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

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by Jill S. Halterman, MD, MPH; Maria Fagnano, MPH; Reynaldo S. Tajon, BA; Paul Tremblay, RN; HongyueWang, PhD; Arlene Butz, ScD, RN; Tamara T. Perry, MD; Kenneth M. McConnochie, MD, MPH

As published in the Journal of Asthma Nov. 30, 2017, DOI: 10.1080/02770903.2017.1396472

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IMPORTANCE

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

JAMA Pediatr. 2018;172(3):e174938. doi:10.1001/jamapediatrics.2017.4938

Published online January 8, 2018.

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Inhaled corticosteroids are the most effective long-term therapy for patients with asthma,1 and guidelines recommend that preventive medications be used daily for all patients with persistent symptoms.2 However, many children with persistent asthma do not receive preventive medications,3-5 and minority children living in poverty are at highest risk of inadequate therapy.6-9 In addition, many children who are prescribed a preventive medication do not achieve optimal control, at least in part because of poor adherence10 and a lack of appropriate follow-up care.11 Thus, efforts to improve the delivery of preventive asthma care are warranted.

 

We have a long-standing partnership with the Rochester City School District to develop programs for urban school-aged children with asthma. Our original School-Based Asthma Therapy study12,13 tested directly observed therapy (DOT) of preventive asthma medications in school for children aged 3 to 10 years. By supervising daily medication administration in school, we could ensure that children consistently received their medications, at least on days they attended school.

 

In a randomized clinical trial, we found that children receiving preventive medications at school had more symptom free days (SFDs) and fewer exacerbations compared with a group receiving usual care.13 However, we found that the program was difficult to maintain in its original design because the coordination of the child’s assessments, medication prescription, and facilitation of medication delivery through school required an unsustainable effort by the research team.14

 

We developed the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program in hopes of achieving sustainability. The SB-TEAM program expands our successful school partnership by integrating 2 systems of care to ensure access to guideline-based preventive asthma treatment.

 

The SB-TEAM program uses school-based DOT of preventive asthma medications to enhance medication adherence, as well as telemedicine to ensure access to appropriate asthma assessments, preventive medication prescription, and follow-up care. Telemedicine allows clinicians to provide assessment and consultation through remote audiovisual technology and removes barriers to accessing care by enabling children to be seen by a clinician without making a trip to their physician’s office.15-20 Our primary hypothesis was that children receiving the SB TEAM intervention would have more SFDs post intervention compared with children in an enhanced usual care (eUC) group.