Preventive Asthma Medications Research Articles

Effect of the Telemedicine Enhanced Asthma Management Through the Emergency Department (TEAM-ED) Program on Asthma Morbidity: A Randomized Controlled Trial

ObjectiveTo test the effectiveness of a telemedicine-based program in reducing asthma morbidity among children who present to the emergency department (ED) for asthma, by facilitating primary care follow-up and promoting delivery of guideline-based care. Study DesignWe included children (3-12 years) with persistent asthma who presented to the ED for asthma, were then randomly assigned to Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED) or enhanced Usual Care (eUC). TEAM-ED included: 1) school-based telemedicine follow-ups, completed by a primary care provider, 2) “point-of-care” prompting to promote guideline-based care, and 3) an opportunity for two additional telemedicine follow-ups. The primary outcome was the mean number of symptom-free days (SFDs) over 2 weeks at 3, 6, 9, and 12 months. ResultsWe included 373 children from 2016 through 2021 (participation rate 68%; 54% Black, 32% Hispanic, 77% public insurance, mean age: 6.4 years). Demographic characteristics and asthma severity were similar between groups at baseline. Most (91%) TEAM-ED children had ≥1 telemedicine visit; 41% completed 3 visits. At 3 months, caregivers of children in TEAM-ED reported more follow-up visits (66%vs.48%, aOR:2.07 [1.28-3.33]), preventive asthma medication actions (90%vs.79%, aOR:3.28 [1.56-6.89]), and use of a preventive medication (82%vs.69%, aOR:2.716 [1.45-5.08]), compared with eUC. There was no difference between groups in medication adherence or asthma morbidity. When only pre-pandemic data were included, there was greater improvement in SFDs over time for children in TEAM-ED versus eUC. ConclusionsTEAM-ED significantly improved follow-up and preventive care after an ED visit for asthma. We also saw improved SFDs with pre-pandemic data. The lack of overall improvement in morbidity and adherence indicates the need for additional ongoing management support.

The Association of Medicaid expansion with prescription drug utilization and expenditure among low-income participants with asthma

Objective This study estimated the association between the 2014 Medicaid expansion and asthma-related prescription drug utilization and expenditures among low-income adult participants with asthma, including those with uncontrolled asthma, in the United States. Methods In this national analysis, using a pooled dataset from 2007–2018 Medical Expenditure Panel Surveys (MEPS), regression discontinuity (D-RD) analyses estimated the association between Medicaid expansion and utilization of and expenditures for asthma-related prescription drugs among participants with asthma aged 26–64 with incomes below vs. at/above 138% of the federal poverty level (FPL). A sub-sample analysis was also conducted among participants with uncontrolled asthma. Utilization and expenditure outcomes were estimated using two-part models with logit as the first part and generalized linear models as the second part. Results Utilization of and total cost for asthma-related prescription drugs increased by 1.89 fills (p < 0.001) and $306.59 (p < 0.001) among participants with asthma with income below 138% FPL after Medicaid expansion. The utilization and total cost of both short-acting bronchodilators and inhaled corticosteroids (ICSs) increased after Medicaid expansion among participants with asthma with incomes below 138% FPL. Among participants with uncontrolled asthma with incomes below 138% FPL, utilization and expenditures increased after Medicaid expansion for all asthma-related prescription drugs and short-acting bronchodilators. Conclusion Medicaid expansion was associated with increased utilization of and total expenditures for both quick-relief and preventive asthma medications among all low-income participants with asthma, but not with utilization of preventive medications among those with uncontrolled asthma.

Obesity May Enhance the Adverse Effects of NO2 Exposure in Urban Schools on Asthma Symptoms in Children

To evaluate relationships between inner-city classroom NO2 exposure and asthma symptoms and morbidity by BMI category.Children aged 4 to 13 (n = 271) years from 37 inner-city schools who had physician-diagnosed asthma for at least 1 year and were using daily preventive asthma medication, had wheezing within the last year, and/or had at least 1 unscheduled health care visit for asthma within the past year.This was a single-center prospective study conducted within the School Inner-City Asthma Study. Before the start of the academic year, baseline demographics, environmental factors, and asthma symptoms and medication use were obtained by questionnaire. Baseline evaluations included skin testing to common seasonal and perennial aeroallergens or by assessment serum-specific IgE to the same allergens, spirometry, and fractional exhaled nitric oxide (FeNO) measurement. BMI percentile was calculated and categorized by using CDC classifications. Classroom NO2 was measured twice during the school year, ∼6 months apart. The primary outcome was the number of days with asthma symptoms within the previous 14 days. The secondary outcomes assessed in the previous 2 weeks were the number of exacerbations (hospitalizations or unscheduled health care visits for asthma), the number of days caretakers had to change plans because of the child’s asthma symptoms, FeNO level, and pulmonary function (forced expiratory volume in 1 second [FEV1] and forced vital capacity [FVC]).Participants were predominantly African American and Hispanic (35% each) and impoverished (49% had an annual household income <$25 000). A total of 50% had normal BMI (fifth percentile to <85th percentile), 15% were overweight (85th percentile to <95% percentile), and 35% were obese (≥95th percentile). Most (69%) were atopic, with specific immunoglobulin E to at least 1 aeroallergen. Obese students with asthma had statistically (but likely not clinically relevant) lower pulmonary function (FEV1 and FVC but not FEV1/FVC ratio), more positive skin test results, and lower FeNO than students with normal weight. The BMI category did not affect asthma symptom days, asthma symptoms, medication use, health care use for asthma, or missed school days. Caretakers of children with normal weight changed their plans more often than those of students who were overweight or obese. For children with normal weight or those who were overweight, NO2 levels were not associated with any of the measured outcomes. However, among children who were obese, for every 10-fold increase in NO2 level there were increased odds of asthma symptom days (1.9-fold), acute asthma-related health care use (2.4-fold), a missed school day because of asthma (3.1-fold), and care takers’ plans being changed because of the child’s asthma (4.2-fold). As compared with children with normal weight, in students who were obese, every 10 parts per billion increase in classroom NO2 level increased the likelihood of an asthma symptom day (odds ratio: 1.86; 95% confidence interval: 1.15 to 3.02) and of care takers changing their plans (odds ratio: 4.24; 95% confidence interval: 2.33 to 7.70). NO2 levels did not affect other outcomes, lung function, or FeNO across BMI categories.Obesity in inner-city students with asthma appears to increase susceptibility to the adverse effects of classroom NO2.NO2 is formed by combustion of liquid or solid fossil fuels. Indoor sources include gas stoves, heaters, and poorly ventilated furnaces and fireplaces. Furthermore, outdoor levels are elevated in heavily trafficked urban areas. The Environmental Protection Agency’s standard for safe outdoor level of NO2 is ∼50 parts per billion over a 1-year averaging time and 100 parts per billion over a 1 hour averaging time. Although the authors of this study do not specifically report classroom NO2 levels, it is clear from the 2 figures in the article that levels did not exceed 30 parts per billion, hence they were nowhere near the level up to which the Environmental Protection Agency considers safe. This is a warning that “safe” might not be safe enough. I think we all recognize the multiple and varied effects that both pollution and obesity have on health. With this study, the authors suggest synergy between 2 health risk factors and indicate that, as physicians, we must address all known risk factors for disease as we provide the best preventive and prospective care we can.

Effect of the School-Based Asthma Care for Teens (SB-ACT) program on asthma morbidity: a 3-arm randomized controlled trial

Urban adolescents with asthma often have inadequate preventive care. We tested the effectiveness of the School-Based Asthma Care for Teens (SB-ACT) program on asthma morbidity and preventive medication adherence. Methods: Subjects/Setting- 12-16yr olds with persistent asthma in Rochester, NY schools. Design- 3-group randomized trial (2014-2019). SB-ACT Intervention- Two core components: 1) Directly observed therapy (DOT) of preventive asthma medications, provided in school for at least 6-8 weeks for the teen to learn proper technique and experience the benefits of daily preventive therapy; 2) 4-6 weeks later, 3 sessions of motivational interviewing (MI) to discuss potential benefits from DOT and enhance motivation to take medication independently. We included 2 comparison groups: 1) DOT-only for 6-8wks, and 2) asthma education (AE) attention control. Masked follow-up assessments were conducted at 3, 5, and 7mos. Outcomes- Mean number of symptom-free days (SFDs)/2 weeks and medication adherence. Analyses- Modified intention-to-treat repeated measures analysis. Results: We enrolled 430 teens (56% Black, 32% Hispanic, 85% Medicaid). There were no group differences at baseline. We found no difference in SFDs at any follow-up timepoint. More teens in the SB-ACT and DOT-only groups reported having a preventive asthma medication at each follow-up (p<.001), and almost daily adherence at 3 and 5-months (p<.001, p=.003) compared to AE. By 7 months there were no significant differences between groups in adherence (p=.49). Conclusion: SB-ACT improved preventive medication availability and short-term adherence but did not impact asthma symptoms. Further work is needed to create developmentally appropriate and effective interventions for this group.

Critical Appraisal on Randomized Controlled Trial to Improve Care for Urban Children with Asthma

Objective-to evaluate the impact of the School-Based Asthma Therapy trial on asthma symptoms among urban children with persistent asthma. Design-Randomized trial, with children stratified by smoke exposure in the home and randomized to a school-based care group or a usual care control group. Setting-Rochester, New York. ParticipantsChildren aged 3 to 10 years with persistent asthma. Interventions-Directly observed administration of daily preventive asthma medications by school nurses (with dose adjustments according to National Heart, Lung, and Blood Institute Expert Panel guidelines) and a home-based environmental tobacco smoke reduction program for smoke-exposed children, using motivational interviewing. Main Outcome Measure-Mean number of symptom-free days per 2 weeks during the peak winter season (November-February), assessed by blinded interviews. Results-We enrolled 530 children (74% participation rate). During the peak winter season, children receiving preventive medications through school had significantly more symptom-free days compared with children in the control group (adjusted difference=0.92 days per 2 weeks;95% confidence interval, 0.50-1.33) and also had fewer nighttime symptoms, less rescue medication use, and fewer days with limited activity (all P&lt;.01). Children in the treatment group also were less likely than those in the control group to have an exacerbation requiring treatment with prednisone (12% Vs 18%, respectively; relative risk=0.64; 95% confidence interval, 0.41-1.00). Stratified analyses showed positive intervention effects even for children with smoke exposure (n=285; mean symptom-free days per 2 weeks: 11.6 for children in the treatment group Vs 10.9 for those in the control group; difference=0.96 days per 2 weeks; 95% confidence interval, 0.39-1.52).Conclusions-The School-Based Asthma Therapy intervention significantly improved symptoms among urban children with persistent asthma. This program could serve as a model for improved asthma care in urban communities.

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

BackgroundAsthma is one of the most common chronic diseases of childhood affecting 6.2 million (8.4%) children (<18 years old) in the USA. Asthma is also a leading cause of school absenteeism. Daily administration of preventive asthma medications improves asthma control. However, poor medication adherence is one of the barriers in achieving improved asthma outcomes. School-based supervised asthma therapy programs have been implemented to address this barrier.ObjectivesTo conduct a review of the literature on school-based supervised asthma therapy interventions and the effect on outcomes in children with persistent asthma.MethodsWe conducted a literature search using electronic search engines (ie, PubMed and Cochrane) and combinations of different search terms “school-based asthma,” “school-based asthma therapy,” and “school-based supervised asthma therapy.” Inclusion criteria were school-based interventions with supervised asthma medication administration conducted in the USA, measuring asthma outcomes. From 443 titles and abstracts, 9 studies met the inclusion criteria.ResultsSchool-based interventions with supervised asthma medication administration revealed improvement in asthma outcomes, including improved medication adherence, increased symptom-free days, decreased daytime and nighttime symptoms, decreased use of rescue medication, decreased asthma-related health care utilization, fewer exacerbations requiring treatment with prednisone, decreased school absenteeism due to asthma, fewer days of activity limitation, improved quality of life, and improvement in both pulmonary inflammatory markers and peak flow readings.ConclusionOur literature review demonstrated that school-based supervised asthma therapy improves asthma outcomes in urban children with persistent asthma. Schools are an ideal setting for implementation of asthma interventions for children and adolescents.

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

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. To evaluate the effect of the SB-TEAM program on asthma morbidity among urban children with persistent asthma. 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. 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. The primary outcome was the mean number of symptom-free days per 2 weeks, assessed by bimonthly blinded interviews. 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). 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. clinicaltrials.gov Identifier: NCT01650844.

Asthma Action Plan Receipt among Children with Asthma 2-17 Years of Age, United States, 2002-2013

To examine national trends in the receipt of asthma action plans, an intervention recommended by the National Asthma Education and Prevention Program guidelines. We used data from the sample child component of the National Health Interview Survey from 2002, 2003, 2008, and 2013 to examine the percentage of children 2-17 years of age with asthma (n = 3714) that have ever received an asthma action plan. Bivariate and multivariate (with adjustment for sociodemographic characteristics and asthma outcomes consistent with greater disease severity) logistic regressions were conducted to examine trends from 2002 to 2013 and to examine, with 2013 data only, the relationship between having received an asthma action plan and both sociodemographic characteristics and indicators of asthma severity. The percentage of children with asthma that had ever received an asthma action plan increased from 41.7% in 2002 to 50.7% in 2013 (P < .001 for trend). In 2013, a greater percentage of non-Hispanic black (58.4%) than non-Hispanic white (47.4%) children (P = .028), privately insured (56.2%) vs those with public insurance only (46.3%) (P = .016), and users of inhaled preventive asthma medication vs those that did not (P < .001) had ever received an asthma action plan. Adjusted results were similar. The percentage of US children with asthma that had ever received an asthma action plan increased between 2002 and 2013, although one-half had never received an asthma action plan in 2013. Some sociodemographic and asthma severity measures are related to receipt of an asthma action plan.

Asthma medication use among late midlife US Adults

Objective: Despite substantial prevalence of asthma, little is known about asthma in late midlife adults (50–64 years). The objective of this study was to examine the factors associated with the use of asthma medications among late midlife adults. Methods: Pooled data were obtained from the 2006 to 2010 Medical Expenditure Panel Survey. Medication use outcome variables include: (a) daily use of a preventive asthma medication and (b) use of more than three canisters of rescue inhalers in last 3 months. The Andersen Behavioral Model of Health Services Utilization was used to guide the selection of independent variables. Descriptive, unadjusted and adjusted logistic regression analyses were performed. Point estimates were weighted to the US civilian population and variance estimates were adjusted to obtain appropriate standard errors. All analyses were conducted using STATA (version 12). Results: A total of 1414 (weighted sample of 15 030 364) self-reported late midlife asthmatics were identified. About 31% of late midlife adults with asthma were using a preventive medication on a daily basis while 11% reported overusing acute medications. Adjusted analyses found that race, rurality and smoking were related to poor use of asthma medications among late midlife adults. Conclusion: Results suggest that asthma medication use is far from optimal among vulnerable groups of late midlife US adults.

Caregiver education to promote appropriate use of preventive asthma medications: what is happening in primary care?

Objective: To describe actions taken by providers at primary care visits to promote daily use of preventive asthma medication, and determine whether patient or encounter variables are associated with the receipt of asthma medication education. Methods: As part of a larger study in Rochester, NY, caregivers of children (2–12 years old) with asthma were approached before an office visit for well-child, asthma-specific or other illness care from October 2009 to January 2013. Eligibility required persistent symptoms and a prescription for an inhaled asthma controller medication. Caregivers were interviewed within two weeks to discuss the health care encounter. Results: We identified 185 eligible children from six urban primary care offices (27% Black, 38% Hispanic, 65% Medicaid). Overall, 42% of caregivers reported a discussion of appropriate preventive medication use, fewer than 25% received an asthma action plan, and 17% reported “ideal” medication education (both discussing proper medication use and completing an asthma action plan); no differences were seen upon comparing well-child and asthma-specific visits with other visits. Well-child and asthma-specific visits together were more likely, compared with other visits, to include a recommendation for a follow-up visit (43% versus 23%, p = 0.007). No patient factors were associated with report of preventive medication education. Conclusions: Guideline-recommended education for caregivers about preventive-asthma medication is not occurring in the majority of primary care visits for urban children with symptomatic persistent asthma. Novel methods to deliver asthma education may be needed to promote appropriate preventive medication use and reduce asthma morbidity.

Screening high-risk children for asthma through a community intervention

Objective: Many children, particularly those from inner city neighborhoods, have undiagnosed asthma. This study was done to evaluate the effectiveness of an asthma screening, referral and follow-up intervention in an inner city community setting in early identification of children at risk for undiagnosed asthma. Methods: A descriptive longitudinal cohort design was used to assess children at baseline and at a 2-year follow-up. Parents of children in a private day school and a church Sunday school (N = 103) completed a validated Asthma Screening Tool at both time periods. Children with asthma and at risk for asthma were referred to a primary care provider (PCP). Results: At baseline, screening of 103 children, ages 3-17 years (mean=7.7 ± 2.9), were categorized as known asthma diagnosis (n = 22), at-risk for undiagnosed asthma (n = 52) and not at-risk for asthma (n = 29). Sixty-two (60.2%) parents responded to the 2-year follow-up. Referral to PCP was kept by 61.5% from the known asthma group and by 24% of children at-risk for asthma. At 2-year follow-up, among not at-risk group, no one converted to at risk status, but majority of children among known asthma group continued to have uncontrolled asthma symptoms, and very few received daily preventive asthma medications. Conclusions: The asthma screening, referral and follow-up intervention for inner city children in a community setting was successful in early identification of patients at-risk for asthma. More education for PCPs on guidelines for diagnosis and management of asthma is needed to decrease childhood asthma morbidity.

Preventive asthma medication discontinuation among children enrolled in fee-for-service Medicaid

Objective: Local-area studies demonstrate that preventive asthma medication discontinuation among Medicaid and Children’s-Health-Insurance-Program (CHIP) enrolled children leads to adverse outcomes. We assessed time-to-discontinuation for preventive asthma medication and its risk factors among fee-for-service Medicaid/CHIP child beneficiaries. Methods: National-Health-Interview-Survey participants (1997–2005) with ≥1 Medicaid- or CHIP-paid claims when 2–17 years old (n = 4262) were linked to Medicaid-Analytic-eXtract claims (1999–2008). Multivariate Cox proportional-hazards models to assess time-to-discontinuation (i.e. failing to refill prescriptions <30 d after previous supplies ran out) included demographic factors and medication regimen (inhaled corticosteroids [ICS], long-acting β2-agonists, leukotriene modifiers, mast cell stabilizers, and monoclonal antibodies). Results: Sixty-three percent discontinued preventive asthma medications by 90 d after the first prescription. Adolescents and toddlers had slightly higher hazards of discontinuation (adjusted hazard ratios [aHR], 1.13; 95% CI, 1.05–1.23; and 1.12; 1.03–1.21, respectively) versus 5–11-year-olds, as did Hispanics (aHR, 1.24; 1.13–1.35) and non-Hispanic blacks (aHR, 1.17; 1.07–1.28) versus non-Hispanic whites, children in households with one adult and ≥3 children (aHR, 1.17; 1.05–1.30) versus multiple adults and ≤2 children, and children with caregivers’ educational-attainment ≤12th grade (aHR, 1.11; 1.02–1.20) versus caregivers with some college. Compared to regimens including both ICS and leukotriene modifiers, discontinuation was greater for those on ICS without leukotriene modifiers or on other preventive asthma medications (aHR, 1.67; 1.56–1.80; and 2.23; 1.78–2.80, respectively). Conclusion: More than 60% of children enrolled in fee-for-service Medicaid/CHIP discontinued preventive asthma medications by 90 d. Risk was increased for minorities and children from disadvantaged households. Understanding these factors may inform future pediatric asthma guidelines.

Asthma medication use among U.S. adults 18 and older

Asthma is a chronic lung disease that currently affects an estimated 25 million Americans. One way to control the disease is by regular use of preventive asthma medications and controlled use of acute medications. However, little is known about adults with asthma and factors associated with their medication use. To identify factors associated with asthma medication use among U.S. adults aged 18 and older. Data were obtained from the 2006 to 2010 Medical Expenditure Panel Survey (MEPS). Medication use outcome variables include: a) daily use of a preventive asthma medication (yes/no) and b) overuse (3+) of acute inhalers in last 3 months (yes/no). The Andersen Behavioral Model of Health Care was used to guide the selection of independent variables. The independent variables were categorized as predisposing, enabling and medical need factors. Logistic regression models were used to examine the relationship between asthma medication use in adults with asthma. Point estimates were weighted to the U.S. non-institutionalized population, and standard errors were adjusted to account for the complex survey design. Compared to Whites, minority adults 18 and older were less likely to use preventive asthma medication daily (Hispanic-OR: 0.72, CI: 0.54-0.96; African American-OR: 0.62, CI: 0.51-0.75 respectively). Similarly, Hispanic adults age 18 and older were at a significantly higher likelihood of overusing rescue medications compared to Whites (OR: 1.47, CI: 1.03-2.11). Non-metropolitan adults age 18 and older were more likely to overuse acute asthma medications than those from Metropolitan Statistical Area (OR: 1.57, CI: 1.15-2.16). Compared to older adults age 65 and over, late mid-life 50-64 year old adults were less likely to use a daily preventive asthma medication (OR: 0.67, CI: 0.54-0.83). Race, rurality and age were important factors associated with poor asthma medication use in U.S. adults. Although this is a first step toward identifying factors that may influence the use of asthma medications, future studies are needed to develop and implement interventions to overcome issues to improve asthma care.

Discrepancies between medical record data and parent reported use of preventive asthma medications

Objective: To assess whether medical record documentation reflects actual home practices regarding the administration of preventive medications to urban children with persistent asthma. Methods: Baseline data from a prompting asthma intervention were used for this cross-sectional analysis. As part of the larger study, we enrolled children (2–12 years) with persistent asthma in the waiting room at 12 primary care offices (2009–2012). Prior to their visit with a healthcare provider, caregivers reported information regarding their child’s asthma symptom severity and current preventive medications (i.e. name and frequency of use). We compared caregiver-reported medication information with medical record data to determine the rate of complete concordance, defined as total consistency between the prescribed medication data documented in the medical record and parent report describing how the child is actually using the medication at home. Results: According to 310 completed medical record reviews, 194 (62%) children had a current prescription for a daily preventive asthma medication. Of these children, 110 (57%) had caregivers who reported complete concordance. Those reporting complete concordance were more likely to have children with greater symptom severity, including fewer symptom-free days in the prior two weeks (6.9 vs. 8.7, p = 0. 018), and ≥1 asthma-related hospitalization in the prior year (16% vs. 6%, p = 0. 042). Conclusions: Medical records may poorly reflect actual home practices and providers should specifically inquire about medication use and barriers to adherence at the time of an office visit to promote guideline-based, consistent treatment for children with persistent asthma.

The School-Based Preventative Asthma Care Trial: Results of a Pilot Study

JS Halterman, M Fagnano, G Montes. J Pediatr. 2012;161(6):1109–1115 To test the feasibility and preliminary effectiveness of the School-Based Preventive Asthma Care Technology (SB-PACT) program, which included directly observing therapy of preventive asthma medications in school facilitated by Web-based technology for systemic symptom screening, electronic report generation, and medication authorization from providers. The study included 100 children (aged 3–10 years) with physician-diagnosed asthma with persistent symptoms based on National Heart, Lung, and Blood Institute guidelines from 19 inner-city schools in Rochester, New York. The investigators conducted a pilot, randomized trial of SB-PACT versus usual care. Outcomes were …

Effect of Type D personality on medication adherence in early adolescents with asthma

ObjectiveMedication adherence for daily preventive asthma medication is especially low during adolescence. In the present study, we aimed to test whether Type D personality (both as a category and with its constituent components (negative affectivity: NA and social inhibition: SI) separately and in interaction) predicts medication adherence of early adolescents with asthma. MethodsIn a prospective study, 188 early adolescents with asthma who were prescribed daily preventive asthma medication completed questionnaires on Type D personality, medication adherence, socio-demographic and clinical information, and depressive symptoms in the Spring/Summer of 2011 (T1) and again 12months later (T2). Multiple regression analyses, controlling for demographic and clinical information and for depressive symptoms, were conducted to test whether Type D personality (either as a categorical or dimensional construct) predicted changes in medication adherence over time. ResultsAdherence was significantly lower at T2 than at T1 and this decrease was predicted by the categorical construct of Type D personality. Analyses of the two separate dimensions NA and SI and their interaction showed that higher scores on NA at T1 predicted more decrease in adherence over time. Neither SI nor the interaction between NA and SI predicted changes in adherence. ConclusionThis is the first study to test the relationship between Type D personality and medication adherence in adolescents. Although categorical Type D personality predicts mediation adherence of adolescent with asthma over time, dimensional analyses suggest that this is due to negative affectivity only, and not to the combination of negative affectivity and social inhibition.

Cost-Effectiveness of the School-Based Asthma Therapy (SBAT) Program

Impoverished urban children suffer disproportionately from asthma and underuse preventive asthma medications. The objective of this study was to examine cost-effectiveness (CE) of the School-Based Asthma Therapy (SBAT) program compared with usual care (UC). The analysis was based on the SBAT trial, including 525 children aged 3 to 10 years attending urban preschool or elementary school who were randomized to either UC or administration of 1 dose of preventive asthma medication at school by the school nurse each school day. The primary outcome was the mean number of symptom-free days (SFDs). The impact of the intervention on medical costs was estimated by using parent-reported child health services utilization data and average national reimbursement rates. We estimated the cost of running the program using wages for program staff. Productivity costs were estimated by using value of parent lost time due to child illness. CE of the SBAT program compared with UC was evaluated based on the incremental CE ratio. The health benefit of the intervention was equal to ∼158 SFD gained per each 30-day period (P < .05) per 100 children. The programmatic expenses summed to an extra $4822 per 100 children per month. The net saving due to the intervention (reduction in medical costs and parental productivity, and improvement in school attendance) was $3240, resulting in the incremental cost-savings difference of $1583 and CE of $10 per 1 extra SFD gained. The SBAT was effective and cost-effective in reducing symptoms in urban children with asthma compared with other existing programs.

Trends in Preventive Asthma Medication Use Among Children and Adolescents, 1988–2008

To examine the trends in preventive asthma medication use among asthmatic children in the United States from 1988 to 2008.Asthmatic individuals aged 1 to 19 years with current asthma as part of the National Health and Nutrition Examination Survey during 3 time periods: 1988 to 1994, 1999 to 2002, and 2005 to 2008.Cross-sectional analysis of the study population for use of preventive asthma medication (PAM), including inhaled corticosteroids, leukotriene receptor antagonists, long-acting β-agonists, mast-cell stabilizers, and methylxanthines.In children with current asthma, there was an increase in the use of PAMs from 17.8% (SE: 3.3) in 1988 to 1994, to 34.9% (SE: 3.3) in 2005 to 2008 (P < .001). Adjusting for age, gender, race/ethnicity, and health insurance status, the odds of PAM use were higher in 2005 to 2008 compared with 1988 to 1994 (adjusted odds ratio [aOR] = 2.6, 95% confidence interval [CI]: 1.5–4.5). A multivariate analysis over all 3 time periods showed lower use of PAMs among non-Hispanic black (aOR = 0.5, 95% CI: 0.4–0.7) and Mexican American (aOR = 0.6, 95% CI: 0.4–0.9) children compared with non-Hispanic white children. PAM use was lower in 12- to 19-year-olds compared with 1- to 5-year-olds and also in children who did not have health insurance compared with those who did have health insurance.Between 1988 and 2008, the use of PAM increased among children with current asthma. Non-Hispanic black and Mexican American adolescents aged 12 to 19 years, and uninsured children with current asthma had lower use of PAM.This study demonstrates an increased use of PAMs in asthmatic children in 2008 vs 1988. Although several factors are likely at work, it seems likely that the National Asthma Education and Prevention Program asthma treatment guidelines, initially released in 1991, are a major reason for this result. These guidelines, and subsequent updates in 1997 and 2007, emphasize the importance of inflammation in the pathophysiology of asthma and the value of preventive medications in reducing adverse outcomes (eg, emergency room visits, hospitalizations, and the use of systemic corticosteroids). It is plausible that the growth of direct-to-consumer pharmaceutical advertising may also have augmented the use of PAMs. The authors also point out that the lower use of PAMs in non-Hispanic black and Mexican American asthmatic children may partially explain the increased risk for adverse outcomes in these patient groups.

Racial and Ethnic Differences in the Management of Childhood Asthma in the United States

Objectives. We examined racial and ethnic differences in the management of childhood asthma in the United States and the extent that care conformed to clinical best practices. Methods. Two years of pooled data from the National Health Interview Survey were analyzed using logistic regression. The sample included all children between ages 2 and 17 years who had asthma currently and had been diagnosed with asthma by a doctor or health professional (n = 1757; 465 African-American, 212 Mexican-American, 190 Puerto Rican and other Hispanic, 806 white, non-Hispanic, and 84 children of other and multiple races and ethnicities). Results. African-American children with asthma were significantly less likely than white, non-Hispanic children to have taken preventive asthma medication, but more likely to have had an asthma management plan. Mexican-American and Puerto Rican and other Hispanic children did not differ significantly from white, non-Hispanic children in either receiving preventive asthma medication or having an asthma management plan. Caregivers of African-American and Puerto Rican and other Hispanic children were more likely to report that they or their child had taken a course or class on how to manage their child’s asthma. We did not find racial or ethnic differences in the extent children used quick-relief asthma medication or received advice about reducing asthma triggers in their home, school, or work environments. Conclusions. This work highlights a need for more research on racial and ethnic differences in asthma management. Implications for public health responses and racial and ethnic disparities in asthma morbidity are discussed.

The School-Based Preventive Asthma Care Trial: Results of a Pilot Study

To test the feasibility and preliminary effectiveness of the School-Based Preventive Asthma Care Technology (SB-PACT) program, which includes directly observed therapy of preventive asthma medications in school facilitated by Web-based technology for systematic symptom screening, electronic report generation, and medication authorization from providers. We conducted a pilot randomized trial of SB-PACT versus usual care with 100 children (aged 3-10 years) from 19 inner-city schools in Rochester, New York. Outcomes were assessed longitudinally by blinded interviewers. Analyses included bivariate statistics and linear regression models, adjusting for baseline symptoms. There were data for 99 subjects for analysis. We screened all children using the Web-based system, and 44 of 49 treatment group children received directly observed therapy as authorized by their providers. Treatment group children received preventive medications 98% of the time they were in school. Over the school year, children in the treatment group experienced nearly 1 additional symptom-free day over 2 weeks versus the usual care group (11.33 vs 10.40, P = .13). Treatment children also experienced fewer nights with symptoms (1.68 vs 2.20, P = .02), days requiring rescue medications (1.66 vs 2.44, P = .01), and days absent from school due to asthma (0.37 vs 0.85, P = .03) compared with usual care. Further, treatment children had a greater decrease in exhaled nitric oxide (-9.62 vs -0.39, P = .03), suggesting reduction in airway inflammation. The SB-PACT intervention demonstrated feasibility and improved outcomes across multiple measures in this pilot study. Future work will focus on further integration of preventive care delivery across community and primary care systems.