Improving Asthma Care In A Pediatric Teaching Clinic
Authors: JS Lee, A Gogo, D Tancredi, U Shaikh
Journal: American Journal of Respiratory and Critical Care Medicine (2016)

Open Access BMJ Quality Improvement Programme Improving asthma care in a pediatric resident clinic Julia Lee, Albina Gogo, Daniel Tancredi, Erik Fernandez y Garcia, Ulfat Shaikh To cite: Lee J, Gogo A, Tancredi D, et al. Improving asthma care in a pediatric resident clinic. BMJ Quality Improvement Reports 2016;5:u214746.w6381. doi:10.1136/bmjquality. u214746.w6381 Received 26 August 2016 Revised 23 September 2016 Published Online First 31 October 2016 UC Davis Medical Center, United States of America Correspondence to Julia Lee julialee@slu.edu ABSTRACT There is variation in pediatric asthma management in the outpatient setting. Adherence to national asthma guidelines provides a systematic standardized approach to asthma management. There is a gap between usual and guideline-consistent asthma care in resident clinics. Practice improvement modules aimed at improving resident physician adherence to asthma care guidelines have not been consistently utilized and have not yet been studied. Our aim was to increase guideline consistent care in our pediatric resident clinic in a twelve-month period via increasing performance on the following measures to 75%: spirometry testing; influenza immunization recommendation; level of control assessed through the use of a standardized questionnaire; appropriate medications per national guideline; and use of written asthma action plans. A summarized pediatric-specific version of the National Heart Lung and Blood Institute National Asthma Education and Prevention Program Expert Panel Report 3 (NHLBI EPR-3) guidelines was made readily available to increase provider education. Electronic health record (EHR) enhancements included adding templates to create standardized asthma action plan, asthma control test and a pediatric asthma controller medication order-set. We also addressed the education of patients by simplifying patient instructions. We monitored our progress through the use of an online practice improvement module. We found statistically significant increases in use of a standardized instrument to determine level of control (20% to 81%); recommendation of influenza immunization (56% to 97%); use of national medication treatment guidelines (28% to 98%); distribution of asthma action plans (29% to 65%); and provision of asthma self-management education (35% to 74%). Standardizing the implementation of national guidelines for pediatric asthma through the use of a practice improvement module and electronic health records improved adherence to guidelines. The module allowed us to identify goals for improvement, collect and analyze our group performance data over time, assess the impact of each change, and redesign our process. Improving adherence to national pediatric asthma care guidelines is especially important in settings such as resident teaching clinics which provide care to underserved populations at higher risk for complications related to asthma. PROBLEM Although the current National Heart Lung and Blood Institute National Asthma Education and Prevention Program Expert Panel Report 3 (NHLBI EPR-3) guidelines were ﬁrst published in 2007, general pediatri- cians do not consistently adhere to them. 1 Poorly controlled asthma can contribute to avoidable emergency room visits and hospita- lizations. Patients with asthma seen at university-based clinics may be more likely to have increased health care utilization com- pared to patients with asthma seen in private practice and community based health clinics. 2 Pediatric residents have been shown to not consistently adhere to national asthma care guidelines regardless of level of training. 3 Our baseline data demonstrated that pediat- ric residents in our teaching clinic at the University of California Davis Health System (California, United States) adhered to the national asthma care guidelines 20-35% of the time in terms of obtaining relevant history to diagnose severity of asthma, recom- mending spirometry testing, recommending inﬂuenza vaccine, using a standardized instrument to assess level of control, refer- ring to national asthma care guidelines for medication dosage, and providing an asthma action plan. Our aims in a 12 month period were to increase performance on the follow- ing measures to 75%: spirometry testing; inﬂuenza immunization; level of control assessed through the use of a standardized questionnaire; appropriate medications per national guideline; and use of written asthma action plans. Our key interventions were provider educa- tion, electronic health record modiﬁcations and patient education. Our team consisted of three general pediatric faculty staff members, one bio-statistician, and one pedi- atric resident. The study was conducted in a resident con- tinuity teaching clinic that occurs four after- noons a week, ranging from ﬁve to seven Lee J, et al. BMJ Quality Improvement Reports 2016;5:u214746.w6381. doi:10.1136/bmjquality.u214746.w6381