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Policy Innovation Profile

National Academy and Affiliated State Chapters Support Pediatricians in Improving Asthma Care, Leading to Better Guideline Adherence and Disease Control, Fewer Acute Episodes


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Snapshot

Summary

The national office of the American Academy of Pediatrics and four of its State chapters—in Alabama, Maine, Ohio, and Oregon—helped 49 pediatric practices adhere to well-established asthma care guidelines and systematically improve asthma care. Over a 1-year period, support included upfront training of the chapters and participating practices on quality improvement concepts, followed by ongoing sharing of data and best practices and assistance with problem-solving. The program improved adherence to recommended care processes, leading to better asthma control.

Evidence Rating (What is this?)

Moderate: The evidence consists of monthly data from patient charts relevant to 14 asthma-related measures.
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Developing Organizations

American Academy of Pediatrics
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Date First Implemented

2009
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Patient Population

Vulnerable Populations > Childrenend pp

Problem Addressed

Pediatric asthma is a common condition, especially for poor families and children in inner-city neighborhoods. It reduces quality of life and often leads to costly emergency department (ED) visits and inpatient admissions. Managing pediatric asthma according to established guidelines can minimize the potential for negative outcomes, but primary care physicians, including pediatricians, often do not adhere to such guidelines.
  • A common condition: Asthma affects more than 22 million Americans each year, about one-third of whom are children.1 The problem tends to be worse for children in poor families, where 12 percent of children have asthma,2 and in inner-city areas.3,4
  • Asthma leads to poor quality of life and need for costly care: When poorly managed, asthma has a negative impact on quality of life and often leads to acute exacerbations requiring ED or inpatient care.5
  • Poor adherence to guidelines: Existing guidelines set by the National Asthma Education and Prevention Program can help practitioners effectively manage pediatric asthma and hence reduce the risk of exacerbations, but adherence to such guidelines remains low among practitioners in a variety of settings, including primary care.5

What They Did

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Description of the Innovative Activity

The national office of the American Academy of Pediatrics and four of its State chapters—in Alabama, Maine, Ohio, and Oregon—helped 49 pediatric practices adhere to well-established asthma care guidelines and systematically improve asthma care. Over a 1-year period, support included upfront training of the chapters and participating practices on quality improvement (QI) concepts, followed by ongoing sharing of data and best practices and assistance with problem-solving. Core program elements are described in more detail below:
  • Chapter training led by national office: Each participating chapter sent a three-person team (a physician practice leader, administrative staffer, and local asthma expert) to the Academy's national office for a weekend training session held in July 2009. Academy QI experts taught the teams leadership skills, how to run a QI collaborative, and how to collect data (including use of the Academy's online "Education in Quality Improvement in Pediatric Practice" system). In addition, a QI expert from Cincinnati Children's Hospital discussed how that hospital improved asthma care.
  • Practice training led by each chapter: After the weekend training session, each participating chapter-based team recruited 12 or 13 practices of varying sizes, including small (two-physician) offices, county health departments, and academic medical center–based practices. In July and August of 2009, Academy officials, in collaboration with each chapter team, ran separate 1.5-day learning sessions in each state for participating practices. Each practice sent a three-person team, typically a physician, nurse, and administrative assistant. During these sessions, the practice teams studied QI principles, learned about data collection, and learned to standardize practices so that patients systematically receive appropriate asthma care.
  • Practice-level testing and implementation: After the chapter-led training, the three-person teams in participating practices began introducing QI projects. They began with small tests, typically with just one or two doctors. The teams also created diagrams to map office workflow, focusing on what happens to asthma patients at every step. This mapping process helped the practices implement several concrete improvements, such as the following:
    • Formal patient tracking: Many practices created systems to identify and track asthma patients, ideally through a formal registry. To collect the data, practices used a standard encounter form that includes questions about asthma severity and control and whether the patient had been offered a flu shot. Practices used the Academy's online system to track, monitor, and evaluate the data.
    • Stepwise treatment: Many practices implemented the guideline-based stepwise treatment approach, which promotes appropriate use of spirometry testing to assess asthma's impact on lung capacity, individualized action plans, and self-management education for patients and family members.
  • Ongoing problem-solving during implementation: During the implementation process, Academy officials and chapter representatives held regular conference calls and provided additional services to help practices overcome obstacles. Specific support included the following:
    • Monthly calls with Academy staff: The four chapter leaders participated in a monthly conference call with Academy staff. These calls helped the chapter leaders make various adjustments to the project, such as adding a new measure for asthma control.
    • Monthly calls within each State: Each state chapter's physician leader held a monthly call with the practice-based teams. The calls allowed the teams to compare their progress through data-sharing and to discuss useful anecdotes, strategies, and lessons learned. The physician leader encouraged practices to take ideas from each other and to implement change as broadly as possible. For example, during one call, a practice in Maine discussed its successful use of flip charts that highlight questions to ask patients during exams. After the call, the State chapter had additional copies produced for use by all 49 practices in the four states.
    • Quarterly webinars for all practices: The Academy sponsored quarterly training sessions for all practice-based teams, providing another opportunity to share effective ideas.
    • Web-based knowledge sharing: Each state chapter set up a listserv where participating practices could discuss the challenges they have encountered and share potential strategies and solutions. For example, one practice used the system to share via e-mail asthma action plan forms that use highly accessible language.
    • QI coach: Teams at participating practices could call or e-mail the QI expert from Cincinnati Children's Hospital Medical Center at any time.

Context of the Innovation

Headquartered in Elk Grove Village, IL, the American Academy of Pediatrics serves 60,000 pediatricians, medical subspecialists, and surgical specialists, helping them promote the health and well-being of their patients. Its 66 chapters in the United States and Canada range in size from under 200 members to more than 1,001. In 2008 and 2009, various factors combined to set the stage for this program. First, a chapter needs assessment highlighted growing interest in leading and participating in quality improvement work. Second, Academy leaders wanted to help members meet the American Board of Pediatrics' new quality improvement requirements for maintaining board certification and to test a new model for supporting State chapters in working on quality improvement with members. Asthma represented a logical target for the initiative, for the following reasons: the National Heart, Lung, and Blood Institute had recently published new asthma care guidelines; asthma is the most common serious chronic disease afflicting children in the United States; and the Academy could draw on asthma care improvement efforts already completed at Cincinnati Children's Hospital Medical Center.

Did It Work?

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Results

The program improved adherence to recommended care processes, leading to better asthma control.
  • Greater adherence to recommended care processes: Within participating practices, the percentage of asthma patients receiving "optimal" care (defined as use of a validated form to assess asthma control and the stepwise treatment approach, development of a patient action plan, and provision of a flu shot) increased from 35 percent at program initiation (October 2009) to 85 percent a year later (September 2010). Adherence to specific guideline-recommended care processes also increased, including providing self-management educational materials (from 60 to 87 percent), developing and discussing asthma action plans (49 to 91 percent), using spirometry testing to diagnose asthma (49 to 62 percent) and a stepwise approach to treatment (83 to 99 percent), and providing or recommending a flu shot (94 to 97 percent).
  • Better asthma control: The percentage of patients at participating practices with well-controlled asthma (as defined by the National Heart, Lung, and Blood Institute) rose from 58 to 72 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of monthly data from patient charts relevant to 14 asthma-related measures.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Recruiting chapters: In 2008, the Academy e-mailed all chapters, inviting them to apply to participate in the project. The application noted that selected chapters would receive $10,000 from the national office to cover some program-related costs. Applicants had to commit to providing the aforementioned three-person team. After reviewing the applications, Academy officials selected the four State chapters they felt had the greatest likelihood of success.
  • Initial year-long phase: As detailed in the "Description of the Innovative Activity" section, participating chapters and practices received training and support for a year-long period.
  • Expansion within participating states: The first phase of the project ended in September 2010. For the second phase, the four participating State chapters are expanding the initiative, both by adding new practices and encouraging the original practices to expand their focus to their entire population of asthma patients, promote greater involvement of parents, and engage with payers. Examples of these expansion efforts are briefly outlined below:
    • The Ohio chapter added 35 practices by partnering with the CareSource Foundation (a Medicaid managed care plan) and the Nationwide Children's Hospital's Partners for Kids.
    • The Alabama chapter added nine practices by partnering with the University of Alabama-Birmingham, the Alabama State Department of Health, and Blue Cross Blue Shield.
    • The Maine chapter worked with the State (which received a Federal grant through the Children's Health Insurance Plan Reauthorization Act of 2009) to promote additional QI work by participating practices on other pediatric health issues.
    • The Oregon chapter collaborated with another organization to create a statewide registry for asthma patients.

Resources Used and Skills Needed

  • Staffing: Project participants included 2.5 full-time equivalents (FTEs) from the Academy, 2 consultants from Cincinnati Children's Hospital and Medical Center, the 4 three-member teams from the participating chapters, these teams' administrative staff (about .4 FTEs per team), and the teams and other staff at the 49 participating practices.
  • Costs: At the national and state level, major expenses consisted of running the training sessions (e.g., travel, facility use, printing) and collecting, analyzing, and producing monthly reports. At the practice level, the chief cost consisted of staff time to participate in training and troubleshooting sessions, implement new systems, enter data, participate in monthly calls to review data and coaching practices, and fill out paperwork. These costs, however, may be offset by increased revenues, as leaders of some participating practices believe the program has encouraged more patients to schedule regular checkups.
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Funding Sources

American Board of Pediatrics; Merck Childhood Asthma Network; American Academy of Pediatrics, Friends of Children Fund
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Tools and Other Resources

The asthma guidelines, developed by the National Asthma Education and Prevention Program and published by the National Heart, Lung, and Blood Institute, are available at http://www.nhlbi.nih.gov/guidelines/asthma/.

Adoption Considerations

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Getting Started with This Innovation

  • Set attainable goals: Practices may initially be intimidated by the scope of the project, because asthma guidelines tend to be lengthy and implementing them systematically requires broad changes in treatment delivery. Project leaders can ease these concerns by breaking the initiative into manageable phases, setting achievable short-term goals, and guiding participants through any rough patches that may be encountered.
  • Share data to win support of physician leaders: At the practice level, persuading senior physician leaders to embrace QI work can be challenging, as they often have permanent board certification and hence are not subject to maintenance requirements. To overcome this resistance, share data demonstrating the program's potential to improve quality and reduce costs.

Sustaining This Innovation

  • Encourage idea sharing: Many of the best ideas come from the practices themselves. Establish as many avenues as possible for sharing of practice-level tactics and strategies, including but not limited to teleconferences, webinars, and online message boards.
  • Offer incentives to participating physicians: The four State chapters offered physicians in participating practices the opportunity to earn credits toward American Board of Pediatrics Maintenance of Certification. During the year-long effort, 92 percent of participating physicians (216) received such credits.
  • Seek funding to support expansion: Program leaders may be able to secure funding to support expansion from a variety of sources, such as managed care companies and other payers (which benefit from reductions in expensive ED visits and hospitalizations), academic institutions, State agencies, and private donors.

More Information

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Contact the Innovator

Judith Cohen Dolins, MPH
Associate Executive Director
Director, Department of Community, Chapter, and State Affairs
American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1019
(847) 434-7911
E-mail: jdolins@aap.org

Innovator Disclosures

Ms. Dolins has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Meyer H. Targeted care improvements show promising results for treating children with asthma. Health Affairs. 2011 Mar;30(3):404-7.

Footnotes

1 National Heart, Lung, and Blood Institute Diseases and Conditions Index. Who is at risk for asthma? U.S. Department for Health & Human Services. Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/atrisk.html.
2 Summary Health Statistics for U.S. Children: National Health Interview Survey, 2008. U.S. Department of Health and Human Services, Vital and Health Statistics, Ser. 10, No. 244; 2009. Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_244.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
3 The Asthma and Allergy Foundation of America. Childhood Asthma Web site. 2005. Available at: http://www.aafa.org/display.cfm?id=8&sub=16&cont=44.
4 Centers for Disease Control and Prevention. The Inner-City Asthma Intervention Web site. Available at: http://www.cdc.gov/asthma/interventions/inner_city_asthma.htm.
5 Bell LM, Grundmeier R, Localio R, et al. Electronic health record based decision support to improve asthma care: a cluster-randomized trial. Pediatrics. 2010;125(4):e770-7. [PubMed]
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Original publication: June 05, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 21, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.