Vol. 12 •Issue 4 • Page 15
Allergy & Asthma
Pilot Projects Test Asthma Screening in Schools
E-J-K-I-N. If a child can’t identify these letters during an elementary school’s vision screening, it could signal an eyesight problem.
Robert M. Miles, MD, thought of vision screening when trying to develop a plan to better diagnose and treat asthma.
“We were trying to form a program that screens children in school like they screen for vision, hearing and scoliosis, so we may be able to pick up young children having asthma symptoms,” said Dr. Miles, past president of the American College of Allergy, Asthma and Immunology, and the allergy and asthma specialist at Allergy and Asthma Associates, Lynchburg, Va.
Dr. Miles chaired an ACAAI pilot project through four facilities that sought to implement and evaluate screening methods. With the second phase of the study now coming to a close, the project sites are trying to fine-tune a master screening tool for use in schools across the country.
PHASE ONE
The project’s sites were diversified in ethnicity, race and socioeconomic status. As part of the project’s first phases, each site put together a short questionnaire that went to children and their parents.
Three sites were in inner-city regions with predominant black and Hispanic populations. La Rabida Children’s Hospital and Research Center in Chicago, led by Raoul L. Wolf, MD, screened about 2,900 children in grades 1 through 6 through an asthma and allergy questionnaire.
Rainbow Babies and Children’s Hospital in Cleveland, led by Susan Redline, MD, MPH, studied more than 3,000 children in kindergarten through grade 6 using parent and student questionnaires designed to identify undiagnosed asthmatics.
The Dallas Asthma Consortium, under the direction of Rebecca S. Gruchalla, MD, PhD, screened 307 inner-city first- through third-grade children for asthma and allergic rhinitis.
Two of the sites — Chicago and Cleveland — developed new questionnaires and then compared the results to physicians’ examinations to determine which questions best predicted asthma.
The Dallas Asthma Consortium used the International Study of Asthma and Allergies in Childhood (ISAAC) asthma questionnaire as a screening tool. All children who had overall scores consistent with a diagnosis of asthma were invited to undergo step testing, as were a subset of children who had negative overall scores.
“The validity of the questionnaire and the step test results were compared with the results of the ‘gold standard’ (methacholine challenge) for establishing bronchial hyperresponsiveness,” Dr. Gruchalla said.
Based upon the cutoff value that had been previously determined in a pilot study, 28 of 300 children (9 percent) had global asthma scores that were considered to be positive. Twenty-four of these 28 children underwent step testing, as did 34 randomly selected children who had negative global asthma scores.
Thirty-one (91 percent) of the 34 children who had negative global asthma scores had negative step tests, she said. Similarly, 20 of 24 children (83 percent) who had positive global asthma scores were step test negative.
Only four children who had positive global asthma scores were step test positive or had reversible airway obstruction at baseline. Using a positive methacholine challenge as the gold standard for establishing bronchial hyperresponsiveness, the global .asthma score derived from the eight-item ISAAC asthma questionnaire yielded a sensitivity of 64 percent, a specificity of 11 percent, a positive predictive value of 47 percent and a negative predictive value of 20 percent, Dr. Gruchalla said.
A fourth site studied a different aspect of school-based asthma screening. Olmsted County Asthma Action Coalition in Rochester, Minn., directed by Barbara P. Yawn, MD, MSc, screened 12,000 mostly middle-class white children in kindergarten through grade 12 for undiagnosed asthma, undertreated asthma and allergy.
Like the other sites, the coalition identified children it thought had a high likelihood of having unrecognized asthma and sent them letters suggesting their parents take them to a doctor for further evaluation, said Dr. Yawn, director of research at Olmsted Medical Center.
“We wanted to know if we could use the screening to get children to their usual source of care because most school districts around the country will not be able to provide in-school care to all the children who fail asthma screening,” Dr. Yawn said.
Using the questionnaire results, the coalition also sent parents a recommendation to seek medical care for a possible medication change for children with known asthma who were having continuing symptoms or frequent visits to the emergency room.
The researchers followed up by looking at the children’s medical records to see how many of them actually were taken for evaluation. “About 20 percent of the parents of the 12,000 children screened reported they had ever been told their child had asthma or reactive airways disease,” Dr. Yawn said. “And, 12 percent of the 12,000 children had been seen within the past two years for an asthma problem.”
PHASE TWO
The four project sites then began phase two, where they selected questions from each group’s individual questionnaires to form a universal survey. The questions were chosen by identifying those that were the best predictors of asthma and those that were associated with the parents’ choice to follow up with a doctor’s visit, Dr. Yawn said.
Currently, the Dallas Asthma Consortium and the other three sites are tallying the results from the universal group questionnaire and dividing the children into three categories: possible asthma, possible allergies and a control group. Dr. Gruchalla is going to schools and conducting histories, physical exams, skin tests and pulmonary function testing for these children.
In a few months, the four directors will have a meeting to discuss the questionnaires and the test results anonymously to decide if the children have asthma or allergies. Each of the four sites will bring their own results to discuss.
“Our ultimate goal is to have a questionnaire that is sensitive and specific enough so that we can go out to the schools and say if (students) are positive on such and such, then it’s likely they have asthma,” said Dr. Gruchalla, associate professor of internal medicine and pediatrics, and section chief in the division of allergy and immunology at UT Southwestern Medical Center in Dallas.
However, making an effective survey is just one challenge. Parents present another. “Of the kids we referred in phase one, the parents .didn’t respond terribly well to those follow-up letters,” Dr. Yawn said. “One problem is the parents don’t believe the screening results. They think they are a better judge of whether their kids have a problem or not.”
If the parents brought their children in for a doctor’s visit, the project worked. At the Olmsted County Asthma Action Coalition, .of the 20 percent of children who received a physician evaluation, 60 percent were diagnosed with asthma, Dr. Yawn said.
To aggravate the problem, many parents don’t understand asthma and the fact that it might not have visible symptoms. Also, asthma diagnosis isn’t always a cut-and-dry process, and that can be difficult for parents to realize. Pulmonary function, for instance, may be normal in between asthma episodes.
That’s why it’s important to educate parents and work with the entire community. “If parents have concerns, I am willing to talk to PTAs and tell them why we are doing this,” Dr. Gruchalla said. “It’s also important to tell parents that this is confidential — and it has nothing to do with giving the information to insurance companies.”
Additionally, Dr. Yawn said it would be beneficial if the researchers could identify the children who are missing school or not doing well because they are tired as children who also could have asthma. Parents might then be able to make the connection between asthma and its detrimental effects.
“For the most part, what we are seeing is the parents are happy and extremely appreciative,” Dr. Gruchalla said.
Cooperation from schools is another component to asthma screening’s success. “The school systems are so busy now with all of their standard learning tests,” Dr. Miles said. “They just don’t have the time for everything.”
Because of this time crunch, it’s imperative the best screening tool be offered, one that doesn’t disrupt the classroom, teaching or the child’s learning time, he stressed.
But no matter how good the screening survey, it won’t solve the big question of how screenings would be paid for. Dr. Miles suggested nurses and physicians in the community could oversee the screening, but he acknowledged that most of that would need to be volunteer work. He recommended approaching the government for grants once the project is finished.
“I hope that this is going to be a model for other chronic diseases and other types of research where there is a vital link between the community, the schools and the hospital,” Dr. Gruchalla said.
Diehl is a freelance writer in the Philadelphia area.
