# The Use of Telemedicine Access to Schools to Facilitate Expert Assessment of Children with Asthma

Authors: David A. Bergman; Paul J. Sharek; Kathryn Ekegren; Shannon Thyne; Michelle Mayer; Mara Saunders
Journal: International Journal of Telemedicine and Applications
 (2008)

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## Abstract

Research has shown that access to an asthma specialist improves asthma outcomes. We hypothesized
that we could improve access to expert asthma care through a telemedicine link between an asthma specialist and
a school-based asthma program. We conducted a prospective cohort study in 3 urban schools to ascertain the
feasibility of using an asthma-focused telemedicine solution. Each subject was seen by an asthma expert at 0, 8,
and 32 weeks. The assessment and recommendations for care were sent to the primary care physician (PCP) and parents
were told to contact their physician for follow-up care.  Eighty three subjects participated in the study. Subjects experienced
improvement (P<.05) in family social activities and the number of asthma attacks. Ninety four percent of subjects rated the
program as good or excellent. This study demonstrates the feasibility and acceptance of a school-based asthma program
using a telemedicine link to an asthma specialist.


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## Body

## 1. Introduction

Asthma affects an
estimated 5–10% of children at ages 0–18 and is the
most common reason for
childhood  hospitalizations [1]. Since 1980, the national
prevalence of asthma has increased to 75%, with the greatest increase occurring
among children [2]. In certain high-risk inner-city locations, asthma prevalence rates exceed 20% [3]. Asthma disproportionately affects minority
and low-income populations, with prevalence rates in African American and
Latino children 2.5 times that of Caucasians [4, 5]. The implications of these data are
substantial, as children with asthma face increased risk for behavior problems,
school dysfunction, and a variety of psychosocial problems which impact their
future development [6–8].It has been 12 years
since the publication of the National Asthma Education and Prevention Program guidelines for
the diagnosis and treatment of asthma.
Despite the widespread availability of these guidelines, there remains a
persistent and significant gap between what constitutes effective asthma care
for children and the actual care received, particularly for minority children
and those from low-income families [9]. For example, minority and
low-income children are less likely than whites and children from households
with higher incomes to receive controller medications to prevent asthma
exacerbations [6]. In one study of an
underserved urban area, researchers
found that 50% of children with asthma were not taking appropriate medications [10].Extensive research
efforts have shown that appropriate management, including the routine use of
controller medications, can dramatically reduce asthma morbidity
in children [11–13]. Yet, translation of these
research findings into clinical practice has been slow, particularly for inner-city children from low-income families. Several strategies have been devised to
increase the access to effective strategies for asthma care in underserved
areas. One of these strategies is the use of school-based asthma programs to bring
asthma care to a site where children are accessible on a daily basis, at least 180
days each year. This strategy dramatically diminishes patient transportation
problems and scheduling difficulties.
Evaluation of these programs has demonstrated increased student access
to needed care and improved students’ understanding of their health and
individual health outcomes; [14–16] however, the quality of care provided at these school-based clinics
has been inconsistent. A study of asthma care in inner-city school-based clinics found that the adherence to the National Heart, Lung, and Blood
Institute guidelines for asthma care was low among programs that did not have access
to expert asthma care and a targeted asthma intervention [17]. Other studies provide evidence that
asthma specialist involvement is a critical component of an effective asthma
program [18–20].Telemedicine is
one potential approach to increasing access to specialty care [21]. Although the evidence base is still growing,
there are identifiable positive outcomes associated with telemedicine. Telemedicine has been used in school settings
to improve access to care, treat otitis
media, and increase appropriate specialist referral and access to expert asthma
care for patients with asthma [10, 22, 23]. Given these findings, we
hypothesized that we could improve access to effective asthma care for
underserved children by combining a school-based program and telemedicine to
increase access to asthma specialty care.We developed a
school-based program that identified children with asthma and used a
telemedicine link to elicit recommendations from an asthma specialist, which
were then communicated to the patient’s primary care physician. This paper describes the feasibility and
acceptance of this program.


## 2. Methods

Study population
We enrolled 96
subjects from 3 elementary schools in an inner-city neighborhood in San Francisco. Potential subjects were identified through
the use of school health records and/or a positive response on the
International Survey of Allergy and Asthma in Children (ISAAC), which was
distributed to families of children in grades K-4, indicating that they had asthma or had
experienced wheezing [24]. Children
between the ages of 5 and 12 who had a diagnosis of asthma on their school
health record or answered positively to the ISAAC survey were considered to be eligible
for study enrollment. Children who were already under the care of an allergist or pulmonologist or spoke a language other than English or Spanish were excluded from the study. This study was
approved by the Stanford University School of Medicine, Institutional Research Board.Intervention
Each subject participated in 4
encounters at their respective schools occurring at baseline (week 0) and weeks
8, 16, and 32. At the baseline visit, an asthma specialist assessed each subject via a telemedicine link and developed an asthma action plan and recommendations based on the patient’s
classification based on NHLBI guidelines. In this setting, telemedicine involved real-time video and audio conferencing between the patient/school nurse dyad on-site
at the school and the asthma specialist on site at San Francisco General Hospital. The asthma specialist directly interviewed the patient and family (if present),
observed an asthma-relevant examination by the on site nurse, and reviewed
spirometry data directly from the laptop computer used at the school site. At
the end of this visit, each child received an asthma action plan and treatment
recommendations. Study personnel sent each subject’s primary care physician a
letter informing them that their patient was a participant in the study and that
they would be receiving a comprehensive patient assessment with treatment
recommendations. We emphasized that we
would only provide recommendations and that implementation of any changes in
asthma management was the responsibility of the PCP. The results of the
assessment and the treatment recommendations were then communicated to the
primary care physician (PCP) using a web-based program called Asthma
e-Coordinator, fax, or mail, depending on their PCP’s preference. The family was then told to schedule an appointment with their PCP and take their asthma action plan and treatment
recommendations to the visit.
At the  week-visit 8, the asthma specialist and school nurse assessed the need for changes in
therapy and communicated these recommendations to the PCP. At the  week-visit 16 each subject received formal,
developmentally-appropriate asthma education using the American Lung
Association’s “Open Airways For Schools” curriculum [25]. Children in grades K-2 had two 30-minute sessions, and subjects in grades 3–5 received four 30-minute
sessions. Parents were encouraged to attend all of these education sessions. Finally, in the  week-visit 32, all data collection tools were completed, and subjects graduated from the program.Data Collection
At the encounters of weaks 0, 8, and 32, data collection included demographics, healthcare
utilization, and assessment of parental and child asthma knowledge. The parent satisfaction survey was given at
weeks 8 and 32; spirometry was conducted at baseline and week 8. One parent or guardian completed the CHSA at
baseline, 8, and 32 weeks. The instrument
measures functional health status and is divided into 5 domains: physical
health of the child, social health of the child, social health of the family,
emotional health of the child, and emotional health of the family. The test-retest
reliability, internal consistency, and construct validity of this instrument
have been reported previously [26, 27]. One home visit, which
occurred between  week-  8 and  week-visits 32, was made by the research nurse
who used a standard checklist to assess the environment relevant to potential
asthma triggers.
The CHSA also
provided data on the frequency of asthma symptoms as well as utilization data
including asthma-related inpatient stays, emergency department use, and
unscheduled outpatient visits. The
number of emergency department and unscheduled outpatient visits were summed up to
produce the total number of urgent care visits. The number of urgent care
visits, asthma-related inpatient stays, wheezing episodes, and asthma attacks
were included in the final analysis.
Pulmonary function tests were
conducted using a portable SpiroCard Spirometer (Medgraphics, St. Paul, Minn, USA)
using percent predicted of normal based on height, sex, and race adjusted norms
using ATS criteria [28]. Children were asked to perform a forced
expiratory maneuver after maximal inhalation to measure forced expiratory
volume in 1 second (FEV1), forced vital capacity, and forced
expiratory flow in the middle half of the forced vital capacity and peak
expiratory flow rate (PEFR). A total of
3 maneuvers were recorded in accordance with American Thoracic Society
standards [28].
We adapted a child
asthma knowledge survey from a previous study of the effectiveness of an asthma
Nintendo game. The modified instrument had been pretested for acceptability [29]. The 15 item survey was administered to
children of  8 years and older. Skipped
items on the survey were treated as incorrect responses.
Similarly, we used
a 16-item survey developed for a previous study [29] to assess parents’ evaluation
of their child’s ability to manage their asthma. This survey was administered to one parent or
guardian at each relevant encounter after the baseline visit. In cases where
parents or guardians did not accompany the subject to the visit, efforts were
made to administer the survey via phone or mail. Likewise, parental satisfaction was assessed
using a previously developed 8-item survey.Statistical analysis
To assess the
effect of the intervention, we compared outcomes between baseline and week 8
and baseline and week 32. The outcomes
of interest included health care utilization and functional health status
(i.e., five domains) from the Child Health Survey for Asthma and child and
parental knowledge. Because the study
did not collect spirometry data at week 32, only baseline and week 8 are
compared. Similarly, only week 8 and
week 32 values are compared for parental satisfaction. For those subjects missing follow-up data, we
used their baseline value to impute the outcome value at follow-up. Because most of our outcomes were not
normally distributed, we used a nonparametric test, Wilcoxons Signed-Rank
test, to perform statistical comparisons.
This
research proposal was review by the institutional review boards of Stanford
University School of Medicine and the San Francisco Unified
School District.


## 3. Results

ISAAC survey
ISAAC surveys were
distributed to 680 students across the three schools; 310 (45%) of surveys were
returned. The prevalence rate for children with self-reported asthma or
wheezing on the ISAAC survey was 32%. Ninety six children with asthma were
identified. Twenty four percent of the
children did not have asthma indicated on their health cards and were identified only by their responses on the ISAAC
survey indicating that they had experienced an episode of wheezing or whistling
in the chest in the past 12 months. Eighty three
(86%) of these identified asthmatic children agreed to participate in the study.Baseline characteristics
Overall 54% of the
study subjects were male. Seventy one
percent of the subjects were African-American, 14% were Latino, and 14% were “Other.”
Thirteen percent of children had Spanish as their primary language spoken at
home, 78% of mothers had a high-school education or higher, and 92% of families
were Medicaid eligible (see Table1).
The study population reported mild to moderate levels of disease
activity based on NHLBI criteria.Table 1
Study subject characteristics.
Number%Child's sexMale4854.5%Child's raceAfrican-american6270.5%Latino1314.8%Other races1314.8%Transportation to medical careCar6175.3%Other1822.2%Marital statusRespondent*
married2944.6%Respondent  separated or divorced or widowed710.8%Respondent  single3960.0%Home languageEnglish
primary language at home7487.1%Mother's education<
12 years1621.3%12
or equivalent3141.3%>
12 years2837.3%Caregiver/employmentPrimary
caregiver employed5461.4%Other  caregiver employed3236.4%Insurance sourceMedical5092.6%Other47.4%Quality of asthma care
Twenty four
percent of the study subjects did not have asthma identified on their  school
health card (see Table2). Sixty nine percent of
parents or guardians of children in the study were never told their children had
asthma. Among children with identified
asthma, 96% stated that they used inhalers and 88% used spacers; however, only
52% monitored their peak flow and 34% had asthma action plans. Sixty percent of patients had persistent
asthma but only 23% of these persistent patients were taking anti-inflammatory
medications. Twenty eight percent of
subjects had previously seen an asthma specialist but were included in the
study as they were not actively being followed by a specialist at the time of
enrollment.Table 2
Quality of care and patient education.
Number of nonmissing observationsNumber with affirmative response% with affirmative responseEver told child has asthma876069.0%Ever saw an asthma specialist872528.7%For children identified with asthmaChild ever taught to use an  inhaler856272.9%Child ever taught to use a  spacer865361.6%Child ever taught to take a peak
flow843339.3%Child ever taught to take about
peak flow zones852428.2%Child ever given care plan by MD/RN863945.3%Child ever taught to control
asthma triggers854856.5%Child now taking anti-inflammatory meds862023.3%Environmental control
In
the home environment,  76% of subjects had carpeting on floor of the bedroom and
47% had feathered or down pillows. Only 19% of subjects had allergy mattress
and pillow covers. Thirty six percent of
subjects had areas of mold or mildew in their home and 21% reported seeing cockroaches
in their home.Study feasibility and implementation
It took
approximately 6 months to screen all eligible children, educate faculty, and
initiate the telemedicine encounters. All 83 children entered in the study were
seen by an asthma expert, underwent spirometry, and received an asthma action
and school emergency plan within three weeks of the baseline visit. The total
time commitment by the asthma specialist to see these children was 24 hours or
3.5 children/hr. Ninety eight percent of the primary care physicians agreed to
participate in the study and received asthma action plans and treatment
recommendations. One hundred percent of
the 83 children completed the study. At the end of the study, 94% of parents
rated the Asthma Telemedicine Program as excellent or good on a 5-point scale.Asthma outcomes
Study subjects
demonstrated a relatively high level of functioning at baseline. Scores on CHSA physical domain and the social
activity of the family domain of the CHSA were in the moderately high range
(80–90), and scores in the emotional health of the child and family domains and
the social activity of the child domain were greater than 90. Similarly, mean spirometry
results showed forced expiratory volume at 1 second (FEV1), forced
vital capacity (FVC), FEV1/FVC, and forced expiratory flow (FEF25-75)
that were all greater than 80% of predicted value. Similarl,y subjects had a low level of
utilization of hospital and emergency department visits as well as unscheduled
visits to their primary care physician.
At the end of the
intervention, subjects demonstrated significant improvement in the physical and
social domains for child on the CHSA (Table3). We were also able to demonstrate a significant improvement in child asthma knowledge and parent
asthma knowledge. In addition, we
observed a trend towards improvement in the number of asthma attacks in the
past 2 weeks (Table 4). There were, however,
no significant changes in spirometry, hospitalizations, emergency department
visits, or unscheduled visits to the primary care physician.Table 3
Functional health outcomes child health survey of asthma.
Mean baselineMean week 8P-value baseline versus week 8Mean week 32P-value baseline versus week 32*Physical84.284.4NS87.4.009Social activity-child92.492.0NS94.7.008Social activity-family92.293.7NS95.2NSEmotional health-child91.890.7NS91.5NSEmotional health -family80.178.9NS81.1NSStatistical comparisons performed using Wilcoxon Signed-Rank test.Table 4
Asthma outcomes.
Mean baselineMean week 8P-value baseline versus week 8Mean week 32P-value baseline versus week 32*Knowledge and satisfactionChild knowledge16.617.7.00717.40.03Parent  knowledge11.913.8< .00114.0< .001Parent  satisfaction—.85—.870.02Asthma symptoms and utilization# wheezing
episodes, past 2 weeks1.181.44NS0.99NS# asthma
attacks, past 2 weeks0.330.58NS0.153(.07)# overnight in
hospital, past 2 weeks0.0120.036NS0.012NS# ED visits,
past 2 weeks0.0590.082NS0.024NS# sick visits,
past 2 weeks0.0720.24.050.072NSSpirometryFEV196.596.7NS——FEF257586.986.3NS——FEF Max97.598.0NS——FEV/FVC94.595.9NS——*For parent satisfaction, the comparison
involves week 8 and week 32.


## 4. Discussion

This study
demonstrated both feasibility and acceptance of a school-based asthma program
that provided subspecialty access through a telemedicine link. We demonstrated that asthma specialists were
able to use their time efficiently to reach a large number of children. In fact, the project rate of 3.5 children per
hour was compared favorably with their experience in the asthma clinic where they
were able to see only 2 children per hour (personal communication, Shannon
Thyne, February 2005). We were also able
to demonstrate that children can easily undergo assessment and asthma education
during the school day with the assistance of a school nurse. The use of the school setting allowed for us
to complete the assessments and asthma education on 100% of our participants.
We were able to enlist a high degree of participation among PCPs as well as among
teachers. Over 98% of the PCPs were
willing to have their patients participating in the study. This may have been due to the fact that we
did not “practice medicine” and only made recommendations. This mitigated  any possible concerns on the part of the PCP that we may be taking their patients or fragmenting their care.This study also
demonstrated the feasibility of bringing subspecialty care to children with
asthma in the context of their school.
Several studies have documented improved outcomes when asthmatic
children have access to subspecialty care [20, 30, 31]. By using a telemedicine link, we were able to
increase the efficiency of the subspecialist’s time and were able to ensure
that 100% of the study children, 92% of whom used California’s version of Medicaid,
had access to subspecialty care.Our study showed
that 24% of the students who screened positive for asthma symptoms were unaware
that they had asthma, which is higher than in a previous report that used more
rigorous spirometry criteria for the diagnosis of asthma [32]. Our study also found that a significant
proportion of students identified as having asthma were not receiving optimal
treatment with a low percentage having asthma action plans, measuring peak
expiratory flow rates and using spacers with their metered dose inhalers. These results are similar to other studies
that have demonstrated inadequate asthma care in urban
school-aged children [3, 14, 33].Though a significant proportion of our
subjects were classified as having mild and moderate persistent asthma according to
the Child Health Survey of Asthma, this degree of morbidity
was not reflected in the CHSA. This may
be due to the fact that health status instruments reflect the degree of impact
on the child and family and may not be directly related to the disease
burden. Because of the relatively high
scores on the preintervention subscales of the CHSA, there was less
opportunity to demonstrate a more significant impact. Previous work however has demonstrated that
the CHSA is the most stable asthma outcome measure and best demonstrates
improvement over time [34]. Compared to baseline, health postintervention outcomes
were improved on two of the 5 subscales of the CHSA.We did not find
evidence of an effect on healthcare utilization. There are several possible reasons for a lack
of effect of the intervention on visits to the emergency department or the physician’s
office. First, the number of subjects in
the study may have been too small to detect a significant difference in
relatively uncommon events. Second, the
intervention did not ensure that the study subjects made a visit to their PCP
to have their medical regimen adjusted in light of recommendations from the
telemedicine encounter. In fact, many of
our families did not know the name or location of their PCP. This lack of an effective partnership between
our study families and their PCP made it difficult to leverage expert
recommendations and asthma action plans and ultimately decrease visits to the
emergency department and the physician office.
Lastly, the intervention for many of our children began in the spring
and with final outcomes assessed during the fall and winter. A lack of impact on utilization may have been
secondary to the increased incidence of respiratory infections during the fall
and winter months leading to increased symptom burden and utilization of health
care services.This study has
several important limitations. Without a
control group, it is difficult to know whether or not our results may be
secondary to secular factors such as seasonality that are unrelated to the
intervention. Second, we did not employ
the “gold standard” for measuring asthma outcomes, the number of days with
asthma symptoms. Our previous work in
this community had raised serious doubts about the reliability of using diary
data to measure symptom days [29]. It may be that the two-week recall window
used on the CHSA was insufficiently sensitive to detect improvement in asthma
outcomes. Third, the inclusion of
relatively low morbidity asthmatics, with low levels of utilization, relatively
high-pulmonary function, and high functional health status gave little
opportunity for statistically significant improvement with our intervention.
The study was underpowered to show significant improvement in these mildly
effected outcomes, but did suggest several important trends in the positive
direction.Another limitation
of this study was our inability to monitor and assess changes in the care
received from the primary care providers.
In an effort to maintain an appropriate link to the primary care
providers of our subjects, we decided to send the asthma specialist
recommendations to them for implementation rather than implementing these
recommendations ourselves. This model values the continuity and relationship
between primary care provider and subject, but did not ensure that the asthma
specialist recommendations were implemented. Hence, the intervention tested was
actually the access to subspecialist recommendations rather than implementation
of these recommendations themselves. In their study of a school-based program
that prompted pediatric primary care physicians as to appropriate asthma care, Halterman
and colleagues found poor compliance on the part of the primary care physicians
with the recommended care [35]. Thus, we suspect that inconsistent
implementation of the subspecialist recommendations by the primary care
provider negatively effected our outcomes.


## 5. Conclusion

This study has demonstrated the
feasibility, efficiency, and acceptance of using a telemedicine link to bring
expert asthma care to underserved children in the school setting. The results also demonstrate the
effectiveness of the program in ensuring that children identified with asthma
receive a comprehensive assessment, asthma action plan, and asthma
education. The use of a telemedicine
link also allowed for a more efficient use of the asthma subspecialist’s time
when contrasted with hospital-based asthma clinics. Finally, there were significant improvements
in functional health status outcomes. While the results suggest a positive
impact on asthma outcomes, a true assessment of program impact will require a randomized,
controlled trial.



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