Home visits for uncontrolled asthma among low-income adults with patient portal access

Abstract

Background: Asthma disproportionately affects low-income and minority adults. In an era of electronic records and Internet-based digital devices, it is unknown whether portals for patient-provider communication can improve asthma outcomes.

Objective: We sought to estimate the effect on asthma outcomes of an intervention using home visits (HVs) by community health workers (CHWs) plus training in patient portals compared with usual care and portal training only.

Methods: Three hundred one predominantly African American and Hispanic/Latino adults with uncontrolled asthma were recruited from primary care and asthma specialty practices serving low-income urban neighborhoods, directed to Internet access, and given portal training. Half were randomized to HVs over 6 months by CHWs to facilitate competency in portal use and promote care coordination.

Results: One hundred seventy (56%) patients used the portal independently. Rates of portal activity did not differ between randomized groups. Asthma control and asthma-related quality of life improved in both groups over 1 year. Differences in improvements over time were greater for the HV group for all outcomes but reached conventional levels of statistical significance only for the yearly hospitalization rate (-0.53; 95% CI, -1.08 to -0.024). Poor neighborhoods and living conditions plus limited Internet access were barriers for patients to complete the protocol and for CHWs to make HVs.

Conclusion: For low-income adults with uncontrolled asthma, portal access and CHWs produced small incremental benefits. HVs with emphasis on self-management education might be necessary to facilitate patient-clinician communication and to improve asthma outcomes.

Trial registration: ClinicalTrials.gov NCT02086565.

Keywords: Asthma; community health worker; electronic health record; health disparities; information technology; patient portal.

Figure 1.

Participant flow diagram (CONSORT).

Figure 2.. Irregular home visits and data collection.

A. Time from randomization to data collection by treatment group. All patients had first data collection at time of randomization (week 0), and following collections were to begin at weeks 12, 24, 36 and 48, corresponding to 3, 6, 9 and 12 months (vertical dotted lines). Numerals 1, 2, 3 and 4 indicate the collection number and the timing, in weeks, of those collections. PT=portal training, PT+HV=home visit plus portal training. B. Time from randomization to home visits. Anticipated home visit times at start of study were at 3, 5, 8 and 25 weeks, with ranges of a few weeks before and after (vertical dotted lines). Numerals 1, 2, 3 and 4 indicate the visit number, and the weeks on the x-axis correspond to the actual visit times in weeks from randomization. A patient could have fewer than 4 home visits. If the last visit was also the second visit, then the patient would have only a "1" and a "2" in this figure; "3"' and "4" would be missing.

Figure 2.. Irregular home visits and data collection.

A. Time from randomization to data collection by treatment group. All patients had first data collection at time of randomization (week 0), and following collections were to begin at weeks 12, 24, 36 and 48, corresponding to 3, 6, 9 and 12 months (vertical dotted lines). Numerals 1, 2, 3 and 4 indicate the collection number and the timing, in weeks, of those collections. PT=portal training, PT+HV=home visit plus portal training. B. Time from randomization to home visits. Anticipated home visit times at start of study were at 3, 5, 8 and 25 weeks, with ranges of a few weeks before and after (vertical dotted lines). Numerals 1, 2, 3 and 4 indicate the visit number, and the weeks on the x-axis correspond to the actual visit times in weeks from randomization. A patient could have fewer than 4 home visits. If the last visit was also the second visit, then the patient would have only a "1" and a "2" in this figure; "3"' and "4" would be missing.