Quality improvement for asthma care within a hospital-based teaching clinic

Increasing Provider Utilization of a Seizure Action Plan in the Outpatient Setting

OBJECTIVES

A seizure action plan (SAP) is a powerful tool that provides actionable information for caregivers during seizures. Guidelines have expressed the need for individualized SAPs. Our quality improvement team aimed to increase implementation of an SAP within a pediatric tertiary center, initially among epilepsy providers and expanded to all neurology providers.

METHODS

Process changes were implemented using Plan-Do-Study-Act cycles and data were evaluated monthly using control charts. The team focused on tracking patients who received SAPs and identified opportunities for improvement, including reminders within the electronic medical record, and standardizing clinic processes. A secondary analysis was performed to trend emergency department (ED) use among our patient population.

RESULTS

The SAP utilization rate among epilepsy providers increased from a baseline of 39% to 78% by December 2019 and reached the goal of 85% by June 2020, with a further increase to 92% by February 2022 and maintained. The SAP utilization rate among general neurology providers increased from 43% in 2018 to 85% by July 2020, and further increased to 93% by February 2022 and maintained. ED visits of established patients with epilepsy decreased from a baseline of 10.2 per 1000 to 7.5 per 1000.

CONCLUSIONS

Quality improvement methodologies increased the utilization of a standardized SAP within neurology outpatient care centers. The SAP is a simplified tool that allows patients and providers to navigate a complex health care system. The utility of an SAP may potentially extend to minimizing unnecessary ED visits.

Development and assessment of a low literacy, pictographic asthma action plan with clinical automation to enhance guideline-concordant care for children with asthma

OBJECTIVE

Asthma is characterized by reversible pulmonary symptoms, frequent hospitalizations, poor quality of life, and varied treatment. Parents with low health literacy (HL) is linked to poor asthma outcomes in children. Recent practice updates recommended inhaled corticosteroids for the management of persistent asthma, but guideline-concordant care is suboptimal. Our aim was to develop and assess an Asthma Action Plan (AAP) that could serve as an individualized plan for low HL families and facilitate guideline-concordant care for clinicians.

METHODS

We followed the National Institute of Health 5-step "Clear & Simple" approach to develop the Uniformed Services AAP. Our AAP included symptom pictographs (dyspnea, cough, sleep, activity) and guideline-concordant clinical automation tools. Caregivers assessed the pictograms for validity (transparency of ≥ 85%; translucency score ≥ 5; and ≥ 85% recall). Readability was assessed using 7 formulas. (<6th Grade was acceptable). Comprehensibility, design quality, and usefulness was assessed by caregivers using the Consumer Information Rating Form (CIRF) (>80% was acceptable). Understandability and actionability was assessed by medical librarians using the Patient Education Materials Assessment Tool-Printable (>80% was acceptable). Suitability was assessed by clinicians using the modified Suitability Assessment of Materials (SAM) instrument (>70% was superior).

RESULTS

All 12 pictograms were validated (N = 118 respondents). Readability demonstrated a 4th grade level. Overall CIRF percentile score = 80.4%. Understandability and Actionability = 100%. Suitability score = 75%.

CONCLUSIONS

Our AAP was formally endorsed by the Allergy & Asthma Network. The Uniformed Services AAP is a novel tool with embedded clinical automation that can address low HL and enhance guideline-concordant care.

Development and Assessment of a Low Literacy, Pictographic Cyclic Vomiting Syndrome Action Plan

OBJECTIVE

To develop and assess an evidence-based, individualized Cyclic Vomiting Syndrome Action Plan (CVSAP) to optimize both preventative and acute care.

STUDY DESIGN

This implementation science project synthesized a combination of clinical practice guidelines, published literature, and clinical experience by a team of CVS clinicians to develop the CVSAP. The tool was developed to include validated pictograms and an automatic, embedded, weight-based dosing calculator to output acute management recommendations. The final version of the CVSAP was tested by patients/caregivers, readability calculators, medical librarians, and clinicians using validated metrics.

RESULTS

All pictograms met the criteria for inclusion in the CVSAP. A composite readability score of 5.32 was consistent with a fifth-grade level. Patients/caregivers (n = 70) judged the CVSAP to be of high quality with consumer information rating form rating of 84.2%. Six medical librarians rated the CVSAP to have 93% understandability and 100% actionability, and 33 clinicians completing the SAM generated a suitability rating of 87.5%.

CONCLUSIONS

The CVSAP visually highlights individualized care plan components to facilitate optimized preventative and acute CVS care. Further investigation will determine if CVSAP increases caregiver confidence and compliance in home management and improves quality of life and clinical outcomes for patients with CVS.

A Quality Improvement Initiative to Improve Attention-Deficit/Hyperactivity Disorder Follow-Up Rates Using School-Based Telemedicine

OBJECTIVE

Patients with a new diagnosis of attention-deficit/hyperactivity disorder (ADHD) who are prescribed stimulant medication need regular follow-up. Guidelines recommend follow-up within 30 days of stimulant initiation or change but this goal is seldom achieved. This quality improvement (QI) study in an urban academic outpatient practice aimed to: 1) assess whether use of school-based telemedicine increases rates of follow-up within 30 days and decreases the number of days to follow-up for ADHD, and 2) compare rates of 30-day follow-up via in-person vs telemedicine visits.

METHODS

We performed three Plan-Do-Study-Act cycles over a 12-month period: QI interventions included clinic wide education, paper prompts for clinicians, and creation of a database to track ADHD patients. We measured days from the index visit to the follow-up visit, and the mode of both visits (in-person or telemedicine). Data were collected for 6 months pre-intervention and 12 months post-intervention.

RESULTS

Follow-up within 30 days increased from 19% (of 191 visits) to 33% (of 661 visits) (P < .001). The time to follow-up decreased from 67 to 34 days (P < .001). Follow up visits by telemedicine were more also more likely to be within 30 days (62% vs. 32%, P < .001).

DISCUSSION

A QI intervention for ADHD care increased rates of follow-up within 30 days, particularly when telemedicine was used, and decreased the number of days to follow-up. This intervention could serve as a model to improve follow-up for ADHD in other settings.

A primary care learning collaborative to improve office systems and clinical management of pediatric asthma

OBJECTIVE

Pediatric asthma is a common, relapsing-remitting, chronic inflammatory airway disease that when uncontrolled often leads to substantial patient and health care system burden. Improving management of asthma in primary care can help patients stay well controlled.

METHODS

The Vermont Child Health Improvement Program (VCHIP) developed a quality improvement (QI) learning collaborative with a primary objective to improve clinical asthma management measures through improvement in primary care office systems to support asthma care. Seven months of medical record review data were evaluated for improvements on eight clinical asthma management measures. Pre and post office systems inventory (OSI) self-assessments detailing adherence to improvement strategies were analyzed for improvement. Logistic regressions were used to test for associations between OSI strategy post scores and the corresponding clinical asthma management measures by month seven.

RESULTS

This study found significant improvement from baseline to month seven on seven of the eight clinical asthma management measures and between pre and post OSI for seven of the nine strategies assessed (N = 19 practices). Additionally, one point higher average OSI scores on the assessment and monitoring of asthma severity, asthma control, asthma action plans, and asthma education strategies were associated with significantly greater odds of improvement in their respective clinical asthma management measures.

CONCLUSIONS

A QI learning collaborative approach in primary care can improve office systems and corresponding clinical management measures for pediatric patients with asthma. This suggests that linking specific office systems strategies to clinical measures may be a helpful tactic within the learning collaborative model.

Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized Controlled Trial

PURPOSE

The purpose of this study was to assess patient and practice outcomes after introducing the Asthma APGAR (Activities, Persistent, triGGers, Asthma medications, Response to therapy) tools into primary care practices.

METHODS

We used a pragmatic cluster-randomized controlled design in 18 US family medicine and pediatric practices to compare outcomes in patients with persistent asthma aged 5 to 45 years after introduction of the Asthma APGAR tools vs usual care. Patient outcomes included asthma control, quality of life, and emergency department (ED), urgent care, and inpatient hospital visits. The practice outcome was adherence to asthma guidelines.

RESULTS

We enrolled 1,066 patients: 245 children, 174 adolescents, and 647 adults. Sixty-five percent (692 patients) completed both baseline and 12-month questionnaires, allowing analysis for patient-reported outcomes. Electronic health record data were available for 1,063 patients (99.7%) for practice outcomes. The proportion of patients reporting an asthma-related ED, urgent care, or hospital visit in the final 6 months of the study was lower in the APGAR practices vs usual care practices (10.6% vs 20.9%, P = .004). The percentage of patients with "in control" asthma increased more between baseline and 1 year in the APGAR group vs usual care group (13.5% vs 3.4%, P =.0001 vs P =.86) with a trend toward better control scores and asthma-related quality of life in the former at 1 year (P ≤.06 and P = .06, respectively). APGAR practices improved their adherence to 3 or more guideline elements compared with usual care practices (20.7% increase vs 1.9% decrease, P = .001).

CONCLUSIONS

Introduction of the Asthma APGAR tools improves rates of asthma control; reduces asthma-related ED, urgent care, and hospital visits; and increases practices' adherence to asthma management guidelines.

A Quality Improvement Intervention to Improve Inpatient Pediatric Asthma Controller Accuracy

OBJECTIVES

Our objective was to investigate if a rigorous quality improvement (QI) intervention could increase accuracy of pediatric asthma controller medications on discharge from an inpatient hospitalization.

METHODS

Our interprofessional QI team developed interventions such as improving documentation and creating standardized language to ensure patients were discharged on an appropriate asthma controller medication and improve assessment of asthma symptom control. Each week of 2015-2016, the first 5 patients discharged with status asthmaticus from the pediatric wards were reviewed for documentation of the 6 asthma control questions and accuracy of the discharge controller therapy. Correct discharge medication was defined as being prescribed the age-appropriate medication and dose on the basis of baseline controller therapy, compliance with baseline medication, and responses to asthma control assessment. The weekly proportion of control questions that were accessed and correct controller medications that were prescribed were analyzed by using Nelson rules and interrupted time series.

RESULTS

A total of 240 preintervention and 252 postintervention charts were reviewed. The primary outcome of the median proportion of patients discharged on appropriate controller therapy improved from 60% in preintervention data to 80% in the postintervention period. The process measure of proportion of asthma control questions that were assessed improved from 43% in the preintervention period to 98% by the final months of the intervention period. Both of these changes were statistically significant as per Nelson's rules and interrupted time series analyses (P = .02 and P < .001, respectively, for postintervention break).

CONCLUSIONS

An interdisciplinary QI team successfully improved the accuracy of asthma controller therapy on discharge and the inpatient assessment of asthma control questions.

SPIROMETRY IN SCHOOLCHILDREN FOR FIELD STUDIES: DOES TESTING ON DIFFERENT DAYS CHANGE THE RESULT OF THE EXAM?

OBJECTIVE

To analyze if there is variation in the results of spirometry performed by healthy schoolchildren on different days.

METHODS

Cross-sectional study with healthy schoolchildren aged 7 to 12 years old, in Florianópolis, Santa Catarina, Southern Brazil. Prepubescent children, non-athletes, born at full term, without cardiorespiratory, rheumatic, musculoskeletal, neurological and visual or hearing deficit were included. The child's health was assessed by a health questionnaire and by the survey International Study of Asthma and Allergies in Childhood. The spirometric test was performed on 3 different days, not exceeding the interval of 15 days between the first and last exams, following the guidelines of the American Thoracic Society. The absolute values and percentages of predicted values of forced vital capacity, forced volume in the first second and peak expiratory flow were analyzed. Statistical analysis was performed using the Shapiro-Wilk normality test followed by one-way analysis of variance or Friedman test and by Bonferroni's post-hoc test for multiple parametric comparisons. Also, the intraclass correlation coefficient was applied to compare results on the same patients on the different tested days.

RESULTS

Twenty-two children were analyzed, with a mean age of 9.3±1.1 years. All the spirometric parameters showed a reduction in absolute value after the first exam, but without significant difference. Regarding reproducibility of spirometry results, the tests presented intraclass correlation coefficient >0.70.

CONCLUSIONS

There was no change in the results of spirometry performed by healthy schoolchildren on three different days.

Improving asthma care in a pediatric resident clinic

There is variation in pediatric asthma management in the outpatient setting. Adherence to national asthma guidelines provides a systematic standardized approach to asthma management. There is a gap between usual and guideline-consistent asthma care in resident clinics. Practice improvement modules aimed at improving resident physician adherence to asthma care guidelines have not been consistently utilized and have not yet been studied.

Our aim was to increase guideline consistent care in our pediatric resident clinic in a twelve-month period via increasing performance on the following measures to 75%: spirometry testing; influenza immunization recommendation; level of control assessed through the use of a standardized questionnaire; appropriate medications per national guideline; and use of written asthma action plans.

A summarized pediatric-specific version of the National Heart Lung and Blood Institute National Asthma Education and Prevention Program Expert Panel Report 3 (NHLBI EPR-3) guidelines was made readily available to increase provider education. Electronic health record (EHR) enhancements included adding templates to create standardized asthma action plan, asthma control test and a pediatric asthma controller medication order-set. We also addressed the education of patients by simplifying patient instructions. We monitored our progress through the use of an online practice improvement module.

We found statistically significant increases in use of a standardized instrument to determine level of control (20% to 81%); recommendation of influenza immunization (56% to 97%); use of national medication treatment guidelines (28% to 98%); distribution of asthma action plans (29% to 65%); and provision of asthma self-management education (35% to 74%).

Standardizing the implementation of national guidelines for pediatric asthma through the use of a practice improvement module and electronic health records improved adherence to guidelines. The module allowed us to identify goals for improvement, collect and analyze our group performance data over time, assess the impact of each change, and redesign our process. Improving adherence to national pediatric asthma care guidelines is especially important in settings such as resident teaching clinics which provide care to underserved populations at higher risk for complications related to asthma.

Improving Pediatric Asthma Care and Outcomes Across Multiple Hospitals

BACKGROUND AND OBJECTIVES

Gaps exist in inpatient asthma care. Our aims were to assess the impact of an evidence-based care process model (EB-CPM) 5 years after implementation at Primary Children's Hospital (PCH), a tertiary care facility, and after its dissemination to 7 community hospitals.

METHODS

Participants included asthmatics 2 to 17 years admitted at 8 hospitals between 2003 and 2013. The EB-CPM was implemented at PCH between January 2008 and March 2009, then disseminated to 7 community hospitals between January and June 2011. We measured compliance using a composite score (CS) for 8 quality measures. Outcomes were compared between preimplementation and postimplementation periods. Confounding was addressed through multivariable regression analyses.

RESULTS

At PCH, the CS increased and remained at >90% for 5 years after implementation. We observed sustained reductions in asthma readmissions (P = .026) and length of stay (P < .001), a trend toward reduced costs (P = .094), and no change in hospital resource use, ICU transfers, or deaths. The CS also increased at the 7 community hospitals, reaching 80% to 90% and persisting >2 years after dissemination, with a slight but not significant readmission reduction (P = .119), a significant reduction in length of stay (P < .001) and cost (P = .053), a slight increase in hospital resource use (P = .032), and no change in ICU transfers or deaths.

CONCLUSIONS

Our intervention resulted in sustained, long-term improvement in asthma care and outcomes at the tertiary care hospital and successful dissemination to community hospitals.

Pediatricians Support Initiation of Asthma Controller Medications in the Emergency Department: A National Survey

OBJECTIVES

Although National Asthma Guidelines recommend that emergency department (ED) physicians consider initiating controller medications, research suggests that this practice occurs infrequently. The goal of this study was to assess primary care pediatricians' (PCP) beliefs and attitudes regarding ED initiation of controller medications for children with persistent asthma symptoms.

METHODS

This was a cross-sectional mail survey of a randomly selected national sample of pediatricians from the American Academy of Pediatrics. The survey posed questions regarding beliefs, barriers, and support for national guideline recommendations.

RESULTS

Eight hundred eighty-six (44.3%) of 2000 subjects responded. Five hundred seventy-two (64.5%) respondents met eligibility for analysis. When presented with a vignette of a child with persistent asthma, 476 (83%) of PCPs felt it was appropriate for the ED physician to initiate controller medications. Most (80%) PCPs supported the national guideline recommendation, although a similar proportion reported they have never or rarely experienced this practice before. Only 11% opposed the practice in all circumstances. Beliefs supporting this practice included the following: opportunity to capture patients lost to follow-up (85%), reinforcement of daily use of controller medications (83%), and controller medication may shorten an acute exacerbation (53%). Barriers included lack of time for education in ED (65%), reinforcement of ED use for primary care (64%), lack of PCP communication (62%), and inability to assess severity appropriately (41%). Most (90%) PCPs expect communication from the ED provider.

CONCLUSIONS

A majority of pediatricians support the practice of ED physicians initiating controller medication during an acute visit for asthma. Communication with the PCP, appropriate screening of severity, and education about controller medications were important considerations expressed by these providers.

Impacting Environmental and Public Health through the Use of Dual Targeted and Tailored Asthma Educational Interventions

Home-based asthma environmental education for parents of asthmatic children is needed since many health professionals lack the time to offer it. However, developing targeted and tailored education is important in order to address the individual needs of participants. This nonrandomized longitudinal study examined knowledge on asthma with an Asthma and Healthy Homes educational intervention training offered to parents of children from low income families who reside in the Rio Grande Valley of Texas. Eighty-nine parents received the training and pre- and posttest surveys were used to measure knowledge outcomes. A standardized assessment on asthma triggers was used to identify the different triggers each child was exposed to, and a follow-up survey was conducted 6 months after the educational intervention to identify how many parents reported household and behavior changes as a result of the training. Results showed significant changes in behavior by participants as a result of the training received. This study suggests that these behavioral changes are attributed to the dual "targeted" and "tailored" educational interventions delivered to parents which resulted in a greater understanding of how to manage asthma by eliminating asthma triggers in their respective homes.

Implementing supported self-management for asthma: a systematic review and suggested hierarchy of evidence of implementation studies

BACKGROUND

Asthma self-management remains poorly implemented in clinical practice despite overwhelming evidence of improved healthcare outcomes, reflected in guideline recommendations over three decades. To inform delivery in routine care, we synthesised evidence from implementation studies of self-management support interventions.

METHODS

We systematically searched eight electronic databases (1980 to 2012) and research registers, and performed snowball and manual searches for studies evaluating implementation of asthma self-management in routine practice. We included, and adapted systematic review methodology to reflect, a broad range of implementation study designs. We extracted data on study characteristics, process measures (for example, action plan ownership), asthma control (for example, patient reported control questionnaires, days off school/work, symptom-free days) and use of health services (for example, admissions, emergency department attendances, unscheduled consultations). We assessed quality using the validated Downs and Black checklist, and conducted a narrative synthesis informed by Kennedy's whole systems theoretical approach (considering patient, practitioner and organisational components and the interaction between these).

RESULTS

We included 18 studies (6 randomised trials, 2 quasi-experimental studies, 8 with historical controls and 3 with retrospective comparators) from primary, secondary, community and managed care settings serving a total estimated asthma population of 800,000 people in six countries. In these studies, targeting professionals (n = 2) improved process, but had no clinically significant effect on clinical outcomes. Targeting patients (n = 6) improved some process measures, but had an inconsistent impact on clinical outcomes. Targeting the organisation (n = 3) improved process measures, but had little/no effect on clinical outcomes. Interventions that explicitly addressed patient, professional and organisational factors (n = 7) showed the most consistent improvement in both process and clinical outcomes. Authors highlighted the importance of health system commitment, skills training for professionals, patient education programmes supported by regular reviews, and on-going evaluation of implementation effectiveness.

CONCLUSIONS

Our methodology offers an exemplar of reviews synthesising the heterogeneous implementation literature. Effective interventions combined active engagement of patients, with training and motivation of professionals embedded within an organisation in which self-management is valued. Healthcare managers should consider how they can promote a culture of actively supporting self-management as a normal, expected, monitored and remunerated aspect of the provision of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (registration number: CRD42012002898 ) Accessed 24 May 2015.

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

Background

Despite robust evidence concerning self-management for some long-term conditions (LTCs), others lack research explicitly on self-management and, consequently, some patient groups may be overlooked.

Aim

To undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts.

Methods

Self-management is ‘the tasks . . . individuals must undertake to live with one or more chronic conditions . . . [including] . . . having the confidence to deal with medical management, role management and emotional management of their conditions’. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus). For each LTC we conducted systematic overviews of systematic reviews of randomised controlled trials (RCTs) of self-management support interventions (‘quantitative meta-reviews’); and systematic overviews of systematic reviews of qualitative studies of patients’ experiences relating to self-management (‘qualitative meta-reviews’). We also conducted an original systematic review of implementation studies of self-management support in the LTCs. We synthesised all our data considering the different characteristics of LTCs. In parallel, we developed a taxonomy of the potential components of self-management support.

Results

We included 30 qualitative systematic reviews (including 515 unique studies), 102 quantitative systematic reviews (including 969 RCTs), and 61 studies in the implementation systematic review. Effective self-management support interventions are multifaceted, should be tailored to the individual, their culture and beliefs, a specific LTC and position on the disease trajectory, and underpinned by a collaborative/communicative relationship between the patient and health-care professional (HCP) within the context of a health-care organisation that actively promotes self-management. Self-management support is a complex intervention and although many components were described and trialled in the studies no single component stood out as more important than any other. Core components include (1) provision of education about the LTC, recognising the importance of understanding patients’ pre-existing knowledge and beliefs about their LTC; (2) psychological strategies to support adjustment to life with a LTC; (3) strategies specifically to support adherence to treatments; (4) practical support tailored to the specific LTC, including support around activities of daily living for disabling conditions, action plans in conditions subject to marked exacerbations, intensive disease-specific training to enable self-management of specific clinical tasks; and (5) social support as appropriate. Implementation requires a whole-systems approach which intervenes at the level of the patient, the HCP and the organisation. The health-care organisation is responsible for providing the means (both training and time/material resources) to enable HCPs to implement, and patients to benefit from, self-management support, regularly evaluating self-management processes and clinical outcomes. More widely there is a societal need to address public understanding of LTCs. The lack of public story for many conditions impacted on patient help-seeking behaviour and public perceptions of need.

Conclusions

Supporting self-management is inseparable from the high-quality care for LTCs. Commissioners and health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded aspect of care. Further research is needed to understand how health service managers and staff can achieve this culture change in their health-care organisations.

Study registration

This study is registered as PROSPERO CRD42012002898.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Prompting asthma intervention in Rochester-uniting parents and providers (PAIR-UP): a randomized trial

IMPORTANCE

A disproportionate number of impoverished and minority children have asthma and receive suboptimal preventive care.

OBJECTIVE

To evaluate whether the Prompting Asthma Intervention in Rochester-Uniting Parents and Providers (PAIR-UP) intervention, administered in primary care offices, improves the delivery of preventive care and reduces morbidity for urban children with asthma.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial in which 12 urban primary care practices were matched based on size and type and randomly allocated to the PAIR-UP intervention or usual care (UC). We enrolled 638 children aged 2 to 12 years with persistent or poorly controlled asthma in the waiting room prior to a visit with a clinician for any reason from October 2009 to January 2013. Blinded interviewers called caregivers within 2 weeks to inquire about preventive measures taken at the visit and called them 2 and 6 months later to assess symptoms.

INTERVENTIONS

Children enrolled at PAIR-UP practices received prompts for the caregiver and clinician at the time of the visit that outlined the child's asthma severity or control as well as specific guideline-based recommendations to enhance preventive care. These practices also received educational resources and periodic feedback on their asthma care performance. The UC practices received copies of the asthma guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was symptom-free days (SFDs) per 2 weeks at the 2-month follow-up.

RESULTS

We enrolled 638 children (participation rate of 80%; 36% were black, 36% were Hispanic, and 68% had Medicaid insurance). Groups were similar in demographic characteristics and asthma severity at baseline. At the index visit, more children in the PAIR-UP group received a preventive medication action (new medication, increased dose, recommendation to restart preventive medication) than in the UC group (58% vs 33%; odds ratio [OR] = 2.8; 95% CI, 1.9 to 3.9). More children in the PAIR-UP group than in the UC group received an asthma action plan (61% vs 23%; OR = 8.3; 95% CI, 3.7 to 18.7), discussions regarding asthma (93% vs 78%; OR = 4.5; 95% CI, 2.8 to 7.2), and secondhand smoke counseling (80% vs 63%; OR = 2.6; 95% CI, 1.2 to 5.5). At the 2-month follow-up, children in the PAIR-UP group had more SFDs per 2 weeks than those in the UC group (mean difference, 0.78 days; 95% CI, 0.29 to 1.27). At 6 months, the improvement in SFDs was no longer statistically significant (mean difference, 0.56; 95% CI, -0.14 to 1.25).

CONCLUSIONS AND RELEVANCE

The PAIR-UP intervention improved the delivery of preventive asthma care and reduced asthma morbidity for high-risk urban children with persistent asthma at 2 months, but the improvement in SFDs was no longer significant at 6 months.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01105754.

Practice-tailored facilitation to improve pediatric preventive care delivery: a randomized trial

OBJECTIVE

Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services.

METHODS

In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application. Thirty practices were randomized to Early or Late Intervention, and outcomes assessed for 16 419 well-child visits. A multidisciplinary team characterized facilitation processes by using comparative case study methods.

RESULTS

Baseline performance was as follows: for Obesity: 3.5% successful performance in Early and 6.3% in Late practices, P = .74; Lead: 62.2% and 77.8% success, respectively, P = .11; and Fluoride: <0.1% success for all practices. Four months after randomization, performance rose in Early practices, to 82.8% for Obesity, 86.3% for Lead, and 89.1% for Fluoride, all P < .001 for improvement compared with Late practices' control time. During the full 6-month intervention, care improved versus baseline in all practices, for Obesity for Early practices to 86.5%, and for Late practices 88.9%; for Lead for Early practices to 87.5% and Late practices 94.5%; and for Fluoride, for Early practices to 78.9% and Late practices 81.9%, all P < .001 compared with baseline. Improvements were sustained 2 months after intervention. Successful facilitation involved multidisciplinary support, rapid-cycle problem solving feedback, and ongoing relationship-building, allowing individualizing facilitation approach and intensity based on 3 levels of practice need.

CONCLUSIONS

Practice-tailored Facilitation Intervention can lead to substantial, simultaneous, and sustained improvements in 3 domains, and holds promise as a broad-based method to advance pediatric preventive care.

The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research

BACKGROUND

The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research.

METHODS

Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized.

RESULTS

Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.

CONCLUSIONS

Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.

Learning from a distance: effectiveness of online spirometry training in improving asthma care

OBJECTIVE

We evaluated the effectiveness of a virtually delivered quality improvement (QI) program designed to improve primary care management for children with asthma.

METHODS

Thirty-six physicians, nurses, and medical assistants from 14 primary care pediatric practices (7 matched practice pairs) participated in a cluster randomized trial from October 2007 to September 2008. All practices received a spirometer and standard vendor training. A 7-month QI program delivered during the study period included: 1) Spirometry Fundamentals™ CD-ROM, a multimedia tutorial; 2) case-based, interactive webinars led by clinical experts; and 3) an internet-based spirometry quality feedback reporting system. Practice pairs were compared directly to each other, and between-group differences were analyzed with the use of mixed effects regression models. Our main outcome measures were the frequency of spirometry testing, percentage of acceptable quality spirometry tests, asthma severity documentation, and appropriate controller medication prescribing.

RESULTS

Participating practices uploaded a total of 1028 spirometry testing sessions, of which 340 (33.1%) were of acceptable quality. During the 7-month intervention period, there was no difference between intervention and control practices in the frequency of spirometry tests performed. Intervention practices were estimated to have significantly greater odds of conducting tests with acceptable quality compared with matched control practices, adjusting for quality in the baseline period (odds ratio 2.85; 95% confidence interval 1.78-4.56, P < .001). Intervention providers also had significantly greater odds of documenting asthma severity during the intervention period (odds ratio 2.9, 95% confidence interval 1.8-4.5; P < .001). Although use of controller medications among patients with persistent asthma approached 100% for both groups, the proportion of asthma patients labeled as persistent increased from 43% to 62% among intervention practices, and decreased from 57% to 50% among controls (NS).

CONCLUSIONS

A multifaceted distance QI program resulted in increased spirometry quality and improved assessment of asthma severity levels. Successful participation in QI programs can occur over distance.