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

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.

Figure 1.. School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) Program Consolidated Standards for Reporting of Trials (CONSORT) Flow Diagram

A CONSORT flow diagram showing the progress of patients throughout the SB-TEAM trial.

Figure 2.. Mean Symptom-Free Days per 2 Weeks by Follow-up Assessment

At the postintervention follow-up time points, children in the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) group had significantly more symptom-free days than children in the enhanced usual care (eUC) group (treatment-by-time interaction, P = .02), adjusted for preventive medication use at baseline. At 6-month follow-up, the mean difference between groups was 0.732 (95% CI, −0.017 to 1.480); at final follow-up, the mean difference was 0.847 (95% CI, 0.101-1.593). The dotted line indicates the telemedicine component of the intervention ending. Error bars indicate 95% CIs.