Significant racial and ethnic health disparities have been documented in many areas within pediatric health care. For example, disparities exist with respect to the quantity and quality of anticipatory guidance delivered to parents and adolescents.13–15
Because of the differences between children and adults, we must be cautious about extrapolating lessons from the adult literature to child health disparities.
Therefore, we reviewed the literature on quality-improvement intervention studies to reduce child health disparities for 2 representative areas: asthma care and immunizations. Asthma is paradigmatic of a chronic health condition that requires ongoing, coordinated care, and immunizations represent preventive measures.
We searched PubMed and Google Scholar by using the following search terms: “intervention,” “evaluation,” “racial and ethnic,” “minority group,” “pediatric,” “childhood,” “child(ren),” “immunization,” “vaccination,” and “asthma.” We included studies published between 1997 and 2008 that focused on reducing racial and ethnic disparities in care or in which at least 50% of study participants were from racial or ethnic minority backgrounds.
Nineteen studies described quality-improvement interventions to decrease health disparities for pediatric asthma (). The studies varied in structure, intervention targets, and outcomes. Some studies measured processes of care such as providing an asthma action plan or prescribing inhaled corticosteroids; others measured clinical outcomes such as numbers of symptom-free days, emergency department visits, and hospitalizations. Many of the interventions were multifactorial, which made it difficult in some cases to identify the most important causative factors. Most studies showed positive changes in process or outcome measures, perhaps reflecting publication bias.
Quality-Improvement Studies for Reducing Disparities in Pediatric Asthma
In general, studies that targeted clinic operation processes and provider education tended to show improvements in processes of care; a minority of these studies showed changes in clinical outcomes as well. Interventions resulted in significant changes in clinical outcomes when they used case management, social workers, or community health workers or when they targeted patient self-management, family, home environment, specialist clinic referrals, or school settings.
The development of written asthma action or management plans was a component of nearly all interventions that were focused on improving care processes. Overall, these interventions improved the identification of pediatric patients with asthma, increased the number of routine visits for asthma management, and reduced emergency or urgent health care use for asthma.
Improving Care Processes in the Clinical Setting
We now describe specific organizational change and quality improvement, physician or provider prompt, provider-education intervention, specialist referral intervention, care coordination, provider-caretaker communication, and nurse-educator studies. Unless otherwise indicated, each intervention improved clinical care processes.
Four studies included planned organizational change or quality-improvement methods.16–19
One study showed that a large-scale, multisite quality-improvement intervention had no effect.18
The investigators cited the challenges of implementing quality-improvement strategies across multiple sites as a possible factor in the intervention’s ineffectiveness.
Two studies included physician or provider prompts to improve the asthmacare process.17–20
These prompts included chart reminders, asthma-visit flow sheets, and clinician pocket guides. Physician or provider education was a component of 4 intervention studies.16–19
The main focus was adherence to the National Asthma Education and Prevention Program guidelines for pediatric asthma care. These studies combined provider education with other components of quality improvement.
Two interventions referred pediatric patients with asthma who frequently used the health care system to specialty care.21,22
Patients in both treatment groups had larger reductions in numbers of emergency department visits and hospitalizations than controls. Four studies focused on improving coordination of asthma care among members of a child’s care team.23–26
One study cited the coordinated care model as the theoretical basis for this intervention, which included a robust multidisciplinary intervention. 25
Three of these interventions significantly decreased the numbers of emergency department visits and hospitalizations.23–25
Two intervention studies were designed to strengthen communication between providers and caretakers.23,26
Both studies used social workers to counsel families on how to communicate effectively with their child’s provider about the child’s asthma symptoms. In addition, both studies included asthma education for families.
A nurse educator provided teaching and follow-up with families in 5 studies. 22,24,27–29
The investigators of all interventions with a nursing education or outreach component reported a significant reduction in emergency health care usage. Nurse educators stayed in close contact with families, ensured that asthma-management plans were up to date, and adjusted the plans as needed. A successful asthma-management plan intervention also assessed family psychosocial barriers to asthma management and provided problem-solving counseling.27
As reported by Weil et al,30
a parent or guardian’s mental health problems often decrease their ability to follow asthma-treatment plans for children, resulting in a greater risk for the child of hospitalization for asthma.
Child and Family Education
Twelve intervention studies included an education component on asthma symptom management for children, families, or both.22–26,28,29,31–35
Three studies coupled family education with home environmental assessments or allergen-remediation tools.23,25,34
Three studies evaluated children’s computer programs or video games that taught asthma self-management techniques. 32,33,35
Two of these studies reported no significant difference between treatment and control groups in the children’s asthma self-management skills.33,35
Social Worker and Community Health Worker Home-Visit Interventions
In 3 studies, a clinic social worker or community health worker coordinated asthma-management plans with children’s schools.17,25,29
One of these interventions involved a school specifically designed for children with chronic illness and incorporated asthma-medication administration into the school day.29
Children with asthma who were attending the school had less health care system use than controls. Overall, interventions that included a school outreach component demonstrated significantly less health care system use by those in the intervention groups than in the control groups.
Three studies included a home-visitation component with environmental health assessments.17,23,25,34
Homes were inspected for allergens (such as cockroaches or pet dander) to which the children were susceptible. The social or community health worker educated caregivers about techniques to reduce exposures, such as cleaning methods. They provided families with concrete tools to help reduce exposures, such as vacuum cleaners and mattress covers. Providing these materials was important for low-income families, significantly reducing the number of days during which their children had asthma symptoms.23,34
Community outreach workers also improved clinical processes of care by providing information to clinic staff and physicians on the factors that affect families’ ability to meet asthma-management goals.17
Reports of 8 studies described quality-improvement interventions to decrease health disparities in pediatric immunizations (). Many of these studies improved immunization rates, considered here to be a clinical outcome. Some also increased the frequency of well-child visits (considered here to be a process measure).
Quality-Improvement Studies for Reducing Disparities in Pediatric Immunizations
The main strategies to improve immunization coverage were changes in clinic operation processes (5 studies), outreach to patients’ families through telephone calls or mailings (5 studies), community health worker visits (primary intervention in 3 studies, adjunct strategy in 1 study), a collaborative community approach (1 study), and provider incentives (1 study).
Overall, community health worker visits and other outreach methods for families seemed to be most effective in increasing immunization rates. Interventions in the clinic setting showed mixed results that depended on how well the clinic actually implemented the changes. For example, 1 study used provider feedback and incentives to try to improve immunization rates. However, approximately half of the participating practices were unaware of the feedback program, and the investigators could not identify the proportion of providers who actually received incentive payments as a reward for their activities.36
Not surprisingly, this intervention did not yield significant changes in immunization rates.
Reminders for providers and for families were the most common immunization quality-improvement interventions. Fiks et al37
found that building electronic medical record– based alert reminder systems into clinic visits for providers was associated with increased immunization rates. Hillman et al36
examined a provider-assessment and feedback system coupled with financial incentives. The postintervention increase in immunizations was not statistically different between treatment and control groups. Rodewald et al38
found no evidence that physician prompting alone improved immunization coverage. The differences between these study outcomes demonstrate that the method of provider prompting has a significant impact on the likelihood of capturing immunization opportunities, thereby improving immunization rates.
Immunization interventions that included a reminder to parents of children who had not received recommended immunizations showed mixed results. When combined with visits by a lay outreach worker from the same community as the families, reminder approaches increased immunization rates.39
However, mailed-letter and telephone-call reminders were less successful, because many families moved or changed their contact information. 40
A crucial component of the family-reminder approach could be removing the barriers to bringing families to the clinic by, for example, reducing wait times41
or providing transportation.39
As in the asthma-intervention literature, lay outreach workers seemed to play an important role in reminding families to ensure that their children’s vaccinations were up to date.38,39,42
Interventions that incorporated a community-outreach component increased immunization coverage in low-income, minority children. A community-wide reminder and outreach intervention significantly reduced the disparity in immunization coverage between inner-city and suburban children, as well as between white and minority children.39