Abstract
New Jersey (NJ) state law requires that asthma treatment plans must be filed in public, parochial, and private schools to permit the use of asthma medication by persons under the age of 18. In response, the Pediatric/Adult Asthma Coalition of New Jersey (PACNJ), a statewide community organization, developed an asthma action plan (AAP) for use by clinicians. A pilot survey was performed in 2004 to assess the Asthma Action Plan. More detailed surveys were sent to public, private, and parochial school nurses in New Jersey in 2004, 2005, and 2010 to evaluate the implementation and effectiveness of the PACNJ Asthma Action Plan for use by clinicians and identify items on the form for improvement. In May 2010, 3663 surveys with return envelopes were sent via US postal mail to the school nurses at public, private, and parochial schools we had identified; 420 surveys were returned. The surveys were entered into a database and analyzed for trends among grade levels and among counties using Microsoft Excel®, EpiInfo™, OpenEpi™, SAS® Software version 9.2, and geographic information software (GIS).[i],[ii],[iii] The results showed that the percentage of school nurses reporting the use of the PACNJ Asthma Treatment Plan (ATP; renamed but equivalent in scope to the Asthma Action Plan) rose from 69.3% in 2005 to 92.3% in 2010, indicating a very high rate of current acceptance by respondents. The results also indicate PACNJ has been successful in improving certain aspects of the implementation of the plan, such as health care provider compliance. Among the schools that reported using the PACNJ Asthma Treatment Plan, the proportion of school nurses noting any problem with physicians refusing to use the PACNJ Asthma Treatment Plan decreased from 62.5% in 2005 to 40.1% in 2010. Overall, the problem of physicians not completing the form dropped from 61.6% in 2005 to 36.1% in 2010. Geographic analysis revealed that PACNJ educational programs and the PACNJ’s Asthma Friendly School Award improved the local use of the PACNJ ATP. There is also evidence indicating further improvements should be made to the PACNJ ATP. However, similar to prior findings from 2005, many respondents complained about the lack of space for the school liability disclaimer. In the current survey, among the important barriers to good control of asthma were: school nurses not being informed of students’ asthma history, and parents do not understand the asthma treatment plan. More than half of the nurses who responded felt that these were significant barriers. The survey response rate was low (11.8%), possibly due to a number of factors, including that the survey was mailed in the last three months of the school year at a time many other issues were confronting the school nurses such as budget cutbacks and nonrenewal of contracts. The asthma rates among schools responding to this study are consistent with other estimates of asthma in New Jersey, suggesting the responding group, although small, in this respect is fairly representative of the public, private, and parochial schools in New Jersey. Further surveys may be of value to further evaluate the awareness and usage of the PACNJ asthma treatment plan, especially among the nonresponders to this study. Analysis of the subset of 159 schools that participated in both 2005 and 2010 surveys showed similar results.
(i)Dean AG, Arner TG, Sunki GG, Friedman R, Lantinga M, Sangam S, Zubieta JC, Sullivan KM, Brendel KA, Gao Z, Fontaine N, Shu M, Fuller G, Smith DC, Nitschke DA, and Fagan RF. Epi Info™, a database and statistics program for public health professionals. Centers for Disease Control and Prevention, Atlanta, Georgia, USA, 2007. Software by Dean AG, Sullivan KM, Soe MM.
(ii)Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version 2.3.1. www.OpenEpi.com, updated 2010/19/09, accessed 2010/11/10.
(iii) The data analysis for this paper was generated using SAS software, Version 9.2 of the SAS System for Windows. Copyright © 2002-2008 SAS Institute Inc. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA
Glossary of Abbreviations
PACNJ – The Pediatric / Adult Asthma Coalition of New Jersey
NJ - New Jersey
UMDNJ - The University of Medicine and Dentistry of New Jersey
NJMS - The New Jersey Medical School
AAP – Asthma Action Plan
ATP – Asthma Treatment Plan
HCP- licensed Health Care Provider: e.g., physician, nurse, nurse practitioner
RAD – Reactive Airway Disease
NJDHSS - New Jersey Department of Health and Senior Services
IRB - Institutional Review Board
Rx - Prescription medicine
AC - Air conditioner
p.o. - Physician's orders
DK - Don't know
References within the article are in superscripted Roman numerals, and also appear in the Bibliography at the end. Footnotes are in superscripted Arabic numerals, and appear at the bottom of each page.
Introduction
According to the National Health Interview Survey, 7.1 million children under the age of 17 in the United States currently have asthma, which corresponds to a percentage of 9.6 %.
[i] Asthma is a potentially fatal condition if exacerbations are not prevented and/or if it is poorly managed. Children with serious or poorly controlled asthma are likely to have many missed school days, and may have emergency department visits and hospitalizations. Asthma is the third-ranking cause of hospitalizations for children under age 15, and accounts for more than 14 million school days lost per year.
[ii] National and international asthma guidelines universally recommend asthma education for all asthma patients, including written instructions, for the management of asthma symptoms and exacerbations. These written instructions are referred to as asthma action plans or asthma treatment plans. Written action plan use significantly reduced acute care visits per child as compared with control subjects in numerous randomized controlled trials. Children using action plans also missed less school, had less nocturnal awakening, and had lessened severity of symptoms.
[iii] New Jersey state law requires that asthma treatment plans must be filed in public, parochial, and private schools to permit the use of asthma medication by persons under the age of 18.
[iv] In response, the Pediatric/Adult Asthma Coalition of New Jersey (PACNJ), a broad-based statewide community coaliiton (see: www.pacnj.org), developed an asthma action plan (AAP) in 2004-2005. This Asthma Action Plan, now referred to as an Asthma Treatment Plan (ATP), is the only written plan specifically approved by the NJ Department of Health and Senior Services as meeting the requirements of New Jersey Law.
[v] These requirements include the minimum of identification of asthma triggers, the treatment plan, and other elements determined by the State Board of Education. There are a multitude of pediatric asthma treatment plans available for use; for example, plans recommended by various international and national guidelines can be found on websites. The majority of asthma treatment plans have three color-coded steps with relatively similar control zone description and complete-the-blank sections for medications.
[vi] The characteristics of pediatric action plans differ from those of adult action plans; a United Kingdom survey revealed the importance of a plan adapted to children through appropriate language, pictorial design, and concepts, providing opportunities for individualization, allowing the child to state his/her personal objectives, and clearly identifying the role of the user. Two separate studies have found that as compared with peak flow-based plans, symptom-based plans significantly reduced the risk of a patient requiring an acute care visit.vi The PACNJ ATP contains both the symptom-based elements and optional peak-flow elements. The PACNJ asthma treatment plan has been in use for several years in NJ. In 2010, the PACNJ changed the name from an asthma action plan to asthma treatment plan to be consistent in terminology with New Jersey regulations. Surveys have been conducted in recent years to evaluate the use of the action plan and its effectiveness, as well as identify barriers to good control of asthma. The results of this survey and previously collected data on asthma have been used to perform statistical evaluation of the PACNJ asthma action plans from 2005-2010. We identify gaps in management of asthma and weaknesses and strengths of the current asthma treatment plan.
(i) Bloom B, Cohen RA. Summary health statistics for U.S. Children: National Health Interview Survey, 2009. National Center for Health Statistics. Vital Health Stat 2010; 10(247).
(ii) Respiratory Health Association of Metropolitan Chicago. National Pediatric Asthma Epidemic. Chicago: Respiratory Health Association of Metropolitan Chicago, 2009.
(iii) Zemek RL, Bhogal SK, Ducharme FM. Systematic review of randomized controlled trials examining written action plans in children: what is the plan? Arch Pediatr Adolesc Med 2008 [Feb]; 162(2):157-163.
(iv) NJ Law, NJSA 18A:40-12.8NJ, Regulations for use of nebulizer in schools.
(v) The New PACNJ Asthma Treatment Plan. The Pediatric/Adult Asthma Coalition of New Jersey. The Pediatric/Adult Asthma Coalition of New Jersey, at www.pacnj.org (accessed 27 July 2010).
(vi) Ducharme FM, Bhogal SK. The role of written action plans in childhood asthma. Curr Opin Allergy Clin Immunol 2008 [Apr]; 8(2):177-188.
Methodology
Dr. Weiss and the team developed the 2010 survey based on the previous 2005 survey. A cover letter explaining the purpose of the survey and an informed consent document were also developed by the researcher and Dr. Weiss. These documents sent to the school nurses and our protocol were approved by the UMDNJ –Newark campus Institutional Review Board (IRB). In early May 2010, PACNJ sent out 3663 packages from an electronic database of New Jersey schools that Dr. Weiss had developed based on federal and PACNJ databases. The packages contained a cover letter, a survey, two informed consent letters, and a postage-prepaid reply envelope. 132 surveys were returned to sender (PACNJ). We researched these 132 schools and were able to confirm correct addresses for 34 of these schools re-mailed these. The remaining 98 schools were determined to be no longer in existence. Thus, there were a total of 3565 surveys which we believe were delivered to the 3565 schools. Of the 34 surveys re-sent, 9 were completed and returned, for a return rate on confirmed addresses of 26.5%. One of the latter nine returned surveys did not include consent (11% missing consent rate). The PACNJ received 438 completed surveys, but 41 of them (9.3%) were returned without a completed consent form. One school sent back a denial of participation. One school reported “we have no asthma” and did not complete the rest of the survey. The 397 surveys with consent were entered into the database. We telephoned the school nurses who had returned the survey without a consent in an attempt to obtain the consent. If contact was not established, a second phone call was made, and e-mails were sent out to any e-mails we had on record. Since it was now June and the school year was ending, we made a final attempt to contact the remaining school nurses who did not provide consent. We also mailed a paper letter requesting the return of a consent from the school nurse for the remaining 30 surveys for which we did not have a signed consent. Our follow-up correspondence of the 41 surveys without consent resulted in the receipt of 23 consents, a return rate of 56%. 18 returned surveys still remain where we could not obtain consent, despite our repeated efforts to contact the school nurses. Out of these 18, we were able to speak with one school nurse. She said she would send in the consent, but we never received it. Thus, the total number of usable surveys returned was 420. Our response rate was 420/3565 = 11.8%.
Data Validation
The surveys were entered into a database using EpiInfo™, public domain software from the Centers for Disease Control (CDC) for epidemiological analysis of survey data. Double data entry was used to verify the data; i.e., two different researchers entered the same data into separate databases. After 10% of the surveys were entered into the two databases, the databases were compared for discrepancies. 1.8% of the entered fields differed in the two databases. On this sample, the discrepancies were identified and the databases were corrected. We then continued to perform double data entry and compared again at about 25%, 50%, and then 100% of surveys double-entered. Although at least 1 discrepancy was found on the majority of forms, this represented only 1.9% of the data. Even with this small discrepancy rate, it was decided that double data entry and comparison should be performed on 100% of the data to maximize accuracy, since the total number of surveys was not very large. The discrepancy rate per surveys declined over time, as experience was gained and an increasingly detailed codebook was developed. A codebook was utilized to develop naming conventions so the data, particularly comments, could be entered an interpreted in a uniform manner. For example, “Respiratory Care Center for Children”, “Goryeb Children’s Hospital,” “Goryeb Children’s Center,” and “Atlantic Health” are all entered into the database as Goryeb. The codebook also addresses how to treat missing values, and situations requiring the survey respondents to be telephoned for follow-up confirmation. Exceptions to the conventions set forth in the codebook are logged in the codebook with detailed resolutions, as mutually discussed with my thesis advisor. We used SAS to determine whether grades matched between the survey responses and the federal database, last updated in 2007. Seven surveys demonstrated a difference in grade levels. A visual inspection was performed on the survey responses identified by this query. Schools were telephoned to verify the current grade levels served, and to obtain the date of when the change in grade levels occurred. As a result of the information obtained from these phone calls, the current database was verified. CDC EpiInfo™ was used to perform a query to identify any survey responses where the number of students permitted to carry inhalers exceeded the total number of asthma action plans (PACNJ+ non-PACNJ). If the number of students permitted to carry inhalers exceeded the total number of action plans, the researchers examined survey question #4 to see whether the responses included “Physician’s orders,” which could also account for students being permitted to carry inhalers. If “Physician’s orders” was not checked, the researchers called school nurses to verify the counts of students permitted to carry and number of asthma action plans on file as well as if Physicians’ orders were accepted at the school. Schools that exclusively served prekindergarten and younger were excluded from the analysis of 2005 data. No surveys were sent to pre-K-only schools in 2010. Pre-K only schools were excluded from analysis because they are not required by New Jersey state law to have a school nurse. Furthermore, accuracy of diagnosing asthma in children under the age of 5 is questionable; they are not mature enough to correctly perform diagnostic tests, such as pulmonary function tests. The sub-sections below deal with each of the 2010 survey questions:
School Grade Levels Participating in Survey
The data entry error rate is described in the table below:
See Illustration 16
Response rate among schools: Using the NCES 2007 data and other data compiled by the researchers through multiple surveys and other methods, we determined that we sent surveys to 3566 unique schools in New Jersey at the end of the 2010 school year. Dr. Weiss and Joshua Parks developed an algorithm to assign one of 4 grade levels (5 including ungraded schools), based on mean grade at the school with Kindergarten assigned as grade 0, first grade as 1, etc. The groupings are:
0 < MeanGrade < =3 (labeled "Primary"),
3 < MeanGrade < 6 ("Middle"),
6< = MeanGrade < 9 ("Intermediate"), and
MeanGrade >=9 ("High").
These names are arbitrary labels for the groupings which we developed based on the observed mean grade level of the schools.
An ungraded school in the NCES database is typically one that caters to special needs students, and a variety of grades are often included plus some students are transient. They also tend to have a higher prevalence of various illnesses than other schools.
The response rates were similar for Primary, Middle, and Intermediate schools, but lower for the High Schools and ungraded schools. High schools have a significantly lower response rate than primary schools (Fishers’ 2-tailed exact test, p=.004).
See Illustration 17
School Nurse Survey Data Analysis: Response by County
The 2005 data contained 714 schools, 20 of which were missing codes for Mean Grade Level 2005. Two schools were missing a unique identifier assigned to each school in our database (School code), and one was partially missing a School code, so these 3 were excluded from this analysis since we could not be certain which school they represented. After manually coding the Mean Grade Level for the remainder, the pre-K-only schools from the 2005 data set (n=3) were also excluded, leaving 708 responding schools from the 2005 survey classified into High, Intermediate, Middle, or Primary, or Ungraded. (Ungraded schools will be included in the analysis of schools by county. See following table). The data were reviewed and analyzed for trends.
This left 1779 graded schools that responded in 2005 and /or in 2010. We classified these into three non overlapping groups:
- Schools that responded to the 2005 survey only, and NOT the 2010 (N=549);
- Schools that responded to both the 2005 and 2010 survey ( N=159); and
- Schools that responded to the 2010 survey only (N=261).
Thus, 810 schools responded to EITHER the 2005 survey OR the 2010 survey, but not both. Of those schools responding in 2005, 22.5% responded again in 2010. Of the 420 schools that responded in 2010, 37.9 % previously responded in 2005.
School Nurse Survey Data Analysis: Response by County
See Illustration 18
With the exceptions of Cape May and Monmouth counties (which had the same number of responses in 2005 and in 2010), in each county schools responded less only in 2010 than in 2005. Out of all schools responding in 2005 and/or 2010, the percent of schools responding in both years was only 16.4%. Salem County contributes the least to repeat responder rate, with only one school (6.3%) of all Salem County school respondents. Four other counties have county-specific repeat responder rates under 10%. The maximum county-specific repeat responder rate is 25% for Cape May and Atlantic Counties. The number of repeat responders decreased substantially in every county from 2005 to 2010, as can be seen by comparing the “2005 Only” column to the “Both Years” column. Of interest is the comparison of those schools responding in both years compared to 2010 responses only. With the exceptions of Warren, Gloucester, and Burlington counties, all counties had more school nurses that responded in 2010-only than repeat responders (i.e., those that responded in both 2005 & 2010), indicating a substantial new segment of responders that had not responded in 2005.
The ungraded schools tend to have students with more medical problems and developmental disabilities. Therefore, the analyses of asthma rates in NJ schools were examined by graded and ungraded schools where so noted. In 2005, some pre-K schools were sent surveys, but they are excluded from all analyses. In 2010, Pre-K only schools were not sent surveys, and thus are not part of the analyses.
School Nurse Survey Paired Data Analysis
The data received from the 2005 and the 2010 surveys were reviewed and respondent school numbers were compared in order to identify schools that responded to both the 2005 and 2010 surveys. 159 schools were identified as having responded to both surveys. This group who responded more than once is useful to illustrate trends in asthma rates that may have occurred over time in a particular population.
See Illustration 19
All of the differences detected in these data appear to be normally distributed. Note that the percent of responding schools using the PACNJ’s Asthma Treatment Plan has increased by nearly 30%. The changes in other measures from 2005 to 2010 are not significant, with the exception of the increase in percentage of students reported to have asthma or Reactive Airway Disease.
Of the 20 regular schools that serve special needs students in 2010, 6 also served special needs in 2005. There are 14 schools that added special needs students to their student bodies since 2005, and 5 schools that eliminated special needs students from their student bodies since 2005.
These statistics are more meaningful examined by grade level. Comparing 2005 to 2010, the mean grade level for these 159 schools did not significantly differ (p=0.12, Student’s t-test). Thus, we can directly compare the schools’ responses from 2005 with responses from 2010 by grade level.
See Illustration20
After comparison of the 2005 data versus 2010 data in the 156 graded schools, the data were reclassified into three groups:
- Schools that responded to the 2005 survey only, and NOT the 2010 (N=549);
- Schools that responded to both the 2005 and 2010 survey ( N=159);
- Schools that responded to the 2010 survey only (N=261).z
810 schools responded to EITHER the 2005 survey OR the 2010 survey, but not both.
In both 2005 and 2010, schools that exclusively served prekindergarten and younger were excluded, as were schools that exclusively served ungraded/special needs schools. The 2005 data contained 714 schools, 26 of which were missing codes for Grade Level. After examining the data, it was determined that Grade Level could be coded for 19 of the schools. After excluding the 3 pre-K-only schools from the 2005 data set and 2 schools that were missing a code, and therefore could not be classified with County information, there were 709 responses schools from the 2005 survey could be classified into High, Intermediate, Middle, or Primary, or Ungraded. Ungraded schools were included in the analyses of schools by county.
1. The percentage of students with asthma or RAD in 2005 (9.0%) was significantly lower than the percentage of students with asthma or RAD in schools responding in 2010 (10.1%) (p=0.02, Student’s t test).
2. There is no statistically significant difference between the percentage of students with asthma or RAD permitted to carry an inhaler in 2005 and the percentage of students with asthma or RAD permitted to carry an inhaler in 2010 (p=0.90, Student’s t test).
3. The difference between the percentage of asthma/RAD students with PACNJ ATP on file in 2005 and the percentage of asthma/RAD students with PACNJ ATP on file in 2010 was statistically significant (p< .0001, Student’s t test).
4. In 2005, the survey requested the “number of students with a current Asthma Action Plan on File.”This does not specifically refer to the PACNJ’s Asthma Action Plan, as it was called in 2005, as the question asks for any type of Asthma Action Plan which includes the PACNJ plan. There is a significantly higher percentage (42.4%) of asthma/RAD students with any ATP on file in 2010 than in 2005 (30.0%) (p< .0001, Student’s t test).
5. The difference between the percentage of asthma/RAD students with PACNJ ATP on file in 2005 and the percentage of asthma/RAD students with PACNJ ATP on file in 2010 was statistically significant (p< .0001, Student’s t test).
6. In 2005, the survey requested the “number of students with a current Asthma Action Plan on File.” It is not clear whether this specifically referred to the PACNJ’s Asthma Action Plan, as it was called in 2005, or whether the question asks for any type of Asthma Action Plan, including the PACNJ plan. If the percent (29) of asthma/RAD students with AAP on file in 2005 refers to any action plan, then the difference between the percentage of asthma/RAD students with PACNJ ATP on file in 2005 and the percentage of asthma/RAD students with any ATP on file in 2010 was statistically significant (p< .0001, Student’s t test).
Do you send an ATP home?
Nurses were asked if they sent home Asthma Treatment Plans for students with "Reactive Airway Disease," or RAD. (N=420)
1. 75.0 % (315) responded yes;
2. 17.6% (74) responded no;
3. 1.2% (5) nurses responded “Not applicable;”
4. 6.2% (26) did not answer the question.
Twenty of the respondents offered unsolicited qualifying comments. 13/20 comments (65%) were for those who responded “yes.” Of those who responded “yes”:
1. 2 schools commented the ATP is on their website.
2. 4 commented they send home if the RAD student has an Rx.
Three commented there is no RAD currently diagnosed in school. However, 4 more schools commented there is no RAD currently diagnosed, but answered No or NA, so it isn’t clear if they would send ATPS home for kids with asthma. Of those who responded “no” (they do not send ATP’s home for RAD diagnosis), only 3 commented: "the MD’s won’t complete them;" "there’s no Prescription;" and "they haven’t sent ATP for RAD home for the last several years." The schools that do NOT send ATP’s home for RAD sometimes still have students with RAD.
Asthma and RAD Diagnoses, action plans, and inhalers
Asthma diagnosis vs. RAD diagnosis
- 1,100 of the 18,865 cases (5.83%) were diagnosed as RAD.
- 476 of the 1,100 RAD cases (43.3%) have action plans on file.
- 9,809 of the 17,765 Asthma cases (55.2%) have action plans on file.
In 2010, 311 of the 420 responding schools recognize reactive airway disease (RAD) as a diagnosis different from asthma. There is a significant trend in decreasing RAD rate with increasing grade level (Wilcoxon test, p< 0.0001):
See Illustration 21
As anecdotally reported by several of the school nurses, the term Reactive Airway Disease (RAD) is often used for younger children because of a social stigma associated with an asthma diagnosis. It is possible that as the students mature, any stigma associated with a diagnosis of asthma lessens, or the diagnosis becomes more acceptable. Although there is no medical distinction between asthma and reactive airway disease, there appears to be a social distinction.
Asthma diagnosis
Among the 420 responding schools in 2010, there are 392 schools identified as regular schools (excluding exclusively special needs/alternative schools). Special needs schools tend to have a higher prevalence of various illnesses than other schools, and thus will be analyzed separately. The overall asthma rate is 8.9 % among regular schools (median =7.6%, interquartile range: .05%-11.2%). Because the data in each grade level are not quite normally distributed, medians, standard deviations, and interquartile (25th and 75th percentile) ranges are provided.
The asthma rates among grouped grade levels are:
See Illustration 22
There is no trend detected in the mean asthma rates among grade levels in regular schools (Wilcoxon test, p= 0.18); that is, there is no statistically significant overall increase or decrease in the asthma rate with grade level. Among the 28 schools identified as special needs or alternative schools, there is no trend in asthma rates among grade levels (Wilcoxon test, p=0.15).
Among the special needs schools, 21 of the 28 special needs schools recognize a diagnosis of RAD. The mean rate o f RAD in these 21 special needs schools is 5.6% (median 0.0%, interquartile range 0.0-2.0%). As found in the regular schools, there is a slight trend of decreasing rates of RAD with increasing grade levels in the 13 special needs schools that are graded (p=.057). Removing the 8 ungraded schools from the analysis allows detection of a trend of differences in RAD rate among the special needs schools that are graded (p=.027). However, this is a very small population, so care must be taken with interpretation of these results.
As reported in 2010 for the 420 schools that responded to the PACNJ survey, the following map depicts the number of schools in each county that were using an Asthma Treatment Plan of any type.
As reported in 2010 by the school nurses, the following map depicts the proportion of the respondent schools where the PACNJ Asthma Treatment Plan was accepted, by NJ County.
The highest rates of PACNJ plan usage are clustered in Somerset, Union, and Middlesex counties. Note that PACNJ is located in Bridgewater, in Somerset County.
We believe it is important to note that the only county in which the PACNJ presented to a county-wide meeting of school nurses information about asthma and asthma treatment plans was Gloucester, a meeting held in Juyly 2009. This may help to explain the very high rate of PACNJ ATP use in that county. In Ocean County, there is also a very high reported rate, which may be due to the PACNJ presenting an Indoor Air Quality training to schools in that county.
Use of PACNJ Asthma Treatment Plan and Outcomes
In examining the 2005 data, respondents were explicitly asked “Do you use the PACNJ Asthma Action Plan?” Of the 714 respondents, 459 (64.3%) said “yes,” 203 said “no” or left it blank. Not surprisingly, the respondents’ pattern of answers in the 2005 survey results differed for these two subgroups.
That same exact question was not asked in 2010, since instead we specifically ascertained the number of PACNJ ATP’s that were on file. Thus, for the purposes of sub grouping the 2010 survey responses, if respondents had at least 1 PACNJ Asthma Treatment Plan on file for either RAD or Asthma, then we interpreted this as “YES, [the school] uses the PACNJ Asthma Treatment Plan.” Of the 420 respondents, 384 (91.4%) were characterized as “yes” – a much higher rate of use among respondents than in 2005. There were 5 (1.2%) schools where responses were neither provided concerning the number with asthma nor for RAD, and 2 (0.5%) schools which reported no students with asthma; these 7 were excluded from the analysis below as there is no way to discern whether or not they use the PACNJ ATP. The remaining 29 (6.9%) were categorized as “no.” Some of these “no’s” are potentially miscategorized, with this especially possible for the small schools or those with low asthma rates: in such schools the expected number can be zero, and thus in the absence of an ATP the school policy is not actually known, although we have characterized it as “no”. Given the small denominator (29), rates in this sub group have a wide confidence interval (i.e., margin of error) and thus comparisons may not be reliable.
Thus, the proportion of respondents using the PACNJ ATP rose from 69.3% to 92.3%, indicating a very high rate of current acceptance among the survey respondents in 2005 and 2010. However, the overall response declined from 714 in 2005 to 420 in 2010; the actual number of survey respondents who reported using the PACNJ ATP declined from 459 to 384. This decline in response rate is likely due to a confluence of factors occurring at schools late last year. However, respondent bias (in terms of which school nurses chose to return our survey) could account for part of this improvement if those schools more actively involved with the PACNJ selectively chose to respond. If PACNJ ATP use remained consistent over the span of five years, it is possible that the nonrespondents in 2010 were not PACNJ ATP users. The responses among repeat respondents helps in this analysis. Among the sub-group of 159 repeat respondents (those responding in both 2005 & 2010), the proportion of respondents using the PACNJ ATP rose from 67.3% to 93.7%, which is a proportion consistent with the overall results. Examining the group of respondents who responded in 2005 only, 351/549 (70.2%) reported using the PACNJ ATP. Among the respondents who responded in 2010 only, 225/261 (91.4%) reported using the PACNJ ATP. Even though the number absolute numbers declined among the one-time survey respondents, the proportion of respondents using the PACNJ ATP increased.
Acceptance of Other non-PACNJ asthma action plans
In 2010, nine nurses did not respond to this question, leaving 411 for analysis. Note that the responses are not mutually exclusive; some nurses will accept many types of forms. Although 26% or the respondents checked “similar action plan developed by other organization,” only 49 specified the name of organizations. The action plans developed by other organizations accepted are:
See Illustration 23
Since physician’s medical orders are legally permitted, the rise in acceptance of these is appropriate, but these orders may only specify permission to use certain medicines, as opposed to comprising an entire plan. We did not try to ascertain how frequently these were provided in lieu of an ATP, and this might be worth exploring in a future survey. In the question above, the problem “Schools/doctors prefer own form” was mentioned infrequently, so it is unclear whether this is a significant problem. It is interesting that 12% of the respondent schools currently do not permit any AAP other than the one promulgated by the PACNJ.
Twenty-four of the nurses responded that they accept other action plans developed by other organizations. The plans most frequently named were the plans developed by Children’s Hospital of Philadelphia (CHOP) and Goryeb Children's Hospital / Respiratory Center for children (RCC) /Atlantic Health Systems. It is not surprising that the nurses using these forms are located in the New Jersey counties near Philadelphia and NJ counties where Atlantic Health Systems facilities are located.
*First 3 letters of each New Jersey County
See Illustration 24
Acceptance of the PACNJ Asthma Treatment Plan as a Physician
If the PACNJ Asthma Treatment Plan is signed by a physician or other HCP, is it accepted as physician's orders (p.o.) - why not?
See Illustration 25
The PACNJ ATP was revised in response to the feedback from the surveys and particularly the analyses of the 2004 and 2005 surveys. The 2010 data, as compared to that from 2005, suggest that the remedies employed were largely successful in reducing these types of problems. Perhaps the most noticeable reason why schools do not accept the PACNJ Asthma Treatment Plan as a physician order is because the school uses its own forms. This was especially true of schools in 2005. The schools that were not using the PACNJ form in 2005 cite this reason almost 3 times more frequently than the next most cited reason (not required to be signed by parent, thus violating district policy). In 2005, the responses for not accepting the PACNJ as a physicians order did not depend on whether the schools were using the PACNJ plan, with the exception of the reason “no parental signature requirement.” The schools that were using the PACNJ plan cited this reason for not accepting PACNJ as a physician order more frequently than schools that were not using PACNJ’s form (p< .0002, Fisher’s exact test). The PACNJ plan has since been modified to include a parental signature, thus eliminating this as a reason to not accept as a physician’s order.
There is a marked decrease in the percentage of schools that are using their own forms in 2010, both in prior respondents a well as the new respondents, suggesting that these schools have grown to accept the PACNJ plan more often, or have chosen to use PACNJ’s form over the school’s own form. Whether the school uses the PACNJ form or not makes no difference in any reasons the PACNJ is not accepted as a physician order in the group of 2010 only respondents or the 2005 & 2010 respondents. The modification of the PACNJ plan to include the parental signature may or may not have contributed to the decrease in noncompliance with district policy, since all problems cited decreased over time. The problem of no space for liability disclaimer has stayed fairly constant over time, and has been cited more frequently by schools not using the PACNJ plan. In the subset of schools that have only participated in 2010, there is no significant difference in selection of any of the reasons for not accepting the PACNJ plan as physician’s order between those schools using the PACNJ form and those not using the PACNJ form.
Acceptance of the NJPAC plan as a physician’s order – grade level effect
See Illustration 26
*This question was not asked again in 2010, since the PACNJ Asthma Treatment Plan had since been modified to include a parental signature, so that the question no longer applied.
Overall, most of the respondents (91.4%) in the 2010 School Nurses survey are currently using the PACNJ ATP. Similarly, among the set of respondents who responded in both 2005 & 2010, their use of PACNJ ATP increased from 67.3% to 94.3% (Fisher exact t test, p < .0001). These data demonstrate a very high rate of acceptance.
Overall, the rates of response for each reason nurses noted a problem with respect to their being able to accept the PACNJ as a physician’s order are not significantly different between the 2010 only respondents, and the group that responded in both 2005 & 2010. There was no difference among the three groups’ response pattern for “no space for a liability disclaimer” or for “not in compliance with district policy.” For the other 4 reasons why the PACNJ ATP is not accepted as a physician’s order (the school uses its own form, unaware that the ATP can be used as a Physician order, the PACNJ ATP does not contain enough information, and other reasons), the 2005 only group responses are significantly different than the 2010 only group (Fishers’ exact test, p< .001 for all tests). The 2005 only group also responded differently than the “both 2005 & 2010” group on these 4 reasons. This overall response pattern suggests the following among the respondents:
- Although cited at a low rate, “no space for liability disclaimer” remained constant for all groups over the years.
- Although cited at a low rate, “compliance with district policy” has remained constant for all groups over the years.
- “Schools using their own form” appears to no longer be a major issue influencing the acceptance of the PACNJ ATP as a physician’s order.
- There is greater awareness that PACNJ can be used as a Physician order.
- The information on the PACNJ ATP now appears to include issues the schools needed to have addressed, reflecting that the changes made since 2005 appear to have largely addressed prior concerns.
None of the four grade levels indicated that the PACNJ plan does not contain enough information was a significant reason not to accept it as physicians’ orders. Only the primary and middle schools selected this as a reason, and the percentage (2.6%, 2.9% of respondents) is pretty low so that this does not appear to be an important issue. There is a minor but statistically significant trend of increasing percentages with decreasing mean grade level in the group that responded in 2005 only. The lower grade levels consistently had the highest percentages citing this reason in all three groups. This reason has been selected much less in 2010, suggesting that the additional information added to the form since 2005 has been sufficient to address this concern. The percentage of schools selecting this reason has decreased from 2005 to 2010 for each grade level.
The use of the school’s own form seems to vary by grade level in the 2005 only group. In this group, the intermediate school nurses do not cite this reason as often as school nurses for other grade levels. In the 2010 only and the Both 2005 & 2010 groups, the proportion citing this reason dropped significantly for each grade level; the middle graded schools cited this reason much less frequently than other grade levels. However, those who responded to the survey in 2010 only, there is little difference between the proportions of grade levels, suggesting no grade level effect on this reason.
Overall, the proportions of respondents who cited noncompliance with district policy are small. The middle school nurses had the largest proportion citing this reason among the 2005-only responders, but the proportion of middle school responders decreased in the 2005 & 2010 responders, and noncompliance is not cited at all in those middle school responders who responded in 2010 only. However, among the High School responders, the proportion has increased from 2005 to 2010, although the proportions are all fewer than 7 % of grade level respondents. The noncompliance with district policy has become even less of an issue for those responding to the survey in both years.
The intermediate school nurses cited “No space for liability disclaimer” more than other grade levels in 2005, but this proportion decreased significantly in 2010 for all 2010 middle school responders. Interestingly, the proportion of middle schools was lowest in the 2005 & 2010 and second lowest among 2010 only responders. The proportion of primary schools citing this reason remained fairly constant.
In the 2005 only responders, the primary schools were most aware that the ATP can be used as a physician order; other grade levels were less aware. The 2010 results suggest that there is a high awareness across all grade levels that the ATP can be used as physician’s order. Other reasons for not accepting as physician order were fairly consistent cross grade levels in 2005 only group. In all 2010 respondents, only middle and primary grade levels provided other reasons, and it was less than 5% of middle and primary grade level responders.
Overall, there does not appear to be any consistent significant trending by grade level in the frequency of reasons for not accepting the PACNJ ATP as physician’s orders. There is a slight trend to cite that the form does not contain enough information with decreasing grade level, as seen in the schools that responded in 2005 only and the schools that responded in 2010 only; however this does not appear to be significant.
Problems encountered with the use of the PACNJ Asthma Treatment Plan
The most common problems encountered deal with compliance. Respondents were presented with a list of nine potential problems, based on responses from prior surveys (2005 and 2007) and were directed to check all problems that apply.
93% of the respondents (384) have at least one PACNJ Asthma Treatment Plan on file for students with Reactive Airway Disease or Asthma. 87.7% of this group (335) accepts the PACNJ Asthma Treatment Plan as a physician’s order. Problems encountered with the use of the form are as follows:
See Illustration 27
There are two improvements of particular interest. Among the schools using the PACNJ, the problem of physician refusal to use the PACNJ ATP form decreased from 62.5% to 40.1%, a rate reduction of over 22%. Likewise, among those nurses who use PACNJ ATP, the problem of ATP not being completed (except peak flow) dropped from 71 % in 2005 to 38% in 2010. Both of these changes are statistically significant (Fishers’ exact test, p< 10-7).
While several other barriers also declined, the issue of fees remained almost the same. Note that the 3 most frequently cited reasons rank the same among both sub-groups in 2010.
84 respondents (21.8%) indicated other problems, using the “other” category or some other response found elsewhere in the survey:
See Illustration 28
To what degree do the following act as barriers to good asthma control for your students?
415 of the 420 respondents answered this series of questions. Question seven asked what factors the nurses believed acted as barriers to good asthma control on a scale of one to three, where 1 is “not at all,” 2 is “a little,” and 3 is “a lot.” BLK means there was no response; DK is “don’t know”; in some instances, respondents inserted “NA” for “not applicable.” See Figure 3.
The responses are fairly equally distributed, with about 65% indicating that not having an action plan on file acts as a barrier to good asthma control in school. See Figure 4.
A minority of nurses responded that “students not bringing their inhalers” was a major barrier. However, as we anticipated that responses were likely to vary among grade levels, the responses were further examined. See Figure 5. These stratified data indeed demonstrate remarkably different patterns by grade. For example, 45 % of the respondents from the ungraded schools stated “not applicable” (NA). This is consistent with students at such special needs schools not being allowed to carry inhalers. A high percentage of nurses at high schools and intermediate schools feel that this is a barrier. Since the intent of the law was that older children be permitted to carry inhalers, the nurses’ concern about the adverse consequences when they fail to bring their inhalers to school is well taken. Many of the nurses from the middle & primary schools did not view this as an issue with many answering “not at all.” This is consistent with the policy of many schools to keep medications for young children in the nurse’s office, so that these children don’t need to bring inhalers with them each day and the use can be supervised by a medical professional. See Figure 6.
Although 43% felt health care providers not authorizing capable students to carry was “not at all” a barrier, roughly the same proportion (41%) felt it did pose a barrier to asthma control. See Figure 7.
85% of school nurses are concerned that if they do not know that the child has asthma, this is a barrier to good asthma control for the students. See Figure 8.
Clearly, incorrect forms pose a barrier to good asthma control. The original PACNJ ATP required healthcare providers to write in the name of each medicine, its dose, and frequency. There are many other areas which required handwritten completion. Analysis of responses from the 2005 survey revealed that the school nurses saw this as a major problem. The PACNJ revised the form so that much more information was pre-printed and could be circled or checked, greatly diminishing problems related to illegible handwriting. This new form was posted on the PACNJ website in March 2008, over 2 years before the current survey. (Additional minor changes to the PACNJ ATP were implemented in March 2009.) Furthermore, the PACNJ form is available on the PACNJ website at www.pacnj.org and can be completed online and then printed, minimizing the opportunity for free text and illegible text. (It has also been translated into multiple languages,) See Figure 9.
Regarding whether or not parents understand the Asthma Treatment Plan, a high percent of nurses responded “Don’t Know” (DK), 37%. This suggests that there are limits to current communication between school nurses and the parent, and ways to improve this should be addressed. See Figure 10. About a quarter of the nurses do not know to what extent this is a barrier, but these data show that not understanding the plan could impede asthma control.
Figure 11 describes the school nurses' perceptions concerning "Students and/or parents don't use peak flow meters to monitor asthma" being a barrier. Nurses feel that peak flow meters are an important tool, and should be used.
Figure 12 displays the nurse reponses concerning compliance with medication use at home. Again, about a quarter of the nurses do not know to what extent this is serving as an actual barrier. Given the high number of parents (64%) perceived as not complying with giving medications at home, this could well serve to impede asthma control.
To our surprise, it appears that indoor air quality (IAQ) issues were not seen by school nurses as barriers to good asthma control. See Figure 13. The PACNJ has worked with schools to make them aware of IAQ issues. It is possible that these data reflect that schools have successfully been working to remediate IAQ problems, which would be excellent news. On the other hand, if this perception were to reflect a lack of recognition of a problem, further education might be needed. A future survey could try to resolve these two possibilities.
Half of the nurses (50%) viewed the presence of other triggers as a barrier to good asthma control. See Figure 14. It makes sense in this case to combine the “blank” responses with the “not at all” responses. Other asthma triggers specified by respondents are in Figure 15.
As an exploratory analysis, we examined whether the response patterns on certain key questions tended to correlate with the responses to other related questions. We found that the degree to which nurses identified “school nurse not informed of asthma history” as a barrier was positively and significantly correlated with the degree to which the following barriers were identified:[1]
- Students permitted to carry inhalers in school do not bring them (r = .29, p < .0001);
- No PACNJ Asthma Treatment Plan or similar document on file (r = .23, p < .0001);
- Health care providers do not authorize capable students to carry inhalers (r = .20, p = .002);
- Health care providers don’t complete or complete incorrectly/illegibly the forms(s) (r = .27, p < .0001);
- Parents do not comply with the medications at home (r = .03, p = .006);
- Students and/or parents don’t use peak flow meters to monitor asthma (r = .19, p < .003).
The r-value is the Pearson correlation coefficient, which reflects the degree to which the responses to the two questions are correlated. The p-value is the Kruskal-Wallis Chi-squared test of the null hypothesis that different responses to “school nurse not informed of asthma history” are not associated with the degree to which the other conditions respectively were seen as barriers. The “Don’t Know” (DK) and “Not applicable” (NA) responses were included in the denominator of this analysis.
Likewise, we found that the degree to which nurses identified “No PACNJ Asthma Treatment Plan or similar document on file” as a barrier was positively and significantly correlated with the degree to which the following barriers were identified:
- Students permitted to carry inhalers in school do not bring them (r = .26, p < .0001);
- School nurse not informed of asthma history (r = .23, p < .0001);
- Health care providers don’t complete or complete incorrectly/illegibly the forms(s) (r = .24, p < .0001);
- Parents do not keep a copy of the Asthma Treatment Plan for use at home (r = .20, p = .005);
- Parents do not understand the Asthma Treatment Plan (r = .15, p = .019);
- Parents do not comply with the medications at home (r = .21, p = .002);
- Exposure to strong or noxious odors in the classroom or school (r = .14, p = .02).
Therefore, the nurses who responded that having No PACNJ Asthma Treatment Plan or similar document on file was a barrier to good asthma control in school to a large degree (i.e., responded “a lot”) were also likely to respond that the aforementioned issues were barriers to good asthma control in school to a large degree.
[1]Pearson correlation coefficient and Kruskal-Wallis Chi-squared calculated using PROC FREQ with exact statistics in SAS 9.2.
8 & 9: Factors Contributing To Better Control of Asthma and Rectifying Issues of Poor Control of Asthma in Schools
We reviewed the comments and classified the responses into a number of factors. We included relevant information that may have been supplied about this issue both from questions 8 & 9 as well as from elsewhere on the survey, as respondents did not necessarily write the information where we expected.
See Illustration 29
Note that the most frequently mentioned factors involve the education of stakeholders, such as parents, students, teachers, and health care providers (factors #1 and #2), and open and effective communication among these stakeholders communication (factor #4). Here and elsewhere in the survey, school nurses emphasize the need for good communication and education in asthma management.
Discussion
The asthma rates among schools responding to this study are consistent with other estimates of asthma in New Jersey, suggesting the responding group, although small, is fairly representative of the public, private, and parochial schools in New Jersey other studies. The survey response for 2010 is low. This could be due to a confluence of factors. The surveys were mailed in May, near the end of the school year, just a few weeks before schools closed. School nurses tend to be especially busy then and may not have time to complete and return the survey. New Jersey budget and school issues were top concerns at the time the survey was distributed; thus, the priority of the survey among school nurses’ concerns was likely low. It was noted that survey responses tended to be higher in counties where PACNJ had recently implemented education sessions and/or contained schools that had earned recognition from the PACNJ in the form of Asthma Friendly school awards. Awareness of PACNJ activity in the county was shown to have a positive effect on survey return rates from those counties. The diagnosis of reactive airway disease declines with an increase in grade level. This suggests that either: 1) the condition labeled as reactive airway disease resolves over time, or 2) healthcare providers change the diagnosis to asthma as the child becomes older. It is possible that there is less of a social stigma of asthma as the child matures; there is anecdotal evidence provided by school nurses that supports that social stigma is often attributed to an asthma diagnosis. In addition to the PACNJ asthma treatment plan, the most widely accepted non-PACNJ asthma action plans among the respondents in 2010 are physician’s orders/physician’s own forms (77% of nurses reported accepting these) and similar district-generated forms. It is not known how frequently these are provided, instead of PACNJ ATPs, as the questionnaire only ascertained whether or not a type of alternative was accepted (at all) by that school. It is worth exploring this concept in a future survey. The differences between PACNJ ATPs and other plans were not investigated; this is also an area for future investigation. As in 2005, the use of the school’s own form remains the top reason for not accepting the PACNJ ATP as a physician’ order. The lack of inclusion and absence of space to add a “liability disclaimer” remains a consistently cited reason for non-acceptance of the PACNJ ATP as in previous surveys. Overall, there does not appear to be any consistent significant pattern in increasing or decreasing of frequency by grade level in the reasons for not accepting the PACNJ ATP as physician’s orders. The major issues encountered with use of the PACNJ form in 2010 are the issue of parents not handing the ATP to HCP (56.2% of 2010 respondents), ATP’s not received back (65.1%), and HCPs not completing the form (40.7%). To understand the obstacles involved in parent or healthcare provider compliance, surveys of these stakeholders might be useful. Among the factors contributing to better asthma management, education remains the most frequently cited factor. The importance of education of healthcare professionals, parents, and patients is consistent with findings that guided self-management education significantly improves outcome6.
Commentary and Recommendations
The information obtained from each of the School Nurse Surveys has been of great value to the PACNJ. With increasing awareness of the PACNJ and the PACNJ Asthma Treatment Plan, the response rate can be increased. The survey should be sent earlier in the school year. Timing the receipt of the survey with the least busy periods for the school nurse would also help response rate. In order to reduce the expense of future surveys, making them available either by e-mail or otherwise through the PACNJ website, has been discussed. Indeed, the 2010 survey collected e-mail addresses of school nurse respondents as part of the informed consent process. Unfortunately, since an e-mail is mainly available from the respondents, there remains a conflict between cost reduction and increasing the response rate. The database was verified by Dr. Weiss and his staff in preparation for this survey. This involved considerable effort, since inconsistencies among various data sources had to be resolved and many schools contacted. Resources need to be allocated so that it can be verified and updated on a continuing basis, since schools open, close, and merge continually. For the above two reasons, the NJDHSS (which funds many PACNJ activities) and the PACNJ should try to identify funding for these types of efforts, perhaps by teaming with other parties (such as UMDNJ and Rutgers University) to find additional grant monies. It is recommended that the PACNJ Quality Care Task Force survey the health care providers to elicit reasons why they are not completing the PACNJ Asthma Treatment Plan. Similarly, the PACNJ might team with organizations such as Mothers Against Asthma to determine roadblocks with respect to the family. Lack of insurance and the cost of medications are some of the already known impediments. After we presented our preliminary findings to the PACNJ and the Quality Care Task Force, they discussed these results and decided that they want to look deeper into the liability disclaimer issue, assess the other asthma treatment plans being used and identify any advantages they may have, reassess and revise the PACNJ ATP as necessary, and assess issues related to electronic medical records that may preclude current use of the PACNJ form.
Based upon our preliminary data, the Quality Care Task Force as well as NJDHSS representatives suggested that the PACNJ Asthma Treatment Plan should be officially designated as the only Treatment plan used in New Jersey and that stakeholders should advocate for a change in the law to mandate this over a period of time compatible with its integration into medical offices and institutions, including their electronic systems.
References
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Acknowledgements
We thank Dr. Vassil Mihaylov for his prior work on this project and analyses, which were performed in part in connection with his MPH thesis prepared as part of the curriculum requirements for hisr MPH degree from the School of Public Health of the University of Medicine and Dentistry of New JerseyWe thank Teresa Lampmann and Maris Chavenson of the PACNJ, and Daniel Rosenblum, PhD of UMDNJ-NJMS, for their assistance with this project. We also thank the many school nurses in New Jersey who kindly returned these surveys, and the many volunteer members of the PACNJ who have developed the form for the asthma treatment plan and helped with its implementation.Inquiries should be directed to Professor Stanley H. Weiss, MD at weiss@umdnj.edu.
Source(s) of Funding
This report is based in part on an MPH thesis prepared as part of the curriculum requirements for Ms. Justine A. Krell for her MPH degree from the School of Public Health of the University of Medicine and Dentistry of New Jersey. The PACNJ did not provide any funding for these analyses.
Competing Interests
Dr. Weiss is the co-chair of the PACNJ Evaluation Workgroup and a member of the PACNJ Coordinating Committee (the equivalent of its executive committee) as well as a member of other PACNJ committees/workgroups. He has not received any financial compensation from the PACNJ for this work. Ms. Justine A. Krell has no competing interests.
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