Physician asthma education program improves outcomes for children of low-income families

Impact of a Pediatric-Focused Communication Course on Patient/Caregiver-Perceived Physician Communication Skills in a Pediatric Emergency Department

OBJECTIVES

To evaluate the impact of a pediatric-focused, relationship-centered communication course on patient/caregiver assessment of emergency department (ED) physician communication skills.

METHODS

This was a prospective study; a previously validated assessment tool (Pediatric Physician Interpersonal Communication Skills Assessment [P-PICSA]) was used to collect pediatric patient/caregiver evaluation of ED physician communication skills. Emergency department physicians were required to attend a 5.5-hour communication course. Differences in precourse/postcourse P-PICSA and top-box scores were analyzed to determine course impact on ED physician communication skills.

RESULTS

From July 2016 to August 2017, 49 pediatric ED physicians participated in the course, and 24 physicians (49%) had 6-month precourse/postcourse P-PICSA data. Postcourse scores were higher for all 13 items, with 3 items achieving statistical significance: (1) the doctor used words I could understand; (2) the way the doctor involved me in making decisions about my child's care in the ED; (3) how the doctor discussed next steps and/or follow-up plans for my child's care after we leave the ED (P < 0.05). Additionally, postcourse, top-box score percentages were higher for 12 items, with 1 item achieving statistical significance (P = 0.0386).

CONCLUSIONS

An organization-wide, pediatric-focused, relationship-centered communication course improved patient/caregiver-perceived ED physician communication. Further research is necessary to assess long-term sustainability.

Oral Dexamethasone to Control Wheezing in Children at an Outpatient Clinic

Asthma, a chronic childhood disease, has resulted in increased emergency department (ED) visits with high costs. Many asthma ED visits are nonemergent and could be treated in outpatient clinics. Literature has concluded that a 2-day course of oral dexamethasone has comparable outcomes to a 5-day course of prednisone in the ED and hospital setting. A retrospective chart review was performed on children requiring in-house treatment with a corticosteroid (dexamethasone n = 23, prednisone n = 40) for acute asthma exacerbations at an ambulatory medical home. The rates of hospital admissions, ED visits, and symptom follow-up were similar between the 2 groups ( P > .05). The cost for a course of dexamethasone was US$1.28 versus US$16.20 for prednisolone. The average cost for an asthma exacerbation office visit was US$79.89 compared with US$3113.28 for an ED visit. A 2-day course of oral dexamethasone appears to be a promising clinical and cost-effective treatment for acute asthma exacerbations at the primary care level.

Evaluating and improving the implementation of a community-based hereditary cancer screening program

Healthcare disparities exist in the provision of cancer genetic services including genetic counseling and testing related to BRCA1/2 mutations. To address this in a community health setting a screening tool was created to identify high-risk women. This study evaluates the implementation of the tool and identifies opportunities for improved cancer genetic screening, including regular clinician education. A mixed-method approach was used to evaluate clinician utilization of the screening tool at Planned Parenthood affiliates. Novel surveys that evaluated acceptance and implementation were administered to clinicians (n = 14) and semi-structured interviews (n = 6) were used to explore clinicians' perspectives and identify gaps in its utilization. Educational modules that addressed gaps were developed, implemented, and evaluated using a post-education survey (n = 8). Clinicians reported confidence in administering and interpreting the screening tool, but reported less confidence in their knowledge of cancer genetics and ability to connect clients with genetic counseling and testing (p = .003). Educational modules resulted in significant gains in clinician knowledge on genetic topics (p < .05) and increased self-reported confidence in connecting clients with genetic services. The modules reinforced the belief that genetic testing is beneficial for patients at increased risk (p = .001) and is important to inform subsequent medical management (p = .027). While building community clinicians' capacity to connect clients with genetic services is crucial, it is challenged by knowledge and confidence gaps in discussions of genetic services with clients. Consistent genetic-focused education with non-genetic clinicians can improve confidence and knowledge, enabling a more effective screening program in community health settings.

IMP2ART systematic review of education for healthcare professionals implementing supported self-management for asthma

Despite a robust evidence base for its effectiveness, implementation of supported self-management for asthma is suboptimal. Professional education is an implementation strategy with proven effectiveness, though the specific features linked with effectiveness are often unclear. We performed a systematic review of randomised controlled trials and controlled clinical trials (published from 1990 and updated to May 2017 using forward citation searching) to determine the effectiveness of professional education on asthma self-management support and identify features of effective initiatives. Primary outcomes reflected professional behaviour change (provision of asthma action plans) and patient outcomes (asthma control; unscheduled care). Data were coded using the Effective Practice and Organisation of Care Taxonomy, the Theoretical Domains Framework (TDF), and Bloom's Taxonomy and synthesised narratively. Of 15,637 articles identified, 18 (reporting 15 studies including 21 educational initiatives) met inclusion criteria. Risk of bias was high for five studies, and unclear for 10. Three of 6 initiatives improved action plan provision; 1/2 improved asthma control; and 2/7 reduced unscheduled care. Compared to ineffective initiatives, effective initiatives were more often coded as being guideline-based; involving local opinion leaders; including inter-professional education; and addressing the TDF domains 'social influences'; 'environmental context and resources'; 'behavioural regulation'; 'beliefs about consequences'; and 'social/professional role and identity'. Findings should be interpreted cautiously as many strategies were specified infrequently. However, identified features warrant further investigation as part of implementation strategies aiming to improve the provision of supported self-management for asthma.

Caring for Young Children with Asthma: Perspectives from Urban Community Health Centers

Asthma disproportionately affects low-income, minority youth, with notable disparities among children <5 years of age. Understanding the perceptions of urban community health centers (CHCs) regarding treating young children with asthma could improve care for these patients. This study uses data from semi-structured focus groups with staff from eight urban CHCs. Themes emerged in three domains. Within the parent/family domain, providers noted low rates of follow-up visits, low health literacy, and-for young children specifically-misunderstanding about the diagnosis. At the CHC level, providers needed more staff, space, and comfort with applying the guidelines to infants and young children. CHCs reported asthma registries, population health oversight, and an asthma champion improved care. At the system level, providers wanted improved communication with emergency departments and community outreach programs. Reducing these multi-level barriers may improve care.

Association Between Survival and Time of Day for Rapid Response Team Calls in a National Registry

OBJECTIVES

Decreased staffing at nighttime is associated with worse outcomes in hospitalized patients. Rapid response teams were developed to decrease preventable harm by providing additional critical care resources to patients with clinical deterioration. We sought to determine whether rapid response team call frequency suffers from decreased utilization at night and how this is associated with patient outcomes.

DESIGN

Retrospective analysis of a prospectively collected registry database.

SETTING

National registry database of inpatient rapid response team calls.

PATIENTS

Index rapid response team calls occurring on the general wards in the American Heart Association Get With The Guidelines-Medical Emergency Team database between 2005 and 2015 were analyzed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was inhospital mortality. Patient and event characteristics between the hours with the highest and lowest mortality were compared, and multivariable models adjusting for patient characteristics were fit. A total of 282,710 rapid response team calls from 274 hospitals were included. The lowest frequency of calls occurred in the consecutive 1 AM to 6:59 AM period, with 266 of 274 (97%) hospitals having lower than expected call volumes during those hours. Mortality was highest during the 7 AM hour and lowest during the noon hour (18.8% vs 13.8%; adjusted odds ratio, 1.41 [1.31-1.52]; p < 0.001). Compared with calls at the noon hour, those during the 7 AM hour had more deranged vital signs, were more likely to have a respiratory trigger, and were more likely to have greater than two simultaneous triggers.

CONCLUSIONS

Rapid response team activation is less frequent during the early morning and is followed by a spike in mortality in the 7 AM hour. These findings suggest that failure to rescue deteriorating patients is more common overnight. Strategies aimed at improving rapid response team utilization during these vulnerable hours may improve patient outcomes.

Can a Short Video Improve Inhaler Use in Urban Youth?

OBJECTIVE

The primary aim was to determine whether watching a short video in the inpatient setting could produce an immediate improvement in pediatric patients' asthma knowledge and inhaler technique.

METHODS

This prospective, quasi-experimental, pre-post study was conducted in a single center, in Detroit, Michigan, which primarily serves an urban, African-American population. Patients were eligible if they were between 8- and 16-years-old, had asthma, and would be discharged with an albuterol metered-dose inhaler. The primary outcome was improvement in the composite score of a knowledge and technique assessment before and after watching a 5-minute video. The lead author developed the video with content validation by pharmacists, pediatricians, elementary school teachers, and a pediatric health education specialist. Secondary outcomes at 30 days included change in asthma control and whether the video was revisited after discharge.

RESULTS

Thirty patients were enrolled. Their average age was 11 ± 2.1 years; they were primarily African American (83%), female (53%), and insured by Medicaid (87%). The composite score of technique assessment and written quiz increased by 3.53 (95% confidence interval [CI] 2.81 to 4.85) of a possible 16 points after watching the video. There was no significant change in asthma control at 30 days as measured by the asthma control test (2, 95% CI -0.53 to 4.53). Eight of 22 patients revisited the video after discharge.

CONCLUSIONS

A brief educational video delivered during a pediatric inpatient visit in an urban medical center resulted in an immediate improvement in patients' disease knowledge and inhaler technique.

Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia

Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.

Effectiveness of a multi-level asthma intervention in increasing controller medication use: a randomized control trial

INTRODUCTION

Poor self-management by families is an important factor in explaining high rates of asthma morbidity in Puerto Rico, and for this reason we previously tested a family intervention called CALMA that was found effective in improving most asthma outcomes, but not effective in increasing the use of controller medications. CALMA-plus was developed to address this issue by adding to CALMA, components of provider training and screening for asthma in clinics.

METHODS

Study participants were selected from claims Medicaid data in San Juan, Puerto Rico. After screening, 404 children in eight clinics were selected after forming pairs of clinics and randomizing the clinics) to CALMA-only or CALMA-plus.

RESULTS

For all three primary outcomes at 12 months, the mean differences between treatment arms were small but in the predicted direction. However, after adjusting for clinic variation, the study failed to demonstrate that the CALMA-plus intervention was more efficacious than the CALMA-only intervention for increasing controller medication use, or decreasing asthma symptoms. Both groups had lower rates of asthma symptoms and service utilization, consistent with previous results of the CALMA-only intervention.

CONCLUSIONS

Compliance of providers with the intervention and training, small number of clinics available and the multiple barriers experienced by providers for medicating may have been related to the lack of difference observed between the groups. Future interventions should respond to the limitations of the present study design and provide more resources to providers that will increase provider participation in training and implementation of the intervention.

A Low-Literacy Asthma Action Plan to Improve Provider Asthma Counseling: A Randomized Study

BACKGROUND AND OBJECTIVES

The use of written asthma action plans (WAAPs) has been associated with reduced asthma-related morbidity, but there are concerns about their complexity. We developed a health literacy-informed, pictogram- and photograph-based WAAP and examined whether providers who used it, with no training, would have better asthma counseling quality compared with those who used a standard plan.

METHODS

Physicians at 2 academic centers randomized to use a low-literacy or standard action plan (American Academy of Allergy, Asthma and Immunology) to counsel the hypothetical parent of child with moderate persistent asthma (regimen: Flovent 110 μg 2 puffs twice daily, Singulair 5 mg daily, Albuterol 2 puffs every 4 hours as needed). Two blinded raters independently reviewed counseling transcriptions.

PRIMARY OUTCOME MEASURES

medication instructions presented with times of day (eg, morning and night vs number of times per day) and inhaler color; spacer use recommended; need for everyday medications, even when sick, addressed; and explicit symptoms used.

RESULTS

119 providers were randomly assigned (61 low literacy, 58 standard). Providers who used the low-literacy plan were more likely to use times of day (eg, Flovent morning and night, 96.7% vs 51.7%, P < .001; odds ratio [OR] = 27.5; 95% confidence interval [CI], 6.1-123.4), recommend spacer use (eg, Albuterol, 83.6% vs 43.1%, P < .001; OR = 6.7; 95% CI, 2.9-15.8), address need for daily medications when sick (93.4% vs 34.5%, P < .001; OR = 27.1; 95% CI, 8.6-85.4), use explicit symptoms (eg, "ribs show when breathing," 54.1% vs 3.4%, P < .001; OR = 33.0; 95% CI, 7.4-147.5). Few mentioned inhaler color. Mean (SD) counseling time was similar (3.9 [2.5] vs 3.8 [2.6] minutes, P = .8).

CONCLUSIONS

Use of a low-literacy WAAP improves the quality of asthma counseling by helping providers target key issues by using recommended clear communication principles.

Policy and system change and community coalitions: outcomes from allies against asthma

Objectives. We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. Methods. We interviewed a sample of 1,477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. Results. A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. Conclusions. Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Patient assessment of primary care physician communication: segmentation approach

Purpose

– The purpose of this paper is to examine how patient assessment of primary care physician (PCP) communication is related to patient satisfaction with the PCP, patient perception of PCP professional competence, patient assessment of the relationship with the doctor and patient demographic characteristics using a segmentation approach.

Design/methodology/approach

– The authors surveyed 514 adult patients waiting for appointments with their PCPs in two US primary care clinics. A latent class analysis was used to identify mutually exclusive unobserved homogeneous classes of patients.

Findings

– The authors identified three distinct classes/groups with regard to patient assessment of physician communication and the physician-patient relationship. The largest group (53 percent of the sample) assessed their PCP communication and other doctor-patient relationship aspects as excellent. However, 37 percent provided mostly negative assessments, expressed high general dissatisfaction with the physician and disagreed with the statement that their PCP was well qualified to manage their health problems. These patients were on average more educated and affluent and the group included more males. About 10 percent of patients expressed generally lower satisfaction with the PCP, though their dissatisfaction was not as extreme as in the highly dissatisfied group.

Research limitations/implications

– Further studies are needed to help physicians develop skills to communicate with different patients.

Originality/value

– Patient segmentation can be an important tool for healthcare quality improvement particularly for emerging approaches to primary care such as patient-centered care.

Effectiveness of asthma principles and practice course in increasing nurse practitioner knowledge and confidence in the use of asthma clinical guidelines

PURPOSE

The Asthma Principle and Practice (APP) course, an evidence-based blended distance-learning educational encounter, was designed to aid in the dissemination of the 2007 asthma clinical guidelines (EPR-3) and priority messages, increase knowledge of content of the guidelines as well as create an environment to enable participants to apply knowledge and skills into clinical practice. Students received a self-study binder 6-week period prior to attendance at an interactive study day. The APP is grounded in adult education principle and practices.

DATA SOURCES

A questionnaire was completed before reading the study binder and post study day to measure demographic variables as well as awareness of and changes in knowledge and confidence in key attributes of the clinical guidelines including patient education.

CONCLUSIONS

The results showed that by taking the APP course confidence levels related to knowledge of asthma and its management increased with specific reference to the asthma clinical guidelines. Confidence in the use of patient education/communication strategies improved as well as the use of pulmonary function tests and the interpretation of test results.

IMPLICATIONS FOR PRACTICE

Nurse practitioners are an important audience to target in the dissemination of clinical guidelines and benefit from educational materials based on adult education strategies.

Pediatrician qualifications and asthma management behaviors and their association with patient race/ethnicity

OBJECTIVE

We sought to understand if pediatrician characteristics and asthma assessment and treatment varied in association with the proportion of African-American and Latino children in the pediatrician's practice.

METHODS

We conducted a cross-sectional survey of 500 American Academy of Pediatrics members between November 2005 and May 2006. Standardized vignettes were used to test how different indicators of a patient's asthma status affect pediatrician asthma assessments and recommendations. Linear and logistic regression models were used to examine the association of pediatrician assessments and treatment recommendations for these vignettes, respectively, with the proportion of reported African-American and Latino children seen in their practice.

RESULTS

There were 270 respondents (response rate = 54%). Based on pediatrician-reported percentage of minority patients, there were no differences in board certification status, recognition of poorly controlled asthma nor in the likelihood of appropriately increasing long-term controller medications to treat poorly controlled asthma (p > 0.05 for all analyses).

CONCLUSIONS

Caring primarily for minority children by AAP pediatricians appears unrelated to training qualifications or in their reported knowledge of how to appropriately assess and treat asthma. Therefore, studies of asthma care disparities should focus on understanding the knowledge-base of non-AAP pediatric providers who care for minority populations and exploring other potential contributory provider-level factors (e.g. communication skills).

Reaching beyond disparity: safely improving asthma control in the at-risk African-American population

In the United States, substantial racial disparities exist in asthma prevalence, etiology, morbidity and mortality, particularly between African Americans and white Americans. African-American patients with asthma have inadequate access to appropriate healthcare, insufficient asthma management guidance from their physicians and poor adherence to asthma medications-all factors that may contribute to disproportionate morbidity. Historically, African Americans have been under-represented in clinical asthma studies, and a paucity of data exists surrounding asthma treatment response. One controversial study from 2006 suggests an increased safety risk with the use of long-acting beta2-adrenergic agonists (LABAs) in African Americans. More recently, several studies have evaluated the use of LABAs in combination with an ICS in African-American populations. This article reviews the existing data on asthma treatment outcomes, with particular emphasis on the recently published short- and long-term studies of ICS/LABA products conducted in African-American populations with moderate-to-severe asthma. Overall, evidence suggests that if African-American patients with asthma are provided with access to well-trained physicians, appropriate asthma management and effective medications, existing disparities in asthma control between African-American and white populations may be overcome.

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.

The effectiveness of continuing medical education for specialist recertification

Evolving professional, social and political pressures highlight the importance of lifelong learning for clinicians. Continuing medical education (CME) facilitates lifelong learning and is a fundamental factor in the maintenance of certification. The type of CME differs between surgical and non-surgical specialties. CME methods of teaching include lectures, workshops, conferences and simulation training. Interventions involving several modalities, instructional techniques and multiple exposures are more effective. The beneficial effects of CME can be maintained in the long term and can improve clinical outcome. However, quantitative evidence on validity, reliability, efficacy and cost-effectiveness of various methods is lacking. This is especially evident in urology. The effectiveness of CME interventions on maintenance of certification is also unknown. Currently, many specialists fulfil mandatory CME credit requirements opportunistically, therefore erroneously equating number of hours accumulated with competence. New CME interventions must emphasize actual performance and should correlate with clinical outcomes. Improved CME practice must in turn lead to continuing critical reflection, practice modification and implementation with a focus towards excellent patient care.

Exploring caregiver understanding of medications immediately after a pediatric primary care visit

OBJECTIVE

Assess accuracy of caregiver understanding of children's prescribed medications and examine factors associated with accurate recall.

METHODS

Cross-sectional, observational study of English- or Spanish-speaking caregivers of primary care patients aged 0-7 years. Child and visit characteristics and caregiver health literacy (short test of health literacy in adults) were assessed. Post-visit, caregivers completed questionnaires on medications prescribed. Caregiver and medical record agreement on medication name and administration (dose and frequency) were examined using chi square and logistic regression.

RESULTS

Analyses included 68 caregivers (28% low health literacy); 96% of children had public insurance. Caregivers indicated that the doctor provided clear medication information (100%) and they could follow instructions (98%). 101 medicines were prescribed; 6 were recalled by caregiver only. 71% of medications were accurately named; 37% of administration instructions were accurately recalled. Accurate naming was more often found for patients 3-7 years, without conditions requiring repeat visits, and new medications. Accurate administration responses were associated with having only 1 child at the visit.

CONCLUSION

Unperceived medication instruction understanding gaps exist at physician visits for caregivers of all literacy levels. Communication and care delivery practices need further evaluation.

PRACTICE IMPLICATIONS

Clinicians should be aware of the frequency of caregiver medication misunderstanding.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated.

OBJECTIVES

To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations.

SEARCH METHODS

For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria.

SELECTION CRITERIA

In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training.

DATA COLLECTION AND ANALYSIS

We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model.

MAIN RESULTS

Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients.

AUTHORS' CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

Successes and Opportunities to Adopting Evidence-Based Practices to Improve Asthma Care in New Orleans

Pediatric asthma is a multifactorial disease, requiring complex, interrelated interventions that target children, families, schools, health care providers, and communities. This article describes components of the Head-off Environmental Asthma in Louisiana (HEAL), phase II project, a collaboration between community and medical facilities for children with asthma in New Orleans. HEAL phase II extends and builds on the lessons learned from HEAL I, a post-Katrina research project, an observational study directed by Tulane University Health Sciences Center and the New Orleans Department of Health. HEAL phase II offers an opportunity to understand, from a health system’s perspective, how factors associated with the health care setting, patient-family, health care provider, asthma education, and community work together to create optimal conditions that support pediatric asthma care in New Orleans. In this context, this article will discuss factors contributing to health disparities in asthma; the need for a multidisciplinary approach to address health disparities in asthma; and describe the 4 key components of the HEAL phase II project: health care providers, integration of asthma education by certified asthma educators into clinical settings, utilization of electronic medical records to improve portability of asthma data, and community outreach.

USPSTF perspective on evidence-based preventive recommendations for children

The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge. This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.

A short-term educational program improved physicians' adherence to guidelines for COPD and asthma in Shanghai

Background

Chronic pulmonary diseases such as chronic obstructive pulmonary disease (COPD) and asthma exert increasing burden on society while the management of them is far from adequate. The objective of this study is to evaluate adherence to guidelines through a patient study, and then investigate the effects of a short-term quality improvement educational program among clinicians in Shanghai, China.

Methods

A prescription survey was performed in a random sample of 100 COPD and asthma outpatients to assess their pharmacological therapy. Then, an educational program was conducted in young pulmonary physicians from 83 hospitals in Shanghai. The training course was divided into 7 sessions of 2 hours delivered over 4 days from July 2010 to August 2011. Three months later, all of the participants were asked to take a written examination to assess the efficiency of training.

Results

Prescription survey among the patients indicated the prescriptions are not consistent with the recommendations of current GOLD and GINA guidelines. The mainly existing issue is the overuse of inhaled glucocorticosteroid. For the educational program, 161 pulmonary physicians have attended the training course, and 110 clinicians finished the tests with an attendance rate of 68.3%. Although most of the clinicians recognized the increasing burden of COPD and asthma, they do not know well about the core elements of guidelines and their clinical practice is not fully in agreement with current recommendations. Through crossover comparison, our results suggested clinicians’ knowledge of the guidelines was improved after training.

Conclusions

We concluded that application of continuous educational programs among physicians might promote their adherence to guidelines, and by that improve the quality of healthcare.

Translating evidence-based interventions into practice: the design and development of the Merck Childhood Asthma Network, Inc. (MCAN)

Pediatric asthma is a multifactorial disease, requiring complex, interrelated interventions addressing children, families, schools, and communities. The Merck Childhood Asthma Network, Inc. (MCAN) is a nonprofit organization that provides support to translate evidence-based interventions from research to practice. MCAN developed the rationale and vision for the program through a phased approach, including an extensive literature review, stakeholder engagement, and evaluation of funding gaps. The analysis pointed to the need to identify pediatric asthma interventions implemented in urban U.S. settings that have demonstrated efficacy and materials for replication and to translate the interventions into wider practice. In addition to this overall MCAN objective, specific goals included service and system integration through linkages among health care providers, schools, community-based organizations, patients, parents, and other caregivers. MCAN selected sites based on demonstrated ability to implement effective interventions and to address multiple contexts of pediatric asthma prevention and management. Selected MCAN program sites were mature institutions or organizations with significant infrastructure, existing funding, and the ability to provide services without requiring a lengthy planning period. Program sites were located in communities with high asthma morbidity and intended to integrate new elements into existing programs to create comprehensive care approaches.

Bringing evidence-based continuing education on asthma to nurses

PURPOSE/OBJECTIVE

The objective of the study was to demonstrate how the clinical nurse specialist (CNS) in community health effectively responds to community need. RATIONALE/BACKGROUND: A needs assessment revealed high rates of asthma in the community and a request from nurses for more information on the care and management of persons with asthma. PROJECT/INTERVENTION: The intervention brings evidence-based continuing education on asthma to nurses using the Nurse Asthma Care Education program developed by the National Respiratory Training Center and the University of Michigan to increase nursing awareness of the National Asthma Education and Prevention Program Asthma Guidelines and encourage nursing leadership in asthma control activities.

DESIGN

A quasi-experimental study examined the ability of the Nurse Asthma Care Education program to increase nurses' confidence and perception of using the guidelines.

SAMPLE

Thirty-four nurses participated in a Nurse Asthma Care Education seminar.

METHODS

A preintervention and postintervention survey was conducted.

FINDINGS

Significant changes were noted in nurses' perceptions of the helpfulness of the National Asthma Education and Prevention Program Asthma Guidelines (P ≤ .001) and their confidence to use the guidelines (P ≤ .001) regardless of age with some variation by work setting and years of experience.

CONCLUSIONS

Using CNSs to assess populations, including nursing populations, and train nurses, the largest number of frontline providers, may be an effective way to increase patient education and improve outcomes related to asthma and other chronic diseases.

IMPLICATIONS FOR PRACTICE

The CNS can significantly impact community health by identifying and addressing the needs of those who provide care in the community.

Improving Communication Between Patients and Providers Using Health Information Technology and Other Quality Improvement Strategies: Focus on Low-Income Children

Effective communication between providers and patients has been linked to improved outcomes. Previous reviews of quality improvement strategies, including health information technology (health IT), have not focused on the needs of low-income children. The authors conducted a systematic review of the literature on studies of communication surrounding the care of low-income children, with an emphasis on interventions and health IT.The search yielded six studies that focused on low-income children; three of the studies used health IT. Key informant interviews provided insight to the current use of health IT for provider—patient communication in geographically diverse, underresourced settings.The authors identify gaps between existing literature and clinical practice. Future research should focus on the specific impact of health IT in pediatric medicine, particularly in underresourced and safety net settings. These efforts should focus on the use of technological innovations to improve care for low-income children and their families.

Teachable moments: improving pediatric asthma outcomes through physician education

In light of concerns about adherence to the 1997 National Heart Lung and Blood Institute guidelines as well as the 2002 update regarding treatment of asthma, the authors evaluate educational interventions designed to have a positive impact on pediatric patient outcomes. Social cognitive theory can provide the foundation of interventions for physicians that are intended to promote self efficacy in treating asthma patients. Emphasizing the need for physician education based on principles of adult learning, the authors call for more research in this area and encourage the incorporation of distance learning techniques into educational endeavors. The purpose of this article is to review research on the impact of healthcare provider education designed to increase use of practice guidelines on the quality of pediatric asthma care as reflected in patient outcomes and, ultimately, in cost of treatment.

Policy and system change and community coalitions: outcomes from allies against asthma

OBJECTIVES

We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes.

METHODS

We interviewed a sample of 1477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels.

RESULTS

A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes.

CONCLUSIONS

Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Two-year evaluation of an educational program for adult outpatients with asthma

OBJECTIVE

To evaluate the understanding of asthma and the clinical improvement in patients with moderate or severe persistent asthma prior to and after their participation in an educational program presented during the routine outpatient visits.

METHODS

This was a prospective pilot study involving 164 patients over a two-year period. The educational program, presented to small groups on outpatient visit days, consisted of lectures divided into three parts: pathophysiology; environmental control; and treatment, including training in the inhalation technique. The program was evaluated using standardized questionnaires on clinical improvement and understanding of the disease.

RESULTS

By the end of the first year, 120 patients had completed three visits, and 51 of those patients were re-evaluated at the end of the second year. The mean age of the patients was 44 years, 70% were female, and 43% had up to eight years of schooling. The educational intervention significantly increased the understanding of the disease (p < 0.001), and allowed greater clinical improvement (p < 0.05) with a decrease in the use of oral corticosteroids, fewer visits to the emergency room and fewer days missed from work or school.

CONCLUSIONS

The educational program offered during the routine outpatient visits of adult patients with asthma at our clinic resulted in a progressive long-term increase in knowledge, as well as in clinical improvement.

Adoption of body mass index guidelines for screening and counseling in pediatric practice

OBJECTIVE

The purpose of this study was to examine pediatrician implementation of BMI and provider interventions for childhood overweight prevention and treatment.

METHODS

Data were obtained from the American Academy of Pediatrics (AAP) Periodic Survey of Fellows No. 65, a nationally representative survey of AAP members. Surveys that addressed the provision of screening and management of childhood overweight and obesity in primary care settings were mailed to 1622 nonretired US AAP members in 2006.

RESULTS

One thousand five (62%) surveys were returned; 677 primary care clinicians in active practice were eligible for the survey. Nearly all respondents (99%) reported measuring height and weight at well visits, and 97% visually assess children for overweight at most or every well-child visit. Half of the respondents (52%) assess BMI percentile for children older than 2 years. Most pediatricians reported that they do not have time to counsel on overweight and obesity, that counseling has poor results, and that having simple diet and exercise recommendations would be helpful in their practice. Pediatricians in large practices and those who had attended continuing medical education on obesity were more familiar with national expert guidelines, were more likely to use BMI percentile, and had higher self-efficacy in practices related to childhood and adolescent overweight and obesity. Multivariate analysis revealed that pediatricians with better access to community and adjunct resources were more likely to use BMI percentile.

CONCLUSIONS

BMI-percentile screening in primary pediatric practice is underused. Most pediatricians believe that they can and should try to prevent overweight and obesity, yet few believe there are good treatments once a child is obese. Training, time, and resource limitations affect BMI-percentile use. Awareness of national guidelines may improve rates of BMI-percentile use and recognition of opportunities to prevent childhood and adolescent obesity.

Practical management of asthma

After completing this article, readers should be able to: 1. Identify the major environmental factors and comorbid conditions that affect asthma. 2. Describe the role of a written asthma action plan in the management of asthma. 3. Know how to assess asthma control and adjust therapy appropriately. 4. Discuss the evaluation and management of the child who has an acute exacerbation of asthma.

Continuing medical education effect on practice performance: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines

BACKGROUND

There has been sizable debate and widespread skepticism about the effect of continuing medical education (CME) on the performance of physicians in the practice setting. This portion of the review was undertaken to examine that effect.

METHODS

The guideline panel used data from a comprehensive review of the effectiveness of CME developed by The Johns Hopkins Evidence-based Practice Center, focusing on the effect of CME on clinical performance.

RESULTS

The review found 105 studies, which evaluated the impact of CME on short- and long-term physician practice performance. Nearly 60% met objectives relative to changing clinical performance in prescribing; screening; counseling about smoking cessation, diet, and sexual practices; guideline adherence; and other topics. Single live and multiple media appeared to be generally positive in their effect, print media much less so. Multiple educational techniques were more successful at changing provider performance than single techniques. The amount or frequency of exposure to CME activities appeared to have little effect on behavior change.

CONCLUSIONS

Overall, CME, especially using live or multiple media and multiple educational techniques, is generally effective in changing physician performance. More research, however, is needed that focuses on the specific types of media and educational techniques that lead to the greatest improvements in performance.

Towards Excellence in Asthma Management: final report of an eight-year program aimed at reducing care gaps in asthma management in Quebec

BACKGROUND AND OBJECTIVES

Asthma care in Canada and around the world persistently falls short of optimal treatment. To optimize care, a systematic approach to identifying such shortfalls or 'care gaps', in which all stakeholders of the health care system (including patients) are involved, was proposed.

METHODS

Several projects of a multipartner, multidisciplinary disease management program, developed to optimize asthma care in Quebec, was conducted in a period of eight years. First, two population maps were produced to identify regional variations in asthma-related morbidity and to prioritize interventions for improving treatment. Second, current care was evaluated in a physician-patient cohort, confirming the many care gaps in asthma management. Third, two series of peer-reviewed outcome studies, targeting high-risk populations and specific asthma care gaps, were conducted. Finally, a process to integrate the best interventions into the health care system and an agenda for further research on optimal asthma management were proposed.

RESULTS

Key observations from these studies included the identification of specific patterns of noncompliance in using inhaled corticosteroids, the failure of increased access to spirometry in asthma education centres to increase the number of education referrals, the transient improvement in educational abilities of nurses involved with an asthma hotline telephone service, and the beneficial effects of practice tools aimed at facilitating the assessment of asthma control and treatment needs by general practitioners.

CONCLUSIONS

Disease management programs such as Towards Excellence in Asthma Management can provide valuable information on optimal strategies for improving treatment of asthma and other chronic diseases by identifying care gaps, improving guidelines implementation and optimizing care.

The relationship between school absence, academic performance, and asthma status

BACKGROUND

Children with asthma experience more absenteeism from school compared with their nonasthma peers. Excessive absenteeism is related to lower student grades, psychological, social, and educational adjustment. Less is known about the relationship between the presence of asthma and the academic achievement in school-aged children. Since students with asthma miss more days from school, this may negatively impact their academic achievement. The goal of this study was to investigate the relationships between absenteeism, presence of asthma, and asthma severity level with standardized test level performance in a predominantly African American urban school district.

METHODS

A cross-sectional analysis was conducted of 3812 students (aged 8-17 years) who took the Missouri Assessment Program (MAP) standardized test during the 2002-2003 academic year.

RESULTS

After adjustment for covariates, a significant inverse relationship was found between absenteeism and test level performance on the MAP standardized test in all children (F = 203.9, p < .001). There was no overall difference in test level achievement between those with and without asthma (p = .12). Though not statistically different, those with persistent asthma showed a modestly increased likelihood of scoring below Nearing Proficient compared with those with mild intermittent asthma (adjusted odds ratio = 1.93, 95% confidence intervals = 0.93-4.01, p = .08).

CONCLUSIONS

A negative impact of absenteeism on standardized test level achievement was demonstrated in children from an urban African American school district. Children with asthma perform the same academically as their nonasthma peers. However, those with persistent asthma show a trend of performing worse on MAP standardized test scores and have more absence days compared with other students. More research is warranted on the effects of persistent asthma on academic achievement.

Relationship between pediatric primary provider visits and acute asthma ED visits

OBJECTIVE

The purpose of this study is to evaluate the relationship between primary care provider visits and emergency department (ED) asthma visits for urban, minority children.

DESIGN

This is a retrospective review of eligibility files and Medicaid claims for children with asthma from 1999 to 2001.

PARTICIPANTS

Children 24 months through 17 years of age with Medicaid or state health insurance, who resided in Hartford, Connecticut, and had persistent asthma, were included.

OUTCOME MEASURES

The primary outcome was the number of ICD-9 asthma-related primary care visits in the 12-month period before asthma ED visits. Secondary outcomes included the number of filled prescriptions for controller medications 3 and 12 months before emergency asthma visits.

RESULTS

One thousand four hundred seventy-four children met study criteria. Children with a greater number of asthma-related primary care visits during the previous 12 months were less likely to have asthma-related ED visits in 2000 and 2001 (both years P < 0.001). Children with an asthma-related ED visit had fewer primary care visits (for any reason) in 2000 but not in 2001 (P < 0.01). In 2000, the odds that children with 3 or more asthma-related primary care visits and a filled inhaled corticosteroid (ICS) had an asthma ED visit were 1/5 those of children with fewer asthma-related PCP visits or no filled ICS (OR = 0.20, 95% CI (0.06, 0.65)). Fewer than 17% of all children with asthma-related ED visits filled any prescription for controller medications in the 3 months before these visits.

CONCLUSION

Asthma-related primary care visits are associated with fewer asthma-related ED visits in urban children.

Comprehensive asthma management for underserved children

In response to the 'asthma epidemic', local organisations in San Francisco formed the Yes We Can Urban Asthma Partnership, which uses a comprehensive medical/social model for paediatric asthma care. The Yes We Can Urban Asthma Partnership reaches out to high-risk children in different clinical settings: urgent visits, the hospital, a comprehensive specialty asthma clinic, and through an expanded community health worker programme. This article highlights the initial development, implementation, and evaluation of the success of this innovative management programme to address the problem of paediatric asthma in underserved urban areas.

Impact of a continuing education program on community pharmacists' interventions and asthma medication use: a pilot study

BACKGROUND

By upgrading the pharmacists' knowledge and skill set through continuing education (CE) programs, they could be better suited to contribute to the enhancement of the management of asthma.

OBJECTIVE

To assess the impact of an asthma CE program provided to community pharmacists on their knowledge, intervention frequency, and the appropriateness of asthma medication use.

METHODS

Community pharmacists were invited to participate in a CE program on asthma. Those who displayed an interest in the program were assigned to either a control or experimental group. Participants in the first group were not offered the CE program until the study was completed; the second group participated in the CE program at the onset of the study period. The knowledge on asthma of both groups of pharmacists was assessed using a questionnaire before the CE program, and the knowledge of the experimental group was reassessed after the CE program. Pharmacists were asked to document their interventions in the study log book over 6 months following the CE program. The appropriateness of asthma medication use was estimated by reviewing the prescription claims for a subgroup of patients covered by Québec's Public Prescription Drug Insurance Plan.

RESULTS

Pharmacists' knowledge improved after the CE program; however, the number of interventions reported during the 6 month period following the program was low and did not differ significantly between the groups, with an average of 3.04 per pharmacy in the experimental group versus 3.26 in the control group. The appropriateness of asthma medication use did not improve once the CE program had been completed.

CONCLUSIONS

Our CE program had little impact on the number of interventions by community pharmacists and the appropriateness of asthma medication use.

The Yes We Can Urban Asthma Partnership: a medical/social model for childhood asthma management

Pediatric asthma programs have struggled to integrate children's medical and social needs. We developed and piloted an integrated team model for asthma care for low-income children through the Yes We Can Urban Asthma Partnership. Program evaluation demonstrated increases in prescribing controller medications (p <0.05), use of action plans (p<0.001), and the use of mattress covers (p<0.001); and decrease in asthma symptoms (p<0.01). Additional changes occurred within the local system of asthma care to support ongoing efforts to improve asthma management. We conclude that pediatric asthma programs can effectively target the social and medical needs of children in a sustainable manner.

The asthma dialogues: a model of interactive education for skills

INTRODUCTION

A gap exists between asthma guidelines and actual care delivered. We developed an educational intervention using simulated physician-patient encounters as part of a project to improve asthma management by community-based primary care providers. We hypothesized that this type of skills-based interactive training would improve learners' care choices for simulated patients after training compared with their choices before training.

METHODS

After a pilot project was done on a small group of providers, a larger group of primary care providers (PCPs) was recruited to be trained with our interactive materials. The pilot session, with 39 providers, showed that the cases were felt to be appropriate, that the time allocated for discussion was adequate, that the models were useful, that the experience was educational, and that the experience captured their interest. Two subsequent training sessions were held with 240 PCPs. Participants completed a questionnaire to elicit perceived barriers and self-efficacy and then viewed a short simulated physician-patient dialogue. They then completed a set of scaled questions about treatment choices. This served as a pretest assessment. A similar simulation was then shown, and the group discussed their thoughts on diagnosis and treatment. Finally, they viewed another physician-patient interaction and responded to the same questions as posed for the pretest assessment; the responses before and after assessment were compared.

RESULTS

Following completion of the intervention, providers were significantly (p < 0.05) more likely to make use of controller medications, asthma equipment, and patient training. Significant (p < 0.05) increases were also seen in action plan development and the availability of office visits. Providers were significantly (p < 0.05) less likely to refer asthma patients to an emergency department or for hospitalization. Significant (p < 0.05) improvements were also seen in perceptions of self-efficacy and barriers to treatment. There were significant (p < 0.05) increases in learners' confidence about their own and patients' abilities to improve asthma care, and fewer barriers to asthma management were reported after the training.

DISCUSSION

This method of training resulted in learners showing a measurable improvement in their intent to follow guidelines as applied to simulated patients. An evaluation addressing actual patient outcomes will need to be done.

Patient-focused care: using the right tools

Patient-focused or patient-centered care is not a new concept, but its value has been overlooked in preference to the technology-based, disease-centered model that has prevailed in medicine for the last 50 years. Patient-focused care includes four broad areas of intervention: communication with patients, partnerships, health promotion, and physical care (medications and treatments). We can conceptualize patient-focused care as being the care we would like our loved ones to receive. There is considerable evidence that patients prefer a patient-focused approach. Unfortunately, there are also many studies detailing physicians' disconnection with patients' needs, particularly the need for information, and misunderstandings and assumptions based on poor communication. However, it is possible to develop physicians' skills in patient-focused care and provide physicians with the tools to overcome the barriers to this approach. The patient-focused approach has been shown to improve physicians' performance, patient satisfaction, and health outcomes without requiring additional investment in time or resources. Patient-focused care has also been shown to improve adherence to medication/advice, a well-known problem in asthma. There are also benefits to the physician in terms of improved outcomes for their patients, higher patient retention, and potentially a reduced risk of litigation. Patient-focused care may be a particularly valuable approach for the management of "difficult-to-treat" patients. In summary, the "three Cs" of patient-focused care-communication, continuity of care, and concordance (finding common ground)-are highly relevant to the effective treatment of pulmonary disease and should be a key component of asthma management.

A randomized clinical trial of clinician feedback to improve quality of care for inner-city children with asthma

CONTEXT

Barriers impede translating recommendations for asthma treatment into practice, particularly in inner cities where asthma morbidity is highest.

METHODS

The purpose of this study was to test the effectiveness of timely patient feedback in the form of a letter providing recent patient-specific symptoms, medication, and health service use combined with guideline-based recommendations for changes in therapy on improving the quality of asthma care by inner-city primary care providers and on resultant asthma morbidity. This was a randomized, controlled clinical trial in 5- to 11-year-old children (n = 937) with moderate to severe asthma receiving health care in hospital- and community-based clinics and private practices in 7 inner-city urban areas. The caretaker of each child received a bimonthly telephone call to collect clinical information about the child's asthma. For a full year, the providers of intervention group children received bimonthly computer-generated letters based on these calls summarizing the child's asthma symptoms, health service use, and medication use with a corresponding recommendation to step up or step down medications. We measured the number and proportion of scheduled visits resulting in stepping up of medications, asthma symptoms (2-week recall), and health care use (2-month recall).

RESULTS

In this population, only a modest proportion of children whose symptoms warranted a medication increase actually had a scheduled visit to reevaluate their asthma treatment. However, in the 2-month interval after receipt of a step-up letter, 17.1% of the letters were followed by scheduled visits in the intervention group compared with scheduled visits 12.3% of the time by the control children with comparable clinical symptoms. Asthma medications were stepped up when indicated after 46.0% of these visits in the intervention group compared with 35.6% in the control group, and when asthma symptoms warranted a step up in therapy, medication changes occurred earlier among the intervention children. Among children whose medications were stepped up at any time during the 12-month study period, those in the intervention group experienced 22.1% fewer symptom days and 37.9% fewer school days missed. The intention-to-treat analysis showed no difference over the intervention year in the number of symptom days, yet there was a trend toward fewer days of limited activity and a significant decrease in emergency department visits by the intervention group compared with controls. This 24% drop in emergency department visits resulted in an intervention that was cost saving in its first year.

CONCLUSIONS

Patient-specific feedback to inner-city providers increased scheduled asthma visits, increased asthma visits in which medications were stepped up when clinically indicated, and reduced emergency department visits.

Life-threatening asthma and anaphylaxis in schools: a treatment model for school-based programs

BACKGROUND

Pediatric asthma is the No. 1 chronic disease in childhood and is responsible for significant morbidity and mortality. In Nebraska, the number of asthma-related deaths is greater than the national average, and in 1998, 2 students died of acute asthma attacks while attending school in the Omaha public schools (OPSs). In response, we designed and implemented a program to respond to this problem.

OBJECTIVE

To implement and study a school-based program for the treatment of life-threatening asthma and anaphylaxis in the OPSs.

METHODS

The Emergency Response to Life-Threatening Asthma or Systemic Allergic Reactions (Anaphylaxis) Protocol was designed and evaluated in 78 OPSs from 1998 to 2003. Nurses and school staff were trained in the protocol, which required the use of nebulized albuterol and/or intramuscular epinephrine in conjunction with an emergency response procedure. Outcomes were measured by improvement in acute care in schools and survival of students.

RESULTS

In the 5 years of evaluation, 98 students were treated successfully. One student died. Of those treated with the protocol, equal numbers had at school both asthma action plans (AAPs) and metered-dose inhalers (MDIs), MDIs only, or neither AAPs nor MDIs. As a result of the program, there has been an increased awareness from parents, teachers, and physicians about the necessity of an emergency response program. In 2002, an outcome of the OPS program resulted in the formation of Attack on Asthma Nebraska to ensure that Nebraska schools have the education, training, and medications to respond to anyone experiencing a life-threatening asthma or anaphylaxis attack at school. The following year, a revised protocol was approved by the Nebraska State Board of Education for use in all Nebraska schools.

CONCLUSIONS

Emergency response protocols provide protection for children while in school. This program should serve as a national model for other school-based programs for children and adolescents with asthma and anaphylaxis.