Improving Pediatric Asthma Control Among Minority Children Participating in Medicaid: Providing Practice Redesign Support to Deliver a Chronic Care Model

Abstract

Background. Asthma, a leading chronic disease of children, currently affects about 6.2 million (8.5%) children in the United States. Despite advances in asthma research and availability of increasingly effective therapy, many children do not receive appropriate medications to control the disease, have overreliance on reliever medication, and lack systematic follow-up care. The situation is even worse for poor inner-city and minority children who have significantly worse asthma rates, severity, and outcomes. National Asthma Education and Prevention Program Guidelines recommend a multimodal, chronic care approach. Objective. The authors assessed the effectiveness of practice redesign and computerized provider feedback in improving both practitioner adherence to National Asthma Education and Prevention Program Guidelines (NAEPP), and patient outcomes in 295 poor minority children across four Federally Qualified Health Centers (FQHC). Methods. In a nonrandomized, two-group (intervention versus comparison), two-phase trial, all sites were provided redesign support to provide quarterly well-asthma visits using structured visit forms, community health workers for outreach and follow-up, a Web-based disease registry for tracking and scheduling, and a provider education package. Intervention sites were given an additional Web-based, computerized patient-specific provider feedback system that produced a guideline-driven medication assessment prompt. Results. Logistic regression results showed that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to our feedback system during the Phase I enrollment period than providers at comparison sites (exp(B) = 2.351, confidence interval [CI] = 1.315–4.204). In Phase II (the postenrollment visit period), hierarchical linear models (HLMs) and latent growth curves were used to show that asthma control improved significantly by .19 (SE = .05) on average for each of the remaining four visits (about 11% of a standard deviation), and improved even more for patients at intervention sites. These results show that implementation of practice redesign support guided by a pediatric chronic care model can improve provider adherence to treatment guidelines as well as patients’ asthma control. Conclusions. The addition of patient-specific feedback for providers results in quicker adoption of guideline recommendations and potentially greater improvements in asthma control compared to the basic practice redesign support alone.

Keywords :

• asthma control
• chronic care
• decision support
• guidelines
• minorities
• pediatric asthma
• practice redesign

Acknowledgments

The authors thank the participating community health centers for their commitment to this research. Funding for this project was provided under grant number U18-HS-011068 from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. As Principal Investigator, Dr. Judith Fifield had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. This study is registered at www.ClinicalTrials.gov, no. NCT00355069.