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Impact of the “Asthma Toolbox” for Improving Documentation of Pediatric Asthma Management in an Urban Community Health Center. Presenter: Delaney Gracy, MD, MPH Co-Authors: Alan Shapiro, MD; Ariel Sarmiento, MPH; Wendy Quinones, BSN, RN, MSN, LPNP; Jo Applebaum, MPH Academy Health - PowerPoint PPT Presentation
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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