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.

Considering the Control Group: The Influence of Follow-Up Assessments on Asthma Symptoms.

OBJECTIVE: It is unclear whether research participation effects contribute to an improvement in asthma symptoms during clinical trials in the absence of any active intervention. We examined the impact of additional follow-up surveys on caregiver-reported symptoms among control subjects in a series of randomized controlled asthma trials. METHODS: We analyzed baseline and follow-up data for children (3-10 years) with poorly controlled persistent asthma that participated as control subjects in 1 of 3 randomized trials of urban school-based asthma care (study duration: 7-10 months). We compared mean symptom-free days (SFD) per 2 weeks between baseline and final follow-up; performed bivariate regressions to explore associations between demographics and changes in SFD; and performed multivariate random-effects generalized least square regression to examine the relationship between number of follow-ups beyond baseline (range: 1-10) and changes in SFD over time. RESULTS: Five hundred and sixteen children were enrolled as controls across the 3 trials (mean age 7.5 years, 61% Black, 28% Hispanic, 81% Medicaid). Mean SFDs increased significantly from baseline to final follow-up (7.8-11.4 days, P < .001). In adjusted analyses, significant improvements in SFD were observed with all follow-up contacts in comparison with baseline. Symptom improvement showed a dose-response relationship with the number of follow-up assessments completed (1, 2-3, 4-5, and 6-10 assessments). CONCLUSIONS: Children with uncontrolled asthma who participate as controls in clinical trials experience a significant increase in SFD with additional follow-up assessments. This improvement should be considered when designing/analyzing asthma interventions, and may help guide clinical outreach efforts for underserved children with persistent asthma.

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

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.