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

Juan Carlos Ivancevich Saturday, 13 January 2018 17:14
Key Points

Question  Can a novel school-based intervention that includes supervised asthma therapy and telemedicine visits overcome key barriers to guideline-based preventive care and improve outcomes for urban children with asthma?

Findings  In this randomized clinical trial that included 400 children, increased symptom-free days and fewer emergency department visits or hospitalizations were seen among children receiving the intervention compared with usual care.

Meaning  School-based programs that incorporate telemedicine to link to primary care can improve outcomes for urban children with asthma.

Abstract

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

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Physician perspectives on the burden and management of asthma in six countries: The Global Asthma Physician Survey (GAPS)

Juan Carlos Ivancevich Wednesday, 10 January 2018 23:24
Kenneth R. ChapmanDavid HindsPeter PiazzaChantal RaherisonMichael GibbsTimm GreulichKenneth GaalswykJiangtao LinMitsuru Adachi and Kourtney J. Davis

Abstract

Background

Despite recognition of asthma as a growing global issue and development of global guidelines, asthma treatment practices vary between countries. Several studies have reported patients’ perspectives on asthma control. This study presents physicians’ perspectives and strategies for asthma management.

Methods

Physicians seeing ≥4 adult patients with asthma per month in Australia, Canada, China, France, Germany, and Japan were surveyed (N=1809; ≈300 per country). A standardised questionnaire was developed for this study and administered by telephone, online or face-to-face. Statistics were weighted to account for the sampling scheme.

Results

Physicians estimated that 71% of their adult patients received maintenance medication, with adherence monitored by 76–97% of physicians. Perceived major barriers to patient adherence included: patients taking treatment as needed; acceptance of symptoms; and patients not perceiving treatment benefits. Written action plans (37%) and technology (15%) were seldom employed by physicians to aid patients’ asthma management. Physicians rarely (10%) used validated patient-reported questionnaires to monitor asthma control, instead monitoring selected symptoms, exacerbations, and/or lung function measurements. Awareness of single maintenance and reliever therapy (SMART/MART) varied among countries (56–100%); although most physicians (72%) had prescribed SMART/MART, the majority (91%) co-prescribed a short-acting bronchodilator at least some of the time.

Conclusions

These results show that physicians generally do not employ standardised tools to monitor asthma control or to manage its treatment and that despite high awareness of SMART/MART, the strategy appears to be commonly misapplied. Better education for patients and physicians is required to improve asthma management and resulting patient outcomes.

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Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE

Juan Carlos Ivancevich Monday, 08 January 2018 20:27
 
John White1James Y Paton2Robert Niven3Hilary Pinnock4 on behalf of the British Thoracic Society
 
 
 

Recovery of hypothalamo–pituitary–adrenal axis suppression during treatment with inhaled corticosteroids for childhood asthma

Juan Carlos Ivancevich Wednesday, 10 January 2018 12:41

 Journal of Asthma and Allergy » Volume 10 - Pages 317—326

Gangadharan AMcCoy PPhyo A, McGuigan MP, Dharmaraj P, Ramakrishnan R, McNamara PS, Blair J

Objective: To describe recovery of adrenal insufficiency in asthmatic children treated with inhaled corticosteroids (ICS) and cortisol replacement therapy.
Design: Retrospective, observational study.
Patients: A total of 113 patients, 74 male; age 10.4 (3.3–16.5) years; beclomethasone-­equivalent ICS dose, 800 µg, (100–1,000), tested by low dose short Synacthen (tetracosactide) test (LDSST), were studied. Test results were classified by basal and peak cortisol concentration: “normal” (basal >100 nmol/L, peak >500 nmol/L), “suboptimal” (basal >100 nmol/L, peak 350–499 nmol/L), “abnormal” (basal <100 nmol/L and/or peak <350 nmol/L). Patients with suboptimal results received hydrocortisone during periods of stress only, and those with abnormal responses received daily hydrocortisone, increased during periods of stress. A total of 73 patients (68%) had ≥2 LDSSTs over 2.2 years (0.2–7.7).
Measurements: Change in cortisol response to repeat LDSST (movement between diagnostic groups, difference in basal and peak cortisol >15% [2× the inter-assay coefficient of variation]), change in BMI and height standard deviation score (SDS).
Results: Baseline test results were abnormal in 17 patients (15%) and all of them had repeat tests. In 13 patients (76%), test results improved (normal in six, suboptimal in seven) and four (24%) remained abnormal. Baseline tests results were suboptimal in 54 patients (48%), of whom 50 (93%) were retested. Repeat tests were normal in 36 patients (72%), remained suboptimal in 11 (22%), and were abnormal in three (6%). Baseline tests results were normal in 42 patients, of whom six patients (14%) were retested. Results remained normal in three (50%), were suboptimal in two (33%), and abnormal in one (17%). Basal and peak cortisol levels increased by >15% in 33/73 (45%) and 42/73 (57%) patients, respectively, and decreased by >15% in 14/73 (19%) and 7/73 (10%), respectively. There was no significant change in height or BMI SDS.
Conclusion: Recovery of adrenal function is common and occurs during continued ICS and cortisol replacement therapy.

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A simple prediction tool for inhaled corticosteroid response in asthmatic children

Juan Carlos Ivancevich Wednesday, 03 January 2018 13:20
Yi-Fan WuMing-Wei SuBor-Luen ChiangYao-Hsu YangChing-Hui Tsai and Yungling L. Lee
BMC Pulmonary Medicine
BMC series – open, inclusive and trusted 2017 17:176

https://doi.org/10.1186/s12890-017-0533-0

Abstract

Background

Inhaled corticosteroids are recommended as the first-line controller medication for childhood asthma owing to their multiple clinical benefits. However, heterogeneity in the response towards these drugs remains a significant clinical problem.

Methods

Children aged 5 to 18 years with mild to moderate persistent asthma were recruited into the Taiwanese Consortium of Childhood Asthma Study. Their responses to inhaled corticosteroids were assessed based on their improvements in the asthma control test and peak expiratory flow. The predictors of responsiveness were demographic and clinical features that were available in primary care settings. We have developed a prediction model using logistic regression and have simplified it to formulate a practical tool. We assessed its predictive performance using the area under the receiver operating characteristic curve.

Results

Of the 73 asthmatic children with baseline and follow-up outcome measurements for inhaled corticosteroids treatment, 24 (33%) were defined as non-responders. The tool we have developed consisted of three predictors yielding a total score between 0 and 5, which are comprised of the following parameters: the age at physician-diagnosis of asthma, sex, and exhaled nitric oxide. Sensitivity and specificity of the tool for prediction of inhaled corticosteroids non-responsiveness, for a score of 3, were 0.75 and 0.69, respectively. The areas under the receiver operating characteristic curve for the prediction tool was 0.763.

Conclusions

Our prediction tool represents a simple and low-cost method for predicting the response of inhaled corticosteroids treatment in asthmatic children.

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Editor: Juan C. Ivancevich, MD

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