Asthma and Schools: a Community Approach to Children s Care

Transcription

1 Asthma and Schools: a Community Approach to Children s Care Jill S. Halterman, MD, MPH Associate Professor of Pediatrics University of Rochester School of Medicine and Dentistry

2 Disclosure None of the investigators have any conflicts of interest to disclose

3 A Typical Child KC is a 6 year old with asthma o 3 emergency visits in the past year o Currently having difficulty sleeping o Missed several days of school in the past month o Sits out from gym class o Starting to fall behind in school work

4 Overview Asthma Basics How Asthma Impacts Children and Schools Management of Asthma and Gaps in Care Community-Based Interventions / Solutions

5 What is Asthma? A chronic disorder of the airways in which inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing in susceptible individuals

6 More About Asthma Asthma is a variable, chronic and life-long disease Asthma is not a psychological condition There is no cure for asthma Asthma symptoms can be well controlled Inhaled corticosteroids (such as Flovent), also known as anti-inflammatory medicines, are the recommended daily treatment for significant asthma Asthma medicines are not addictive

7 Asthma in U.S. Children How common is it? Asthma affects approximately 8 million children under the age of 18 Childhood asthma morbidity and mortality are increasing Asthma is more common among children living in urban areas Source: American Lung Association, Epidemiology and Statistics Unit, Research and Program Services. Trends in Asthma Morbidity and Mortality January 2009.

8 Prevalence of Childhood Asthma United States, Akinbami LJ. The State of childhood asthma, United States, Advance data from vital and health statistics; no 381, Hyattsville, MD: National Center for Health Statistics

9 Asthma in Rochester: Prevalence among children in the RCSD Approximately 12% of students (1 in 8) are listed with asthma on Medi-Alerts One-quarter of students in grades 4-12 (23% - 25%) reported a physician diagnosis of asthma Approximately 1 in 5 students required emergency medical visits due to asthma in the past year Source: The Current State of Asthma among RCDS Pupils, Pre-K K and Grades RCSD Office of Accountability. June, 2008.

10 How Does Asthma Affect Children? There are about 470,000 hospitalizations and more than 5,000 deaths each year from asthma Asthma is the most frequent admitting diagnosis in children s hospitals Many children with asthma are limited in their daily activities and may have poor sleep and quality of life

11 The Cost of Asthma Children with asthma cost health plans almost twice as much compared to other sick children It is estimated that 1 billion is lost in productivity each year by working parents caring for children who miss school due to asthma

12 Impact on School Attendance: Absenteeism Asthma is a leading cause of absenteeism due to illness Accounts for approximately 14 million missed school days per year Absences can be related to episodes, health care appointments, and hospitalizations

13 Impact on School Performance: Learning Difficulties Fatigue - children up at night with symptoms are tired in the morning Missed class time due to absences as well as frequent school health office visits Compromised learning due to symptoms during class time

14 Impact on School Participation: Activity Limitation Limited participation in gym at school Restrictions on field trips Missed opportunities to play organized sports, informal active play and games that other children enjoy

15 On average, 3 children in a classroom of 30 are likely to have asthma. 4 4 Epidemiology and Statistics Unit. Trends in Asthma Morbidity and Mortality. NYC: ALA, July 2006.

16 In Rochester, 5 children in a classroom of 30 are likely to have asthma.

17 What Should Most Children with Not miss school Asthma be Able to Do? Be active without symptoms; includes participating in sports and physical activity Sleep better through the night without having symptoms Prevent asthma episodes Have the best possible lung function

18 What it feels like to have Asthma

19 Controlling Asthma: Guidelines for Successful Long-Term Management Accurate assessment of severity Control of environmental factors and avoidance of triggers Medications Monitoring for control including frequent follow-up

20 Assessment of Asthma Severity Asthma Severity primarily assessed by: Daytime symptoms Nighttime symptoms Need for rescue medications Limitation of activity Asthma exacerbations Persistent Asthma briefly defined as ANY of the following: Day symptoms > 2x/week Night symptoms > 2x/month Need for rescue medications > 2x/week OR asthma attacks > 2/last year

21 Allergens Asthma Triggers Pollen, animal dander, dust mites, cockroaches, mold Irritants Cold air, perfume, chalk dust, vehicle exhaust Respiratory infections Viral illnesses, influenza Physical exercise

22 Triggers: Environmental Tobacco Smoke (ETS) Associated with worsening symptoms and decreased lung function in children with asthma Children exposed to smoke have higher requirements for medications and more visits to the ED Cigarette smoking may reduce the anti-inflammatory action of inhaled corticosteroids, making management of symptoms more difficult

23 Relationship Between ETS and Lung Function Chilmonczyk BA, et al. N Engl J Med. 1993;328:

24 Asthma Medications Two Types of Asthma Medications: Reliever or Rescue Medications - given for quick, temporary relief of symptoms when needed Long-term Controller or Preventive Medications - taken daily on a long-term basis to prevent symptoms and maintain control of asthma

25 Asthma Medications Daily controller medications are recommended for all children with persistent asthma These medications reduce symptoms, improve lung function, and prevent attacks Adjustments in medications are needed for all children who are not well controlled

26 Gaps in Asthma Care Despite recommendations, several studies indicate that inadequate therapy is common Many children are not achieving the symptom control that they could have with optimal treatment

27 Family recognizes symptoms Delivery of Preventive Care for Asthma Contact with provider Relay information about severity to provider Provider recognizes severity as mild persistent to severe Prescribes preventive medications Routinely assess control Family administers medication daily

28 Family recognizes symptoms Delivery of Preventive Care for Asthma Contact with provider Relay information about severity to provider What we have found: Nationally and locally, many young children are not receiving recommended medicines Halterman JS, et al Pediatrics. 2000;105: Routinely assess control Provider recognizes severity as mild persistent to severe Prescribes preventive medications Family administers medication daily

29 Family recognizes symptoms Delivery of Preventive Care for Asthma Contact with provider Relay information about severity to provider What we have found: Parents may not realize that their child s asthma could be better controlled Halterman JS, et al Ambulatory Pediatrics 2002;102:(3) Routinely assess control Provider recognizes severity as mild persistent to severe Prescribes preventive medications Family administers medication daily

30 Family recognizes symptoms Delivery of Preventive Care for Asthma Contact with provider Relay information about severity to provider What we have found: Providers underestimate the severity of symptoms Halterman JS, et al Arch Pediatr Adolesc Med. 2002;141 Routinely assess control Provider recognizes severity as mild persistent to severe Prescribes preventive medications Family administers medication daily

31 Family recognizes symptoms Delivery of Preventive Care for Asthma Contact with provider Relay information about severity to provider What we have found: Many children experience poor symptom control despite use of preventive medications Halterman JS, et al Ambulatory Pediatrics 2007;7: Routinely assess control Provider recognizes severity as mild persistent to severe Prescribes preventive medications Family administers medication daily

32 Family recognizes symptoms Delivery of Preventive Care for Asthma Contact with provider Relay information about severity to provider What we have found: Many children continue to be exposed to environmental tobacco smoke Halterman, et al. Ambulatory Pediatrics, 2006;6: Routinely assess control Provider recognizes severity as mild persistent to severe Prescribes preventive medications Family administers medication daily

33 Smoke Exposure Among Urban Children with Persistent Asthma Halterman, et al. Ambulatory Pediatrics, 2006;6:

34 Family recognizes symptoms Delivery of Preventive Care for Asthma Contact with provider Relay information about severity to provider What we have found: There are significant barriers to reducing smoke exposure Halterman, et al. Journal of Asthma, 2007:44;83-88 Provider recognizes severity as mild persistent to severe Prescribes preventive medications Routinely assess control Family administers medication daily

35 Overcoming Barriers to Reducing Smoke Exposure Many parents tell us they want to quit There are many challenges to quitting Establishing smoking bans in the home and car with no exceptions allowed can be a helpful first step towards limiting exposure Halterman JS, Fagnano M, Conn KM, et al (2007). J Asthma, 44, 83-8.

36 Improving Asthma Outcomes: Intervention Studies Many Approaches The Environment Educational Interventions Family Child Provider Healthcare Delivery System Case management Community based interventions

37 Improving Asthma Outcomes: Intervention Studies Many Approaches The Environment Educational Interventions Family Child Provider Healthcare Delivery System Case management Community based interventions

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39 School-Based Asthma Intervention Initial Study, Goal: To test the effectiveness of school-based delivery of preventive medications to young urban children with asthma Hypothesis: Enhanced asthma care delivered to children in the school setting can reduce asthma symptoms

40 School-Based Asthma Intervention Initial Study Randomized trial, conducted over two school years Treatment Group: received preventive medication (fluticasone propionate) from the school nurse Control Group: usual care 181 children enrolled Main Outcome: Symptom-free days over two weeks

41 School-Based Asthma Intervention Initial Study A total of 54 city schools participated

42 School-Based Asthma Intervention Initial Study - Results Treatment n=89 Control n=91 p-value Symptom-free days Symptom nights Days using Rescue Inhaler Change in Quality of Life Mean Total Absences > 3 Acute Visits, % 20% 29%.23 > 1 Hospitalizations, % 3% 7%.50 p-value <.05 Halterman JS, et al. Arch Pediatr Adolesc Med. 2004;158:

43 School-Based Asthma Intervention Initial Study Results Based on Smoke Exposure Overall n=180 Smoke Exposure n=79 No Smoke Exposure n=101 Treatment Control Treatment Control Treatment Control Symptom-free days Symptom nights Rescue Inhaler Use Quality of Life Mean Absences > 3 Acute Visits, % 20% 29% 29% 24% 13% 32% > 1 Hospitalizations, % 3% 7% 2% 5% 4% 7% p-value <.05 Halterman JS, et al. Arch Pediatr Adolesc Med. 2004;158:

44 School-Based Asthma Intervention Summary One of the first community-based interventions to use the school system as a site for the delivery of preventive medications Children receiving the intervention: Had greater improvement in parent quality of life scores Missed less school due to asthma Different effects of the intervention were seen based on secondhand smoke exposure

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46 School-Based Asthma Therapy (SBAT) Trial Preventive medications through school Symptom-based dose adjustments Home-based smoke reduction program Hypothesis: Children receiving preventive asthma medications in school AND an Environmental Tobacco Smoke reduction program (for smoke-exposed children) would experience less asthma-related morbidity NIH RO1HL079954

47 School-Based Asthma Therapy (SBAT) Trial Enrollment Children 3-10 years of age attending preschool or elementary school in the Rochester City School District (RCSD) Inclusion Criteria: Persistent asthma (based on NHLBI guidelines) Signed physician permission to enroll the child No other significant medical conditions

48 School-Based Asthma Therapy (SBAT) Trial Baseline Comprehensive baseline assessment Asthma severity Standard family and health history variables Exposure to ETS by interview survey and cotinine Exhaled nitric oxide Home environmental assessment

49 School-Based Asthma Therapy (SBAT) Trial Intervention School Nurse Given a canister of preventive medication with a spacer and mask Asked to give one dose of medication to the child during the school day Parent Medication delivered Instructed to use on weekend days and other days the child does not attend school

50 School-Based Asthma Therapy (SBAT) Trial Intervention Dose Adjustments Assessment following the first 3 follow-up interviews Adjustments made for children who continued to have persistent symptoms

51 School-Based Asthma Therapy (SBAT) Trial ETS Reduction ETS Reduction Program Targeted toward primary caregiver and one other smoker in the household Aimed at motivating smoking cessation and decreasing their child s exposure to ETS Used a counseling method called motivational interviewing

52 School-Based Asthma Therapy (SBAT) Trial ETS Reduction Motivational Interviewing Patient-centered approach to health behavior change The MI counselor helps the parent explore their reasons for engaging in the behavior Attempts to elicit the parent s own concerns about the behavior

53 School-Based Asthma Therapy (SBAT) Trial ETS Reduction Motivational Interviewing Patient-centered approach to health behavior change The MI counselor helps the parent explore their reasons for engaging in the behavior Attempts to elicit the parent s own concerns about the behavior min home-based counseling session 2 follow-up phone calls Feedback on the child s cotinine level

54 Decisional Balance Exercise The Good Things helps me keep my cool SMOKING The Less Good Things expense - $30-45/week smell in church, like an ashtray can t breathe, teeth stains winter too cold to open windows QUITTING The Good Things less worry about smell, taste more money The Less Good Things hard to stay quit around smokers will be hard in beginning

55 School-Based Asthma Therapy (SBAT) Trial Cotinine Feedback 5 Smoke Exposure & Cotinine Levels 3.2 ng/ml High Exposure 4 Cotinine (ng/ml) ng/ml No Exposure Exposure < 0.5 ng/ml Exposure ng/ml Smoke Exposure Exposure ng/ml

56 School-Based Asthma Therapy (SBAT) Trial Results 530 children enrolled from more than 60 schools Response rate: 74% Completed final data collection at the end of the last school year

57 School-Based Asthma Therapy (SBAT) Trial Results Mean outcomes, peak winter season (Nov-Feb, n=530) Outcomes Treatment Control p-value Symptom Free Days Symptom nights Days using rescue inhaler <.001 Days with activity limitation

58 School-Based Asthma Therapy (SBAT) Trial Results Mean outcomes throughout the school year (n=530) Outcomes Treatment Control p-value Symptom Free Days <.001 Days Absent >2 Acute Visits 22 (11) 38 (19).035

59 Symptom Free Days over 2 Weeks Winter Months Symptom Free Days / 2 wks P<.001 Treatment Control Baseline November December January February

60 School-Based Asthma Therapy (SBAT) Trial Results Mean outcomes, peak winter season Nov-Feb Overall n=530 Smoke Exposure n=245 No Smoke Exposure n=285 Treatment Control Treatment Control Treatment Control Symptom-free days Symptom nights Rescue Inhaler Use Activity Limitation Mean Absences P-value <.05

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62 School-Based Asthma Therapy (SBAT) Trial Parent Survey

63 School-Based Asthma Therapy (SBAT) Trial Parent Survey I did not have to worry about medications and others showed concern for my daughter s asthma. I knew she was always getting her medications at school.

64 School-Based Asthma Therapy (SBAT) Trial Parent Survey I did not have to worry about medications and others showed concern for my daughter s asthma. I knew she was always getting her medications at school. When he was on Flovent, I know he didn t get sick it was like a miracle he didn t get sick!

65 School-Based Asthma Therapy (SBAT) Trial Nurse Survey I don't feel this program was in any way a burden. I think it was a big help. None of the children in the asthma program were seen in the nurse's office for any asthma (illness). If there is a way to help improve student health, I want to be a part of it. Many parents are overwhelmed. The asthma program helped to decrease some of their concerns.

66 Asthma and Schools Since 2000, the RCSD/URMC collaborative school-based asthma programs: 2338 students had asthma systematically assessed 744 participated in programs 348 received daily preventive asthma medications provided by programs and administered through school health office More than 750 families homes visited 200+ hours of counseling with caregivers

67 Future Directions This program has the potential to serve as a model for improved asthma care in urban communities

68 Future Directions This program has the potential to serve as a model for improved asthma care in urban communities Currently implementing a new schoolbased program: Using a Novel Technology to Improve Asthma Focus on sustainability and dissemination

69 Future Directions This program has the potential to serve as a model for improved asthma care in urban communities Currently implementing a new schoolbased program: Using a Novel Technology to Improve Asthma Focus on sustainability and dissemination New developmentally focused program for Rochester teens intended to promote self-management

70 Our Typical Child now KC is a 6 yo with asthma

71 Our Typical Child now KC is a 6 yo with asthma School nurse provided with updated asthma action plan

72 Our Typical Child now KC is a 6 yo with asthma School nurse provided with updated asthma action plan Began to consistently receive preventive medicine

73 Our Typical Child now KC is a 6 yo with asthma School nurse provided with updated asthma action plan Began to consistently receive preventive medicine Mom implemented smoking ban in home

74 Our Typical Child now KC is a 6 yo with asthma School nurse provided with updated asthma action plan Began to consistently receive preventive medicine Mom implemented smoking ban in home Now achieving many of the goals of therapy Sleeping through the night Participating in activities Improved performance in school

75 Schools, families, and the community can work together to help students better manage their asthma.

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77 Key Points Asthma is common and debilitating among school-aged children, influencing many aspects of a child s well-being and quality of life.

78 Key Points Asthma is common and debilitating among school-aged children, influencing many aspects of a child s well-being and quality of life. Asthma can be well-controlled with effective therapies. Gaps in care can be addressed to improve asthma outcomes.

79 Key Points Asthma is common and debilitating among school-aged children, influencing many aspects of a child s well-being and quality of life. Asthma can be well-controlled with effective therapies. Gaps in care can be addressed to improve asthma outcomes. Collaborative solutions are promising: Schools, health care providers, parents, and the community all have a role in working together to help children with asthma.

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81 Acknowledgements Funding: Halcyon Hill Foundation National Heart, Lung, and Blood Institute Robert Wood Johnson Foundation UR CTSI Collaborators: Rochester City School District School Nurses and School Nurse Program Primary Care Providers Children/Families Community Leaders Andrew MacGowan Donna Hill Flora McEntee Marybeth Schlabach Dirk Hightower Mentors / Co-investigators: Belinda Borrelli, PhD Arlene Butz, PNP, PhD Susan Fisher, PhD Guillermo Montes, PhD Kristin Riekert, PhD Peter Szilagyi, MD, MPH Cynthia Rand, PhD

82 Team Leadership: Maria Fagnano Alison Bayer Bryan Clutz Nurses: Paul Tremblay Susan Blaakman Acknowledgements Research Associates: Reynaldo Tajon Carrie Isensee Joe Sauer Chris Gettings Elise Wiesenthal Porchea Lewis Students /Volunteers

83 World Asthma Day Art Contest Winner