………………..…………………………………………………………………………………………………………………………………….. School Based Asthma Therapy: Improving Asthma Care for our Most Vulnerable Children Elizabeth D. Allen, MD Pediatric Pulmonology

………………..…………………………………………………………………………………………………………………………………….. Nationally 7.1 million children affected >600,000 ED visits in Third leading cause of hospitalization in <15 yo’s 169 deaths in < 15 yo’s 2011 NCH >10,000 patients just in our 11 Primary Care network clinics >2500 ED visits/year >800 Hospital admissions/year Asthma in Kids

Asthma : Chronic airway irritation with episodes of spasm/swelling Bronchial Tube Airway smooth muscle Bronchiole Swollen lining Thick mucusInflamed airway Thin mucus Trapped air Tight muscle

………………..…………………………………………………………………………………………………………………………………….. Asthma Triggers Allergens

………………..…………………………………………………………………………………………………………………………………….. Asthma Triggers Pollutants

………………..…………………………………………………………………………………………………………………………………….. Asthma Triggers Other Stuff

………………..…………………………………………………………………………………………………………………………………….. Asthma Symptoms

Asthma Treatment PreventionRescue Every Day Trigger Avoidance “Controller” Medications* When Needed Albuterol Oral steroids Emergency Help * For patients with frequent and/or severe symptoms

………………..…………………………………………………………………………………………………………………………………….. Acute Symptoms Plan ALL asthmatic children require Includes: –Ability to recognize symptoms –Immediate use of albuterol –Plan for seeking help if albuterol “isn’t working” Nip it in the Bud mentality

………………..…………………………………………………………………………………………………………………………………….. Chronic Prevention Plan Trigger avoidance For “persistent” asthma, daily controller medication

Classification of Asthma Severity: Clinical Features before Treatment IntermittentMild Persistent Moderate Persistent Severe Persistent Daytime Symptoms ≤ 2days/week> 2days/weekDaily Throughout the day Nighttime Symptoms ≤ 2/month*3-4/month*> 1/week*Nightly* Rescue Inhaler Use ≤ 2days/week> 2days/weekDaily Several times a day Exercise limitation NoneMinorSomeExtremely FEV1 FEV1/FVC >80% >85% >80% 60-80% 75-80% <60% <75% “RISK” 0-1 oral steroids/year >2 oral steroids in 6 months Infants: OR >4 flares/yr lasting >24 & “at risk”

………………..…………………………………………………………………………………………………………………………………….. Inhaled Corticosteroids N Engl J Med 2000; 343:

………………..…………………………………………………………………………………………………………………………………….. Options for Stepping Up Therapy Double ICS Add Montelukast Add LABA

………………..…………………………………………………………………………………………………………………………………….. Flares are treated promptly Controller medications are given when they’re supposed to be Inhalers are used with correct technique Preventive Therapy Won’t Work Unless...

………………..…………………………………………………………………………………………………………………………………….. U.S. Asthma Disparities Significant differences exist between the worst markers of asthma morbidity: Urgent Care, Emergency Department, Hospitalizations, and Deaths Based on: Socioeconomic Status Race/Ethnicity

………………..…………………………………………………………………………………………………………………………………….. The Magnitude of the Problem Black vs White children: Approx 1.6 fold rates of having asthma Approx 2.5 fold rates of ED Use for Asthma Approx 4.5 fold rates of death due to asthma

………………..…………………………………………………………………………………………………………………………………….. Contributors to Development and Severity of Asthma Prematurity/Low Birth weight Outdoor Air Pollution Second Hand Smoke Exposure Viral respiratory infections Psychosocial Stress

Poverty & Exposure to Second Hand Smoke

2012 Franklin County Asthma-Related Patient Origin Unique Inpatient/ED Utilizers Source: PFK Dataset

“Last year, there were 264 people between 1 and 19 years old who were victims of gun violence...” Source: Columbus Dispatch. October 2013

………………..…………………………………………………………………………………………………………………………………….. Barriers to Medical Care Availability of clinics Transportation problems Seeking care in the first place – cultural norms

………………..…………………………………………………………………………………………………………………………………….. Quality of Care: Provider Characteristics Appointment length Provider continuity Provider knowledge base & biases

………………..…………………………………………………………………………………………………………………………………….. Home Adherence to the Asthma Plan Medication costs Treatment plan comprehension Beliefs regarding illness Beliefs regarding medications Challenges around executing –Chaos, stress and prioritization

………………..…………………………………………………………………………………………………………………………………….. How Should Disparities Be Addressed? Multi-dimensional solutions are needed Improvement in care at the provider level Enhanced communication strategies Support in the home and community –Environmental improvements –Medical care engagement

………………..…………………………………………………………………………………………………………………………………….. Improving Asthma through Community Action = School Based Asthma Therapy (SBAT)

………………..…………………………………………………………………………………………………………………………………….. SBAT

………………..…………………………………………………………………………………………………………………………………….. SBAT Intervenes in Multiple Barriers to Care Parents unaware (or accepting) of symptom level Child with no recent medical visit Level of symptoms not communicated to provider at medical visit Symptoms communicated – but guideline therapy not provided Guideline therapy provided – but not executed (for lots of reasons... ) Lack of follow-up

………………..……………………………………………………………………………………………………………………………………..

Asthma Control Test (ACT) Standardized assessment to evaluate asthma control Two age-based versions Total Score of ≥ 20 suggests good control Increase of 3 reflects clinically significant improvement

………………..…………………………………………………………………………………………………………………………………….. Impact on Asthma Control Test On SBAT (18)Pre SBAT (24) Pre SBAT (57) On SBAT (52) P < 0.001

………………..…………………………………………………………………………………………………………………………………….. One Student’s Story* Pre-SBAT 2 nd grader habitually in the nurses office Any time he ran, he reported trouble breathing Audible wheezing, sats low 90’s Albuterol stabilized (but SN constantly worried!) Mom believed this was “normal” *From his grateful school nurse

………………..…………………………………………………………………………………………………………………………………….. One Student’s Story On-SBAT Very few ill visits to SN (no more wheezing heard) “I don’t wake up at night anymore not being able to breathe!” “I feel great, I can run on the playground!”

………………..…………………………………………………………………………………………………………………………………….. Conclusions Asthma remains a vexing and dangerous problem A multitude of barriers to control exist – particularly for those affected by racial or socioeconomic disparities Teamwork between parents, community and providers is key Schools can play an important role in the care of children with asthma