Decision-Making Tool May Improve Pediatric Asthma Management

Laurie Barclay, MD

May 09, 2011

May 9, 2011 — Using a decision-making tool significantly increased documentation of pediatric asthma management, according to the results of a retrospective medical record review reported in the May issue of the Archives of Pediatric & Adolescent Medicine.

"To facilitate provider adherence and optimize care, we developed the Asthma Toolbox, a decision-making tool initially based on the 2002 [National Asthma Education and Prevention Program] guideline update," write Alan Shapiro, MD, from Community Pediatric Programs, Montefiore Medical Center, New York City, and colleagues.

"The Asthma Toolbox is incorporated into paper and electronic records to efficiently guide providers through assessment, monitoring, and treatment of pediatric asthma during primary care visits. The objective of this study was to assess change in documentation of key asthma indicators after implementation in 2 New York programs: a community health center in the South Bronx and a mobile medical program serving homeless families and youth throughout New York City."

For 1-year periods before and after implementation and after revision reflecting 2007 guideline modifications, the investigators reviewed records from independent, random samples. These included 600 paper records from patients aged 6 months to 18 years with at least 1 asthma visit to a community health center, and 646 electronic health records (EHRs) from patients of the same age range seen at a mobile medical program serving family homeless shelters.

The intervention consisted of incorporating the Asthma Toolbox into paper encounter forms and embedding it in the EHR to guide physicians and nurse practitioners through evaluation and management for pediatric asthma.

Study endpoints included the documentation of a subset of asthma severity/control measures, emergency department visits, hospitalizations, and percentage of patients with persistent asthma for which controller medications were prescribed.

In both programs, documentation of each asthma indicator increased after implementation (P < .001 for all comparisons by chi square tests). For paper records, documentation of severity/control measures improved from 25.5% to 77.5%, and for EHRs, improvements were from 11.7% to 85.1% (P < .001).

After revision of the Asthma Toolbox, improvements were sustained for all indicators in both programs. The percentage of patients with persistent/uncontrolled asthma for whom controller medications were prescribed reached 96% to 97%.

"Use of the Asthma Toolbox, an asthma decision-making tool, significantly increased documentation of pediatric asthma management among providers working in high-disparity, urban primary care settings," the study authors write.

Limitations of this study include its cross-sectional design, its small sample size, that it used documentation of selected asthma indicators as a proxy measure for delivery of guideline-based care, and the failure to evaluate other aspects of care measured in the Asthma Toolbox.

"Effective quality improvement efforts must first address process outcomes (eg, documentation of severity) to evaluate clinical outcomes," the study authors write. "The effectiveness of the Asthma Toolbox is 1 step toward providing quality, evidence-based care to underserved populations. Further study is needed to determine whether the use of decision-making tools, incorporated into routine pediatric care, improves asthma outcomes."

The Children's Health Fund supported this study. The study authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2011;165:412-418. Abstract

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