The Journal of School Nursing2024, Vol. 40(4) 440–445© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221100470journals.sagepub.com/home/jsn
Abstract
Asthma morbidity disproportionately impacts children from low-income and racial/ethnic minority communities. Schoolsupervised asthma therapy improves asthma outcomes for up to 15 months for underrepresented minority children, but little is known about whether these benefits are sustained over time. We examined the frequency of emergency department (ED) visits and hospital admissions for 83 children enrolled in Asthma Link, a school nurse-supervised asthma therapy program serving predominantly underrepresented minority children. We compared outcomes between the year preceding enrollment and years one-four post-enrollment. Compared with the year prior to enrollment, asthma-related ED visits decreased by 67.9% at one year, 59.5% at two years, 70.2% at three years, and 50% at four years post-enrollment (all p-values< 0.005). There were also significant declines in mean numbers of total ED visits, asthma-related hospital admissions, and total hospital admissions. Our results indicate that school nurse-supervised asthma therapy could potentially mitigate racial/ethnic and socioeconomic inequities in childhood asthma.
Keywords
school-supervised asthma therapy, school nurse, long-term outcomes, underrepresented minority children, low-income, asthma emergency department visits, asthma hospital admissions
Children from underrepresented racial and ethnic minority groups and socioeconomically disadvantaged backgrounds continue to experience disproportionate asthma morbidity (Grant et al., 2022; Louisias & Phipatanakul, 2017; Volerman, Chin, et al., 2017). A major contributor to these disparities is poor adherence to guideline-recommended inhaled corticosteroids (ICS) with adherence rates as low as 28% (Boutopoulou et al., 2018), particularly among underrepresented minority patients (McQuaid, 2018). The scientific community has been called to engage historically marginalized populations in asthma research (Warren et al., 2022) and to develop robust clinical-community partnerships as a sustainable approach to advance health equity (Clinical-Community Linkages, 2016; Prevention, 2016).
Asthma Link, a clinical-school partnership in central Massachusetts, is one such strategy wherein school nurses supervise the administration of ICS for children with poorly controlled asthma, ensuring daily adherence to preventive therapy on school days. School-supervised asthma therapy is known to improve asthma outcomes for underrepresented racial and ethnic minority children, increasing ICS adherence and leading to more symptom-free days, decreased exacerbations, and decreased healthcare utilization (Allen et al., 2018; Gerald et al., 2009; Halterman, Szilagyi, Fisher, et al., 2011; Halterman, Szilagyi, Yoos, et al., 2004; Harrington et al., 2018; Millard et al., 2003; Pertzborn et al., 2018; Salazar et al., 2018; Trivedi, Patel, Lessard, et al., 2017). Compared to other supervised asthma therapy programs in schools (Allen et al., 2018; Gerald et al., 2009; Halterman, Szilagyi, Fisher, et al., 2011; Halterman, Szilagyi, Yoos, et al., 2004; Harrington et al., 2018; Millard et al., 2003; Pertzborn et al., 2018; Salazar et al., 2018), Asthma Link is unique because it serves children with poorly controlled asthma, reserving the allocation of school resources to children most significantly impacted by asthma. Moreover, the program operates without research resources, promoting sustainability in real-world practice. We have demonstrated that participants in Asthma Link experienced significant reductions in asthma-related emergency department (ED) visits and hospital admissions at one-year post-enrollment compared with the year prior to enrollment (Trivedi, Patel, Lessard, et al., 2017).
While school-supervised asthma therapy has improved healthcare utilization for children for up to twelve (Allen et al., 2018; Pertzborn et al., 2018; Trivedi, Patel, Lessard, et al., 2017) and fifteen months (Gerald et al., 2009), it remains unclear whether these outcomes are sustained over time, specifically for underrepresented minority children most affected by asthma. The objective of this study was to determine whether children enrolled in Asthma Link experienced sustained reductions in ED visits and hospital admissions for up to four years.
The core components of Asthma Link include the partnership of pediatric practices, school nurses and staff, and families to deliver school-supervised asthma therapy to children with poorly controlled asthma. Details of the Asthma Link protocol have been published (Trivedi, Patel, Lessard, et al., 2017). In brief, children are eligible for Asthma Link if they are 6 to 18 years old, prescribed daily ICS, have poorly controlled asthma despite optimized medical therapy, and have a history of poor medication adherence. Poorly controlled asthma is defined as an Asthma Control Test score less than 19 or one ED visit, hospital stay, or oral corticosteroid course for asthma in the last year. History of poor medication adherence is defined as a parent or child reporting missing frequent doses of the medicine or based on pharmacy information that reports an inconsistent ICS refill history.
To enroll a child in Asthma Link, pediatric providers identify children with poorly controlled asthma within their practice and send medication orders to the child’s school nurse for supervised administration of ICS therapy. Pediatric staff then communicate with the child’s school nurse by phone to discuss any pertinent details of the child’s asthma history. Families are responsible for picking up an extra inhaler, prescribed by their provider, and bringing it to the school where the school nurse supervises daily, preventive inhaler therapy. School nurses are vital to Asthma Link implementation as they are the trusted community partners and health professionals who see these children daily, communicate with pediatric practice staff and families, seek out students if they forget to come to the nurse’s office to take their medication, and ensure daily medication adherence.
We performed a quasi-experimental, time-series design study to examine changes in ED visits and hospital admissions for Asthma Link participants between the year prior to enrollment and the one to four years post-enrollment. Previously, our analysis for the one-year pre/post study included children enrolled in Asthma Link between 2012 through 2015 (Trivedi, Patel, Lessard, et al., 2017). We examined these same records for the current study but excluded children who did not have electronic medical record (EMR) data available beyond one-year post enrollment. A research assistant (not involved in the program’s operation) reviewed the EMRs for the following outcomes: number of asthma-related ED visits, total ED visits, asthma-related hospital admissions, and total hospital admissions. “Asthma-related” was defined by a primary diagnosis/complaint of one of the following: “asthma,” “cough,” “shortness of breath,” or “wheeze.” A pediatric pulmonologist randomly reviewed 10% of charts to ensure agreement with the research assistant’s classification, and over 90% of subjects received all their medical care within the UMass Memorial Medical Center health system. All subjects’ EMRs were reviewed for four years following their date of enrollment in the program regardless of the number of years the subject participated in the program.
Participant characteristics were recorded as reported in the EMR. We noted the number of years each child participated in the program and thus the number of years each subject received school-supervised asthma therapy. We also noted whether a child had non-allergic asthma or allergic asthma defined as a history of atopic dermatitis, eczema, allergic rhinitis, hay fever, or food allergy. The Institutional Review Board at the University of Massachusetts Chan Medical School approved this study and waived informed consent due to its minimal risk. Data is available upon request to the corresponding author.
Descriptive statistics for the study population were collected, and we used Nonparametric Wilcoxon signed rank sum tests to analyze differences in mean counts of outcomes at each time point. Linear mixed models were used to analyze the change in ED visits and admission counts over the study period, including the following potentially confounding variables: number of years the child was enrolled in the program and asthma type (allergic vs. non-allergic). Since the pre/post-intervention design of the study allowed for the subjects to serve as their own controls, we did not control for additional potential confounders. All analyses were conducted using SAS v 9.4.
A total of 83 children met our inclusion criteria and were included in our analysis with descriptive statistics noted in Table I. Compared with the year prior to enrollment, asthma-related ED visits decreased by 67.9% at one year, 59.5% at two years, 70.2% at three years, and 50% at four years post-enrollment (all p-values < 0.005). There were also statistically significant declines in mean numbers of total ED visits, asthma-related hospital admissions, and total hospital admissions over one to four years post- enrollment (Table II). There were no statistically significant differences according to asthma type (allergic vs. nonallergic) and exposure time (number of years enrolled in program) at each time point examined.
Our diverse study population experienced sustained reductions in ED visits and hospital admissions for up to four years after enrolling in school nurse-supervised asthma therapy. These reductions were not dependent on the number of years children were enrolled in Asthma Link, suggesting that participation in school-supervised therapy for even one year may have a lasting impact on healthcare utilization.
Our study builds on prior research describing the benefits of school-supervised asthma therapy up to 15 months post-enrollment (Allen et al., 2018; Gerald et al., 2009; Halterman, Szilagyi, Fisher, et al., 2011; Halterman, Szilagyi, Yoos, et al., 2004; Harrington et al., 2018; Millard et al., 2003; Pertzborn et al., 2018; Salazar et al., 2018; Trivedi, Patel, Lessard, et al., 2017) as well as literature advocating for school-based asthma management programs (Kakumanu et al., 2017), adding new data on the sustainability of improved outcomes up to four years. Specifically, our school-supervised asthma therapy program relies on school nurses as a trusted health professional to supervise ICS administration. Our findings suggest that this model of school nurse-supervision for preventive asthma therapy is one that could potentially produce sustainable improvements in health outcomes, particularly for populations of children who bear the greatest burden of asthma symptoms and morbidity.
We propose several explanations for our observation of sustained reductions in ED visits and hospital admissions. First, school-nurse supervision of daily, preventive asthma therapy may have supported the formation of a daily habit for these children which is an effective way to increase medication adherence (Badawy et al., 2020). Also, the formation of early habits related to medication regimens have been correlated with increased medication adherence later in life (Rehman et al., 2020). It is possible that children and families noticed improvements in asthma symptoms during school-supervised therapy, helping them to recognize the importance of continued adherence even after school-supervised therapy ended. Additionally, a review of seven school nurse-led asthma interventions showed that these interventions improved childhood asthma outcomes, largely due to school nurses’ leadership roles in schools and frequent contact with children, especially when compared to that of other health care professionals, allowing them to be uniquely suited to act as change agents for child health through developing thorough knowledge of children’s chronic conditions and management plans and promoting the development and adherence to individualized self-management strategies (Kindi et al., 2022). This unique and impactful position of school nurses likely contributed to the success of our school nurse-led asthma program. Finally, the improvements in asthma outcomes seen in our study population may have been due, in part, to improvements in inhaler technique with school nurse supervision. In our previous qualitative study, school nurses reported that Asthma Link participants were more confident that the inhaler medication was administered correctly when received with school nurse supervision (Trivedi, Patel, Hoque, et al., 2019), overcoming a major barrier in pediatric asthma care wherein only 8–22% of children have been found to use their asthma inhalers with correct technique (Volerman, Kan, et al., 2021).
The present study has a number of important strengths. First, our study population included a large percentage of underrepresented minority and Medicaid-insured children, enhancing applicability to the populations that suffer the most from asthma-related morbidity. School-based asthma programs have a unique capacity to reach diverse racial, ethnic, and socioeconomically disadvantaged populations because of their accessibility to all children that attend school. Second, we demonstrate a model wherein school nurses participate in preventive asthma care, rather than the more traditional acute asthma care. This study highlights the pivotal role of school nurses in chronic disease management and demonstrates the potential for school nurses to support preventive asthma care in a way that produces lasting improvements in childhood asthma outcomes. Third, we show how school nurses can participate in preventive asthma care through a sustainable partnership between school nurses and pediatric practices, two groups that are fully committed to child health. Such community-clinical collaborations have been specifically recommended by health experts, including the Centers for Disease Control, as a potent strategy to sustainably address child health inequities (Clinical-Community Linkages, 2016; Hegde & Eid, 2021; Prevention, 2016). Finally, because Asthma Link is ongoing and operates using the established infrastructure of pediatric practices and school nursing staff rather than research staff, this program was not time-limited by a grant, facilitating data collection up to four years.
It is important to consider our findings within the limitations of our study design which does not include a control group. This makes it difficult to assess whether children not enrolled in Asthma Link would have had a natural decrease in ED visits or hospital admissions over time. However, it is important to note that for school-aged children with a primary diagnosis of asthma, a previous asthma-related ED visit or hospital admission are both significant predictors for repeated ED visits and admissions (Ardura-Garcia et al., 2018; Buelo et al., 2018; Das et al., 2017). Furthermore, we saw consistent reductions in ED visits and admissions for our study population over the four year period without erratic changes or regression to the mean indicating that our observations are unlikely to be random. A larger randomized controlled trial of Asthma Link with assessment of long-term outcomes is needed to provide a more robust evaluation of this program.
Participation in Asthma Link, a school nurse-supervised asthma therapy program, is associated with sustained improvements in asthma health outcomes for a study population of largely underrepresented minority and Medicaidinsured children. Partnering pediatric practices with school nurses to deliver school-supervised therapy to children with asthma has the potential to make a long-term beneficial impact on reducing health disparities in pediatric asthma.
We would like to acknowledge and thank the children, families, school staff, and pediatric clinic staff that have participated in Asthma Link and contributed to this scientific research, especially the school nurses without whom this program would not be possible.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health [Award number UL1TR001453-01, KL2TR001455]; the National Heart, Lung, And Blood Institute of the National Institutes of Health [Award number K23HL15034]; the National Cancer Institute [Award number T32 CA172009].
Holly N. Shillan https://orcid.org/0000-0002-5160-3608
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Holly N. Shillan, BS, is a fourth-year medical student at the University of Massachusetts Chan Medical School, Worcester, MA.
Janki P. Luther, MD, MPH, is a resident physician in the Department of Medicine at the Washington University School of Medicine in St. Louis, MO.
Grace W. Ryan, PhD, MPH, is a post-doctoral fellow at the University of Massachusetts Chan Medical School, Worcester, MA.
Shushmita Hoque, MD, MS, is a resident physician in the Department of Medicine at the University of Massachusetts Chan Medical School, Worcester, MA.
Michelle A. Spano, MA, is a research coordinator in the division of Pediatric Pulmonology, Department of Pediatrics at the University of Massachusetts Chan Medical School, Worcester MA.
Darleen M. Lessard, MS, is a biostatistician in the Department of Population and Quantitative Health Sciences at the University of Massachusetts Chan Medical School, Worcester, MA.
Lynn B. Gerald, PhD, MSPH, is a Professor and Zuckerman Family Endowed Chair at the Mel and Enid Zuckerman College of Public Health, and Scientist at the Asthma and Airway Disease Research Center at the University of Arizona, Tucson, AZ.
Lori Pbert, PhD, is a Professor in the Department of Population and Quantitative Health Sciences at the University of Massachusetts Chan Medical School, Worcester, MA.
Wanda Phipatanakul, MD, MS is a Professor of Pediatrics at the Harvard Medical School and the Director of the Research Center for Asthma, Allergy, Dermatology, Rheumatology, Immunology at Boston Children’s Hospital, Boston, MA.
Robert J. Goldberg, PhD, is a Professor Emeritus in the Department of Population and Quantitative Health Sciences at the University of Massachusetts Chan Medical School, Worcester, MA.
Michelle K. Trivedi, MD, MPH, is an Associate Professor of Pediatrics (Division of Pediatric Pulmonology) and Population and Quantitative Health Sciences at the University of Massachusetts Chan Medical School, Worcester, MA.
1 University of Massachusetts Chan Medical School, Worcester, MA, USA
2 Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
3 Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
4 Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
5 Division of Pulmonary Medicine, Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, USA
6 Department of Health Promotion Sciences, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, AZ, USA
7 Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ USA
8 Department of Asthma, Allergy, and Immunology, Boston Children’s Hospital, Boston, MA, USA
Corresponding Author:Holly Shillan, University of Massachusetts Chan Medical School, 55 North Lake Ave, Worcester, MA 01655.Email: holly.shillan@umassmed.edu