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asthma inhailer

Picture imperfect: Eliminating asthma triggers through smartphones

asthma inhailer

Children’s National is among five awardees sharing $10 million in funding under Fannie Mae’s Sustainable Communities Innovation Challenge: Healthy Affordable Housing, a national competition to identify innovative ideas to help children and families enjoy safer homes. Fannie Mae made the funding announcement on May 21, 2019.

Children’s funding will underwrite a pilot program to use smartphones to enable virtual home visits, leveraging the skills of Children’s pediatric asthma specialists, health educators and community housing remediation specialists who will video conference with families in the home to identify potential housing asthma triggers.

According to the Centers for Disease Control and Prevention, 1 in 12 children and adolescents (6 million) have asthma, and one in six children with asthma visit the emergency department each year. In Washington, D.C., substandard housing can play an outsized role in triggering asthma exacerbations. Asthma-related hospital visits are 12 times higher in the city’s poorest neighborhoods, compared with affluent ZIP codes.

Working with community partners, Children’s faculty aim to eliminate asthma triggers right at the source, improving children’s well-being and creating healthier homes.

Right now during in-home visits, staff look for holes under kitchen sinks and gaps in the walls or flooring where pests and vermin might enter as well as leaks where mold and mildew can bloom. These systematic visits yield detailed notes to best direct resources to remediate those housing woes. The in-person visits however, are labor intensive and require delicate diplomacy to first open doors then to point out potential asthma triggers without coming off as judgmental.

“The beauty of our innovation is that residents can show us these same problematic locations using their smartphones, facilitating our efforts to target resources for that household. It’s a win for Children’s families because eliminating asthma triggers in the home means our kids will miss fewer school days, improving their lives and overall health,” says Ankoor Y. Shah, M.D., MBA, MPH, medical director for Children’s IMPACT DC Asthma Clinic.

Children’s collaborative project includes a number of partners, including:

Dr. Shah says the project will start in July 2019 with the pilot of virtual home visits starting in early 2020. This proof-of-concept model will hopefully be able to be replicated in other cities across the country.

asthma medication delivery

School’s in for asthma medication adherence

asthma medication delivery

A research team from Children’s National tried to reduce missed doses of daily medications, improve asthma control and tamp down on schoolchildren’s asthma attacks by outsourcing morning delivery of inhaled corticosteroids to the school nurse.

Doctors and researchers have long known that the level of stress patients experience is inversely linked to how adherent they are with taking medications: The higher the stress, the less likely patients are to take doses of their medication correctly, on time or at all. For families of school-aged children, there are few times more stressful than mornings, when parents or caregivers need to get kids ready for their school day, pack everything they need and get them out the door on time.

These stressful mornings, says Stephen J. Teach, M.D., M.P.H., chair of the Department of Pediatrics at Children’s National Health System, can spell danger for children with persistent asthma. This chronic condition is typically treated with nightly and morning doses of inhaled corticosteroids (ICS), medications that decrease lung inflammation to prevent asthma attacks. When children miss a morning dose because their families are too busy, their asthma symptoms can exacerbate, causing them to miss school, be unable to participate in activities like sports or lose sleep at night.

But Dr. Teach and colleagues had a simple idea to bypass the morning struggle for many families: Instead of trying to fit delivery of ICS into an already packed schedule, why not outsource it to the school nurse?

“We thought that if we could have those morning doses administered by these medically trained individuals with great technique and regularity, then maybe we would see some improved outcomes in kids,” Dr. Teach says. “And we did, in a striking way.”

Dr. Teach and colleagues recruited 46 children to participate in a pilot study, published online June 8, 2017 in the Journal of Asthma. To be eligible, these participants had to be in grades kindergarten through eighth in the Washington, D.C. public school system and on Medicaid, demonstrating the type of financial need that can add to the cumulative stress a family already faces. The children were scattered across 18 schools.

“We thought that if we could have those morning doses administered by these medically trained individuals with great technique and regularity, then maybe we would see some improved outcomes in kids,” Dr. Teach says. “And we did, in a striking way.”

Twenty-one of these participants received morning doses of ICS (the intervention group), which the researchers provided to school nurses along with an asthma action plan. The rest (the control group) remained on their prescribed morning and evening doses at home.

After 60 days, the researchers followed up with schools and families. Through electronic records kept by each school, the researchers found that the intervention group received more than 90 percent of their prescribed morning doses—about the same number reported by parents of the control group. However, the two groups demonstrated impressive differences in quality-of-life measures:

  • While about 24 percent of the intervention group missed one or fewer days of school due to asthma during the 60-day trial, about 44 percent of the control group did.
  • About 43 percent of the intervention group reported functional limitations due to their asthma, compared with 74 percent of the control group.
  • The intervention group reported only 1.7 nights with asthma-related sleep loss in the previous two weeks, compared with 4.1 nights in the control group.
  • Additionally, only about one-quarter of the intervention group required adjustments in family life to accommodate their asthma, compared with more than one-half of the control group.

The reasons for these differences aren’t clear, says Dr. Teach. But he and colleagues suggest that they might be due to over-reporting of how many doses were delivered at home in the control group or improper administration of these drugs at home.

Regardless, he says, the results show that this type of school-based intervention was not only feasible for children, school nurses and families, but also led to numerous positive health outcomes for the participants who received it. Based on the results of this study, Dr. Teach and colleagues have started to prescribe school-based administration of morning ICS doses to families interested in receiving them as a new standard of care.

“These data, combined with data from similar studies at other institutions, suggest that school-based therapy is increasingly becoming a very real and proven option for clinicians and families when adherence is a struggle,” he says.