Quality-of-life and cost-benefit analysis of a home environmental assessment program in Connecticut.

Abstract

The National Asthma Education Prevention Program's (NAEPP) Expert Panel Report 3 (EPR3) guidelines have stressed the need for environmental control measures for asthma, but there is limited evidence of their efficacy.
To examine the effectiveness of an in-home asthma intervention program for children and adults in Connecticut, we conducted a panel study to analyze quality-of-life indicators for asthmatic patients and the cost-benefit relationship in preventive care versus acute care.
The Asthma Indoor Reduction Strategies (AIRS) program was developed to reduce acute asthma episodes and improve asthma control through patient education and a home environmental assessment. Follow-up was conducted at 2-week, 3-month, and 6-month intervals. Measured quality-of-life indicators included number of unscheduled acute care visits, days absent from school/work due to asthma, times rescue inhaler used, and number of symptom-free days. Repeated measures analysis of variance (ANOVA) was used to determine whether significant differences exist in quality-of-life indicators at follow-up compared to that at the initial visit. Cost-benefit analysis was conducted by tabulating costs associated with physician office visits and emergency department (ED) visits due to asthma for children and adults separately.
Twenty percent of participants in the program met the criteria for well-controlled asthma, 16% for not well-controlled asthma, and 64% for very poorly controlled asthma. At 6 months follow-up, the mean number of unscheduled acute care visits, days absent from school/work due to asthma, and times rescue inhaler used in the past week decreased by 87%, 82%, and 74%, respectively, whereas the mean number of symptom-free days increased by 27% compared to the initial visit. Furthermore, the percent of participants with very poorly controlled asthma decreased from 64% at initial visit to 13% at 6 months follow-up. All changes were statistically significant at p < 0.05. A net savings of $26,720 per 100 participants was estimated at 6 months follow-up due to decreases in unscheduled acute care visits for adults and children.
Significant improvement in quality-of-life and decreases in healthcare resource utilization and costs were found after implementation of the AIRS program in Connecticut.

Full text

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Journal of Asthma, Early Online, 1–9, 2010
Copyright © 2010 Informa Healthcare USA, Inc.
ISSN: 0277-0903 print / 1532-4303 online
DOI: 10.3109/02770903.2010.535881
Quality-of-Life and Cost–Benefit Analysis of a Home Environmental
Assessment Program in Connecticut
KIMBERLY H. NGUYEN, M.S., M.P.H.,∗EILEEN BOULAY, R.N., B.S.N., AND JUSTIN PENG, M.P.H.
Connecticut Department of Public Health, Hartford, CT, USA.
Background. The National Asthma Education Prevention Program’s (NAEPP) Expert Panel Report 3 (EPR3) guidelines have stressed the
need for environmental control measures for asthma, but there is limited evidence of their efficacy. Objective. To examine the effectiveness
of an in-home asthma intervention program for children and adults in Connecticut, we conducted a panel study to analyze quality-of-life
indicators for asthmatic patients and the cost–benefit relationship in preventive care versus acute care. Methods. The Asthma Indoor Reduction
Strategies (AIRS) program was developed to reduce acute asthma episodes and improve asthma control through patient education and a home
environmental assessment. Follow-up was conducted at 2-week, 3-month, and 6-month intervals. Measured quality-of-life indicators included
number of unscheduled acute care visits, days absent from school/work due to asthma, times rescue inhaler used, and number of symptom-free
days. Repeated measures analysis of variance (ANOVA) was used to determine whether significant differences exist in quality-of-life indicators
at follow-up compared to that at the initial visit. Cost–benefit analysis was conducted by tabulating costs associated with physician office visits
and emergency department (ED) visits due to asthma for children and adults separately. Results. Twenty percent of participants in the program
met the criteria for well-controlled asthma, 16% for not well-controlled asthma, and 64% for very poorly controlled asthma. At 6 months
follow-up, the mean number of unscheduled acute care visits, days absent from school/work due to asthma, and times rescue inhaler used in
the past week decreased by 87%, 82%, and 74%, respectively, whereas the mean number of symptom-free days increased by 27% compared
to the initial visit. Furthermore, the percent of participants with very poorly controlled asthma decreased from 64% at initial visit to 13% at 6
months follow-up. All changes were statistically significant at p < 0.05. A net savings of $26,720 per 100 participants was estimated at 6 months
follow-up due to decreases in unscheduled acute care visits for adults and children. Conclusion. Significant improvement in quality-of-life and
decreases in healthcare resource utilization and costs were found after implementation of the AIRS program in Connecticut.
Keywords
asthma, cost–benefit analysis, environmental exposure, intervention studies, quality-of-life
INTRODUCTION
Patients with asthma may be exposed to multiple indoor
allergens and environmental tobacco smoke (ETS) in their
homes, which may contribute to increased asthma-related
exacerbations (1, 2). Many patients with asthma, partic-
ularly those who live in poverty and rely on emergency
departments (EDs) as their primary source of healthcare,
may not be receiving adequate education about asthma
self-management and how to avoid environmental expo-
sures to asthma triggers. According to the most recent
asthma surveillance report, the prevalence of asthma
among adults is higher in Connecticut than in the United
States as a whole and appears to be increasing, 9.3% in
2006, up from 7.8% in 2000 (3). Approximately 248,000
adults (9.3%) and 86,000 children (10.5%) in Connecticut
reportedthattheyhadasthmain2006,withthemajorityof
individuals with asthma living in the poorest urban areas
of Connecticut (4, 5).
The National Asthma Education Prevention Programs
EPR3 (NAEPP) guidelines have stressed the need for
environmental control measures, but there is limited evi-
dence in previous studies of their efficacy. Numerous
studies of asthma patient education and intervention pro-
grams have been conducted in the United States, United
∗Corresponding author: KH Nguyen is now working for the Centers for
Disease Control and Prevention, Atlanta, GA. USA; Tel: 678-530-8840;
E-mail: uxp1@cdc.gov.
Kingdom, and elsewhere. However, results of the pro-
grams have been mixed—many have shown distinct ben-
efits but others have not. A meta-analysis of 32 trials
involving 3706 patients by Guevara et al. concluded
that education programs are effective in improving self-
management of asthma in young people and should be
included as part of routine care (6). The ELECTRA study
in Britain (7), an educational intervention in a Yale study
(8),andahome-basedenvironmentalinterventionstudyin
seven major cities across the United States (9) have shown
positive improvements in children and adults. However,
several studies failed to achieve statistically significant
results (10, 11). One potential limitation of all these inter-
vention strategies is their focus on decreasing exposure to
a single allergen, rather than improving the indoor envi-
ronment as a whole. In addition, previous studies did
not combine both an educational and home assessment
component that focuses on changing behavior as well as
environment for managing asthma outcomes.
To examine the effectiveness of an in-home asthma
interventionprogramfor
Connecticut, we analyzed
for asthmatic patients and the cost–benefit of preven-
tion versus acute care treatment. The Putting on AIRS
(Asthma Indoor Reduction Strategies) program was
developed to reduce acute asthma episodes and improve
asthma control through increased patient understand-
ing on how to manage their asthma and recognition
and elimination/reduction of environmental and other
children
quality-of-life
andadults
indicators
in
1
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2K. H. NGUYEN ET AL.
asthma triggers. The AIRS program provides the
patient/family/caregiver with one or more one-on-one,
interactive, health education sessions focusing on patient
education and asthma self-management. This program
follows the National Heart, Lung, and Blood Institute
(NHLBI) NAEPP EPR3 Guidelines for the Diagnosis
and Management of Asthma. Funding was provided
by the Centers for Disease Control and Prevention
(CDC) and the Environmental Protection Agency (EPA)
to the Connecticut Department of Public Health to
support implementation by six local health department
contractors. The program grew out of a pilot project
developed and evaluated by Connecticut’s Ledge Light
Health District that illustrated the need for formalized
documentation and procedures/protocols (12, 13). The
objective of this evaluation is to assess quality-of-life
indicators and cost–benefit of implementing the AIRS
program within the State of Connecticut.
METHODS
AIRS Program
The AIRS program serves diverse populations in six
funded asthma regions in Connecticut. Participants may
be children, adults, or families who are referred from
the ED, healthcare providers, school health services, or
self-referral. Although children are the primary target, the
AIRS program is open to people with asthma of all ages.
For the remainder of this document “participant” will be
used to identify children and their caregivers, adults, or
families who are referred to the program. The program is
free to anyone regardless of income or insurance status.
One local health department in each region takes the lead
to expand the program through other health departments
within their respective region. Local health department
staffprovidespatienteducationandahomeenvironmental
assessment.
A nurse, health educator, or respiratory therapist who
each may also be a Certified Asthma Educator con-
ducts the education session, reviews medications and
administration technique, and provides phone support
and follow-up after the initial visit. For the remainder
of this document “nurse” will be used to identify this
role. The nurse conducts follow-up with the participant
at 2-week, 3-month, and 6-month intervals. A Registered
Environmental Health Specialist/Registered Sanitarian
(REHS/RS) is someone who is certified by the National
Environmental Health Association (NEHA) and shows
competency in environmental health issues, directs and
trains personnel to respond to routine or emergency envi-
ronmental situations, and frequently provides education
to their communities on environmental health concerns
(14). The registered sanitarian conducts an environmen-
tal assessment of the home and/or caregiver location,
identifies asthma triggers, and makes recommendations to
reduce or eliminate exposure.
Prior to the initial visit, the nurse administers an
intake questionnaire with the participant via telephone
and schedules a home visit. On the first home visit, the
asthma project nurse and environmental specialist both
participate in the initial home visit. The nurse administers
a home assessment questionnaire that captures baseline
data on knowledge of common asthma triggers, such
as cockroaches, furred or furry pets, dust mites, ETS,
and mold/mildew. The nurse collects additional base-
line data regarding missed school days, ED visits due
to asthma, asthma-related physician visits in the previ-
ous month, medication usage and technique, and current
asthma action plan and begins a dialog with the partic-
ipant about issues and questions. All baseline data are
self-reported.
Both the nurse and the environmental specialist con-
duct a walk-through of the home, assessing and record-
ing sources of environmental triggers for asthma. These
triggers include household characteristics, such as the
presence of sanitation tools (i.e., vacuum, broom, or
mop), self-reported weekly household cleaning, presence
of scented aerosolized products (i.e., cleaning chemi-
cals,scentedcandles,perfumes),self-reportedevidenceof
cockroaches and rodents, pets currently in home, stuffed
animals or extra pillows on bed, carpeting in bedroom or
living room, gas stoves, mold/mildew on walls or ceil-
ings, water damage in any room or surface, water in
basement or crawl spaces, and exposure to ETS.
Results from the home assessment inform an envi-
ronmental summary care plan which outlines low or
no-cost options to reduce or eliminate the trigger
sources. The environmental summary care plan is dis-
cussed with the participant. At the end of the visit,
the participant/caregiver retakes the home assessment
questionnaire regarding knowledge of asthma triggers
for the purpose of post-assessment evaluation. Staff
reviews post-assessment results with the patient to rein-
force knowledge of asthma triggers. Staff leaves a folder
of educational information with the participant containing
various brochures/fact sheets including “Helping Your
Child Manage Asthma: A Parent Handbook,” “What
Everyone Should Know About Asthma,” and “Controlling
Asthma and Allergies in Your Home,” as well as an
asthma action plan and fact sheets on medications specific
to the participant. Patient-specific materials for reducing
exposure to ETS or smoking cessation would be offered
when there are smokers in the home. General information
regarding recognizing asthma symptoms, when to take
medications, and when to call the doctor are provided,
along with information on identifying indoor asthma trig-
gers and ways to reduce or eliminate exposure to those
triggers.
The program may also provide pillow/mattress covers,
spacers, and peak flow meters, if available. A spacer is
provided if the medication order from the doctor specifies
itand/orthepatientverbalizestheyuseonebutlostit.Bed
covers are provided for all patients based on availability
of funds. In the past 2 years they have been available and
provided. Peak flow meters are only provided if the doctor
ordered it and if the patient currently does not have one.
Informed consent to participate in the in-home assess-
ment was given at the time of referral. Because data
were de-identified upon analysis, the study was exempt
from IRB review at the Connecticut Department of Public
Health.
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AIRS PROGRAM IN CONNECTICUT3
Follow-Up Home Evaluations
Subsequent to the visit, an in-home evaluation summary
with recommended action items is completed and sent
to the participant and the participant’s medical providers
(i.e., primary care physician, school nurse, asthma spe-
cialist,schoolhealthservices,school-basedhealthcenter).
At 2 weeks after the initial visit, the nurse follows up
with the participant either in-person or by telephone.
The nature of the follow-up is to evaluate the partic-
ipant’s progress in implementing the recommendations
suggested on the In-Home Evaluation Summary and to
answer any questions regarding their asthma manage-
ment.
At 3 months follow-up, the asthma project nurse con-
tacts the participant to review the progress in imple-
menting the care plan recommendations. The nurse
offers recommendations and answers questions and con-
cerns. If progress is not occurring, another visit is
encouraged. Otherwise, the nurse collects data regard-
ing self-reported missed days from school or work
due to asthma, rescue inhaler use, symptom frequency,
and asthma-related emergency room visits and physician
visits.
At 6 months follow-up, the nurse attempts to make a
final follow-up call to determine if any additional support
or answers to questions are needed. Then, the nurse col-
lects final data regarding self-reported missed days from
school or work due to asthma, rescue inhaler use, symp-
tom frequencies, and asthma-related emergency room
visits and physician visits. A program evaluation form
is provided to the patient with a self-addressed stamped
envelope to gather feedback about the program following
the final 6 months follow-up.
Statistical Analysis
Quality-of-life indicators included asthma-related visits to
the ED, visits to a physician, missed days of school or
work due to asthma, rescue inhaler use, and symptom-
free days. Indicators were collected on day of initial visit
and at 3 months and 6 months follow-up. Asthma control
was categorized as “well controlled,” “not well con-
trolled,” and “very poorly controlled” and defined based
in part on the NAEPP EPR3 Guidelines control parame-
ters (15), according to events at the initial visit (Table 1).
Participants who reported no unscheduled acute care vis-
its (i.e., physician office visits and ED visits) in the past
3 months, no days absent from school or work due to
asthma in the past 3 months, less than or equal to two
times rescue inhaler used in the past 1 week, and greater
than or equal to 10 symptom-free days in the past
2 weeks were categorized as “well controlled.” Those
who reported one unscheduled acute care visit in the
past 3 months, 1–3 days absent from school or work
due to asthma in the past 3 months, three to six times
rescue inhaler used in the past 1 week, or 2–9 symptom-
free days in the past 2 weeks were categorized as “not
well controlled.” Finally, those who reported two or more
unscheduled acute care visits in the past 3 months, 4 or
TABLE 1.—Classification of asthma control at initial visit.
Well
controlled
Not well
controlled
Very poorly
controlled
Average number of unscheduled
acute care visitsain the past 3
months
Average number of days absent from
school/work due to asthma in the
past 3 months
Average number of times rescue
inhaler used in the past 1 week
Average number of symptom-free
days in the past 2 weeks
012 or more
0 1–3 4 or more
≤2 3–6 7 or more
10–14 2–9
≤1
aDefined as physician’s office visits or emergency room visits for worsening asthma
symptoms in the past 3 months.
more days absent from school or work due to asthma in
the past 3 months, one or more times of rescue inhaler
use per day in the past 1 week, or 1 or less symptom-free
days in the past 2 weeks were categorized as “very poorly
controlled.”
Medications corresponded to self-reported prescribed
medications. They were categorized as “controller” or
“rescue”basedontheNAEPPEPR3Guidelines.Thecate-
gories were determined based on the medication used and
not on the delivery method (i.e., nebulized albuterol was
included in counting the use of rescue inhaler).
To measure hygienic quality of the home, several vari-
ables were created to determine whether the participant
had any sanitation tools in the home or reported clean-
ing on a weekly basis. A participant was categorized
as having sanitation tools if they reported having either
a vacuum, broom, or mop. A participant who reported
either changing the sheets, dusting, sweeping, or vacu-
uming at least once a week was categorized as having
cleaned on a weekly basis. Scented aerosolized products
are defined as using any cleaning chemicals, scented can-
dles, or perfumes. ETS is defined as reporting a person(s)
in household who smokes or having any visible ashtray or
tobacco products in the home.
For examining bivariate associations, we used chi-
square tests to evaluate any differences in demographic
and household characteristics by level of asthma con-
trol. We used repeated measures analysis of variance
(ANOVA) to examine whether significant differences
exist in the mean number of unscheduled acute care vis-
its, days absent from school/work due to asthma, times
rescue inhaler used, and number of symptom-free days
at 3 months and 6 months follow-up compared to these
responses at the initial visit. In addition, ANOVA was
used to examine differences in level of asthma control at
3 months and 6 months follow-up compared to the initial
visit.
Cost–benefit analysis was conducted by tabulating
costs associated with physician office visits and ED vis-
its due to asthma for children and adults separately. The
estimated cost was $525 per ED visit for children with a
primary diagnosis of asthma, $652 per ED visit for adults
with a primary diagnosis of asthma, and $98 per patient
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4K. H. NGUYEN ET AL.
office visit, for children and adults, which includes history
and exam (3, 16).
RESULTS
Study Population
From 2005 to 2009, there were 454 participants with
home visits, out of 592 referrals to the AIRS pro-
gram (Table 2). The majority (79%) of the participants
were under 18 years of age and 52% were female.
Approximately half (49%) of the participants were non-
Hispanic White, 13% were non-Hispanic Black, 33%
were Hispanic, and 5% were categorized as other.
At the initial visit, 84% of the participants reported
understanding at least one asthma self-management edu-
cation component (i.e., asthma pathophysiology, medica-
tions, correct inhaler administration technique and when
to use, peak flow meter use, recognizing symptoms of
exacerbations and responding appropriately to reduce
them) or having a written asthma action plan (Table 2).
However, only 17% were able to use a peak flow meter
correctly and only 20% had a written asthma action
plan. Among participants, 83% were prescribed at least
one controller or rescue medication. Sixty-seven percent
were prescribed controller medications, 76% were pre-
scribed rescue medications, and 61% were prescribed
both. Sixteen percent were prescribed rescue medications
only.
Seventy percent reported having any one of the follow-
ing sanitation tools: broom, mop, or vacuum (Table 3).
Sixty percent reported cleaning on a weekly basis,
which includes changing bedding, dusting, sweeping, or
vacuuming. Almost half (46%) reported using scented
aerosolized products (i.e., scented candles, perfumes, or
cleaning chemicals). Twenty-one percent reported evi-
dence of rodents or cockroaches in the home and 40%
reported having pets in the bedroom. Twenty-eight per-
cent of participants had mold/mildew on walls or ceilings,
water damage in any room or surface inside or outside, or
water in basement or crawl spaces. A quarter of partici-
pants had a gas stove, and 45% reported being exposed to
ETS in the home.
Based on the classification developed by the Asthma
Programforasthmacontrol(Table1),20%metthecriteria
for well-controlled asthma, 16% for not well-controlled
asthma, and 64% for very poorly controlled asthma
(Table 2).
Bivariate Analyses
The level of asthma control was significantly associated
with prescribed controller and rescue medications, pres-
ence of any sanitation tools (e.g., vacuum, broom, mop),
frequency of cleaning, use of scented aerosolized prod-
ucts, the presence of mold/moisture in the home, and
presence of a gas stove (Table 3). Participants who were
prescribed controller or rescue medications or both had
a significantly lower level of asthma control compared
to those who were not prescribed controller or rescue
medications. Participants who were prescribed rescue
medications only had significantly higher levels of asthma
control compared to those prescribed both controller and
rescue medications. Those who reported having no sani-
tation tools (i.e., vacuum, broom, mop) had significantly
higher levels of asthma control. In addition, those who
reported cleaning on a weekly basis (i.e., changed bed-
ding, dusted, or vacuumed), having scented aerosolized
products, having mold/moisture in the home, or having
gas stoves had significantly lower level of asthma control.
Differences in Quality-of-Life Indicators at 3 and
6 Months Follow-Up
The mean number of unscheduled acute care visits in the
past 3 months decreased significantly by 77% at 3 months
and 87% at 6 months follow-up compared to the initial
visit (Table 4). The mean number of days absent from
school/work due to asthma in the past 3 months was sig-
nificantly reduced by 75% at 3 months and 82% at 6
months after visit compared to the initial visit. The mean
number of times rescue inhaler was used in the past week
decreased significantly by 74% at 6 months compared to
theinitialvisit.Inaddition,themeannumberofsymptom-
free days in the past 2 weeks significantly increased by
23% at 3 months and by 27% at 6 months compared to
the initial visit.
Differences in Levels of Asthma Control at 3 and
6 Months Follow-Up
The percent of participants with well-controlled asthma
increased significantly from 20% at the initial visit to
63% at 3 months and 76% at 6 months follow-up
(Table 5). Likewise, the percent of participants with not
well-controlled asthma decreased significantly to 10% at
6 months compared to 16% at initial visit (p < 0.01).
Finally, the percent of participants with very poorly con-
trolled asthma decreased significantly from 64% at initial
visit to 21% and 13% at 3 and 6 months follow-up,
respectively.
Cost–Benefit Analysis
A net savings of $19,507 per 100 participants and $26,720
per 100 participants was estimated at 3 months and
6 months follow-up, respectively, due to decreases in
number of total unscheduled acute care visits for adults
and children in the previous 3 months. Costs for unsched-
uled acute care visits were estimated at $38,865 per
100 participants for children and adults at initial visit
(Table 6). At 3 months, the estimated total cost asso-
ciated with unscheduled acute care visits was $19,358
per 100 participants, for a net savings of $19,507 com-
pared to that at initial visit. At 6 months, the estimated
total cost associated with unscheduled acute care vis-
its was $12,145 per 100 participants, for a net savings
of $26,720 compared to that at 3 months prior to
visit.
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AIRS PROGRAM IN CONNECTICUT5
TABLE 2.—Demographic characteristics by level of asthma control (AIRS, 2009).
Level of asthma control
Respondent characteristicsNumber Percenta
Well
controlled
Not well
controlled
Very poorly
controlled
Number referred
Number with home visits
Age
<18
≥18
Sex
Male
Female
Race/ethnicity
Non-Hispanic White
Non-Hispanic Black
Hispanic
Other
Patient education
Understands asthma pathophysiology
Yes
No
Understands medications
Yes
No
Uses inhaler correctly
Yes
No
Uses peak flow meter correctly
Yes
No
Understands asthma management
Yes
No
Has written asthma action plan
Yes
No
Prescribed medication
Controller medication∗∗∗
Yes
No
Rescue medication∗
Yes
No
Rescue medication alone∗∗∗
Yes
No
Controller and rescue medication∗∗∗
Yes
No
Controller or rescue medication∗∗
Yes
No
592
454
100.0
76.7
—
20.4
—
16.0
—
63.6
353
95
78.8
21.2
73.4
26.6
81.0
19.0
77.2
22.8
230
212
48.0
52.0
47.5
52.5
50.8
49.2
52.3
47.7
141
40
100
15
49.0
13.2
32.9
4.9
59.7
8.8
28.1
3.5
47.1
13.7
27.5
11.8
46.6
12.1
38.5
2.9
361
93
79.5
20.5
83.8
16.2
87.3
12.7
89.6
10.4
336
118
74.0
26.0
81.3
18.7
77.8
22.2
83.6
16.4
239
215
52.6
47.4
58.8
41.2
54.0
46.0
60.8
39.2
77
376
17.0
83.0
21.3
78.7
7.4
92.6
20.8
79.2
260
194
57.3
42.7
61.3
38.7
65.1
34.9
66.0
34.0
93
361
20.5
79.5
15.0
85.0
19.1
80.9
25.2
74.8
305
149
67.2
32.8
48.8
51.2
66.7
33.3
85.6
14.4
346
108
76.2
23.8
76.3
23.7
82.5
17.5
87.6
12.4
71
383
15.6
84.4
36.3
63.7
23.8
76.2
9.5
90.5
275
179
60.6
39.4
41.3
58.7
57.1
42.9
78.2
21.8
376
78
82.8
17.2
86.3
13.7
87.3
12.7
95.2
4.8
aPercent based on participants with home visits only.
∗p < .05;
∗∗p < .01;
∗∗∗p < .0001.
Note. Percentages may not add to 100 because of rounding.
DISCUSSION
We found that a home-based intervention, focusing
on patient self-management education and reducing
exposure to multiple indoor allergens or irritants and
ETS, significantly decreased unscheduled acute care
visits, missed school/work days, rescue inhaler use,
and symptoms among patients with asthma. Use of
controller and/or rescue medications was found to be
significantly associated with level of asthma control.
Household characteristics such as the lack of any sanita-
tion tools (i.e., vacuum, broom, mop), scented aerosolized
products, mold/moisture, and gas stoves were also found
to be significantly associated with level of asthma control.
Unscheduled acute care visits for asthma in the past
3 months decreased significantly by 87% at 6 months
follow-up compared to the initial visit. We observed a
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