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Jomy J, Lin KX, Huang RS, Chen A, Malik A, Hwang M, Bhate TD, Sharfuddin N. Closing the gap on healthcare quality for equity-deserving groups: a scoping review of equity-focused quality improvement interventions in medicine. BMJ Qual Saf 2024:bmjqs-2023-017022. [PMID: 38866468 DOI: 10.1136/bmjqs-2023-017022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/26/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION Quality improvement (QI) efforts are critical to promoting health equity and mitigating disparities in healthcare outcomes. Equity-focused QI (EF-QI) interventions address the unique needs of equity-deserving groups and the root causes of disparities. This scoping review aims to identify themes from EF-QI interventions that improve the health of equity-deserving groups, to serve as a resource for researchers embarking on QI. METHODS In adherence with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, several healthcare and medical databases were systematically searched from inception to December 2022. Primary studies that report results from EF-QI interventions in healthcare were included. Reviewers conducted screening and data extraction using Covidence. Inductive thematic analysis using NVivo identified key barriers to inform future EF-QI interventions. RESULTS Of 5,330 titles and abstracts screened, 36 articles were eligible for inclusion. They reported on EF-QI interventions across eight medical disciplines: primary care, obstetrics, psychiatry, paediatrics, oncology, cardiology, neurology and respirology. The most common focus was racialised communities (15/36; 42%). Barriers to EF-QI interventions included those at the provider level (training and supervision, time constraints) and institution level (funding and partnerships, infrastructure). The last theme critical to EF-QI interventions is sustainability. Only six (17%) interventions actively involved patient partners. DISCUSSION EF-QI interventions can be an effective tool for promoting health equity, but face numerous barriers to success. It is unclear whether the demonstrated barriers are intrinsic to the equity focus of the projects or can be generalised to all QI work. Researchers embarking on EF-QI work should engage patients, in addition to hospital and clinic leadership in the design process to secure funding and institutional support, improving sustainability. To the best of our knowledge, no review has synthesised the results of EF-QI interventions in healthcare. Further studies of EF-QI champions are required to better understand the barriers and how to overcome them.
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Affiliation(s)
- Jane Jomy
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ke Xin Lin
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ryan S Huang
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alisia Chen
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Aleena Malik
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Tahara D Bhate
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Nazia Sharfuddin
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
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Hersey SJ, Retzke J, Allen ED, Snyder D, Hardy C, Groner J. A Primary Care-Based Quality Improvement Project to Reduce Asthma Emergency Department Visits. Pediatrics 2023; 152:e2023061355. [PMID: 37960935 DOI: 10.1542/peds.2023-061355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Asthma exacerbation is a common and often preventable cause of Emergency Department (ED) utilization. Children eligible for Medicaid are at increased risk of poor asthma control and subsequent ED visits. In 2010, we implemented a multicomponent longitudinal quality improvement project to improve pediatric asthma care for our primary care population, which was 90% Medicaid-eligible. Our goal was to reduce asthma-related ED visits by patients ages 2 to 18 years by 3% annually. METHODS The setting was a multisite large urban high-risk primary care network affiliated with a children's hospital. We implemented 5 sequential interventions within our network of pediatric primary care centers to increase: use of asthma action plans by clinicians, primary care-based Asthma Specialty Clinic visits (extended asthma visits in the main primary care site), use of a standard asthma note at all visits, documentation of the Asthma Control Test, and step-up therapy for children with poorly controlled asthma. RESULTS At baseline in 2010, there were 21.7 asthma-related ED visits per 1000 patients per year. By 2019, asthma-related ED visits decreased to 14.5 per 1000 patients per year, a 33% decrease, with 2 center line shifts over time. We achieved and sustained our goal metrics for 4 of 5 key interventions. CONCLUSIONS We reduced ED utilization for asthma in a large, high-risk pediatric population. The interventions implemented and used over time in this project demonstrate that sustainable outcomes can be achieved in a large network of primary care clinics.
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Affiliation(s)
| | | | - Elizabeth D Allen
- Professor Emeritus, The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Charles Hardy
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
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Bynum M. Community Health Centers Primary Care Physicians' Asthma Management Perception of Uninsured Patients. Prof Case Manag 2021; 25:335-342. [PMID: 33017370 DOI: 10.1097/ncm.0000000000000406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF STUDY Explore the perceptions of primary care physicians (PCPs) from community health care centers (CHCs) in Franklin County, Ohio, regarding factors that contribute to their inability to consistently provide sustainable asthma management services to their uninsured patient population. PRIMARY PRACTICE SETTING Asthmatic patients are not consistently receiving sustainable asthma management in CHCs in Ohio. Primary care physicians in CHCs play a pivotal role in closing health care gaps for asthmatic patients. To minimize the barriers that impede the efforts of PCPs to control asthma for their uninsured patients, asthma disease management programs that include case management services in CHCs in Franklin County, Ohio, are needed. METHODOLOGY AND SAMPLE A convenience sample of 4 PCPs from 2 CHCs in Franklin County, Ohio, was interviewed face-to-face. Interviews, direct observation, and previously published research were the sources of data utilized for this study. RESULTS Results indicated that 75% of participants did not use standard guidelines while treating their patients. Physician time constraints and access to affordable medication were identified as some of the barriers to providing sustainable asthma management services. IMPLICATIONS FOR CASE MANAGEMENT Asthma is a complex chronic disease. Disease case managers not only are capable of coordinating health care services for a variety of patient populations but are also effective in managing complex diseases such as asthma for disadvantaged populations. Evidence-based case management models are needed to support PCPs in CHCs. Without the inclusion of asthma-specific case managers as part of the care delivery structure, CHCs may continue to provide subpar disease management services for uninsured asthmatic patients.
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Affiliation(s)
- Mary Bynum
- Mary Bynum, MA, BSN, RN, CCM, DHA, is the Department Chair for Healthcare Programs, Program Chair for the Healthcare Management Program, and Lead Faculty for the Public Administration Program at Franklin University. Dr. Bynum received her doctorate in Health Administration from the University of Phoenix. In addition, she holds a Master of Arts in Public Policy and Management and Bachelor of Science in Nursing from the Ohio State University. Dr. Bynum is a certified case manager and a registered nurse. She has an extensive background in operational excellence, project management, regulatory adherence, and health care policy. She has served more than 22 years in both the public and private sectors. Her research interests include vulnerable populations, health disparities, health policy, and social determinants of health. Dr. Bynum is a national speaker and wellness enthusiast. She is a member of Alpha Kappa Alpha Sorority, Incorporated, Franklin County Children Services Citizens Advisory Committee, Central Ohio Case Management Network, and Fort Hayes Metropolitan Education Center Health Science and Dental Hygiene Advisory Board and is the founder of the Legacy Group of Ohio. She is the recipient of the Stephan Shank award for Teaching Excellence. In addition, she is a marathon runner and fitness guru
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Sauers-Ford H, Statile AM, Auger KA, Wade-Murphy S, Gold JM, Simmons JM, Shah SS. Short-term Focused Feedback: A Model to Enhance Patient Engagement in Research and Intervention Delivery. Med Care 2021; 59:S364-S369. [PMID: 34228018 PMCID: PMC8263145 DOI: 10.1097/mlr.0000000000001588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Our grant from the Patient-Centered Outcomes Research Institute (PCORI) focused on the use of nurse home visits postdischarge for primarily pediatric hospital medicine patients. While our team recognized the importance of engaging parents and other stakeholders in our study, our project was one of the first funded to address transitions of care issues in patients without chronic illness; little evidence existed about how to engage acute stakeholders longitudinally. OBJECTIVE This manuscript describes how we used both a short-term focused feedback model and longitudinal engagement methods to solicit input from parents, home care nurses, and other stakeholders throughout our 3-year study. RESULTS Short-term focused feedback allowed the study team to collect feedback from hundreds of stakeholders. Initially, we conducted focus groups with parents with children recently discharged from the hospital. We used this feedback to modify our nurse home visit intervention, then used quality improvement methods with continued short-term focus feedback from families and nurses delivering the visits to adjust the visit processes and content. We also used their feedback to modify the outcome collection. Finally, during the randomized controlled trial, we added a parent to the study team to provide longitudinal input, as well as continued to solicit short-term focused feedback to increase recruitment and retention rates. CONCLUSION Research studies can benefit from soliciting short-term focused feedback from many stakeholders; having this variety of perspectives allows for many voices to be heard, without placing an undue burden on a few stakeholders.
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Affiliation(s)
| | - Angela M. Statile
- Division of Hospital Medicine
- James M. Anderson Center for Healthcare Improvement, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Katherine A. Auger
- Division of Hospital Medicine
- James M. Anderson Center for Healthcare Improvement, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Susan Wade-Murphy
- Department of Patient Services
- Home Care Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jennifer M. Gold
- Home Care Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jeffrey M. Simmons
- Division of Hospital Medicine
- James M. Anderson Center for Healthcare Improvement, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Samir S. Shah
- Division of Hospital Medicine
- James M. Anderson Center for Healthcare Improvement, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
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Chan M, Gray M, Burns C, Owens L, Woolfenden S, Lingam R, Jaffe A, Homaira N. Community-based interventions for childhood asthma using comprehensive approaches: a systematic review and meta-analysis. Allergy Asthma Clin Immunol 2021; 17:19. [PMID: 33588934 PMCID: PMC7885565 DOI: 10.1186/s13223-021-00522-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/29/2021] [Indexed: 12/21/2022] Open
Abstract
Objective We conducted a systematic review and meta-analysis to determine the effectiveness of comprehensive community-based interventions with ≥ 2 components in improving asthma outcomes in children. Methods A systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Cochrane Library and hand search of reference collections were conducted to identify any research articles published in English between 2000 and 2019. All studies reporting community-based asthma interventions with ≥ 2 components (e.g., asthma self-management education, home environmental assessment or care coordination etc.) for children aged ≤ 18 years were included. Meta-analyses were performed using random-effects model to estimate pooled odds ratio (OR) with 95% confidence intervals (CIs). Results Of the 2352 studies identified, 21 studies were included in the final analysis: 19 pre-post interventions, one randomised controlled trial (RCT) and one retrospective study. Comprehensive asthma programs with multicomponent interventions were associated with significant reduction in asthma-related Emergency Department (ED) visits (OR = 0.26; 95% CI 0.20–0.35), hospitalizations (OR = 0.24; 95% CI 0.15–0.38), number of days (mean difference = − 2.58; 95% CI − 3.00 to − 2.17) and nights with asthma symptoms (mean difference = − 2.14; 95% CI − 2.94 to − 1.34), use of short-acting asthma medications/bronchodilators (BD) (OR = 0.28; 95% CI 0.16–0.51), and increase use of asthma action plan (AAP) (OR = 8.87; 95% CI 3.85–20.45). Conclusion Community-based asthma care using more comprehensive approaches may improve childhood asthma management and reduce asthma related health care utilization.
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Affiliation(s)
- Mei Chan
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, 2031, Australia
| | - Melinda Gray
- Respiratory Department, Sydney Children's Hospital, Randwick, NSW 2031, Australia
| | - Christine Burns
- Respiratory Department, Sydney Children's Hospital, Randwick, NSW 2031, Australia
| | - Louisa Owens
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, 2031, Australia.,Respiratory Department, Sydney Children's Hospital, Randwick, NSW 2031, Australia
| | - Susan Woolfenden
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, 2031, Australia.,Respiratory Department, Sydney Children's Hospital, Randwick, NSW 2031, Australia
| | - Raghu Lingam
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, 2031, Australia.,Respiratory Department, Sydney Children's Hospital, Randwick, NSW 2031, Australia
| | - Adam Jaffe
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, 2031, Australia.,Respiratory Department, Sydney Children's Hospital, Randwick, NSW 2031, Australia
| | - Nusrat Homaira
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, 2031, Australia. .,Respiratory Department, Sydney Children's Hospital, Randwick, NSW 2031, Australia.
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Gardner K, Sibthorpe B, Chan M, Sargent G, Dowden M, McAullay D. Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: a scoping systematic review. BMC Health Serv Res 2018; 18:541. [PMID: 29996836 PMCID: PMC6042325 DOI: 10.1186/s12913-018-3308-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 04/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous Quality Improvement (CQI) programs have been taken up widely by Indigenous primary health care (PHC) services in Australia and there has been national policy commitment to support this. However, international evidence shows that implementing CQI is challenging, impacts are variable and little is known about the factors that impede or enhance effectiveness. A scoping review was undertaken to explore uptake and implementation in Indigenous PHC, including barriers and enablers to embedding CQI in routine practice. We provide guidance on how research and evaluation might be intensified to support implementation. METHODS Searches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews. Key websites and publications were handsearched. Studies conducted in Indigenous PHC which demonstrated some combination of CQI characteristics and assessed some aspect of implementation were included. A two stage analysis was undertaken. Stage 1 identified the breadth and focus of literature. Stage 2 investigated barriers and enablers. The Framework for Performance Assessment in PHC (2008) was used to frame the analysis. Data were extracted on the study type, approach, timeframes, CQI strategies, barriers and enablers. RESULTS Sixty articles were included in Stage 1 and 21 in Stage 2. Barriers to implementing CQI processes relate primarily to professional and organisational processes and operate at multiple levels (individual, team, service, health system) whereas barriers to improved care relate more directly to knowledge of best practice and team processes that facilitate appropriate care. Few studies described implementation timeframes, number of CQI cycles or improvement strategies implemented and only two applied a change theory. CONCLUSION Investigating barriers and enablers that modify implementation and impacts of CQI poses conceptual and methodological challenges. More complete description of CQI processes, implementation strategies, and barriers and enablers could enhance capacity for comparisons across settings and contribute to better understanding of key success factors.
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Affiliation(s)
- Karen Gardner
- Public Service Research Group, Business School, UNSW Canberra, Canberra, Australia
| | | | - Mier Chan
- Australian Primary Health Care Research Institute, Australian National University, Canberra, ACT 0200 Australia
| | - Ginny Sargent
- Research, Evaluation and Public Health Nutrition Section, Population Health Division, Health Improvement Branch, ACT Health, Canberra, ACT 260 Australia
| | - Michelle Dowden
- One Disease, Menzies Building, RDH Campus, Rocklands Drive, Tiwi, NT 0810 Australia
| | - Daniel McAullay
- Kurongkurl Katitjin, Edith Cowan University, 2 Bradford St, Mount Lawley, WA 6050 Australia
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Yawn BP, Wollan PC, Rank MA, Bertram SL, Juhn Y, Pace W. Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized Controlled Trial. Ann Fam Med 2018; 16. [PMID: 29531100 PMCID: PMC5847347 DOI: 10.1370/afm.2179] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
PURPOSE The purpose of this study was to assess patient and practice outcomes after introducing the Asthma APGAR (Activities, Persistent, triGGers, Asthma medications, Response to therapy) tools into primary care practices. METHODS We used a pragmatic cluster-randomized controlled design in 18 US family medicine and pediatric practices to compare outcomes in patients with persistent asthma aged 5 to 45 years after introduction of the Asthma APGAR tools vs usual care. Patient outcomes included asthma control, quality of life, and emergency department (ED), urgent care, and inpatient hospital visits. The practice outcome was adherence to asthma guidelines. RESULTS We enrolled 1,066 patients: 245 children, 174 adolescents, and 647 adults. Sixty-five percent (692 patients) completed both baseline and 12-month questionnaires, allowing analysis for patient-reported outcomes. Electronic health record data were available for 1,063 patients (99.7%) for practice outcomes. The proportion of patients reporting an asthma-related ED, urgent care, or hospital visit in the final 6 months of the study was lower in the APGAR practices vs usual care practices (10.6% vs 20.9%, P = .004). The percentage of patients with "in control" asthma increased more between baseline and 1 year in the APGAR group vs usual care group (13.5% vs 3.4%, P =.0001 vs P =.86) with a trend toward better control scores and asthma-related quality of life in the former at 1 year (P ≤.06 and P = .06, respectively). APGAR practices improved their adherence to 3 or more guideline elements compared with usual care practices (20.7% increase vs 1.9% decrease, P = .001). CONCLUSIONS Introduction of the Asthma APGAR tools improves rates of asthma control; reduces asthma-related ED, urgent care, and hospital visits; and increases practices' adherence to asthma management guidelines.
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Affiliation(s)
- Barbara P Yawn
- Department of Research, Olmsted Medical Center, Rochester, Minnesota
| | - Peter C Wollan
- Department of Research, Olmsted Medical Center, Rochester, Minnesota
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic, Scottsdale, Arizona
| | - Susan L Bertram
- Department of Research, Olmsted Medical Center, Rochester, Minnesota
| | - Young Juhn
- Department of Pediatrics and Adolescent Medicine, Asthma Epidemiology Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Wilson Pace
- National Research Network, American Academy of Family Physicians, Leawood, Kansas
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Holder-Niles F, Haynes L, D'Couto H, Hehn RS, Graham DA, Wu AC, Cox JE. Coordinated Asthma Program Improves Asthma Outcomes in High-Risk Children. Clin Pediatr (Phila) 2017; 56:934-941. [PMID: 28436286 DOI: 10.1177/0009922817705186] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Innovative approaches within primary care are needed to reduce fragmented care, increase continuity of care, and improve asthma outcomes in children with asthma. Our objective was to assess the impact of coordinated team-based asthma care on unplanned asthma-related health care utilization. A multidisciplinary asthma team was developed to provide coordinated care to high-risk asthma patients. Patients received an in-depth diagnostic and family needs assessment, asthma education, and coordinated referral to social and community services. Over a 2-year period, 141 patients were followed. At both 1 and 2 years postintervention, there was a significant decrease from preintervention rates in urgent care visits (40%, P = .002; 50%, P < .0001), emergency department visits (63%, P < .0001; 70%, P < .0001), and inpatient hospitalization (69%, P = .002; 54%, P = .04). Our coordinated asthma care program was associated with a reduction in urgent care visits, emergency department visits, and inpatient hospitalizations among high-risk children with asthma.
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Affiliation(s)
- Faye Holder-Niles
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | | | - Helen D'Couto
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | | | - Dionne A Graham
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Ann Chen Wu
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA.,3 Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Joanne E Cox
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
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Makhinova T, Barner JC, Richards KM, Rascati KL. Asthma Controller Medication Adherence, Risk of Exacerbation, and Use of Rescue Agents Among Texas Medicaid Patients with Persistent Asthma. J Manag Care Spec Pharm 2016; 21:1124-32. [PMID: 26679962 PMCID: PMC10401995 DOI: 10.18553/jmcp.2015.21.12.1124] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adherence to asthma long-term controller medications is one of the key drivers to improve asthma management among patients with persistent asthma. While suboptimal use of controller medications has been found to be associated with more frequent use of oral corticosteroids (OCS), few studies exist regarding the relationship between adherence to controller therapy and the use of short-acting beta2-agonists (SABAs). A better understanding of the association between adherence to asthma controller agents and use of reliever medications will help health care providers and decision makers enhance asthma management. OBJECTIVE To determine if there is a relationship between asthma controller adherence, risk of exacerbation requiring OCS, and use of asthma rescue agents. METHODS Texas Medicaid claims data from January 1, 2008, to August 31, 2011, were retrospectively analyzed. Continuously enrolled patients aged 5-63 years with a primary diagnosis of asthma (ICD-9-CM code 493) and with 4 or more prescription claims for any asthma medication in 1 year (persistent asthma) were included. The index date was the date of the first asthma controller prescription, and patients were followed for 1 year. The primary outcome variables were SABA (dichotomous: less than 6 vs. ≥ 6) and OCS (continuous) use. The primary independent variable was adherence (proportion of days covered [PDC]) to asthma long-term controller medications. Covariates included demographics and nonstudy medication utilization. Multivariate logistic and linear regression analyses were employed to address the study objective. RESULTS The study sample (n = 32,172) was aged 15.0 ± 14.5 years, and adherence to controller therapy was 32.2% ± 19.7%. The mean number of SABA claims was 3.7 ± 3.1, with most patients having 1-5 claims (73.2%), whereas 19.4% had ≥ 6 SABA claims. The mean number of OCS claims was 1.0 ± 1.4. Adherent (PDC ≥ 50%) patients were 96.7% (OR = 1.967; 95% CI = 1.826-2.120) more likely to have ≥ 6 SABA claims when compared with nonadherent (PDC less than 50%) patients (P less than 0.001). As for OCS use, adherent patients had 0.11 fewer claims compared with nonadherent patients (P less than 0.001). Importantly, patients with ≥ 6 SABA claims had 0.7 more OCS claims compared with patients with less than 6 claims for SABA (P less than 0.001). The odds of having ≥ 6 SABA claims were higher for concurrent dual therapy users, older age, males, African Americans and higher number of nonstudy medications (P less than 0.001). Dual therapy users, younger age, Hispanic ethnicity, and higher number of nonstudy medications were associated with an increase in OCS use (P less than 0.005). CONCLUSIONS Adherence to long-term controller medications was suboptimal among patients with asthma. Adherent patients had fewer OCS claims, indicating that adherence to controller therapy is critical in preventing asthma exacerbations requiring OCS use. Although there was a positive relationship between adherence to long-term controller medication and SABA use, increased SABA use served as a predictor of increased OCS use, which indicates poor asthma control. Health care providers should be aware of OCS and SABA use among patients who are both adherent and nonadherent to asthma controller medications.
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Affiliation(s)
- Tatiana Makhinova
- The University of Texas at Austin, 2409 University Ave., STOP A1930, Austin, TX 78712-1120.
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10
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Provider Adherence to Evidence-Based Asthma Guidelines in a Community Health Center. J Dr Nurs Pract 2016; 9:128-138. [PMID: 32751016 DOI: 10.1891/2380-9418.9.1.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Improved outcomes for patients with asthma have been proven with the use of the Expert Panel Report 3 (EPR-3) evidence-based asthma guidelines. These clinical guidelines are tools developed for providers to direct appropriate high-quality patient care that leads to positive outcomes. However, research has shown health care providers do not routinely follow the evidence-based asthma guidelines adequately. Objective: To develop and implement an evidence-based asthma protocol in a community clinic and improve provider adherence and attitudes/beliefs to the EPR-3 guidelines resulting in improved asthma outcomes, asthma control, and self-management for patients with asthma. Methods: The study was conducted in 2 parts over a period of 3 months. First, all medical providers at a community clinic were invited to participate in the research study. The intervention included implementing the asthma protocol within the current electronic health record (EHR). A pre- and postintervention questionnaire measuring provider's adherence and attitudes to evidence-based practice was administered. In addition, pre- and postclinic aggregate data for International Classification of Diseases codes specific to asthma that correlate to 7 identified aims based on the EPR-3 guidelines were collected. Results: Results show statistical significance among the provider attitudes/beliefs with the intervention, the greatest effect being found for the medical doctors. Four of the 7 aims showed improvement. Conclusions: The findings of this application research quality improvement study indicate that providing necessary tools and resources needed to adhere to evidence-based asthma guidelines can positively affect providers' adherence and attitudes/beliefs toward evidence-based guidelines.
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Shin P, Sharac J, Rosenbaum S. Community Health Centers And Medicaid At 50: An Enduring Relationship Essential For Health System Transformation. Health Aff (Millwood) 2015; 34:1096-104. [DOI: 10.1377/hlthaff.2015.0099] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Peter Shin
- Peter Shin ( ) is an associate professor of health policy in the Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University, in Washington, D.C
| | - Jessica Sharac
- Jessica Sharac is a senior research associate in the Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University
| | - Sara Rosenbaum
- Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy in the Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University
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Lion KC, Raphael JL. Partnering health disparities research with quality improvement science in pediatrics. Pediatrics 2015; 135:354-61. [PMID: 25560436 PMCID: PMC4306804 DOI: 10.1542/peds.2014-2982] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2014] [Indexed: 01/17/2023] Open
Abstract
Disparities in pediatric health care quality are well described in the literature, yet practical approaches to decreasing them remain elusive. Quality improvement (QI) approaches are appealing for addressing disparities because they offer a set of strategies by which to target modifiable aspects of care delivery and a method for tailoring or changing an intervention over time based on data monitoring. However, few examples in the literature exist of QI interventions successfully decreasing disparities, particularly in pediatrics, due to well-described challenges in developing, implementing, and studying QI with vulnerable populations or in underresourced settings. In addition, QI interventions aimed at improving quality overall may not improve disparities, and in some cases, may worsen them if there is greater uptake or effectiveness of the intervention among the population with better outcomes at baseline. In this article, the authors review some of the challenges faced by researchers and frontline clinicians seeking to use QI to address health disparities and propose an agenda for moving the field forward. Specifically, they propose that those designing and implementing disparities-focused QI interventions reconsider comparator groups, use more rigorous evaluation methods, carefully consider the evidence for particular interventions and the context in which they were developed, directly engage the social determinants of health, and leverage community resources to build collaborative networks and engage community members. Ultimately, new partnerships between communities, providers serving vulnerable populations, and QI researchers will be required for QI interventions to achieve their potential related to health care disparity reduction.
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Affiliation(s)
- K Casey Lion
- Department of Pediatrics, University of Washington, Seattle, Washington; Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Jean L Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Archibald MM, Caine V, Ali S, Hartling L, Scott SD. What is left unsaid: an interpretive description of the information needs of parents of children with asthma. Res Nurs Health 2015; 38:19-28. [PMID: 25557981 DOI: 10.1002/nur.21635] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2014] [Indexed: 11/09/2022]
Abstract
Parents of children with asthma provide the vast majority of day-to-day asthma care. Understanding their information needs is an essential step to provide meaningful and effective family-centered asthma education. To gain insight into the information needs and information deficits of parents of children with asthma, we conducted an interpretive descriptive study to capture the perspectives of 21 parents from diverse backgrounds whose 23 children with asthma had a range of illness trajectories and management scenarios. Parents were purposively sampled from two asthma clinics and one pediatric emergency department in a large urban center in North America. Semi-structured interviews were conducted in 2011-2012. In data analysis, parents' self-identified information needs were distinguished from analysts' interpretations of information deficits. Participants' knowledge did not always reflect time since diagnosis, and information needs and deficits persisted for years. Parents often reported receiving little or no little or no education about asthma and its management. An asthma management information hierarchy was identified, starting with the most foundational, recognizing severity; followed by acute management; prevention versus crisis orientation; and knowing "about" asthma. In the absence of adequate and accurate education, parents' beliefs about the nature of asthma as an acute rather than chronic condition shaped their asthma management decisions and information-seeking behaviors. Information deficits were affected by interactions with health care providers. These parents' pervasive unmet information needs and deficits highlight the need for comprehensive, problem-oriented asthma education.
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Affiliation(s)
- Mandy M Archibald
- PhD Candidate, Faculty of Nursing, University of Alberta, Level 3, Edmonton Clinic Health Academy (ECHA), Avenue 11405 87, Edmonton, T6G 1C9, Alberta, Canada
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Community-based interventions in asthma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 795:105-15. [PMID: 24162905 DOI: 10.1007/978-1-4614-8603-9_7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Community and public health interventions provide potentially powerful means of decreasing morbidity, hospitalizations, emergency room visits, and mortality from asthma. This chapter thus provides an overview of community-based interventions, which have been demonstrated to be effective-and/or ineffective-in reducing the burden of disease, including development of asthma coalitions, interventions for both provider and patient education, environmental controls to reduce exposure to asthma triggers, and institutional policy and systems change. Perhaps most important is the demonstrated effect of integrated, comprehensive approaches to asthma management and control. A multidisciplinary approach spanning T1 through T4 translational research, coupled with public health activities is promising and has already demonstrated success in reducing the burden of disease.
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The influence of organizational context on the use of research by nurses in Canadian pediatric hospitals. BMC Health Serv Res 2013; 13:351. [PMID: 24034149 PMCID: PMC3848566 DOI: 10.1186/1472-6963-13-351] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 09/06/2013] [Indexed: 11/23/2022] Open
Abstract
Background Organizational context is recognized as an important influence on the successful implementation of research by healthcare professionals. However, there is relatively little empirical evidence to support this widely held view. Methods The objective of this study was to identify dimensions of organizational context and individual (nurse) characteristics that influence pediatric nurses’ self-reported use of research. Data on research use, individual, and contextual variables were collected from registered nurses (N = 735) working on 32 medical, surgical and critical care units in eight Canadian pediatric hospitals using an online survey. We used Generalized Estimating Equation modeling to account for the correlated structure of the data and to identify which contextual dimensions and individual characteristics predict two kinds of self-reported research use: instrumental (direct) and conceptual (indirect). Results Significant predictors of instrumental research use included: at the individual level; belief suspension-implement, research use in the past, and at the hospital unit (context) level; culture, and the proportion on nurses possessing a baccalaureate degree or higher. Significant predictors of conceptual research use included: at the individual nurse level; belief suspension-implement, problem solving ability, use of research in the past, and at the hospital unit (context) level; leadership, culture, evaluation, formal interactions, informal interactions, organizational slack-space, and unit specialty. Conclusions Hospitals, by focusing attention on modifiable elements of unit context may positively influence nurses’ reported use of research. This influence of context may extend to the adoption of best practices in general and other innovative or quality interventions.
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Okelo SO, Butz AM, Sharma R, Diette GB, Pitts SI, King TM, Linn ST, Reuben M, Chelladurai Y, Robinson KA. Interventions to modify health care provider adherence to asthma guidelines: a systematic review. Pediatrics 2013; 132:517-34. [PMID: 23979092 PMCID: PMC4079294 DOI: 10.1542/peds.2013-0779] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Sande O. Okelo
- David Geffen School of Medicine and Mattel Children’s Hospital, University of California at Los Angeles, Los Angeles, California; and
| | | | - Ritu Sharma
- Bloomberg School of Public Health Baltimore, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Shauna T. Linn
- Bloomberg School of Public Health Baltimore, Johns Hopkins University, Baltimore, Maryland
| | - Manisha Reuben
- Bloomberg School of Public Health Baltimore, Johns Hopkins University, Baltimore, Maryland
| | | | - Karen A. Robinson
- School of Medicine and,Bloomberg School of Public Health Baltimore, Johns Hopkins University, Baltimore, Maryland
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Szefler SJ. Advances in pediatric asthma in 2011: moving forward. J Allergy Clin Immunol 2012; 129:60-8. [PMID: 22196525 DOI: 10.1016/j.jaci.2011.11.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 11/11/2011] [Indexed: 01/14/2023]
Abstract
Last year's "Advances in pediatric asthma" concluded with the following statement: "Perhaps new directions in personalized medicine and improved health care access and communication will help maintain steady progress in alleviating the burden of this disease in children, especially young children." This year's summary will focus on recent advances in pediatric asthma that show significant accomplishments in reducing asthma morbidity and mortality over the last 10 years and discuss some pathways to further reduce asthma burden, as indicated in Journal of Allergy and Clinical Immunology publications in 2011. Some of the recent reports continue to shed light on methods to improve asthma management through steps to reduce asthma exacerbations, identify features of the disease in early childhood, alter asthma progression, intervene with nutrition, and more effectively implement the asthma guidelines. As new information evolves, it is also time to consider a revision of the asthma guidelines based on key studies that affect our management of the disease since the last revision in 2007. Now is also the time to use information recorded in electronic medical records to develop innovative disease management plans that will track asthma over time and enable timely decisions on interventions to maintain control that can lead to disease remission and prevention.
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Affiliation(s)
- Stanley J Szefler
- Division of Pediatric Clinical Pharmacology and Allergy and Immunology, Department of Pediatrics, National Jewish Health, University of Colorado School of Medicine, Denver, Colo 80206, USA.
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Halterman JS, Sauer J, Fagnano M, Montes G, Fisher S, Tremblay P, Tajon R, Butz A. Working toward a sustainable system of asthma care: development of the School-Based Preventive Asthma Care Technology (SB-PACT) trial. J Asthma 2012; 49:395-400. [PMID: 22455402 DOI: 10.3109/02770903.2012.669441] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE We previously conducted the School-Based Asthma Therapy trial to improve adherence to national asthma guidelines for urban children through directly observed administration of preventive asthma medications in school. The trial successfully improved outcomes among these children; however, several factors limit its potential for dissemination. To enhance sustainability, we subsequently developed a new model of care using web-based guides for efficient communications and integration within school and community systems. This article describes the development of the School-Based Preventive Asthma Care Technology (SB-PACT) trial. METHOD We developed the SB-PACT web-based system based on stakeholder feedback, and conducted a pilot randomized trial with 100 children to establish its feasibility in facilitating preventive asthma care for high-risk children. The SB-PACT system represents a new model of care using web-based guides for asthma symptom screening, follow-up control assessments, and electronic communications with providers. RESULT We enrolled and successfully screened all children using the web-based system. Most providers used the electronic communication system without difficulty, and the majority of children in the intervention group received preventive medications through school as planned and dose adjustments as needed. Several challenges to implementation also were encountered. CONCLUSIONS This program is designed to promote sustainability of school-based asthma care, reduce program costs, and ultimately succeed in a real-world setting. With further refinements, it has the potential to be implemented nationally in schools.
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Affiliation(s)
- Jill S Halterman
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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