 |
|
Effectiveness of an Asthma Management Program for Pediatric Members of a Large Health Maintenance Organization
Susan L. Lukacs, DO, MSPH;
Eric K. France, MD, MSPH;
Anna E. Barón, PhD;
Lori A. Crane, PhD, MPH
Arch Pediatr Adolesc Med. 2002;156:872-876.
ABSTRACT
| |
Objective To assess the impact of an asthma management program on the dispensing
of inhaled corticosteroids, hospitalizations, and emergency department (ED)
visits on children, adolescents, and young adults.
Design We used medical record and pharmacy data for the 18 months after initiation
of a pilot asthma management program. Two intervention offices were matched
with 2 control offices on pediatric volume, number of pediatricians or family
practitioners, and specialist availability.
Setting Primary care offices at Kaiser Permanente Colorado, in Denver and Boulder.
Patients We identified 298 patients, 18 years or younger, who were listed in an
asthma registry between February 1 and July 31, 1997, as having moderate or
severe asthma.
Intervention The Kaiser Permanente Colorado Asthma Care Management Program is an
outpatient-based program that provides comprehensive evaluation, education,
and follow-up to patients identified from an asthma registry or referred by
providers.
Main Outcome Measures The proportion of patients who received more than 1 dispensing of inhaled
corticosteroid during the observation period. Additional outcomes measured
the proportion of patients with 1 or more hospitalizations or ED visits.
Results A significantly greater proportion of patients from the intervention
group received more than 1 dispensing of inhaled corticosteroid compared with
controls (relative risk [RR], 1.41; 95% confidence interval [CI], 1.08-1.72).
We found no significant difference in the proportion of patients who were
hospitalized (RR, 1.37; 95% CI, 0.48-3.71) or visited the ED (RR, 0.86; 95%
CI, 0.49-1.40).
Conclusions The presence of an asthma management program may improve dispensing
of inhaled corticosteroids to young patients with moderate or severe asthma,
as recommended by national guidelines. This type of program may not have an
effect on hospitalizations or ED visits.
INTRODUCTION
ASTHMA, THE most common chronic illness of childhood, affects an estimated
4.8 million children, adolescents, and young adults in the United States.1 This number represents a marked increase in prevalence
during the past 2 decades.1-2
Medical treatment of asthma has also recently changed. Changes in therapy
are due to awareness of airway inflammation as a major mechanism in the pathophysiology
of chronic asthma. National guidelines developed by the National Asthma Education
Program of the National Institutes of Health recommend inhaled anti-inflammatory
medications as a major component of treatment.3
Published literature suggests that provider compliance with National Asthma
Education Program guidelines is low.4-7
When guidelines are followed, evidence suggests improved outcomes for patients
receiving inhaled anti-inflammatory medications. Some studies indicate a 40%
to 50% reduction in hospital admissions for children and adults with asthma.8-11
Recently, asthma management programs have evolved as a response to increasing
trends in prevalence, morbidity, and mortality of asthma. Outcome evaluations
of asthma management programs have identified increasing knowledge about asthma
and symptom-free days,12-16
but the effects on emergency department (ED) visits and hospitalizations are
less clear.16-22
Few studies have examined the effect of asthma programs on processes of health
care, particularly studies targeting children.
In February 1997, a pilot asthma management program began at 2 of the
15 offices of Kaiser Permanente Colorado (KPC). We compared the effects of
the program on intervention group patients receiving health care where the
asthma management program was available and control group patients receiving
health care at an office where the program was not available. The KPC pilot
asthma program targeted high-risk patients with moderate or severe disease.
The primary aim of our study was to determine whether this program resulted
in improved medical management for children, adolescents, and young adults
with moderate or severe asthma as measured by an increase in the dispensing
of inhaled corticosteroids. The secondary objective of the study was to assess
the effect of asthma management on the use of health care services (hospitalizations
and ED, acute outpatient, and allergy-related visits).
PATIENTS AND METHODS
STUDY SETTING
The study was conducted at KPC, a nonprofit, group-model health maintenance
organization that serves 350 000 members and approximately 86 000
pediatric members in the Denver/Boulder metropolitan area. Members of KPC
receive comprehensive health care, including prescription medications and
equipment. Approximately 97% of members have a pharmacy benefit. In 1997,
3% of KPC patients aged 5 to 18 years (approximately 2000 patients) were identified
as having persistent asthma.
Subjects for the study were identified from the Asthma Disease Management
System at KPC. This is a registry of all members identified with asthma from
the KPC administrative databases (outpatient, ED, inpatient, and pharmacy
tables). Asthma care managers can manually add missed members or delete members
from the registry when their medical charts indicate an incorrect assessment.
Criteria for entry include members who, in the previous 12 months, meet at
least 1 of the following: 1 inpatient hospitalization for asthma, 2 or more
outpatient asthma-related visits, 2 or more ß-agonist dispensings, 1
or more corticosteroid and 1 or more ß-agonist dispensings, or 4 or more
of the total of all ß-agonist, cromolyn sodium, corticosteroid, and theophylline
dispensings.
The intervention group for the study included 2 offices that piloted
the KPC Asthma Care Management Program. The control group was ascertained
during study design by selecting 2 KPC offices matched to the 2 intervention
offices by geographic location, pediatric department size, number of pediatricians,
office hours, accessibility to an allergist, and patients' Medicaid status.
Intervention and control groups consisted of 1 larger office and 1 smaller
office. The larger office in both groups included 8 to 9 pediatricians and
an on-site allergist. These offices had daytime hours, 7 days a week. The
smaller office in both groups included 1 pediatrician and 3 family practitioners.
No allergist was staffed at either small office. Office hours were daytime,
Monday through Friday. Routine asthma care for all patients at KPC included
medical therapy by a primary care physician or a midlevel provider with the
availability of allergy consultation, standardized written home health care
plans, and regionwide asthma education programs. Intervention group patients
and their providers also had an on-site asthma care nurse. Intervention group
patients with moderate or severe asthma were eligible for outreach by the
asthma care nurse and could receive care if identified and if the parents
agreed to participate.
THE ASTHMA CARE MANAGEMENT PROGRAM
The KPC Asthma Care Management Program began development in 1995 to
provide disease management to members with asthma. In addition to focusing
on individual patient care, asthma care nurses identified high-risk patients
for outreach, provided physicians with consultation and guidelines for referral,
created patient-status reports, and provided education and in-service training
for staff. Two registered nurses performed all program activities after receiving
education on asthma management from an asthma nurse specialist and a KPC pulmonologist.
Initial evaluation of program implementation during the pilot period
indicated that the asthma care nurses spent approximately 40% of their time
with patients (eg, giving patient care and making telephone calls) and 60%
of their time with administration, training and education, and meetings. Asthma
classes were also provided during the pilot period to members with less severe
disease who were referred by their health care provider.
STUDY POPULATION
The study population consisted of patients 18 years or younger who were
identified from the asthma registry between February 1 and July 31, 1997.
A total of 6274 patients were identified. The population was limited to those
whose primary office site was 1 of the 2 pilot offices or 1 of the 2 control
offices (n = 2615). The population was further limited to continuous KPC members
from 1 year before registry identification to the end of the 18-month study
after registry identification (February 1, 1996, through August 1, 1998) (n
= 1921).
From this population, patients with moderate or severe asthma were identified.
Criteria for defining these patients were based on similar criteria used by
asthma care nurses to identify high-risk patients. The criteria reflect National
Asthma Education Program classification of asthma severity and included patients
with 1 or more of the following: at least 1 hospitalization or ED visit for
asthma in reater than 6 canister equivalents of ß-agonist in the past
6 months, or dispensing of 2 or more oral prednisone bursts in the past 6
months.
Study population patients receiving care at a pilot office were eligible
to receive the asthma management program. Nurses identified patients with
moderate or severe asthma from the monthly asthma registry and provided outreach
to patients they identified as being at high risk. Parents of identified patients
were contacted via telephone and participation was voluntary. If a parent
agreed to participate, the patient received an initial comprehensive evaluation
by the asthma care nurse, including a thorough medical and environmental history.
Patients and parents also received education regarding asthma physiology,
symptom and trigger recognition, and methods to avoid triggers. Patients and
their families were educated on proper use of medications and equipment, such
as peak flow meters and inhalers. Finally, each patient was given a written
home health care plan for long-term treatment and for response to exacerbations.
All patients received a follow-up telephone call within 2 to 3 weeks after
the initial visit. Continued telephone contacts or office visits depended
on the patient's needs. Patients were discharged from the program when they
demonstrated the ability to manage their asthma at home, the patient or the
parent declined further management, or the patient left KPC.
OUTCOMES MEASURED
The observation period was defined as the 18 months after initiation
of the pilot program (February 1, 1997, through August 1, 1998). The primary
outcome of interest was the proportion of patients with more than 1 dispensing
of an inhaled corticosteroid during the observation period and was measured
by means of electronic pharmacy data. We hypothesized that a greater proportion
of intervention group children would receive more than 1 dispensing of inhaled
corticosteroid than controls. Since dispensing of 1 canister of inhaled corticosteroid
may represent short-term or rescue use of the medication during an acute exacerbation,
our primary outcome attempted to characterize the dispensing of an inhaled
corticosteroid as a controller or long-term medication. Although the number
of inhaled corticosteroid canisters dispensed may be the ideal outcome, this
measurement was not possible because of the large number of subjects not dispensed
any inhaled corticosteroids during the observation period. This necessitated
the use of a dichotomous outcome variable.
Hospitalizations, ED visits, acute asthma-related outpatient visits,
and referrals to an allergist were assessed as secondary health care outcomes
and measured by means of electronic claims data. We hypothesized that proportionately
fewer intervention group patients than controls would have 1 or more hospitalizations,
ED visits, acute asthma-related outpatient visits (defined as an outpatient
asthma-related visit with a nebulized ß-agonist treatment given at the
visit), or allergy referrals. Finally, in an effort to assess medical treatment
after an acute asthma exacerbation, we hypothesized that a greater proportion
of intervention group patients would be dispensed an inhaled corticosteroid
within 1 month of an acute visit for asthma (outpatient or ED visit or hospital
admission) and would have had no dispensing of an inhaled corticosteroid in
the previous 2 months.
STATISTICAL ANALYSIS
Analysis was performed using SAS Version 8.0 software.23
Baseline characteristics were measured for the 12 months preceding the study
period (February 1, 1996, through January 31, 1997). Baseline covariates included
age, sex, dispensing of asthma medications, asthma-related visits, asthma-related
hospitalizations, ED visits, and referrals to an allergist. Information regarding
income and race/ethnicity was not available. We performed univariate analyses
using  2 tests. Logistic regression was used to estimate the
odds ratios of the various outcomes for the intervention group vs the controls
after controlling for the primary outcome at baseline and for important confounders.
Relative risks (RRs) were then calculated from the odds ratios according to
the methods of Zhang and Yu.24 We tested interactions
between the group assignment and the primary outcome at baseline and between
the group assignment and the covariates retained in the final model. In all
models, the independent variables age, sex, dispensing of baseline ß-agonist
and inhaled corticosteroid, baseline allergy referral, baseline asthma-related
hospitalizations, and ED and acute outpatient visits were retained. Post hoc
power analyses were performed for observed intervention differences, because
sample size was limited to data available. Consistent with the intention-to-treat
model, all subjects were included in the analyses according to their site
assignment and regardless of actual enrollment in the asthma management program.
RESULTS
Of the 1921 patients identified from the asthma registry and eligible
for this study population, 298 met the defined criteria for moderate or severe
asthma (Figure 1). Patients enrolled
in Medicaid constituted less than 3% of the population.
|
|
|
|
Determination of study population. KPC indicates Kaiser Permanente
Colorado; ED, emergency department; and ACMP, Asthma Care Management Program.
|
|
|
Table 1 compares the characteristics
of the intervention and control groups during the 12-month baseline period.
Significant differences at baseline included a higher percentage of intervention
group patients dispensed a ß-agonist (P = .02)
and a higher percentage of controls referred to an allergist (P = .04).
|
|
|
|
Characteristics of Patients With Asthma*
|
|
|
Forty-five (28%) of the 163 patients in the intervention group visited
the asthma care nurse. Baseline characteristics of these 45 patients compared
with those in the intervention group who did not receive the program revealed
no significant differences in age, sex, use of health care services, or dispensing
of asthma medications. Data were not available to determine the extent to
which patients not participating in the program were contacted regarding participation.
During the 18-month observation, 86 (53%) of 163 patients in the intervention
group and 55 (41%) of 135 controls received more than 1 dispensing of inhaled
corticosteroid (crude RR, 1.30; 95% confidence interval [CI], 1.01-1.56).
Results of multivariate analysis indicated that the RR for more than 1 dispensing
of inhaled corticosteroid was significantly greater for patients receiving
health care at an office where an asthma management program was available
(RR, 1.41; 95% CI, 1.08-1.72). This result was independent of the patient's
age, sex, and baseline asthma characteristics (ie, dispensing of a ß-agonist
medication or >1 inhaled corticosteroid, referral to an allergist, and asthma-related
hospital admissions, ED visits, and acute outpatient visits during the baseline
period).
During the observation period, we found a trend toward intervention
group patients having a greater proportion of hospital admissions (n = 17
[10%]) compared with controls (n = 6 [4%]). After controlling for baseline
differences between groups, the adjusted RR for hospitalizations was 1.37,
and was not statistically significant (95% CI, 0.48-3.71). Assessment of ED
visits indicated that the proportions of intervention group patients and controls
visiting the ED were similar during the observation period (26% and 22%, respectively).
Results of multivariate analysis also showed no significant difference between
the groups (RR, 0.86; 95% CI, 0.49-1.40).
Multivariate analysis predicting 1 or more acute outpatient asthma-related
visits showed no significant difference between the intervention and control
groups (RR, 1.16; 95% CI, 0.70-1.84). Also, no significant difference was
found between the intervention and control groups for the proportion of patients
referred to an allergist during the observation period (RR, 0.92; 95% CI,
0.52-1.48). Finally, we examined all patients who had any type of acute visit
(outpatient or ED visit or hospitalization) and did not receive a dispensing
of an inhaled corticosteroid in the preceding 2 months and compared the proportion
of intervention and control patients who received a dispensing of an inhaled
corticosteroid within 1 month of their visit. We found no significant difference
for this outcome (RR, 1.11; 95% CI, 0.65-1.59).
COMMENT
This study evaluated the effectiveness of an outpatient-based asthma
management program for pediatric members of a large health maintenance organization
by assessing the dispensing of inhaled corticosteroids and the use of various
health care services (asthma-related hospital admissions, ED and acute outpatient
visits, and allergy referrals). The program, delivered by registered nurses
to patients of all ages in a primary care office, was designed to provide
thorough evaluation, education, treatment, and follow-up to patients and consultative
support to staff and health care providers.
We found that a significantly greater proportion of intervention group
patients received more than 1 dispensing of inhaled corticosteroid compared
with controls. Our result suggests that the presence of this type of program
may improve clinical management of moderate or severe asthma in our study
age group. Our data, however, limit us from inferring improvement in adherence
to recommended treatment guidelines. Continued emphasis on program delivery
may lead to better guideline adherence over time and possibly to better clinical
outcomes measured by hospitalizations and ED visits.
The absence of a reduction in asthma-related hospitalizations and ED
or acute outpatient visits in this study may be due to a lack of statistical
power to detect a difference of the magnitude observed. Other studies have
shown mixed results for these outcomes. Greineder et al17
evaluated an asthma management program provided in a large health maintenance
organization outpatient setting. Intervention group patients receiving the
program plus telephone follow-up for 1 year demonstrated an additional 57%
decline in ED visits and an additional 75% decline in hospitalizations compared
with controls receiving the initial program only. Two studies evaluating hospital-based
programs in the United Kingdom showed a significant decline in hospital readmission.20-21 Several other studies evaluating
the effects of programs on hospital and ED visits, however, showed no significant
difference.16, 18, 22, 25
Interpreting results from this study may be limited by the lack of program
implementation to most of the intervention group. Although a statistically
significant RR was found for patients receiving care where an asthma management
program was available, the effect of the intervention itself is indeterminate.
Lack of significant effect on the use of health care services may also be
due to a lack of program implementation. As noted, only 27% of the patients
identified with moderate or severe asthma actually received the program. Lack
of an effect on use of health care services may be due to what McKinley26 has termed type III error,
ie, the conclusion that an intervention is not effective when in actuality
the intervention is not implemented. Examining program effectiveness, however,
may be useful and clinically important because it better reflects the effects
of an active, working program in a primary care setting.
The lack of full implementation in this study also highlights the inability
of many programs to reach all of their target population and suggests the
need to improve recruitment to or participation by the most needy groups.
In our study, asthma care nurses saw approximately 300 adults and children
and contacted an additional 250 persons by telephone during the observation
period. Asthma care nurses spent less than half of their time providing patient
care and the remainder identifying high-risk patients, consulting, and performing
administrative duties. Thus, the workload of asthma care nurses may limit
the feasibility of the program to reach children with more severe asthma.
One strategy might be to refer children with less severe asthma to more general
asthma classes and to restrict use of the asthma management program to those
with more severe disease.
This study was also limited by unknown differences among providers and
staff working in the intervention and control offices that could affect the
management of asthma. Finally, this study measured only the dispensing of
asthma medications, which does not take into account compliance or proper
medication use.
CONCLUSIONS
This study suggests that presence of an asthma care management program
may increase the proportion of children and adolescents with moderate or severe
asthma who are dispensed an inhaled corticosteroid. It did not find a reduction
in clinical outcomes of asthma-related hospital admissions, ED or acute outpatient
visits, or allergy referrals. The lack of significant clinical effect may
be due to the small percentage of patients with moderate or severe asthma
actually receiving the program, which emphasizes the need for improved recruitment
and implementation of the program to these patients. Further evaluation assessing
the effect of increased dispensing of inhaled corticosteroids on the quality
of the lives of children, adolescents, and young adults (eg, symptom-free
days, hospitalizations, and ED visits) would be useful.
| What This Study Adds
Asthma care management programs have become an adjunct to medical treatment
of patients with asthma. Unlike many studies evaluating asthma management
programs, this study evaluates the effects of a program for children, adolescents,
and young adults in a managed-care setting.
Findings from this study suggest that the presence of an asthma management
program may improve dispensing of inhaled corticosteroids to children with
moderate or severe asthma, and therefore, implies better medical management
of asthma for children and adolescents. The program did not appear to have
a short-term effect on use of health care services.
|
|
AUTHOR INFORMATION
Accepted for publication March 7, 2002.
We thank Laurie Crounse, MPH, for her assistance in computer programming,
Debra Ritzwoller, PhD, for her knowledge and assistance with the asthma registry,
and Michael Bodily, MBA, for assistance with data extractions.
Corresponding author and reprints: Susan L. Lukacs, DO, MSPH, National
Center for Health Statistics, Centers for Disease Control and Prevention,
6525 Belcrest Rd, Room 790, Hyattsville, MD 20782 (e-mail: srl2{at}cdc.gov).
From the Department of Preventive Medicine and Biometrics, University
of Colorado Health Sciences Center, Denver (Drs Lukacs, France, Barón,
and Crane), and the Department of Preventive Medicine, Kaiser Permanente (Dr
France), Colorado, Denver. Dr Lukacs is now with the National Center for Health
Statistics, Centers for Disease Control and Prevention, Hyattsville, Md.
REFERENCES
| |
1. Centers for Disease Control and Prevention. Asthma mortality and hospitalization among children and adults—United
States, 1980-1993. MMWR Morb Mortal Wkly Rep. 1996;45(17):350-353.
2. Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for asthma: United States, 1960-1995. Mor Mortal Wkly Rep CDC Surveill Summ. 1998;47:1-27.
3. National Asthma Education Prevention Program. Expert Panel Report II: Guidelines for the Diagnosis
and Management of Asthma. Bethesda, Md: National Heart, Lung, and Blood Institute; 1997.
4. Meng YY, Leung KM, Berkbigler D, Halbert RJ, Legorreta AP. Compliance with US asthma management guidelines and specialty care:
a regional variation or national concern? J Eval Clin Pract. 1999;5:213-221.
FULL TEXT
|
ISI
| PUBMED
5. Goodman DC, Lozano P, Stukel TA, Chang C, Hecht J. Has asthma medication use in children become more frequent, more appropriate,
or both? Pediatrics. 1999;104(2, pt 1):187-194.
6. Halterman JS, Aligne CA, Auinger P, McBride JT, Szilagyi PG. Inadequate therapy for asthma among children in the United States. Pediatrics. 2000;105(1, pt 3):272-276.
7. Vollmer WM, O'Hollaren M, Ettinger KM, et al. Specialty differences in the management of asthma: a cross-sectional
assessment of allergists' patients and generalists' patients in a large HMO. Arch Intern Med. 1997;157:1201-1208.
FREE FULL TEXT
8. Wennergren G, Kristjansson S, Strannegard IL. Decrease in hospitalization for treatment of childhood asthma with
increased use of anti-inflammatory treatment, despite an increase in the prevalence
of asthma. J Allergy Clin Immunol. 1996;97:742-748.
FULL TEXT
|
ISI
| PUBMED
9. Gerdtham UG, Hertzman P, Jonsson B, Boman G. Impact of inhaled corticosteroids on acute asthma hospitalization in
Sweden 1978 to 1991. Med Care. 1996;34:1188-1198.
FULL TEXT
|
ISI
| PUBMED
10. Blais L, Ernst P, Boivin J, Suissa S. Inhaled corticosteroids and the prevention of readmission to hospital
for asthma. Am J Respir Crit Care Med. 1998;158:126-132.
FREE FULL TEXT
11. Donahue JG, Weiss ST, Livingston JM, Goetsch MA, Greineder DK, Platt R. Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997;277:887-891.
FREE FULL TEXT
12. Evans III R, Gergen PJ, Mitchell H, et al. A randomized clinical trial to reduce asthma morbidity among inner-city
children: results of the National Cooperative Inner-City Asthma Study. J Pediatr. 1999;135:332-338.
FULL TEXT
|
ISI
| PUBMED
13. Gebert N, Hummelink R, Konning J, et al. Efficacy of a self-management program for childhood asthma: a prospective
controlled study. Patient Educ Couns. 1998;35:213-220.
FULL TEXT
|
ISI
| PUBMED
14. Wilson SR, Latini D, Starr NJ, et al. Education of parents of infants and very young children with asthma:
a developmental evaluation of the Wee Wheezers program. J Asthma. 1996;33:239-254.
ISI
| PUBMED
15. Holzheimer L, Mohay H, Masters IB. Educating young children about asthma: comparing the effectiveness
of a developmentally appropriate asthma education video tape and picture book. Child Care Health Dev. 1998;24:85-99.
FULL TEXT
|
ISI
| PUBMED
16. Christiansen SC, Martin SB, Schleicher NC, Koziol JA, Mathews KP, Zuraw BL. Evaluation of a school-based asthma education program for inner-city
children. J Allergy Clin Immunol. 1997;100:613-617.
FULL TEXT
|
ISI
| PUBMED
17. Greineder DK, Loane KC, Parks P. A randomized controlled trial of a pediatric asthma outreach program. J Allergy Clin Immunol. 1999;103(pt 1):436-440.
18. McCowan C, Neville RG, Crombie IK, Clark RA, Warner FC. The facilitator effect: results from a four-year follow-up of children
with asthma. Br J Gen Pract. 1997;47:156-160.
PUBMED
19. Ronchetti R, Indinnimeo L, Bonci E, et al for the Italian Study Group on Asthma Self-Management Programmes. Asthma self-management programmes in a population of Italian children:
a multicentric study. Eur Respir J. 1997;10:1248-1253.
ABSTRACT
20. Wesseldine LJ, McCarthy P, Silverman M. Structured discharge procedure for children admittted to hospital with
acute asthma: a randomised controlled trial of nursing practice. Arch Dis Child. 1999;80:110-114.
FREE FULL TEXT
21. Madge P, McColl J, Paton J. Impact of a nurse-led home management training programme in children
admitted to hospital with acute asthma: a randomised controlled study. Thorax. 1997;52:223-228.
ABSTRACT
22. Persaud DI, Barnett SE, Weller SC, Baldwin CD, Niebuhr V, McCormick DP. An asthma self-management program for children, including instruction
in peak flow monitoring by school nurses. J Asthma. 1996;33:37-43.
ISI
| PUBMED
23. SAS Version 8.0. Cary, NC: SAS Institute Inc; 1999-2001.
24. Zhang J, Yu KF. What's the relative risk? a method of correcting the odds ratio in
cohort studies of common outcomes. JAMA. 1998;280:1690-1691.
FREE FULL TEXT
25. Clark NM, Gong M, Schork MA, et al. Impact of education for physicians on patient outcomes. Pediatrics. 1998;101:831-836.
FREE FULL TEXT
26. McKinley JB. The new public health approach to improving physical activity and autonomy
in older populations. In: Heikkinen E, ed. Preparation for Aging.
New York, NY: Plenum Publishing Corp; 1995:87-103.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Effects of Asthma Education on Children's Use of Acute Care Services: A Meta-analysis
Coffman et al.
Pediatrics 2008;121:575-586.
ABSTRACT
| FULL TEXT
|
