Improving outcomes for underserved adolescents with asthma

BACKGROUND AND OBJECTIVE

Asthma is the most common chronic disease of childhood. Treatment adherence by adolescents is often poor, and their outcomes are worse than those of younger patients. We conducted a quality improvement initiative to improve asthma control and outcomes for high-risk adolescents treated in a primary care setting.

METHODS

Interventions were guided by the Chronic Care Model and focused on standardized and evidence-based care, care coordination and active outreach, self-management support, and community connections.

RESULTS

Patients with optimally well-controlled asthma increased from ∼10% to 30%. Patients receiving the evidence-based care bundle (condition/severity characterized in chart and, for patients with persistent asthma, an action plan and controller medications at the most recent visit) increased from 38% to at or near 100%. Patients receiving the required self-management bundle (patient self-assessment, stage-of-readiness tool, and personal action plan) increased from 0% to ∼90%. Patients and parents who were confident in their ability to manage their or their adolescent's asthma increased from 70% to ∼85%. Patient satisfaction and the mean proportion of patients with asthma-related emergency department visits or hospitalizations remained stable at desirable levels.

CONCLUSIONS

Implementing interventions focused on standardized and evidence-based care, self-management support, care coordination and active outreach, linkage to community resources, and enhanced follow-up for patients with chronically not-well-controlled asthma resulted in sustained improvement in asthma control in adolescent patients. Additional interventions are likely needed for patients with chronically poor asthma control.

Parents' perceptions of a patient portal for managing their child's chronic illness

Through interviews, we sought to describe parents' perceptions of a patient portal for the management of their child's chronic illness. Parents perceive patient portals as beneficial, providing easier communication with care providers, convenience, a sense of control, reduced anxiety, and reassurance. Future research should aim to quantitate these benefits.

Improving notification of sexually transmitted infections: a quality improvement project and planned experiment

BACKGROUND AND OBJECTIVE

Inadequate follow-up of positive sexually transmitted infection (STI) test results is a gap in health care quality that contributes to the epidemic of STIs in adolescent women. The goal of this study was to improve our ability to contact adolescent women with positive STI test results after an emergency department visit.

METHODS

We conducted an interventional quality improvement project at a pediatric emergency department. Phase 1 included plan-do-study-act cycles to test interventions such as provider education and system changes. Phase 2 was a planned experiment studying 2 interventions (study cell phone and patient activation card), using a 2 × 2 factorial design with 1 background variable and 2 replications. Outcomes were: (1) the proportion of women aged 14 to 21 years with STI testing whose confidential telephone number was documented in the electronic medical record; (2) the proportion of STI positive women successfully contacted within 7 days.

RESULTS

Phase 1 interventions increased the proportion of records with a confidential number from 24% to 58% and the proportion contacted from 45% to 65%, and decreased loss to follow-up from 40% to 24%. In phase 2, the proportion contacted decreased after the electronic medical record system changed and recording of the confidential number decreased. Study interventions (patient activation card and study cell phone) had a synergistic effect on successful contact, especially when confidential numbers were less reliably documented.

CONCLUSIONS

Feasible and sustainable interventions such as improved documentation of a confidential number worked synergistically to increase our ability to successfully contact adolescent women with their STI test results.

Pilot and feasibility test of adolescent-controlled text messaging reminders

PURPOSE

This pilot study assessed the feasibility, acceptability, and utility of a text messaging system that allowed teenagers with asthma to generate and control medical reminders sent to their mobile phones.

METHODS

The 12 teens in the study group were able to create their own reminder text messages, add or change reminders, and determine when and how often the messages were sent to their cell phone.

RESULTS

In total, 18 of the 21 unique messages created were reminders to take medication. No teen made changes to their original text messages or delivery schedule on their own. They gave high ratings on the usefulness, acceptability, and ease of use of the text messaging system. Self-reported asthma control at baseline was similar for both the study and comparison groups and did not change significantly.

CONCLUSIONS

Allowing teens to control the timing and content of reminder text messages may support self-management of chronic disease.

Overestimation of impairment-related asthma control by adolescents

We investigated the concordance between adolescents' perceived and impairment-related asthma control. Based on self-reported medication use, symptoms, and activity limitations, most overestimated their impairment-related control (73.8%). Providers should ask detailed, structured questions to get the most comprehensive picture of a patient's impairment-related control so they can ultimately improve disease outcomes.

Usability testing finds problems for novice users of pediatric portals

OBJECTIVE

Patient portals may improve pediatric chronic disease outcomes, but few have been rigorously evaluated for usability by parents. Using scenario-based testing with think-aloud protocols, we evaluated the usability of portals for parents of children with cystic fibrosis, diabetes or arthritis. DESIGN Sixteen parents used a prototype and test data to complete 14 tasks followed by a validated satisfaction questionnaire. Three iterations of the prototype were used.

MEASUREMENTS

During the usability testing, we measured the time it took participants to complete or give up on each task. Sessions were videotaped and content-analyzed for common themes. Following testing, participants completed the Computer Usability Satisfaction Questionnaire which measured their opinions on the efficiency of the system, its ease of use, and the likeability of the system interface. A 7-point Likert scale was used, with seven indicating the highest possible satisfaction.

RESULTS

Mean task completion times ranged from 73 (+/- 61) seconds to locate a document to 431 (+/- 286) seconds to graph laboratory results. Tasks such as graphing, location of data, requesting access, and data interpretation were challenging. Satisfaction was greatest for interface pleasantness (5.9 +/- 0.7) and likeability (5.8 +/- 0.6) and lowest for error messages (2.3 +/- 1.2) and clarity of information (4.2 +/- 1.4). Overall mean satisfaction scores improved between iteration one and three.

CONCLUSIONS

Despite parental involvement and prior heuristic testing, scenario-based testing demonstrated difficulties in navigation, medical language complexity, error recovery, and provider-based organizational schema. While such usability testing can be expensive, the current study demonstrates that it can assist in making healthcare system interfaces for laypersons more user-friendly and potentially more functional for patients and their families.