July 2000
BOSTON - The way that physicians manage asthma patients varies greatly from National Institutes of Health guidelines published in 1997.
Although the guidelines specify that patients be classified for severity of symptoms, that anti-inflammatories be prescribed and that patients receive a written management plan, this rarely happens.
However, according to results from a study recently presented here at the Pediatric Academic Societies and the American Academy of Pediatrics Joint Meeting, simple quality improvement techniques may help physicians better follow these guidelines.
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Results of the uncontrolled nine-month intervention study indicate that both patients and physicians may benefit from following existing guidelines. Discussion of nighttime symptoms, activity limits and management plans increased by more than 20% with those quality improvements. Documentation of severity in the chart increased by 50%. Management plans in the chart increased by 32%, and plans given to the patient/parent increased by 28%.
The study "helped providers identify a lot of patients who had not previously been diagnosed with asthma," said Patricia Heinrich, RN, BSN, quality improvement specialist for the National Initiative for Children's Healthcare Quality, a program of the Institute for Healthcare Improvement here. "Patients really found it helpful to have a diagnosis and have an understanding of what their disease was and then collaborate with their providers to help take care of their own chronic illness."
Additionally, once patients were classified appropriately, the proper medications could be given. Physicians saw process improvements as well.
"Office efficiency really improved," Heinrich said. "They were able to identify their patients. Working together as a team, office staff were able to get important information prior to the encounter with the physician; that was really new for many of these offices."
Participating practices received a tool kit of asthma protocols, teaching materials and quality improvement aids. These included a combination medication and severity poster. One side of the poster listed criteria for severity, "so providers could classify the patient's severity fairly easily," Heinrich said. Different classifications of severity were given different colors, and the back of the poster listed medication doses and ranges, also color-coded based on severity.
Additionally, a "Living with Asthma" survey was also useful. The survey consisted of questions about coughing, wheezing and exercise, as well as other questions concerning patient symptoms.
"Information necessary for the doctor to do that classification was collected in a very efficient manner, while the patient was in the waiting room," Heinrich said. "Those kind of questions really take the provider some time to go through and ask individually. They can use that time more effectively by doing things like teaching."
A form for a written asthma plan was also available in triplicate, so that physicians, patients and schools or day care centers could all have a copy.
Twenty geographically disbursed practices entered the study, and 17 completed it. Practice teams, each consisting of a pediatrician and a nurse, were given formal instruction in two workshops (baseline and five months later) in asthma management and implementation of rapid cycle change quality improvement.
Practice teams also participated in biweekly conference calls led by asthma and quality improvement experts in which participating pediatricians and nurses shared and discussed asthma care and experiences. Practices made changes in asthma care according to their own needs and using feedback from conference calls.
Data were collected from patients/parents, pediatricians and through chart reviews for 10 consecutive asthma patients from each practice in three cycles: immediately before the first workshop, before the second workshop and two months after the second workshop.
The American Academy of Pediatrics Pediatric Research in Office Settings (PROS) cosponsored this project. All participating practices were PROS members.
For more information:
- Homer CJ, Finch SA, Heinrich P, et al. Quality improvement technique improves management of asthma in office-based practices. Poster Session 1160. Presented at the Pediatric Academic Societies and the American Academy of Pediatrics Joint Meeting. May 12-16, 2000. Boston.
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