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Researchers identify features of primary care practice that enhance the quality of pediatric asthma care

Poor and minority children are at greater risk of being hospitalized for asthma than other children, often due to inadequate primary care for their asthma. The quality of asthma care could be improved for impoverished, Medicaid-insured children if primary care practices promote cultural competence, provide feedback reports to clinicians, and provide easy access to and continuity of care, according to a study supported in part by the Agency for Healthcare Research and Quality (HS09935). Primary care for asthma is also improved when one practice physician is trained in asthma care guidelines as a peer leader, and nurses visit patients and provide self-management support, according to a second AHRQ-supported study (HS08363). Both studies are described here.

Lieu, T.A., Finkelstein, J.A, Lozano, P., and others (2004, July). "Cultural competence policies and other predictors of asthma care quality for Medicaid-insured children." Pediatrics 114(1):e102-110.

This study found that when primary care practices are attuned to the needs of poor and minority patients, allow for same-day appointments and evening and weekend telephone advice, and provide physicians with reports on asthma patients and feedback on their asthma care, quality of care is improved for Medicaid-insured children with asthma.

The investigators surveyed 83 primary care practices of five health plans in California, Washington, and Massachusetts, and their clinicians about their policies to promote cultural competence (understanding of and ability to communicate with different minority/ethnic groups), use of several types of reports to clinicians, and support of self-management of asthma (for example, making peak flow meters available at low cost), case management and care coordination, and access to and continuity of care. They also interviewed parents of children with asthma cared for at the practices at baseline and 1 year later. Finally, the researchers measured the children's quality of care based on five measures.

Of the 1,663 children studied, 38 percent were black, 19 percent Latino, and 53 percent had household incomes below the poverty level. At 1-year follow-up, patients of practice sites with the highest cultural competence scores were 85 percent less likely to be underusing preventive asthma medications, and the practices had better parent ratings of care. Also, use of asthma reports to clinicians (for example, reminders about asthma care for particular patients or feedback reports to improve asthma care) substantially reduced the underprescribing of preventive medication.

Children cared for at practice sites with policies to promote access to and continuity of care (for example, easy same-day appointments and evening and weekend telephone advice) had 44 percent less underuse of preventive medications. Practice size, organizational type, percentage of patients insured by Medicaid, mechanism of payment for specialty care, and other primary care features were not consistently associated with asthma care quality measures.

Lozano, P., Finkelstein, J.A., Carey, V.J., and others (2004, September). "A multisite randomized trial of the effects of physician education and organizational change in chronic asthma care." Archives of Pediatric and Adolescent Medicine 158, pp. 875-883.

Compared with usual primary care for asthma, use of physician peer leaders and asthma care planning coordinated by a nurse improves children's adherence to asthma controller medication (inhaled steroids, cromolyn, nedocromil, long-acting bronchodilators, and theophylline). This approach also substantially reduces their need for an oral steroid burst each year to get control of their asthma, according to the Pediatric Asthma Care Patient Outcomes Research Team-II study. The study included children aged 3 to 17 years cared for at 1 of 42 primary care pediatric practices affiliated with four managed care organizations.

In the peer leader education intervention, one physician was trained at each practice site to serve as an asthma "champion," sharing asthma care guidelines and other information with colleagues and encouraging their implementation. For the planned care intervention, a nurse trained in asthma care guidelines and self-management support techniques proactively scheduled four to five planned asthma care visits during the 2 years of the study to augment children's visits to the primary care physician. Between visits, the nurse provided telephone and other followup efforts to monitor each child's progress.

Of the 688 children who were initially screened, 55 percent were taking controller medications. Overall, children suffered from asthma symptoms (including cough, wheeze, limited activity, or night wakening) an annualized mean of 107 days. Children in the peer leader group had 6.5 fewer symptom days per year, a nonsignificant difference, but they had a 36 percent lower oral steroid burst rate per year compared with usual care children. Children in the planned care group had an average of 13.3 fewer symptom days annually and a 39 percent lower oral steroid burst rate per year relative to the usual care group. Both interventions showed small, but significant improvements in activity levels and physical health.

Editor's Note: Another AHRQ-supported study on a related topic found no differences in health-related quality of life (HRQOL) in young urban children with asthma based on current asthma or severity of asthma, and concluded that HRQOL for these children is influenced by several factors other than asthma status and severity. For more details, see Montalto, D., Bruzzese, J.M., Moskaleva, G., and others (2004). "Quality of life in young urban children: Does asthma make a difference?" (AHRQ grant HS10136). Journal of Asthma 41(4), pp. 497-505.

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