School Supervision of Asthma Meds May Not Improve Asthma Control

FOR RELEASE

Embargoed until May 21, 2:15 p.m. ET

Session: A94 Improving Asthma Management: Research at the Forefront

Abstract Presentation Time: Sunday, May 21, 2:45 p.m. ET

Location: Walter E. Washington Convention Center, Room 202B (South Bldg., Level 2)

Newswise — ATS 2017, WASHINGTON, DC─Supervising the use of inhaled corticosteroids (ICS) in elementary school children with asthma may not improve asthma symptoms, prevent school absences or reduce health care use, according to new research presented at the ATS 2017 International Conference.

Researchers conducted a randomized controlled trial of a comprehensive school-based asthma program among 361 children, most of whom were from Hispanic and low-income families, living in Tucson, Arizona. Of these children, 73 percent had asthma that was not well controlled when evaluated by a study physician, but only 36 percent reported taking an ICS to control their asthma. All the children participated in the American Lung Association’s Open Airways for Schools program that educates students about asthma, its triggers and its treatment.

The children were randomized into two groups: those who would begin taking their asthma control medication under school supervision immediately and those who would start in the supervised program a year later.

“Adherence to daily controller medication is quite poor,” said lead study author Joe K. Gerald. MD, PhD, assistant professor at the University of  Arizona College of Public Health, who noted national statistics showing that only about one-fourth of the asthma medicines prescribed for children are filled.  “Although there are many reasons for this, we have found affordability and inconvenience to be the most important.”

Because children are required to attend school, Dr. Gerald and colleagues hypothesized that providing children with their medicines and then making sure they took the medicine once each day during school would not only increase adherence, but also improve their asthma control.

Students completed the Juniper Asthma Control questionnaire. The questionnaire asks six questions about asthma symptoms, including one about rescue inhaler use. Despite the fact that the study achieved 95 percent adherence at school, the researchers found no difference in questionnaire scores, the primary outcome, between those who took ICS under supervision and those who did not. There was also no difference in secondary outcomes, including quality of life, school absences or health care utilization as measured by use of oral corticosteroids, the emergency department or hospitalization.

Previously, the researchers conducted a similar study in Birmingham, Alabama. That study showed that school-based treatment reduced episodes of poor asthma control in a student population that was mostly low-income and African American. The current study was designed to replicate those findings in another school system with a different student population.     

 Dr. Gerald said two factors may help explain why the current study did not confirm previous results. Students in the current study had a high rate of absenteeism and their measure of asthma control, based on the Juniper questionnaire, was more stringent that the asthma control measure used in the Birmingham study.

Still, Dr. Gerald noted, both studies demonstrate the feasibility of using schools to ensure medication compliance near 100 percent during school days.

“More study is needed,” he said. “Just because this study did not find a difference does not mean that school-based programs cannot be effective.”

Contact for Media: Joe K. Gerald. MD, PhD, [email protected]

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Abstract 3864

Supervised Asthma Medicine in Schools: The SAMS Study

Authors: J.K. Gerald1, M.A. Brown2, D. Billheimer1, J. Fisher1, C. Clemens3, M. Moore3, S. Carvajal1, D. Bryson4, N. Stefan5, L.B. Gerald1; 1University of Arizona - Tucson, AZ/US, 2Denver Children's Hospital - Denver, CO/US,

3University of Arizona - Tucson, AZ/US, 4American Lung Association of Tucson - Tucson, AZ/US, 5Tucson

Unified School District - Tucson, AZ/US

RATIONALE: Medication nonadherence is an important cause of preventable morbidity among children with asthma. Supervising the use of inhaled corticosteroids (ICS) at school can increase adherence and reduce episodes of poor asthma control. Because many schools serve low-income, ethnically diverse populations, partnering with them can reach children who are most burdened by the consequences of medication nonadherence.

METHODS: The Supervised Asthma Medicine in Schools (SAMS) study was a prospective, parallel group, delayed intervention, randomized controlled trial of a comprehensive school-based asthma program. SAMS identified English- or Spanish-speaking children with previously diagnosed asthma and provided them with comprehensive asthma education, monitored their asthma control over time, provided them with albuterol (Proventil®), initiated once-daily treatment with mometasone furoate (Asmanex®), and supervised its use in the school setting. Twenty Tucson Unified School District elementary schools serving primarily low-income, Hispanic students were randomized to immediate or delayed intervention groups. We hypothesized that after 1 year of treatment, students in immediate intervention schools would achieve lower (better) scores on the Juniper Asthma Control (ACQ) questionnaire than students in delayed intervention schools. Secondary outcomes included asthma symptom free days, quality-adjusted life years, medication adherence, school absences, and health care utilization.

RESULTS: Three-hundred and sixty-one children had a valid ACQ data point during Year 1; 208 in the immediate and 153 in the delayed intervention group. Demographic characteristics are presented in Table 1. At baseline, 73% of children had not-well-controlled asthma (ACQ score ≥0.75) and 36% reported taking a controller medication. Among those in the immediate intervention group, 75% of those evaluated by a study physician had not-well-controlled asthma and 79% were prescribed ICS, suggesting many were undertreated. More than 95% of all prescribed doses were administered by school personnel when children were present at school. However, when weekends, holidays, and absences were considered, overall calendar adherence was 52%. Based on an intention-to-treat protocol, no differences in ACQ scores were observed between children assigned to the immediate and delayed intervention groups, -0.08 (CI95% -0.32, 0.16). No differences were observed among any of the secondary outcomes.

DISCUSSION: School-based administration of once-daily ICS achieved calendar adherence of 50% which is twice that of claims-based estimates. However, supervised administration did not improve asthma control as compared to usual asthma care practices. Potential explanations include over-enrollment of children with well-controlled asthma at baseline and calendar adherence below the amount hypothesized (>80%) to be needed to achieve optimal asthma control.

Table 1. Demographic Characteristics