Outcomes for a comprehensive school-based asthma management program

This article describes the evaluation of a comprehensive school-based asthma management program in an inner-city, largely African-American school system. All 54 elementary schools (combined enrollment 13,247 students) from a single urban school system participated in this study. Schools were randomly divided between immediate and delayed intervention programs. The intervention consisted of 3 separate educational programs (for school faculty/staff, students with asthma, and peers without asthma) and medical management for the children with asthma (including an Individual Asthma Action Plan, medications, and peakflow meters). Children with asthma were identified using a case detection program and 736 were enrolled into the intervention study. No significant differences were observed in school absences, grade point average, emergency room visits, or hospitalizations between the immediate and delayed intervention groups. Significant increases in knowledge were observed in the immediate intervention group. This study of a school-based asthma management education and medical intervention program did not show any differences between the intervention and control groups on morbidity outcomes. Our experience leads us to believe that such measures are difficult to impact and are not always reliable. Future researchers should be aware of the problems associated with using such measures. In addition, connecting children with a regular source of health care in this population was difficult. More intensive methods of medical management, such as school-based health centers or supervised asthma therapy, might prove more effective in inner-city schools.     

Screening and referral outcomes of school-based health services in a low-income neighborhood.

A school health program, conducted by the Division of Community and Social Pediatrics of Harlem Hospital Center at two elementary schools in central Harlem, provides screening, followup, and health education services. The children attending these schools are largely dependent on public medical care, with low accessibility and lack of continuity of care. The effectiveness of the program''s services were evaluated with respect to screening and referral outcomes. During the spring of 1974, the school health records were reviewed for the 221 children who had been in the program for 1 year in one of the schools. The evaluation results indicated that although major health conditions were not commonly disclosed by the screening component of the program, the examining physicians noted that 57% of the children had one or more health problems. Children with dental caries were the most frequently observed as well as the most frequently referred for care. Children with two-thirds of the medical problems who were referred for further care received medical attention. The program demonstrates the capability of relevant school-based health services in a low-income neighborhood to address the medical needs of elementary school children.     

A Matched-Cohort Evaluation of a Bedside Asthma Intervention for Patients Hospitalized at a Large Urban Children’s Hospital

Emergency care and hospitalizations account for 36% of asthma-related medical expenses for children. National asthma guidelines emphasize the need for asthma self-management education at multiple points of care, including the hospital, to help prevent acute exacerbations. The integration of a bedside asthma education program into discharge planning at a busy urban children’s hospital aimed to reduce repeat emergency department (ED) visits and hospitalizations by educating the community’s highest-risk children and their families about asthma. A trained respiratory professional provided 45 minutes of individualized bedside education to families at the hospital and one follow-up support phone call within 3 weeks after discharge. Children receiving the intervention were matched to a control group of children not receiving the intervention by age and 2 markers of past utilization using data obtained from hospital records. Repeat ED utilization was analyzed using a Cox proportional hazards model controlling for sex, residence, race or ethnicity, and year. Compared to 698 matched controls, no significant improvement was observed in the 698 intervention participants or any subgroups followed for 12 months after the intervention.     

Using school staff to establish a preventive network of care to improve elementary school students' control of asthma

School-based asthma interventions delivered by nonschool staff have been successful but are limited in their reach because of the cost and effort of bringing in outside educators and their inability to establish improved communication about asthma between schools, families, and primary care providers (PCPs). To address these problems, Columbia University and the New York City Department of Education and the New York City Department of Health and Mental Hygiene undertook a randomized controlled trial to test the efficacy of a comprehensive school-based asthma program. In this intervention, school nurses were trained to facilitate the establishment of a preventive network of care for children with asthma by coordinating communications and fostering relationships between families, PCPs, and school personnel. PCPs also received training regarding asthma management. There was limited support for this model. While case detection helped nurses identify additional students with asthma and nurses increased the amount of time spent on asthma-related tasks, PCPs did not change their medical management of asthma. Few improvements in health outcomes were achieved. Relative to controls, 12-months posttest intervention students had a reduction in activity limitations due to asthma (-35% vs -9%, p < .05) and days with symptoms (26% vs 39%, p = .06). The intervention had no impact on the use of urgent health care services, school attendance, or caregiver's quality of life. There were also no improvements at 24-months postintervention. We faced many challenges related to case detection, training, and implementing preventive care activities, which may have hindered our success. We present these challenges, describe how we coped with them, and discuss the lessons we learned.     

The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma

Abstract: Pediatric asthma rates are reaching epidemic proportions, adversely affecting children's quality of life, educational potential, and health care costs, especially those in the inner city. This study evaluated the effectiveness of a school-based asthma case management (CM) approach with medically underserved inner-city children attending Memphis City schools. Fourteen elementary schools with high rates of asthma-related hospital utilization were grouped according to school size, percentage of children with asthma enrolled, and percentage of children eligible for free or reduced-price lunch. Schools were randomized to either a nurse CM intervention or a usual care (UC) condition. The CM group included 115 students; 128 students were in the UC group. A longitudinal design was used to follow students' progress. Students were primarily African-American children diagnosed with asthma. In CM schools, nurse case managers conducted weekly group sessions incorporating the Open Airways curriculum, followed up on students' school absences, and coordinated students' asthma care with families, school personnel, and medical providers. In UC schools, students received routine school nursing services. CM students had fewer school absences than their counterparts in UC schools (mean 4.38 vs 8.18 days, respectively) and experienced significantly fewer emergency department visits (p < .0001) and fewer hospital days (p < .05) than UC students. No such differences existed before program initiation. Replication and follow-up in year 2 showed continued significant improvements. School-based nurse CM can achieve significant improvements in school attendance and medical utilization. (J Sch Health. 2006;76(6):320-324)     

Improved asthma outcomes using a coordinated care approach in a large medical group.

The objective of this study was to review the development of a multidisciplinary asthma disease management program in a large medical group practice in an urban area, and evaluate the impact of the program on processes of care and health care utilization for adults and children with asthma. The disease management intervention included the development of a patient registry, a systematic approach to assessment of asthma control using the Asthma Therapy Assessment Questionnaire (ATAQ), case management, and physician education. An administrative database was used to examine hospital admissions and emergency department (ED) visits. A medical record audit was conducted to examine recorded compliance with asthma guidelines and documentation practices. The baseline study population included 3486 adults and children with asthma. The ATAQ suggested that, at baseline, control problems were frequent, with 34% of adult respondents missing work because of asthma. ATAQ also revealed several areas for care improvement. For example, only 20% of adult respondents reported having a written treatment plan. The chart review and administrative claims analyses showed that the program had beneficial results in several areas. Medical record documentation improved for asthma diagnosis (83.3% vs. 98.6%; p < 0.001) and patient education (15.7% vs. 26.1%; p < 0.001). No improvements were seen in documentation of peak flow ownership/use, smoking cessation advice, or influenza vaccination. ED visits related to asthma decreased from 148 per 1000 to 88 per 1000 (p < 0.001), and hospitalizations related to asthma decreased from 81 per 1000 to 37 per 1000 (p < 0.001). The outcomes suggest that this program was associated with a marked reduction in rates of hospitalization and ED usage for asthma, as well as significant improvement in several essential processes of care.     

Child for child in Zaire: school children in the service of health

In Gecamines, Zaire, a coordination unit examines ways to introduce medical education in 90 business schools in order to promote and protect health with and through children and in favor of the community. Its activities include analyses of the causes of failure to implement medical education in the past; proposing solutions and strategies allowing the unit to succeed at proposed activities; initiating a training program for physicians, teachers, social workers, and all persons promoting the program; introducing the child-to-child pedagogy at schools and for health education for children; informing teachers about screening methods for certain abnormalities and early detection of illnesses; and helping teachers control the vaccination status of children and participate in increasing vaccination coverage. School-based activities are personal hygiene; general cleanliness of class rooms, halls, and rest rooms; screening for illnesses, especially sight, hearing, and walking anomalies; children-organized health education conferences; and transmission of health education messages via drama, songs, conferences, and drawings. Out-of-school activities include relay of new health information to families and the community through children and surveillance of schools to prevent window thefts (source of air currents leading to upper and lower respiratory infections). The oldest children care for the health of other children, especially those who live near them; inform their parents about community health resources; serve as health volunteers (e.g., growth monitoring); and actively help control and evaluate the progress of health activities in their neighborhoods. After one year of primary health care coordination activities, the results are encouraging. Children play a substantial role favoring the promotion and protection of health. They can give life to prevention activities and even care for the youngest children. They can be excellent health volunteers in their community. They influence adults and other children.     

Asthma and respiratory dysfunction among urban, primarily Hispanic school children

A screening program identified children with poorly managed asthma or respiratory dysfunction. Children in grades 2-5 in all Passaic, New Jersey, schools were eligible for screening with questionnaires and a biometric test. Those with risk factors or failed biometric screening were referred to primary care providers. Of the 6,579 eligible children, 3,657 (56%) had parental questionnaires returned and 3,834 (58%) were biometrically screened. Over the 4-yr study period, 6-22% of children were previously diagnosed with asthma. Approximately 20% of children demonstrated peak flow measures <75% of predicted values. Predictors of a prior diagnosis of asthma and a medical treatment plan for asthma management were health care coverage and ethnicity. Predictors of peak flow test failure were the presence of roaches and mold in the home, pesticide use, and a family member with asthma.     

Children with asthma in schools: an opportunity for "healthy alliances" between health and education authorities

Head teachers of all primary and secondary schools in County Durham were surveyed during 1994 to investigate school policy and management of children with asthma. Results indicate a need and opportunity to improve asthma care for children at school through healthy alliances between the health and education authorities.     

Health and special education: a study of new developments for handicapped children in five metropolitan communities

Since the implementation in 1977 of the Education for All Handicapped Children Act (Public Law 94-142), public school systems have provided special education and related services to students with a wide range of handicapping conditions, including some children served previously in hospitals or other institutions. Although the Federal law does not require physician participation in the special education process, it does imply an active new role for the medical care community, both public and private, in helping schools to identify and diagnose children with disabilities and in ensuring that those children have adequate access to health services. This study explores the experience of five nationally dispersed urban school systems in implementing P.L. 94-142, with particular reference to the interaction of physicians and the schools. The findings highlight continued problems with early identification of certain types of childhood handicaps, classification of children's functional disorders, and adequate participation of practicing physicians in the program, especially with regard to developmental and behavioral issues. In addition, inequities in community health services are documented for a substantial number of the children studied. Improved collaboration between the health and education sectors is needed to address these concerns in order to fulfill the intent of national special education policy and to maximize the potentialities of these children and their families.     

The awesome Asthma School Days Program: educating children, inspiring a community

Program planners developed an educational program to improve the health of children with asthma in grades three to five in Milwaukee (Wis.) Public Schools. During 1997-1998, 1,400 students from 74 elementary schools participated in the Awesome Asthma School Days education program. In a cross-sectional survey, about 40% of children reported play interrupted and sleep disturbed by asthma, more than 50% of children reported exposure to smoke in their home, most children lacked asthma self-care tools, and most children with persistent symptoms did not use an anti-inflammatory inhaler. The educational program improved students' expectations about normal play and sleep and improved their understanding of asthma. Leaders in Milwaukee used the survey results to develop a community action plan. The educational program, surveys, community partnerships, and strategic plans can be replicated in other schools.     

Children with a tracheostomy: experience of their carers in school

OBJECTIVE: Tracheostomies in children are increasingly performed for chronic medical conditions. There are no published studies reporting the experience of children with a tracheostomy in school. Such information would be valuable in planning the care and education of these children. The aims of this study were to identify those children with a tracheostomy in Nottinghamshire schools and determine the support they were receiving. DESIGN, SETTING AND PARTICIPANTS: Questionnaire survey to families and school carers of 11 children with a tracheostomy. RESULTS: All children of school age were in full-time education (five mainstream, five special schools). One preschool child attended a Family Centre. Four had problems finding suitable carers, delaying return to school in three. Four parents were dissatisfied with aspects of the child's experience at school: two felt the teaching staff were unsupportive, one was unhappy with the care of the tracheostomy, and one had problems funding a carer. Ten out of 11 school carers were satisfied with their training; 10 would have liked regular update sessions. The amount of care required varied. Those with complex medical problems in a special school setting needed frequent care, and one had required admission to hospital from school. One child had time off school because of lack of carer availability. Those who were severely disabled had less time off school for ill health after the tracheostomy than before the tracheostomy. CONCLUSION: Children with tracheostomies can successfully and safely achieve full-time education in both mainstream and special schools. A dedicated multidisciplinary team, including input from the parents, is essential to achieve this goal. Regular revision of skills and information sessions for the teaching staff would be beneficial.     

Development of a health education program for parents of preschool children with asthma

This paper presents the development and pilot testing of a self-management education program for parents of preschool children (0-4 years) with asthma, involving general practitioners, asthma nurses, community nurses and doctors of child health centers. The program intends to integrate education in the medical care provided to the child (and the parent). The program contains four manuals, one for each group of health care providers, and a booklet for parents. The manuals identify the educational tasks per discipline and regulate referral from one discipline to another. The booklet provides written information for parents. In the development of the program, representative from both the target population and the providers of the education were involved in needs assessment surveys. Findings of these surveys were integrated into the design of the program. Then, a pilot study was conducted to test the efficacy of the program during group sessions. Findings indicate that the variables measured (knowledge, attitude, self-efficacy and self-management behaviors) improved significantly from pre- to post-test. Finally, the program was revised for the next phase in which the program will be evaluated in primary health care with a controlled trial.     

Access to specialized health care for asthmatic children in Norway: the significance of parents' educational background and social network

What determines access to the Voksentoppen Children's Asthma and Allergy Centre, the most specialized health care facility for asthmatic children in Norway? This publicly funded national institution is mandated to serve all segments of the population equally. The paper reports from the experiences of families with children having a confirmed diagnosis of moderate to severe asthma. The study population was selected from a national register of state cash-benefit recipients. Within this register, all families with a child under the age of 9 and with the diagnosis of asthma at the end of 1997 were selected (N = 2564). Further information about the population was gathered in a postal survey. It was found that access to the facility, measured as at least one admission during the period of the disease, was primarily determined by variations in morbidity. In particular, measures of health condition that presupposed a professional's evaluation of the child's health condition were significant. In addition, access was influenced by several factors not directly related to the need for treatment. Notably, children from families in which parents had a graduate education were over-represented among those with access to the top level of the institution's medical hierarchy. Multivariate analysis was used to search for causal mechanisms. It was found that families with a doctor in their social network had greater likelihood of access, and this in part accounted for the observed association between education and access. The pattern of access was also influenced by geographical factors, but not in a way that reduced the significance of educational background. Membership of, and participation in, patient organizations also increased the families' chances of receiving top-level professional treatment. The results depart from professional norms and officially stated health policy in Norway, which assert that health condition is the only valid criterion for allocating scarce medical goods.     

Evaluation and sustainability of the healthy learners asthma initiative

The Healthy Learners Asthma Initiative (HLAI) involved collaboration between Minneapolis Public Schools (MPS), local health care providers/payors, parents, and other partners. The intervention included development of enhanced asthma care in school health offices and clinic performance improvement projects to foster adoption of National Institutes of Health asthma guidelines. Goals were to improve asthma management among school children and reduce asthma-related school absences, hospitalizations, and emergency department visits. The effectiveness evaluation utilized a randomized community trial design with 16 elementary and middle schools matched and randomly assigned to either an intervention or a control group. Outcomes investigated were (a) school health office impacts and (b) school attendance. Data sources included school health office records, district attendance, enrollment, and demographics files. Following implementation of the HLAI, asthma visits to health offices were significantly lower in intervention schools compared to control schools (91 vs 121 visits per 100 students with asthma per month), and intervention schools had greater availability of medication and asthma action plans and more peakflow measurements, asthma education, and parent communication. Clinics initiated significantly more asthma action plans and sent them to MPS. Attendance differences between groups were limited to students who received asthma care through the school health office. Monitoring of asthma management activities provided through school health offices from 2002 to 2005 indicates sustained implementation of enhanced asthma care in schools and increased asthma communication between school, parents, and health care providers.     

Cognitive predictors of self-management behavior of asthmatic children and their families in Alexandria

The aim of this work was to study self-management behavior (SMB) of asthmatic children and their parents, its cognitive predictors as well as its effect on the child stress and health care utilization. Data was collected by interviewing 500 asthmatic children aged 9-18 years and 500 of their parents. The study revealed that very low percentage of the respondents had good asthma management behavior. The most frequent behaviors were taking medication, going to doctor and avoiding asthma triggers. The least practiced behaviors were breathing exercises and bronchial hygiene practices. The main predictor for children's SMB which constituted 36.3% of its variance was parental management behavior. Most of the studied cognitive factors were proved as predictors for children's SMB including knowledge, self-efficacy, health locus of control, perceived seriousness and barriers. Socioeconomic status was the main predictor of parental SMB, together with knowledge, powerful others health locus of control, health value, perceived barriers and father's education shared by 46.4% in explanation of its variance. Child knowledge, parental SMB, and socioeconomic status were significantly predicting health care utilization and level of child stress. A need was highlighted for initiation an asthma management educational program to families of asthmatic children.     

The Breathmobile Program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program.

Despite more than a decade of education and research-oriented intervention programs, inner city children with asthma continue to engage in episodic "rescue" patterns of healthcare and experience a disproportionate level of morbidity. The aim of this study was to establish and evaluate a sustainable community-wide pediatric asthma disease management program designed to shift inner city children in Los Angeles from acute episodic care to regular preventive care in accordance with national standards. In 1995 the Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA), the Los Angeles County Department of Health Services (LAC DHS), and the Los Angeles Unified School District (LAUSD) established an agreement to initiate and sustain the Breathmobile Program. This program includes automated case identification, mobile school-based clinics, and highly structured clinical encounters supported by an advanced information technology solution. Interdisciplinary teams of asthma care specialists provide regular and ongoing care to children at school and county clinic sites over a wide geographic area of urban Los Angeles. Each team operates in a specially equipped mobile clinic (Breathmobile), efficiently moving a structured healthcare process to school and county clinic sites with large numbers of children. Demographic, clinical, and participation data is tracked carefully in an electronic medical record system. Program operations, clinical oversight, and patient tracking are centralized at a care coordination center. Clinical operations and methods have been replicated in fixed specialty clinic sites at the Los Angeles County + University of Southern California Medical Center. Clinical and process measures are regularly evaluated to assure quality, plan iterative improvement, and support evidence-based care. Four Breathmobiles deliver ongoing care at more than 90 school sites. The program has engaged over five thousand patients and their families in a continuity care model that has demonstrated efficacy over usual episodic care. More than 90% of patients in all asthma severity categories achieved clinical control of asthma with significant reductions in inpatient (IP) and emergency department (ED) use. On February 14, 2002, the program became the first program in the United States to receive the award of disease-specific care certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Proper design and resource allocation can sustain a school-based community-wide pediatric asthma disease management program and shift a population of inner city children from acute episodic care to routine preventive care in accordance with national standards. An evidence-based approach to evaluating and maintaining quality, coupled with stratified care delivery, can assure the efficient use of safety net healthcare resources.     

Relationships between welfare status,health insurance status,and health and medical care among children with asthma

OBJECTIVES: This study evaluated the relationships between health insurance and welfare status and the health and medical care of children with asthma. METHODS: Parents of children with asthma aged 2 to 12 years were interviewed at 6 urban clinical sites and 2 welfare offices. RESULTS: Children whose families had applied for but were denied welfare had more asthma symptoms than did children whose families had had no contact with the welfare system. Poorer mental health in parents was associated with more asthma symptoms and higher rates of health care use in their children. Parents of uninsured and transiently insured children identified more barriers to health care than did parents whose children were insured. CONCLUSIONS: Children whose families have applied for welfare and children who are uninsured are at high risk medically and may require additional services to improve health outcomes.     

Evaluation of an Asthma Disease Management Program in a Medicaid Population

In 2002, an asthma disease management program was initiated in Washington State in the US. The program was designed for clients of the state’s Medicaid program, which provides health coverage for qualified low-income state residents. In response to the escalating cost of healthcare and because of concerns about the quality of care, the Washington State Legislature mandated implementation of this disease management program as a pilot project to assist individuals to improve their health. Medicaid administrators used a carefully designed process to identify client needs and to obtain proposals for disease management programs.The asthma program seeks to narrow the gap between the standards of care and its practice. In particular, the program aims to provide patients with a richer understanding of asthma and how to control it. This is accomplished through disease education, symptom awareness and management, trigger avoidance, self-monitoring, and education on recommended medication strategies. The program is based on the US National Institutes of Health’s published guidelines on the optimal treatment of asthma.Enrollment of Medicaid clients into the asthma program began in April 2002. This article describes three approaches to evaluation of the first 3 years of the program: (i) 3 years of self-reported client data; (ii) an independent evaluation of the first year’s changes in utilization and quality of care; and (iii) an actuarial analysis of cost effectiveness. The first study used vendor-reported data collected during initial and follow-up assessments. The authors of this first study also reported the results of a satisfaction survey conducted on behalf of the vendor. The independent evaluation conducted by the University of Washington relied on medical record review and claims analysis, and reported statistical analysis of pre/post comparisons. The actuarial study also reported pre/post comparisons using an analysis of claims per member per month in periods before the program started and at 1 and 2 years of program operations.Clients were assessed according to several dimensions of health including self-management, symptoms, functional status, medication management, and trigger management. Numerous interventions were provided to study participants including access to round-the-clock telephone consultation with a registered nurse, self-care education, alerts sent to the primary provider, and symptom issue follow-up. The asthma disease management program outcomes provide evidence of initial success for those clients who completed the reassessment process. The results of the first 3 years of participation in the program indicate trends toward improved health status and client satisfaction with the program. Long-term evaluation will be necessary to determine if the program reduces costs and closes the quality chasm. If successful, this program could serve as a model for programs with similar clients and similar challenges.     

Students with chronic illnesses: guidance for families,schools, and students

ABSTRACT: Developed by a work group representing several nonprofit and federal health and education organizations, Students with Chronic Illnesses: Guidance for Families, Schools, and Students provides cross-cutting action steps to facilitate full participation in learning and other school activities by students with chronic diseases. Between 10% and 15% of children in the United States are affected by at least one chronic disease. This guide offers practical tips to help ensure that schools are responsive to the health needs of children with chronic illnesses.
Children with chronic health conditions are more likely to miss days from school, need specialized health care, and require special education services or homebound teaching. School health advocates agree that meeting the needs of these children requires collaboration among the students, their families, school personnel, and community health care providers. Such efforts can help students establish better attendance, improve their alertness and physical stamina, and face fewer restrictions on physical activity at school and fewer medical emergencies.
The guide addresses issues such as routine and urgent care needs of students, medication access and administration, and school personnel training to ensure compliance with applicable local, state, and federal regulations. While emphasizing the value of adopting general policies for supporting students with chronic conditions, the guide also encourages schools to develop and implement condition-specific and individualized protocols. The responsibilities of family members, school district officials, teachers and school administrators, and students are outlined to help each constituent fulfill these objectives.
The guide is available online at http: www.nhlbi.nih.gov health public lung asthma guidfam.htm .