Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) Program on Asthma Morbidity

Abstract

Poor adherence to recommended preventive asthma medications is common, leading to preventable morbidity. We developed the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program to build on school-based supervised therapy programs by incorporating telemedicine at school to overcome barriers to preventive asthma care. OBJECTIVE To evaluate the effect of the SB-TEAM program on asthma morbidity among urban children with persistent asthma. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, children with persistent asthma aged 3 to 10 years in the Rochester City School District in Rochester, New York, were stratified by preventive medication use at baseline and randomly assigned to the SB-TEAM program or enhanced usual care for 1 school year. Participants were enrolled at the beginning of the school year (2012-2016), and outcomes were assessed through the end of the school year. Data were analyzed between May 2017 and November 2017 using multivariable modified intention-to-treat analyses. INTERVENTIONS Supervised administration of preventive asthma medication at school as well as 3 school-based telemedicine visits to ensure appropriate assessment, preventive medication prescription, and follow-up care. The school site component of the telemedicine visit was completed by telemedicine assistants, who obtained history and examination data. These data were stored in a secure virtual waiting room and then viewed by the primary care clinician, who completed the assessment and communicated with caregivers via videoconference or telephone. Preventive medication prescriptions were sent to pharmacies that deliver to schools for supervised daily administration. MAIN OUTCOMES AND MEASURES The primary outcome was the mean number of symptom-free days per 2 weeks, assessed by bimonthly blinded interviews. RESULTS Of the 400 enrolled children, 247 (61.8%) were male and 230 (57.5%) were African American, and the mean (SD) age was 7.8 (1.7) years. Demographic characteristics and asthma severity in the 2 groups were similar at baseline. Among children in the SB-TEAM group, 196 (98.0%) had 1 or more telemedicine visits, and 165 (82.5%) received supervised therapy through school. We found that children in the SB-TEAM group had more symptom-free days per 2 weeks postintervention compared with children in the enhanced usual care group (11.6 vs 10.97; difference, 0.69; 95% CI, 0.15-1.22; P = .01), with the largest difference observed at the final follow-up (difference, 0.85; 95% CI, 0.10-1.59). In addition, children in the SB-TEAM group were less likely to have an emergency department visit or hospitalization for asthma (7% vs 15%; odds ratio, 0.52; 95% CI, 0.32-0.84). CONCLUSIONS AND RELEVANCE The SB-TEAM intervention significantly improved symptoms and reduced health care utilization among urban children with persistent asthma. This program could serve as a model for sustainable asthma care among school-aged children. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01650844

Introducing telehealth and adherence monitoring to school‐centered asthma management

“…An a priori stratification by asthma severity showed a substantial improvement in CASI scores amongst those with more severe asthma following the intervention. These findings are consistent with observations made with other school‐based intervention strategies 7,9–11,17 . In a comparison of two recent school‐centered asthma programs, one strategy focused on providing a nurse‐centered school‐based asthma intervention on children with high risk for an asthma exacerbation identified by uncontrolled asthma or a recent asthma exacerbation while another program focused its efforts on providing once‐daily inhaled corticosteroid using a school‐based intervention program 10,11 .…”

“…Where health care delivery in conventional settings has failed to address these well‐documented disparities, innovative delivery models in communities, schools, and homes that address social determinants of health have made some inroads 7–11 . It is clear that health care delivered in a silo is not effective, and strategies that move the needle on addressing common barriers to access to high‐quality care are needed.…”

School-based supervised therapy programs to improve asthma outcomes: current perspectives

“…Four studies observed less health care utilization, which may translate to a decrease in cost and disease burden 10,12,15,18. Health care utilization includes emergency department visits, ambulatory visits, hospitalizations, and urgent care visits.…”

“…In addition to implementing supervised asthma therapy programs, supplemental interventions were concurrently integrated in 4 studies, including a tobacco reduction program for smoke-exposed children,14 counseling sessions incorporating motivational interviewing techniques,13 and peak flow meter monitoring 17,18. School-based telemedicine visits were conducted to ensure appropriate assessment, preventive medication prescription, and follow-up care in 1 study 12. Web-based technology was utilized in 2 studies 11,17.…”

“…In 5 studies, both groups received asthma education, resulting in potential intervention effects for both 11,12,16–18. To address the barrier of access to medication, Gerald et al17 provided medication to both groups, making it difficult to predict if improved adherence was due to medication availability.…”