Ensuring Access to Albuterol in Schools: From Policy to Implementation. An Official ATS/AANMA/ALA/NASN Policy Statement.

Rationale: For children with asthma, access to quick-relief medications is critical to minimizing morbidity and mortality. An innovative and practical approach to ensure access at school is to maintain a supply of stock albuterol that can be used by any student who experiences respiratory distress. To make this possible, state laws allowing for stock albuterol are needed to improve medication access.Objectives: To provide policy recommendations and outline steps for passing and implementing stock albuterol laws.Methods: We assembled a diverse stakeholder group and reviewed guidelines, literature, statutes, regulations, and implementation documents related to school-based medication access. Stakeholders were divided into two groups-legislation and implementation-on the basis of expertise. Each group met virtually to review documents and draft recommendations. Recommendations were compiled and revised in iterative remote meetings with all stakeholders.Main Results: We offer several recommendations for crafting state legislation and facilitating program implementation. 1) Create a coalition of stakeholders to champion legislation and implement stock albuterol programs. The coalition should include school administrators, school nurses and health personnel, parents, or caregivers of children with asthma, pediatric primary care and subspecialty providers (e.g., pulmonologists/allergists), pharmacists, health department staff, and local/regional/national advocacy organizations. 2) Legislative components critical for effective implementation of stock albuterol programs include specifying that medication can be administered in good faith to any child in respiratory distress, establishing training requirements for school staff, providing immunity from civil liability for staff and prescribers, ensuring pharmacy laws allow prescriptions to be dispensed to schools, and suggesting inhalers with valved holding chambers/spacers for administration. 3) Select an experienced and committed legislator to sponsor legislation and guide revisions as needed during passage and implementation. This person should be from the majority party and serve on the legislature's health or education committee. 4) Develop plans to disseminate legislation and regulations/policies to affected groups, including school administrators, school nurses, pharmacists, emergency responders, and primary/subspecialty clinicians. Periodically evaluate implementation effectiveness and need for adjustments.Conclusions: Stock albuterol in schools is a safe, practical, and potentially life-saving option for children with asthma, whether asthma is diagnosed or undiagnosed, who lack access to their personal quick-relief medication. Legislation is imperative for aiding in the adoption and implementation of school stock albuterol policies, and key policy inclusions can lay the groundwork for success. Future work should focus on passing legislation in all states, implementing policy in schools, and evaluating the impact of such programs on academic and health outcomes.

Improving the Affordability of Prescription Medications for People with Chronic Respiratory Disease. An Official American Thoracic Society Policy Statement.

BACKGROUND: Mounting evidence indicates that out-of-pocket costs for prescription medications, particularly among low- and middle-income patients with chronic diseases, are imposing financial burden, reducing medication adherence, and worsening health outcomes. This problem is exacerbated by a paucity of generic alternatives for prevalent lung diseases, such as asthma and chronic obstructive pulmonary disease, as well as high-cost medicines for rare diseases, such as cystic fibrosis. Affordability and access challenges are especially salient in the United States, as citizens of many other countries pay lower prices for and have greater access to prescription medications. METHODS: The American Thoracic Society convened a multidisciplinary committee comprising experts in health policy pharmacoeconomics, behavioral sciences, and clinical care, along with individuals providing industry and patient perspectives. The report and its recommendation were iteratively developed over a year of in-person, telephonic, and electronic deliberation. RESULTS: The committee unanimously recommended the establishment of a publicly funded, politically independent, impartial entity to systematically draft evidence-based pharmaceutical policy recommendations. The goal of this entity would be to generate evidence and action steps to ensure people have equitable and affordable access to prescription medications, to maximize the value of public and private pharmaceutical expenditures on health, to support novel drug development within a market-based economy, and to preserve clinician and patient choice regarding personalized treatment. An immediate priority is to examine the evidence and make recommendations regarding the need to have essential medicines with established clinical benefit from each drug class in all Tier 1 formularies and propose recommendations to reduce barriers to timely generic drug availability. CONCLUSIONS: By making explicit, evidence-based recommendations, the entity can support the establishment of coherent national policies that expand access to affordable medications, improve the health of patients with chronic disease, and optimize the use of public and private resources.

The Impact of Parent's Health Literacy on Pediatric Asthma Outcomes.

Background: Health literacy has been associated with health disparities in many disease outcomes, including children's asthma. Parents are responsible for most of children's healthcare. Therefore, parents' health literacy may impact children's health outcomes, including asthma control. This study sought to determine the association between parent health literacy and children's asthma control among a cohort of predominately minority urban children aged between 6 and 12 years. Methods: This cross-sectional study assessed children with asthma and their parents at a single outpatient visit. English-speaking parents and their children, aged between 6 and 12 years with physician-diagnosed asthma, were eligible for this study. Healthcare providers assessed asthma control and severity, and parents completed demographic, health literacy, asthma control, and asthma knowledge measures. Children completed a pulmonary function test as part of the Asthma Control Questionnaire (ACQ) scoring. Results: A total of 281 parent-child dyads provided data, with the majority of parents being mothers and African American, with a high school level education or less. Lower parent health literacy was associated with worse asthma control as rated both by the provider (p=0.007) and the ACQ (p=0.013), despite only moderate concordance between ratings (ρ=0.408, p<0.0001). Lower parent health literacy also was associated with less asthma knowledge, which was associated with worse asthma control. Conclusions: Higher parent health literacy was associated with more parent asthma knowledge and better child asthma control. Pediatric providers should consider tailoring education or treatment plans or utilizing universal precautions for low health literacy.

The relationships among family management behaviors and asthma morbidity in maternal caregivers of children with asthma.

Numerous studies have identified the relationship of the family caregiver's perception regarding asthma management and the child's asthma outcomes, although few have examined family caregiver asthma management behaviors. The primary aim of this study was to examine the relationship among family management behaviors and asthma morbidity as perceived by maternal caregivers. The Family Management Style Framework was used to guide the research. Maternal caregivers (N = 101) with school-aged children diagnosed with persistent asthma and living in the United States were recruited from a specialty asthma clinic. When caregivers perceived they were expending much effort on their child's asthma management and were not confident in their ability to perform management activities, the child's asthma outcomes were worse. This is the first study to examine family management behaviors with maternal caregivers of school-aged children with asthma. Findings from this study encourage health care providers to tailor each educational opportunity with families to improve child asthma outcomes. An ongoing effort must be made to include families in asthma management. Health care partnerships between provider and family can lead to improved asthma management.

Measurement characteristics of the pediatric asthma health outcome measure.

INTRODUCTION: The Pediatric Asthma Health Outcome Measure (PAHOM) was designed to measure quality-adjusted life years (QALYs) in children with asthma. Our objective was to compare parent- and child-reported PAHOM scores to each other, to parent-reported scores on the Juniper Asthma Control Questionnaire (ACQ), and to physician-rated asthma control. METHODS: A convenience sample of primarily African-American parent-child dyads (N = 261) was recruited from asthma clinics between May 2008 and May 2010. Correlations and differences in scores between the instruments and respondents were compared across variables of interest. The sensitivity and specificity of each, relative to physician-rated asthma control, were estimated. RESULTS: Mean (SD) parent- and child-reported PAHOM scores were significantly different, 0.91 (0.13) and 0.95 (0.08), respectively, (p < .01) and were weakly correlated (0.24). Parent-reported PAHOM and parent-reported ACQ, 5-item version (ACQ5) scores were moderately correlated (-0.69). Both the parent- and child-reported PAHOM scores distinguished between physician-rated well-controlled and not well-controlled asthma (p < .01 and p < .01, respectively). When compared with physician-rated asthma control, the areas under the receiver operating characteristic (ROC) curves for the parent-reported PAHOM and the ACQ5 were similar (p = .11), but both performed better than the child-reported PAHOM (both p < .01). Discussion. The validity of the PAHOM is supported by its moderate correlation with the ACQ and its association with physician-rated asthma control. Although intended to be administered to children, parent-reported scores were better predictors of physician-rated asthma control. CONCLUSIONS: A validation study in a more economically and ethnically diverse population is needed. Until then, we recommend the PAHOM to be administered to both parents and children.

Cost-effectiveness of school-based asthma screening in an urban setting.

BACKGROUND: Much has been done to promote population-based childhood asthma screening; however, concerns remain regarding its cost-effectiveness. OBJECTIVES: To conduct a cost-effectiveness analysis of school-based asthma screening strategies. METHODS: A 5 health state Markov approach (symptom-free, symptom, exacerbation recovery, emergency department, and hospitalization day) was used to evaluate school-based screening in a simulated population of urban elementary-age school children. Two questionnaire and 2 multistage strategies incorporating spirometry or spirometry with exercise testing were evaluated from the societal perspective by using 365 daily cycles. The outcome was 2006 dollars per quality-adjusted life year (QALY). RESULTS: The most efficient strategy identified children with previously diagnosed but poorly controlled asthma at a cost of $150,000 per QALY (95% CI, $65,800-$318,000). Uncertainty surrounding the cost-effectiveness estimate was primarily a result of the symptom day preference weight estimate (44%), the probability of confirmation after screening (17%), the adequacy of asthma control in the population (9%), and the estimated treatment effect on symptoms (6%). Screening generated an additional 21 symptom-free day equivalents per child identified with previously diagnosed but not well controlled asthma and led to $85.55, $12.36, and $2.58 in additional screening, daily treatment, and indirect costs and $5.01 less in emergency department and hospitalization costs. CONCLUSION: Population-based asthma screening is not cost-effective at $50,000 per QALY and has only a 20% chance of being cost-effective at $100,000 per QALY. The most efficient approach is to screen for previously diagnosed but poorly controlled asthma. Linking screening with better treatment, and long-term adherence strategies might yield future cost-effective approaches.

Targeted tuberculosis contact investigation saves money without sacrificing health.

BACKGROUND: Health departments require an efficient strategy to investigate individuals exposed to Mycobacterium tuberculosis. The contact priority model (CPM) uses a decision rule to minimize testing of low-risk contacts; however, its impact on costs and disease control is unknown. METHODS: A cost-effectiveness analysis compared the CPM with the traditional concentric circle approach (CCA) in a simulated population of 1000 healthy, community-dwelling adults with a 10% background rate of latent tuberculosis (TB) infection. The analysis was conducted from the perspective of the Alabama Department of Public Health. Model inputs were derived from the literature and the Alabama Department of Public Health. Lifetime costs (2004 dollars) and outcomes were discounted 3 percent annually. Incremental cost-effectiveness ratios were used to compare the strategies. RESULTS: Over the lifetime of 1000 simulated contacts, the CPM saved $45,000 but led to 0.5 additional TB cases and 0.24 fewer years of life. The CCA is more effective than the CPM, but it costs $92,934 to prevent one additional TB case and $185,920 to gain one additional life year. CONCLUSIONS: The CPM reduces costs with minimal loss of disease control and is a viable alternative to the CCA under most conditions.

The potential for reducing asthma disparities through improved family and social function and modified health behaviors.

The National Workshop To Reduce Asthma Disparities assembled a multidisciplinary group comprised of scientists, clinicians, and community representatives to examine factors related to asthma disparities. Attention was given to the importance of discerning family, social, and behavioral factors that facilitate or impede the use of health-care services suitable to the medical status of an individual. This review highlights select biopsychosocial factors that contribute to these disparities, the manner in which they may contribute or protect persons affected by asthma, and recommended directions for future research.

A decision tree for tuberculosis contact investigation.

The University of Alabama at Birmingham and the Alabama Department of Public Health recently developed a logistic regression model showing those variables that are most likely to predict a positive tuberculin skin test in contacts of tuberculosis cases. However, translating such a model into field application requires a stepwise approach. This article describes a decision tree developed to assist public health workers in determining which contacts are most likely to have a positive tuberculin skin test. The Classification and Regression Tree analysis was performed on 292 consecutive cases and their 2,941 contacts seen by the Alabama Department of Public Health from January 1, 1998, to October 15, 1998. Several decision trees were developed and were then tested using prospectively collected data from 366 new tuberculosis cases and their 3,162 contacts from October 15, 1998, to April 30, 2000. Testing showed the trees to have sensitivities of 87-94%, specificities of 22-28%, and false-negative rates between 7 and 10%. The use of the decision trees would decrease the number of contacts investigated by 17-25% while maintaining a false-negative rate that was close to that of the presumed background rate of latent tuberculosis infection in the state of Alabama.