domingo, 13 de mayo de 2012

Innovation Profile:

National Academy and Affiliated State Chapters Support Pediatricians in Improving Asthma Care, Leading to Better Guideline Adherence and Disease Control, Fewer Acute Episodes

Pediatric Asthma Is a Worthy Quality Improvement Target

By Paul V. Williams, MD
Northwest Asthma & Allergy Center

Efforts to improve pediatric asthma care are important, given the prevalence of the condition and its potential for causing adverse health outcomes. As a pediatric allergist, I’ve been involved in quality improvement in my own practice, though not specifically focused on adherence to asthma treatment guidelines. We can gain some insights into the challenges of quality improvement related to asthma care by considering two innovation profiles featured on the AHRQ Health Care Innovations Exchange. One profile—National Academy and Affiliated State Chapters Support Pediatricians in Improving Asthma Care, Leading to Better Guideline Adherence and Disease Control, Fewer Acute Episodes—describes a 1-year quality improvement project by the American Academy of Pediatrics (AAP) that helped 49 pediatric practices in 4 states to better adhere to established asthma care guidelines. The other profile—Mobile Clinic And In-Home Educator Generate Small, Short-Term Increases in Symptom-Free Days in Inner-City Preschool Children With Asthma But No Improvements in Other Key Outcomes—describes an attempt to use a mobile pediatric asthma clinic to improve asthma management among children enrolled in the Head Start program in Baltimore.

The pediatricians who organized the AAP initiative succeeded in what they tried to do, based on the impressive improvements in physician performance reported among the participating practices, with the percentage of patients receiving “optimal” care rising from 35 percent at baseline to 85 percent a year later. It appears that the practices—located in Alabama, Maine, Ohio, and Oregon—represent a reasonable cross-section of pediatric practices in the United States. It’s somewhat surprising that only 58 percent of the patients were considered to have well-controlled asthma at baseline, because you might expect that primary care pediatricians would tend to care for patients with relatively well-controlled, intermittent asthma. However, the practices may have tended to focus their quality improvement efforts on patients with a history of having less-than-optimal disease control.

After the intervention, 72 percent of the patients were classified as having well-controlled asthma, an outcome similar to results in other studies aimed at improving pediatric asthma care. As with other quality improvement studies, the key question is, what will happen to these patients over the long term? If the practices achieved lasting improvement in the asthma care process, the measured gains in physician performance could lead to long-term improvements in asthma control. In any case, if pediatricians in other settings can achieve even a fraction of the reported performance improvements, and demonstrate that the gains are sustainable, there’s a real potential for success. That’s why the AAP is continuing to support quality improvement initiatives that focus on asthma care.

Assuming that proper assessment of asthma severity and control has been accomplished, inadequate adherence to prescribed treatment is generally the main barrier to successful asthma management. We know that many patients who say that they are taking their medications actually haven’t filled or refilled their prescriptions, but their physicians often lack a good way to assess adherence. Even in practices like my own that use an electronic health record system, the infrastructure often is not yet in place to enable electronic communication with pharmacies.

The mobile pediatric asthma clinic that was used in the Baltimore program was introduced in 1995 in Los Angeles. The original Breathmobile program achieved some great successes by taking care to the patients. Back in the 1990s, though, it was probably easier to make a big difference in asthma care. After all, it was only in 1991 that the National Asthma Education and Prevention Program had distributed its initial guidelines on diagnosis and management of asthma, in response to the lack of standardization in asthma care. By 2005, when Baltimore’s Breathmobile program began serving children enrolled in Head Start, the level of asthma care may have been fairly good already. And given the low rates of family participation, we shouldn’t be surprised that the program had such a limited impact on patient outcomes.

Asthma diagnosis is difficult in preschool children, because young children have great variability in disease expression and are not developmentally able to undergo spirometry assessments. Also, we have relatively few data on treatment efficacy in preschool children and their symptoms often improve spontaneously. Although these factors can make it difficult to assess the value of early intervention, efforts to identify and treat high-risk populations are worth pursuing as we seek to address unmet needs for effective care among children with asthma.
About the Author:

Paul V. Williams, MD, is an allergy and asthma specialist at the Mount Vernon, WA, office of the Northwest Asthma & Allergy Center. He is a member of the Board of Directors of the Joint Council on Allergy, Asthma and Immunology, and represents the American Medical Association on the National Asthma Education and Prevention Panel.

Disclosure Statement: Dr. Williams has been involved in a variety of leadership roles with the American Academy of Pediatrics, which developed the asthma care quality improvement project described in the innovation profile about the AAP initiative.

Original publication: May 09, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 09, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.