31 School-Based Asthma Screening

Many school-age children have asthma, a chronic lung disease that causes cough, chest tightness, and shortness-of-breath. Sometimes, these symptoms are so severe that children must be hospitalized. Medications, like inhaled corticosteroids, can reduce symptoms and prevent attacks, but many children go without treatment because their asthma is undiagnosed. If schools screened students for asthma — like they do for vision abnormalities and scoliosis — perhaps children could be diagnosed earlier. However, schools are reluctant to do so because screening is costly. To investigate whether schools were making good decisions, I analyzed the cost-effectiveness of screenings for my doctoral dissertation.

Given that many questions need answers, why did I choose this one? In retrospect, the decision was quite calculated. As a physician undertaking additional graduate training, I had prior knowledge that I could apply in a new way. In other words, I didn’t have to start from scratch. I also chose to collaborate with faculty mentors who also wanted an answer but needed a little help. Therefore, they were invested in helping me because it also helped them — our goals were aligned. Lastly, I had taken two cost-effectiveness courses that provided me with the skills to be successful and the confidence to try.

While undergraduates are not expected to complete dissertations, you will still be asked to choose topics for papers and projects. Applying a similar rationale to the one I outlined above can help you pick questions that position your project for success. Choose topics you can bring prior knowledge to bear. Choose topics that others are invested in — mentors should be allies not just subject-matter experts. Choose topics that allow you to apply newly acquired skills so you can build deeper knowledge. Admittedly, doing all three will be difficult in the beginning, but over time there should be more opportunities to align these principles within your program of study.

Whether you are an undergraduate student working on a research paper or a graduate student working on a dissertation, answering difficult questions can be overwhelming. To prevent negative emotions from sabotaging your work, focus on the writing process and not the outcome. After all, answers are not misplaced artifacts to be found but rather rewards to be earned. Focusing on process creates a positive feedback loop where repeated, purposeful practice improves your analytic skills, makes questions easier to answer, and leads to higher grades.

When starting a new project, the blank page can be paralyzing. Breaking the project into more manageable tasks can help you build momentum. One of the first questions I had to answer in my dissertation research was: how many children had asthma, and how many of them were undiagnosed? If asthma was uncommon, then screening might have a high false positive rate, meaning it would mistakenly label many healthy children as having asthma. If asthma was common, then the reverse might be true. By answering small questions like this one-at-a-time, I was eventually able to calculate screening’s cost-effectiveness. By doing so, I also learned how to answer questions in my discipline and become the cost-effectiveness researcher I hoped to be.

Successful starts on research projects are often followed by setbacks and frustration, making even simple tasks difficult. For me, deciding how many children actually had asthma was overwhelming. The answer depended on so many things: the definition of asthma, the methods used to diagnose it, and the populations of children at risk. Some researchers estimated that 35% of students who attended low-income urban schools had asthma by relying on parental reports of cough, wheeze, and shortness-of-breath. Others reported that 10% of students who attended upper-income suburban schools had asthma by relying on physician diagnoses in medical records. As an inexperienced student I struggled for weeks, paralyzed by self-doubt. Experienced researchers would have sifted through the contradictory reports, made an educated guess, and moved on. Oh well, a lesson learned the hard way!

Struggling to overcome mistakes forces us to critically appraise our work, strengthens our understanding of the problem, and helps us recognize our faulty thinking. By correcting mistakes, we learn to accept that they are things we make, not who we are! With this acceptance comes greater freedom to take risks we might not have previously taken.

Weeks before my final dissertation defense, I identified an error that threatened to upend my results. I had failed to consider that estimates of screening accuracy were based on studies of children at higher-than-average risk of having asthma. Remember, from above, that asthma’s commonness or prevalence impacts the number of false positive and false negative results. By not accounting for the higher prevalence in these prior studies, I had overestimated screening’s accuracy or its positive predictive value when conducted among children with average risk. This error made screening appear to be more valuable than it really was because there were too few false positive results. Because my skills had improved, I was able to correct the mistake before it delayed my graduation.

While earning a PhD was important, what I really wanted was a good job. To get one, I needed to see my dissertation published in a peer-reviewed journal. While being graded by your teacher is scary, being evaluated by your peers is worse. That is why I was mortified when I found another error when condensing my dissertation into a shorter manuscript. A misplaced parenthesis in a line of code overturned my results.

During my dissertation defense, I said that the best screening procedure was a detailed symptom questionnaire followed by lung function and exercise step testing if needed. Even though this procedure was expensive, its higher accuracy made screening cost-effective at $107,000 per quality-adjusted life-year. After correcting the error, I concluded that screening children using a simpler two-item questionnaire and then referring them to their pediatrician if needed was best. Even though it was less accurate, it was much cheaper. Correcting the error meant screening overall turned out to be less cost-effective at $151,000 dollars per quality-adjusted life-year. This meant that schools had been making the right decision all along by not screening their students for asthma.

Even though I made mistakes, I was able to defend my dissertation and see it published in the Journal of Allergy and Clinical Immunology. Afterwards, it was recognized as one of the most important school health papers published that year. Soon afterwards, I secured a faculty position at UA where I am now a tenured associate professor and sharing my experience with new students like you.

My experience taught me that big questions can be answered by breaking them into smaller manageable problems, by staying focused on the writing process, and by accepting mistakes as learning opportunities. As you work towards your goals, consider these lessons and bear in mind that your grades, while important, are not nearly as valuable as the knowledge and skills that you will gain while earning them.

Works Cited

Gerald, Joe K., et al. “Cost-Effectiveness of School-Based Asthma Screening in an Urban Setting.” Journal of Allergy and Clinical Immunology, vol. 125, no. 3, 2010, pp. 643–650.e12.

About the author

name: Joe Gerald

Joe Gerald, a physician and health services researcher, is an associate professor in the Zuckerman College of Public Health. When not working to improve medical care for children with asthma, he is reading or watching sci-fi with one or more of his three shelter dogs sitting in his lap. Even though he tells bad “Dad jokes,” students continue to attend his General Education course: Health Care in the U.S.