of Health National Institute of Allergy and Infectious Dis-
eases for asthma management, including asthma counselors
and environmental interventions, on symptom control in
distinct geographical community health centers (CHCs).
STUDY POPULATION. This study included patients aged 5 to 12
years (n 5 590) with moderate to severe asthma in high-
risk, low-income communities in Arizona, Michigan,
and Puerto Rico.
METHODS. CHCs (n 5 3) fulfilling the criteria of a Federally
Qualified Health Center were recruited along with 3
geographically matched control sites in Arizona, Michi-
gan, and Puerto Rico. Study participants at each site
received a baseline visit that included a clinical risk as-
sessment, inhalant allergen testing, and spirometry.
Asthma counselors conducted a minimum of 4 site visits,
1 of which occurred in the home. Symptoms and health
care use were assessed at 6 and 12 months.
RESULTS. The majority of participants were boys (61% in
the intervention group) and Hispanic (83%). The mean
age was 7.8 years in both groups. Compliance was high
throughout the intervention group, with all sites aver-
aging .4 asthma counselor visits and achieving rates of
96% and 89% for performing allergy testing and in-
home assessment of allergen exposures, respectively.
Across all sites, the intervention group showed a
significant difference (P , .01) in symptom days,
prednisone usage (∼50% reduction), and fewer urgent
care visits compared with controls. Hospitalization rates
between the groups differed significantly in Puerto Rico,
but no difference was observed in Arizona or Michigan.
CONCLUSIONS. The intervention sites successfully trans-
lated evidenced-based interventions and tailored them
for practical application into diverse CHCs. Despite
demographic variation among the sites, each site
implemented a minimally agreed on intervention, with
clinically significant improvements in asthma morbidity
compared with control sites.
REVIEWER COMMENTS. It truly takes a village to care for at-risk
children with asthma in the community setting. Translating
clinical outcomes from randomized controlled trials and
guideline-based recommendations has been a challenge
for real-world application. This study revealed that an
evidenced-based approach and in-home environmental
assessments are beneficial for at-risk children with
asthma. Use of community health workers, along with
flexibility to implement a variety of environmental
control measures, reveals that there is not a 1-size-
fits-all approach to successful implementation because
communities differ in their level of provider training
credentials and accessibility to educational tools. In
our current era of quality improvement and focus on
implementation of guidelines into practice, this study
reveals the importance of providing communities with
S260 BEST ARTICLES RELEVANT TO PEDIATRIC ALLERGY AND IMMUNOLOGY
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a blueprint for successful application of evidence-based mea-
sures to spearhead asthma control, irrespective of location.
URL: www.pediatrics.org/cgi/doi/10.1542/peds.2018–2420CCCC
Lisa M. Martorano, DO
David R. Stukus, MD
Columbus, OH
Effect of the School-Based Telemedicine
Enhanced Asthma Management (SB-TEAM)
Program on Asthma Morbidity
Halterman J, Fagnano M, Tajon R, et al. JAMA Ped.
2018;172(3):1–7
PURPOSE OF THE STUDY. To determine whether school-based,
directly observed asthma therapy combined with
telemedicine visits can overcome barriers to guideline-
based preventive care (poor adherence, lack of follow-up
care) to improve outcomes for urban children with asthma.
STUDY POPULATION. The study included 400 children (247
male, 230 African American, 127 Hispanic, 305 with public
health insurance, 193 co-residing with a smoker, 132 with
caregiver symptoms of depression) aged 3 to 10 years
(mean 7.8 years) with physician-diagnosed asthma with
persistent symptoms or poor control from 49 schools in
Rochester, New York. Children and/or families who did
not speak English, did not have telephone access, or who
had other significant medical conditions were excluded.
METHODS. Participants were stratified by preventive med-
ication use and randomly assigned to the School-Based
Telemedicine Enhanced Asthma Management (SB-
TEAM) program (supervised school administration of
preventive asthma medications with telemedicine
visits) or enhanced usual care for 1 school year with
outcomes measured at the end of the school year. The
primary outcome was the mean number of symptom-
free days per 2 weeks based on blinded interviews.
RESULTS. Children in the SB-TEAM group had more
symptom-free days per 2 weeks compared with the
enhanced usual care group (11.6 vs 10.97). They had
fewer symptom days, symptom nights, and days with
limited activity and less asthma-related unplanned
health care use. They had a greater decline in FeNO
level, but there was no significant difference between
groups in quality of life improvement for caregivers.
CONCLUSIONS. A combination of school-based, directly-
observed therapy and telemedicine significantly improved
symptoms and reduced health care use among urban
children with persistent or poorly controlled asthma.
REVIEWER COMMENTS. In this study, the authors highlight that
improved adherence to guideline-based therapy results in
improved outcomes for children with asthma and
presents 1 model for doing so. The SB-TEAM concept
eliminates many barriers to care and, particularly with
changing reimbursement for telemedicine, presents a
sustainable model for care. It is unclear from this study,
however, how disruptive the SB-TEAM model may be to
participants’ and their peers’ learning as well as whether
a typical urban school would have the appropriate
resources, particularly nursing staffing, to implement and
maintain this model of care. Additionally, to better
understand if improved care results from the SB-TEAM
model itself versus just participating in the study, it would
have been helpful to see a comparison between symptoms
on school days and nonschool days such as weekends or
school vacations.
URL: www.pediatrics.org/cgi/doi/10.1542/peds.2018–2420DDDD
Neelam A. Phadke, MD
Michael Pistiner, MD
Boston, MA
Electronic Monitoring of Adherence to Inhaled
Corticosteroids: An Essential Tool in Identifying
Severe Asthma in Children
Jochmann A, Artusio A, Jamalzedeh A, et al. Eur Respir J.
2017;50(6):1700910
PURPOSE OF THE STUDY. To study if electronic monitoring
could be used to separate patients with severe asthma
with poor control. In addition, the purpose was to observe
if electronic monitoring would lead to the optimization
of standard asthma therapy.
STUDY POPULATION. This was a prospective observational
cohort of children aged 5 to 17 years. The study included
108 children with asthma recruited from the outpatient
department of Royal Brompton Hospital in London,
United Kingdom.
METHODS. All children had an asthma diagnosis by standard
protocols. Children were classified into 3 groups: severe
therapy-resistant asthma, difficult asthma, and mild-
to-moderate asthma. Baseline and end–of–monitoring
period assessments included an asthma control test,
lung function, fractional exhaled nitric oxide, asthma-
related quality of life, and medication adherence using
a smart inhaler.
RESULTS. Data for 93 children who completed the study
were analyzed. The median days of monitoring was 92.
Good adherence was found in 42% of patients who took
$80% of medications. Suboptimal adherence was noted
in 58% of patients (27% took 60%–79% of medications,
and 31% took ,60% of medications). No significant
differences were seen between the adherence groups for
the asthma control test, fractional exhaled nitric oxide,
forced expiratory volume in 1 second, the exacerbation
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rate, or oral corticosteroid use. Four groups were iden-
tified after the data analysis: (1) good adherence with
improved control (24%; likely previous poor adher-
ence), (2) good adherence with poor control (18%; se-
vere therapy-resistant asthma), (3) poor adherence with
good control (26%; likely overtreated), and (4) poor
adherence with poor control (32%).
CONCLUSIONS. This study revealed the importance of ac-
curate adherence monitoring in children with asthma.
Suboptimal adherence was noted in 58% of patients
despite knowing that adherence was being monitored.
The authors of this study identified patients with true
severe asthma despite good adherence to therapy, sug-
gesting that patients would merit further phenotyping of
their asthma. In the study, researchers also confirmed the
inadequacy of self-reported adherence and the limitation
of prescription records.
REVIEWER COMMENTS. Not surprisingly, 58% of the study
patients had suboptimal adherence. This represents real-
world data and the difficulty with asthma adherence
despite education, monitoring, and routine follow-up.
This study also reveals that electronic monitoring could
be helpful in identifying poor adherence as a cause of
asthma poor control. Therefore, for some, improved
education may be more beneficial than prescribing
more medications.
URL: www.pediatrics.org/cgi/doi/10.1542/peds.2018–2420EEEE
Sai R. Nimmagadda, MD
Chicago, IL
Asthma Exacerbations and Triggers in Children
in TENOR: Impact on Quality of Life
Chipps BE, Haselkorn T, Rosén K, Minks DR, Trzaskoma
BL, Luskin AT. J Allergy Clin Immunol Pract. 2018;6(1):
169–176.e2
PURPOSE OF THE STUDY. To assess the impact of asthma trig-
gers and exacerbations on asthma-specific quality of life
in children.
STUDY POPULATION. A 3-year observational study, The Epi-
demiology and Natural History of Asthma Outcomes and
Treatment Regimens, included a cohort of 438 children
aged 6 to 12 years with severe or difficult-to-treat asthma
recruited from 283 sites in the United States.
METHODS. Patients were seen at 6-month intervals, and data
on health care use, asthma exacerbations, and number of
recent asthma triggers were obtained. Patients and parents
completed the Pediatric Asthma Quality of Life Ques-
tionnaire (PAQLQ) and the Asthma Therapy Assessment
Questionnaire. Multivariable linear regression was used to
model the PAQLQ score as a function of common asthma
triggers.
PEDIATRICS Volume 142, Supplement 4, December 2018 S261
 Effect of the School-Based Telemedicine Enhanced Asthma Management
(SB-TEAM) Program on Asthma Morbidity
Neelam A. Phadke and Michael Pistiner
Pediatrics 2018;142;S260
DOI: 10.1542/peds.2018-2420DDDD

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 Effect of the School-Based Telemedicine Enhanced Asthma Management
(SB-TEAM) Program on Asthma Morbidity
Neelam A. Phadke and Michael Pistiner
Pediatrics 2018;142;S260
DOI: 10.1542/peds.2018-2420DDDD

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/142/Supplement_4/S260

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