School-based supervised therapy programs to improve asthma outcomes: current perspectives

Figures & data

Figure 1 Results of the literature review using the PubMed and Cochrane databases.

Table 1 Study characteristics and intervention components

Study	Study design	Sample size	US study location	Population and demographics	Intervention components
Halterman et al,^Citation15 2004	RCT	184	Rochester,NY	African-American (59%) Hispanic (32%) Medicaid (75%) Smokers in home (44%)	School-based care group was provided with 2 metered dose inhalers of fluticasone propionate and a spacer, and children in this group received a single dose (2 puffs) of fluticasone propionate each school day, administered by the school nurse. The second inhaler was given to the family to administer at home, when the child was not in school.
Millard et al,^Citation18 2003	RCT	50	Dallas, TX	African-American communities	Children were randomly assigned to 1 of 4 arms: 1) school-based delivery of inhaled steroids, 2) home-based delivery of inhaled steroids, 3) home-based delivery of inhaled steroids with school-based asthma education, and 4) control group with no change in current therapy. Students in the treatment arms received beclomethasone twice a day, either at school (upon arrival and before leaving) or at home.
Gerald et al,^Citation17 2009	RCT	290	Birmingham, AL	African-American (91%) Smokers in home (29%)	Children were prescribed and provided with budesonide once daily to facilitate adherence. For children randomized to the supervised therapy arm, use of ICSs was supervised by study staff at school each day. If a child was observed using their inhaler incorrectly, staff provided education with the aid of a placebo inhaler. Children were also provided with an AAP and 2 peak flow meters (for home and school).
Halterman et al,^Citation14 2011	RCT	530	Rochester, NY	African-American (63%) Hispanic (28%) Medicaid (73%) Smokers in home (54%)	Single dose of fluticasone was administered by school nurses, with dose adjustment based on NHLBI guidelines to the treatment group. A home-based environmental tobacco smoke reduction program for smoke-exposed children in treatment group was provided as well, using motivational interviewing.
Halterman et al,^Citation13 2011	Pilot, pre- and-post	30	Rochester, NY	African-American (53%) Hispanic (33%)	Teens were provided with a start-up preventive inhaler as authorized and prescribed by their physician. A second inhaler was delivered to the school nurse for single-dose DOT of preventive medication. Teens also received 3 MI counseling sessions (1 in-home and 2 via telephone) exploring attitudes about asthma management, building motivation for medication adherence, and supporting transition to independent preventive medication use.
Halterman et al,^Citation11 2012	Pilot, RCT	100	Rochester, NY	African-American (57%) Hispanic (26%) Medicaid (69%) Smokers in home (58%)	DOT of preventive asthma medications in school was facilitated by web-based technology. Web-based technology was also used for systematic symptom screening, electronic report generation, and medication authorization from providers. One dose of medication was given at school during the school day (if more frequent dosing was needed, additional doses were taken at home).
Trivedi et al,^Citation10 2017	Retrospective	84	Central Massachusetts	African-American (19%) Hispanic (67%) Medicaid (95%)	Providers determined medication dosing (once vs twice daily dosing) based on each child’s requirement. All children in the program started the school day by going to the school nurse office for supervised preventive asthma medication/ICS. For a child receiving twice-daily dosing at school, the nurse would administer the second dose at the end of the school day.
Harrington et al,^Citation16 2018	Pilot, RCT	48	Washington, DC	African-American (I: 95%) (C: 88%) Medicaid (100%) Smokers in home (I: 14%) (C: 28%)	Clinician in clinic provided a specific order for the school nurse to administer ICS every day that school was in session, and prescribed ICS for administration at home every evening on school days and every morning and evening on weekends and holidays.
Halterman et al,^Citation12 2018	RCT	400	Rochester, NY	African-American (58%) Hispanic (32%) Medicaid (76%) Smokers in home (48%)	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 was done in intervention group. Most children received once-daily dosing to allow for medication administration during school hours but if more frequent dosing was needed, additional doses were given at home.

Abbreviations: RCT, randomized controlled trial; ICS, inhaled corticosteroids; AAP, asthma action plan; NHLBI, National Heart, Lung, and Blood Institute; DOT, directly observed therapy; MI, motivational interviewing; C, control; I, intervention.

Table 2 Recruitment characteristics and study outcomes

Study	Recruitment location	Intervention duration	Setting	Age group	Study outcomes
Halterman et al,^Citation15 2004	School	1 school year for 2 consecutive school years	54 schools and preschools	3–7 years old	aN=180; school-based provision of ICSs significantly improved symptoms (experienced more SFDs during early winter months and were less likely to have 3 or more acute visits for asthma), quality of life, and absenteeism among urban children with mild persistent to severe persistent asthma. This effect was seen only among children not exposed to secondhand smoke.
Millard et al,^Citation18 2003	School	14 weeks	8 elementary schools	5–12 years old; mean age: 8.44 years	aN=50; average peak flows were significantly higher for the home and school medication groups. Treatment groups showed improvement in asthma control, higher peak flow, decreased bronchodilator use, decreased nighttime symptoms, improved school attendance, and reduced health care encounters. Treatment groups rated their asthma as “better than the week before” more frequently than the control group.
Gerald et al,^Citation17 2009	School, physician office, health department	15 months	36 elementary schools	Mean age: 11 years	aN=240; children in the supervised therapy group showed greater improvement in asthma control. Odds of experiencing an EPAC during the baseline period were 1.57 times the odds of experiencing an EPAC during the follow-up period in the supervised therapy group. There were no differences in the likelihood of an EPAC between the baseline and follow-up period in the usual-care group.
Halterman et al,^Citation14 2011	School	1 school year for 3 consecutive school years	67 elementary and preschools	3–10 years old; mean age: 7.1 years	aN=523; the school-based asthma therapy intervention improved symptoms among urban children with persistent asthma. Children in the treatment group had significantly more SFDs, fewer nighttime symptoms, less rescue medication use, fewer days with limited activity, and were less likely to have an exacerbation requiring prednisone treatment. Analyses showed positive intervention effects for children with smoke exposure as well.
Halterman et al,^Citation13 2011	School	6–8 weeks	Rochester City School District	12–15 years old; mean age: 13.6 years	aN=28; overall reduction of symptoms with more SFDs per 2 weeks for 2-month and final assessments. Teens also reported fewer days with symptoms, less activity limitation, and less rescue medication use. Exhaled nitric oxide levels decreased, suggesting less airway inflammation. At the final assessment, teens reported significantly higher motivation to take their preventive medication every day. Quality of life improved at both 2 month and final assessments.
Halterman et al,^Citation11 2012	School	1 school year	19 elementary and preschools	3–10 years old; mean age: 7.2 years	aN=99; children in the treatment group experienced nearly 1 additional SFD per 2 weeks. Treatment children also experienced fewer symptom nights, days requiring rescue medications, and days absent from school due to asthma. Treatment children had a greater decrease in exhaled nitric oxide, suggesting reduction in airway inflammation.
Trivedi et al,^Citation10 2017	Clinic	1 year prior to enrollment and 1 year after enrollment	Grades 1–12, public schools	6–18 years old; mean age: 10.5 years	aN=84; reductions in health care utilization (decreased emergency department visits, decreased hospital admissions, decreased asthma rescue medication refills) were seen comparing preintervention to postintervention. There were also nonsignificant declines in school absences and oral steroid use for children enrolled postintervention.
Harrington et al,^Citation16 2018	Clinic	60 days	18 public and public charter schools (K-8)	Mean age: 8.21 years	aN=44; the intervention group received 91.7% of expected morning doses of ICS at school and reported significantly less functional limitation, adjustment to family life, and sleep loss.
Halterman et al,^Citation12 2018	School	1 school year for 4 consecutive school years	49 elementary schools	3–10 years old; mean age: 7.8 years	aN=400; children in the intervention group had more SFDs per 2 weeks postintervention compared with children in the enhanced usual care group. In addition, children in the intervention group were less likely to have an emergency department visit or hospitalization for asthma.

Notes:

a N = the number of subjects who completed the study.

Abbreviations: ICS, inhaled corticosteroids; SFD, symptom-free day; EPAC, episode of poor asthma control.

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