David Evans, PhD, AE-C1
Robert Mellins, MD1
Sandra Wiesemann, RN-CS, MSN, MPH2
Marcia Pinkett-Heller, MPH3
Barry J. Zimmerman, PhD4
Katherine Lobach, MD5
Carmen Ramos-Bonoan, MD6
1 College of Physicians & Surgeons
Pediatric Pulmonary Division, Columbia University
2 Medical and Health Research Association of New York
City, Inc
3 New Jersey City University
4 City University of New York Graduate Center
5 Albert Einstein College of Medicine
6 New York City Department of Health and Mental Hygiene
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NYC Department of Health & Mental
Hygiene
Bureau of Chronic Disease Prevention
Childhood Asthma Initiative
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2 Lafayette Street, 20th Floor, CN#36A
New York, NY 10007
Telephone: 311
Lorna Davis, MS
Director, Childhood Asthma Initiative
Andrew Goodman, M.D., M.P.H.
Associate Commissioner
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Partners
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About the Developers
Led by Dr. David Evans, the development team
for Creating a Medical Home for Asthma included pediatricians,
asthma specialists, a health educator, and an educational psychologist.
The following is a list that provides a brief description of
their positions, interests, and contact information.
David Evans, PhD
Title(s):
Director, Asthma Health Education Research Program;
Professor of Clinical Sociomedical Sciences (in Pediatrics)
Interests:
Dr. Evans and his colleagues conduct research
to identify effective methods for teaching patients and health
care professionals about asthma. Programs developed by the group
include Open Airways for Schools, a school-based program for
children aged 8 to 11 years with asthma.
Contact Information:
Office Telephone: (212) 305-6732
Office Fax: (212) 305-2692
Robert B. Mellins, MD
Title(s):
Professor of Pediatrics; Past President, American
Thoracic Society, The Fleischner Society, and the American Lung
Association of New York
Interests:
Dr. Mellins studies asthma in minority populations
in the inner city and chest disease in children and young adults.
Contact Information:
Office Telephone: (212) 305-5122
Office Fax: (212) 305-6103
Sandra Wiesemann, RN-CS, MSN, MPH
Title(s):
Clinical Nurse Specialist; Nurse Educator; Project
Coordinator, Asthma Health Education Research Program
Interests:
Ms. Wiesemann works to identify children with
asthma and to help them manage and prevent chronic symptoms so
they can lead normal, active lives.
Contact Information:
Office Telephone: (212) 305-6721
Office Fax: (212) 305-6103
Marcia Pinkett-Heller, MPH
Title(s):
Assistant Professor
Department of Health Sciences
New Jersey City University
Interests:
Ms. Pinkett-Heller is a health educator with
special interest in facilitating organizational change and cross-cultural
communication.
Contact Information:
Office Telephone: (201) 200-3431
Office Fax: (201) 200-3284
Barry Zimmerman, PhD
Title(s):
Distinguished Professor of Educational Psychology,
Department of Educational Psychology, City University of New
York Graduate Center
Interests:
Dr. Zimmerman is interested in developing interventions
to enhance self-regulated learning in health, education, and
other settings.
Contact Information:
Office Telephone: (212) 817-8291
Office Fax: (212) 817-1631
Katherine Lobach, MD
Title(s):
Clinical Professor of Pediatrics, Albert Einstein
College of Medicine/Montefiore Medical Center
Interests:
Dr. Lobach is a pediatrician with broad interests
in improving the administration and quality of pediatric care.
Dr. Lobach was Director of the Child Health Clinics when the
CMHA program was developed.
Contact Information:
Office Telephone: (718) 920-6497
Office Fax: (718) 920-5289
Carmen Ramos-Bonoan, M.D.
Title(s):
Consultant (formerly Assistant Commissioner for
Child and Adolescent Health)
Bureau of School Health, Division of Health Promotion and Disease
Prevention
New York City Department of Health and Mental Hygiene
Interests:
Dr. Ramos-Bonoan is a pediatrician interested
in improving the quality of pediatric care in public health settings.
She was Medical Director of the Child Health Clinics when the
CMHA program was developed.
Contact Information:
Telephone: 311
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Acknowledgments
The development of Creating a Medical Home
for Asthma (CMHA) involved active collaboration among several
public and private organizations, including the New York City
Department of Health and Mental Hygiene's Bureau of Child Health (BCH), Columbia
University College of Physicians and Surgeons, and the Medical
and Health Research Association of New York City, Inc. With funding
from the National Heart, Lung, and Blood Institute (NHLBI, Grant
No. HL56348), the CMHA project staff developed, pilot-tested
and evaluated the original version of this program in a controlled
study from 1990 to 1995.
Following publication of the findings, the Centers
for Disease Control and Prevention (CDC) selected the CMHA program
for inclusion in its program to translate effective intervention
programs into a form that can be disseminated to health and public
health professionals for widespread use. CDC contracted with
Research Triangle Institute (RTI) to work with the CMHA team
to translate the CMHA program and materials into a web-based
application program. The New York City Department of Health and
Mental Hygiene agreed to serve as the Internet host for the program.
In addition to the individuals and organizations
listed on the title page, many individuals have contributed to
the development, review and translation of the CMHA program.
They are:
Ilene Klein, MD
Deirdre Burke, RN, MPH
Moshe Levison, PhD
Bruce Levin, PhD |
Caroline Donahue, RN,
MA
Virginia Taggart, MPH
Joan Wolle, PhD
Noreen Clark, PhD |
Monique Winslow, Ph.D.
Winston Liao, Ph.D.
Michelle Hsiang, Ph.D.
Ranjani Manjunath, MSPH |
We also acknowledge the contributions of several
hundred staff members of the 45 Child Health Clinics and the
central administrative office, who worked hard to introduce and
sustain this program in the clinics throughout New York City.
Above all, it is their commitment to improving the quality of
care for asthma that has made this program a success.
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Background
1. Program Description
Creating a Medical Home for Asthma (CMHA)
is an asthma management program that encourages public health
clinics to implement a team-based approach to pediatric asthma
management and care. The team-based approach encourages all clinic
personnel to work together as a team to effectively deliver patient-centered
asthma management and care. Therefore, CMHA is designed to offer
a training program that teaches clinic staff- including physicians,
nurses, laboratory technicians, clerical staff, and receptionists-strategies
to increase communication between the patient and health care
provider, as well as to deliver effective asthma treatment using
the latest treatment protocols.
2. Program History
In 1990, a team of investigators from Columbia
University, led by Dr. David Evans, received a grant from the
National Heart, Lung, and Blood Institute (NHLBI, Grant No. HL56348)
to develop the Creating a Medical Home for Asthma program
in collaboration with the New York City Department of Health
and Mental Hygiene (DOHMH) and the Medical and Health Research
Association of New York City, Inc. At the start of the study,
the New York City Department of Health's Bureau of Child Health
(BCH), now part of the Health and Hospitals Corporation of New
York City, operated 45 Child Health Clinics that provided primary
and preventive care to approximately 100,000 children, primarily
from low-income African-American and Latino families.
Historically, these clinics emphasized preventive
medicine, but because of the undersupply of primary care services
for children in New York City, BCH decided in 1987 to begin providing
continuing care for acute and chronic illnesses. Prior to this
decision, clinic staff reviewed the medical records and discovered
that only 2% of registered patients had been given a diagnosis
of asthma by BCH physicians. This was far less than the expected
rate of 5-10% in this urban minority population. They also found
that BCH physicians referred many patients to local hospital
emergency departments for treatment of asthma, and that the care
rendered in the clinics was largely episodic and did not include
the use of new therapies for asthma such as anti-inflammatory
agents. To improve services for patients with asthma, BCH approached
the Columbia University Asthma Health Education Research group
and proposed a collaboration to improve the quality of care for
asthma in BCH.
Following a pilot study to develop the CMHA training
program, CMHA was tested in a controlled study in which 11 clinics
received the program, and another 11 clinics served as controls.
Follow-up data were collected over a two-year period to evaluate
the program. Following the program, training teams were formed
from BCH staff working in the 11 clinics that received the CMHA
program, to extend the program to the 11 control clinics and
the other BCH clinics that had not taken part in the study. In
this way, the program was sustained and made a regular part of
the Child Health Clinic system.
Study findings showed that in both the first
and second follow-up years, the program clinics had significantly
greater positive changes than control clinics on measures of
access, continuity, and quality of care (Evans et al., 1997).
The program clinics identified 1,065 new patients, an increase
of 87% compared to the previous year, while the number of new
patients in the control clinics remained unchanged. Asthma patients
in the program clinics were more likely than those in control
clinics to return for care the following year, and made a greater
number of scheduled visits for asthma care, a positive marker
for preventive care. Program clinic physicians were more likely
to treat patients with anti-inflammatory therapy, and to prescribe
spacer devices to help families administer medicine to the children
successfully. Physicians and nurses who received the training
were both more likely than controls to provide asthma education
to their patients, show patients how to modify their therapy
in response to changes in symptoms, and provide further guidelines
for changing therapy.
A complete bibliography can be found at the end
of this document for readers interested in more
detailed information about the study results. The bibliography
also provides sources for other studies used to support the information
contained in this and other documents related to the CMHA program.
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Asthma: A National
Perspective
Public attention has recently focused on asthma
because its prevalence, morbidity, and mortality have increased
in the greatly since 1980, with children under five years old experiencing the highest rate
of increase. These increases have been especially marked in low-income
urban areas. Several published reports indicate that asthma may
stem from greater exposure to indoor allergens or irritants,
greater exposure to outdoor environmental irritants, and changes
in the immune systems of children.
Based on the results of national studies, there
are several reasons asthma has become a national priority.
1. Asthma Is a National Epidemic
Asthma affects an estimated 17 million Americans,
or 6.4% of the U.S. population, with children accounting for
almost 5 million of the nation's asthma sufferers. Between 1980
and 1995, the prevalence of asthma in children in the United States increased
74% (Mannino, 1998).
Minority populations have a higher prevalence
of asthma than other groups. In 1998, National Health Interview
Survey data reported that the prevalence of asthma attacks among
black non-Hispanic children was approximately 30% higher than
among white non-Hispanic children. During this same time, the
prevalence among Hispanic children increased rapidly. The report
also noted that the prevalence of asthma in Hispanics was about
17% greater than among their white counterparts.
Minority populations also experience greater
morbidity or chronic illness and hospitalization due to asthma.
A study in New York City showed that among children and young
adults with asthma, the hospitalization rate for African-Americans
and Hispanics was five times greater than for non-Hispanic whites
(Carr, Zeitel, & Weiss, 1992).
2. Asthma Is a Burden on the Quality of Life
Pediatric asthma has a tremendous impact on school, absences, work disruption,
and limited recreational activities that negatively affect the quality
of life for children with asthma and their family. Affecting
people of all races, ages, ethnicities, and socioeconomic groups,
asthma imposes serious burdens on daily life, and results in
significant losses in productivity for children and their caregivers.
Asthma is the leading cause of school absenteeism due to chronic
illness and the second most important respiratory condition leading
to home confinement for adults. Each year, asthma causes more
than 18 million days of restricted activity, and millions of
visits to physicians' offices and emergency rooms. Studies have
shown that children with asthma lose an extra 10 million school
days each year; this problem is compounded by an estimated $1
billion in lost productivity for their working parents (Figure
1).
Figure 1:
Lost Productivity Due to Asthma in 2001
Source: American Lung Association,
2001
3. Asthma Is Costly and a Burden on the Health
Care System
The treatment of children with chronic asthma
places a heavy strain on the health care system, in terms of
both economic costs and hospital usage. Data from 1990 showed
that asthma posed severe economic costs on the health care system
that year-an estimated $3.6 billion in direct medical expenditures
(i.e., hospital care, medications, and physicians' services)
and an estimated $2.6 billion in indirect expenditures (i.e.,
school days lost, workdays lost, and mortality) with a combined
total of more than $6.2 billion in health care costs. By 2000,
these combined costs had increased to more than $12 billion,
with $8.1 billion of that amount in direct medical expenditures
and $4.6 billion in indirect expenditures (Figure 2).
Figure 2: A Comparison
of 1990 and 2000 Economic Costs of Asthma
Source: National Heart Lung and
Blood Institute, 2001In 1996, asthma was responsible for 9.9 million
visits to health care providers per year, over 1.9 million emergency
room visits per year, and 474,000 hospitalizations per year.
By 1999, asthma was responsible for 10.8 million outpatient visits
to private physicians' offices and hospital clinics (33% of these
involved children under 15), approximately 2 million emergency
room visits (33% involved children under 15), and 478,000 hospitalizations
(40% involved children under 15), as illustrated in Figure 3.
Figure 3: 1999
Healthcare Use Associated with
Asthma for Adults and Children (<15 yrs)
Source: Centers for Disease Control
and Prevention, 20024. Asthma Can Be Controlled
Many of the previously mentioned outcomes and
costs associated with asthma are preventable with appropriate
medical care and patient education. The most recent report of
the 2002 expert panel for The Guidelines for Diagnosis and Management
of Asthma developed by the National Heart, Lung, and Blood Institute
recommend four strategies that can reduce the frequency and severity
of asthma attacks. They are:
Assessment and monitoring of symptoms associated with asthma,
Identification and control of environmental and other triggers
to limit exposure to allergens,
Use of appropriate medication to manage asthma, and
Education of the patient and family in asthma care.
The report also recommends secondary prevention
through use of appropriate therapy, written treatment plans,
and patient education and outreach which can help patients to manage
their asthma successfully on a daily basis.
In addition, two large-scale national programs
provide resources for asthma control. First, in 1992, the National
Heart, Lung, and Blood Institute established the National Asthma
Education and Prevention Program (NAEPP) to coordinate efforts
to educate people with asthma, health care professionals, and
the public on how to identify and control asthma. The NAEPP program
includes information about the following initiatives that can
be accessed at the NAEPP website: http://www.nhlbi.nih.gov/about/naepp/naep_pd.htm
Guidelines for the Diagnosis and Management of Asthma were developed
and are periodically updated by an expert panel.
The Model Asthma Management Program provides user-friendly guides
for treating and educating patients.
The Global Initiative for Asthma is a collaborative effort to
provide treatment guides and educational materials worldwide
in easily translatable formats, plus information about the costs
of therapy.
Second, in 1999, the Centers for Disease Control
and Prevention (CDC), in support of its Healthy People 2010 objectives,
developed the following programs for asthma education and management
that target several areas:
The National Asthma Control Program stimulates the implementation
of asthma programs across the nation through state health agencies
that emphasize tracking, monitoring, and intervention related
to asthma. The National Asthma Control Program also provides
intervention programs that focus on reducing asthma prevalence
in major metropolitan and inner-city areas.
The Americans Breathing Easier Program emphasizes asthma
education interventions in schools across the nation to reduce
the number of asthma-related school absences.
Both researchers and federal sponsors believe
that as many of these asthma education and outreach programs
evolve nationwide, the severity of asthma as an epidemic will
decrease, resulting in a reduced burden of asthma for patients,
families, and the health care system.
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Rationale for the
CMHA Program
Creating a Medical Home for Asthma was designed
to improve pediatric asthma care within public health clinics.
It promotes a team-based approach to asthma management, and includes
strategies to improve communication among the clinic staff, as
well as with the parent or caregiver of a child with asthma.
This program stems from recent studies demonstrating
the lack of continuity of care for children with asthma. Several
studies reported that many patients were given episodic care
rather than continuous care for their chronic asthma and were
provided insufficient patient education.
As noted earlier, research findings also indicated
that physicians were under-diagnosing asthma in minority children
by as much as 50%. This was associated with increased levels of morbidity
in low-income minority children, when compared to the expected
rate of asthma in an urban minority population. These findings
suggested that clinics and other providers of care needed to
focus on implementing better strategies to improve the current
care of asthma.
Program Goals
The strategies described in the CMHA program
are based largely on the National Asthma Education and Prevention
Program Guidelines for the Diagnosis and Management of Asthma.
The NAEPP supports the use of screening procedures to identify
new cases and health education to improve family management of
asthma. Thus, the goals of the CMHA program are to:
- Provide continuing care in primary and specialized clinics
to greater numbers of individuals with asthma, with a focus on
pediatric asthma;
- Improve the health status of the children suffering from
asthma through appropriate treatment, including patient education
and family self-management; and
- Improve quality of life for the entire family through communication
about asthma between the family and the entire clinic staff.
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Underlying Assumptions
The rationale for this program was based on the
premise that effective communication between physicians and families
about asthma management and treatment will likely reduce asthma
symptoms and decrease use of emergency health services. The program
rationale also relied on the following assumptions:
There are many children with asthma who are registered in public
health clinics throughout the United States and who might not
be receiving continuing medical care for asthma from any health
care provider.
Asthma is a chronic disease that requires an ongoing relationship
between the clinician and the patient.
Not all clinicians are aware of the elements, such as communication
techniques and teaching skills, necessary to maintain the ongoing
relationship with the patient.
Clinicians seeing patients with asthma need to change the way
they work to take advantage of recent research regarding the
patient's self-management of asthma.
Based on goals and assumptions described earlier
the development team created the CMHA program to help resolve
some of the issues that affect children and families in underserved
communities.
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The CMHA Philosophy
Creating a Medical Home for Asthma
is centered on the system of care philosophy,
which views asthma management as a collaborative effort focused
on providing organized, coordinated, asthma education and treatment.
Thus, a "medical home" is created whereby families
develop a relationship with the health care provider and receive
continuous and comprehensive care for their children's asthma.
Further, CMHA is a comprehensive education program
that incorporates concepts from many different disciplines. It
is designed to promote learning from multiple perspectives, which
makes it applicable for all types of health care employees, including
non-clinical staff, such as administrative employees.
The system of care philosophy provides a foundation
to guide the development of a systematic approach to delivering
effective asthma care. Described below, these guiding principals
incorporate key strategies that facilitate the development of
a team-based approach to asthma management and care within the
health care clinic. The manual titled "Getting Started with
CMHA" described each in more detail as it relates to coordinating
the CMHA program.
Creating
a Medical Home for Asthma
Guiding Principles and Key Strategies
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- Identify an individual as an advocate or "champion"
of the program who can promote and coordinate implementation
of the program.
- Conduct a careful needs assessment of the problems and desired
outcomes for asthma care, including an assessment of barriers
to change and positive assets for change within both the clinic
and the community.
- Obtain the commitment of top leadership to the change process.
- Involve all clinic personnel in the learning process to develop
a team approach to CMHA.
- Use interactive learning strategies to actively engage clinic
staff in identifying and overcoming barriers to change and to
help them take ownership of the program.
- Make supervisory staff part of the intervention team with
initial training that prepares them to realize the goals of the
program through supervisory action.
- Base asthma care on current best practices guidelines for
asthma care as recommended in the NAEPP guidelines.
- Recognize that adherence to treatment guidelines is not enough
for a successful CMHA program. The key ingredients are teamwork
and coordination of care among staff, and the development of
partnerships among clinic staff and patients that enable patients
to learn how to control asthma.
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The CMHA Training Website
The documents on the CMHA website [To be inserted
by NYCDOH] provide the necessary materials to conduct the CMHA
training program, to prepare for implementation into the clinic
setting, and to support evaluation. They are meant to serve as
a guide for program coordinators and staff in public health clinics
or health care organizations who are interested in adopting the
program.
The CMHA training website contains the following
documents:
The Introduction and Background
provides the background and program history of the development
of CMHA, results of the evaluation, and the philosophy and rationale
for the program. It provides the reader with a comprehensive
overview of the program and each component.
The Getting Started
manual provides guidance on how to obtain the information necessary
to prepare for implementing the CMHA program in your healthcare
setting. It also presents the steps involved obtaining support
from management, and includes a PowerPoint presentation to help
demonstrate the value of the program to decision makers.
The Instructor's Guide
details all instructions, content, handouts, and agenda for the
sessions that are provided with the training program.
The Program Handbook
can be distributed to the participants of the training as it
contains the key learning principles, handouts, and agenda of
the program.
The Implementation Guide
offers guidance on adapting and implementing the CMHA training
program in a clinic. It defines the procedures or steps to follow
for creating a management plan and successfully integrating the
principles of the program. It also provides the necessary forms
and plans that accompany implementation of the program.
Finally, the Evaluation Plan
offers a framework to measure the results and success of the
training program in the clinic.
Each of the above documents represents a "unique
section" on the website. Other sections on the website provide
additional resources and materials that can be used to supplement
the information provided in the program documents. The other
sections include information regarding supplemental "components",
such as:
Links
to informative asthma-related sources
Program
related references
Treatment
plans and clinic forms
The CMHA program materials are available on the
website and are formatted in HTML so the full text can be viewed
on-line. Materials are also available in Microsoft Word and Adobe
Acrobat, and can be downloaded for use in hardcopy format. Also,
the program materials listed above were developed as a series
of manuals that should be used in the order in which they are
presented. Each manual builds on the information provided from
the previous and may not be fully understood if viewed out of
order. The exception to this ordering is the Instructor's Guide
and Program Handbook. Since these are intended for training purposes,
they should be used simultaneously.
For additional information on the CMHA program
or to request technical assistance, please contact:
Andrew Goodman
Associate Commissioner, Community HealthWorks,
New York Department of Health and Mental Hygiene
40 Worth Street Room 1602
New York, N Y 10013
Contact Information:
Telephone: 311
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Bibliography
Program Related References
Evans D, Mellins RB, Lobach KS, et al. Improving
care for minority children with asthma: Professional education
in public health clinics. Pediatrics 1997;99(2):157-164.
Lobach KS. Childhood asthma: Providing a "medical
home." City Health Information (The New York City Department
of Health) 1996;15(3):1-3.
Mellins RB. Developing a therapeutic plan for
asthma in a primary-care setting. City Health Information (The
New York City Department of Health) 1996;15(3):4-6.
Mellins R, Evans D, Clark N, Zimmerman B, Wiesemann
S. Developing and communicating a long-term treatment plan for
asthma. American Family Physician 2000;61(8):2419-28, 2433-4.
Zimmerman BJ, Bonner S, Evans D, Mellins RB. Self-regulating childhood asthma: a developmental model of family change. Health Education & Behavior 1999;26:55-71.
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General Asthma References
American Academy of Allergy, Asthma, & Immunology,
Inc. Pediatric asthma promoting best practice: Guide for managing
asthma in children. Rochester, N.Y.: Academic Services Consortium,1998.
Carr W, Zeitel L, Weiss K. Variations in asthma
hospitalizations and deaths in New York City. Am J Public Health
1992;82:59-65.
Centers for Disease Control and Prevention. Key clinical activities for quality asthma care: recommendations of the National Asthma Education and Prevention Program. MMWR 2003;52 (No. RR-6):1-8.
Clark NM, Gong M, Schork MA, et al. Impact of
education for physicians on patient outcomes. Pediatrics 2000a;101:831-836.
Clark NM, Gong M, Schork MA, et al. Long-term
effects of asthma education for physicians on patient satisfaction
and use of health services. Eur Respir J 2000b;16:15-21.
Forecasted state-specific estimates of self-reported
asthma prevalence - United States, 1998. MMWR Morb Mortal Wkly
Rep 1998;47:1022-5.
Mannino D, Homa D, Pertowski C. Surveillance
from asthma - United States, 1960-1995. MMWR Morb Mortal Wkly
Rep, 1998;47:1-27.
Measuring asthma prevalence before and after
the 1997 redesign of the National Health Interview Survey - United
States. MMWR Morb Mortal Wkly Rep 2000;49(40):908-911.
National Heart, Lung, and Blood Institute. A
practical guide for the diagnosis and management of asthma. Bethesda,
Md.: U.S. Department of Health and Human Services, Public Health
Service, 1997.
National Heart, Lung, and Blood Institute. Morbidity
and mortality: Chartbook on cardiovascular, lung, and blood diseases.
N Eng J Med 1992;362(13).
National Heart, Lung, and Blood Institute. National
Asthma Education and Prevention Program, 2001a.
National Heart, Lung, and Blood Institute, National
Institutes of Health. NHLBI reports new asthma data for World
Asthma Day 2001. Washington, D.C.: NHLBI Communications Office,
May 3, 2001b.
National Institute of Allergy and Infectious
Diseases, National Institutes of Health. Asthma: A concern for
minority populations, 2001, October.
New asthma estimates: Tracking prevalence, health
care, and mortality. Atlanta, Ga.: National Center for Health
Statistics, Centers for Disease Control and Prevention, 2001,
October.
Newacheck, PW, Halfon N. Prevalence, impact,
and trends in childhood disability due to asthma. Arch Pediatr
Adolesc Med 2000;154:287-293.
Trends in asthma morbidity and mortality. American
Lung Association, 2002, February. (Accessed March, 2002, at http://www.lungusa.org/data/asthma/ASTHMAdt.pdf)
U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention. Asthma's impact on
children and adolescents, 2002. (Accessed March, 2002, at http://www.cdc.gov/nceh/airpollution/asthma/children.htm)
U.S. Department of Health and Human Services.
Action against asthma: A strategic plan for the Department of
Health and Human Services. Washington, DC: DHHS Asthma Workgroup,
May, 2000.
Weiss KB, Gergen PJ, Hodgson TA. An economic
evaluation of asthma in the United States. N Eng J Med 1992;326:862-6.
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