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School-based telemedicine program decreases severity of asthma
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The implementation of an urban school-based telemedicine program that promotes preventive care for children with persistent asthma is able to increase the number of days without symptoms and decrease the likelihood of hospitalization and ED visits.
“Inhaled corticosteroids are the most effective long-term therapy for patients with asthma, and guidelines recommend that preventive medications be used daily for all patients with persistent symptoms,” Jill S. Halterman, MD, MPH, from the department of pediatrics at the University of Rochester, and colleagues wrote. “However, many children with persistent asthma do not receive preventive medications, and minority children living in poverty are at highest risk of inadequate therapy.”
“In addition, many children who are prescribed a preventive medication do not achieve optimal control, a least in part because of poor adherence and a lack of appropriate follow-up care,” the researchers continued. “Thus, efforts to improve the delivery of preventive asthma care are warranted.”
To assess the results from the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program developed by Halterman and colleagues in relation to the severity of persistent asthma in urban children, the researchers conducted a randomized clinical trial that included children between the ages of 3 and 10 years located in the Rochester City School District in New York. All children were classified according to their use of preventive medications at baseline.
Once stratified, children were then assigned to participate in the program or enhanced usual care for 1 school year between 2012 and 2016. The researchers examined outcomes once the school years were completed. Multivariable modified intention-to-treat analyses were used to assess data, specifically the average number of symptom-free days per 2 weeks. This outcome was examined using bimonthly blinded interviews.
Over half of the 400 children included in the study were male (61.8%), and 57.5% were black. The average age of the participants was 7.8 (1.7) years.
When assessed at baseline, both groups had similar demographic characteristics and severity of disease. Most children who were placed in the SB-TEAM cohort had one or more telemedicine visits (98.0%), and most were administered supervised therapy in the school setting (82.5%).
These children also had more days in which they were symptom free per 2 weeks after the intervention when compared with children who received enhanced usual care (11.6 vs. 10.97; difference, 0.69; 95% CI, 0.15-1.22; P = .01). The researchers observed the most notable difference between the two groups during follow-up (difference, 0.85; 95% CI, 0.10-1.59).
Furthermore, children placed in the SB-TEAM group were less likely to receive care from EDs or require hospitalization related to their asthma (7% vs. 15%; OR, 0.52; 95% CI, 0.32-0.84).
“It is important to note that the role of the school nurses or health aides in this program is critical. This study took place in an impoverished school district. Most of the nurses covered multiple schools and had many competing demands on their time, yet children received their preventive medications almost every day they were in school,” Halterman and colleagues wrote. “Nurses did not receive extra compensation for their efforts for this program. However, they frequently told us that they prefer to focus on preventive care rather than caring for children when they are experiencing an exacerbation.”
“We suspect that the benefits related to supervised medication administration reach beyond simply assuring adherence to effective preventive medications and include the therapeutic relationships that were built between students and school nurses, as well as the opportunities for ongoing monitoring and education,” they continued. – by Katherine Bortz
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Matthew Greenhawt, MD, MBA, MSc
For children with persistent asthma, we are searching for any edge we can gain in trying to increase medication adherence, improve control, maximize symptom-free days, and keep children out of the ED, inpatient unit, or PICU. This can often be a challenging task.
Haltzerman et al explore an innovative strategy to supplement their school-based asthma program, which provides directly observed therapy to ensure medication adherence. They randomized 400 children with poorly controlled persistent asthma to either the standard school-based DOT program, or to this program in addition to periodic telemedicine visits with either their child’s primary care practice (or if not available, with a provider from a local large academic referral center). The team noted multiple significant differences in the telemedicine group, including more symptom-free days per 2-week period, a higher rate of these children being prescribed a preventative asthma medication, and fewer hospitalizations. Outcomes improved at each time point measured throughout the 1-year intervention.
These are encouraging results and highlight the potential for telemedicine supplementing a school-based asthma program.
However, it should be noted that some of the effects seen were small, despite being significant. The absolute differences in the number of symptom-free days and hospitalizations observed were small. In particular, there was only an 8% absolute risk reduction in hospitalizations in the telemedicine group (NNT=12.5), which is of unclear clinical significance. As well, issues regarding how cost-effective this intervention is, or how generalizable the intervention could be to other settings requires additional study. However, small gains are very welcomed within this at-risk asthma subgroup, and hopefully this group and others can build upon this promising study.
Overall, this is a nice study, which demonstrates a potentially innovative strategy to help improve asthma related outcomes among those with persistent and poorly controlled asthma. I look forward to seeing how applications of telemedicine can continue to evolve to help improve health care delivery.
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