Using qualitative process data to validate quantitative outcome conclusions

Controlling Asthma in the Richmond Metropolitan Area (CARMA), primarily funded by the CDC, uses outcome and impact evaluations to assess community-driven interventions to improve the management of pediatric asthma. The majority of pediatric asthma is treated by pediatricians and family practitioners. Many PCPs do not follow best practice guidelines. In 2004, CARMA initiated a Provider Quality Improvement (PQI) intervention. PQI is offered to pediatric practices that meet one or more of the following criteria: serve patients in high hospitalization rate zip codes; are identified by a pharmaceutical company as high prescribers; request information about CARMA; have a practitioner who signed up for a CARMA CME workshop. Led by a primary care physician and pediatric nurse practitioner, PQI is modeled on “academic detailing,” an intervention derived from drug company marketing strategies, with demonstrated success in changing practice patterns. Ten Key Clinical Activities recommended by the National Asthma Education and Prevention Program are the basis for physician and nursing asthma management objectives. One provider and one nurse are identified in each practice as a “Champion,” responsible for the dissemination of asthma information throughout the practice. Participating practices agree to periodic chart review for evaluation of practice change by key indicators. The indicators are severity classification, patient education, spirometry and action plans. To date, six practices have completed PQI, with pre- and post-intervention chart review. Overall, these six practices had a 37% improvement in performance on the four indicators, with a range from 16% to 63%. The challenge is to demonstrate that this outcome is directly related to changes in practice and to the PQI intervention. This was done through individual interviews, conducted by an outside evaluator, of the physician and nurse champions. Qualitative analysis of these interviews provides the evidence linking the intervention to real practice changes and to observed charting changes. The presentation will detail the logic, methodology, analytic methods and results of the qualitative analysis.