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Evaluation of a practice-based intervention to improve the management of pediatric asthma.

ABSTRACT: Pediatric asthma remains a significant burden upon patients, families, and the healthcare system. Despite the availability of evidence-based best practice asthma management guidelines for over a decade, published studies suggest that many primary care physicians do not follow them. This article describes the Provider Quality Improvement (PQI) intervention with six diverse community-based practices. A pediatrician and a nurse practitioner conducted the year-long intervention, which was part of a larger CDC-funded project, using problem-based learning within an academic detailing model. Process and outcome assessments included (1) pre- and post-intervention chart reviews to assess eight indicators of quality care, (2) post-intervention staff questionnaires to assess contact with the intervention team and awareness of practice changes, and (3) individual semi-structured interviews with physician and nurse champions in five of the six practices. The chart review indicated that all six practices met predefined performance improvement criteria for at least four of eight indicators of quality care, with two practices meeting improvement criteria for all eight indicators. The response rate for the staff questionnaires was high (72%) and generally consistent across practices, demonstrating high staff awareness of the intervention team, the practice "asthma champions," and changes in practice patterns. In the semi-structured interviews, several respondents attributed the intervention's acceptability and success to the expertise of the PQI team and expressed the belief that sustaining changes would be critically dependent on continued contact with the team. Despite significant limitations, this study demonstrated that interventions that are responsive to individual practice cultures can successfully change practice patterns.

SUBMITTER: Ragazzi H

PROVIDER: S-EPMC3042075 | biostudies-literature | 2011 Feb

REPOSITORIES: biostudies-literature

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Evaluation of a practice-based intervention to improve the management of pediatric asthma.

Ragazzi Helen H Keller Adrienne A Ehrensberger Ryan R Irani Anne-Marie AM

Journal of urban health : bulletin of the New York Academy of Medicine 20110201

Pediatric asthma remains a significant burden upon patients, families, and the healthcare system. Despite the availability of evidence-based best practice asthma management guidelines for over a decade, published studies suggest that many primary care physicians do not follow them. This article describes the Provider Quality Improvement (PQI) intervention with six diverse community-based practices. A pediatrician and a nurse practitioner conducted the year-long intervention, which was part of a ...[more]

PMID: 21337050

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Project description:OBJECTIVE:The aim of this study was to design and evaluate a smartphone-based application for improving self-management in patients with asthma and evaluate its effects on their knowledge. METHODS:In this applied research, based on the Clinical Practice Guideline and a systematic review, a questionnaire was designed to determine the application information content and functionality requirements by 15 pediatric and adult asthma and allergy specialist. Then the application was designed and developed using Adobe Air software on the Android operating system. Usability evaluation of the mobile application was performed using the standard questionnaire for user interaction satisfaction (QUIS), which completed by 30 patients with asthma, 8 information technology (IT) specialists, and 2 asthma and allergy specialists. Self-management knowledge of 30 asthma patients was measured using a researcher-made questionnaire before and after using the application. RESULTS:The number of specialists in the both Delphi rounds was 15 and the mean work experiences were 17.6 years. The most important elements for asthma self-management were avoiding exposure to allergen and triggers (96%), drug treatment (94.6%), and how to use the therapeutic tools (92.4%), and the most important functionalities were alerting the patients when they did not control asthma (92%), setting reminders for timely drug use (85.4%) and therapeutic tools (82.6%), recording prescription drugs (82.6%), and peak flow meter values (82%). Usability evaluation showed that 30 patients with asthma, 8 IT specialists, and 2 physicians evaluated the application at a "good" level. The mean score of the patients' knowledge before intervention was 2.43?±?0.95 which after intervention was significantly increased to 4.3?±?0.56 (p?<?0.001). CONCLUSION:Considering the desirable outcomes of application evaluation and a positive impact of this educational intervention on asthma patients' knowledge, it is possible to use mobile-based self-management programs to help these patients to manage illness and gain knowledge and self-management skills.

Project description:PurposeAsthma interventions targeting urban adolescents are rare, despite a great need. Motivating adolescents to achieve better self-management of asthma is challenging, and the literature suggests that certain subgroups are more resistant than others. We conducted a school-based, randomized controlled trial (RCT) to evaluate Puff City, a Web-based, tailored asthma intervention, which included a referral coordinator, and incorporated theory-based strategies to target urban teens with characteristics previously found to be associated with lack of behavior change.MethodsTo identify eligible teens, we administered questionnaires on asthma diagnoses and symptoms to ninth through 12th graders of participating schools during a scheduled English class. We randomized eligible, consenting students to Puff City (treatment) or generic asthma education (control).ResultsWe randomized 422 students (98% African-American, mean age = 15.6 years). At 12-month follow-up, adjusted odds ratios (aORs) (95% confidence intervals) indicated intervention benefit for treatment teens for symptom-days and restricted activity days (analyzed as categorical variables) as aOR = .49 (.24-.79), p = .006 and .53 (.32-.86), p = .010, respectively. Among teens meeting baseline criteria for rebelliousness, treatment teens reported fewer symptom-days, symptom-nights, school absences, and restricted activity days: aOR = .30 (.11-.80), .29 (.14-.64), .40 (.20-.78), and .23 (.10-.55); all p < .05. Among teens reporting low perceived emotional support, treatment students reported only fewer symptom-days than controls: aOR = .23 (.06-.88), p = .031. We did not observe statistically significant differences in medical care use.ConclusionsResults suggest that a theory-based, tailored approach, with a referral coordinator, can improve asthma management in urban teens. Puff City represents a viable strategy for disseminating an effective intervention to high-risk and hard-to-reach populations.

Project description:BackgroundAsthma is a chronic disease requiring effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management is increasing. However, there is limited knowledge concerning how and to what extent psychological theory has been applied to the development of digital interventions, or how using theory impacts outcomes.ObjectiveThe study aimed to examine the use and application of theory in the development of digital interventions to enhance asthma self-management and to evaluate the effectiveness of theory-based interventions in improving adherence, self-management, and clinical outcomes.MethodsElectronic databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched systematically using predetermined terms. Additional studies were identified by scanning references within relevant studies. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Full-text review was undertaken for relevant studies. Those meeting inclusion criteria were assessed for risk of bias using the Cochrane Collaboration tool. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study outcomes were classified as medication adherence, self-management, asthma control, clinical markers of health, quality of life, other quality of life outcomes, and health care utilization. Effectiveness was calculated as an average outcome score based on the study's reported significance. The Theory Coding Scheme (TCS) was used to establish the extent to which each intervention had applied theory and which theoretical constructs or behavioral determinants were addressed. Associations between TCS scores and asthma outcomes were described within a narrative synthesis.ResultsFourteen studies evaluating 14 different digital interventions were included in this review. The most commonly cited theories were Social Cognitive Theory, Health Belief Model, and Self-Efficacy Theory. A greater use of theory in the development of interventions was correlated with effective outcomes (r=.657; P=.01): only the 3 studies that met >60% of the different uses of theory assessed by the TCS were effective on all behavioral and clinical outcomes measured. None of the 11 studies that met ≤60% of the TCS criteria were fully effective; however, 3 interventions were partially effective (ie, the intervention had a significant impact on some, but not all, of the outcomes measured). Most studies lacked detail on the theoretical constructs and how they were applied to the development and application of the intervention.ConclusionsThese findings suggest that greater use of theory in the development and application of digital self-management interventions for asthma may increase their effectiveness. The application of theory alone may not be enough to yield a successful intervention, and other factors (eg, the context in which the intervention is used) should be considered. A systematic approach to the use of theory to guide the design, selection, and application of intervention techniques is needed.

Project description:BackgroundInterventions designed to narrow the gap between research findings and clinical practice may be effective, but also costly. Economic evaluations are necessary to judge whether such interventions are worth the effort. We have evaluated the economic effects of a tailored intervention to support the implementation of guidelines for the use of antihypertensive and cholesterol-lowering drugs. The tailored intervention was evaluated in a randomized trial, and was shown to significantly increase the use of thiazides for patients started on antihypertensive medication, but had little or no impact on other outcomes. The increased use of thiazides was not expected to have an impact on health outcomes.Methods and findingsWe performed cost-minimization and cost-effectiveness analyses on data from a randomized trial involving 146 general practices from two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Only patients that were being started on antihypertensive medication were included in the analyses. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders. Pharmacists conducted the visits. A cost-minimization framework was adopted, where the costs of intervention were set against the reduced treatment costs (principally due to increased use of thiazides rather than more expensive medication). The cost-effectiveness of the intervention was estimated as the cost per additional patient being started on thiazides. The net annual cost (cost minimization) in our study population was 53,395 US dollars, corresponding to 763 US dollars per practice. The cost per additional patient started on thiazides (cost-effectiveness) was 454 US dollars. The net annual savings in a national program was modeled to be 761,998 US dollars, or 540 US dollars per practice after 2 y. In this scenario the savings exceeded the costs in all but two of the sensitivity analyses we conducted, and the cost-effectiveness was estimated to be 183 US dollars.ConclusionsWe found a significant shift in prescribing of antihypertensive drugs towards the use of thiazides in our trial. A major reason to promote the use of thiazides is their lower price compared to other drugs. The cost of the intervention was more than twice the savings within the time frame of our study. However, we predict modest savings over a 2-y period.

Project description:BackgroundAsthma control in adolescents is low with half of the young people in a London study identified as having suboptimal control when measured using the Asthma Control Test. Control of asthma symptoms can be improved by addressing barriers to good self-management, such as poor understanding of asthma and adherence to medication. The aim of this study was therefore to develop the My Asthma in School (MAIS) intervention for the improvement of asthma control and self-management in adolescents and to test its initial feasibility. The intervention intended to combine a strong focus on theory with a design specifically aimed to engage adolescents.MethodsThe intervention development was based on previous qualitative and quantitative findings, and on guidelines from the Medical Research Council for the development of complex interventions. The COM-B (Capability, Opportunity, Motivation-Behaviour) model was applied to inform the design of intervention elements. Behavioural targets were identified from existing barriers to good asthma self-management and were then used to guide the development of engaging intervention elements, which were described using the Behavioural Change Technique (BCT) Taxonomy version 1. Adolescents were involved throughout this process. The MAIS intervention was tested in a feasibility phase in London secondary schools with adolescents aged between 11 and 13.ResultsThe complex school-based MAIS intervention comprised a first school visit from a theatre group, who conducted a workshop with all year 7-8 students and addressed peer understanding and attitudes to asthma. The second visit included four self-management workshops for adolescents with asthma, including games, short-films and role play activities. Forty different types of techniques to change behaviour were applied, totalling 163 instances of BCT use across intervention elements, addressing all areas of capability, opportunity and motivation. In this initial feasibility study, 1814 adolescents with and without asthma from nine schools received the theatre intervention visit; 23 adolescents with asthma from one of the schools attended the workshop visit. The intervention was found acceptable and engaging, and 91.4% of participants agreed that the workshops changed how they think or feel about asthma.ConclusionThis study demonstrates development and initial feasibility of a complex theory-based intervention, and how it can combine engaging media and interactive elements, to achieve a multi-directional approach to behavioural change. However more work is needed to assess the feasibility of trial processes, including recruitment and delivery format of the workshops.

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Evaluation of a practice-based intervention to improve the management of pediatric asthma.

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Evaluation of a practice-based intervention to improve the management of pediatric asthma.

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