Improving Asthma Outcomes and Self-management Behaviors of Inner-city
Children

A Randomized Trial of the Health Buddy Interactive Device and an Asthma
Diary

Author Information
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#aainfo>   Sylvia
Guendelman, PhD; Kelley Meade, MD; Mindy Benson, PNP; Ying Qing Chen, PhD;
Steven Samuels, PhD
Background  Asthma is an important cause of morbidity, absence from school,
and use of health services among children. Computer-based educational
programs can be designed to enhance children's self-management skills and to
reduce adverse outcomes.
Objective  To assess the effectiveness of an interactive device programmed
for the management of pediatric asthma.
Design  A randomized controlled trial (66 participants were in the
intervention group and 68 were in the control group).
Setting  Interventions conducted at home and in an outpatient hospital
clinic.
Participants  Inner-city children aged 8 to 16 years diagnosed as having
asthma by a physician.
Intervention  An asthma self-management and education program, the Health
Buddy, designed to enable children to assess and monitor their asthma
symptoms and quality of life and to transmit this information to health care
providers (physicians, nurses, or other case managers) through a secure Web
site. Control group participants used an asthma diary.
Main Outcome Measures  Any limitation in activity was the primary outcome.
Secondary outcomes included perceived asthma symptoms, absence from school,
any peak flow reading in the yellow or red zone, and use of health services.
Results  After adjusting for covariates, the odds of having any limitation
in activity during the 90-day trial were significantly (P = .03) lower for
children randomized to the Health Buddy. The intervention group also was
significantly (P = .01) less likely to report peak flow readings in the
yellow or red zone or to make urgent calls to the hospital (P = .05).
Self-care behaviors, which were important correlates of asthma outcomes,
also improved far more for the intervention group.
Conclusion  Compared with the asthma diary, monitoring asthma symptoms and
functional status with the Health Buddy increases self-management skills and
improves asthma outcomes.
Arch Pediatr Adolesc Med. 2002;156:114-120
POA10257
ASTHMA IS an important cause of morbidity, absence from school, and use of
health services among children in the United States. Approximately 4.8
million children have asthma, and prevalence rates are increasing. 1
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r1> , 2
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r2>  More and more,
asthma is being considered an "ambulatory care sensitive condition" for
which hospitalizations can be avoided with appropriate and timely outpatient
care. 3 <http://archpedi.ama-assn.org/issues/v156n2/rfull/#r3> (p245), 4
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r4>  National guidelines
for clinicians in 1991 5
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r5>  and revised in 1997
6 <http://archpedi.ama-assn.org/issues/v156n2/rfull/#r6>  recommended the
use of written asthma plans, with medications to be initiated or increased
for exacerbations to avoid unnecessary hospitalizations. Additional
preventive interventions 7-9
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r7>  focus on
environmental modifications, such as removing dust mites or reducing
cockroach exposure, while others 10-13
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r10>  are directed at
educating families and achieving behavioral changes and skills management.
Effective management of pediatric asthma requires involvement of children
and their families, who learn to: (1) alter the child's activities and home
environment contingent on the child's particular sensitivities; (2) adjust
the child's medications, depending on the child's physiologic state; and (3)
communicate with the child's clinician to tailor the treatment regimen. 6
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r6> , 14
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r14>  The National Heart,
Lung, and Blood Institute (NHLBI) recommends that patients monitor their
asthma with a daily diary or a periodic self-assessment sheet before a visit
to the physician to capture their impression of whether the asthma is
controlled and to assess self-management skills. 6
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r6>
Several self-management programs that seek to enhance the child's and the
family's efficacy in asthma care have been developed. While education
programs delivered to parents and children by health professionals in health
care settings can improve asthma management skills, these programs often
imply large expenditures of staff time and operational challenges. 14
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r14>  Furthermore, life
strains and health care access barriers refrain many poor families from
participating in teaching sessions and finding the time and resources
required to manage asthma. 15
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r15> , 16
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r16>
More recently, interactive computer-based educational programs, such as
Asthma Command 12 <http://archpedi.ama-assn.org/issues/v156n2/rfull/#r12>
and Asthma Control, 14
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r14>  have appeared.
Unlike traditional methods, these programs do not rely on the interaction
between the child and a health professional. Randomized trials 12
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r12> , 14
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r14>  of these software
programs in clinic settings have demonstrated mixed results in their ability
to affect asthma management behaviors.
Another approach, the use of interactive health communication devices,
through its information and decision support, has the potential to change
behaviors and thereby improve patient quality of life and reduce the burden
of illness. 17 <http://archpedi.ama-assn.org/issues/v156n2/rfull/#r17>
These devices work on the premise that the best method of affecting
behaviors is to learn specific behaviors in a safe and stimulating
environment while trying them out in a real environment. 18
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r18>
We evaluated the efficacy of a new interactive device, the Health Buddy,
programmed for the care of inner-city children with asthma (children were
defined as those aged 8-16 years in this study). This home-based device
monitors asthma symptoms, quality of life, and self-care, and sends
information through a secured Web site to the health care provider
(physicians, nurses, or other case managers). We postulated that by allowing
children an opportunity to acquire knowledge about asthma and symptom
recognition and receive immediate feedback on their decisions and behaviors,
asthma symptoms among Health Buddy users would decrease. 18
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r18>  The continued use
of the Health Buddy would also help to increase self-care behaviors, which
in turn would reduce symptoms.



PARTICIPANTS AND METHODS



SAMPLE AND STUDY PROTOCOL

A randomized controlled trial of a computerized interactive asthma
self-management and education program, the Health Buddy, was conducted in
the primary care clinic at Children's Hospital Oakland, Oakland, Calif. This
clinic is a comprehensive pediatric health center and resident teaching
facility that serves a predominantly Medicaid-insured population. Children
were eligible for inclusion in the study if they were between the ages of 8
and 16 years, had an English-speaking caregiver, had a telephone at home,
and were diagnosed as having persistent asthma following NHLBI clinical
practice guidelines. 13
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r13>  Patients with 2 or
more emergency department (ED) visits and/or at least 1 inpatient admission
during the year before the study were identified for possible recruitment
through hospital administrative lists. All other children were recruited at
the time of their scheduled clinic appointment for either a health care
maintenance or an illness visit, including asthma. Patient lists were
reviewed the day before the clinic appointment, and all children with asthma
as the reason for the visit were screened for study eligibility. Potential
recruits were also referred by the attending physicians at the hospital.
Patients were excluded if they were involved in other asthma or drug
efficacy studies, if they were involved in research that required behavior
modification, or if they had mental or physical challenges that made it
difficult to use the Health Buddy. Children with comorbid conditions that
could affect their quality of life were also excluded.
Approximately 500 children aged 8 to 16 years attending the clinic had
asthma, not necessarily persistent. A screening tool that included the
criteria previously described was used, and 136 children identified as
eligible were approached for participation in the study between April 8,
1999, and July 5, 2000. Families were told that the purpose of the study was
to find out if keeping track of asthma symptoms at home would help the
families and physicians to manage the child's asthma better and that 2
methods of keeping track were being evaluated. The nurse coordinator (M.B.)
obtained informed consent for 134 children and their parents or legal
guardians. Two families declined to participate because of time constraints.
After consent was given, the nurse conducted a standardized teaching session
in which each participating child was given a peak flow measuring device and
instructed on proper technique and how to establish his or her personal
best. In addition, this teaching session also covered green-yellow-red zone
determination and the appropriate use of medications and of health care
services. Subsequently, the nurse coordinator administered the baseline
questionnaire to the child and the accompanying family member, and gave each
family a $20 incentive for completing the interview. Following the
interview, the nurse opened a sealed envelope containing the treatment
assignment and children were randomized to either the intervention (n = 66)
or the control (n = 68) group and given instructions on how to use the
assigned tracking method to record their peak flow readings and symptoms.
(Sample size calculations were based on a comparison of 2 management
approaches by Lieu et al, 13
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r13>  who observed mean
numbers of episodes of children's cough and other asthma symptoms in the
previous 2 months of 2.43 for intensively treated children and 3.08 for
controls, with a pooled SD of 1.25. To detect a similar difference with 85%
power, a 2-sided 2-sample t test requires 67 subjects per group.)
INTERVENTION

The Health Buddy is a personal and interactive communication device
developed by Health Hero Network, Mountain View, Calif. The device is
connected to a home telephone and can be programmed to present questions and
information on a screen and to record responses. The nurse coordinator sends
a set of queries each day using a standard Internet browser. The patient
answers the queries, called dialogues, by pressing 1 of 4 buttons. The
device automatically telephones a data processing center at night, which
processes the responses and publishes them to a secure Web site the next
day, from which the nurse coordinator reviews the information. Three of us
(S.G., K.M., and M.B.) developed a protocol with a team of software
programmers and asthma specialists at Health Hero Network. Following the
NHLBI clinical practice guidelines, 6
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r6>  the protocol
consisted of 10 questions about asthma symptoms, peak flow readings, use of
medications and of health services, and functional status, such as school
attendance and activity limitations. Each answer to a question received
immediate feedback from the device: praise for a correct answer or
encouragement to try again. In addition to the core inmutable questions,
asthma facts and trivia questions, which changed daily, were included to
peak children's curiosity and enhance learning. The dialogues were designed
for a third-grade reading level. The following excerpt illustrates the
dialogue between the child and the Health Buddy:
Hi! Thanks for hanging out with your Health Buddy today.
Your questions are now ready for you.
Do you know how much a McDonald's hamburger cost in 1963? (Trivia)
Have you had any coughing or wheezing in the last day?
If child answers Yes:
This could be a sign that your asthma is acting up. You may need to take
your Albuterol as directed by your doctor when you are coughing and
wheezing.
If No:
That's great! You must be taking your preventor [sic] medicine.
Did you miss out on any sports, exercise, or play yesterday because of your
asthma?
If child answers Yes:
Sorry to hear you missed out on some fun. If your asthma acts up while doing
sports, exercise, or play, please talk to your doctor about this. It is
important to know what activities might trigger your asthma.
If No:
That is fantastic! Sports and exercise are fun and healthy.
By protocol, children had to access the device once a day, preferably at a
regular time. The children were encouraged to access and interact with the
Health Buddy on their own. Parents were instructed on its use at the first
visit and requested to be available to supervise its use only when the child
indicated a need for help. Before implementation, the protocol was pilot
tested among children of comparable age to the study children, but of higher
socioeconomic status.
The comparison method for monitoring symptoms was a standard asthma diary.
13 <http://archpedi.ama-assn.org/issues/v156n2/rfull/#r13>  The diary
allowed patients to log their symptoms and to monitor peak flow, medication
use, and restricted activity.
Families whose children were assigned to the Health Buddy were given a
demonstration on how to use the device and explained how to install it at
home. The nurse coordinator called those families whobecause they had not
installed the device properlywere not transmitting information through the
Web to review the installation instructions. No further telephone contact
was established with the participants other than to schedule follow-up
appointments. All children were asked to return for 2 follow-up visits at 6
and 12 weeks. At each follow-up visit, families were interviewed by the
nurse coordinator and given a standardized teaching session that reinforced
peak flow measurement, compliance with medicines, and tracking of symptoms.
Families received a participation incentive, and children were asked to hand
in their health diaries. They were also examined by a physician. Medical
management remained at the discretion of the physician and followed NHLBI
guidelines. Because all participants were diagnosed as having persistent
asthma before the study, they were prescribed a daily prevention medication
and a quick-relief medication to use as needed, and were requested to
measure peak flows. Treatment regimens were kept constant between visits and
changed at the follow-up visits only if there was a significant
deterioration or improvement in asthma symptoms.
MEASURES

The measures for this study were obtained from the interviews that the nurse
coordinator conducted with the child and the primary caregiver at each
visit. The questionnaire was designed according to well-validated
instruments. 19-21 <http://archpedi.ama-assn.org/issues/v156n2/rfull/#r19>
The self-reported information at the follow-up visits was validated against
the nurse's knowledge of the patients and assisted by a medical record
review at the time of the visit.
The primary outcome measure was limitation in activity, which referred to
the occurrence of restricted physical activity, such as exercise or play,
due to asthma. This measure has been a valid indicator of functional status
in other studies. 19 <http://archpedi.ama-assn.org/issues/v156n2/rfull/#r19>
Secondary outcome measures consisted of other self-reported perceived asthma
symptoms in the 14 days before the interview, any missed school days because
of asthma in the 6 weeks before the interview, any peak flow reading in the
red or yellow zone in the 14 days before the interview, and use of health
services because of asthma in the past 6 weeks. The symptom indicators
included the occurrence of chest tightness, coughing, shortness of breath or
wheezing, and trouble sleeping at night as a result of coughing or wheezing.
Peak flow readings in the yellow or red zone were based on the best of 3
readings obtained by the patient on the peak flow meter, a measure of the
maximum flow rate that can be generated during a forced expiratory maneuver.
Although peak flow meters are criticized because they tend to measure the
amount of obstruction in the larger airways only, and often compliance with
its use is low, they provide the only readily available objective means of
patient monitoring at home. 22
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r22> , 23
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r23>  Peak flow readings
in the yellow zone (50%-80% of the personal best) indicated that the child's
asthma was not under sufficient control and required additional medication.
Readings in the red zone (<50% of the personal best) signaled a severe
asthma exacerbation. Children were instructed to take daily peak flow
measurements and to record them in their diary.
Use of health services was measured by the presence of hospital admissions,
ED visits, or urgent calls to the hospital.
Self-care behaviors assessed the degree of compliance with prescribed
medications and with the use of the Health Buddy or asthma diary, as
appraised by the main caregiver. These self-care behaviors, along with the
asthma outcomes and demographic characteristics, were assessed through a
30-minute questionnaire consisting predominantly of close-ended questions.
The questionnaires were administered at baseline and at the 2 follow-up
visits at 6 and 12 weeks. In addition, tracking with the Health Buddy or
asthma diary was recorded by each child. At baseline, children were
classified according to NHLBI practice guidelines into mild persistent,
moderate persistent, or severe persistent asthmatic categories. These levels
of asthma severity are based on symptom frequency and severity, exercise
tolerance, ED visits, hospitalizations, and current medications. 13
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r13>
DATA ANALYSIS

chi2 Tests, Fisher exact tests, and 2-sample t tests were used to compare
the 2 study groups for demographic characteristics (at baseline), asthma
outcomes, and self-care behaviors at baseline and at the 2 follow-up visits.
Logistic regression was used to model the main effects of treatment. The
results with P.05 were justified as significant. Because observations at the
2 follow-up visits were not independent, the technique of generalized
estimating equations 24
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r24>  was used to
estimate treatment effects. For each outcome, the baseline results, the
asthma severity score, and the visit were included as covariates. The effect
is presented as the intervention odds ratio, which is the ratio of odds of
an outcome in the Health Buddy group to the odds of the same outcome in the
asthma diary group, adjusted for visit, baseline responses, and asthma
severity. A generalized estimating equation was also used to evaluate the
effects of self-care behaviors on selected asthma outcomes, adjusted for
visit, other behaviors, and treatment effects. Interaction terms between
treatment and time were evaluated for all outcomes. Missing data were
handled by assuming missing at random. 25
<http://archpedi.ama-assn.org/issues/v156n2/rfull/#r25>



RESULTS



The Health Buddy and asthma diary groups had similar demographic
characteristics, illness history, home environment, and use of health
services at baseline, as expected from the random assignment ( Table 1
<http://archpedi.ama-assn.org/issues/v156n2/fig_tab/poa10257_t1.html> ).
Follow-up of participants occurred similarly across all 4 seasons in the 2
groups. Ninety-six percent of the participants (63 in the Health Buddy group
and 65 in the asthma diary group) returned for the first follow-up visit at
6 weeks and 91% (62 in the Health Buddy group and 60 in the asthma diary
group) returned for the follow-up visit at 12 weeks. Reasons for dropping
out of the study included moving out of the area (n = 3) or life crises
experiences (n = 4). Five families who dropped out were unavailable for
contact. Baseline characteristics of children who did and did not complete
the trial did not differ.
Children in both arms of the study reported a decrease in asthma symptoms
and a decrease in peak flow readings in the yellow or red zone at 6 and 12
weeks compared with baseline ( Table 2
<http://archpedi.ama-assn.org/issues/v156n2/fig_tab/poa10257_t2.html> ).
Although almost half of the children did not use a peak flow device at
baseline, at the 6-week follow-up visit, 85% of the participants reported
that they used it. Significantly fewer children randomized to the Health
Buddy had peak flow readings in the yellow or red zone during the 14 days
before the 6-week follow-up visit compared with children randomized to the
asthma diary (P = .02).
After adjusting for time and baseline covariates, children in the Health
Buddy group were less likely to report limitation in activities.
Furthermore, the odds of having peak flow readings in the yellow or red zone
were significantly lower for children randomized to the Health Buddy.
The use of health services did not vary significantly between the 2 groups,
except for urgent calls. The odds of an urgent call with the Health Buddy
was 0.43 of the odds of an urgent call with the asthma diary, after
adjusting for time and baseline covariates ( Table 3
<http://archpedi.ama-assn.org/issues/v156n2/fig_tab/poa10257_t3.html> ). No
significant interactions between treatment and time were found for any
outcome.
For self-care behaviors, at 12 weeks children with the Health Buddy were
significantly more likely to take asthma medicines without reminders (P =
.04) and to use the Health Buddy with few or no reminders (P = .001) ( Table
4 <http://archpedi.ama-assn.org/issues/v156n2/fig_tab/poa10257_t4.html> ).
These self-care behaviors were significant correlates of asthma outcomes
after adjusting for treatment effects, time, and other self-care behaviors
(data not shown). Children who always used the Health Buddy or the asthma
diary without a reminder were significantly less likely to report coughing
or wheezing (odds ratio, 0.70; 95% confidence interval, 0.50-0.99) and had a
lower probability of having a limitation in activities (odds ratio, 0.70;
95% confidence interval, 0.50-0.90).
On average, during the 90-day trial period, 77% of the children used their
tracking system 3 days a week or more (59 [89%] of the 66 children in the
Health Buddy group vs 44 [65%] of the 68 children in the asthma diary group;
P<.001). The daily compliance rates declined as time progressed for both
treatment arms, but the decline was faster in the early stages of the
intervention for the asthma diary group (P = .0004, data not shown). An
analysis of time effects adjusted for treatment assignment (data not shown)
indicated that asthma symptoms and use of health services declined markedly
from one visit to the next for both groups.
We found no strong indication that the correlation between asthma diary and
Health Buddy responses and interview responses differed between the 2 study
groups. However, responses across visits seemed to be more stable for the
Health Buddy group.



COMMENT



This randomized trial conducted in an inner-city ambulatory care clinic
assessed the efficacy of the Health Buddy for self-management of persistent
asthma in children. We compared the effects of this device, which is a
nonintrusive interactive system that linked patients at home to the nurse
coordinator, with the effects of the standard asthma diary.
One of the goals of asthma control is to be free of activity limitation.
Children randomized to the Health Buddy had 48% lower odds of reporting a
limitation in activity after adjusting for baseline response, asthma
severity, and time. Children randomized to the Health Buddy also had
significantly lower odds of reporting a peak flow reading below 80% of their
personal best (red or yellow zone) after adjusting for covariates. Despite
missing data for this outcome, especially among children in the asthma diary
group, the higher rate of children with peak flow readings remaining in the
green zone among Health Buddy users is an indicator of improved control of
asthma symptoms and improved response to anti-inflammatory therapy.
Spirometry was not available for the study.
The percentage of children randomized to the Health Buddy who used the
device was, until near the end of the study, much larger than the percentage
of children who kept diaries. This leads to the following question: Was
self-monitoring, per se, associated with improved outcomes? The analysis of
this question does not benefit from randomization. Children who used the
Health Buddy or asthma diaries with few or no reminders were far less likely
to report coughing or wheezing and to have a limitation in activities.
Several children reported after the trial that they liked the Health Buddy
because it was fun and it reminded them to take their medicines. In
contrast, several children who received the asthma diary reported that they
either lost it or forgot to log information in it. Many children who kept
diaries reported that they had forgotten to take their medicines. These
results occurred despite the decline in Health Buddy use and suggest that
children with the Health Buddy device learned management skills that helped
them to comply with their treatment and medication regimens.
The short duration of the trial and the small sample size did not yield
marked group differences in the occurrence of ED visits or hospital
admissions. However, after adjusting for time, asthma severity, and urgent
calls before the baseline interview, the risk of urgent calls was twice as
high for children assigned to the asthma diary group. This finding would
suggest a weaker autonomy in the management of asthma for the child and the
family assigned to the control arm of the study.
Despite the marked advantages of the Health Buddy monitoring system over the
standard asthma diary, use in both groups declined as children approached
the end of the trial. These declines probably reflect the anticipated end of
the study, the lack of perceived additional benefit of monitoring, and, for
Health Buddy users, saturation with the educational messages. This trend
would suggest that the benefits of self-monitoring with a device like the
Health Buddy might be especially strong at critical care management times
(eg, at the start of care for asthma or after an acute asthma exacerbation,
an ED visit, a hospitalization, or a step up in severity class).
Although asthma symptoms declined more for the Health Buddy group, symptoms
also declined for the asthma diary group. This decline may have partly
resulted from the consistent standardized asthma education given to children
in both arms of the study and the availability of the nurse coordinator,
which was a new intervention to the clinic. Furthermore, because this
intervention took place shortly after dissemination of the revised NHLBI
asthma guidelines, the findings may reflect enhanced care by the hospital
staff resulting from adherence to these guidelines.
The results must be interpreted with caution given the study limitations.
Despite the attempts by the nurse coordinator to check the self-reported
data at each interview, there may have been some case ascertainment bias.
Furthermore, children in the asthma diary group who filled out diaries
retrospectively may have overstated compliance. In addition, some of the
results were leaning toward significance, suggesting that there might have
been a lack of power to detect significant differences because of a small
sample size. Further research is needed to assess the effects of this device
on the behavior of health care providers. At the time of the study,
implementation graphs and other data outputs were not readily or
consistently available for providers. The system now has the capacity to
summarize longitudinally patient data on symptoms, health behaviors, and
knowledge levels. Research is also warranted to evaluate individual
differences in self-management skills, outcomes, and saturation points
associated with Health Buddy use among inner-city children. A longer
follow-up study could determine whether changes in asthma self-care
behaviors and symptoms persist over time. The cost of using the Health Buddy
technology and service consists of one-time implementation fees and patient
activation fees, which vary by disease and by patient volume. The average
monthly cost per patient ranges from $20 to $45. Additional costs involve
the case manager and depend on caseload. A cost-effectiveness analysis
focusing on ED visits, hospitalizations, and other burdens to the health
care system would help to determine if the extra expense of the computer
telephone system is worth the observed improvement vs close follow-up by the
nurse case manager alone. Nevertheless, the significant group effects in
self-care behaviors and asthma outcomes found with the Health Buddy suggest
that such easy-to-use devices empower children to provide more of their own
care, while perhaps reducing the burden of illness on the family and on the
health care system.



Author/Article Information


From the Maternal and Child Health Program (Drs Guendelman and Samuels), the
Division of Health Policy and Management (Dr Guendelman), and the Division
of Biostatistics (Dr Chen), School of Public Health, University of
California, Berkeley; and Ambulatory Services, Children's Hospital Oakland,
Oakland, Calif (Dr Meade and Ms Benson).

Corresponding author and reprints: Sylvia Guendelman, PhD, Division of
Health Policy and Management, University of California, Berkeley, 404 Earl
Warren Hall, 7360, Berkeley, CA 94720-7360 (e-mail:
[log in to unmask] <mailto:[log in to unmask]> ).
Accepted for publication October 18, 2001.
This study was supported in part by an unrestricted educational grant from
Health Management Services, Merck & Co, Inc, Whitehouse Station, NJ.
We thank Scott Hambly and Mara Sanderson for their clerical support.


What This Study Adds
Several programs that seek to enhance efficacy in self-management have been
developed in asthma care. Randomized trials of computer-based educational
programs conducted in clinic settings have demonstrated mixed results in
their ability to affect asthma management behaviors. We evaluated the
efficacy of a new home-based interactive health communication device, the
Health Buddy, that was designed to enable children to assess and monitor
their asthma symptoms and quality of life and to transmit this information
to a case manager through a secure Web site. This study presents the results
of a randomized, controlled, 90-day clinical trial of inner-city children
with persistent asthma. Compared with children assigned to an asthma diary,
children randomized to the Health Buddy were more likely to improve
self-care behaviors and to reduce asthma symptoms, while making fewer urgent
calls to the hospital, after adjusting for other factors. Easy-to-use
Web-based devices such as the Health Buddy may be useful tools to empower
children to provide their own care while reducing asthma symptoms and health
care use in pediatric settings.






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Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.