Telemedicine Enhanced Asthma Management - Uniting Providers (TEAM-UP)

在美国，来自少数民族和种族背景的儿童患哮喘的比例不成比例。尽管 根据既定的指导方针，哮喘治疗不足的情况很常见，尤其是对于穷人和少数族裔来说 人口。我们以前的工作已经证明，以学校为基础的直接观察治疗（DOT）的预防 哮喘药物可以改善患有持续性哮喘的贫困城市儿童的预后。我们还 发现基于学校的远程医疗可以有效地促进初级保健提供者（PCP）的评估 用于DOT的预防性药物处方和后续护理。然而，我们担心， 发现孩子们并没有从我们的项目中平等地受益。具体而言，在患有 基线时中度至重度持续性或难以控制哮喘，大多数未达到控制 尽管有这些学校的干预措施。事实上，尽管对PCP进行了远程医疗随访评估， 虽然促使根据指南逐步加强治疗，但这些儿童中有许多仍然没有得到充分治疗。我们 我意识到，我们现有的方案可能不足以满足这些儿童的需要，因为它们不包括专家， 优化药物管理或识别和治疗共病的咨询 条件和触发器。重要的是，贫困儿童和少数民族儿童对专家护理的利用率大大不足 他们承担着哮喘最大的发病负担，导致基于指南的 治疗和持续的差异。为回应PAR-15-279，我们建议一个创新的校本 针对城市中重度持续性或难以控制哮喘儿童的项目。远程医疗 加强哮喘管理团结供应商（团队）计划提高了我们的学校为基础， 初级保健指导的哮喘计划，专家支持的护理，以确保最佳的指南为基础 治疗我们提出了一个随机试验的团队与加强护理比较组。我们将 促使所有入组儿童（n=360，4-12岁）的PCP启动以学校为基础的预防性哮喘DOT 药物治疗，并建议转诊给哮喘专家。对于TEAM-UP中的儿童， 将通过学校的远程医疗得到促进。第一次远程医疗专家访问将安排在4 周的DOT，以便对药物和护理需求进行准确的基于指南的评估， 建立每日控制药物的依从性。还将进行2次远程医疗随访 专家访问，以评估儿童对治疗的反应，并作出必要的调整。我们将利用 通过在学校实施远程医疗和DOT，利用现有的社区基础设施， 保持与PCP的合作。我们将评估TEAM-UP的临床和成本效益， 降低发病率和改善基于指南的护理（主要结局：第3、6、9和 12个月）对比加强护理。在研究完成后，该方案将被更好地定义为 以可持续的方式改善护理，降低难以控制哮喘的高危儿童的发病率。

In the US, children from minority ethnic and racial backgrounds suffer disproportionately from asthma. Despite well established guidelines, under-treatment for asthma is common, especially for poor and minority populations. Our prior work has demonstrated that school-based directly observed therapy (DOT) of preventive asthma medications can improve outcomes for poor, urban children with persistent asthma. We have also found that school-based telemedicine can effectively facilitate assessments by primary care providers (PCPs) for preventive medication prescriptions for DOT and for follow-up care. However, to our concern we have found that children do not benefit equally from our programs. Specifically, among the subgroup of children with moderate to severe persistent or difficult to control asthma at baseline, the majority did not achieve control despite these school-based interventions. In fact, despite telemedicine follow-up assessments with PCP prompting for guideline-based step-ups in treatments, many of these children remained under-treated. We realize that our existing programs may be insufficient for these children, since they do not include specialist consultation for optimization of medication management or for identification and treatment of co-morbid conditions and triggers. Importantly, specialist care is substantially underutilized by poor and minority children who bear the greatest morbidity burden from asthma, leading to inconsistent delivery of guideline-based treatments and continued disparities. In response to PAR-15-279, we propose an innovative school-based program for urban children with moderate to severe persistent or difficult to control asthma. The Telemedicine Enhanced Asthma Management-Uniting Providers (TEAM-UP) program enhances our school-based, primary care directed asthma program with specialist-supported care to ensure optimal guideline-based treatment. We propose a randomized trial of TEAM-UP versus an enhanced care comparison group. We will prompt PCPs of all enrolled children (n=360, 4-12 years) to initiate school-based DOT of preventive asthma medication and will recommend referral to an asthma specialist. For children in TEAM-UP, the specialist visits will be facilitated via telemedicine at school. The initial telemedicine specialist visit will be scheduled after 4 weeks of DOT, in order to allow for accurate guideline-based assessments of medication and care needs once adherence with a daily controller medication is established. There will also be 2 telemedicine follow-up specialist visits to assess the child's response to treatment and make needed adjustments. We will capitalize on the existing community infrastructure by implementing both telemedicine and DOT in schools, and maintaining collaboration with the PCP. We will assess the clinical and cost-effectiveness of TEAM-UP in reducing morbidity and improving guideline-based care (primary outcome: symptom-free days at 3, 6, 9, and 12 months) versus enhanced care. At the study's completion, the program will be better defined as a sustainable means to improve care and reduce morbidity for high risk children with difficult to control asthma.