URMC pediatrician: Local program making a difference for school children with asthma, serving as model for other regions of the country
By Chris Motola
A: Our programs really focus on improving the delivery of preventive care to kids with asthma in the community. The idea is really that we know, first of all, that asthma is one of the most common chronic illnesses of childhood and that it leads to a lot of suffering including not only ongoing symptoms, but also emergency visits, hospitalization, limitation of activity, loss of school days and loss of work days for their parents. So, our goal is really to improve those outcomes for those kids. We also know that there are preventive treatments for asthma that can really make a difference if they get to the kids who need them. What we found in our early work is that there are many kids who should be receiving preventive care who aren’t. We’re trying to make sure that all those kids who would be helped by those drugs are getting them.
Q: How has the program evolved?
A: One of our earliest programs was a partnership with nurses from the city school district where we identified children who experienced significant asthma, and we partnered with the nurses to have them deliver one dose of the medication each day they were at school and give parents one less thing to worry about. We found that that model really helped kids improve their outcomes. The telemedicine piece was added to provide an assessment for the children and link them back to their healthcare provider to see how well their asthma was controlled and whether any adjustments needed to be made to their medication.
Q: Is this being used as a screening tool as well?
A: No, it’s not being used to determine whether they have asthma or not, but one of the methods we used to screen was identifying those who have persistence symptoms and needed more preventive care. We know there are a lot of kids who have persistent symptoms whose providers may not be aware of those symptoms.
Q: Do you distinguish between different types of asthma for this program?
A: We didn’t really separate any groups, just looked at kids who were already diagnosed with asthma and were having ongoing symptoms. Because those are the kids who really need enhanced preventive care. So, any kid who has persistent asthma should be receiving a daily controller medication.
Q: What are some of the challenges of getting asthma under control in children?
A: It’s really tricky getting it under control because there are so many steps involved in getting a child optimal care. First, the family needs to recognize that the child is having significant symptoms and relay that to a healthcare provider. And there are often gaps just in that first step. Then once the provider is connected with the patient, they need to prescribe the medicine for prevention as the guidelines outline. Then families need to be able to afford, pickup and administer them to our children daily. It’s tricky because these medications are preventive, not symptom-relieving. So, it’s hard to remember every day when you don’t see an immediate response. And to be honest, there are misconceptions about the medications that make parents concerned about giving them daily. And then, over time, symptoms need to be reassessed to make sure the child is experiencing good control. That requires another connection with the primary care provider with appropriate symptom-screening and adjustments as needed. So, it’s very complex and there are many steps along the way. Our program is really designed to fill some of those gaps and reaching out to them where they’re spending most of their day.
Q: Does the program tackle any issues associated with affordability?
A: We try very hard to work within the child’s normal system of care, within their own health insurance. Fortunately, most children in Rochester have their own health insurance, which is great. However, there are significant barriers in terms of high co-pays or gaps in insurance. And, since we’re administering it in school, they need a second canister for home for the days when they’re not in school. The insurance companies need to be willing to pay for two canisters at once, even though they’ll last twice as long and help them avoid the emergency room. So, it’s a bigger cost upfront. Some insurance companies are willing to do it; others are more hesitant.
Q: How have the outcomes been?
A: The paper we just published found that the children who received the full intervention had a number of improved outcomes. They had more symptom-free days. They had fewer nighttime symptoms. Less activity limitations. And they were less likely to be hospitalized, which is also a big deal when we’re talking about cost.
Q: Do you see this as a model that can be used for other pediatric diseases?
A: We see it as a model in two ways. One is that we’re already seeing programs around the country implement similar systems of care using the resources in their community, and they’re consulting with us on how to make it work. And we’re also seeing it as a model for other chronic illnesses of childhood. Some physicians are trying to use telemedicine, for example, to check up on children with ADHD and adjust their medications if necessary.
Name: Jill S. Halterman, M.D., M.P.H.
Position: Executive vice chairwoman, department of pediatrics at University of Rochester School of Medicine; chief of the Division of General Pediatrics at URMC
Affiliations: University of Rochester School of Medicine
Organizations: American Academy of Pediatrics; Academic Pediatric Association
Family: Married, two children
Hobbies: Spending time with family, outdoor activities