Presenter: Delaney Gracy, MD, MPH

Impact of the “Asthma Toolbox” Impact of the “Asthma Toolbox” for Improving Documentation for Improving Documentation

of Pediatric Asthma of Pediatric Asthma Management in an Urban Management in an Urban

Community Health Center Community Health Center

Presenter: Presenter: Delaney Gracy, MD, MPHDelaney Gracy, MD, MPHCo-Authors: Co-Authors: Alan Shapiro, MD; Ariel Sarmiento, Alan Shapiro, MD; Ariel Sarmiento, MPH; Wendy Quinones, BSN, RN, MSN, LPNP; Jo MPH; Wendy Quinones, BSN, RN, MSN, LPNP; Jo

Applebaum, MPHApplebaum, MPH

Academy HealthAcademy HealthNational Research MeetingNational Research Meeting

Washington DC, June 8, 2008Washington DC, June 8, 2008

Childhood Asthma InitiativeChildhood Asthma Initiative A multidisciplinary program to improve A multidisciplinary program to improve

asthma care for severely disadvantaged and asthma care for severely disadvantaged and under-served pediatric population since 1997under-served pediatric population since 1997

Funded by the Picower FoundationFunded by the Picower Foundation

Implemented in Community Pediatric Implemented in Community Pediatric Programs of the Children’s Hospital at Programs of the Children’s Hospital at MontefioreMontefiore South Bronx Health Center for Children South Bronx Health Center for Children

and Families (FQHC)and Families (FQHC) New York Children’s Health Project (HCH)New York Children’s Health Project (HCH)

Research ObjectiveResearch Objective

To evaluate a standardized provider To evaluate a standardized provider reminder tool developed to reminder tool developed to document the assessment and document the assessment and treatment of pediatric asthma treatment of pediatric asthma patients in a primary care settingpatients in a primary care setting

Population StudiedPopulation Studied

Pediatric patients at the South Bronx Pediatric patients at the South Bronx Health Center for Children and FamiliesHealth Center for Children and Families community health centercommunity health center underserved inner-city neighborhoodunderserved inner-city neighborhood 96% minority96% minority 27% pediatric asthma prevalence (2006)27% pediatric asthma prevalence (2006) childhood asthma hospitalization rates childhood asthma hospitalization rates

in community served twice that of NYC in community served twice that of NYC overall (9.6-11.0 vs 5.4/1000)overall (9.6-11.0 vs 5.4/1000)

Asthma ToolboxAsthma Toolbox Boxed set of questions based on NHLBI Boxed set of questions based on NHLBI

guidelines printed on all pediatric medical guidelines printed on all pediatric medical chart forms (well child, follow-up and walk-in chart forms (well child, follow-up and walk-in forms) forms)

Prompts providers to consistently and Prompts providers to consistently and accurately assess and treat pediatric asthma accurately assess and treat pediatric asthma patients in a busy primary care settingpatients in a busy primary care setting

Use of NHLBI guidelines facilitated by Use of NHLBI guidelines facilitated by streamlined set of questions that can be streamlined set of questions that can be completed quicklycompleted quickly

Sample Toolbox

Study DesignStudy Design

Chart review conducted to determine Chart review conducted to determine whether the Asthma Toolbox improved whether the Asthma Toolbox improved documentation of:documentation of: asthma severity classificationasthma severity classification prescribing of controller medications prescribing of controller medications visits to the emergency department (ED) visits to the emergency department (ED) hospitalizationshospitalizations

Study DesignStudy Design (cont’d)(cont’d)

Sample (N=300)Sample (N=300) 100 patients for each measurement 100 patients for each measurement

periodperiod randomly selectedrandomly selected ages 6 mo to 20 y with a non-urgent visitages 6 mo to 20 y with a non-urgent visit

Measurement periodsMeasurement periods pre: 11/1/04-10/31/05pre: 11/1/04-10/31/05 post: 12/1/05-11/30/06post: 12/1/05-11/30/06 late post: 1/1/07-6/30/07late post: 1/1/07-6/30/07

Study DesignStudy Design (cont’d)(cont’d)

Chart reviewChart review Last asthma visit in measurement period Last asthma visit in measurement period

selected for reviewselected for review If visit excluded, previous visit reviewedIf visit excluded, previous visit reviewed

Statistical analysisStatistical analysis Chi-square tests used to compare percentage Chi-square tests used to compare percentage

of patients with variables documented of patients with variables documented pre- vs post-; post- vs late post-pre- vs post-; post- vs late post-

implementationimplementation

Findings: Documentation of Findings: Documentation of Assessment and TreatmentAssessment and Treatment

Chi-square tests used to compare percentage of patients with variables documented at last eligible visit in the measurement period.

Perc

en

t (%

)

0

20

40

60

80

100PrePostLate post

p=.000

p<.01p=.000

p=.000

82

95

100

16

58

84

50

62

90

Severity Overall PersistentOn Controller

Findings: Findings: Documentation of ED Documentation of ED

VisitsVisitsP

erc

en

t (%

)

6 5

37 39

8090

0

20

40

60

80

100 PrePostLate post

p=.000 all comparisons

Prior 4 mo Prior 12 mo

Chi-square tests used to compare percentage of patients with variables documented at last eligible visit in the measurement period.

Findings: Findings: Documentation of HospitalizationDocumentation of Hospitalization

Perc

en

t (%

)

7 7

39 38

7888

0

20

40

60

80

100 PrePostLate post

p=.000 all comparisons

Prior 4 mo Prior 12 mo

Chi-square tests used to compare percentage of patients with variables documented at last eligible visit in the measurement period.

ConclusionsConclusions The Asthma Toolbox significantly improved The Asthma Toolbox significantly improved

the documentation of key variables in the documentation of key variables in pediatric asthma management, including pediatric asthma management, including asthma severity classification and asthma severity classification and prescribing of controller medications in prescribing of controller medications in persistent asthmaticspersistent asthmatics

A standardized brief provider-prompt A standardized brief provider-prompt assisted providers in complying with current assisted providers in complying with current asthma guidelines in the context of complex asthma guidelines in the context of complex medical encountersmedical encounters

Acceptance of provider-prompt Acceptance of provider-prompt demonstrated by high percentage of usagedemonstrated by high percentage of usage

Implications for Primary Care Practice and Policy

Use of provider-prompts incorporated into Use of provider-prompts incorporated into the medical record can improve adherence the medical record can improve adherence to clinical guidelinesto clinical guidelines

Assessment, treatment and monitoring of Assessment, treatment and monitoring of pediatric asthmatics can be improved in a pediatric asthmatics can be improved in a busy primary care settingbusy primary care setting

Consistent documentation in the chart can Consistent documentation in the chart can assist in quality improvement activities by assist in quality improvement activities by facilitating data collection from the medical facilitating data collection from the medical record and improve outcome trackingrecord and improve outcome tracking

Next StepsNext Steps

The Asthma Toolbox has been revised The Asthma Toolbox has been revised to reflect NHLBI 2007 guidelinesto reflect NHLBI 2007 guidelines

To be incorporated into adult medical To be incorporated into adult medical record formsrecord forms

The Asthma Toolbox has been adapted The Asthma Toolbox has been adapted for and will be incorporated into an for and will be incorporated into an electronic health record templateelectronic health record template

Thank YouThank You