School asthma documentation associated with student return to class after stock inhaler use

Abstract

Objective:

To evaluate the association between asthma documentation at school (asthma diagnosis and asthma action plan [AAP]) and outcomes after stock inhaler use at school.

Methods:

This observational study examined respiratory events and outcomes in a statewide program that provided albuterol metered dose inhalers to Illinois public schools. Nurses registered online and reported each inhaler use (event). This report collected individual characteristics, asthma documentation, and event outcomes. Analyses included Pearson’s Chi-squared tests, Fisher’s exact tests, Wilcoxon rank-sum tests, and logistic regression models.

Results:

In 2023–2024 school year, 656 events occurred requiring stock inhaler use among students across Illinois schools. Students had an asthma diagnosis on file at school in 63% of events (n=413); among these students, 42% had an AAP on file (42%, n=175). For disposition after stock inhaler use, 76% of students returned to class (n=497). Students with an asthma diagnosis documented at school had 2.6 times higher odds of returning to class after stock inhaler use versus those without documentation (95% CI 1.81–3.75). Similarly, students with asthma who also had AAPs on file at school had 2.41 times higher odds of returning to class after respiratory events versus those without AAPs (95% CI 1.39–4.33). These associations remained significant in adjusted models.

Conclusions:

In a statewide stock inhaler program in Illinois, we found students with asthma diagnoses and AAPs documented at school had higher rates of return to class after stock inhaler use for respiratory symptoms compared to students without such documentation.

Background

Asthma affects over 4.3 million US school-aged children.¹ Along with experiencing health effects, children with asthma are three times more likely to be absent from school than those unaffected, potentially contributing to poor academic performance.² Support in daily environments like schools is crucial to minimize these negative outcomes for affected children.

To enable support, schools should be aware of students’ asthma and have established protocols, which necessitate that parents/guardians provide documentation of asthma diagnoses and asthma action plans (AAPs). However, research shows asthma is under-documented in schools, with one study finding prevalence is 2–4 times higher than documented.³ Further, literature suggests AAPs can promote asthma education but is inconclusive about whether AAPs can contribute to better outcomes;⁴ more research is needed to clarify effects of having AAPs in schools.

Additionally, medication access in schools is critical to respond to respiratory symptoms. However, studies show only 14% of children with asthma have quick-acting inhalers at school.⁵ To optimize medication access, approximately half of states have adopted legislation allowing schools to stock undesignated quick-relief inhalers to use in case of respiratory distress.^6,7 This study investigated the association between asthma documentation at school and stock inhaler outcomes.

Methods

This observational study examined respiratory events and outcomes within a statewide program (RESCUE) that provided quick-acting inhalers to Illinois public schools in 2023–2024. This research was approved by the University of Chicago Biological Sciences Division Institutional Review Board. Informed consent was waived due to the use of anonymous event-level data.

Albuterol metered dose inhalers and supplies were distributed to participating schools throughout Illinois starting in summer/fall 2023. School nurses and staff registered online and reported each use of RESCUE-provided stock inhalers (event). This report collected individual characteristics (gender, race/ethnicity, age), asthma documentation at school (diagnosis, AAP), and event outcomes (disposition following event).

This study included all reports about events that occurred between July 2023 and June 2024. In Illinois, legislation specifies that stock inhalers can by utilized by any individual in the school experiencing respiratory distress, regardless of age or known asthma diagnosis. Given the research question focuses on students’ asthma documentation, this study only included events in which students received stock inhalers in that timeframe.

Analyses included Pearson’s Chi-squared, Fisher’s exact, Welch two-sample t, and Wilcoxon rank-sum tests. Binary logistic regressions examined the association between disposition and having asthma documentation at school (diagnosis, AAP). In adjusted models, covariates included student characteristics (gender, race/ethnicity, age) and number of inhaler puffs administered. For analyses, Bonferroni correction was used due to multiple comparisons made. In bivariate analyses, significance was defined by p<0.005 due to ten comparisons made across the analyses for asthma diagnosis and AAP. In regression models, significance was defined by p<0.025 for each model (diagnosis and AAP). RStudio (R version 4.4.2) was used for analyses.

Results

In the 2023–2024 school year, a total of 656 events occurred requiring stock inhaler use among students in Illinois schools participating in the RESCUE program (n=2,171) (Table 1). In nearly two-thirds of events (63%, n=413), students had documentation of their asthma diagnosis at school. Among students with a documented asthma diagnosis, fewer than half had AAPs on file (42%, n=175).

Table 1:

Characteristics of students who used undesignated quick-acting inhalers at school as part of Illinois program in 2023–2024, based on documented asthma diagnosis and asthma action plan at school

Characteristics	Overall N=656	Asthma diagnosis documented for student at school1, N=656			Among students with asthma diagnosis asthma action plan (AAP) on file at school1, N=413
		Yes* N=4132	No/Unsure N=2432	p-value3	Yes* N=1752	No/Unsure N=2382	p-value3
Gender4				0.06			0.4
Boy / Man	340 (52%)	223 (56%)	117 (49%)		89 (54%)	134 (58%)
Girl / Woman	298 (45%)	174 (44%)	124 (51%)		76 (46%)	98 (42%)
Race/ethnicity5				0.8			>0.9
Non-Hispanic Black	253 (39%)	162 (43%)	91 (39%)		64 (42%)	98 (44%)
Non-Hispanic White	181 (28%)	107 (28%)	74 (32%)		45 (30%)	62 (28%)
Hispanic or Latino	119 (18%)	72 (19%)	47 (20%)		29 (19%)	43 (19%)
Non-Hispanic other	57 (8.7%)	35 (9.3%)	22 (9.4%)		13 (8.6%)	22 (9.8%)
Age6	11.0 (3.4)	11.3 (3.6)	10.4 (3.1)	<0.001	11.4 (3.4)	11.3 (3.7)	0.8
Number of inhaler puffs administered7	2.71 (1.28)	2.50 (1.06)	3.05 (1.51)	<0.001	2.50 (1.11)	2.50 (1.02)	>0.9
Returned to class after stock inhaler use	496 (76%)	340 (82%)	156 (64%)	<0.001	156 (89%)	184 (77%)	0.002

Note: Under “Overall”, percents reported include all events, including those with missing data. For significance testing, percents only include events for which data was available for that characteristic.

¹Asthma diagnosis and asthma action plan are based on students having documentation on file in school records.

²n (%); Mean (SD).

³Pearson’s Chi-squared test; Fisher’s exact test, W elch two-sample t-test. Significance defined by p<0.005, based on Bonferroni correction used for multiple comparisons made across asthma diagnosis and asthma action plan.

⁴Gender was not reported for 17 events, including 15 students with asthma diagnosis (10 with AAP); one additional student was reported to have non-binary gender (with asthma diagnosis, no AAP) and was combined with unknown for analysis.

⁵Race/ethnicity was not reported for 46 events total, including 37 with asthma diagnosis (24 with AAP).

⁶Age was not reported for 21 events total, including 15 students with asthma diagnosis (4 with AAP). Analysis conducted using both parametric tests and non-parametric tests with similar results. Results from parametric tests are presented in table 1 with mean and standard deviation due to ease of interpretation. Results from non-parametric tests (Wilcoxon rank sum test) are presented as median (IQR) – overall: 11 years (8–14); asthma diagnosis: yes 11 (8–14), no/unsure 10 (8–12), p=0.001; asthma plan: yes 11 (8–14), no/unsure 11 (8–15), p=0.8.

⁷Number of puffs was not reported for 139 events total, including 94 students with asthma diagnosis (37 with AAP). Analysis conducted using both parametric tests and non-parametric tests with similar results. Results from parametric tests are presented in table 1 with mean and standard deviation due to ease of interpretation. Results from non-parametric tests (Wilcoxon rank sum test) are presented as median (IQR) – overall: 2 puffs (2–4); asthma diagnosis: yes 2 (2–2), no/unsure 2 (2–4), p<0.001; asthma plan: yes 2 (2–2), no/unsure 2 (2–2), p=0.8.

Among respiratory events, students who had documented asthma diagnoses at school were older (mean (SD): 11.3 (3.6) vs. 10.4 (3.1); p=0.001) and received fewer stock inhaler puffs (mean (SD): 2.50 (1.06) vs. 3.05 (1.51); p<0.001) than those without documented diagnoses. Age and inhaler puffs did not differ between students with and without AAPs. There was no difference in student gender or race/ethnicity in events based on documented asthma diagnosis and AAP.

Regarding disposition, 76% of students returned to class after using stock inhalers (n=496). A smaller proportion left with parents/guardians / were sent home (22%, n=147) or required emergency medical services transport (1.7%, n=11).

In unadjusted models, when analyzing disposition, students who had an asthma diagnosis documented at school had 2.6 times higher odds of returning to class after stock inhaler use versus those without a documented asthma diagnosis at school (95% CI 1.81–3.75). Similarly, students with asthma who also had AAPs on file at school had 2.41 times higher odds of returning to class after respiratory events versus those without AAPs (95% CI 1.39–4.33). These associations remained significant in adjusted models (Table 2).

Table 2:

Odds of students returning to class after stock inhaler use in Illinois in 2023–2024 school year for all respiratory events and for events among students with asthma diagnosis, unadjusted and adjusted for student and event characteristics¹

Characteristics	Unadjusted, OR (CI)2	p-value3	Adjusted, OR (CI)2	p-value3
All student events, N=656
Has asthma diagnosis4	2.60 (1.81–3.75)	<0.001	1.94 (1.23–3.09)	0.005
Events among students with asthma diagnosis4, N=413
Has asthma action plan4,5	2.41 (1.39–4.33)	0.002	2.56 (1.29–5.35)	0.01

¹Adjusted for student gender, race/ethnicity, and age as well as number of inhaler puffs administered during respiratory event.

²Odds ratio (95% confidence interval) from binary logistic regression model.

³Significance defined by p<0.025, based on Bonferroni correction used for models for asthma diagnosis and asthma action plan.

⁴Reference group: No/Unsure

⁵Asthma diagnosis and asthma action plan are based on students having documentation on file in school records.

Discussion

In a statewide stock inhaler program in Illinois, we found students with asthma diagnoses and AAPs documented at school had higher rates of return to class after stock inhaler use for respiratory symptoms than students without such documentation.

This study shows that, across the state of Illinois, the majority of respiratory events requiring stock inhaler use involved students with documented asthma at school, similar to a county-level stock inhaler program in Arizona.⁸ However, one-third of events occurred in students with no asthma diagnosis on file, suggesting the stock inhaler program met a need for children both with and without asthma diagnoses documented at school. Further, we found students with documented asthma diagnoses were, older, used fewer inhaler puffs, and had higher odds of return to class after stock inhaler use, on average, even after adjusting for other characteristics. Among students with documented asthma diagnoses at school, those with AAPs similarly had higher odds of return to class.

These novel findings may reflect potential benefits of having asthma documentation at school, which can help support asthma care through enhanced communication, medication access, and emergency response.⁹ Further, documentation may raise awareness of affected children in schools. Such documentation, along with medication access, are key components of evidence-based management to foster asthma-friendly and supportive environments in schools.¹⁰

This study did not examine potential mechanisms for the findings, although literature suggests various reasons for these findings. For students with no documentation at school, they may have an asthma diagnosis but face one or more barriers to effective self-management, including quality healthcare access, health literacy, and communication, which can make it more challenging to obtain and submit this documentation.¹¹ Also, students may have experienced respiratory symptoms at school for the first time, such as with a new asthma diagnosis, previously quiescent asthma, or a non-asthma related cause (viral respiratory infection). Literature describes that some parents found it challenging to manage symptoms before diagnosis and identify severity of respiratory distress, which influences their decision about seeking medical attention;¹² as such, the child and/or their parent/guardian may not feel comfortable returning to class post-event. Alternatively, the presence of documentation on file at school may indicate the child and/or parent/guardian(s) have better healthcare access or greater self-efficacy, leading to higher rates of students returning to class. Further, while research varies on the outcomes of AAPs (e.g., healthcare utilization),⁴ our findings suggest having AAPs in schools may be associated with the proximal outcome of keeping students in class. Additional research is important to delineate the factors and mechanisms at play, for example how students’ asthma action plans are used when administering school stock inhalers and how stock inhaler use differs among students who had documented asthma diagnoses and/or plans at school.

This study was restricted to schools in Illinois, so its findings may not be generalizable to other states or regions with different demographic profiles. Further, event reports were not associated with student asthma history or school asthma prevalence, precluding analyses related to asthma severity or control. Despite these limitations, this study suggests enhancing asthma documentation and medication access at school may help improve outcomes for students experiencing respiratory events, helping support asthma control and continued learning.