基于学校的远程医疗哮喘强化管理项目（SB-TEAM）对哮喘病情的影响一项随机临床试验
2019/02/27
摘要
重要性：指南推荐的预防性哮喘用药普遍存在依从性差的情况，导致可预防的病情加重。我们开发了基于学校的远程医疗强化管理项目（School-Based Telemedicine Enhanced Asthma Management，SB-TEAM），旨在通过在学校结合远程医疗来克服预防性哮喘护理的障碍，从而建立基于学校的监督治疗计划。
目标：评价SB-TEAM项目对城市持续期哮喘儿童病情的影响。
试验设计、研究地点与受试者：在这项随机临床试验中，纽约罗彻斯特市学区3至10岁患有持续期哮喘的儿童，按照基线时预防性药物使用情况进行分层，并随机分配到SB-TEAM计划组或加强常规护理对照组1学年。受试者在学年初（2012-2016）登记，并在学年结束前评估结局。采用多变量改良意向性分析方法，对2017年5月至2017年11月的数据进行分析。
干预措施：监督管理学校预防性哮喘药物使用以及3次基于学校的远程医疗访问，以确保正确评估、预防药物处方和后续保健。远程医疗访问的校园部分由远程医疗助理完成，获取病史与检查数据。这些数据安全存储在虚拟候诊室中，然后由初级保健医生查看，他们完成评估并通过视频会议或电话与保健人员进行沟通。预防性药物处方被送到药房，药物送到学校进行日常管理。
主要结果和测量方法：主要结局指标为每2周无症状天数的均值，通过2月一次的盲法访谈进行评估。
结果：400例入组儿童中，男性247例（61.8%），非裔230例（57.5%），平均年龄7.8岁（标准差1.7岁）。两组患者的基线人口学特征与哮喘严重程度相似。在SB-TEAM组中，196例（98.0%）儿童接受过1次或1次以上的远程医疗，165例（82.5%）在学年内接受了全程监督治疗。我们发现，与加强常规护理组相比，SB-TEAM组的儿童干预后每2周无症状天数更多（11.6天vs 10.97天；差异，0.69； 95%CI，0.15-1.22；P=0.01），在末次随访时差异达到最大（差异0.85；95%CI，0.10-1.59）。此外，SB-TEAM组儿童因哮喘而去急诊科就诊或住院的可能性更小（7% vs 15%, 比值比，0.52；95%CI，0.32-0.84）。
结论和相关性：SB-TEAM干预显著改善了城市儿童持续期哮喘的症状，降低了医疗保健利用率。该项目可作为学龄儿童哮喘可持续保健的典范。
Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) Program on Asthma Morbidity A Randomized Clinical Trial
Halterman JS; Fagnano M; Tajon RS; Tremblay P; Wang HY; Butz A; Perry TT; McConnochie KM
JAMA Pediatr. 2018;172(3):e174938.
Abstract
Importance：Poor adherence to recommended preventive asthma medications is common, leading to preventable morbidity. We developed the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program to build on school-based supervised therapy programs by incorporating telemedicine at school to overcome barriers to preventive asthma care.
Objective：To evaluate the effect of the SB-TEAM program on asthma morbidity among urban children with persistent asthma.
Design, Setting, and Participants：In this randomized clinical trial, children with persistent asthma aged 3 to 10 years in the Rochester City School District in Rochester, New York, were stratified by preventive medication use at baseline and randomly assigned to the SB-TEAM program or enhanced usual care for 1 school year. Participants were enrolled at the beginning of the school year (2012-2016), and outcomes were assessed through the end of the school year. Data were analyzed between May 2017 and November 2017 using multivariable modified intention-to-treat analyses.
Interventions：Supervised administration of preventive asthma medication at school as well as 3 school-based telemedicine visits to ensure appropriate assessment, preventive medication prescription, and follow-up care. The school site component of the telemedicine visit was completed by telemedicine assistants, who obtained history and examination data. These data were stored in a secure virtual waiting room and then viewed by the primary care clinician, who completed the assessment and communicated with caregivers via videoconference or telephone. Preventive medication prescriptions were sent to pharmacies that deliver to schools for supervised daily administration.
Main Outcomes and Measures：The primary outcome was the mean number of symptom-free days per 2 weeks, assessed by bimonthly blinded interviews.
Results：Of the 400 enrolled children, 247 (61.8%) were male and 230 (57.5%) were African American, and the mean (SD) age was 7.8 (1.7) years. Demographic characteristics and asthma severity in the 2 groups were similar at baseline. Among children in the SB-TEAM group, 196 (98.0%) had 1 or more telemedicine visits, and 165 (82.5%) received supervised therapy through school. We found that children in the SB-TEAM group had more symptom-free days per 2 weeks postintervention compared with children in the enhanced usual care group (11.6 vs 10.97; difference, 0.69; 95% CI, 0.15-1.22; P = .01), with the largest difference observed at the final follow-up (difference, 0.85; 95% CI, 0.10-1.59). In addition, children in the SB-TEAM group were less likely to have an emergency department visit or hospitalization for asthma (7% vs 15%; odds ratio, 0.52; 95% CI, 0.32-0.84).
Conclusions and Relevance：The SB-TEAM intervention significantly improved symptoms and reduced health care utilization among urban children with persistent asthma. This program could serve as a model for sustainable asthma care among school-aged children.
重要性：指南推荐的预防性哮喘用药普遍存在依从性差的情况，导致可预防的病情加重。我们开发了基于学校的远程医疗强化管理项目（School-Based Telemedicine Enhanced Asthma Management，SB-TEAM），旨在通过在学校结合远程医疗来克服预防性哮喘护理的障碍，从而建立基于学校的监督治疗计划。
目标：评价SB-TEAM项目对城市持续期哮喘儿童病情的影响。
试验设计、研究地点与受试者：在这项随机临床试验中，纽约罗彻斯特市学区3至10岁患有持续期哮喘的儿童，按照基线时预防性药物使用情况进行分层，并随机分配到SB-TEAM计划组或加强常规护理对照组1学年。受试者在学年初（2012-2016）登记，并在学年结束前评估结局。采用多变量改良意向性分析方法，对2017年5月至2017年11月的数据进行分析。
干预措施：监督管理学校预防性哮喘药物使用以及3次基于学校的远程医疗访问，以确保正确评估、预防药物处方和后续保健。远程医疗访问的校园部分由远程医疗助理完成，获取病史与检查数据。这些数据安全存储在虚拟候诊室中，然后由初级保健医生查看，他们完成评估并通过视频会议或电话与保健人员进行沟通。预防性药物处方被送到药房，药物送到学校进行日常管理。
主要结果和测量方法：主要结局指标为每2周无症状天数的均值，通过2月一次的盲法访谈进行评估。
结果：400例入组儿童中，男性247例（61.8%），非裔230例（57.5%），平均年龄7.8岁（标准差1.7岁）。两组患者的基线人口学特征与哮喘严重程度相似。在SB-TEAM组中，196例（98.0%）儿童接受过1次或1次以上的远程医疗，165例（82.5%）在学年内接受了全程监督治疗。我们发现，与加强常规护理组相比，SB-TEAM组的儿童干预后每2周无症状天数更多（11.6天vs 10.97天；差异，0.69； 95%CI，0.15-1.22；P=0.01），在末次随访时差异达到最大（差异0.85；95%CI，0.10-1.59）。此外，SB-TEAM组儿童因哮喘而去急诊科就诊或住院的可能性更小（7% vs 15%, 比值比，0.52；95%CI，0.32-0.84）。
结论和相关性：SB-TEAM干预显著改善了城市儿童持续期哮喘的症状，降低了医疗保健利用率。该项目可作为学龄儿童哮喘可持续保健的典范。
(朱文娟1 张红萍1 王刚2 四川大学华西医院中西医结合科呼吸病组 610041 摘译)
（JAMA Pediatr. 2018;172(3):e174938.）
（JAMA Pediatr. 2018;172(3):e174938.）
Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) Program on Asthma Morbidity A Randomized Clinical Trial
Halterman JS; Fagnano M; Tajon RS; Tremblay P; Wang HY; Butz A; Perry TT; McConnochie KM
JAMA Pediatr. 2018;172(3):e174938.
Abstract
Importance：Poor adherence to recommended preventive asthma medications is common, leading to preventable morbidity. We developed the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program to build on school-based supervised therapy programs by incorporating telemedicine at school to overcome barriers to preventive asthma care.
Objective：To evaluate the effect of the SB-TEAM program on asthma morbidity among urban children with persistent asthma.
Design, Setting, and Participants：In this randomized clinical trial, children with persistent asthma aged 3 to 10 years in the Rochester City School District in Rochester, New York, were stratified by preventive medication use at baseline and randomly assigned to the SB-TEAM program or enhanced usual care for 1 school year. Participants were enrolled at the beginning of the school year (2012-2016), and outcomes were assessed through the end of the school year. Data were analyzed between May 2017 and November 2017 using multivariable modified intention-to-treat analyses.
Interventions：Supervised administration of preventive asthma medication at school as well as 3 school-based telemedicine visits to ensure appropriate assessment, preventive medication prescription, and follow-up care. The school site component of the telemedicine visit was completed by telemedicine assistants, who obtained history and examination data. These data were stored in a secure virtual waiting room and then viewed by the primary care clinician, who completed the assessment and communicated with caregivers via videoconference or telephone. Preventive medication prescriptions were sent to pharmacies that deliver to schools for supervised daily administration.
Main Outcomes and Measures：The primary outcome was the mean number of symptom-free days per 2 weeks, assessed by bimonthly blinded interviews.
Results：Of the 400 enrolled children, 247 (61.8%) were male and 230 (57.5%) were African American, and the mean (SD) age was 7.8 (1.7) years. Demographic characteristics and asthma severity in the 2 groups were similar at baseline. Among children in the SB-TEAM group, 196 (98.0%) had 1 or more telemedicine visits, and 165 (82.5%) received supervised therapy through school. We found that children in the SB-TEAM group had more symptom-free days per 2 weeks postintervention compared with children in the enhanced usual care group (11.6 vs 10.97; difference, 0.69; 95% CI, 0.15-1.22; P = .01), with the largest difference observed at the final follow-up (difference, 0.85; 95% CI, 0.10-1.59). In addition, children in the SB-TEAM group were less likely to have an emergency department visit or hospitalization for asthma (7% vs 15%; odds ratio, 0.52; 95% CI, 0.32-0.84).
Conclusions and Relevance：The SB-TEAM intervention significantly improved symptoms and reduced health care utilization among urban children with persistent asthma. This program could serve as a model for sustainable asthma care among school-aged children.
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