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Improved asthma outcomes among at-risk children in a pharmacist-led, interdisciplinary school-based health clinic: A pilot study of the CAReS program

Open AccessPublished:November 10, 2021DOI:https://doi.org/10.1016/j.japh.2021.11.008

      Abstract

      Background

      Disparities in access to care and outcomes have been identified among children with asthma living in underserved communities. The Caring for Asthma in our Region’s Schoolchildren program was established to reduce disparities by providing school-based, comprehensive asthma care by a pharmacist-led, interdisciplinary team to high-risk pediatric populations in the Greater Pittsburgh area.

      Objective

      To investigate program impact on follow-up appointment attendance, delivery of guideline-based care, asthma control, asthma morbidity (emergency department [ED] visits, oral corticosteroid [OCS] requirement), and asthma-related knowledge and quality of life.

      Methods

      The study enrolled 50 children with asthma from 6 elementary schools (September 2014-December 2017). Children completed 5 visits over a 3-month period. McNemar’s test assessed improvement in guideline-based controller therapy use and reduced morbidity (ED visits or OCS requirement). Generalized estimating equation analyses determined the significance of monthly improvements in asthma control, asthma knowledge, and quality of life.

      Results

      A 100% show rate was achieved in nearly all participants (92.0%). Most of the patients were African-American (56%). In children with persistent disease, only 21.4% were prescribed controller therapy at baseline, which improved to 78.5% upon enrollment (P < 0.05). Asthma control statistically significantly improved (P < 0.05), and a reduction in percentage of patients who required an ED visit or an OCS burst pre-to postintervention was also statistically significant (31.3% vs. 14.6%, P < 0.05). The goal of 100% treatment plan knowledge was achieved in 67% of caregivers within 1 month and increased from 6% to 60% in children over 3 months (P < 0.05). Asthma-related quality of life also improved statistically significantly pre-to postintervention (P < 0.05).

      Conclusions

      Disparities in asthma outcomes owing to inadequate access to health care can be addressed. Improved asthma control, asthma medication knowledge, quality of life, and reduced morbidity in high-risk pediatric patients are achievable as demonstrated by our study. Our findings support the feasibility and value of a pharmacist-led, interdisciplinary school-based health care delivery model in providing comprehensive asthma care to at-risk pediatric populations.

       Background

      • Asthma disparities among non-Hispanic black children and those from lower income families have been attributed, in part, to a lack of access to preventative care, underdiagnosis of asthma, and underuse of controller medications.
      • Mobile, school-based asthma clinics that provide care to underserved children have resulted in improved symptom-free days and achieved direct medical cost savings by decreasing hospitalizations and emergency department visits.
      • There is a paucity of literature on the pharmacist’s role in addressing pediatric asthma disparities as well as the role of pharmacists in school-based chronic disease management.

       Findings

      • This study showed that a pharmacist-led, school-based asthma clinic resulted in compliance with chronic disease management appointments, statistically significant improvements in asthma treatment plan knowledge, asthma-related quality of life, and asthma control, as well as decreased morbidity postintervention.
      • Our findings support the feasibility and value of a pharmacist-led, interdisciplinary school-based health care delivery model in providing comprehensive asthma care to at-risk pediatric populations.
      • Future studies are needed to explore the cost-effectiveness of pharmacist management of asthma and other chronic diseases in the school setting.

      Background

      Asthma is one of the most common chronic diseases, affecting nearly 6 million American children annually.
      Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007.
      Asthma is a complex condition involving chronic inflammation and recurrent episodes of airway obstruction and bronchial hyperresponsiveness.
      Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007.
      Research suggests that the cause of asthma is a combination of genetic and environmental factors, including exposure to airborne allergens, environmental tobacco smoke (ETS), and air pollution.
      Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007.
      Increased exposure to environmental factors among inner-city pediatric populations may increase the prevalence and severity of asthma-like symptoms.
      • Milligan K.L.
      • Matsui E.
      • Sharma H.
      Asthma in urban children: epidemiology, environmental risk factors, and the public health domain.
      Disparities in asthma control as well as asthma-related morbidity and mortality have been identified among children of non-Hispanic black descent and from lower income families.
      Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007.
      • Milligan K.L.
      • Matsui E.
      • Sharma H.
      Asthma in urban children: epidemiology, environmental risk factors, and the public health domain.
      Summary health statistics: national health interview survey 2015. National Center for Health Statistics.
      Centers for Disease Control and Prevention (CDC)
      Vital signs: asthma prevalence, disease characteristics, and self-management education: United States, 2001–2009.
      • Akinbami L.J.
      • Schoendorf K.C.
      Trends in childhood asthma: prevalence, health care utilization, and mortality.
      Previous studies have suggested that an increased incidence of asthma-related emergency department (ED) visits, hospitalization, and mortality is in part due to a lack of access to ambulatory care, underdiagnosis of asthma, and underuse of anti-inflammatory, controller medications.
      • Homer C.J.
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      Does quality of care affect rates of hospitalization for childhood asthma?.
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      Health consequences for children with undiagnosed asthma-like symptoms.
      • Warman K.L.
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      Asthma symptoms, morbidity, and antiinflammatory use in inner-city children.
      Mobile, school-based clinics have been proposed as a solution to the lack of access to quality medical care among at-risk pediatric populations. Established in Los Angeles, CA in 1995, the Breathmobile was the first comprehensive mobile pediatric asthma management program in the nation. Studies demonstrated that this mobile, school-based asthma clinic providing care to underserved children improved symptom-free days and achieved direct medical cost savings by decreasing hospitalizations and ED visits.
      • Jones C.A.
      • Clement L.T.
      • Hanley-Lopez J.
      • et al.
      The Breathmobile program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease Management Program.
      • Liao O.
      • Morphew T.
      • Amaro S.
      • Galant S.P.
      The Breathmobile: a novel comprehensive school-based mobile asthma care clinic for urban underprivileged children.
      • Bollinger M.E.
      • Morphew T.
      • Mullins C.D.
      The Breathmobile program: a good investment for underserved children with asthma.
      • Scott L.
      • Morphew T.
      • Bollinger M.E.
      • et al.
      Achieving and maintaining asthma control in inner-city children.
      • Morphew T.
      • Scott L.
      • Li M.
      • et al.
      Mobile health care operations and return on investment in predominately underserved children with asthma: the Breathmobile program.
      In addition, asthma education and management facilitated by a multidisciplinary health care team, including pharmacists, can increase medication compliance and self-management. Improving compliance to asthma medications has also been shown to improve asthma control and decrease the prevalence of asthma-related morbidity and mortality.
      • Abraham O.
      • Brothers A.
      • Alexander D.S.
      • Carpenter D.M.
      Pediatric medication use experiences and patient counseling in community pharmacies: perspectives of children and parents.
      • Carpenter D.M.
      • Abraham O.
      • Alexander D.S.
      • Horowitz K.
      Counseling of children and adolescents in community pharmacies: results from a 14-day observational study.
      • Guevara J.P.
      • Wolf F.M.
      • Grum C.M.
      • Clark N.M.
      Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis.
      • Elliott J.P.
      • Harrison C.
      • Konopka C.
      • et al.
      Pharmacist-led screening program for an inner-city pediatric population.
      • Bradley C.L.
      • Luder H.R.
      • Beck A.F.
      • et al.
      Pediatric asthma medication therapy management through community pharmacy and primary care collaboration.
      • Woods E.R.
      • Bhaumik U.
      • Sommer S.J.
      • et al.
      Community asthma initiative: evaluation of a quality improvement program for comprehensive asthma care.
      • Bartholomew L.K.
      • Sockrider M.
      • Abramson S.L.
      • et al.
      Partners in school asthma management: evaluation of a self-management program for children with asthma.
      • Elliott J.P.
      • Marcotullio N.
      • Skoner D.P.
      • Lunney P.
      • Gentile D.A.
      Impact of student pharmacist-delivered asthma education on child and caregiver knowledge.
      The Caring for Asthma in our Region’s Schoolchildren (CAReS) program was modeled after the Breathmobile to address barriers contributing to disparities in asthma care among children in Pittsburgh, PA. The mission of the CAReS program was to provide school-based, comprehensive asthma care facilitated by a multidisciplinary health care team to high-risk pediatric populations in the Greater Pittsburgh area. A key differentiator from previously published models is that the CAReS program was a pharmacist-led clinic and care transitioned from a mobile unit to shared space within each school during the study period.

      Objective(s)

      The goal of this study was to evaluate if a pharmacist-led, multidisciplinary school-based health care delivery model would affect follow-up appointment attendance, delivery of guideline-based care, asthma control, asthma morbidity (ED visits, oral corticosteroid [OCS] requirement), and asthma-related knowledge and quality of life.

      Methods

      Before implementation, the institutional review board at Duquesne University approved this longitudinal cohort study. The study enrolled 50 children, aged 6-11 years, from 6 elementary schools located in the Greater Pittsburgh area from September 2014 to December 2017. All children with known asthma were referred by the school nurse, and asthma diagnosis was confirmed by the study physician at the baseline visit. For this pilot project, care was initially delivered at the school site using a mobile clinic modeled after the Breathmobile program,
      • Jones C.A.
      • Clement L.T.
      • Hanley-Lopez J.
      • et al.
      The Breathmobile program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease Management Program.
      • Liao O.
      • Morphew T.
      • Amaro S.
      • Galant S.P.
      The Breathmobile: a novel comprehensive school-based mobile asthma care clinic for urban underprivileged children.
      • Bollinger M.E.
      • Morphew T.
      • Mullins C.D.
      The Breathmobile program: a good investment for underserved children with asthma.
      • Scott L.
      • Morphew T.
      • Bollinger M.E.
      • et al.
      Achieving and maintaining asthma control in inner-city children.
      • Morphew T.
      • Scott L.
      • Li M.
      • et al.
      Mobile health care operations and return on investment in predominately underserved children with asthma: the Breathmobile program.
      but then transitioned to shared space within each school. The care delivery team consisted of a pharmacist, student-pharmacists, a physician who was a board-certified allergist, and school nurses at each site who provided continuity of care across visits for the patients and their families. Children and their caregivers were informed of the nature of the study, as well as the potential risks and benefits; informed consent and assent were obtained from each child and caregiver who voluntarily participated in the study. Caregivers were encouraged but not required to attend appointments with their child.
      Children completed 5 study visits over a 3-month period, during the academic year, and were assessed at baseline, 2 weeks, 4 weeks, 8 weeks, and 12 weeks. The pharmacist worked with the school nurse to schedule clinic dates within study window. Parent-reported patient characteristics were collected at the initial visit by the pharmacist and included gender, age, ethnicity, and a comprehensive asthma and allergy history. Confirmation of an asthma diagnosis and a baseline assessment of asthma severity were documented at the first visit by a licensed medical physician; asthma control was assessed at each visit by the pharmacist or licensed medical physician by the asthma control test (ACT) and spirometry. An asthma treatment plan knowledge assessment, given to both the patient and caregiver, was administered at each visit. The 7-item pharmacotherapy knowledge survey (Appendix 1) had good internal consistency at baseline as measured by Cronbach’s alpha of 0.87 in assessment of patient identification of their asthma medications by name, ability to differentiate reliever and controller medications by mode of action (reason for use), understanding of how often to take each type of medication, and demonstration of proper use of reliever and controller medications prescribed as part of their treatment plan. Patients not on controller medication were only asked 4 questions specific to their reliever medication. Placebo inhalers with spacers were used to evaluate technique and the same pharmacist verbally administered the pharmacotherapy knowledge survey at each appointment. The 23-item Pediatric Asthma Quality of Life Questionnaire (PAQLQ) was administered at the first and last visit by the pharmacist. The PAQLQ was developed to measure the functional problems (physical, emotional, and social) that are most troublesome to children with asthma. Children respond to each question on a 7-point scale, and the overall PAQLQ score is a mean of all 23 responses.
      • Juniper E.F.
      • Guyatt G.H.
      • Feeny D.H.
      • Ferrie P.J.
      • Griffith L.E.
      • Townsend M.
      Measuring quality of life in children with asthma.
      Changes to drug therapy were recommended by a pharmacist and initiated by the study physician and were based on The National Heart, Lung, and Blood Institute’s Guidelines for the Diagnosis and Management of Asthma (Expert Panel Report 3) Stepwise Approach to Managing Asthma.
      Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007.
      Visit summaries including results of lung function tests and medication changes were faxed to each child’s primary care provider. The pharmacist provided asthma self-management education at every visit, emphasizing appropriate inhaler technique and reinforcing the importance of medication compliance in achieving and maintaining asthma control. The pharmacist provided ongoing support to families and school nurses between visits: resolving insurance problems, working with pharmacies to get medications delivered to the home, making sure children had an asthma action plan and reliever medication at school, and providing continued education and counseling to improve asthma knowledge and medication compliance. Parents’ reports of their child’s asthma medication prescriptions and compliance were further verified by the examination of an inhaler dose-counter or pill count if available and the verification of pharmacy records.

       Statistical analysis

      Demographic and clinical characteristics of patients at baseline were described by percentage with defined trait and by mean (SD) for continuous factors. The binomial test procedure assessed whether the show rate goal of at least 4 of 5 visits was achieved in 80% or more of participants. In patients with persistent disease, the increased percentage prescribed controller therapy after enrollment was assessed for significance using McNemar’s test. This test procedure also assessed the significance of reduction in the percentage of patients who required an ED visit or an OCS steroid burst (pre-to postintervention) with 1-sided significance reported. The pre- 3-month period was estimated by dividing the total number ED visits in the prior year by 4 then rounding to determine if greater than or equal to 1 (yes). This was replicated for OCS use, and the maximum of both variables was used to determine if participants required an ED visit or an OCS burst in the preintervention 3-month period (Y/N). Percentage of children (and caregivers) with complete asthma treatment plan knowledge and whose asthma was well controlled (ACT score ≥ 20) were described at baseline and across the first 3 months of intervention. Average scores on the ACT and PAQLQ were also described at baseline and across the first 3 months of intervention. Generalized estimating equations (GEE) analyses were performed to assess the significance of monthly improvement. Models accounted for repeat measures within subjects (baseline, month 1, month 2, and month 3) with specification of first-order autoregressive correlation structure and applied binomial logistic for dichotomous and linear regression for continuous outcomes. All analyses were conducted using SPSS software, version 18.0 (IBM Corp, Armonk, NY).

      Results

      Characteristics of 50 children who enrolled in the CAReS program are described in Table 1. The average age of participants was 8.9 years (SD = 1.7), and most were African American (56%) or Caucasian (34%). More than half were male (52%), reported lifetime exposure to ETS (56%), and had elevated body mass index as indicated by percentage overweight (14.3%) or obese (38.8%). The expectation of 80% show rate across the 5 visits was met by 92% of participants (P = 0.011). Asthma status at baseline showed 57.1% had persistent disease. Yet only 21.4% of those with persistent underlying disease severity were prescribed or taking controller therapy before their baseline visit. This improved to 78.5% upon enrollment in the program (P < 0.001).
      Table 1Baseline demographic and clinical characteristics
      DemographicsValid % or mean (SD)

      N = 50
       Age, y (range: 6–11 y)8.9 (1.7)
       Male52
       Race
       African American
      Includes 7 patients who specified African American and Caucasian and 1 patient who specified
      56
       Caucasian34
       Other6
       BMI
       Healthy (5th percentile to <85th percentile)46.9
       Overweight (85th to <95th percentile)14.3
       Obese (≥95th percentile)38.8
      ETS exposureds
       Current ETS exposure42
       Lifetime ETS exposure56
       Mother smoked while pregnant20
      Comorbidities
       Allergic rhinitis56
       Atopic dermatitis46
       Food allergies10
      Clinical status at baseline
       Underlying disease severity
       Intermittent42.9
       Mild persistent30.6
       Moderate persistent20.4
       Severe persistent6.1
       On controller therapy before entry12 (21.4 of persistent patients)
       Rx controller therapy at baseline visit44 (78.5 of persistent patients)
       Used reliever in last 12 mo92
       OCS use in last 12 mo (≥2/y)26.5
       FEV1 predicted ≤80%, [mean (SD)]18.8, [90.7 (16.4)]
       FEV1/FVC% ≤80%, [mean (SD)]0.0, [100 (7.7)]
      Abbreviations used: BMI, body mass index; ETS, environmental tobacco smoke; FEV1, forced expiratory volume; FVC, forced vital capacity; OCS, oral corticosteroid; Rx, prescription.
      Note: P value < 0.01 comparing percentage of 28 patients with persistent baseline severity who were on controllers 78.5% (Rx at baseline) to 21.4% (before baseline) based on McNemer’s test.
      African American and Other race.
      a Includes 7 patients who specified African American and Caucasian and 1 patient who specified
      Parent response to ACT survey items suggested approximately 52.1% of patients had controlled asthma (ACT ≥ 20) at baseline compared with 76.9% after 1 month, 77.1% after 2 months, and 89.7% after 3 months of participation (P = 0.003). Average ACT scores improved from 20 (SD = 3.6) to 22.9 (SD = 3.4) during the 3-month period (P = 0.001). Approximately 31.3% of the children had been to the ED or required an OCS burst owing to their asthma in the 3 months before program participation (Figure 1). In the postintervention period, the percentage of children with asthma who experienced a morbidity event was reduced to 14.6% (P = 0.029).
      Figure thumbnail gr1
      Figure 1Reduction in percentage of patients who required an ED visit or OCS burst pre-to postintervention was significant, P = 0.029, (McNemar test with exact 1-tailed significance reported). Abbreviations used: ED, emergency department; OCS, oral corticosteroid.
      The percentage of children with asthma who had complete asthma knowledge on the 7-item survey was 6.1% at baseline but improved significantly with each subsequent month of program participation to reach 60% by the third month (P < 0.001) (Table 2). In caregivers, the percentage with complete knowledge at baseline was 37.8%, although higher than in children, and improved by the first month to 66.7% without further increase (P = 0.010). PAQLQ scores also improved statistically significantly from baseline to the last visit with an increase of 0.7 points from 5 to 5.7 (95% CI 0.5–1.0), P < 0.001).
      Table 2Improvement in outcomes from baseline thru 3 months of intervention, N = 50
      OutcomesBaseline1 mo of Intervention2 mo of Intervention3 mo of InterventionP value
      GEE analyses were used to determine P values. Models accounted for repeat measures within subjects, specified AR(1) correlation structure, and applied binomial logistic for dichotomous and linear regression for continuous outcomes. P value indicates significance of improvement across time. Percentages based on those who had outcome data at respective time point with means (SD) estimated from GEE model.
      Dichotomous outcomes, %
      Asthma knowledge (7 items)
       Child - 100% on knowledge test6.131.3
      P < 0.01 comparison to baseline.
      43.2
      P < 0.01 comparison to baseline.
      60
      GEE analyses were used to determine P values. Models accounted for repeat measures within subjects, specified AR(1) correlation structure, and applied binomial logistic for dichotomous and linear regression for continuous outcomes. P value indicates significance of improvement across time. Percentages based on those who had outcome data at respective time point with means (SD) estimated from GEE model.
      < 0.001
       Caregiver - 100% on knowledge test37.866.7
      P < 0.01 comparison to baseline.
      62.5
      P < 0.05 comparison to baseline.
      65.7
      P < 0.05 comparison to baseline.
      0.010
      Asthma control test ≥20 (Controlled)52.176.9
      P < 0.01 comparison to baseline.
      77.1
      P < 0.05 comparison to baseline.
      89.7
      P < 0.01 comparison to baseline.
      0.003
      Continuous outcomes, mean score (SD)
      Asthma control test,20 (3.6)21.6 (3.5)
      P < 0.01 comparison to baseline.
      21.4 (3.4)
      P < 0.05 comparison to baseline.
      22.9 (3.4)
      P < 0.01 comparison to baseline.
      0.001
      PAQLQ5 (1.2)5.7 (1.3)
      P < 0.01 comparison to baseline.
      < 0.001
      Abbreviations used: AR(1), first-order autoregressive, GEE, generalized estimating equations; PAQLQ, Pediatric Asthma Quality of Life Questionnaire.
      a GEE analyses were used to determine P values. Models accounted for repeat measures within subjects, specified AR(1) correlation structure, and applied binomial logistic for dichotomous and linear regression for continuous outcomes. P value indicates significance of improvement across time. Percentages based on those who had outcome data at respective time point with means (SD) estimated from GEE model.
      b P < 0.01 comparison to baseline.
      c P < 0.05 comparison to baseline.

      Discussion

      In this study, we demonstrated that a pharmacist-led, interdisciplinary school-based health care delivery model in an at-risk pediatric population was able to achieve visit compliance greater than 80% in nearly all participants (92%). Furthermore, the impact of the CAReS program was statistically significant with respect to achieving program goals (P < 0.05). The goal of 100% asthma treatment plan knowledge was achieved within 1 month in 67% of caregivers and steadily increased from 6% to 60% in children over the 3-month intervention period. Improvement in average quality of life by 0.7 points was clinically meaningful, defined by Young et al.
      • Young N.L.
      • Foster A.M.
      • Parkin P.C.
      • et al.
      Assessing the efficacy of a school-based asthma Education Program for Children: A pilot study.
      as a magnitude of change that exceeds 0.5 points on the 7-point PAQLQ scale. The percentage of patients with well-controlled asthma (ACT ≥ 20) increased from 52.1% at baseline to 89.7% by the third month of participation. Improved health status was further evidenced by a reduction in percentage of patients requiring an ED visit or an OCS burst owing to their asthma from 31.3% to 14.6% (P < 0.05). An improvement in medication compliance was noted by the pharmacist, however, the inability to consistently monitor this outcome as intended in our population precluded more formalized evaluation in the pilot study.
      To achieve improvement in clinical outcomes through a school-based health care delivery model requires care coordination and participant engagement. Coordination with the school nurse and the pharmacy, parent reminder phone calls for upcoming appointments, and continuity of care by the same caring staff are effective tools to achieve good retention.
      • Morphew T.
      • Scott L.
      • Li M.
      • et al.
      Mobile health care operations and return on investment in predominately underserved children with asthma: the Breathmobile program.
      ,
      • Goldman H.
      • Fagnano M.
      • Perry T.T.
      • Weisman A.
      • Drobnica A.
      • Halterman J.S.
      Recruitment and retention of the Hardest-to-Reach families in community-based asthma interventions.
      The high retention rate in our patient population was expected based on findings from other asthma programs that used similar coordination and care delivery strategies.
      • Morphew T.
      • Scott L.
      • Li M.
      • et al.
      Mobile health care operations and return on investment in predominately underserved children with asthma: the Breathmobile program.
      ,
      • Goldman H.
      • Fagnano M.
      • Perry T.T.
      • Weisman A.
      • Drobnica A.
      • Halterman J.S.
      Recruitment and retention of the Hardest-to-Reach families in community-based asthma interventions.
      Bollinger et al.
      • Bollinger M.E.
      • Morphew T.
      • Mullins C.D.
      The Breathmobile program: a good investment for underserved children with asthma.
      reported those lost to follow-up in their study of inner-city, high-risk children were more likely to have less severe asthma, which would have lowered retention expectations in our study in which 42.9% had intermittent disease. However, the study by Goldman et al.
      • Goldman H.
      • Fagnano M.
      • Perry T.T.
      • Weisman A.
      • Drobnica A.
      • Halterman J.S.
      Recruitment and retention of the Hardest-to-Reach families in community-based asthma interventions.
      of recruitment and retention in a community-based asthma intervention in 311 children found that those with more severe asthma were more likely to be the “hardest-to-reach,” wherein the families required many contact attempts to complete at least 1 follow-up. Difficulty often occurs at the stage of recruitment requiring rescheduling of appointments for the enrollment visit as noted by Goldman et al.,
      • Goldman H.
      • Fagnano M.
      • Perry T.T.
      • Weisman A.
      • Drobnica A.
      • Halterman J.S.
      Recruitment and retention of the Hardest-to-Reach families in community-based asthma interventions.
      but once enrolled, high retention is feasible as was achieved in their study (96%) and our pilot study (92%). Additional influencing factors for consideration when going to scale include caseloads and a number of calls to families required by care coordinators.
      • Findley S.
      • Rosenthal M.
      • Bryant-Stephens T.
      • et al.
      Community-based care coordination: practical applications for childhood asthma.
      Findley et al.
      • Findley S.
      • Rosenthal M.
      • Bryant-Stephens T.
      • et al.
      Community-based care coordination: practical applications for childhood asthma.
      reported a wide range in retention, from 43% to 93% at 6 months, for their community-based asthma intervention.
      Patient and caregiver knowledge of pharmacotherapy are also essential to achieving asthma control and reduced morbidity in patients with persistent disease. A paucity of literature exists on children’s ability to differentiate their reliever and controller medications, identify reasons for use of both types of medication, know how often to use, and demonstrate proper technique. Medication use in pediatric patients is generally supervised by a caregiver or a school nurse; however, acquiring knowledge regarding asthma medications will contribute to their ability to properly self-manage in the future. Franks et al.
      • Franks T.J.
      • Burton D.L.
      • Simpson M.D.
      Patient medication knowledge and adherence to asthma pharmacotherapy: a pilot study in rural Australia.
      found in a pilot study of 83 adults with asthma that patient understanding of the mode of action for medication translated to increased ability for them to distinguish controller and reliever medications. In patients using controller medication, they found optimal administration technique ranged from 34% to 75% with the most common reasons for suboptimal technique (errors) described as “Did not inspire slowly” and “Did not inspire deeply.”
      • Franks T.J.
      • Burton D.L.
      • Simpson M.D.
      Patient medication knowledge and adherence to asthma pharmacotherapy: a pilot study in rural Australia.
      More than 60% of children in our pilot study and their caregivers achieved 100% knowledge with respect to the identification of their asthma medications and to distinguish, demonstrate proper technique, and correctly state the frequency of use for their reliever and controller medications per their treatment plan. Still, approximately one-third of children and caregivers had not yet achieved full knowledge regarding their/their child’s asthma treatment plan after 3 months of participation. Although beyond the scope of this study, further investigation to identify specific pharmacological knowledge items that present difficulty for the child/caregiver and how this affects asthma control and morbidity outcomes is recommended for future study.
      The achievement of asthma control in 88% of our patients by the third month of participation was on par with the estimate of 80% of patients who achieved well-controlled asthma by their third visit in a large study that involved 7822 patients across 34,339 visits.
      • Scott L.
      • Morphew T.
      • Bollinger M.E.
      • et al.
      Achieving and maintaining asthma control in inner-city children.
      Postintervention morbidity in our pilot study trended down as expected based on postyear reductions reported in the study by Scott et al.
      • Scott L.
      • Morphew T.
      • Bollinger M.E.
      • et al.
      Achieving and maintaining asthma control in inner-city children.
      The cohort of patients in their study who were similar in demographic and clinical composition to our pilot study resided in Chicago, IL and Baltimore, MD. The Chicago cohort comprised 2384 patients of whom 44% reported an ED visit in the year before the intervention, which was similar to the 48% found in our study before converting to quarterly (3 month) average.
      • Scott L.
      • Morphew T.
      • Bollinger M.E.
      • et al.
      Achieving and maintaining asthma control in inner-city children.
      The cohort of patients in their study who resided in Baltimore, MD was more likely to have persistent disease than in our cohort (67% vs. 57%), which was reflected by the higher percentage who required an ED visit preyear (68%). Morbidity reductions after a complete year of follow-up in the Chicago and Baltimore cohorts ranged from 56% to 74% for ED visits.
      • Scott L.
      • Morphew T.
      • Bollinger M.E.
      • et al.
      Achieving and maintaining asthma control in inner-city children.
      Although the maximum postexposure follow-up time in our study was limited to 3 months, the 53.3% reduction from 31.3% to 14.6% aligned with expectations based on the study by Scott et al.
      • Scott L.
      • Morphew T.
      • Bollinger M.E.
      • et al.
      Achieving and maintaining asthma control in inner-city children.
      There were limitations to our study. Although intent-to-treat approach was used in the analyses, approximately 10% of children/caregivers did not complete the treatment plan knowledge nor the ACT survey at 1 or more follow-up visits. We were unable to demonstrate improved medication compliance in our study population owing to child/caregiver inconsistency in bringing medications to visits, which as a result informed our decision to investigate the inclusion of pharmacy claims data in future studies. Achieving a higher ratio of controllers to total asthma medication (controllers and relievers) defined by the asthma medication ratio is feasible with this health care delivery model
      • Morphew T.
      • Altamirano W.
      • Bassin S.L.
      • Galant S.P.
      The Breathmobile improves the asthma medication ratio and decreases emergency department utilization.
      but requires consideration of mitigating factors to improve adherence such as a caregiver’s worry about medication adverse effects.
      • Butz A.
      • Morphew T.
      • Lewis-Land C.
      • et al.
      Factors associated with poor controller medication use in children with high asthma emergency department use.
      In the morbidity reduction analyses, maximum exposure time in the postperiod per patient was 3 months; however, at-risk patients generally require an average of 3 visits to first achieve asthma control based on the study by Scott et al.,
      • Scott L.
      • Morphew T.
      • Bollinger M.E.
      • et al.
      Achieving and maintaining asthma control in inner-city children.
      which would suggest potential bias toward more conservative rate reduction estimates. Furthermore, reductions in hospitalizations were not analyzed owing to limited data (only 1 patient required hospitalization in the postperiod). Generalizability of our findings was limited to high-risk pediatric patients, predominately representative of African American children, living in underserved areas, and with exposure to secondhand smoke higher than the national average. Study enrollment was limited to 50 children given the frequency of visits and the availability of the study physician and the pharmacist. Replication of this study in a larger population of at-risk children and in other settings with other providers (pediatricians, physician extenders) would further substantiate and increase generalizability of the study findings. Future studies are also needed to explore the cost-effectiveness of pharmacist management of asthma in the school setting through Collaborative Practice Agreements.

      Conclusion

      Asthma is one of the most common chronic diseases that affects children. Disparities in asthma control owing to inadequate access to health care increase the incidence of asthma-related morbidity. Asthma control and reduced morbidity in high-risk pediatric patients are achievable as demonstrated by our study. Our findings support the feasibility and value of a pharmacist-led, interdisciplinary school-based health care delivery model in providing comprehensive asthma care to at-risk pediatric populations.

      Acknowledgments

      The authors thank the school nurses and administrators at Clairton City School District and Woodland Hills School District for their partnership in this project.

      Appendix 1. Pharmacotherapy Knowledge Survey

      Questions 2,4, and 6 are only to be asked to children and caregivers of children currently prescribed a controller medication.
      ∗∗Mark each question answered correct with a check mark and each question answered incorrectly with an X. Include notes for each question marked with an X to guide future education efforts.
      Child Assessment
      • 1.
        What is/are the name(s) of your asthma medication(s)?
      • 2.
        Which medication(s) is/are your controller medication(s)?
      • 3.
        Which medication is your rescue medication?
      • 4.
        How often and when are you supposed to take each controller medication?
      • 5.
        How often and when are you supposed to use your rescue inhaler?
      • 6.
        Show me how you use your controller inhaler(s).
      • 7.
        Show me how you use your rescue inhaler.
      Caregiver Assessment
      • 1.
        What is/are the name(s) of your child’s asthma medication(s)?
      • 2.
        Which medication(s) is/are your child’s controller medication(s)?
      • 3.
        Which medication is your child’s rescue medication?
      • 4.
        How often and when is your child supposed to take each controller medication?
      • 5.
        How often and when is your child supposed to use their rescue inhaler?
      • 6.
        Show or explain to me how your child is supposed to use his/her controller inhaler(s).
      • 7.
        Show or explain to me how your child is supposed to use his/her rescue inhaler.
      Evaluation Date:
      Education Session #:
      Children currently prescribed a controller medication
      • Child Assessment (circle 1):
        • Complete Knowledge (7 correct)
        • Partial Knowledge (1-6 correct)
        • No Knowledge (0 correct)
      • Caregiver Assessment (circle1)
        • Complete Knowledge (7 correct)
        • Partial Knowledge (1-6 correct)
        • No Knowledge (0 correct)
      Children NOT currently prescribed a controller medication
      • Child Assessment (circle 1):
        • Complete Knowledge (4 correct)
        • Partial Knowledge (1-3 correct)
        • No Knowledge (0 correct)
      • Caregiver Assessment (circle1)
        • Complete Knowledge (4 correct)
        • Partial Knowledge (1-3 correct)
        • No Knowledge (0 correct)

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      Biography

      Jennifer Padden Elliott, PharmD, Director, Center for Integrative Health, Ed and Karen Fritzky Family Chair in Integrative Medicine and Wellbeing; and Associate Professor of Medicine and Pharmacy, Duquesne University, Pittsburgh, PA
      Tricia Morphew, MS, Biostatistician/Research Analyst, Morphew Consulting, LLC, Bothell, WA
      Deborah Gentile, MD, Medical Director, Allergy and Asthma Wellness Centers, Butler, PA; at time of study: Director of Allergy and Asthma Research, Allegheny Health Network, Pittsburgh, PA
      Paige Williams, MPH, Community Health Initiatives Manager, Center for Integrative Health, Duquesne University, Pittsburgh, PA; at time of study: Program Manager, American Lung Association, Pittsburgh, PA
      Christine Barrett, PharmD, Hematology/Oncology Pharmacy Specialist, Allegheny Health Network, Pittsburgh, PA; at time of study: Student Pharmacist, Duquesne University, Pittsburgh, PA
      Nicole Sossong, MPH, Senior Manager of Professional Engagement, American Diabetes Association, Pittsburgh, PA; at time of study: Program Manager, Allegheny Health Network, Pittsburgh, PA