Benefits of a School-Based Asthma Treatment Program in the Absence of Secondhand Smoke Exposure: Results of a Randomized Clinical Trial

Abstract

Halterman JS, Szilagyi PG, Yoos HL, et al. Arch Pediatr Adolesc Med. 2004;158:460–467To evaluate the impact of providing inhaled corticosteroids in the school setting on asthma symptoms of urban children with asthma.Children aged 3 to 7 years from 54 urban schools in Rochester, New York, with asthma ranging in severity from mild persistent to severe.The study had 2 arms into which patients were randomized: a school-based care group or a usual-care group. In the school-based care group, 2 puffs of fluticasone, 110 μg per puff, were given with a spacer each day that the children were in school. Identical medication with a spacer was given for home use on days that the children were not in school. Those children who were using >1 preventive medication were instructed to continue their other medications at the discretion of their primary care providers. For the patients in the usual-care group, their primary care providers and parents were informed of the severity of their asthma, but there were no other interventions. The main outcome measure was the number of symptom-free days during the 2 weeks leading up to monthly telephone interviews.Of 242 eligible children, 184 were enrolled; 93 children were allocated to the school-based group, and 91 were allocated to the usual-care group. The overall response rate for the follow-up interviews was 94%. Although there was not a significant difference in symptom-free days between the treatment groups, there were significant improvements in the school-based group in secondary measures such as caregiver quality of life (0.63 change score vs 0.24; P = .047), missed school days because of asthma (6.8 vs 8.8 days; P = .047), and symptom-free days during early winter months (mean days per 2-week period: 9.2 vs 7.3; P = .02). A posthoc analysis revealed that all the significant changes were among children where were not exposed to smoking in the home. Furthermore, among children who were not exposed to second-hand smoke, the school-based care group had more symptom-free days overall (11.5 vs 10.5 days; P = .046), had fewer days needing rescue medications (1.6 vs 2.3 days; P = .03), and were less likely to have had ≥3 acute visits for asthma (6 of 47 vs 17 of 54 children; P = .03).This study demonstrates that a system involving the provision of inhaled corticosteroids in the school improves a number of outcome measures of asthma including missed school days and quality of life of caregivers. This study also demonstrates that such improvements in asthma outcomes are negated by smoke exposure in the home.Health care providers of children with asthma are often frustrated with patients’ poor adherence to medical treatment plans. This study demonstrated that a change in the system of care, using resources that are available in schools, led to improved outcomes. The investigators did not report specifics about actual adherence to the medical treatment given but stated that the children in the school-based treatment group received their medication 84% of days that school was in session, whereas 63% of those in the usual-care group reported using the daily medication. The difference in outcome measures between the school-based and usual-care groups may have been greater if the authors had controlled for several confounding factors (weekend management, asthma severity, etc). Nonetheless, this study points the way to future research about and implementation of new systems of asthma care.