173136 Using CQI strategies, clinician champions, and asthma coordinators to improve asthma-related health outcomes among low-income, multi-ethnic children

Monday, October 27, 2008: 1:15 PM

Patricia G. Porter, RN, MPH, CHES , California Asthma Public Health Initiative, California Department of Public Health, University of California, San Francisco, San Francisco, CA
Sibylle Lob, MD, MPH , California Asthma Public Health Initiative, University of California, San Francisco, Sacramento, CA, CA
Jennifer Holloman Boer, MA , California Asthma Public Health Initiative, University of California, San Francisco, Sacramento, CA, CA
Christine Brennan, MPH , California Asthma Public Health Initiative, University of California, San Francisco, Sacramento, CA, CA
Nuny Khamphay, BAS , California Asthma Public Health Initiative, University of California, San Francisco, Sacramento, CA, CA
David Nunez, MD, MPH , California Asthma Public Health Initiative, University of California, San Francisco, Sacramento, CA, CA
Patrick Fox, PhD , Institute for Health & Aging, University of California San Francisco, San Francisco, CA
Background. Asthma is the most common chronic disease of childhood, with low income and minority children disproportionately affected. The optimal management of asthma is frequently compromised by non-compliance with national asthma care guidelines. In 2005 we reported significant improvements in both adherence to clinical guidelines and health outcomes in school-aged community clinic patients using a continuous quality improvement (CQI) process, community health workers (CHWs), and intensive technical assistance (TA) by a central project team.

Purpose. To evaluate whether guideline-based care processes and asthma-related health outcomes improve in this subsequent, larger-scale project, which expands both the number of community clinics involved and the age range of the patients (0-18 years), streamlines the CQI process, and decreases the amount of TA provided.

Methods. Seventeen community clinics treating approximately 12,000 children with asthma were evaluated. Multidisciplinary CQI teams at each clinic developed data-driven clinic-specific CQI activities that were planned, implemented and evaluated according to the “Plan Do Check Act” cycle. Asthma coordinators provided patient education and home visits, and were active members of the CQI teams. A subset of patients with signs of more severe asthma (n=981) were evaluated longitudinally by family interviews (including validated quality of life questionnaires) at baseline and 12 months; the overall population with asthma was assessed through random cross-sectional chart reviews at baseline and 12 months (n=1360).

Results. Children were predominantly Hispanic (71%) and African-American (10%); 58% were enrolled in Medicaid, 9% uninsured. Comparing follow-up to baseline, in the longitudinal sample significantly fewer patients reported acute clinic visits (25.6 vs. 49.6%), emergency department visits (8.0 vs. 29.6%), hospitalizations (1.6 vs. 11.6%), frequent day and nighttime symptoms (15.7 and 19.7% vs. 44.0 and 45.8%, respectively), and missing school (13.3 vs. 27.8%). Significantly more patients reported excellent or very good quality of care (84.7 vs. 67.5%) and a high level of confidence in asthma self-management (92.3 vs. 71.7%). Quality of life scores increased significantly for both children and caregivers and were larger than the published minimal important difference. Cross-sectional data showed clinic-wide improvements in documentation of: asthma severity, review of action plans, health services utilization, and asthma symptoms (p<0.0001 for all outcomes).

Conclusions. Even on a larger scale with less TA, this comprehensive approach to improving asthma care was able to effect changes in clinic processes and provider practice producing major improvements in clinical outcomes. It holds great potential for significantly improving asthma-related health outcomes among low-income children.

Learning Objectives:
Learning Objectives: 1) To describe a research study utilizing principles of quality improvement and asthma coordinators to improve health outcomes for high-risk, low-income school-age children with asthma. 2) To characterize improvements in clinical and process outcomes achieved by seventeen community-based clinics in California. 3) To articulate lessons learned about the development, implementation, and evaluation of a CQI model to improve asthma outcomes in a community-based clinical setting.

Keywords: Asthma, Health Care Quality

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the BPCA Program Director and one of the study investigators.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

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