Pediatric asthma continues to pose a significant challenge to population health. Despite more than 25 years of management guidelines1 from the National Heart, Lung, and Blood Institute and the wide availability of effective controller medications, asthma morbidity rates in the United States have stagnated.2 In this issue of JAMA Pediatrics, Kercsmar et al3 detail the influence of a triphasic quality improvement initiative on asthma outcomes in a population of Medicaidinsured children and adolescents (aged 2-17 years) in Hamilton County, Ohio. The 3 domains of bundled quality improvement (QI) interventions (inpatient, outpatient, and community) were sequentially implemented during a 5-year period and engaged a multidisciplinary team grounded in the chronic care model. Compared with a 2-year baseline period, this approach to asthma care yielded impressive outcomes, including a 36% relative reduction in asthma-related hospitalizations and a 42% relative reduction in asthma-related emergency department (ED) visits.3 A persistent effect was observed for at least 12 months after the completion of phase 3. The number of patients with oral corticosteroids and inhaled controller medications in hand at the time of hospital discharge increased, and the authors speculate that morbidity results were at least partly driven by these efforts. Although providing access to controller medications does not ensure adherence, it is a critical step toward reducing barriers to routine inhaled corticosteroid use, which has been repeatedly associated with decreased hospitalizations and ED visits.4-6 A few comments on methods are warranted. The lack of Medicaid enrollment data before 2007 only permitted a 2-year baseline period, which may not be sufficiently long term to reflect local or regional trends in asthma morbidity. Despite the stable background rates of asthma-related hospitalization and ED use described, morbidity increased in Hamilton County during the baseline period.3 It is unclear whether the observed increases represent a true surge in use or whether a wider range of baseline data would have better approximated the steady rates in greater Ohio and the United States, an important consideration when differentiating the influence from regression to the mean. The limited baseline data available for process measures (eg, medications in hand at discharge) prevented meaningful comparison with postintervention rates. In addition, the lack of process-related outcome measures for some of the costliest interventions (eg, home visitation, care coordination, and school screening and referral) impedes understanding of the value of these specific components and the potential generalizability to other communities. Although the large number of interventions precludes determination of which individual components were most influential, the multifaceted approach should be considered to be a strength of the program. Enhancing care delivery within a tiered theoretical framework such as the chronic care model necessitates actions in multiple domains, and improved outcomes are likely attributable to the synergistic influence on patients and processes. The children and adolescents at highest risk face many social, economic, and environmental challenges in addition to their chronic illness. After years of elevated morbidity, the work of Kercsmar et al3 is a demonstration of how interdisciplinary care focused within a biopsychosocial model can improve outcomes for vulnerable children. Future efforts to replicate these results in other communities should continue to emphasize this patientcentered, biopsychosocial philosophy, with heightened attention to the challenges that remain for children and families. Racial and ethnic disparities in pediatric asthma are well documented in the United States. Black and Hispanic children and adolescents have higher background rates of asthma prevalence and morbidity than do white children and adolescents.2 This morbidity gap is driven in part by access to effective controller medications: minority pediatric patients are less likely to be prescribed or adhere to controller medications.7,8 Although a recent at-risk analysis indicates that racial disparities in pediatric asthma morbidity may be shrinking,9 much work remains. Future analyses from this Cincinnati data set might examine whether the observed influences are distributed equitably among children and adolescents from different racial/ ethnic backgrounds. If so, this would represent a significant step forward in asthma care for pediatric patients at highest risk that would be worthy of broad replication. Different communities will determine how best to leverage their unique strengths and available resources to implement similar initiatives, and including patients as stakeholders will be key to success in any setting. Whether by inclusion on multidisciplinary care teams or through community-based participatoryresearch,patientsarebestsituatedtoidentifytheirown needs, cultural frameworks, and barriers to care. If this is not feasible, examples in the literature of how to deliver high-quality, patient-centered asthma care that bridges health care and community settings are increasing. Kercsmar et al3 describe the use of care coordination and home visits; expanding these efforts by using community health workers to deliver communitybased, culturally appropriate outreach care can help reduce asthma symptoms and acute health care utilization.10 Partnering with schools to conduct school-based asthma screening is described in the article3; coupling this with the supervised administration of controller medications in schools can help improve symptoms and reduce school absenteeism.11 Finally, use of emerging technologies, such as telemedicine, to ensure access to preventive asthma visits offers the potential to improve care and reduce health disparities. Of importance, any future efforts to replicate this work in a patient-centered way should include consideration of how Related article page 1072 Editorial Opinion

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通过在住院、门诊和社区环境之间建立桥梁来改善哮喘护理

小儿哮喘继续对人口健康构成重大挑战。尽管国家心肺血液研究所制定了超过 25 年的管理指南 1 并且有效的控制药物广泛可用，但美国的哮喘发病率却停滞不前。 2 在本期 JAMA Pediatrics 中，Kercsmar 等人 3 详细介绍了三阶段质量改进计划对俄亥俄州汉密尔顿县医疗保险儿童和青少年（2-17 岁）人群哮喘结果的影响。捆绑质量改进 (QI) 干预的 3 个领域（住院、门诊和社区）​​在 5 年内依次实施，并聘请了一个以慢性病护理模式为基础的多学科团队。与 2 年基线期相比，这种哮喘护理方法产生了令人印象深刻的结果，包括与哮喘相关的住院治疗相对减少了 36%，与哮喘相关的急诊科 (ED) 就诊次数相对减少了 42%。3 在治疗后至少 12 个月内观察到持续效果完成第 3 阶段。出院时手中持有口服皮质类固醇和吸入控制药物的患者数量增加，作者推测发病率结果至少部分是由这些努力驱动的。尽管提供控制药物的使用并不能确保依从性，但这是减少常规吸入性皮质类固醇使用障碍的关键一步，这反复与减少住院和 ED 就诊相关。4-6 需要对方法进行一些评论。由于缺乏 2007 年之前的医疗补助登记数据，因此只允许 2 年的基线期，这可能不足以反映当地或区域哮喘发病率的趋势。尽管描述了哮喘相关住院治疗和 ED 使用的稳定背景率，但基线期间汉密尔顿县的发病率增加。 3 目前尚不清楚观察到的增加是否代表真正的使用激增，或者更广泛的基线数据是否会更好近似于大俄亥俄州和美国的稳定率，这是区分回归对均值的影响时的一个重要考虑因素。可用于过程测量的有限基线数据（例如，出院时手头的药物）阻碍了与干预后比率的有意义的比较。此外，一些最昂贵的干预措施（例如，家访、护理协调、学校筛查和转诊）缺乏与过程相关的结果措施，阻碍了对这些特定组成部分的价值和对其他社区的潜在推广的理解。尽管大量干预措施排除了确定哪些单个组成部分最有影响力的可能性，但应将多方面的方法视为该计划的优势。在诸如慢性病护理模型等分层理论框架内加强护理服务需要在多个领域采取行动，而改善的结果可能归因于对患者和过程的协同影响。处于最高风险中的儿童和青少年除了患有慢性病之外，还面临着许多社会、经济和环境挑战。经过多年的高发病率，Kercsmar 等人 3 的工作证明了在生物心理社会模型中的跨学科护理如何改善弱势儿童的结果。未来在其他社区复制这些结果的努力应继续强调这种以患者为中心的生物心理社会哲学，并高度关注儿童和家庭面临的挑战。儿科哮喘的种族和民族差异在美国已有详细记录。与白人儿童和青少年相比，黑人和西班牙裔儿童和青少年的哮喘患病率和发病率背景率更高。 2 这种发病率差距部分是由于获得有效的控制药物：少数儿科患者不太可能开处方或坚持控制药物。 7，8 尽管最近的一项风险分析表明，儿童哮喘发病率的种族差异可能正在缩小，9 但仍有许多工作要做。来自辛辛那提数据集的未来分析可能会检查观察到的影响是否在来自不同种族/民族背景的儿童和青少年中公平分布。如果是这样，这将代表着对高危儿科患者的哮喘护理向前迈出的重要一步，值得广泛复制。不同的社区将决定如何最好地利用其独特的优势和可用资源来实施类似的举措，将患者作为利益相关者将是在任何环境中取得成功的关键。无论是通过纳入多学科护理团队还是通过基于社区的参与式研究，患者最适合确定自己的需求，文化框架和护理障碍。如果这不可行，文献中关于如何提供以患者为中心的高质量哮喘护理以连接医疗保健和社区环境的例子正在增加。Kercsmar 等人 3 描述了护理协调和家访的使用；通过使用社区卫生工作者提供以社区为基础的、文化上适当的外展护理来扩大这些努力，可以帮助减少哮喘症状和急性卫生保健的利用。10 文章中描述了与学校合作进行基于学校的哮喘筛查；将此与学校中控制药物的监督管理相结合，可以帮助改善症状并减少旷课。 11 最后，使用新兴技术，例如远程医疗，确保获得预防性哮喘就诊提供了改善护理和减少健康差异的潜力。重要的是，未来以患者为中心的方式复制这项工作的任何努力都应包括考虑如何相关文章第 1072 页编辑意见