Physicians, guidelines, and cognitive tasks

How can evidence-based interventions give the best value for users in social services? Balance between adherence and adaptations: a study protocol

Background

Using evidence-based interventions (EBIs) is a basic premise of contemporary social services (e.g., child and family social services). However, EBIs seldom fit seamlessly into a specific setting but often need to be adapted. Although some adaptions might be necessary, they can cause interventions to be less effective or even unsafe. The challenge of balancing adherence and adaptations when using EBIs is often referred to as the adherence and adaptation dilemma. Although the current literature identifies professionals’ management of this dilemma as problematic, it offers little practical guidance for professionals. This research aims to investigate how the adherence and adaptation dilemma is handled in social services and to explore how structured decision support can impact the management of the dilemma.

Methods

The design is a prospective, longitudinal intervention with a focus on the feasibility and usefulness of the structured decision support. The project is a collaboration between academic researchers, embedded researchers at three research and development units, and social service organizations. A multi-method data collection will be employed. Initially, a scoping review will be performed, and the results will be used in the development of a structured decision support. The decision support will be further developed and tested during a series of workshops with social service professionals. Different forms of data—focus group interviews, questionnaires, and documentation—will be used on several occasions to evaluate the impact of the structured decision support. Qualitative and quantitative analysis will be performed and usefulness for practice prioritized throughout the study.

Discussion

The study will contribute with knowledge on how the adherence and adaption dilemma is handled and experienced by social service professionals. Most importantly, the study will generate rich empirical data on how a structured decision support impacts professionals’ management of adherence and adaptions. The goal is to produce more strategic and context-sensitive implementation of EBIs in social service, which will increase value for service users.

Improving Asthma-Related Outcomes Among Children Participating in the Head-Off Environmental Asthma in Louisiana (HEAL), Phase II Study

PURPOSE

Pediatric asthma disproportionately affects low-income and minority children. The HEAL (Head-Off Environmental Asthma in Louisiana), Phase II Project was a collaborative effort with a primary focus to improve pediatric asthma management in New Orleans, Louisiana. The purpose of this article is to report clinical outcomes captured at baseline and 12-month follow-up.

METHOD

HEAL (Head-off Environmental Asthma in Louisiana), Phase II was a pre-post intervention study that enrolled children ages 2 to 18 years of age with a diagnosis of asthma to receive asthma education within the clinic setting. Enrollees received an asthma education intervention, an environmental evaluation, and a 12-month follow-up session. Endpoints included symptom days, level of asthma control, asthma exacerbations, emergency room visits, hospitalizations, and missed school days.

RESULTS

The majority of participants were aged 5 years and older, male, Black, and persistent asthmatics. Emergency room visits decreased from 41% to 20% ( p < .001). Improvements in coughing (83% to 62%, p < .001), wheezing (50% to 26%, p < .001), and chest tightness (29% to 18%, p < .001) were also seen.

CONCLUSION

The novel intervention was associated with improved asthma outcomes among pediatric patients receiving care at the clinical sites in the Greater New Orleans area.

Patient-centered outcomes research to improve asthma outcomes

The Patient-Centered Outcomes Research Institute is funding 8 comparative effectiveness research projects to improve patient-centered outcomes for African American and Hispanic/Latino patients with uncontrolled asthma. These projects aim to compare multilevel interventions with known efficacy at the community, home, and health system levels to enhance patient and clinician uptake of the National Heart, Lung, and Blood Institute's National Asthma Education Prevention Program guidelines and improve outcomes. The National Asthma Education Prevention Program guidelines provide clinicians with a range of acceptable approaches for the diagnosis and management of asthma and define general practices that meet the needs of most patients. Yet disparities in asthma care and outcomes remain pervasive for African Americans and Hispanics/Latinos. The National Heart, Lung, and Blood Institute AsthmaNet consortium has identified several top research priorities for pediatric and adult populations, including a recommendation to examine tailored approaches based on race/ethnicity. In addition, the guidelines emphasize the need for studies that focus on multicomponent interventions recognizing that single interventions are generally ineffective. This article will describe the Patient-Centered Outcomes Research Institute-funded asthma projects and how they are individually and collectively addressing evidence gaps in asthma care by focusing on multicomponent and tailored approaches for improving outcomes and reducing disparities for African American and Hispanic/Latino patients.

Using decision support for population tracking of adherence to recommended asthma guidelines

OBJECTIVE

Decision support systems linked to administrative databases provide a unique opportunity to monitor adherence to guidelines and target disease management strategies towards patients not receiving guideline-based therapy. The objective of this study was to evaluate the discrepancy between actual asthma treatments prescribed by primary care physicians compared to those recommended by evidence-based guidelines using a decision support tool linked to a provincial health administrative database.

DESIGN

The drug and medical services information of individuals with asthma was identified from the provincial health database and was pushed through an asthma decision support system (ADSS). Recommendations aimed at optimising asthma treatment were generated on two index dates, 15 September 2007 (index date 1) and 15 March 2008 (index date 2).

SETTING

Primary care settings in a large Canadian metropolitan area.

PARTICIPANTS

Individuals with asthma and provincial health insurance primary and secondary outcome measures: well controlled asthma.

RESULTS

16 803 eligible individuals were identified on index date 1, and 18 103 on index date 2. The distribution of recommendation categories was similar on both index dates. 94% were classified as well controlled and 7% as not well controlled. Among well-controlled individuals, the largest proportion was in the maintain treatment category (63.8%), followed by the maintain/decrease treatment category (28.2%) and the decrease treatment category (2.7%). Almost all individuals who were not well controlled had the recommendation to increase treatment (88%) with a small proportion in the refer category (1%).

CONCLUSIONS

The ADSS was able to identify subgroups of patients from an administrative database that could benefit from a medication review and possible change. Decision support systems linked to an administrative database can be used to identify individuals with uncontrolled asthma or prescriptions that deviate from recommended treatment. When connected to the point of care, this can provide an opportunity for physicians to intervene early.

Validation of parental reports of asthma trajectory, burden, and risk by using the pediatric asthma control and communication instrument

BACKGROUND

Despite a growing interest, few pediatric asthma questionnaires assess multiple dimensions of asthma morbidity, as recommended by national asthma guidelines, or use patient-reported outcomes.

OBJECTIVE

To evaluate a questionnaire that measures multiple dimensions of parent-reported asthma morbidity (Direction, Bother, and Risk).

METHODS

We administered the Pediatric Asthma Control and Communication Instrument (PACCI) and assessed asthma control (PACCI Control), quality of life, and lung function among children who presented for routine asthma care. The PACCI was evaluated for discriminative validity.

RESULTS

A total of 317 children participated (mean age, 8.2 years; 58% boys; 44% African American). As parent-reported PACCI Direction changed from "better" to "worse," we observed poorer asthma control (P < .001), mean Pediatric Asthma Caregiver Quality of Life Questionnaire (PACQLQ) scores (P < .001), and FEV1% (P = .025). Linear regression showed that, for each change in PACCI Direction, the mean PACQLQ score decreased by -0.6 (95% CI, -0.8 to -0.4). As parent-reported PACCI Bother changed from "not bothered" to "very bothered," we observed poorer asthma control (P < .001) and lower mean PACQLQ scores (P < .001). Linear regression showed that, for each change in PACCI Bother category, the mean PACQLQ score decreased by -1.1 (95% CI, -1.3 to -0.9). Any reported PACCI Risk event (emergency department visit, hospitalization, or use of an oral corticosteroid) was associated with poorer asthma control (P < .05) and PACQLQ scores (P < .01).

CONCLUSIONS

PACCI Direction, Bother, and Risk are valid measures of parent-reported outcomes and show good discriminative validity. The PACCI is a simple clinical tool to assess multiple dimensions of parent-reported asthma morbidity, in addition to risk and control.

Interventions to modify health care provider adherence to asthma guidelines: a systematic review

BACKGROUND AND OBJECTIVE

Health care provider adherence to asthma guidelines is poor. The objective of this study was to assess the effect of interventions to improve health care providers' adherence to asthma guidelines on health care process and clinical outcomes.

METHODS

Data sources included Medline, Embase, Cochrane CENTRAL Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, PsycINFO, and Research and Development Resource Base in Continuing Medical Education up to July 2012. Paired investigators independently assessed study eligibility. Investigators abstracted data sequentially and independently graded the evidence.

RESULTS

Sixty-eight eligible studies were classified by intervention: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement/pay-for-performance, multicomponent, and information only. Half were randomized trials (n = 35). There was moderate evidence for increased prescriptions of controller medications for decision support, feedback and audit, and clinical pharmacy support and low-grade evidence for organizational change and multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans. Moderate evidence supports use of decision support tools to reduce emergency department visits, and low-grade evidence suggests there is no benefit for this outcome with organizational change, education only, and quality improvement/pay-for-performance.

CONCLUSIONS

Decision support tools, feedback and audit, and clinical pharmacy support were most likely to improve provider adherence to asthma guidelines, as measured through health care process outcomes. There is a need to evaluate health care provider-targeted interventions with standardized outcomes.

A guideline-based approach to asthma management

The management of asthma has dramatically improved in recent years because of a better understanding of the disease and an organized approach to therapy. All of the various components and tools for evaluating individuals with asthma may be found in the Expert Panel Report Guidelines by the National Heart, Lung, and Blood Institute, initially published in 2007. These comprehensive guidelines help health care professionals care for individuals with asthma throughout their lifespan. This article will assist the health care provider to use these evidence-based guidelines.

Evaluating acceptance and user experience of a guideline-based clinical decision support system execution platform

This study aims to determine what the initial disposition of physicians towards the use of Clinical Decision Support Systems (CDSS) based on Computerised Clinical Guidelines and Protocols (CCGP) is; and whether their prolonged utilisation has a positive effect on their intention to adopt them in the future. For a period of 3 months, 8 volunteer paediatricians monitored each up to 10 asthmatic patients using two CCGPs deployed in the-GuidesMed CDSS. A Technology Acceptance Model (TAM) questionnaire was supplied to them before and after using the system. Results from both questionnaires are analysed searching for significant improvements in opinion between them. An additional survey was performed to analyse the usability of the system. It was found that initial disposition of physicians towards e-GuidesMed is good. Improvement between the pre and post iterations of the TAM questionnaire has been found to be statistically significant. Nonetheless, slightly lower values in the Compatibility and Habit variables show that participants perceive possible difficulties to integrate e-GuidesMed into their daily routine. The variable Facilitators shows the highest correlation with the Intention to Use. Usability of the system has also been rated very high and, in this regard, no fundamental flaw has been detected. Initial views towards e-GuidesMed are positive, and become reinforced after continued utilisation of the system. In order to achieve an effective implementation, it becomes essential to facilitate conditions to integrate the system into the physician's daily routine.