An Official ATS Workshop Report: Issues in Screening for Asthma in Children
The workshop participants concluded that, at this time, the adoption of population-based asthma case detection programs is unwarranted given the lack of evidence of improvement in health outcomes as a result of case detection. It is important to note, however, that there are advocates for nationwide asthma screenings. One such ongoing effort is sponsored by the American College of Allergy, Asthma, and Immunology; on their website, the chair of their screening effort states, "We believe the nationwide screenings help raise awareness about asthma and the fact that the disease doesn't have to lead to major lifestyle compromises. By informing people about the symptoms of asthma and by offering free screenings and consultation by an allergist, we can help improve quality of life for children and adults with asthma" (http://www.acaai.org/ public/lifeQuality/nasp/nasp.htm, accessed August 15, 2006). The actual health outcomes of these screenings, however, are unclear. Although such voluntary programs in community settings may have value, the external validity of their outcomes is limited by self-selection of the individuals choosing to be screened. The participants of this workshop believe that limited case detection programs may be appropriate in areas where there is a high prevalence of undiagnosed asthma and where newly identified patients have functional access to consistent, high-quality asthma care. Methods to identify children with significant asthma symptoms may also be appropriate. The use of case detection methods to identify children with undiagnosed asthma may be a worthy future goal. However, before this panel can recommend widescale case detection, a number of issues should be addressed: 1. Health care systems should be adapted to deliver care that optimizes health outcomes in populations that are difficult to reach through our traditional health care delivery mechanisms. The goal is to guarantee timely access to asthma care consistent with existing guidelines and access to education to improve daily self-management. Access to health behavior experts and social workers will be important to address psychosocial and health literacy issues which impact on adherence and health outcomes. 2. The primary site of asthma case detection should be the primary care clinician's office. Clinicians should be attentive to respiratory symptoms and reports of morbidity or missed school days among children. If populations are identified that are not reached by primary care, then alternative methods should be developed for other sites (possibly schools, community centers, or youth-serving organizations). In some settings, it may be prudent to combine asthma case detection with other case detection procedures that identify other common, chronic diseases, such as vision screening for myopia. 3. Tools should be refined to identify those who would benefit most from further assessment and treatment for undiagnosed and/or undertreated asthma. 4. Identification of a preclinical state for asthma may allow for true screening and treatment to prevent the onset of the disease. A better understanding of the different asthma phenotypes and their natural history is needed to help inform the nature, timing, and possibly the setting of ideal asthma case detection or screening programs. 5. The cost-effectiveness of asthma case detection programs should be examined. Until these issues are addressed, parents, school personnel, and primary health care providers should be attentive to respiratory symptoms in children. Given that public health resources within communities and schools are very limited, current efforts should seek to identify and intervene with those children who are experiencing significant morbidity from respiratory symptoms. This targeted use of resources should include connection to proper medical care to have an impact on asthma morbidity.