An evidence-based, point-of-care tool to guide completion of asthma action plans in practice

Integrating asthma care guidelines into primary care electronic medical records: a review focused on Canadian knowledge translation tools

INTRODUCTION

Asthma is one of the most common chronic respiratory diseases globally. Despite national and international asthma care guidelines, gaps persist in primary care. Knowledge translation (KT) electronic tools (eTools) exist aiming to address these gaps, but their impact on practice patterns and patient outcomes is variable. We aimed to conduct a nonsystematic review of the literature for key asthma care gaps and identify limitations and future directions of KT eTools optimised for use in electronic medical records (EMRs).

METHODS

The database OVID Medline was searched (1999-2024) using keywords such as asthma, KT, primary healthcare and EMRs. Primary research articles, systematic reviews and published international/national guidelines were included. Findings were interpreted within the knowledge-to-action framework.

RESULTS

Key asthma care gaps in primary care include under-recognition of suboptimal control, underutilisation of pulmonary function tests, barriers to care delivery, provider attitudes/beliefs, limited access to asthma education and referral to asthma specialists. Various KT eTools have been validated, many with optimisation for use in EMRs. KT eTools within EMRs have been a recent focus, including asthma management systems, decision support algorithms, data standards initiatives and asthma case definition validation for EMRs.

CONCLUSIONS

The knowledge-to-action cycle is a valuable framework for developing and implementing novel KT tools. Future research should integrate end-users into the process of KT tool development to improve the perceived utility of these tools. Additionally, the priorities of primary care physicians should be considered in future KT tool research to improve end-user uptake and overall asthma management practices.

Improving Asthma Action Plan Completion Rates across Five Divisions in an Academic Children's Hospital

Introduction

Asthma is the most common chronic disease among children. Asthma Action Plans (AAPs) enable asthma self-management tailored to each patient and should be updated annually. At our institution, providers face challenges in creating reliable processes to consistently complete AAPs for patients with asthma. This project's aim was to increase the percentage of patients across five hospital divisions who have an up-to-date AAP from 80% in May 2021 to 85% by October 1, 2021.

Methods

We launched a quality improvement (QI) project using the Model for Improvement, focusing on improving AAP completion rates across five hospital divisions providing ambulatory care for asthma patients. The divisions (Adolescent/Young Adult Medicine, Allergy, Pulmonary, and two Primary Care sites) participated in the QI process using tools to understand the problem context. They implemented a cross-divisional AAP completion competition from June to October 2021. Each month during Action Periods, divisions trialed their interventions using Plan-Do-Study-Act cycles. We held monthly Learning Sessions for divisions to collaborate on successful intervention strategies.

Results

Statistical process control chart analysis demonstrated that the overall AAP completion rate increased from a baseline of 80% to 87% with the initiation of the competition. All divisions showed improvement in AAP completion rates during the active intervention period, but sustainment varied.

Conclusions

The cross-divisional competition motivated five divisions to improve processes to increase AAP completion rates. This approach effectively fostered engagement and idea sharing to boost performance, and may be considered for other QI projects.

Self-management education for children with epilepsy and their caregivers. A scoping review

Self-management education programs have been highly successful in preparing people to manage medical conditions with recurring events. A detailed curriculum for epilepsy patients, and their caretakers, is lacking. Here we assess what is available for patients who have disorders with recurring events and offer an approach to developing a potential self-care curriculum for patients with seizures and their caregivers. Among the anticipated components are a baseline efficacy assessment and training tailored to increasing self-efficacy, medication compliance, and stress management. Those at risk of status epilepticus will also need guidance in preparing a personalized seizure action plan and training in how to decide when rescue medication is appropriate and how to administer the therapy. Peers, as well as professionals, could teach and provide support. To our knowledge, no such programs are currently available in English. We encourage their creation, dissemination, and widespread use.

Advancing Digital Solutions to Overcome Longstanding Barriers in Asthma and COPD Management

Maintenance therapy delivered via inhaler is central to asthma and chronic obstructive pulmonary disease (COPD) management. Poor adherence to inhaled medication and errors in inhalation technique have long represented major barriers to the optimal management of these chronic conditions. Technological innovations may provide a means of overcoming these barriers. This narrative review examines ongoing advances in digital technologies relevant to asthma and COPD with the potential to inform clinical decision-making and improve patient care. Digital inhaler devices linked to mobile apps can help bring about changes in patients' behaviors and attitudes towards disease management, particularly when they build in elements of interactivity and gamification. They can also support ongoing technique education, empowering patients and helping providers maximize the value of consultations and develop effective action plans informed by insights into the patient's inhaler use patterns and their respiratory health. When combined with innovative techniques such as machine learning, digital devices have the potential to predict exacerbations and prompt pre-emptive intervention. Finally, digital devices may support an advanced precision medicine approach to respiratory disease management and help support shared decision-making. Further work is needed to increase uptake of digital devices and integrate their use into care pathways before their full potential in personalized asthma and COPD management can be realized.

A Predictive Machine Learning Tool for Asthma Exacerbations: Results from a 12-Week, Open-Label Study Using an Electronic Multi-Dose Dry Powder Inhaler with Integrated Sensors

PURPOSE

Machine learning models informed by sensor data inputs have the potential to provide individualized predictions of asthma deterioration. This study aimed to determine if data from an integrated digital inhaler could be used to develop a machine learning model capable of predicting impending exacerbations.

PATIENTS AND METHODS

Adult patients with poorly controlled asthma were enrolled in a 12-week, open-label study using ProAir® Digihaler®, an electronic multi-dose dry powder inhaler (eMDPI) with integrated sensors, as reliever medication (albuterol, 90 µg/dose; 1-2 inhalations every 4 hours, as needed). Throughout the study, the eMDPI recorded inhaler use, peak inspiratory flow (PIF), inhalation volume, inhalation duration, and time to PIF. A model predictive of impending exacerbations was generated by applying machine learning techniques to data downloaded from the inhalers, together with clinical and demographic information. The generated model was evaluated by receiver operating characteristic area under curve (ROC AUC) analysis.

RESULTS

Of 360 patients included in the predictive analysis, 64 experienced a total of 78 exacerbations. Increased albuterol use preceded exacerbations; the mean number of inhalations in the 24-hours preceding an exacerbation was 7.3 (standard deviation 17.3). The machine learning model, using gradient-boosting trees with data from the eMDPI and baseline patient characteristics, predicted an impending exacerbation over the following 5 days with an ROC AUC of 0.83 (95% confidence interval: 0.77-0.90). The feature of the model with the highest weight was the mean number of daily inhalations during the 4 days prior to the day the prediction was made.

CONCLUSION

A machine learning model to predict impending asthma exacerbations using data from the eMDPI was successfully developed. This approach may support a shift from reactive care to proactive, preventative, and personalized management of chronic respiratory diseases.

New Concepts and Technological Resources in Patient Education and Asthma Self-Management

Asthma is a chronic disease that is associated with significant morbidity and mortality. In general, the use of technology resources or electronic health (e-health) has been shown to have beneficial effects on patients with asthma. E-health can impact a broad section of patients and can be cost-effective and associated with high patient satisfaction. E-health may enable remote delivery of care, as well as timely access to health care, which are some of the common challenges faced by patients with asthma. Web-based asthma self-management systems have been found to improve quality of life, self-reported asthma symptoms, lung function, reduction in asthma symptoms/exacerbations, and self-reported adherence for adults. Social media is commonly being used as a platform to disseminate information on asthma to increase public awareness. It can facilitate asthma self-management in a patient friendly manner and has shown to improve asthma control test scores as well as self-esteem. Text massages reminders can increase awareness regarding asthma treatment and control, thus potentially can improve adherence to medications and asthma outcome. Mobile health applications can support asthma self-management, improve a patient's quality of life, promote medication adherence, and potentially reduce the overall costs for asthma care. Inhaler trackers have shown to be beneficial to asthma outcome in various populations by improving adherence to asthma medications. Barriers such as physician financial reimbursement as well as licensing for rendering tele-healthcare services are important concerns. Other limitations of using technology resources in health care are related to liability, professionalism, and ethical issues such as breach of patient confidentiality and privacy. Additionally, there may be less face-to-face interaction and care of the patient when e-health is used.

Essential Role of Pharmacists in Asthma Care and Management

Asthma, a chronic respiratory disease characterized by chronic airway inflammation, bronchial hyperresponsiveness, and reversible airflow obstruction, poses a substantial economic burden on patients and caregivers alike. Moreover, the heterogeneous nature of the disease and the presence of various phenotypes make the treatment of asthma challenging and nuanced. Despite the availability of several approved pharmacological treatments, approximately half of patients with asthma in the United States experienced exacerbations in 2016, highlighting the need for effective add-on treatments. Furthermore, asthma control remains suboptimal due to low adherence to medications, poor inhaler technique, and several patient-related factors. Importantly, the primary care setting, in which pharmacists play an integral role, represents a critical environment for providing long-term follow-up care for the effective management of chronic diseases, such as asthma. Pharmacists are uniquely positioned to ensure optimal clinical outcomes in patients with asthma since they have the clinical expertise to educate patients on their disease state and the role of asthma medications, provide training on inhalation technique, address patients’ concerns about potential side effects of medications, and improve adherence to therapy. Therefore, in this review article, we discuss the overall role of pharmacists in effective asthma care and management.

A system uptake analysis and GUIDES checklist evaluation of the Electronic Asthma Management System: A point-of-care computerized clinical decision support system

OBJECTIVE

Computerized clinical decision support systems (CCDSSs) promise improvements in care quality; however, uptake is often suboptimal. We sought to characterize system use, its predictors, and user feedback for the Electronic Asthma Management System (eAMS)-an electronic medical record system-integrated, point-of-care CCDSS for asthma-and applied the GUIDES checklist as a framework to identify areas for improvement.

MATERIALS AND METHODS

The eAMS was tested in a 1-year prospective cohort study across 3 Ontario primary care sites. We recorded system usage by clinicians and patient characteristics through system logs and chart reviews. We created multivariable models to identify predictors of (1) CCDSS opening and (2) creation of a self-management asthma action plan (AAP) (final CCDSS step). Electronic questionnaires captured user feedback.

RESULTS

Over 1 year, 490 asthma patients saw 121 clinicians. The CCDSS was opened in 205 of 1033 (19.8%) visits and an AAP created in 121 of 1033 (11.7%) visits. Multivariable predictors of opening the CCDSS and producing an AAP included clinic site, having physician-diagnosed asthma, and presenting with an asthma- or respiratory-related complaint. The system usability scale score was 66.3 ± 16.5 (maximum 100). Reported usage barriers included time and system accessibility.

DISCUSSION

The eAMS was used in a minority of asthma patient visits. Varying workflows and cultures across clinics, physician beliefs regarding asthma diagnosis, and relevance of the clinical complaint influenced uptake.

CONCLUSIONS

Considering our findings in the context of the GUIDES checklist helped to identify improvements to drive uptake and provides lessons relevant to CCDSS design across diseases.

The Electronic Asthma Management System (eAMS) improves primary care asthma management

A high prevalence of suboptimal asthma control is attributable to known evidence–practice gaps. We developed a computerised clinical decision support system (the Electronic Asthma Management System (eAMS)) to address major care gaps and sought to measure its impact on care in adults with asthma.

This was a 2-year interrupted time-series study of usual care (year 1) versus eAMS (year 2) at three Canadian primary care sites. We included asthma patients aged ≥16 years receiving an asthma medication within the last 12 months. The eAMS consisted of a touch tablet patient questionnaire completed in the waiting room, with real-time data processing producing electronic medical record-integrated clinician decision support.

Action plan delivery (primary outcome) improved from zero out of 412 (0%) to 79 out of 443 (17.8%) eligible patients (absolute increase 0.18 (95% CI 0.14–0.22)). Time-series analysis indicated a 30.5% increase in physician visits with action plan delivery with the intervention (p<0.0001). Assessment of asthma control level increased from 173 out of 3497 (4.9%) to 849 out of 3062 (27.7%) eligible visits (adjusted OR 8.62 (95% CI 5.14–12.45)). Clinicians escalated controller therapy in 108 out of 3422 (3.2%) baseline visits versus 126 out of 3240 (3.9%) intervention visits (p=0.12). At baseline, a short-acting β-agonist alone was added in 62 visits and a controller added in 54 visits; with the intervention, this occurred in 33 and 229 visits, respectively (p<0.001).

The eAMS improved asthma quality of care in real-world primary care settings. Strategies to further increase clinician uptake and a randomised controlled trial to assess impact on patient outcomes are now required.

The Electronic Asthma Management System is a systematically developed and evidence-based computerised decision support tool that engages both patients and healthcare providers to improve the quality of asthma care in real-world primary care settingshttp://ow.ly/w43Z30nxALB

Asthma and Allergy Mobile Apps in 2018

PURPOSE OF REVIEW

This paper offers a comprehensive review of interactive mobile allergy and asthma smartphone applications available within the USA in 2018, with an emphasis on interactive asthma apps.

RECENT FINDINGS

Primary care and specialty clinicians interested in introducing digital health apps into their practices will soon have more choices, for Apple® and major electronic medical record software companies are investing heavily in the mobile medical marketplace, guaranteeing personal health information and access to care will always be immediately available in one's digital hand. Interactive mobile asthma applications are valuable assets for patients and caregivers alike, for they offer immediate communications between patients and those responsible for providing for their needs.

New evidence-based tool to guide the creation of asthma action plans for adults

OBJECTIVE

To improve the use of asthma action plans (AAPs) among primary care physicians.

SOURCES OF INFORMATION

In a 2017 article, recent asthma guidelines and adult studies (January 2010 to March 2016) addressing acute loss of asthma control were reviewed to develop an evidence-based tool to help guide physicians in creating AAPs to maximize adherence and minimize errors. Evidence supporting the effects of AAPs is level I. Evidence supporting the recommendations in the tool ranges from level I to consensus.

MAIN MESSAGE

A lack of knowledge about and training in creating appropriate AAP content is an important barrier to the use of AAPs, as is the fact that instructions provided by asthma guidelines are often difficult to integrate into real-world practice. In order to address these issues, a freely accessible, practical, evidence-based tool has recently been created, addressing both the knowledge and the practical barriers to AAP creation. This tool has been formatted as a printable bedside chart for the point of care, but could also be integrated into a computerized electronic decision support system in the future.

CONCLUSION

Asthma action plans, in conjunction with asthma education and regular follow-up, can improve patients' symptoms and quality of life and reduce hospitalization. This novel point-of-care tool provides practical advice on how to complete AAPs to improve patients' asthma self-management.

Nouvel outil factuel pour orienter la création de plans d’action pour l’asthme chez les adultes

Objectif

Améliorer l’utilisation des plans d’action pour l’asthme (PAA) par les omnipraticiens.

Sources de l’information

Un article publié en 2017 passait en revue les récentes lignes directrices de prise en charge de l’asthme et les études menées auprès d’adultes (de janvier 2010 à mars 2016) portant sur la perte aiguë de la maîtrise de l’asthme, dans le but de créer un outil factuel pouvant orienter les médecins dans la création de PAA de manière à optimiser l’observance du traitement et à réduire les erreurs au minimum. Les données probantes étayant les effets des PAA sont de niveau I. Les données probantes étayant les recommandations faites dans l’outil varient entre le niveau I et le consensus.

Message principal

Un obstacle important à l’emploi des PAA est l’absence de connaissances des PAA et de formation pour créer un contenu approprié, de même que la difficulté d’intégrer dans la pratique réelle les instructions fournies dans les lignes directrices sur l’asthme. Pour faire tomber ces obstacles, un outil factuel, pratique et facilement accessible a récemment vu le jour; il aborde les obstacles pratiques et liés aux connaissances en matière de création d’un PAA. Cet outil prend la forme d’un tableau à imprimer pouvant être utilisé au chevet du patient, mais il pourra aussi à l’avenir être intégré dans un système informatisé d’aide à la décision.

Conclusion

Les plans d’action pour l’asthme, jumelés à l’éducation sur l’asthme et au suivi régulier, soulagent les symptômes, améliorent la qualité de vie et réduisent les hospitalisations. Ce nouvel outil de point de service fournit des conseils pratiques sur la façon de créer un PAA dans le but d’améliorer l’autoprise en charge de l’asthme.

Development process and patient usability preferences for a touch screen tablet-based questionnaire

We sought to design a touch tablet asthma questionnaire while identifying patient preferences for usability features of such questionnaires. We created an evidence-based prototype and employed rapid-cycle design (semi-structured focus group testing, analysis, corresponding modifications, re-testing) with asthma patients aged ⩾16 years. We analyzed transcripts using deductive and inductive content analysis. Quantitative measures included Likert-type-scale responses, the System Usability Scale, and questionnaire completion times. There were 20 participants across five focus groups (15/20 female, age 49.1 ± 15.6 years). Usability-related themes included (1) "Touch Technology" (hygiene, touch technology familiarity, ease of use) and (2) "Questionnaire Design" (visual characteristics, navigation). Completion time was 11.7 ± 5.9 min. Summative Likert-type scale responses suggested high system usability, as did a System Usability Scale score of 84.2 ± 14.7. In summary, Attention to specific technology- and design-related preferences can result in a highly usable patient-facing touch tablet questionnaire. Our findings can inform touch questionnaire design across other diseases.

Patient preferences for a touch screen tablet-based asthma questionnaire

OBJECTIVE

Assessment of asthma control and provision of asthma action plans are seldom performed in practice, partly due to limited time for physicians to ascertain required information. A patient-facing electronic asthma questionnaire could facilitate information collection. We sought to design a touch-tablet asthma questionnaire for use in the clinic waiting room and to describe patient preferences for the content of such a questionnaire.

METHODS

We created a questionnaire prototype based on best evidence and employed rapid-cycle design (semi-structured focus group testing; analysis; corresponding modifications and re-testing) with asthma patients aged ≥16 years. We analyzed transcripts using deductive and inductive content analysis. Quantitative measures included Likert-scale questions and questionnaire completion times.

RESULTS

There were 20 participants across five focus groups (15/20 (75%) female, age 49.1 ± 15.6 years). Content-related themes included: 1) comprehensibility (language) (how questionnaire language affected ease and accuracy of comprehension) and b) information collection (issues arising during information collection in the following identified subthemes: personal asthma symptoms and triggers; asthma control; asthma medications and contact information). Average questionnaire completion time was 11.7 ± 5.9 min. Summative Likert scale responses suggested high levels of question comprehension and confidence with responses.

CONCLUSIONS

Our analysis provides novel insight about how best to formulate and present asthma-related content in an electronic questionnaire. Such questionnaires might facilitate quality improvement by improving efficiency of data collection, enabling better assessment of asthma control and medication adherence, and personalization of asthma action plans. Future studies should measure real-world uptake of such a questionnaire and impact on care.