Telemedicine Program Halves Pediatric Emergency Visits for Asthma

The trial featured schoolchildren with persistent asthma from an urban region.

Jill S. Halterman, MD, MPH

A telemedicine-based program for urban schoolchildren with asthma reported significantly improved symptoms with fewer health care interventions versus common therapy programs.

In a randomized trial involving children with persistent asthma from the Rochester City School District in Rochester, NY, children to undergo an implemented School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program reported more symptom-free days in the 2 weeks following intervention, than those to undergo supervised therapy from their school.

The SB-TEAM program — led by Jill S. Halterman, MD, MPH, Department of Pediatrics, University of Rochester — is an integration of 2 systems. It combines school-based directly observed therapy (DOT) of preventive asthma medications that serves to improve treatment adherence, with telemedicine methods that ensure assessment and follow-up access.

The patient population was at-hand to researchers due to a long-standing partnership with school district, and was valued because of its demographics. Researchers noted that inhaled corticosteroids are the advised daily therapy for patients with persistent asthma symptoms.

“However, many children with persistent asthma do not receive preventive medications, and minority children living in poverty are at highest risk of inadequate therapy,” researchers wrote. “In addition, many children who are prescribed a preventive medication do not achieve optimal control, at least in part because of poor adherence and a lack of appropriate follow-up care.”

Researchers recruited 400 children, aged 3 to 10 years old, from 49 schools in the Rochester area, from 2012 to 2016. Participants were required to be diagnosed with asthma with persistent symptoms or poor control — based on the National Heart, Lung, and Blood Institute guidelines —and therefore needed daily therapy.

The children were split 1:1 to either the SB-TEAM intervention group or an enhanced usual care (eUC) group, and assessed routinely from the start through the end of the school year. Both groups were provided baseline symptom assessments, recommendations for preventive therapies, and asthma education materials.

Follow-up telemedicine assessments occurred 4 to 6 weeks following the start of DOT (baseline), then again another 4 to 6 weeks later. These assessments allowed clinicians to consider optimal treatment in response to emerging triggers or comorbid conditions.

“Clinicians were encouraged to deliver asthma education and make guideline based

medication adjustments (or specialist referral) for children who continued to have poor control,” researchers wrote. “Changes to medications were implemented as DOT through school.”

Researchers assessed both groups’ outcomes via telephone interviews with caregivers, as well as in review of medical and school records. Primary outcome was gauged at SFDs in postintervention — after 4 months, 6 months, and at final assessment. SFDs were characterized as 24 hours without coughing, wheezing, or shortness of breath, as dictated by the child’s caregiver.

The mean SFDs by patients in the SB-TEAM program were 11.6, while patients in the eUC program reported a mean 10.97 SFDs (95% CI; 0.15-1.22; P = 0.01). SB-TEAM patients also reported less frequent emergency department visits or hospitalizations for asthma, averaging 7% versus 15% of eUC patients (95% CI; 0.32-0.84).

The study proved SB-TEAM had comparable results to other community-based asthma programs, but was novel because of its use of telemedicine to connect children patients with primary care physicians (PCPs).

“The telemedicine model is one form of connected care that enhances access to medical services for traditionally underserved children and was an efficient way to link children to primary care and facilitate asthma assessment and treatment in this study,” researchers wrote. “We were able to initiate telemedicine visits for almost all children in the SB-TEAM group, and most started DOT of preventive asthma medications at school.”

The implication that telemedicine could benefit children with asthma in urban areas could be a great benefit. Previous studies, such as a follow-up analysis of the New York City Neighborhood Asthma and Allergy Study (NYCNAAS), found that there could be greater associations between pollutant exposure and urgent medical visits in New York City children living in neighborhoods with high asthma prevalence.

The 2 studies may have varied in the availability of patients’ resources, however. The 190 children with asthma analyzed from the NYCNAAS were from middle-income families recruited through health insurance providers, while children from the Rochester-based study relied on school-based interventions and previously lacked frequent PCP intervention.

Rochester-based researchers called for sustained and enhanced funding for school-based programs, which on their own are almost capable of improving symptoms in children with persistent asthma.

“The integration of telemedicine with school based care represents one successful method to enhance access to guideline-based treatments and ensure appropriate primary care follow-up assessments,” researchers wrote. “As we continue to work toward sustainability of these care models, it is important to consider resources available in each community to build collaborations that can be continued.”

The study, "Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) Program on Asthma Morbidity," was published online in JAMA Monday.