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Targeting Improvements in Asthma Morbidity in Chicago^*

A 10-Year Retrospective of Community Action

^* From the Division of Pulmonary Medicine (Dr. Shannon), John H. Stroger, Jr. Hospital of Cook County, Chicago, IL; Rush University College of Nursing (Dr. Catrambone), Rush University Medical Center, Chicago, IL; and Pediatric Case Management Services (Ms. Coover), Highland, IN.

Correspondence to: John Jay Shannon, MD, FCCP, Parkland Health and Hospital System, Administration Suite, 5201 Harry Hines Blvd, Dallas, TX 75214; e-mail: jshann{at}parknet.pmh.org

	Abstract

TOP Abstract Introduction Policy and Advocacy Initiatives Disparity Initiatives Education Initiatives Surveillance Initiatives Research Initiatives Quality Improvement Consortia Community Initiatives Glossary: Asthma Initiatives,... References

 
Chicago has been described as "asthma ground zero" due to its disproportionately high rates of asthma-related hospitalization and mortality. Asthma prevalence rates in Chicago are higher for whites and African Americans than the national average. In an effort to address the asthma burden and disparities in Chicago, multiple initiatives throughout the city have been launched and continue due largely to the support of the Otho S.A. Sprague Memorial Institute. The purpose of this article is to describe the policy, advocacy, educational, surveillance, research, quality improvement, community, and consortia activities over the past 10 years and their impact on asthma morbidity and disparities in Chicago.

Key Words: asthma • community action • consortia • quality improvement • surveillance

	Introduction

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Chicago continues to be "asthma ground zero" due to its disproportionately high rates of asthma-related hospitalization and mortality.¹ Prevalence rates for asthma for persons in Chicago are higher for whites and African Americans than the national average.² However, this increased prevalence does not explain that the Chicago asthma hospitalization rate for African Americans is nearly double that of the nation as a whole.³

In the mid 1990s, with the help of The Otho S.A. Sprague Memorial Institute, a number of community- and medical center-based collaborative efforts were launched with the aim of reducing asthma morbidity in Chicago. This multifaceted approach involved health-care providers, public health agencies, academic medical centers, and community advocates. This review summarizes the many asthma intervention strategies, initiatives and programs that were initiated during the last decade, and highlights some of the successful programs.

Recent asthma interventions in Chicago can be considered in eight major activity domains: policy and advocacy, work addressing disparities, education, surveillance, research, quality improvement, consortium development, and community initiatives. While it is useful to classify these efforts for reporting, many of the activities overlapped categories due to their multifaceted design.

	Policy and Advocacy Initiatives

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Many of the community-based advocacy and policy projects related to asthma have been accomplished by joint efforts of the Chicago Asthma Consortium (CAC) and the American Lung Association of Metropolitan Chicago (ALAMC).

Legislative Activities
Legislative activity included the following efforts: (1) allowed students to carry inhalers in schools, (2) improved private insurance coverage for inhalers, (3) advanced tobacco control and clean air policy, (4) reduced youth access to tobacco, and (5) developed targeted tax funding for asthma and lung disease research with an optional "check box" on the Illinois state income tax form.

One of the early major successes of the CAC was to catalyze a change in Chicago Public School policy to allow children better access to their ß-agonist inhalers while in school. That success catalyzed a new state inhaler law that requires all schools to allow children to carry and use life-saving asthma medications. This legislation was later expanded to allow children to carry inhalers to recreational camps. To address restrictions imposed by private insurers on the number of inhalers an individual with asthma may receive in a month, the ALAMC and American Lung Association of Illinois worked together with partners to get a law passed through the Illinois Legislature disallowing restrictions on "medically necessary" inhalers.

Tobacco Control and Clean Air
The ALAMC, CAC, and many other partners, including local health departments, have been working on a multifaceted effort to support communities that desire to go smoke free. After a 16-year struggle, the Illinois General Assembly passed legislation that grants the right to strengthen indoor air laws to all Illinois communities. Previously only 21 communities could strengthen their clean indoor air laws. There are currently campaigns in many communities to make all public workplaces smoke-free. The Smoke-Free Chicago campaign led to a clean indoor ordinance for Chicago in 2005.

The Clean Diesel Campaign focuses on reducing diesel emissions in Illinois through the Clean School Bus program and the No-Idling Initiative. With funding from the Illinois Environmental Protection Agency, the ALAMC has assisted school districts in the Chicago area retrofit > 90 school buses with pollution-control technology, improving air quality in neighborhoods with high asthma prevalence. The No-Idling Initiative advocates public policy to reduce unnecessary idling of diesel vehicles throughout the state. The Clean Power Campaign successfully lobbied the Chicago City Council for an ordinance to limit emissions from two antiquated coal-fired power plants that have been linked to increased asthma emergency department (ED) visits.

City-Wide Asthma Action Plan
In 2004, the ALAMC formed an Advisory Council to create and implement an Asthma Action Plan for Chicago.⁴ The council is comprised of leaders from key local coalitions, education, businesses, insurers, and health-care professionals from > 20 organizations and agencies. On World Asthma Day 2004, the council publicly proposed five key recommendations to improve the status of asthma in Chicago: (1) to broaden community awareness of asthma symptoms and control, (2) to improve indoor and outdoor air quality, (3) to improve access to quality care in the community setting, (4) to enhance coordination of asthma care services and epidemiology, and (5) to address asthma health disparities. An updated plan released on World Asthma Day 2005 called for a uniform hospital/emergency care discharge policy based on recommendations from National Asthma Education and Prevention Program Expert Panel Report 2 guidelines. The 2006 plan called for air-quality improvements, specifically achieved through accelerated retrofitting of diesel vehicles and passage of legislation further restricting smoking in all public and work places, including restaurants and bars. The most recent World Asthma Day 2007 proposed improved training of physical education teachers and coaches about recognition and management of asthma. Each of these declarations was done with professional and community representation, usually with persons with asthma or their caregivers. They were major media events covered by print, radio, and television.

	Disparity Initiatives

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Chicago is a city with a high concentration of people from lower socioeconomic groups; these groups typically show higher asthma prevalence and morbidity. Over the past 10 years, there have been a number of community-based strategies that focused on reducing asthma disparities. A few of these projects are highlighted.

The Mobile C.A.R.E. Foundation operates two medical vans to provide free and comprehensive medical care, health education, and medications to children with asthma in underserved communities. Its goal is to reduce health disparities related to asthma. Beginning in 1999, vans staffed by a medical team made regularly scheduled stops at > 40 schools and Head Start Program sites in low-income areas of the city. To date, Mobile C.A.R.E. Foundation has provided > 8,000 patient visits to > 2,500 children.

The Asthma and Lead Prevention Program of the Chicago Housing Administration (CHA) project addressed simultaneously two major health concerns in public housing: asthma and lead poisoning in children who reside in four CHA developments. A series of targeted asthma training sessions was held for CHA residents by community health educators living in the housing developments. Hundreds of families were reached, linked with quality care, and educated about asthma and self-management.

Funded by the Centers for Disease Control and Prevention (CDC), the Controlling Asthma in American Cities Project is a community-based, peer-educator program aimed at decreasing environmental risk factors for asthma. The goals of the project are to increase understanding of the processes by which asthma develops in children, identify modifiable risk factors, and demonstrate the effectiveness of intervention strategies that target the needs of underserved populations. This project is focusing on the south side of Chicago, an area particularly hard-hit by rising rates of asthma prevalence and asthma morbidity.

The Chicago Initiative to Raise Asthma Health Equity is a 5-year study funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health. A joint effort of Northwestern University Feinberg School of Medicine and John H. Stroger, Jr. Hospital of Cook County, the Chicago Initiative to Raise Asthma Health Equity is a prospective study of adolescents and young adults in Chicago with asthma, assessing the impact of socioeconomic status and psychosocial stressors on the development and expression of asthma morbidity. Major aims of the study are to explicate the degree of and reasons for disparities in asthma morbidity among urban poor populations, and to develop interventions based on this understanding to reduce or eliminate these disparities.

	Education Initiatives

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Numerous organizations, community groups, researchers, and medical providers have assumed an active role in addressing the asthma education needs of various sectors in the city heavily impacted by asthma.

School-Based Efforts
Asthma 101, a program of proven benefit that teaches 8- to 11-year-old students how to manage asthma, and Open Airways for Schools (OAS), an asthma awareness program for faculty and school staff, have been utilized by several organizations to increase local, neighborhood capacity for asthma management. These programs were developed by the American Lung Association. Largely through efforts of the ALAMC, Asthma 101 has reached > 12,000 students and OAS has reached > 1,500 school staff in Chicago. Despite medical volunteers and program funding, it has been difficult to integrate this curriculum in the Chicago public schools, the third-largest public school system in the nation, and one in which almost 20% of the students have asthma.⁵ With support from The Otho S. A. Sprague Memorial Institute, in 2003 the ALAMC initiated a Stakeholders Collaboration to Improve Student Health. This effort aims to create greater access for Chicago public school students to participating organizations and agencies for health-related services. In response to this collaboration with > 200 organizations, access and coordination have greatly increased, allowing for more systematic and successful utilization of programs. The Stakeholders Collaboration is currently performing a project in 15 schools to determine asthma outcomes, including utilization of community services and asthma-related absenteeism.

Community-Based Efforts
The ALAMC has worked with numerous community organizations to build partnerships and capacity for addressing the asthma problem in Chicago. For example, the success of day and overnight asthma camps is linked to strong local support and involvement. Asthma day camps have garnered aldermanic and local business support. Both day and overnight camps provide children a fun educational experience that empowers them to manage asthma effectively, and they encourage and teach physical activity as an essential feature of living well with asthma. The child participates in at least 1 h of daily asthma education in addition to traditional camp activities. Evaluations over the past 2 years have demonstrated over a 60% increase in competency for taking asthma medications.

Professional Education
Many organizations provided key asthma education in the professional community. Since its inception, the CAC has hosted 29 quarterly meetings; these typically include one clinical review. Asthma educators at University of Illinois developed asthma focused problem-based learning sessions for primary care providers.⁶ The Nursing Assembly of the ALAMC has conducted comprehensive review courses for providers preparing for certification as asthma educators annually since 2003.

	Surveillance Initiatives

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Many organizations, consortia, and collaboratives collected and distributed information on asthma prevalence and severity, attitudes, and behaviors regarding asthma therapy in various clinical settings, and knowledge and attitudes about asthma in Chicago communities. In data workshops sponsored by the CAC annually since 1997, epidemiologists, community leaders, and health-care providers have presented focused analyses of many of the issues concerning asthma in Chicago. University of Chicago and Chicago Department of Public Health epidemiologists have developed detailed maps of how asthma variably affects different neighborhoods and how treatment varies from community to community.⁷ These analyses have been critical for asthma care in Chicago and have helped to focus research and treatment programs.

Two important surveillance projects include the Chicago Asthma Surveillance Initiative (CASI) and the Illinois Emergency Department Asthma Collaborative (IEDAC). The CASI was a citywide surveillance program sponsored by the Otho S. A. Sprague Memorial Institute.⁸ The CASI had the following aims: (1) to characterize the variations in asthma care in hospitals, EDs, primary care and asthma specialty practices, managed-care organizations, and communities of Chicago and the surrounding counties; (2) to provide data to various organizations with community-wide programs in asthma education, such as the CAC; (3) to establish a method for monitoring changes in Chicago-area asthma care and effectiveness of community-wide asthma awareness efforts; and (4) to characterize awareness of asthma in various community settings.

The results from these cross-sectional surveys were featured in a CHEST Supplement^910111213 that addressed how individuals and communities were affected by asthma, how the health-care system was responding, described asthma knowledge and care practice of health providers, and community responses to asthma in Chicago. The working groups of authors came from many universities, hospitals, community organizations, and the activity around that collaborative activity was the seed that blossomed into stronger cross-institution relationships of coinvestigators.

The IEDAC, funded by the CDC, developed and tested an ED-based system of asthma surveillance with the goal of improving quality of care in ED asthma patients. Three surveillance instruments measured the following: (1) asthma risk assessment, (2) asthma process of care in the ED, and (3) asthma-outcomes assessment. A 15-month period of data collection assessed the feasibility and responsiveness of the proposed surveillance program. After refinement of the surveillance model, the assessment tools were transferred to an Internet environment for broader dissemination. The IEDAC showed that many children coming to Illinois EDs were not using effective controller medications, and that those who were prescribed the medications were not taking them in an effective manner.¹⁴ The IEDAC demonstrated the usefulness of an ED-based surveillance system in assessing asthma risk within the community, describing acute care practice in relation to national standards, and measuring relapse following an ED visit.

	Research Initiatives

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In addition to basic research on asthma biology and genetics ongoing in many Chicago centers, Chicago has been an important center for clinical studies in asthma in the past 10 years.

The School-based Pediatric Asthma Research in Chicago investigators analyzed the social, behavioral, environmental, and biological factors influencing racial and ethnic disparities in childhood asthma in Chicago. A short questionnaire, completed by parents, was used to screen > 11,000 children in 14 Chicago public elementary schools for asthma or symptoms consistent with asthma, followed by a series of telephone and home interviews. Evaluation included allergy testing for children and a household dust analysis for common aeroallergens. Physicians were surveyed to understand the nature of asthma practice patterns in this population. Results were shared with families and communities.¹⁵

The Impact of Air Purifiers on Pediatric Asthma Outcomes in the Inner City study¹⁶ observed the effect of high-efficiency particulate air (HEPA) filters on asthma in Chicago children. There were no significant differences between homes with HEPA or placebo filters. The study¹⁶ concluded that while air purifiers may be easy to use and affordable, their benefit was not clear in low-income populations. Further study of HEPA filter efficacy is needed before advocating widespread adoption.

The Relationship of Life Stressors and Maternal Depression to Pediatric Asthma Morbidity in a Subspecialty Practice project interviewed caregivers of children with asthma aged 18 months to 12 years to explore the relationships among demographics, caregiver life stressors and depressive symptoms, and asthma outcomes in children. Children were more likely to have difficulty with their asthma if they had caregivers with increased depressive symptoms and negative life stressors and if the child was female, after controlling for race, residence, and Medicaid status.¹⁷ This study offers an important insight into the complex modifiers of asthma morbidity in the urban poor.

The Development and Validation of a Brief Pediatric Screen for Asthma and Allergies project¹⁸ revised a validated asthma screen (Brief Pediatric Asthma Screen) by adding an allergy component and establishing the sensitivity and specificity with a low-income, African-American population. Three predominantly low-income, African-American, elementary schools were screened. A sample of children and parents participated in the validation, consisting of an examination by a pediatric allergist who estimated the probability of an asthma or allergy diagnosis. The asthma portion of the Brief Pediatric Asthma Screen Plus (BPAS+) had 73% sensitivity and 74% specificity. The allergy portion had 71% sensitivity and 77% specificity.¹⁹

Validation of Spanish and English versions of the asthma section of the BPAS+ was conducted in four low-income, Hispanic, elementary schools. Students were screened for the prevalence of asthma and asthma symptoms using the BPAS+ in both English and Spanish languages. Two bilingual clinicians conducted interviews and examinations and classified students as to the likelihood of an asthma diagnosis: no further evaluation warranted, possible evaluation warranted, further evaluation definitely warranted. In Hispanics, the Spanish BPAS+ had 74% sensitivity and 86% specificity, compared to the English version (61% sensitivity and 83% specificity).²⁰

The American Lung Association established the Asthma Clinical Research Center (ACRC) network to conduct multicenter clinical trials. The ACRC network has grown to include 20 research centers. The Chicago center includes investigators from Northwestern University, University of Chicago, Rush University and University of Illinois at Chicago. The ACRC has completed an important study²¹ demonstrating the safety and efficacy of influenza vaccine in asthmatics. The "Lodo" placebo-controlled trial compared low doses of theophylline with the leukotriene receptor antagonist montelukast as add-on therapy in patients symptomatic despite use of inhaled corticosteroids. While both medications led to modest improvements in airway physiology, neither significantly reduced asthma exacerbations compared to placebo. In patients not receiving inhaled corticosteroids, the addition of low-dose theophylline resulted in symptom improvement.²²

	Quality Improvement

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Supported by funding from The Otho S.A. Sprague Memorial Institute, a series of Chicago-area collaboratives were formed to assess current asthma care patterns and to use social networking theory to improve quality and reduce unwanted variation in care of asthma in Chicago. Three collaboratives were conducted: (1) the Chicago Emergency Department Asthma Collaborative (CEDAC), a 1-year collaborative with 21 participating EDs; (2) the Chicago-Area Hospital Asthma Collaborative, a 6-month collaborative with 17 participating hospitals; and (3) the Chicago Primary Care Asthma Collaborative (CPAC), a 6-month collaborative with 15 participating practices.

The collaboratives used techniques pioneered by the Institute for Healthcare Improvement. They provided participants with tools to measure simple process-of-care elements; shared knowledge, skill, and techniques of improved asthma care using social learning networks; assisted participants in setting and attaining specific asthma quality-improvement goals; and convened regular meetings in which teams reported quality improvement cycles and shared asthma-care process-attainment rates. The collaboratives generated tremendous enthusiasm among the participants because they were a venue for discussing asthma quality improvement efforts, and they modeled cross-disciplinary quality improvement teams. The collaboratives were not designed to show improvement in patient outcomes. However, many teams showed improvements in asthma care practices. For example, the CEDAC effort showed a significant increase in the percent of asthma patients that received systemic steroids while in the ED.²³

The Community-Provider-Patient Partnership to Improve Asthma Care was a project of the Chicago/Cook County Community Health Council that aimed to create organizational change in primary health-care sites to improve asthma care. Funded by the Robert Wood Johnson Foundation and The Otho S. A. Sprague Memorial Institute, the partnership included an intensive 5-month intervention. Clinical coordinators at 30 primary care sites impacted 211 providers in five underserved regions in Chicago/Cook County. The goal was to increase prescriptions of antiinflammatory medications, increase use of asthma action plans, improve asthma self-management support, and improve the quality of asthma trigger assessment and avoidance. The project directly supported 627 patients to more fully participate in their care, and developed five coalitions that increased awareness of the seriousness and controllability of asthma in the targeted regions.

The Asthma Champion Initiative, a project of the Cook County Bureau of Health Services, continued to expand the pool of primary care providers with asthma expertise in Chicago neighborhoods. This project was jointly funded by the Centers for Medicaid and Medicare Services and the Illinois Department of Public Aid. A total of 34 primary care providers and 16 nurses/health educators from 27 primary care sites participated in a 16-week clinical rotation in an asthma specialty clinic that modeled optimal asthma assessment and chronic illness comanagement. Similar to the CPAC, the Asthma Champion Initiative used quarterly group meetings to facilitate asthma quality improvement efforts at each site, and to share strategies around achieving these goals.

	Consortia

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CAC
The CAC was formed in January 1996 as a collaborative effort of the ALAMC and the American College of Chest Physicians. The vision for the CAC was to bring individuals and organizations together as a community health network in an effort to work collectively, interdependently, and in synergy to combat the Chicago asthma epidemic. Cofounders Sydney Parker, PhD, and the late Alan Shaw, ALAMC Deputy Executive Director, envisioned an integrated network of regional leaders and organizations working together to improve the status of asthmatics in Chicago. The Otho S.A. Sprague Memorial Institute provided the major funding for the CAC; the CAC received supplemental support from the CHEST Foundation of the American College of Chest Physicians.

The CAC provides an opportunity for health professionals, health-care organizations, community organizations, and families affected by asthma to share information and resources. It serves as a common platform for these groups to organize policy and advocacy efforts. The success of the CAC is due largely to the efforts of its school, data, education, and community task forces.

The CAC has held > 30 quarterly meetings that typically feature clinical reviews, updates on asthma advocacy and policy efforts, and informal networking. The CAC Web site (http://www.chicagoasthma.org/) is an important resource for the community, providing a resource directory, list of community clinics, and a community calendar for all asthma activities in the state. The CAC list server promotes communication, education, information, and resource sharing. The CAC facilitates projects with many local, city, and state organizations.

The CAC is the vanguard organization for all local/regional asthma consortia in America. The CAC has provided leadership at annual American College of Chest Physicians meetings to bring consortia together for information and sharing experiences. In 1999, the Illinois Department of Public Health was one of four state health departments to receive CDC funding for replication of the consortium model across Illinois. With the support of this grant, the Illinois Asthma Partnership was established and several grants were provided to local communities through Illinois to address asthma education and awareness. The CAC has provided leadership locally and nationally for groups interested in forming collaboratives. There are now 15 consortia in Illinois alone.

	Community Initiatives

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There have been many asthma programs targeted to underserved communities in Chicago. More than 50 community asthma programs have been conducted in Chicago, mainly in high-prevalence or high-morbidity areas as characterized by "asthma maps" (http://www.chicagoasthmaatlas.org/htmls/about.asp).

Trained community health workers are widely used in city asthma programs and provide a grassroots connection within their communities. The programs were funded by grants from the Environmental Protection Agency, the CHA, the Department of Human Services, the National Institute for Environmental Health Sciences, the CDC, the National Asthma Education and Prevention Program, and the National Institutes of Health. Community health worker-based models for addressing asthma needs in urban communities with high asthma prevalence are believed to be an important model for sustainable community empowerment for asthma.²⁴

The Otho S.A. Sprague Memorial Institute-funded Head Start community asthma program deployed mothers of children with asthma to teach other parents about asthma management, leading to improved asthma control and fewer ED visits and hospitalizations for these children.²⁵ This approach has since been used as a model for many other community asthma programs in the city.

In the decade following the identification of Chicago as an urban center with extraordinary asthma morbidity, the Chicago community has responded with a broad mix of activities, from quality improvement in clinical sites to public policy to community action. This action agenda would not have been possible without support from philanthropy (The Otho S.A. Sprague Memorial Institute), the CDC, the Robert Wood Johnson, the CHEST Foundation, and the National Institutes of Health. The CAC, ALAMC, and the American College of Chest Physicians have played major leadership roles. Perhaps most encouraging has been the grassroots response of community organizations that have forged effective partnerships that keep asthma on the front burner of politicians and health officials. The dedication and voluntary efforts of dozens, if not hundreds, of Chicago citizens from persons with asthma to health-care providers, and community leaders has been an inspiration. While progress has been made to address the asthma epidemic, this progress required major effort by a single philanthropic organization, constant guidance by the ALAMC and CAC, and consistent and persistent asthma champions. For distinct areas as large and diverse as Chicago, it is the focused efforts of clinical, organizational, community, and public health leadership that bring to the table the many parties needed to address asthma issues in an effective collaborative fashion. As the capacity for electronic means of asthma surveillance improves, data need to be widely shared and used to drive asthma care improvement if asthma health outcomes are to improve. It has been through such efforts that Chicago is beginning to successfully change its position as asthma ground zero, to that of an "asthma safe zone."

	Glossary: Asthma Initiatives, Programs, and Consortia

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• (1) Advocacy

  School inhaler law
  

  Inhaler insurance coverage
  

  Restriction of youth access to tobacco
  

  Income tax deduction option for asthma/lung research
  

  Asthma Action Plan for Chicago
  

  Stakeholders collaboration to improve student health
  

  CampACTION Counselor Assistant Program
  

  
  
  
• (2) Disparities

  Mobile C.A.R.E. Foundation asthma van/Breathmobile free asthma clinics
  

  Asthma and lead prevention in Chicago public housing
  

  
  
  
• (3) Education

  Educational guide to lung health for elementary school curriculum
  

  Asthma day camps
  

  Asthma 101/OAS
  

  Professional education programs by the ALAMC
  

  
  
  
• (4) Surveillance

  Chicago Department of Health
  

  Geographic Variations in Chicago Asthma Medication Prescribing
  

  CASI
  

  
  
  
• (5) Research

  School-based Pediatric Asthma Research in Chicago: allergy testing
  

  Impact of air purifiers
  

  Relationships of life stressors/maternal depression to pediatric asthma morbidity
  

  Validation of Spanish/English versions of the asthma section of the BPAS+ among Hispanics
  

  Development/validation of brief pediatric screen for asthma/allergies among children
  

  ACRC
  

  
  
  
• (6) Quality improvement

  CEDAC
  

  Chicago-Area Hospital Asthma Collaborative
  

  CPAC
  

  IEDAC
  

  Asthma Champion Initiative
  

  
  
  
• (7) Chicago Area and Illinois Asthma Consortia

  CAC
  

  Suburban Asthma Consortium
  

  Rockford Asthma Consortium
  

  Lake/McHenry Asthma Consortium
  

  Asthma Coalition for the Greater St. Louis Metro-East
  

  Bureau Putnam County
  

  Decatur Community Partnership
  

  
  
  

	Acknowledgements

 
The authors would like to thank Allen Goldberg, MD, Michael McDermott, MD, Lori Weiselberg, and Rhonda Williams for their thoughtful comments and suggestions for this article.

	Footnotes

 
Abbreviations: ACRC = Asthma Clinical Research Center; ALAMC = American Lung Association of Metropolitan Chicago; BPAS+ = Brief Pediatric Asthma Screen Plus; CAC = Chicago Asthma Consortium; CASI = Chicago Asthma Surveillance Initiative; CDC = Centers for Disease Control and Prevention; CEDAC = Chicago Emergency Department Asthma Collaborative; CHA = Chicago Housing Administration; CPAC = Chicago Primary Care Asthma Collaborative; ED = emergency department; HEPA = high-efficiency particulate air; IEDAC = Illinois Emergency Department Asthma Collaborative; OAS = Open Airways for Schools

The authors have no conflicts of interest to disclose.

Received for publication December 20, 2006. Accepted for publication August 2, 2007.

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