Early Childhood and Adolescent Indicators

Hospitalisation rate for asthma

Background

Asthma is a chronic disease of the bronchial (the air passages leading to and from the lungs) that is characterised by recurrent attacks of breathlessness and wheezing.  During an ‘asthma attack’, the lining of the bronchial tubes swell causing the airways to narrow and the flow of air to and from the lungs to decrease (WHO, 2008).  Asthma is associated with poorer physical and mental health, sleep disturbances, reduced physical activity levels, school and work absenteeism and high rates of hospitalisations (Australian Bureau of Statistics, 2006; Poulos et al., 2005). 

The precise causes of asthma are unknown, but are likely to involve genetic factors combined with environmental exposure to inhaled substances and particles that provoke allergic reactions or irritate the airways.  Other risk factors for asthma include age, sex, diet and lifestyle (e.g. smoking) (Australian Bureau of Statistics, 2006). 

Asthma is a common problem health problem among Australian children.  Approximately 10% of Australians report asthma as a long term health condition; asthma is particularly common in children aged 0 to 14 years (Australian Bureau of Statistics, 2006), and in Indigenous populations where the prevalence is 16%. 

In 2004-2005 there were 37,461 hospitalisations for asthma, half of which were for children (Australian Bureau of Statistics, 2006; Watson, Turk and Rabe, 2007).  Therefore, asthma hospitalisations represent a major problem in Australia, and also pose a considerable economic burden.  Identifying effective and practical strategies for decreasing the rate of asthma hospitalisations will be important in minimising the impact of asthma and improving the health and wellbeing of Australian children. 

The evidence base

A number of strategies and interventions that aim to reduce the hospitalisation rate for asthma in children have been developed and trialled.  The majority of these strategies aim to reduce hospitalisations rate for asthma by educating children and adults about asthma symptoms and effective management strategies. 

Most education interventions have been based in the school, whilst others have also been home, physician or community-based.  The majority of studies evaluating these programs have been randomised controlled trials (RCTs) or quasi-experimental designs; hence the evidence supporting these strategies is strong.  Furthermore, these strategies have been trialled in a number of diverse populations, including disadvantaged children, CALD populations and children from families with a low socioeconomic status. 

Selection of interventions

Several school-based programs aimed at reducing asthma hospitalisations by increasing awareness and promoting asthma management have been trialled.  For example, Levy et al. (2006) examined whether a school-based intervention developed to increase child knowledge of asthma led to a reduction in asthma hospitalisations.  In this program, a nurse case manager met weekly with students to provide information about asthma symptoms and treatment techniques.  The nurse also monitored the health status of the children and coordinated care when required.  The program was evaluated through an RCT of 243 children aged 6 to 10 years.  At 12 months follow up, asthma knowledge had increased significantly and there were 14.5% fewer ED presentations and 60% fewer hospitalisations compared to the control group. 

DePue et al. (2007) examined the effect of a school-based education program on health outcomes in 559 primary school children with asthma.  The program consisted of a single 2.5 hour workshop for parents that aimed to improve understanding of asthma medications and effective behavioural strategies.  Separate workshops, which were more interactive, were also conducted for children.  At 12 month follow up, ED visits for asthma had decreased from 35% to 4% and inpatient admissions for asthma had also decreased from 11% to 2%.

A specific example of a school-based asthma education program developed for Australian children is ‘Asthma Friendly Schools’ (Henry et al., 2006; Sawyer et al., 2006).  This is a national initiative targeted towards all primary and secondary school children to improve the health outcomes of children with asthma.  The aim of this program is to involve the whole school community in the management of asthma by improving management strategies and increasing awareness.  For example, the program provides education kits for staff, students and parents, asthma-specific first aid kits and information posters.  The program also provides recommendations for minimising asthma triggers in the school environment.  

Schools are encouraged to register with this program and are classed as ‘Asthma Friendly’ if they successfully increase asthma awareness and develop a safe, healthy and supportive school environment for students with asthma.  In 2008, 84% of Australian schools were registered in the AFS program and 36% were recognised as Asthma Friendly.  Currently there are no data evaluating the impact of these programs on hospitalisation rates.  However, the evidence supporting school-based programs in general suggests that ‘Asthma Friendly Schools’ could be beneficial in reducing asthma hospitalisations in children, especially given the wide reach of this program. 

Several home-based education programs have also been trialled in children.  For example, Bryant-Stephens and Li (2008) examined the effect of a home visit education and environmental intervention on subsequent hospitalisation rates for children with asthma.  In this program, trained individuals visited the homes of children at risk of asthma.  The purpose of these visits was to remove environmental triggers for asthma in the home by controlling pests, supplying hypoallergenic pillows and bedding.  The program also had an education component, whereby children and their parents were educated on how to manage asthma.  The program was trialled on 153 asthmatic children aged 2 to 16 years and led to a 47% reduction in hospital admissions over a two year period. 

Several studies have also examined the impact of physician education programs on asthma hospitalisations in children.  For example, Clark et al. (2008) examined a physician education program targeted towards increasing physician communication skills and asthma knowledge.  The program consisted of two group seminars for physicians (approximately 2.5 hours each).  At two-years follow up there was a significant reduction inpatient admissions and ED presentations. 

The Easy Breathing Program is a specific physician education program that aims to increase physician adherence to national guidelines for asthma treatment and management (US National Asthma Education and Prevention Program for Anti-Inflammatory use) (Cloutier et al., 2002, 2005, 2008).  The program consists of seminars where physicians are provided with information on guidelines for treating and managing asthma as well as more effective ways to communicate with parents and their children.  This program was trialled in a number of medical centres and practices in the US, and the outcomes were measured in 3748 children.  The Easy Breathing Program increased the proportion of physicians adhering to asthma guidelines from 38% to 96%, and led to a 35% reduction in hospitalisations and a 27% reduction in ED visits. 

Community-based programs have also been developed to reduce asthma hospitalisations in under-privileged children who would not otherwise have access to primary health care.  The Harlem Children’s Zone Project in the US, is a specific example of a community-based program.  This program involves a community health team comprised of community workers, nurses and physicians, providing medical, educational, environmental, social and legal services for eligible children.  This program was trialled on 314 children with asthma over an 18 month period and reduced the proportion of ED and unscheduled physician visits from 35% to 8%.

Several other types of programs have also been trialled.  For example, Ng et al. (2006) examined the effect of a hospital-based education program on children who had been hospitalised following an asthma attack.  Compared to baseline, this program led to a 44 – 47% reduction in subsequent hospitalisations.  School clinics that provide primary health care for school-aged children on asthma hospitalisations have also been examined.  These programs involve a mobile health centre regularly visiting schools to provide primary health care to school aged children.  These programs have been effective in reduction hospitalisations by up to 71% (Guo et al., 2005; Liao et al., 2006; Patel et al., 2007), but are expensive compared to the interventions described above. 

Discussion

The literature reviewed above indicates that a number of different types of interventions are effective in reducing asthma hospitalisations in children.  The most effective interventions have been those involving a strong education component, where the aim is to improve the awareness of children and their families about asthma in general and provide effective strategies for managing asthma.

Based on the evidence reviewed above, the following four interventions have been included in this catalogue:

• General School Based Interventions
• Asthma Friendly Schools
• The Easy Breathing Program
• Home-Based Interventions

School-based interventions appear to be the most effective in reducing hospitalisations for asthma.  Asthma Friendly Schools is an Australian Government initiative that aims to promote asthma education and reduce environmental triggers for asthma.  Although the effect of this program on asthma hospitalisations has not yet been examined, similar school based interventions are effective.  Furthermore, this program has the potential to have a large impact on asthma hospitalisations given that 84% of Australian schools are registered with this program.

Home-based interventions and the Easy Breathing Program are also included in this catalogue as there is solid evidence supporting the effectiveness of both strategies. Importantly, all of the interventions included in this catalogue are practical, have a relatively low cost and have been trialled on diverse populations including CALD and children from families with a low socioeconomic status.

References

Anderson ME, Freas MR, Wallace AS, Kempe A, Gelfand EW and Liu AH (2005) Successful School-Based Intervention for Inner-City Children with Persistent Asthma. Journal of Asthma, Vol. 41, No. 4, pp. 445-453.

Australian Bureau of Statistics (2006) Asthma in Australia: A Snapshot, 2004-2005. Canberra: ABS.

Bryant-Stephens T and Li Y (2008) Outcomes of a home-based environmental remediation for urban children with asthma. Journal of the National Medical Association, Vol. 100, No. 3, pp. 306-316.

Clark NM, Gong M, Schork M, Kaciroti N, Evans D et al. (2000) Long-term effects of asthma education for physicians on patient satisfaction and use of health services. European Respiratory Journal, Vol. 16, No. 1, pp. 15-21.

Cloutier MM, Wakefield DB, Hall CB and Bailit HL (2002) Childhood asthma in an urban community: prevalence, care system, and treatment. Chest, Vol. 122, No. 5, pp. 1571-1579.

Cloutier MM, Hall CB, Wakefield DB and Bailit HL (2005) Use of Asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children. Journal of Pediatrics, Vol. 146, pp. 591–597.

Cloutier MM, Jones GA, Hinckson V and Wakefield DB (2008) Effectiveness of an asthma management program in reducing disparities in care in urban children. Annals of Allergy, Asthma and Immunology, Vol. 100, No. 6, pp. 545–550.

DePue JD, McQuaid EL, Koinis-Mitchell D, Camillo C, Alario A and Klein RB (2007) Providence school asthma partnership: School-based asthma program for inner-city families. Journal of Asthma, Vol. 44, No. 6, pp. 449–453.

Guo JJ, Jang R, Keller KN, McCracjen AL, Pan W and Cluxton RJ (2005) Impact of school-based health centers on children with asthma. Journal of Adolescent Health, Vol. 37, No. 4, pp. 266–274.

Henry RL, Lough S and Mellis C (2006) National policy on asthma management for schools. Journal of Paediatrics and Child Health, Vol. 42, No. 9, pp. 491–495.

Levy M, Heffner B, Stewart T and Beeman G (2006) The efficacy of asthma case management in an urban school district in reducing school absences and hospitalization for asthma. Journal of School Health, Vol. 76, No. 6, pp. 320–324.

Liao O, Morphew T, Amaro S and Galant SP (2006) The Breathmobile: a novel comprehensive school-based mobile asthma care clinic for urban underprivileged children. Journal of School Health, Vol. 76, No. 6, pp. 313–319.

Ng DK, Chow P, Lai W, Chan K, Tsang B and So H (2006) Effect of a structured asthma education program on hospitalized asthmatic children: a randomised controlled study. Pediatrics International, Vol. 48, No. 2, pp. 158–162.

Nicholas SW, Hutchinson VE, Ortiz B, Klihr-Beall S, Jean-Louis BSK, et al. (2005) Reducing childhood asthma through community-based service delivery in New York City, 2001-2004. Morbidity and Mortality Weekly Report, Vol. 54, No. 1, pp. 11–14.

Patel B, Sheridan P, Detjen P, Donnersberger D, Gluck E, et al. (2007) Success of a comprehensive school-based asthma intervention on clinical markers and resource utilization for inner-city children with asthma in Chicago: The Mobile C.A.R.E Foundation’s Asthma Management Program. Journal of Asthma, Vol. 42, No. 2, pp. 113–188.

Poulos LM, Toelle BG and Marks GB (2005) The burden of asthma in children: an Australian perspective.  Paediatric Respiratory Reviews, Vol. 6, No. 1, pp. 20–27.

Sawyer SM (2006) Asthma friendly schools: The importance of school policy for children with asthma. Journal of Paediatrics and Child Health, Vol. 42, No. 9, pp. 483–485.

Watson L, Turk F and Rabe KF (2007) Burden of asthma in the hospital setting: an Australian analysis.  International Journal of Clinical Practice, Vol. 61, No. 11, pp. 1884–1888.

World Health Organization (2008) Asthma fact sheet (no. 307). Geneva: WHO.

Key

Supporting evidence:

1. Well-supported practice – evaluated with a prospective randomised controlled trial
2. Supported practice – evaluated with a comparison group and reported in a peer-reviewed publication
3. Promising practice – evaluated with a comparison group
4. Acceptable practice – evaluated with an independent assessment of outcomes, but no comparison group (such as pre- and post-testing, post-testing only or qualitative methods) or historical comparison group (such as normative data)
5. Emerging practice – evaluated without an independent assessment of outcomes (such as formative evaluation, service evaluation conducted by host organisation)

Replication:
Has the intervention been implemented and independently evaluated at more than one site? (yes or no)

Documentation:
Are the content and methods of the intervention well documented (such as provider training courses and user manuals) and standardised to control quality of service delivery? (yes or no)

Theoretical basis:
Is the intervention based on a well-accepted theory or developed from a continuing body of work in its field? (yes or no)

Cost Effectiveness:
Are cost-effectiveness studies available? (yes or no)

Cultural reach:
Has the program been trialed with people in disadvantaged communities, Indigenous people or people from culturally and linguistically diverse backgrounds? (LOW SES/INDIGENOUS/CALD). Universal if no specific target group identified.

	Supporting evidence	Replication	Documentation	Theoretical basis	Cultural reach
(24.1) School-based education	1	Y	N	Y	Low SES CALD
(24.2) Asthma Friendly Schools	5	N	Y	Y	Universal
(24.3) The Easy Breathing Program	3	Y	Y	Y	Low SES CALD
(24.4) Home-based interventions	1	N	N	Y	CALD

Recommended strategy 1 - School Based Education

Name of intervention	School Based Education
Organisation	Various
Brief literature review	There are a variety of school based programs that aim to educate children about asthma symptoms and management to reduce asthma hospitalisations.  These programs typically involve a health practitioner (e.g. a nurse) holding regular information sessions with children (and in some cases parents) to increase knowledge about asthma and promote effective behavioural strategies.  Some programs also include a case-management component where at-risk children are monitored weekly through the program.
How and why does this intervention work?	This program works by increasing general awareness of asthma amongst children.  This includes educating children on effective management strategies for asthma and first aid techniques in the event of asthma attacks.  Children involved in school based education programs have 14.5% fewer ED presentations and 60% fewer ED presentations compared to controls.
On what population does this intervention work best?	This program has been shown to be effective in a wide range of populations, including CALD and children from a low socioeconomic background.
Where will this intervention work best?	School-Based settings
What is required to implement this intervention?	School staff to organise the seminars and the involvement of suitably qualified health professionals
Resources and contact information	There are no specific resources or contact information for these programs, given that they are so varied.
References	DePue et al. (2007) Levy et al. (2006) Ng et al. (2006)

Recommended strategy 2 - Asthma Friendly Schools

Name of intervention	Asthma Friendly Schools
Organisation	Asthma Foundations of Australia
Brief literature review	This is a specific example of a school-based program that has been developed for Australian schools.  The aim of this program is to involve the whole school community in the management of asthma by improving management strategies and increasing awareness.  For example, the program provides education kits for staff, students and parents, asthma specific first aid kits and information posters.  The program also provides recommendations for minimising asthma triggers in the school environment
How and why does this intervention work?	The effect of this program on asthma hospitalisations has not yet been examined.  However, similar school based programs have been shown to be effective.  Furthermore, given that 84% of Australian schools are registered with this program, there is potential for this program to have a considerable impact on asthma hospitalisations in Australia.
On what population does this intervention work best?	This program is targeted towards all primary and secondary school children in Australia.  It is not yet clear whether this program is more effective in specific populations.
Where will this intervention work best?	At present, this is unclear.
What is required to implement this intervention?	A ‘Principal Package’, which includes information and resources, and teaching materials.  This is available by contacting Asthma Friendly Schools via phone or email (see below).
Resources and contact information	Phone (03) 9326 7088 Email schools@asthma.org.au
References	Asthma Friendly Schools (http://asthmafriendlyschools.org.au/home/index.php) Henry et al. (2006); Sawyer (2006)

Recommended strategy 3 - The Easy Breathing© program

Name of intervention	The Easy Breathing© program
Organisation	Connecticut Children's Medical Center
Brief literature review	The Easy Breathing Program is a series of seminars for physicians that aim to increase physician adherence to national guidelines for asthma treatment and management (US National Asthma Education and Prevention Program for Anti-Inflammatory use).  The seminars also aim to facilitate communication between the physician and patient.
How and why does this intervention work?	The Easy Breathing Program is effective in improving physician adherence to national guidelines on the use of medication to manage asthma and other effective strategies.  The program also improves physician communication with the patient.  As a consequence, the Easy Breathing Program has been shown to reduce asthma hospitalisations by 35% and ED presentations by 27%.
On what population does this intervention work best?	This program has been shown to be effective in reducing asthma hospitalisations in a range of populations including CALD children and those from low socio-economic backgrounds.
Where will this intervention work best?	Community and health care settings.
What is required to implement this intervention?	Trained staff to organise and deliver seminars.
Resources and contact information	Michelle M. Cloutier, Professor of Pediatrics in the University of Connecticut Health Center.
References	Cloutier et al. (2005) Cloutier et al. (2008)

Recommended strategy 4 - Home Based Interventions

Name of intervention	Home Based Interventions
Organisation	None
Brief literature review	Bryant-Stephens et al. (2008) trialled a home-based program developed to reduce asthma hospitalisations.  The program involved home-visits by trained individuals that educated children and their families on asthma symptoms and management strategies.  The trained home visitors also aimed to reduce the amount of environmental triggers for asthma in the home by controlling pests, and supplying hypoallergenic pillows and bed sheets.
How and why does this intervention work?	This program has been shown to be effective in reducing asthma hospitalisations by 43 – 47% over a two year period.  The program is effective because it reduces environmental factors that cause or exacerbate asthma symptoms and also educates families on how to manage asthma.
On what population does this intervention work best?	This intervention has been shown to be effective in disadvantaged children in an urban setting.
Where will this intervention work best?	Communities where there is a higher incidence of asthma
What is required to implement this intervention?	Trained home visitors, educational material, equipment and home supplies (e.g. hypoallergenic pillows and bedding).
Resources and contact information	Tyra Bryant-Stephens stephenst@email.chop.edu
References	Bryant-Stephens et al. (2008)