Joe K. Gerald

Changes in environmental tobacco smoke exposure and asthma morbidity among urban school children.

BACKGROUND Environmental tobacco smoke (ETS) exposure is associated with poor asthma outcomes in children. However, little is known about natural changes in ETS exposure over time in children with asthma and how these changes may affect health-care utilization. This article documents the relationship between changes in ETS exposure and childhood asthma morbidity among children enrolled in a clinical trial of supervised asthma therapy. METHODS Data for this analysis come from a large randomized clinical trial of supervised asthma therapy in which 290 children with persistent asthma were randomized to receive either usual care or supervised asthma therapy. No smoking cessation counseling or ETS exposure education was provided to caregivers; however, children were given 20 min of asthma education, which incorporated discussion of the avoidance of asthma triggers, including ETS. Asthma morbidity and ETS exposure data were collected from caregivers via telephone interviews at baseline and at the 1-year follow-up. RESULTS At baseline, 28% of caregivers reported ETS exposure in the home and 19% reported exposure outside of the primary household only. Among children whose ETS exposure decreased from baseline, fewer hospitalizations (p = 0.034) and emergency department (ED) visits (p < or = 0.001) were reported in the 12 months prior to the second interview compared to the 12 months prior to the first interview. Additionally, these children were 48% less likely (p = 0.042) to experience an episode of poor asthma control (EPAC). CONCLUSIONS This is the first study to demonstrate an association between ETS exposure reduction and fewer EPACs, respiratory-related ED visits, and hospitalizations. These findings emphasize the importance of ETS exposure reduction as a mechanism to improve asthma control and morbidity. Potential policy implications include supporting ETS reductions and smoking cessation interventions for parents and caregivers of children with asthma. Research to identify the most cost-effective strategy is warranted.

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

Asthma morbidity among children evaluated by asthma case detection.

150,000 per QALY (95% CI,

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65,800-

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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

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85.55,

Measurement Characteristics of the Pediatric Asthma Health Outcome Measure

12.36, and

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2.58 in additional screening, daily treatment, and indirect costs and

Redesigning a large school-based clinical trial in response to changes in community practice

5.01 less in emergency department and hospitalization costs. CONCLUSION Population-based asthma screening is not cost-effective at

Asthma Medications Should Be Available for Over-the-Counter Use: Pro

50,000 per QALY and has only a 20% chance of being cost-effective at