an evaluation of the asthma intervention of the new york state healthy neighborhoods program

JOURNAL OF ASTHMA

Vol 41 No 5 pp 583ndash595 2004

ORIGINAL ARTICLE

An Evaluation of the Asthma Intervention of the New York StateHealthy Neighborhoods Program

Shao Lin PhD1 Marta I Gomez MS1 Syni-An Hwang PhD1

Eileen M Franko DrPH2 and Joan K Bobier BS2

1Bureau of Environmental and Occupational Epidemiology and2Bureau of Community Sanitation and Food Protection New York State

Department of Health Troy New York USA

ABSTRACT

Background The Healthy Neighborhoods Programs (HNP) are funded by the Federal

Preventive Health and Health Services block grants and administered by the New

State Department of Health (NYSDOH) Eight county and local health departments

are funded for 3 years for a total of $125 million per year to target households at risk

for environmental health and safety hazards The HNP asthma intervention uses home

visits to identify asthmatics assess asthma morbidity and management and identify

environmental asthma triggers Outreach workers provide education about asthma

referrals and controls for asthma triggers The purpose of this evaluation was to assess

the impact of the HNP asthma intervention for the 1997ndash1999 funding cycle and for

the first year of the 2000ndash2002 funding cycle Because of changes in reporting

requirements across the funding cycles the findings for 1997ndash1999 and 2000 were

analyzed separately Methods We analyzed one final outcome measure the rate of

self-reported hospitalizations (admissions and emergency room visits) and three

intermediate outcome measures (the percent of homes with cockroaches the percent

of asthmatics with a written management plan and the percent of asthmatics using a

peak flow meter) We also estimated the net savings resulting from a reduction in

hospital admissions due to asthma Results For the 1997ndash1999 funding cycle the

average hospitalization rate was 86 hospitalizations per 100 asthmatics per year at the

intervention visit (ie the baseline rate) and 445 at the 1-year follow-up a decrease

of 48 This was a larger decrease than the 24 average annual decrease in the

baseline rates during the 3 years In 2000 there were 96 hospitalizations per 100

asthmatics per year at the intervention visit and 25 at the one-year follow-up a

Correspondence Shao Lin PhD Bureau of Environmental and Occupational Epidemiology New York State Department of

Health Troy NY 12180 USA E-mail sxl05healthstatenyus

583

DOI 101081JAS-120033992 0277-0903 (Print) 1532-4303 (Online)

Copyright D 2004 by Marcel Dekker Inc wwwdekkercom

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decrease of 74 In 2000 there were about 110 fewer hospital admissions thought to

be due to the net effects of the HNP intervention resulting in an estimated gross

savings of $905300 (110$8230) After subtracting the estimated cost of the asthma

intervention ($624683) the net savings were $280617 Conclusion New Yorkrsquos

HNP seems to be succeeding in reducing asthma morbidity as measured by the

hospitalization rates among asthmatics who have received the intervention The HNP

was successful in decreasing cockroach infestation in HNP homes A standardized

evaluation methodology and instrument are necessary to conduct a more rigorous

evaluation of the HNP

Key Words Asthma Healthy neighborhoods programs (HNP) New York State

Department of Health (NYSDOH) Safety hazards

INTRODUCTION

Since 1992 the Federal Preventive Health and

Health Services block grants have funded the Healthy

NeighborhoodsndashPreventive Health Cornerstones pro-

grams The Healthy Neighborhoods Program (HNP)

was designed to provide preventive health services to

targeted populations with a high rate of unmet

environmental health needs that can result in adverse

health outcomes The aim of these programs is to have

a positive impact on the target populations by

improving sanitation safety and health care and by

establishing communication networks that facilitate the

allocation of neighborhood services

The goals of the HNP are based on Healthy People

2000 The 1993ndash1996 programs focused on deaths due

to home fires and falls In 1997ndash1999 the program

was expanded to include additional environmental

health problems including asthma and carbon monox-

ide poisoning Since 2000 the goals of the program

focus on four main environmental health and safety

problems asthma morbidity lead poisoning in children

younger than 6 years of age fire injuries and deaths

and carbon monoxide poisoning

Thirty-six full-service county health departments

and the New York City Health Department are eligible

to compete for the HNP grants administered by the New

York State Department of Health (NYSDOH) Appli-

cations are submitted to and granted by the Bureau of

Community Sanitation and Food Protection (BCSFP)

Center for Environmental Health NYSDOH Eight

health departments were funded for each 3-year grant

cycle The health departments that apply for the funding

must demonstrate that they serve neighborhoods with

high levels of environmental risk factors that can lead

to asthma morbidity and mortality residential fire

injuries and death carbon monoxide poisoning and

childhood lead poisoning The programs must identify

populations at risk including households with minor-

ities children under 14 residents with less than a high

school education or with an annual income less than

$16452 In addition neighborhoods with inadequate

physical environments are identified such as those with

substandard housing older housing that may have lead

paint neighborhoods with rodent or garbage com-

plaints or households in remote rural areas

The prevalence of asthma has increased in the

general population over the last 15ndash20 years One

national survey found that between 1980 and 1994 the

prevalence of self-reported asthma increased 75 the

largest increase was among infants and children up to

4 years of age (1) Moreover hospitalization rates for

asthma have increased steadily in states in the Northeast

and among blacks Between 1990 and 1995 in New York

State the death rate due to asthma among blacks was

49 per million people compared to 17 per million in

the general population of New York State (1) These

populations and others are at increased risk for asth-

ma morbidity and mortality and may benefit from

asthma intervention

In addition to targeting at-risk populations the HNP

focuses on the indoor environment as an important

factor in the increased exacerbation of asthma and

morbidity associated with asthma Many although not

all people with asthma are sensitive to agents found

in the indoor environment including dust mites

cockroaches other animals (eg rodents and cats)

fungi chemicals (eg nitrogen dioxide) and cigarette

smoke (2)

Programs and Interventions

The health departments that have been funded

range from large central metropolitan to nonmetropol-

itan counties Each program provides environmental

and educational assistance unique to its population and

geography The HNP asthma interventions use home

visits to identify asthmatics assess asthma morbidity

584 Lin et al

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and management and identify environmental asthma

triggers In addition the programs provide a variety of

controls for asthma triggers and education to change

behavior and improve asthma management These

programs also enhance the local public health infra-

structure by funding outreach workers who are trained

to work with asthmatics and to address the cultural and

linguistic needs of the target households

Prior to initiating contact with households out-

reach workers visit a targeted neighborhood and leave

door hangers announcing the programrsquos arrival The

HNP intervention visits are then initiated at a sub-

sequent visit to the neighborhood In homes where no

adult resident is available two additional attempts are

made at other times of the day or on different days of

the week If there is no response on the third visit to a

residence a door hanger is left with a short summary

of the program and a telephone number to call to

schedule an appointment

Once a household agrees to participate in the

program an adult resident is interviewed to determine

the individual needs of the residents including

children and the asthma status of each resident A

room-by-room visual inspection of the dwelling is then

conducted which includes identifying asthma triggers

deteriorating paint sources of carbon monoxide and

fire safety hazards Program interventions include

providing education various environmental controls

and referrals to other agencies related to the goals of

the HNP Education about asthma management

community services and reducing asthma triggers

including the risks of cigarette smoke is conducted

during the home visit with residents who have asthma

Environmental controls are provided and may include

mattress and pillow covers furnace filters rodent baits

cleaning equipment and vacuums Demonstrations of

their proper use are also conducted If a child does not

have a physician the program will make a referral to

Child Health Plus (CHPlus) a health insurance

program for children younger than 19 years of age

from low-income families The coverage is provided by

private health insurance companies and subsidized by

the state government

The programs are required to revisit a sample of

households at least 90 days after the initial HNP visit

During the 1997ndash1999 cycle the goal was to revisit

25 of all households in the program During the

2000ndash2002 cycle the programs were expected to revisit

all asthmatics and target other high-risk households

with the goal of revisiting a total of 25 of the

households seen in one fiscal quarter selected by the

individual programs during each funding year This

results in fewer revisits than in the previous funding

cycle but prioritizes revisits on needier and higher risk

households During both funding cycles the purpose of

the 90-day revisits is to determine if safety products

and environmental controls were still in use to assess

the outcome of referrals to other agencies and to

determine if educational materials were used and

resulted in a change in behavior In addition the

programs are required to attempt to revisit all house-

holds with an asthmatic member 1 year after the initial

visit The purpose of these 1-year revisits is to de-

termine if there was improvement in asthma morbidity

(ie fewer hospital admissions and emergency room

visits) and medical management of asthma (ie use of

a written management plan and a peak flow meter)

and to assess the reduction in asthma triggers present

in the home

Data Collection

Each program must collect baseline information on

asthma morbidity (eg hospital admissions due to

asthma) childhood lead poisoning carbon monoxide

poisoning and residential fires in their target commu-

nities as well as a description of the target area based

on census data such as the age of housing median

annual family income the percentage of households

with children under the age of 14 years and the

percent of minority households This information is

used to evaluate the efficacy of the interventions and

ensure that at-risk populations are being targeted

During the initial HNP visit the outreach workers

complete a survey form that includes the findings from

the interview and home assessment For each resident

with asthma an additional survey form is completed

with information specific to asthma morbidity severity

asthma triggers and medical management

Through the 90-day revisits the programs ascer-

tain the effectiveness of the home visit educational

materials and environmental controls Information is

collected on the use of safety products (eg smoke

detectors products to reduce household allergens) and

the result of any referrals made to other agencies An

assessment is made of whether sources of allergens

were reduced or eliminated in each dwelling Residents

are interviewed to determine if they read any of the

educational materials provided and if they changed

their behavior as a result Residents are asked if they

are satisfied with the program and if they think the

program is worthwhile in their community

At the 1-year revisit to households with a resident

with asthma information is collected on the number of

hospital admissions emergency room (ER) visits and

school or work days lost due to asthma Information is

Asthma Intervention of NY State HNP 585

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also collected on the number of persons with asthma who

have a written management plan from their physician

who know the early warning signs of an asthma at-

tack and who monitor their peak expiratory flow daily

The programs maintain data from the initial visits

90-day revisits and 1-year asthma revisits Summary

data are reported quarterly and again at the end of the

funding year to the BCSFP (NYSDOH) Staff from

BCSFP also assist in the development of the regional

programs and conduct regular site visits to evaluate

the programs

PROGRAM EVALUATION

Purpose

The purpose of this evaluation is to assess the

impact of the HNP asthma intervention on the

populations targeted by the program to identify the

nature and scope of the problems with the programs

funded during the 2000ndash2002 cycle and to improve

HNP in future funding cycles This evaluation was

done by analyzing the change in measures of asthma

morbidity environmental exposures and asthma-relat-

ed behaviors In this report we present data from the

1997ndash1999 funding cycle and for federal funding year

(FFY) 2000 of the 2000ndash2002 funding cycle Because

of changes in reporting requirements across funding

cycles this report presents the findings for 1997ndash1999

and 2000 separately

Outcome Variables

Two types of outcome variables were used in this

evaluation final (or direct) outcomes and intermediate

(or indirect) outcomes Due to data limitations only

one final outcome variable the rate of self-reported

hospitalizations (hospital admissions and ER visits)

per person with asthma per year was used in this

report to measure the direct impact on asthma by

the HNP

Three intermediate outcome variables were used to

measure steps toward reaching the program goals

percent of homes with cockroaches percent of

asthmatics with a written management plan and

percent of asthmatics using a peak flow meter The

percent of homes with cockroaches is one indicator of

the presence of indoor asthma triggers in the home A

written management plan is considered an important

part of effective asthma treatment For asthmatics

taking daily medical therapy using a peak flow meter

to measure their peak expiratory flow is a way to

recognize the onset and severity of an asthma attack

Multiple intermediate indicators were used to attempt

to capture the effect of the programs and to allow the

strengths of one measure to compensate for the

weaknesses of another

The change in the percentage of asthmatics with a

written asthma management plan and the percentage

using a peak flow meter could not be calculated

directly given the data that were collected First the

programs were only asked to report the percentage of

households with a written management plan at the

initial visit This is only an estimate of the percentage

of asthmatics with a written management plan because

there can be more than one asthmatic in a household

Second the data collected at the revisit was the

percentage of asthmatics without a written plan at the

initial visit who had a written plan at the revisit In

addition only some of the asthmatics were revisited

after 1 year For these reasons an estimate of the total

percentage of asthmatics with a written plan 1 year

after the asthma intervention was calculated as follows

given a=the proportion with a written plan at the initial

visit and b=proportion without a written plan at the

initial visit who had a written plan at the revisit then

the total percentage with a written plan one year after

the intervention is [a+(1 - a)b]100 For peak flow

meter use the data collected at the revisit was the

percentage of asthmatics who had not used a peak flow

meter at the initial visit who were using one at the

revisit Therefore the estimate of the total percentage

of asthmatics using a peak flow meter 1 year after the

intervention was calculated by using the same formula

as for the written management plan

For 1997ndash1999 two outcome variables are pre-

sented the average rate of self-reported hospitalizations

per person with asthma per year and the average

percentage of participating households with cockroach

infestation Given the way that the data were collected

it was not possible to separate hospital admissions and

ER visits before 2000 Data on cockroach infestation

could only be analyzed for all households and not

separately for households with asthmatics

For 2000 three outcome variables are presented

the rate of self-reported hospitalizations per person

with asthma per year the percentage of asthmatics

using a written management plan and the percentage

of asthmatics using a peak flow meter Even though

hospital admissions and ER visits were reported sep-

arately in 2000 they were combined so that the rates

were comparable to the 1997ndash1999 hospitalization

586 Lin et al

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rates During the 2000ndash2002 funding cycle informa-

tion on cockroach infestation is not being collected at

revisits and therefore is not presented

Evaluation Methods

Pre- vs Postintervention Comparison

The effects of the HNP measured with the final or

intermediate outcome variables were assessed by

comparing the pre-HNP rates (baseline at the initial

HNP visit) to the post-HNP rates (HNP revisit rates)

using the percent change in the average rate or

percentage for the 1997ndash1999 funding cycle For

1997ndash1999 the 3-year average hospitalization rate

and percent of homes with cockroaches were computed

for the initial visits and revisits for each program with

complete data and for all programs combined For

2000 the 1-year hospitalization rate was computed for

the initial visits and revisits for each program with

complete data and for all programs combined These

rates were compared across all programs In addition

the percent change in the hospitalization rate (or

percent of homes with cockroaches) from the initial

visit (ie pre-HNP) to the revisit (ie post-HNP) was

calculated as [(post-HNP ratepre-HNP rate)(pre-

HNP rate)]100 A negative change indicates a

decrease (or improvement) in the rate or percentage

after the program intervention and a positive change

indicates an increase (or worsening) after the program

intervention This change does not take into account

other factors such as media campaigns or community

interventions that may have influenced the change in

the same period of time

The programs reported the total number of

persons hospital admissions etc for each funding

year rather than data at the individual or household

level Because there were only aggregated data it was

not possible to perform statistical tests such as the chi-

square test to determine if the change in an outcome

variable was significant In addition it is difficult to

calculate the standard error (SE) of the mean percent

change therefore we used the computer-intensive

bootstrap resampling method to estimate the SE of

the mean (3) This method uses the observed sample

itself to mimic the original sampling from the unknown

population that resulted in the observed sample In the

current analysis this was done by randomly drawing a

large number of samples (10000 in the current

analysis) from the observed sample For example from

the percent change in the hospitalization rates (1997ndash

1999) that we observed for six programs we drew

10000 random samples each with six observations

The mean and SE of the 10000 samples were then

computed For a one-sided test (because wersquore in-

terested in improvement after the intervention) if the

mean percent change was beyond 165SE (ie

more negative) then the improvement was considered

statistically different from zero with plt005 The

resampling and calculations of the mean and SE were

performed by using SAS statistical software (4)

Analysis of Trends over Time

Natural variations (increases or decreases) in the

rates of asthma hospitalizations and the other interme-

diate outcomes may have occurred independently of the

HNP intervention This can result from trends over time

in asthma prevalence media health education other

intervention programs changes in the prevalence of

asthma triggers in ambient air and other unknown

factors Design effects (eg reliability and validity) can

also affect the measurement of the outcome variables In

other words the gross effect is a combination of the

effects of intervention (net effect) and the effects of other

processes (confounding factors) To control for these

effects the change in the initial (or baseline) rates across

the program years was computed For 1997ndash1999 the

trend in the hospitalization rates for the regional

programs combined was estimated by computing the

change in the initial rates from 1997 to 1998 and from

1998 to 1999 The average percent change was (

change 1997 to 1998+ change 1998 to 1999)2

Comparison of Different Programs

A cross-sectional comparison (ie comparing

outcome variables across programs) was used to

evaluate the impact of different interventions imple-

mented by the regional programs and to identify which

programs were more effective than others in terms of

the outcome evaluation Because no standardized

intervention program was required by the NYSDOH

the programs developed their own intervention pro-

grams and components In this report the percent

change from the initial visit to the revisit for the final

outcome variable (hospitalization rates) and the inter-

mediate outcome variables (percent of homes with

cockroaches in 1997ndash1999 percent of homes with

asthmatics with a written management plan in 2000

and percent of asthmatics using a peak flow meter in

2000) were compared among the eight programs The

differences in percent change across the programs

could be due to differences in the effectiveness of the


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intervention programs how well the interventions were

implemented by the individual programs and differ-

ences in baseline rates

Cost Analysis

Although a typical cost-benefit analysis could not

be performed due to limitations in the data the monies

encumbered by each program are presented in this

report along with the total number of household visits

(initial HNP visits 90-day revisits and 1-year asthma

revisits) and the cost per visit The cost of a visit also

includes other costs incurred by the program that are

not directly related to a household visit including

operating expenses (eg training and supplies) and

monies spent on other types of interventions (eg

educational meetings in the community)

Using the monies encumbered by the HNP we

estimated the savings resulting from a reduction in

hospital admissions after the HNP intervention Of the

four program goals (asthma lead poisoning fire

injuries prevention and carbon monoxide poisoning)

the asthma intervention is the largest component of the

program We assumed therefore that one-half of the

annual funds went toward the asthma intervention

Although this may be a rough overestimate of the

cost it may provide evidence regarding the net cost of

the program

RESULTS

Direct Outcomes

For the 1997ndash1999 cycle the average hospitaliza-

tion rate reported by asthmatics at the initial visits and

asthma revisits are presented in Table 1 for the six

programs that reported complete data (Oneida and

Orange Counties reported incomplete data and were

excluded from this portion of the evaluation) The

initial hospitalization rates varied greatly among the six

programs The programs in the highly urbanized

regions of the state (Erie County New York City

and Westchester County) had substantially higher

initial hospitalization rates than the other three

programs The average hospitalization rate at the initial

visit for the six programs combined was 860 hospital-

izations per 100 persons with asthma per year At the

1-year asthma revisit the average hospitalization rate

was 445 a decrease of 483 The average percent

change for the six programs was 612 a significant

decrease after the HNP intervention (plt005)

The trend over time for the six programs combined

was determined by examining the annual hospitaliza-

tion rates reported by participants at the time of initial

HNP visits From data not presented the rates for

1997 1998 and 1999 were 1095 864 and 622

hospitalizations per 100 persons with asthma per year

respectively This represents a decrease over the study

period in the baseline hospitalization rate of 212

from 1997 to 1998 and a decrease of 280 from 1998

to 1999 for an average decrease of 245 This

indicates that there was a decrease in the baseline

hospitalization rate independent of the HNP interven-

tion in the range of 21 and 28 which is lower than

the apparent decrease from the initial visits to the

revisits of 483

Four programs showed decreases in their hospital-

ization rates ranging from 97 to 73 during the

1997ndash1999 cycle For example Erie Countyrsquos average

hospitalization rate decreased from 2330 to 59


Table 1 Hospitalization rates (hospitalizationsa per 100 diagnosed asthmatics) at the initial HNP visits and 1-year HNP revisits

(ie before and after the HNP intervention) (programs with complete data) 1997ndash1999

Initial HNP visits One-year HNP revisitsPercent change in average rate

initial to revisitbProgram Asthmatics Average rate Asthmatics Average rate

Clinton Co 227 465 24 28 940

Erie Co 253 2330 24 59 975

New York City 632 1021 214 1308 281

Niagara Co 781 385 201 222 423

Onondaga Co 1009 576 211 157 727

Westchester Co 326 1680 127 188 888

All programs 3228 860c 801 445 483

aReported as hospital visits which include hospital admissions and ER visits

bThe decrease in the percent change in the six programs was statistically significant (plt005)cBased on six counties with complete data the initial rate decreased 212 from 1997 to 1998 and 280 from 1998 to 1999 an

average decrease of 245 (data not shown)

588 Lin et al

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and Clinton Countyrsquos rate decreased from 465 to 28


the two largest reductions among the regional pro-

grams Niagara County reported a more modest

decrease of 423 from 385 to 222 hospitalizations

per 100 persons with asthma per year similar to the

decrease observed without the intervention On the

other hand New York City had an increase of 281

in the hospitalization rate from 1021 to 1308


The hospitalization rates among asthmatics at the

initial visits and 1-year asthma revisits for FFY 2000 of

the 2000ndash2002 cycle are presented in Table 2 for the

five programs that reported complete data The two

programs that began in 1999 and were new to the

HNP Cayuga and Rockland Counties did not conduct

asthma revisits in FFY 2000 and Onondaga County

was unsuccessful in its attempts to conduct asthma

revisits therefore these programs could not be

included in this portion of the evaluation The

hospitalization rate at the initial visit for the five

programs combined was 956 hospitalizations per 100

persons per year and at the 1-year asthma revisits was

249 a decrease of 739 These five programs all

showed decreases in their rates ranging from 100 to

33 The average percent change for the five programs

was 681 a significant decrease after the HNP

intervention (plt005) The largest decreases were in

Clinton County (100 from 512 to 00 hospital-

izations per 100 persons with asthma per year) and

Niagara County (81 from 612 to 113 hospital-

izations per 100 persons with asthma per year) The

rate for New York City decreased by 586

Intermediate Outcomes

Information on cockroach infestation was collected

at both the initial visits and 90-day revisits during the

1997ndash1999 cycle (Table 3) For the seven programs

with complete data 102 of homes had cockroaches

at the initial visit After implementing controls during

the initial visit or making referrals immediately after

Table 3 Percent of homes with cockroaches at the initial HNP visits and 90-day HNP revisits (ie before and after the HNP

intervention) (programs with complete data) 1997ndash1999

Program

Initial HNP visits 90-day HNP revisits

Homes Average percentage Homes Average percentage Percent change

initial to revisita

Clinton Co 869 08 66 00 1000

Erie Co 2575 84 74 88 48

Niagara Co 2729 44 330 05 886

Oneida Co 1439 32 668 10 688

Onondaga Co 3159 217 566 144 336

Orange Co 901 139 525 56 597

Westchester Co 2951 97 238 99 21

All programs 14623 102b 2467 58 431

aThe decrease in the percent change in the seven programs was statistically significant (plt005)

Table 2 Hospitalization rates (hospitalizationsa per 100 diagnosed asthmatics) at the initial HNP visits and one-year HNP Revisits

(ie Before and After the HNP intervention) (programs with complete data) 2000

Program

Initial HNP visits One-year HNP revisitsPercent change in rate

initial to revisitbAsthmatics Rate Asthmatics Rate

Clinton Co 86 512 13 00 1000

Erie Co 46 391 38 263 327

New York City 260 1681 46 696 586

Niagara Co 369 612 221 113 815

Westchester Co 74 986 175 320 676

All programs 835 956 493 249 739

aHospitalizations include hospital admissions and ER visits

bThe decrease in the percent change in the five programs was statistically significant (plt005)


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the visit the overall percentage of homes with

cockroaches dropped to 58 a reduction of 431

The average percent change for the seven programs

was 491 a significant decrease (plt005) The

initial rate decreased 250 from 1997 to 1998 and

156 from 1998 to 1999 an average decrease of

203 This decreasing trend was smaller than the

decrease observed after the intervention The largest

percent decreases were by the Clinton Niagara and

Oneida programs (100 886 and 688 respec-

tively) in which the initial rates were relatively low

(08 44 and 32 of households respectively)

The two programs with highest percentage of homes

with cockroaches Onondaga and Orange Counties also

showed large improvements (336 and 597

respectively) Two programs Erie and Westchester

Counties showed no improvement In New York City

this information was not collected at all visits

Information collected during the 2000ndash2002 cycle

about the percent of asthmatics using a written plan for

managing asthma and using a peak flow meter are

presented in Tables 4 and 5 for FFY 2000 At the initial

visits the percentage of households with an asthmatic

who already had a written management plan ranged from

18 in Westchester County to 778 in Clinton

County with an average of 331 Five programs

Table 4 Percent of households with asthmatics with a written management plan at the initial HNP visits and 1-year HNP revisits

(ie before and after the HNP intervention 2000

Asthma households with

a written management plan

at the initial visit

Asthmatics who did not

have plan initially with a

written management plan

at the revisit

Total with a written

management plan at

initial and revisit

Program Homes Percent Asthmatics Percent Percent

Cayuga Co 26 269 NAa mdash mdash

Clinton Co 63 778 NAb mdash 778

Erie Co 34 618 38 368 759

New York City 231 82 46 174 242

Niagara Co 297 559 221 95 601

Onondaga Co 180 272 NAa mdash mdash

Rockland Co 21 48 NAa mdash mdash


aHad not completed any revisitsbAll households with asthmatics at the initial visit had written management plans therefore there were no additional asthmatics with

a plan at the revisit

Table 5 Percent of asthmatics using daily therapy using a peak flowmeter at the initial HNP visits and 1-year HNP revisits (ie

before and after the HNP intervention) 2000

ProgramAsthmatics using peak flow

meter at the initial visit

Asthmatics who had not

used a peak flow meter and

were using one at the revisit

Total using a peak flow meter

at the initial visit and revisit

Cayuga Co 33 NAa mdash

Clinton Co 00 NAb mdash

Erie Co 140 132 253

New York City 650 326 764

Niagara Co 230 41 262

Onondaga Co 150 NAa mdash

Rockland Co 00 NAa mdash

Westchester Co 46 NAb mdash

aHad not completed any revisits

bDid not collect this information at the revisits

590 Lin et al

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collected comparable information at the revisits In Erie

County 618 had a written management plan at the

initial visit and 368 without a plan had one at the

asthma revisit giving an estimated total of 759

[(0618 + 0368 (10618))100] of participating

asthmatics who had a written plan 1 year after the

HNP intervention Niagara County reached 601 with

a written management plan after 1 year New York City

had 242 and Westchester County had 63 Clinton

County remained unchanged from the initial visits at

778 On average 489 of HNP asthmatics had a

written management plan 1 year after the intervention

At the initial visit the percentage of persons with

asthma using a peak flow meter was zero in Clinton

and Rockland Counties 65 in New York City and

less than 25 in all other counties with an average of

156 For the revisits this information was only

available for three of the programs Among asthmatics

who were revisited and did not use a peak flow meter

at the initial visit 326 in New York City started

using one after the initial visit 132 in Erie County

and 41 in Niagara County One year after the initial

visit the estimated percentage of asthmatics using a

peak flow meter in these three counties was 764 in

New York City 253 in Erie County and 262 in

Niagara County (average percentage 426)

Cost Analysis

Table 6 presents the monies encumbered by New

York State for each program and the cost per program

visit by program year The total monies granted were

$1248011 per year for the 1997ndash1999 cycle and

$1249367 per year for the 2000ndash2002 cycle For

1997ndash1999 the annual funds ranged from $49370 per

year to Oneida County to $353508 to New York City

For the 2000ndash2002 funding cycle the annual funds

ranged from $49370 per year to Cayuga County to

$325000 to New York City The average cost per visit

for all of the programs combined was $148 per visit in

1997 $161 in 1998 $111 in 1999 and $171 in 2000

The average cost per visit varied widely across

programs and from year to year within programs In

2000 the two new programs had relatively high costs

per visit In four of the six programs that had

participated since 1997 the cost per visit was highest

in 2000 compared to 1997ndash1999

An analysis of savings resulting from the asthma

intervention was conducted for FFY 2000 only the

first year that hospital admissions were distinguished

from ER visits in the HNP data The hospital

admission rate among asthmatics in the HNP fell from

272 to 97 (data not shown) a reduction of about

146 hospital admissions Assuming a 25 annual

decrease in the baseline hospitalization rate similar

to 1997ndash1999 (146025=36 admissions) there

were about 110 fewer hospital admissions due to

the net effect of the HNP We estimated that of the

$1249367 funds granted in 2000 approximately one-

half ($624683 a conservative estimate) was spent on

the asthma component of the program Based on

hospital discharge data collected by New York State

the cost of a single asthma hospitalization in calendar

year 2000 averaged $8230 (5) Therefore the re-

duction in hospital admissions due to the HNP re-

presents gross savings of $905300 (110$8230)

Table 6 Monies encumbered and cost per visit for 1997ndash2000 healthy neighborhoods programs

Program

Monies encumbered (dollarsyear) Average cost per visit (dollars)

1997ndash1999a 2000b 1997a 1998a 1999a 2000b

Cayuga Co ndash 49369 ndash ndash ndash 437

Clinton Co 53862 65000 163 144 211 262

Erie Co 205500 204221 232 425 157 524

New York City 353508 325000 94 169 95 134

Niagara Co 118000 125000 227 88 85 59

Oneida Co 49370 ndash 297 55 47 ndash

Onondaga Co 166467 170000 128 148 110 209

Orange Co 73000 ndash 329 144 84 ndash

Rockland Co ndash 78777 ndash ndash ndash 847

Westchester Co 228304 232000 184 250 196 208

All programs 1248011 1249367 148 161 111 171

aCayuga and Rockland Counties were added in 2000

bOneida and Orange Counties were dropped in 2000


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After subtracting $624683 (the estimate of the cost

of the asthma intervention) from the gross savings

the net savings resulting from a reduction in asthma

hospitalizations was approximately $280617

DISCUSSION

Asthma still affects many Americans producing an

enormous impact on the quality of life of persons with

asthma and their families and placing a strain on the

medical care system In 1998 an estimated 106 million

people (39 per 1000 persons) had an asthma attack in

the previous 12 months including 68 million adults and

38 million children (6) In the same year there were

139 million outpatient visits 2 million emergency

department visits 423000 hospitalizations for asthma

and 5348 deaths due to asthma It is estimated that the

indirect and direct costs of asthma totaled $113 billion

in 1998 and hospitalizations for asthma accounted for

the largest portion of this cost (7)

Based on the National Health Interview Survey

(NHIS) the prevalence of self-reported asthma in-

creased 75 between 1980 and 1994 (1) Although the

annual age-adjusted hospital admission rates for asthma

remained stable during this period the rates increased

in states in the Northeast and were consistently higher

among blacks In 1996 and 1997 the New York State

Behavioral Risk Factor Surveillance System (NYS

BRFSS) surveyed a sample of New York adults about

asthma emergency room use for asthma and counsel-

ing on asthma management (8) At the time of the

survey approximately 87000 adults (64 of the

population) had asthma The prevalence of asthma for

women was almost twice as high as for men (81 vs

46 respectively) There was a decreasing trend in

asthma prevalence as income increased 10 for adults

with a household income below $15000 compared to

5 for adults with a household income above $50000

The prevalence of asthma among non-Hispanic whites

was 6 among non-Hispanic blacks was 8 and

among Hispanics was 10 with a significant differ-

ence between non-Hispanic whites and Hispanics

Baseline Asthma Prevalence

Based on the number of asthmatics visited in 1997

by all of the HNP regional programs the prevalence of

asthma (defined as ever diagnosed with asthma by a

physician) was about 13 This is similar to the

prevalence of asthma among non-white and Hispanic

adults (99) and children (116) from the New York

State Minority Health Survey conducted in 1997

(unpublished report) The prevalence of asthma from

the HNP (13) was also comparable to the prevalence

of 116 among minorities from the NYS BRFSS

(unpublished report 1997) These facts suggest that the

study population targeted by our HNP is similar to

other minority surveys and that the baseline prevalence

of asthma between minority groups in New York is

probably similar to that of minorities based on other

sources of data

Direct Outcomes

There is evidence that the overall HNP sponsored

by the NYSDOH resulted in improvement in asthma

morbidity Between 1997 and 1999 the average

hospitalization rate dropped 48 1 year after the

intervention (Table 1) After accounting for the decrease

in baseline rates of about 25 over this period the

decrease attributable to the program was about 23 We

found that there are large variations among the

programs in the amount of improvement in the rates

of asthma hospitalizations before and after the inter-

vention In addition the programs with a high initial

hospitalization rate showed a greater improvement after

the intervention based on the percent change from the

initial rate This variation among the programs may be

due to differences in reporting implementation of their

interventions and underlying differences in their target

populations and baseline rates In addition the initial

hospitalization rates for 1997ndash1999 were notably higher

among the programs in urban regions namely Erie

County New York City and Westchester County

(Table 1) This may indicate an urbanrural disparity

in baseline hospitalization rates

DrsquoSouza et al evaluated asthma morbidity in 69

adults from a rural Maori community in New Zealand

who participated in an asthma self-management

program (9) Six years after completing the program

the percentage of participants who made an emergency

visit to a general practitioner fell from 41 to 18 a

56 reduction without considering decreases over time

that might have occurred independently of the program

Although a reduction in asthma morbidity was

observed after 6 years the reduction was less than

that observed after 2 years The authors believe that

these findings suggest that underrecognition of asthma

symptoms and undertreatment of asthma with inhaled

steroids is a major problem contributing to asthma

morbidity in this indigenous population and that

continued reinforcement of asthma self-management

skills is necessary to maintain any benefits In a trial of

a written self-management plan for children with

592 Lin et al

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asthma in a New Zealand community (N=110) Gillies

et al reported that after introducing the plan the

percentage of nights that children woke due to asthma

fell from 182 to 121 a 33 reduction (plt0001)

and the number of days children reported being lsquolsquoout of

actionrsquorsquo due to asthma fell from 64 to 41 a 36

reduction (plt0001) (10) The need for acute medical

treatment also fell during the intervention period with

a reduction in visits to a general practitioner of 67

In a prospective randomized controlled trial in

Canada Cote et al evaluated the effectiveness of an

asthma education program on morbidity knowledge

and compliance with inhaled corticosteroid treatment

(11) One hundred eighty-eight adult patients with

asthma needing anti-inflammatory treatment were

randomly assigned to one of three intervention groups

1) education and action plan based on peak flow

monitoring 2) education and action plan based on

monitoring of asthma symptoms or 3) control group

with no formal education This study found that asthma

morbidity decreased significantly in all groups after

1 year Although all asthma morbidity indicators in the

first group showed a larger reduction (70 for

unscheduled medical visits 83 for hospitalizations

and 75 for absenteeism from workschool) than in the

control group (67 81 and 46 respectively)

these differences were not statistically significant

Nonetheless the authors indicated that the study results

do not refute the possibility of a benefit of educational

interventions aimed at improving asthma-related mor-

bidity over a long period of time or in patients with

less optimal care or with high-risk factors In another

analysis the same researchers found that among the

patients receiving the educational interventions there

was a significant increase in the number of days per

month without daytime asthma symptoms after 1 year

(p=003) (12) In addition asthma daily symptom

scores decreased significantly in the intervention group

compared to the control group (p=0006)

In summary the available literature regarding the

evaluation of asthma interventions were conducted in

New Zealand and Canada Most of these studies found

favorable reductions in asthma indicators ranging from

33 to 83 However these studies involved popula-

tions that are not directly comparable to the HNP target

population In addition reductions due to secular trends

or other factors were not adjusted for in any of these

studies as they were in the current evaluation


The intermediate indicators of asthma management

and asthma triggers showed possible improvement after

the HNP intervention although less definitive than the

improvement in the direct measures of asthma morbid-

ity For example we found that 156 of asthmatics

used peak flow meters at the initial HNP visit which is

similar to the weighted percentage of 159 from the

New York State Minority Health Survey (unpublished

report) However these baseline rates of peak flow

meter use for the HNP population are lower than those

reported by two other studies Mendenhall and Tsien

reported that 44 of 54 asthmatic study volunteers used

a peak flow meter and DrsquoSouza et al reported use by

54 of their participants (913) One year after the HNP

intervention the percentage of asthmatics using a peak

flow meter increased to 43 which is similar to the

baseline rate reported by these other studies

The average percentage of participants in the HNP

with a written asthma management plan rose increased

by 48 (Table 4) There was no literature with

comparable data by which to judge this change The

percentage of asthmatics with a written management

plan ranged widely across programs that collected

these data It is not possible to say if the HNP

intervention had an immediate effect on asthma

management As indicated by these findings this

component of the HNP intervention needs to be

monitored carefully over time to determine if the use

of peak flow meters is adequate and if it results in

improved asthma management

Other studies on the daily use of peak flow meters

have shown limited compliance and possibly a decrease

in compliance over time In a study in the United States

of 65 minority children who were instructed in the

use of peak flowmeters Redline et al found that the

percentage of days with missing diary entries increased

from the first to the third week after instruction

(plt0004) (14) Cote et al studied 26 adult asthma

patients who were instructed to monitor their peak

expiratory flow twice a day (15) They found that 63

of measurements were recorded in the first month and

50 after 12 months

During the 1997ndash1999 cycle most programs

succeeded in reducing the percentage of homes with

cockroaches (Table 3) Overall 10 of homes had

cockroaches at the initial visit and 6 had cockroaches

90 days after the intervention The initial rate is much

lower than the 366 observed in the New York State

Minority Health Survey and therefore cockroach

infestation may have been underreported in the HNP

A study of innercity children that assessed the

effectiveness of housecleaning and extermination by

measuring cockroach antigen levels found that antigen

levels were at least as high as baseline levels after 12

months (16) Because the HNP recorded only the


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absence or presence of cockroaches in homes im-

provement was based on eliminating cockroaches

rather than reducing infestations or antigen levels in

individual homes This may have made it difficult to

detect an improvement In addition eliminating

cockroaches may be difficult and follow-up beyond

90 days may be needed to maintain improvement

Cost Analysis

Our cost analysis is limited in scope and the cost

per program visit ranged widely across regional

programs and funding years No patterns of increasing

or decreasing cost per visit emerged The cost per visit

in 2000 was relatively high for the two new programs

presumably due to start-up costs in their first year The

higher cost per visit in four of the programs may be

explained in part by the expanded goals of the 2000ndash

2002 funding cycle

We found that the HNP asthma intervention may

have resulted in a cost savings by reducing hospital

admissions due to asthma The cost of the HNP may

have been underestimated becuase in-kind support by

the local health departments was not added to the cost

based on the grant funds On the other hand if we

overestimated the cost of the asthma intervention (half

of the annual funds spent on all four interventions) the

net savings would have been even greater We also

believe that the actual net savings due to the HNP is

greater than the cost savings described above because

the savings from reductions in ER visits deaths

unplanned physician visits and work or school

absenteeism due to asthma have not been computed

in this analysis Unfortunately there are no data to

which to compare our cost analysis findings

Limitations

This evaluation has several limitations First

although a large amount of data have been collected

they have not been collected in a consistent and

standardized manner across programs and across funding

years Some outcome measures could not be compared

among all programs for all years and before and after

the intervention For this reason trends over time or

intervention effects could only be computed for some

indicators and for the program overall In addition

denominator data were not collected for some outcome

indicators Second because only aggregated data were

collected for each program improvement after the

interventions within households and specific individual

groups such as the young or elderly subpopulations

could not be assessed Third definitions of asthma

outcomes were not standardized or not consistent across

programs making it difficult to compare the effects

among them Fourth the lack of complete and reliable

data for the 2000ndash2002 funding cycle was a critical

problem For some outcome variables about half of the

programs had missing data Finally a more detailed cost

evaluation will be necessary to identify spending patterns

and expenditures for specific interventions Subsequent

cost evaluations should attempt to estimate the total cost

of each intervention of the HNP including in-kind

support from the local health departments

To better evaluate the asthma component of the

HNP information on measures of asthma morbidity

environmental triggers and asthma management need

to be collected more consistently before and after the

intervention across different programs and over time

Based on this evaluation we recommended that the

core data collected for evaluation purposes should be

standardized by NYSDOH rather than by the individual

programs This would enable us to calculate percen-

tages and rates that can be compared before and after

the intervention and across programs and program

years Since this evaluation was completed the

NYSDOH has defined the outcome measures necessary

to effectively evaluate the HNP and the programs are

using a standardized data collection instrument and

guidelines Sociodemographic and environmental data

will be gathered on all households and asthma data will

be collected for asthmatics

CONCLUSION

In summary New Yorkrsquos HNP seems to be

succeeding in reducing asthma morbidity as measured

by hospitalization rates among asthmatics who have

received the intervention The HNP was also successful

in decreasing cockroach infestation in HNP homes

although data are not complete It is not possible to say

if the programs are succeeding in educating asthmatics

in asthma management techniques due to large

proportion of incomplete data A standardized evalua-

tion methodology and instrument are necessary to

conduct a more rigorous evaluation of the HNP

REFERENCES

1 Centers for Disease Control and Prevention Surveil-

lance for asthmamdashUnited States 1960 ndash 1995

MMWR CDC Surveillance Summaries 199847(SS-1)30 pp

2 Institute of Medicine Clearing the Air Asthma

594 Lin et al

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and Indoor Air Exposure Washington DC

National Academy Press 2000 438 pp

3 Efron B Tibshirani RJ An Introduction to the

Bootstrap Boca Raton Chapman amp HallCRC

1993 436 pp

4 The SAS System for Windows Release 802 Cary

NC SAS Institute Inc 1999ndash2001

5 New York State Department of Health State-

wide Planning and Research Cooperative System

(SPARCS)Table13A 2000 Top 50 Federal

DRGs httpwwwhealthstatenyusnysdoh

sparcsannual t2000_13htm (accessed March

2002)

6 National Center for Health Statistics New Esti-

mates for Asthma Tracked News Release October

5 2001 httpwwwcdcgovnchsreleases01facts

asthmahtm (accessed January 2002)

7 National Heart Lung and Blood Institute Data

Fact Sheet Asthma Statistics Bethesda Na-

tional Institutes of Health US Department of

Health and Human Services MD January 1999

4 pp

8 Fritz PM Recer G Luttinger D Asthma among

adult New Yorkers Behav Risk Factor Surv Syst

1999 7(1)1ndash49 DrsquoSouza WJ Slater T Fox C Fox B Te Karu H

Gemmell T Ratima MM Pearce NE Beasley RB

Asthma morbidity 6 yrs after an effective asthma

self-management programme in a Maori communi-

ty Eur Respir J 2000 15464ndash469

10 Gillies J Barry D Crane J Jones D MacLennan

L Pearce N Reid J Toop L A community trial

of a written self management plan for children

with asthma N Z Med J 1996 109(1015)30ndash33

11 Cote J Cartier A Robichaud P Boutin H Malo J

Rouleau M Fillion A Lavallee M Krusky M

Boulet L Influence on asthma morbidity of asthma

education programs based on self-management

plans following treatment optimization Am J

Respir Crit Care Med 1997 1551509ndash151412 Cote J Cartier A Robichaud P Boutin H Malo J

Rouleau M Boulet L Influence of asthma educa-

tion on asthma severity quality of life and en-

vironmental control Can Respir J 2000 7(5)395ndash400

13 Mendenhall AB Tsien AY Evaluation of physi-

cian and patient compliance with the use of peak

flow meters in commercial insurance and Oregon

health plan asthmatic populations Ann Allergy

Asthma amp Immun 2000 84(5)523ndash52714 Redline S Wright EC Kattan M Kercsmar C

Weiss K Short-term compliance with peak flow

monitoring results from a study of inner city

children with asthma Pediatr Pulmonol 199621(4)203ndash210

15 Cote J Cartier A Malo J Rouleau M Boulet L

Compliance with peak expiratory flow monitoring

in home management of asthma Chest 1998113(4)968ndash972


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decrease of 74 In 2000 there were about 110 fewer hospital admissions thought to

be due to the net effects of the HNP intervention resulting in an estimated gross

savings of $905300 (110$8230) After subtracting the estimated cost of the asthma

intervention ($624683) the net savings were $280617 Conclusion New Yorkrsquos

HNP seems to be succeeding in reducing asthma morbidity as measured by the

hospitalization rates among asthmatics who have received the intervention The HNP

was successful in decreasing cockroach infestation in HNP homes A standardized

evaluation methodology and instrument are necessary to conduct a more rigorous

evaluation of the HNP

Key Words Asthma Healthy neighborhoods programs (HNP) New York State

Department of Health (NYSDOH) Safety hazards

INTRODUCTION

Since 1992 the Federal Preventive Health and

Health Services block grants have funded the Healthy

NeighborhoodsndashPreventive Health Cornerstones pro-

grams The Healthy Neighborhoods Program (HNP)

was designed to provide preventive health services to

targeted populations with a high rate of unmet

environmental health needs that can result in adverse

health outcomes The aim of these programs is to have

a positive impact on the target populations by

improving sanitation safety and health care and by

establishing communication networks that facilitate the

allocation of neighborhood services

The goals of the HNP are based on Healthy People

2000 The 1993ndash1996 programs focused on deaths due

to home fires and falls In 1997ndash1999 the program

was expanded to include additional environmental

health problems including asthma and carbon monox-

ide poisoning Since 2000 the goals of the program

focus on four main environmental health and safety

problems asthma morbidity lead poisoning in children

younger than 6 years of age fire injuries and deaths

and carbon monoxide poisoning

Thirty-six full-service county health departments

and the New York City Health Department are eligible

to compete for the HNP grants administered by the New

York State Department of Health (NYSDOH) Appli-

cations are submitted to and granted by the Bureau of

Community Sanitation and Food Protection (BCSFP)

Center for Environmental Health NYSDOH Eight

health departments were funded for each 3-year grant

cycle The health departments that apply for the funding

must demonstrate that they serve neighborhoods with

high levels of environmental risk factors that can lead

to asthma morbidity and mortality residential fire

injuries and death carbon monoxide poisoning and

childhood lead poisoning The programs must identify

populations at risk including households with minor-

ities children under 14 residents with less than a high

school education or with an annual income less than

$16452 In addition neighborhoods with inadequate

physical environments are identified such as those with

substandard housing older housing that may have lead

paint neighborhoods with rodent or garbage com-

plaints or households in remote rural areas

The prevalence of asthma has increased in the

general population over the last 15ndash20 years One

national survey found that between 1980 and 1994 the

prevalence of self-reported asthma increased 75 the

largest increase was among infants and children up to

4 years of age (1) Moreover hospitalization rates for

asthma have increased steadily in states in the Northeast

and among blacks Between 1990 and 1995 in New York

State the death rate due to asthma among blacks was

49 per million people compared to 17 per million in

the general population of New York State (1) These

populations and others are at increased risk for asth-

ma morbidity and mortality and may benefit from

asthma intervention

In addition to targeting at-risk populations the HNP

focuses on the indoor environment as an important

factor in the increased exacerbation of asthma and

morbidity associated with asthma Many although not

all people with asthma are sensitive to agents found

in the indoor environment including dust mites

cockroaches other animals (eg rodents and cats)

fungi chemicals (eg nitrogen dioxide) and cigarette

smoke (2)

Programs and Interventions

The health departments that have been funded

range from large central metropolitan to nonmetropol-

itan counties Each program provides environmental

and educational assistance unique to its population and

geography The HNP asthma interventions use home

visits to identify asthmatics assess asthma morbidity

584 Lin et al

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in the home

Data Collection




































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the programs

PROGRAM EVALUATION

Purpose














and 2000 separately

Outcome Variables








the HNP






























































586 Lin et al

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Evaluation Methods































































































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Cost Analysis






















the program

RESULTS

Direct Outcomes























1997 1998 and 1999 were 1095 864 and 622










revisits of 483










Clinton Co 227 465 24 28 940

Erie Co 253 2330 24 59 975

New York City 632 1021 214 1308 281

Niagara Co 781 385 201 222 423

Onondaga Co 1009 576 211 157 727

Westchester Co 326 1680 127 188 888

All programs 3228 860c 801 445 483




588 Lin et al

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029

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For

pers

onal

use

onl

y











































Program



initial to revisita

Clinton Co 869 08 66 00 1000

Erie Co 2575 84 74 88 48

Niagara Co 2729 44 330 05 886

Oneida Co 1439 32 668 10 688

Onondaga Co 3159 217 566 144 336

Orange Co 901 139 525 56 597


All programs 14623 102b 2467 58 431




Program



Clinton Co 86 512 13 00 1000

Erie Co 46 391 38 263 327

New York City 260 1681 46 696 586

Niagara Co 369 612 221 113 815

Westchester Co 74 986 175 320 676

All programs 835 956 493 249 739




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onal

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at the revisit


management plan at

initial and revisit




Erie Co 34 618 38 368 759

New York City 231 82 46 174 242

Niagara Co 297 559 221 95 601

















Erie Co 140 132 253








590 Lin et al

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Cost Analysis












1997 $161 in 1998 $111 in 1999 and $171 in 2000



























Program


1997ndash1999a 2000b 1997a 1998a 1999a 2000b


Clinton Co 53862 65000 163 144 211 262

Erie Co 205500 204221 232 425 157 524

New York City 353508 325000 94 169 95 134

Niagara Co 118000 125000 227 88 85 59


Onondaga Co 166467 170000 128 148 110 209



Westchester Co 228304 232000 184 250 196 208

All programs 1248011 1249367 148 161 111 171




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





DISCUSSION




















































sources of data

Direct Outcomes









































592 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





































































in the home

Data Collection




































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y











the programs

PROGRAM EVALUATION

Purpose














and 2000 separately

Outcome Variables








the HNP






























































586 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y




Evaluation Methods































































































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y




Cost Analysis






















the program

RESULTS

Direct Outcomes























1997 1998 and 1999 were 1095 864 and 622










revisits of 483










Clinton Co 227 465 24 28 940

Erie Co 253 2330 24 59 975

New York City 632 1021 214 1308 281

Niagara Co 781 385 201 222 423

Onondaga Co 1009 576 211 157 727

Westchester Co 326 1680 127 188 888

All programs 3228 860c 801 445 483




588 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y











































Program



initial to revisita

Clinton Co 869 08 66 00 1000

Erie Co 2575 84 74 88 48

Niagara Co 2729 44 330 05 886

Oneida Co 1439 32 668 10 688

Onondaga Co 3159 217 566 144 336

Orange Co 901 139 525 56 597


All programs 14623 102b 2467 58 431




Program



Clinton Co 86 512 13 00 1000

Erie Co 46 391 38 263 327

New York City 260 1681 46 696 586

Niagara Co 369 612 221 113 815

Westchester Co 74 986 175 320 676

All programs 835 956 493 249 739




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



































at the revisit


management plan at

initial and revisit




Erie Co 34 618 38 368 759

New York City 231 82 46 174 242

Niagara Co 297 559 221 95 601

















Erie Co 140 132 253








590 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























Cost Analysis












1997 $161 in 1998 $111 in 1999 and $171 in 2000



























Program


1997ndash1999a 2000b 1997a 1998a 1999a 2000b


Clinton Co 53862 65000 163 144 211 262

Erie Co 205500 204221 232 425 157 524

New York City 353508 325000 94 169 95 134

Niagara Co 118000 125000 227 88 85 59


Onondaga Co 166467 170000 128 148 110 209



Westchester Co 228304 232000 184 250 196 208

All programs 1248011 1249367 148 161 111 171




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





DISCUSSION




















































sources of data

Direct Outcomes









































592 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y











the programs

PROGRAM EVALUATION

Purpose














and 2000 separately

Outcome Variables








the HNP






























































586 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y




Evaluation Methods































































































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y




Cost Analysis






















the program

RESULTS

Direct Outcomes























1997 1998 and 1999 were 1095 864 and 622










revisits of 483










Clinton Co 227 465 24 28 940

Erie Co 253 2330 24 59 975

New York City 632 1021 214 1308 281

Niagara Co 781 385 201 222 423

Onondaga Co 1009 576 211 157 727

Westchester Co 326 1680 127 188 888

All programs 3228 860c 801 445 483




588 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y











































Program



initial to revisita

Clinton Co 869 08 66 00 1000

Erie Co 2575 84 74 88 48

Niagara Co 2729 44 330 05 886

Oneida Co 1439 32 668 10 688

Onondaga Co 3159 217 566 144 336

Orange Co 901 139 525 56 597


All programs 14623 102b 2467 58 431




Program



Clinton Co 86 512 13 00 1000

Erie Co 46 391 38 263 327

New York City 260 1681 46 696 586

Niagara Co 369 612 221 113 815

Westchester Co 74 986 175 320 676

All programs 835 956 493 249 739




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



































at the revisit


management plan at

initial and revisit




Erie Co 34 618 38 368 759

New York City 231 82 46 174 242

Niagara Co 297 559 221 95 601

















Erie Co 140 132 253








590 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























Cost Analysis












1997 $161 in 1998 $111 in 1999 and $171 in 2000



























Program


1997ndash1999a 2000b 1997a 1998a 1999a 2000b


Clinton Co 53862 65000 163 144 211 262

Erie Co 205500 204221 232 425 157 524

New York City 353508 325000 94 169 95 134

Niagara Co 118000 125000 227 88 85 59


Onondaga Co 166467 170000 128 148 110 209



Westchester Co 228304 232000 184 250 196 208

All programs 1248011 1249367 148 161 111 171




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





DISCUSSION




















































sources of data

Direct Outcomes









































592 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y




Evaluation Methods































































































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y




Cost Analysis






















the program

RESULTS

Direct Outcomes























1997 1998 and 1999 were 1095 864 and 622










revisits of 483










Clinton Co 227 465 24 28 940

Erie Co 253 2330 24 59 975

New York City 632 1021 214 1308 281

Niagara Co 781 385 201 222 423

Onondaga Co 1009 576 211 157 727

Westchester Co 326 1680 127 188 888

All programs 3228 860c 801 445 483




588 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y











































Program



initial to revisita

Clinton Co 869 08 66 00 1000

Erie Co 2575 84 74 88 48

Niagara Co 2729 44 330 05 886

Oneida Co 1439 32 668 10 688

Onondaga Co 3159 217 566 144 336

Orange Co 901 139 525 56 597


All programs 14623 102b 2467 58 431




Program



Clinton Co 86 512 13 00 1000

Erie Co 46 391 38 263 327

New York City 260 1681 46 696 586

Niagara Co 369 612 221 113 815

Westchester Co 74 986 175 320 676

All programs 835 956 493 249 739




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



































at the revisit


management plan at

initial and revisit




Erie Co 34 618 38 368 759

New York City 231 82 46 174 242

Niagara Co 297 559 221 95 601

















Erie Co 140 132 253








590 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























Cost Analysis












1997 $161 in 1998 $111 in 1999 and $171 in 2000



























Program


1997ndash1999a 2000b 1997a 1998a 1999a 2000b


Clinton Co 53862 65000 163 144 211 262

Erie Co 205500 204221 232 425 157 524

New York City 353508 325000 94 169 95 134

Niagara Co 118000 125000 227 88 85 59


Onondaga Co 166467 170000 128 148 110 209



Westchester Co 228304 232000 184 250 196 208

All programs 1248011 1249367 148 161 111 171




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





DISCUSSION




















































sources of data

Direct Outcomes









































592 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y




Cost Analysis






















the program

RESULTS

Direct Outcomes























1997 1998 and 1999 were 1095 864 and 622










revisits of 483










Clinton Co 227 465 24 28 940

Erie Co 253 2330 24 59 975

New York City 632 1021 214 1308 281

Niagara Co 781 385 201 222 423

Onondaga Co 1009 576 211 157 727

Westchester Co 326 1680 127 188 888

All programs 3228 860c 801 445 483




588 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y











































Program



initial to revisita

Clinton Co 869 08 66 00 1000

Erie Co 2575 84 74 88 48

Niagara Co 2729 44 330 05 886

Oneida Co 1439 32 668 10 688

Onondaga Co 3159 217 566 144 336

Orange Co 901 139 525 56 597


All programs 14623 102b 2467 58 431




Program



Clinton Co 86 512 13 00 1000

Erie Co 46 391 38 263 327

New York City 260 1681 46 696 586

Niagara Co 369 612 221 113 815

Westchester Co 74 986 175 320 676

All programs 835 956 493 249 739




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



































at the revisit


management plan at

initial and revisit




Erie Co 34 618 38 368 759

New York City 231 82 46 174 242

Niagara Co 297 559 221 95 601

















Erie Co 140 132 253








590 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























Cost Analysis












1997 $161 in 1998 $111 in 1999 and $171 in 2000



























Program


1997ndash1999a 2000b 1997a 1998a 1999a 2000b


Clinton Co 53862 65000 163 144 211 262

Erie Co 205500 204221 232 425 157 524

New York City 353508 325000 94 169 95 134

Niagara Co 118000 125000 227 88 85 59


Onondaga Co 166467 170000 128 148 110 209



Westchester Co 228304 232000 184 250 196 208

All programs 1248011 1249367 148 161 111 171




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





DISCUSSION




















































sources of data

Direct Outcomes









































592 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y











































Program



initial to revisita

Clinton Co 869 08 66 00 1000

Erie Co 2575 84 74 88 48

Niagara Co 2729 44 330 05 886

Oneida Co 1439 32 668 10 688

Onondaga Co 3159 217 566 144 336

Orange Co 901 139 525 56 597


All programs 14623 102b 2467 58 431




Program



Clinton Co 86 512 13 00 1000

Erie Co 46 391 38 263 327

New York City 260 1681 46 696 586

Niagara Co 369 612 221 113 815

Westchester Co 74 986 175 320 676

All programs 835 956 493 249 739




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



































at the revisit


management plan at

initial and revisit




Erie Co 34 618 38 368 759

New York City 231 82 46 174 242

Niagara Co 297 559 221 95 601

















Erie Co 140 132 253








590 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























Cost Analysis












1997 $161 in 1998 $111 in 1999 and $171 in 2000



























Program


1997ndash1999a 2000b 1997a 1998a 1999a 2000b


Clinton Co 53862 65000 163 144 211 262

Erie Co 205500 204221 232 425 157 524

New York City 353508 325000 94 169 95 134

Niagara Co 118000 125000 227 88 85 59


Onondaga Co 166467 170000 128 148 110 209



Westchester Co 228304 232000 184 250 196 208

All programs 1248011 1249367 148 161 111 171




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





DISCUSSION




















































sources of data

Direct Outcomes









































592 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



































at the revisit


management plan at

initial and revisit




Erie Co 34 618 38 368 759

New York City 231 82 46 174 242

Niagara Co 297 559 221 95 601

















Erie Co 140 132 253








590 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























Cost Analysis












1997 $161 in 1998 $111 in 1999 and $171 in 2000



























Program


1997ndash1999a 2000b 1997a 1998a 1999a 2000b


Clinton Co 53862 65000 163 144 211 262

Erie Co 205500 204221 232 425 157 524

New York City 353508 325000 94 169 95 134

Niagara Co 118000 125000 227 88 85 59


Onondaga Co 166467 170000 128 148 110 209



Westchester Co 228304 232000 184 250 196 208

All programs 1248011 1249367 148 161 111 171




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





DISCUSSION




















































sources of data

Direct Outcomes









































592 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























Cost Analysis












1997 $161 in 1998 $111 in 1999 and $171 in 2000



























Program


1997ndash1999a 2000b 1997a 1998a 1999a 2000b


Clinton Co 53862 65000 163 144 211 262

Erie Co 205500 204221 232 425 157 524

New York City 353508 325000 94 169 95 134

Niagara Co 118000 125000 227 88 85 59


Onondaga Co 166467 170000 128 148 110 209



Westchester Co 228304 232000 184 250 196 208

All programs 1248011 1249367 148 161 111 171




J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





DISCUSSION




















































sources of data

Direct Outcomes









































592 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





DISCUSSION




















































sources of data

Direct Outcomes









































592 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y



























































































50 after 12 months















J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y








Cost Analysis









2002 funding cycle

















Limitations













































CONCLUSION












REFERENCES





594 Lin et al

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y





1993 436 pp








2002)









4 pp

































J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

rec

om b

y T

he U

nive

rsity

of

Man

ches

ter

on 1

029

14

For

pers

onal

use

onl

y

an evaluation of the asthma intervention of the new york state healthy neighborhoods program

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