Medication fill duration in pediatric hypertension: adherence, blood pressure control, and disparities.

BACKGROUND: Medication nonadherence is a barrier to hypertension control. The Centers for Disease Control and Prevention recommends prescribing 90-day fills for maintenance medications yet antihypertensives are often dispensed as 30-day fills. Our objectives were to examine how often patients receive 30-day supplies of medication despite prescriptions for longer duration and to examine the effect of medication fill duration on adherence and hypertension control. METHODS: We conducted a retrospective cohort study of pediatric patients with hypertension over a 3-year period. For each patient, days prescribed per fill were compared to days dispensed per fill using pharmacy reports and insurance claim data. Proportion of Days Covered (PDC) was calculated to estimate adherence. Hypertension control was determined by provider assessment of control and blood pressure measurement at the final visit. RESULTS: Final cohort included 449 patients. A total of 70% had at least one prescription for ≥ 90 days but only 37% had at least one dispense for ≥ 90 days. There was no difference in the likelihood of being prescribed a 90-day fill by insurance type (public vs. private); however, patients with public insurance were less likely to be dispensed a 90-day fill (OR = 0.068, p < 0.001). Patients who received 90-day fills had better adherence (median PDC 77.5% vs. 58.1%, p < 0.001) and were more likely to have hypertension control based on provider assessment. CONCLUSIONS: Longer fill duration is associated with improved adherence and hypertension control. Patients with public insurance are markedly less likely to be dispensed 90-day fills, a modifiable barrier to improving adherence.

Feasibility of text message follow-up for pediatric asthma care after an emergency department visit.

Background: Many children seen in the Emergency Department (ED) for asthma do not follow-up with their primary care provider. Text messaging via short message service (SMS) is a ubiquitous, but untested means of providing post-ED asthma follow-up care.Objective: To evaluate responses to an asthma assessment survey via SMS following an ED visit and estimate the likelihood of response by sociodemographic and clinical characteristics. Methods: We recruited 173 parents of children 2-17 years-old presenting for ED asthma care to receive a follow-up text (participation rate: 85%). One month later, parents received via SMS a 22-item survey that assessed asthma morbidity. We assessed response rates overall and by various sociodemographic and clinical characteristics, including age, parental education, and indicators of asthma severity.Results: Overall, 55% of parents (n = 95) responded to the SMS survey. In multivariable logistic regression (MLR), parents who graduated high school had a four-fold higher response rate compared to parents with less than a high school degree (OR: 4.05 (1.62, 10.13)). More parents of children with oral steroid use in the prior 12 months responded to survey items (OR: 2.53 (1.2, 5.31)). Reported asthma characteristics included: 48% uncontrolled, 22% unimproved/worse, 21% with sleep disruption, and 10% who were hospitalized for asthma.Conclusions: Text messaging may be a viable strategy to improve post-ED asthma assessment and to identify children with persistent symptoms in need of enhanced care or modification of care plans.

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

OBJECTIVE: To 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 DESIGN: We included children (3-12 years of age) with persistent asthma who presented to the ED for asthma, who were then randomly assigned to Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED) or enhanced usual care. 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 2 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. RESULTS: We 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 and 41% completed 3 visits. At 3 months, caregivers of children in TEAM-ED reported more follow-up visits (66% vs 48%; aOR, 2.07; 95% CI, 1.28-3.33), preventive asthma medication actions (90% vs 79%; aOR, 3.28; 95% CI, 1.56-6.89), and use of a preventive medication (82% vs 69%; aOR, 2.716; 95% CI, 1.45-5.08), compared with enhanced usual care. There was no difference between groups in medication adherence or asthma morbidity. When only prepandemic data were included, there was greater improvement in SFDs over time for children in TEAM-ED vs enhanced usual care. CONCLUSIONS: TEAM-ED significantly improved follow-up and preventive care after an ED visit for asthma. We also saw improved SFDs with prepandemic data. The lack of overall improvement in morbidity and adherence indicates the need for additional ongoing management support. TRIAL REGISTRATION: NCT02752165.

The prevalence of childhood asthma: interpreting falling rates in the context of shifting measurement and the COVID-19 pandemic.

PURPOSE OF REVIEW: The estimated prevalence of childhood asthma in the United States, as measured by the National Health Information Survey (NHIS), has decreased by 30% since 2017. This review provides context for observed changes in asthma rates by describing recent shifts in NHIS data collection and analysis, and considers whether the COVID-19 pandemic might impact asthma prevalence in years to come. RECENT FINDINGS: The NHIS underwent a planned redesign in 2019 with updated sampling weights to better match the U.S. population. In early 2020, the COVID-19 pandemic resulted in unplanned modifications to NHIS implementation, which may have included fewer children from populations at a heightened risk for asthma. Decreasing prevalence estimates in recent years are likely at least in part due to these survey changes rather than true epidemiologic shift. However, pandemic-related changes to risk factors for childhood asthma (including exposure to rhinovirus infections and allergic sensitization) may also influence prevalence in the future. SUMMARY: Recent changes in estimated rates of childhood asthma in the USA are likely driven by changes to survey methods and implementation, both before and during the COVID-19 pandemic. Additional years of data are needed to determine whether a true shift in disease prevalence is occurring.

Allergic rhinitis co-morbidity on asthma outcomes in city school children.

BACKGROUND: School based asthma programs have demonstrated that preventive asthma therapy administered in school reduces asthma morbidity. The burden of co-morbid allergic disease on asthma outcomes in a large school based asthma cohort has been unexplored. OBJECTIVE: Evaluate the prevalence of allergic rhinitis (AR) in historically minoritized school children with persistent asthma, and determine if AR is an independent risk factor for asthma morbidity. METHODS: We evaluated the prevalence of AR in children enrolled in 3 NIH funded school based asthma programs in Rochester, NY. We used linear regression and multivariate analyses to compare asthma outcomes for children whose caregivers did and did not report AR. RESULTS: We used data from 1,029 children with asthma (mean age 7.4, 60.4% Black, 29.5% Hispanic, 72.8% insured with Medicaid). 63% of children reported AR. Children with AR had significantly fewer symptom free days over 2 weeks compared to children without AR (7.2 vs. 8.3, p < 0.001). Children with AR also had more daytime symptoms, (4.7 vs. 3.7, p < 0.001), more rescue medication use (4.5 vs. 3.4, p < 0.01), and more activity limitation due to asthma (3.6 vs. 2.5, p < 0.001). Only 44% of children with AR reported allergy medication use. CONCLUSIONS: Among a large school-based cohort of minoritized children with asthma, we found that the majority of children have comorbid allergic rhinitis, which was associated with increased asthma morbidity. Inadequate recognition and treatment for allergic rhinitis likely represents substantial preventable morbidity for this group.

School-Based Telemedicine for Hypertension Management in Urban Adolescents.

PURPOSE: The aim of this study is to determine if hypertensive adolescents from impoverished neighborhoods in Rochester, New York have improved blood pressure (BP) control with the use of school-based telemedicine. METHODS: Adolescents receiving antihypertensive medication had monthly study telemedicine visits at school. BP was measured by a telehealth clinical assistant (CTA) at the school using standard procedures, followed in real time by a teleconferencing visit with the study physician. RESULTS: Six participants were enrolled, and all completed school-based telemedicine visits prior to school closure due to the SARS-CoV-2 pandemic. Mean systolic and diastolic BP at baseline were 139 ± 5 and 75 ± 8 mmHg. All six participants had significant improvement in their blood pressure (final school mean BPs, 127 ± 4 and 67 ± 5 mmHg; systolic, baseline vs. final, p = .003). DISCUSSION: In this pilot study, adolescents with very high levels of neighborhood disadvantage had consistent adherence with school-based telemedicine and significant improvement in hypertension (HTN) control.

Adolescent Knowledge of When to Use Inhaled Asthma Medications: Implications for Management.

PURPOSE: It is unclear how often adolescents with persistent asthma know when to use different inhaled medications (as-needed rescue vs. daily controller; 'accurate use'), or whether this knowledge is associated with clinical asthma outcomes. This study aimed to characterize adolescent knowledge of accurate use; examine whether accurate use is associated with controller medication adherence, asthma symptoms, or exacerbations requiring acute health care services; and determine whether knowledge of accurate use improves following regular exposure to controller medications with school-based directly observed therapy (DOT). METHODS: We analyzed baseline and 7-month data from the School-Based Asthma Care for Teens trial. Adolescents (12-16 years) identified inhaled medications on a chart and stated when each is used. We compared accurate use with adolescent-reported adherence, recent symptoms, and asthma-related acute health care visits; and exposure to DOT. Analyses were limited to subjects with controller medication. RESULTS: Of 430 participants, 252 had controller medication at baseline. Knowledge of accurate use was described by 62%, and associated with adherence (odds ratio [OR]: 2.06, 95% confidence interval [CI]: 1.12-3.83). By 7 months, 313 adolescents had controller medication; 75% described accurate use, which was associated with adherence (OR: 3.46, 95% CI: 1.83-6.54), health care (OR: 0.39, 95% CI: 0.20-0.79), and DOT exposure (OR: 1.83, 95% CI: 1.10-3.32). Associations with adherence and health care at 7 months persisted in adjusted analyses. DISCUSSION: Adolescent knowledge of accurate medication use was linked with greater adherence (baseline, 7 months), less acute health care (7 months), and exposure to in-school DOT. Interventions to support adolescents with persistent asthma should consider school-based care strategies and facilitate adolescent understanding of when to use different medications.

Utilization of the emergency department as a routine source of care among children with asthma.

Objective: To describe characteristics of children with persistent asthma in the ED who receive most of their healthcare in emergency settings; and determine whether recent asthma experiences or historic patterns of care are associated with identifying the ED as a typical location for care.Methods: We conducted a sub-analysis of baseline data from Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED), an RCT of children (3-12 years) presenting to the ED with persistent asthma (2016-2020). Caregivers identified reasons for seeking emergency care, including if their child received most overall healthcare in the ED ('ED Care'; primary outcome) or not ('Other Care'). Independent variables included demographics, recent symptoms and quality of life (QOL), and historic preventive care and healthcare use. We compared responses between ED Care and Other Care groups using bivariate and multivariate analyses.Results: We analyzed data for 355 children (31% ED Care, 69% Other Care). Compared with Other Care, ED Care respondents were more likely to identify the ED as the closest source of healthcare; report fewer symptom nights but a poorer quality of life; and describe the ED as a usual place for sick care, despite most having a PCP.Conclusions: Many children with asthma use the ED as a typical source of healthcare, and are distinguished by need for proximity, poorer caregiver QOL, and historic patterns of care-seeking. Efforts to improve timely access to outpatient care and reinforce the role of PCP-directed asthma management, such as through telemedicine, may reduce preventable morbidity including ED visits.

Self-Determination Theory and Preventive Medication Adherence: Motivational Considerations to Support Historically Marginalized Adolescents With Asthma.

INTRODUCTION: Using self-determination theory, we explored relationships between autonomous motivation (AM) and perceived competence (PC) with previously validated measures of motivation and adolescent-reported asthma medication adherence. METHOD: Data were from adolescents (n = 260) enrolled in the School-Based Asthma Care for Teens study and taking preventive medication at baseline. Eligible adolescents (aged 12-16 years) had physician-diagnosed persistent asthma or poor control. RESULTS: Adolescents taking daily preventive medicine reported higher AM and PC for adherence, whereas adolescents likely to miss ≥1 dose in the next 2 weeks had lower AM and PC. Adolescents taking medicines as prescribed, with plans to continue, and those feeling able to follow provider care plans, had higher AM and PC. Findings remained significant in regressions with control variables. DISCUSSION: Many factors interfere with adolescent medication-taking. Clinicians' efforts to build AM and PC with patients and caregivers may be key to promoting adherence in this group.

Caregiver Experiences Managing Persistent Childhood Asthma During the COVID-19 Pandemic.

COVID-19 has adversely affected child wellness, but it is unclear whether the pandemic led to changes in home management of chronic diseases like asthma. We surveyed 93 caregivers of children with persistent asthma from 2 ongoing asthma trials to measure changes in home asthma management, stressors, access to health care, and caregivers' worry about COVID-19 affecting their child's health. We conducted descriptive analyses, and assessed whether caregiver worry about COVID-19 was associated with asthma management, stressors, health care access, or recent symptoms. Most (80%) caregivers worried that COVID-19 would affect their child's health, and >50% restricted their child's physical activity to avoid asthma symptoms. We observed a dose-dependent relationship between increasing worry about COVID-19 and activity restrictions, financial hardship, difficulty obtaining asthma medications, and nocturnal asthma symptoms. These findings raise concern that children with persistent asthma may be at particular risk for weight gain and obesity-associated asthma morbidity due to the pandemic.

Use of a validated asthma questionnaire to increase inhaled corticosteroid prescribing in the pediatric emergency department.

BACKGROUND: Asthma guidelines recommend assessment of asthma control and treatment with an ICS when appropriate. Children seen for asthma in the ED often have poorly controlled asthma. Validated questionnaires are rarely used in the ED and ICS are prescribed at less than 5% of ED asthma encounters, leaving many children at risk for continued poor outcomes. OBJECTIVE: To determine if use of a validated asthma questionnaire can increase the proportion of children who receive an ICS prescription during an ED asthma visit. METHODS: We administered a validated asthma questionnaire (Pediatric Asthma Control and Communication Instrument-ED version [PACCI-ED]) to parents of children 2 - 17 years old presenting for asthma care at a large, urban, academic pediatric ED. Based on national asthma guidelines, the PACCI-ED results were used to determine ICS dose recommendations. ED physicians reviewed the PACCI-ED results and ICS dose recommendations and chose whether to prescribe an ICS upon discharge. ICS prescribing rates during the intervention period were assessed via medical record review and compared to historical controls. We also surveyed parents to examine the association of sociodemographic factors with receipt of an ICS prescription, and surveyed physicians regarding their prescribing decisions. RESULTS: Thirteen physicians and seventy-nine children participated. Historically, the ICS prescribing rate for asthma exacerbations discharged from the ED was 13%. The intervention increased ICS prescribing to 56% (p < 0.001). Children with ≥2 asthma exacerbations in the prior year (p < 0.02) and those with moderate-severe persistent asthma (p < 0.02) were more likely to receive an ICS prescription. There were no statistically significant differences in ICS prescribing by sociodemographic characteristics. CONCLUSION: A validated asthma questionnaire increased ICS prescribing for children presenting for to the ED for asthma care. Additional strategies are needed to promote prescribing in this setting and ensure that all eligible children receive guideline-based asthma care.

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.

A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools.

OBJECTIVE: To test the feasibility and effectiveness of a multifaceted intervention administered through school-based health centers (SBHCs) to improve asthma control for children in high-poverty schools with not well controlled asthma. METHODS: Students 4-14 years old with persistent asthma were enrolled from three SBHCs. The centers' advanced practice providers received training on evidence-based asthma guidelines. Students randomized to the intervention received directly observed therapy of their asthma controller medication, medication adjustments as needed by the centers' providers, and daily self-management support. Students randomized to usual care were referred back to their primary care provider (PCP) for routine asthma care. RESULTS: We enrolled 29 students. Students in the intervention group received their controller medication 92% of days they were in school. Ninety-four percent of follow-up assessments were completed. During the study, 11 of 12 intervention students had a step-up in medication; 2 of 15 usual care students were stepped up by their PCP. Asthma Control Test scores did not differ between groups, although there were significant improvements from baseline to the 7 month follow-up within each group (both p < .01). Both FEV1% predicted and FEV1/FVC ratio significantly worsened in the usual care group (both p = .001), but did not change in the intervention group (p = .76 and .28 respectively). CONCLUSIONS: Our pilot data suggest that a multifaceted intervention can be feasibly administered through SBHCs in communities with health disparities. Despite the small sample size, spirometry detected advantages in the intervention group. Further study is needed to optimize the intervention and evaluate outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03032744.

Children with under-diagnosed asthma presenting to a pediatric emergency department.

BACKGROUND: Undiagnosed asthma in children presenting to the emergency department (ED) for respiratory illnesses might be associated with subsequent asthma morbidity and repeat ED visits. OBJECTIVE: To examine the prevalence of undiagnosed asthma among children presenting for ED care, and explore associations with sociodemographic and clinical characteristics. METHODS: We surveyed parents of children ages 2-17 years seeking ED care for respiratory symptoms (including asthma) regarding sociodemographic characteristics, asthma symptoms, prior asthma care and morbidity, and prior asthma diagnosis. Undiagnosed asthma was defined as a positive screening for asthma and no prior diagnosis. We compared sociodemographic and clinical factors of those with diagnosed versus undiagnosed asthma using chi-square, t-tests and multivariable logistic regression model. RESULTS: Of 362 children, 36% had undiagnosed asthma. Undiagnosed children were younger, had younger parents, and had parents less likely to speak English versus diagnosed children (all p < 0.05). Among undiagnosed children, 42% had moderate or severe asthma and 66% reported ≥1 exacerbation in the prior 12 months. Parent-reported controller medication use was higher among diagnosed versus undiagnosed children (60% vs. 21%, p=.001). In a multivariable logistic regression (adjusting for insurance, education, income and preferred language), no controller usage (aOR 4.26), no asthma exacerbations in the prior year (aOR 2.41) and younger age (aOR 0.76) were significantly associated with undiagnosed asthma. CONCLUSION: Children presenting to the ED with undiagnosed asthma commonly experience significant prior asthma morbidity. Strategies to improve asthma diagnosis and messaging to their parents may reduce future morbidity.

The relationship between teen-reported nocturnal asthma symptoms and daily functioning.

OBJECTIVE: This study aims to identify associations between nocturnal asthma awakenings and functional health outcomes in a cohort of teenagers with asthma. METHODS: We analyzed baseline data from teenagers enrolled in SB-ACT, an NIH-funded RCT. During an at-home baseline survey, teenagers with asthma answered questions about demographics, recent asthma symptoms, and functional health outcomes. We conducted regression analyses to explore the relationship between persistent nocturnal asthma symptoms (≥2 nights of nocturnal asthma awakenings in the past 14 days) and functional health measures. RESULTS: Of the 430 teens enrolled (Participation rate = 79%, Mean Age = 13.4), 30% reported persistent nocturnal asthma symptoms. Compared to teens with intermittent nocturnal asthma symptoms, teens with persistent nocturnal asthma symptoms were more likely to report physical limitation during strenuous activities (OR = 1.9, 1.3-3.0), moderate activities (OR = 1.9, 1.2-3.1), and school gym (OR = 2.4, 1.5-3.8). They were also more likely to report depressive symptoms (OR = 2.3, 1.5-3.6), more asthma-related school absenteeism in the past 14 days (0.81 vs 0.12, p < 0.01) and poorer quality of life (4.6 vs 5.9, p < 0.01). These findings remained significant when controlling for daytime asthma symptoms, weight status, race, ethnicity, gender, age, and smoke exposure. CONCLUSIONS: In this cross-sectional study, persistent nighttime asthma symptoms were associated with poor functional health outcomes among teens, independent of day-time symptoms. Identifying nighttime symptoms and improving asthma control at night may positively impact daily functioning for these teens.

What Parents Want Doctors to Know: Responses to an Open-Ended Item on an Asthma Questionnaire.

OBJECTIVE: Unstructured parental comments could solicit important information about children's asthma, yet are rarely captured in clinical asthma questionnaires. This mixed-methods study describes parents' written responses to an open-ended question in a validated asthma questionnaire. METHODS: The Pediatric Asthma Control and Communication Instrument (PACCI) asthma questionnaire was administered to parents of children with asthma symptoms presenting to 48 pediatric primary care offices (PPCP), 1 pediatric pulmonology office, and 1 emergency department (ED). Responses to the question, "Please write down any concern or anything else you would like your doctor to know about your child's asthma" were analyzed using a phenomenological approach until thematic saturation was achieved for each site. Logistic regressions tested whether sociodemographic and clinical characteristics were associated with responding to the open-ended question. RESULTS: Of 7,988 parents who completed the PACCI, 954 (12%) responded to the open-ended question-2% in PPCP, 31% in the ED, and 50% in the pulmonary setting. More severe asthma was associated with higher odds of responding (odds ratio, 2.01; 95% confidence interval, 1.42-2.84). Based on responses provided, we identified 3 communication types: 1) clarifying symptoms, 2) asking questions, and 3) communicating distress. Responses also covered 5 asthma-related themes: 1) diagnostic uncertainty, 2) understanding asthma etiology and prognosis, 3) medication management, 4) impact on child function, and 5) personal asthma characteristics. CONCLUSION: Parents of children with severe asthma provided clarifying details, asked questions, and relayed health concerns and distress. None of these topics may be easily captured by closed-ended asthma questionnaires.

Applying theoretical models of positive emotion to improve pediatric asthma: A positive psychology approach.

Positive emotion, encompassing feelings such as joy and happiness, has been shown to predict a multitude of health outcomes. However, the role of positive emotion in pediatric asthma is not understood. No work to date has examined how positive emotion may offer benefits to children and adolescents with asthma. Based on theory and models of positive emotion and health, we hypothesize that positive emotion may improve asthma outcomes through mediators such as health behaviors and health-relevant physiological functioning. Moreover, boosting positive emotion during times of stress may be particularly relevant in mitigating asthma symptoms. In the present commentary, we elaborate on the hypothesized mechanisms behind such associations grounded within positive emotion theoretical frameworks. Additionally, we summarize the methodologically rigorous work of positive emotion interventions in other clinical settings to propose that positive emotion could be a useful tool in the management of pediatric asthma.

A National Mental Health Profile of Parents of Children With Medical Complexity.

OBJECTIVES: The mental health of parents of children with medical complexity (CMC) is poorly understood, yet it drives child and family health outcomes. For parents of CMC, compared with parents of noncomplex children with special health care needs (CSHCN) and children without special health care needs (non-CSHCN), we examined self-reported mental health, knowledge of community sources for help, and emotional support. METHODS: Using parent-reported data from the combined 2016-2017 National Survey of Children's Health, we divided the population into 3 groups: households with CMC, noncomplex CSHCN, and non-CSHCN. We compared these groups regarding the following: (1) parents' risks for poor or fair mental health and knowledge of where to go for community help and (2) parent-reported sources of emotional support. RESULTS: Of 63 955 588 parent-child dyads (weighted from a sample of 65 204), parents of CMC had greater adjusted odds of reporting poor or fair mental health compared with parents of noncomplex CSHCN (adjusted odds ratio [aOR] 2.0; 95% confidence interval [CI] 1.1-3.8) and non-CSHCN (aOR 4.6; 95% CI 2.5-8.6). Parents of CMC had greater odds of not knowing where to find community help compared with parents of noncomplex CSHCN (aOR 2.1; 95% CI 1.4-3.1) and non-CSHCN (aOR 2.9; 95% CI 2.0-4.3). However, parents of CMC were most likely to report receiving emotional support from health care providers and advocacy groups (P < .001). CONCLUSIONS: Among all parents, those with CMC were at the highest risk to report suboptimal mental health. They more often reported that they do not know where to find community help, but they did say that they receive emotional support from health care providers and advocacy groups. Future researchers should identify ways to directly support the emotional wellness of parents of CMC.

Evaluating the Financial Sustainability of the School-Based Telemedicine Asthma Management Program.

Using telemedicine to improve asthma management in underserved communities has been shown to be highly effective. However, program operating costs are perceived as the main barrier to dissemination and scaling up. This study evaluated whether a novel, evidence-based School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program, designed to overcome barriers to care for families of urban school-aged children, can be financially sustainable in real-world urban school settings. Eligible children (n = 400) had physician-diagnosed asthma with persistent or poorly controlled symptoms at baseline. Total costs included the cost of implementing and running the SB-TEAM program, asthma-related health care costs, cost of caregiver lost productivity in wages related to child illness, and school absenteeism fees. Using data from the SB-TEAM study and national data on wages and equipment costs, the authors modeled low, actual, and high-cost scenarios. The actual cost of administering the SB-TEAM program averaged $344 per child. Expenses incurred by families for medical care ($982), caregiver productivity cost ($415), and school absenteeism costs ($284) in SB-TEAM were not different from the costs in the control group ($1594, $492, and $318 [P > 0.05]). The study findings remained robust under sensitivity analyses for various state- and school-specific regulations, staffing requirements, and wages. The authors concluded that the SB-TEAM program operating costs may be offset by the reduction in health care costs, caregiver lost wages, and school absenteeism associated with the program health benefit.

Nurse-delivered outpatient asthma education for children and caregivers: a pilot study to promote shared asthma management.

OBJECTIVES: To assess the feasibility of nurse-delivered asthma education for caregiver/child dyads in a busy clinic setting, and measure the preliminary effectiveness of the intervention. METHODS: We conducted a pilot study of nurse-delivered asthma education in a busy outpatient clinic. We enrolled a convenience sample of children (7-16 years) with uncontrolled persistent asthma who had a prescription for an inhaled controller medication and public health insurance. After provider visits, nurses taught dyads using picture-based materials, teach-back methods, and colored labels applied to asthma medications. The intervention was repeated at 1-month follow-up. We assessed feasibility by reviewing nurse documentation in the electronic medical record, detailing whether each component was implemented and the time required for education at each visit. We measured preliminary effectiveness by surveying children and caregivers separately before each clinic visit about asthma management responsibility, self-efficacy, caregiver quality of life, and symptoms; caregivers also completed a final telephone survey 2 months after the follow-up visit. We examined pre-post differences in continuous outcomes within-subjects using Wilcoxon signed rank tests. RESULTS: We enrolled 22 child/caregiver dyads. Nursing documentation indicated a high rate of component delivery at each visit; the initial and 1-month visits required 25 and 15 min, respectively. We observed significant increases in child responsibility, child/caregiver self-efficacy, caregiver quality of life, and child symptoms at each follow-up. CONCLUSION: This intervention of patient-centered asthma education can be delivered by nurses to caregiver/child dyads with high fidelity in a busy pediatric practice. Preliminary data indicate potential benefit for both children and caregivers.