PROJECT SUMMARY Asthma causes substantial morbidity among children and much of it is attributable to medication non-adherence. School-based supervision of daily inhaled corticosteroid (ICS) treatment increases medicationadherence and reduces episodes of poor asthma control. However recruiting children from schools enrollsmany children with mild asthma and infrequent health care use. Therefore initiating supervised treatment forthese children tends to diminish the program's cost-effectiveness. To address this inefficiency we propose totarget children who are at high risk of poor outcomes by recruiting children who are discharged from theemergency department (ED) following treatment of an asthma attack. While guidelines recommend ED cliniciansconsider initiating ICS treatment at discharge <20% of children discharged from the ED following treatment foran asthma attack receive a prescription for controller therapy. Data indicates that patients who use ICS followingdischarge are half as likely as non-users to experience a repeat ED visit. However simply providing patients witha prescription does not ensure that they will fill it and use it consistently once discharged. To ensure access andadherence to controller medication we propose to dispense ICS at discharge and supervise its use at school. We propose to work within the Pediatric Emergency Care Applied Research Network to conduct a pilotclinical trial with the following aims: Aim 1. Determine the feasibility and acceptability of dispensing inhaledcorticosteroids in the emergency department and supervising its use in the school setting. Following EDmanagement of an asthma attack elementary-age children with mild-to-moderate asthma randomized to theED-SAMS program will be prescribed once-daily budesonide inhalation power to be supervised as school. Aim2. Estimate a range of plausible intervention effect sizes to support the development of a larger multi-center clinical trial. Ninety children from 3 EDs will be randomized to receive an ICS prescription for at-homeuse (control) or ICS dispensing for at-home and at-school use (intervention). The primary outcome will be 90-day ED recidivism. Aim 3. Conduct a preliminary cost-effectiveness analysis. We will estimate interventioncosts to determine the probability that the intervention could be cost-effective within a range of plausible effectsizes. Successful completion of this pilot trial will support the development of a larger multicenter trial todetermine whether the intervention cost-effectively reduces exacerbation risk among elementary-age childrenwith mild-to-moderate asthma.