School-Based Asthma Intervention Significantly Improved Symptoms of Persistent Asthma in Urban Children

Results of a randomized trial [Arch Pediatr Adolesc Med. 2011;165(3):262-268] show that urban children with persistent asthma have significant improvement in symptoms when treated by a school-based asthma therapy intervention compared with the usual care treatment. Although urban children with asthma, particularly poor and minority children, have the greatest morbidity from asthma, they often do not receive adequate preventive therapy despite their frequent exposure to environmental triggers such as tobacco smoke. Previous data have shown that directly observed therapy using preventive asthma medication in schools can reduce asthma symptoms in urban children. To test their hypothesis that urban children with asthma who receive a school-based intervention would have more symptom-free days during the peak winter season than children treated with usual care, investigators randomized 530 children with asthma to treatment with a school-based intervention (treatment group, n=265) or usual care (control group, n=265). All children enrolled in the study were between 3 and 10 years of age, enrolled in the Rochester City School District, and diagnosed with asthma by a physician. Children with medical conditions that could interfere with assessment of asthma-related outcomes were excluded, as were children of non–English-speaking primary care givers, those who had no access to follow-up, and those planning to leave the school district within 6 months. Children in the treatment group received directly observed administration of daily preventive asthma medications by school nurses, with dose adjustments as needed according to guidelines by the National Heart, Lung, and Blood Institute Panel. In the control group, caregivers were encouraged to contact their primary care physician to discuss the child’s asthma symptoms and were responsible for filling and daily administration of asthma medications. Of the children enrolled in the study, the mean age was 7.1 years, and most were male (58%), black (63%), and covered by Medicaid (73%). After adjusting for baseline symptoms and covariates (age, sex, race, caregiver’s education, insurance, maternal depression, and smoke exposure), the study found that during the peak winter season of November through February, children in the treatment group had significantly more symptom-free days compared with those in the control group (adjusted difference, 0.92 days per 2 weeks; 95% confidence interval [CI], 0.50-1.33; P<.001), significantly fewer nighttime symptoms (adjusted difference, −0.68; 95% CI, −1.01 to −0.35; P<.001), significantly fewer days with limited activity (adjusted difference, −0.47; 95% CI, −0.78 to −0.16; P=.003), and a significant reduction in the need for rescue medication (adjusted difference, −1.06; 95% CI, −1.41 to −0.72; P<.001). The study also looked at a subgroup of 280 children exposed to tobacco smoke randomized to treatment (n=137) or control (n=143). Along with receiving the directly observed preventive asthma medications, treatment included a tobacco smoke (ETS) reduction program that included counseling primary caregivers about reducing smoke in the home as well as ways to quit smoking. In this subgroup of children, the study found that the mean symptom-free days per 2 weeks was 11.6 for the children in the treatment group compared with 10.9 in the control group (adjusted difference, 0.96 days per 2 weeks; 95% CI, 0.39-1.52). Although the authors acknowledge the difficulty of determining with certainly which component of the intervention was the most beneficial in the treatment group, they conclude that the intervention as a system of care is effective for young urban children with asthma. “The intervention is widely applicable for asthma care in communities nationwide as well as for management of other chronic diseases,” they conclude, adding that additional studies are needed to evaluate the cost of the intervention and ways to disseminate the intervention.