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

在美国，少数族裔和种族背景的儿童患哮喘的比例更高。尽管 制定了完善的指南，哮喘治疗不足是很常见的，特别是对穷人和少数族裔来说 人口。我们先前的工作已经证明，以学校为基础的直接观察疗法(DOT)可以预防 哮喘药物可以改善患有持续性哮喘的贫穷城市儿童的预后。我们还有 发现校本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，令我们担忧的是，我们有 我们发现，儿童并没有从我们的计划中平等受益。具体地说，在患有疾病的儿童亚群中 中至重度持续性哮喘或难以控制在基线水平，大多数没有达到控制 尽管有这些以学校为基础的干预。事实上，尽管对PCP进行了远程医疗后续评估 这些儿童中的许多人仍然没有得到治疗，这促使他们在治疗中采取基于指导方针的步骤。我们 认识到我们现有的计划可能不足以满足这些儿童的需求，因为他们不包括专家 优化用药管理或识别和治疗合并症的会诊 条件和触发器。重要的是，贫困儿童和少数族裔儿童对专科护理的利用严重不足。 谁因哮喘承担了最大的发病率负担，导致以指南为基础的交付不一致 治疗和持续的差异。为了响应PAR-15-279，我们提出了一种创新的校本 为患有中度到重度持续性哮喘或难以控制的哮喘的城市儿童制定的计划。远程医疗 增强的哮喘管理-联合提供者(团队)计划增强了我们的校本、 初级保健指导的哮喘计划和专家支持的护理，以确保最佳指南为基础 治疗。我们建议进行一项随机试验，将团队合作与加强护理对照组进行比较。我们会 促使所有注册儿童(n=360，4-12岁)的初级保健医生启动以学校为基础的预防哮喘DOT 药物治疗，并将建议转介给哮喘专家。对于团队中的儿童，专家会访问 将通过学校的远程医疗提供便利。首次远程医疗专家会诊将安排在4点之后。 几周的DOT，以便一次对药物和护理需求进行基于指南的准确评估 坚持每日服用控制性药物已确立。还将有2个远程医疗后续行动 专家会诊，评估儿童对治疗的反应，并做出必要的调整。我们将利用这一点 在现有的社区基础设施上，通过在学校实施远程医疗和DOT，以及 保持与PCP的合作。我们将评估团队合作的临床和成本效益 减少发病率和改善基于指南的护理(主要结果：3、6、9和9天无症状 12个月)与加强护理相比。在研究完成后，该计划将被更好地定义为 为难以控制哮喘的高危儿童改善护理和降低发病率的可持续手段。

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.