Research on asthma frequently recruits patients from clinics because the ready pool of patients leads to easy access to patients in office waiting areas, emergency departments, or hospital wards. Patients with other chronic conditions, and with mobility problems, face exposures at home that are not easily identified at the clinic. In this article, we describe the perspective of the community health workers and the challenges they encountered when making home visits while implementing a research intervention in a cohort of low-income, minority patients. From their observations, poor housing, often the result of poverty and lack of social resources, is the real elephant in the chronic asthma room. To achieve a goal of reduced asthma morbidity and mortality will require a first-hand understanding of the real-world social and economic barriers to optimal asthma management and the solutions to those barriers.

Background: Asthma disproportionately affects low-income and minority adults. In an era of electronic records and Internetbased digital devices, it is unknown whether portals for patientprovider communication can improve asthma outcomes. Objective: We sought to estimate the effect on asthma outcomes of an intervention using home visits (HVs) by community health workers (CHWs) plus training in patient portals compared with usual care and portal training only. Methods: Three hundred one predominantly African American and Hispanic/Latino adults with uncontrolled asthma were recruited from primary care and asthma specialty practices serving low-income urban neighborhoods, directed to Internet access, and given portal training. Half were randomized to HVs over 6 months by CHWs to facilitate competency in portal use and promote care coordination. Results: One hundred seventy (56%) patients used the portal independently. Rates of portal activity did not differ between randomized groups. Asthma control and asthma-related quality of life improved in both groups over 1 year. Differences in improvements over time were greater for the HV group for all outcomes but reached conventional levels of statistical significance only for the yearly hospitalization rate (20.53; 95% CI, 21.08 to 20.024). Poor neighborhoods and living conditions plus limited Internet access were barriers for patients to complete the protocol and for CHWs to make HVs. Conclusion: For low-income adults with uncontrolled asthma, portal access and CHWs produced small incremental benefits. HVs with emphasis on self-management education might be necessary to facilitate patient-clinician communication and to improve asthma outcomes. (J Allergy Clin Immunol 2019;144:846-53.)

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RATIONALE: Correct inhaler technique is essential for asthma control. We evaluated metered dose (MDI) and dry powder inhaler (DPI) technique in adults with uncontrolled asthma. We hypothesized that inhaler technique is suboptimal, and wanted to determine which steps of inhaler technique are most error-prone. METHODS: 301 adults living in low-income Philadelphia neighborhoods were recruited. All had uncontrolled asthma, defined as requiring prednisone, an ED visit, or hospitalization for asthma in the past 12 months. At enrollment, subjects' inhaler techniques were rated by community health workers. MDI technique was rated using inhaler guidelines from the NAEPP Expert Panel Report 3, and DPI technique by published and manufacturers' instructions. MDI technique had 7 steps; DPI technique had 6 steps; each step was rated as 'yes' or 'no.' Incorrect steps were corrected. RESULTS: The mean age was 49613 years. 90% were female. 50% experienced hospitalizations and 83% had ED visits for asthma in the prior year. Among 203 patients with spirometry, mean FEV1 percent predicted was 69.5%. Of the 300 evaluable subjects, 281 were rated using MDIs; 81 were rated using DPIs. Among MDI users, 93 (33%) made at least one error. Common missed steps were exhaling before actuating the inhaler (23%), actuating only once per inhalation (19%), and breath hold for 6-10 seconds (16%). Of DPI users, 18 (22%) made at least one error. Common missed steps were inhaling deeply (11%), breath hold for 6 seconds (17%), and not blowing into the Diskus (12%). CONCLUSIONS: MDI and DPI technique is suboptimal and should be reviewed regularly.