance, the REACH study is also investigating the contribution of genetic factors to asthma severity and responsiveness to pharmacotherapy. In addition, the Lung Center has become one of six centers of the nationwide Asthma Clinical Research Network (funded by the National Heart, Lung, and Blood Institute). This will give patients access to state-of-the-art technology for the clinical assessment of asthma and enable a precise characterization of risk factors for asthma in Harlem and the development of appropriate intervention strategies.
Researchers at the Harlem Lung Center are Darlene De Graffinreidt, Sally Findley, Jean Ford, Vince Hutchinson, Diane McLean, Ilan Meyer, Sami Nachman, and Lynne Richardson.