improvingoutcomesforunderservedadolescentswith asthma ...drs britto and byczkowski conceptualized...
TRANSCRIPT
Improving Outcomes for Underserved Adolescents WithAsthma
abstractBACKGROUND AND OBJECTIVE Asthma is the most common chronicdisease of childhood Treatment adherence by adolescents is oftenpoor and their outcomes are worse than those of younger patientsWe conducted a quality improvement initiative to improve asthma con-trol and outcomes for high-risk adolescents treated in a primary caresetting
METHODS Interventions were guided by the Chronic Care Model andfocused on standardized and evidence-based care care coordinationand active outreach self-management support and communityconnections
RESULTS Patients with optimally well-controlled asthma increasedfrom sim10 to 30 Patients receiving the evidence-based carebundle (conditionseverity characterized in chart and for patientswith persistent asthma an action plan and controller medicationsat the most recent visit) increased from 38 to at or near 100Patients receiving the required self-management bundle (patient self-assessment stage-of-readiness tool and personal action plan)increased from 0 to sim90 Patients and parents who wereconfident in their ability to manage their or their adolescentrsquosasthma increased from 70 to sim85 Patient satisfaction and themean proportion of patients with asthma-related emergencydepartment visits or hospitalizations remained stable at desirablelevels
CONCLUSIONS Implementing interventions focused on standardized andevidence-based care self-management support care coordination andactive outreach linkage to community resources and enhanced follow-up for patients with chronically not-well-controlled asthma resulted insustained improvement in asthma control in adolescent patientsAdditional interventions are likely needed for patients with chronicallypoor asthma control Pediatrics 2014133e418ndashe427
AUTHORS Maria T Britto MD MPHab Anna-Liisa BVockell MSN CNPac Jennifer Knopf Munafo MAac PamelaJ Schoettker MSb Janet A Wimbergac Raymond PruettMSb Michael S Yi MD Mscad and Terri L ByczkowskiPhDe
aDivision of Adolescent Medicine Center for Innovation in ChronicDisease Care bJames M Anderson Center for Health SystemsExcellence cCenter for Professional Excellence and eDivision ofEmergency Medicine Cincinnati Childrenrsquos Hospital MedicalCenter Cincinnati Ohio and dMercy Health Partners CincinnatiOhio
KEY WORDSasthma adolescents quality improvement evidence-based careself-management care coordination
ABBREVIATIONSCCHMCmdashCincinnati Childrenrsquos Hospital Medical CenterEDmdashemergency department
Drs Britto and Byczkowski conceptualized and designed theproject contributed to the acquisition of the data and analysisand interpretation of the results and drafted the initialmanuscript Ms Vockell Ms Munafo Ms Wimberg and Mr Pruettcontributed to the conception and design the project theacquisition of the data and analysis and interpretation of theresults Ms Schoettker contributed to the analysis andinterpretation of the results and drafted the initial manuscriptDr Yi contributed to the conception and design of the projectand helped to draft the initial manuscript and all authorsapproved the final manuscript as submitted
wwwpediatricsorgcgidoi101542peds2013-0684
doi101542peds2013-0684
Accepted for publication Oct 1 2013
Address correspondence to Terri L Byczkowski PhD Division ofEmergency Medicine Cincinnati Childrenrsquos Hospital MedicalCenter MLC 2008 3333 Burnet Ave Cincinnati OH 45229-3039E-mail terribyczkowskicchmcorg
PEDIATRICS (ISSN Numbers Print 0031-4005 Online 1098-4275)
Copyright copy 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE The authors have indicated they haveno financial relationships relevant to this article to disclose
FUNDING No external funding
POTENTIAL CONFLICT OF INTEREST The authors have indicatedthey have no potential conflicts of interest to disclose
e418 BRITTO et al
Asthma is the most common chronicdisease of childhood affecting an es-timated 7 million children in the UnitedStates 94 of all children1 The eco-nomic and public health costs relatedto asthma are enormous It results inan estimated 105 million missedschool days 640 000 emergency de-partment (ED) visits and 157 000 hos-pitalizations for children each year2 In2007 there were 185 reported pediat-ric deaths from asthma2 Asthmaprevalence morbidity and mortalityrates appear to be higher in adoles-cents than in younger children3 andhigher in minority and inner-city ado-lescents4ndash6 Adolescents with symp-tomatic asthma have more physicaland emotional symptoms more activitylimitations lower perceived well-beingmore negative behaviors and moreacute recurrent and chronic comor-bidities than adolescents withoutasthma7
The goals of asthma treatment are toachieve andmaintain control of clinicalmanifestations of the disease for ex-tended periods8 When their asthma iscontrolled patients are better able toprevent attacks avoid symptoms andmaintain physical activity Howeverdespite the availability of clinical practiceguidelines and efficacious treatmentoptions9ndash14 asthma is not well controlledfor many patients15 and poorer asthmacontrol is associated with higher costsand increased resource use15ndash18 In ad-dition large gaps still exist between thecare recommended by guidelines andthat actually provided19ndash28 and there isan inadequate focusonself-management29
A study from the Rand Corporation pub-lished in 2007 showed that adherence to 17recommended ambulatory care indicatorsfor children with asthma was only 4630
Using data from 2008 another studyshowed that whereas 96 of children andtheir families were taught how to use aninhaler 72were taught to recognize earlysigns or symptoms of an episode of
asthma and 78 were taught how torespond to an episode only 44 weregiven an asthma management planand 53were advised to change thingsat home school or work to improvetheir asthma2
On average adolescent outcomes areworse than those of younger patients2
The poor outcomes observed for ado-lescents may be related to the intenseemotional psychological developmentaland social changes teenagers charac-teristically undergo during theseyears31ndash34 Many adolescents withasthma particularly those with moresevere disease suffer from anxietydepression and low self-esteem32 Inaddition treatment adherence by adoles-cents is often poor3335ndash38 with rates ofadherence to controller medicationsas low as 2538
In 2003 the Institute of Medicine des-ignated quality improvement in asthmacare as a priority area39 To date qualityimprovement initiatives designed tochange the behavior of patients theircaretakers or health care providershave shown varying degrees of suc-cess A systematic review of controlledtrials found that education inter-ventions for asthma in children led toimprovement in lung function andfeelings of self-control and reducedschool absences days of restrictedactivity and ED use40 Educational inter-ventions were not associated withreductions in hospitalizations A recentsystematic review of 79 quality im-provement interventions for childrenwith asthma found that several types ofinterventions improved process andoutcomes of care although the mag-nitude of improvement was oftenmodest41 Of the 6 studies that exclu-sively enrolled adolescent patientsnone showed significant improvementin key asthma outcomes such asmedication use asthma symptom con-trol or use of health services In addi-tion these studies often did not
quantitate the process improvementsthat were associated with improve-ment in outcomes These results sug-gest the need for additional studies ofquality improvement interventions foradolescents with asthma
We report here on a quality improve-ment initiative guided by the ChronicCare Model42ndash46 to improve asthmacontrol and outcomes for high-riskadolescents treated in a primary caresetting
METHODS
Setting
Cincinnati Childrenrsquos Hospital MedicalCenter (CCHMC) is a large urban pe-diatric academic medical center TheTeen Health Center at CCHMC providesprimary care to 8000 primarily un-derserved and African Americanyouths 12 to 22 years of age Approxi-mately 15 carry a diagnosis ofasthma
To accelerate our learning regardingasthma care improvement in 2007 weinstituted a Tuesday afternoon primarycare clinic where all the patients haveasthma All Teen Health prospectivepatients requesting a new patient ap-pointment are asked if they haveasthma If so they are offered a slot inthe Tuesday clinic If they come to theirnew appointment they are added to thedenominator for the clinic (and for allmeasures included in this article) Theyremain in the targetpopulationwhetherthey come for follow-up visits with thisspecial clinic session or not until theyage out of the Teen Health Center(typically at 22 years of age) inform usthey are receiving care elsewhere ormake no visits to the Teen Health Centerfor 14 months Bringing together an un-selected group of patients with asthmaallows us to more rapidly test and im-plement changes in asthma care Onaverage sim200 patients are in the groupat any time
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e419
Outcomes of Interest
We developed a 3-level system of out-come measures At the highest levelmultifaceted outcome measures weredeveloped to capture the overall aim ofthe team to improve clinical outcomesforadolescentswithasthmaTheprimaryoutcomemeasurewas the percentage ofpatients with optimally well-controlledasthma defined as the best score (16)on our modified asthma control scorequestionnaire47 Our score was based onthe Asthma Control Test48 but wasadapted to be consistent with the 2007National Heart Lung and Blood Instituteasthma guidelines13 When CCHMC tran-sitioned to an electronic health record tobe consistent across the medical centerwe began using the top score of 25 on theoriginal Asthma Control Test48 for ourmeasure of optimally well-controlled and20 for the usual Asthma Control Testcutoff for well controlled Other mea-sures were as follows (1) the percent-age of patients who were hospitalizedandor visited the ED a measure ofhealth care utilization and (2) patientsatisfaction with the clinic visit mea-sured by using a modified ConsumerAssessment of Healthcare Providers andSystems question49 thatmeasures overallsatisfaction with the care patients re-ceived For the satisfaction measurepatients were asked to fill out ananonymous 11-point Likert scale sur-vey at the end of their visit The teammonitors the proportion of patientsgiving their care the highest rating
Within the second level of measureswhich were specific to the inter-ventions the delivery of standardizedandevidence-based carewasevaluatedby using the proportion of patientsreceiving a bundle of care elementsa written asthma action plan severityclassified and controller medicationsprescribed for patients with persistentasthma The overall outcome measurefor self-management support wasthe percentage of patients who were
confident in theirability tomanage theirasthma measured during each clinicvisit by using a Likert scale questiondeveloped and validated by Lorig et al50
for patients with arthritis
The third level of measures were de-veloped to measure the success of thenumerous and targeted Plan-Do-Study-Act cycles51 used in the testing andimplementation of the interventionsFor example while conducting tests toimprove mental health access we de-veloped a process measure of theproportion of patients each weekneeding a mental health referral whoreceived the new standard referralprocess
Interventions
The Chronic Care Model42ndash46 was usedas the evidence-based framework toguide changes in care delivery Duringthe planning phase suggestions andfeedback on proposed changes wereobtained from patients and familiesthrough questionnaires and involvementof the Teen Asthma Advisory Board anadolescent focus group and duringclinic visits The interventions imple-mented included delivery system re-design to provide standardized andevidence-based care productive inter-actions between informed patients andprepared clinicians self-managementsupport community linkages clinicalinformation systems and decisionsupport (Table 1) A quality improve-ment consultant coached the team inquality improvement methods anda data specialist guided the data col-lection process and assisted with thedata analysis
Standardized Evidence-Based Care
In 2007 we began administering theasthma control questionnaires toteenagers and their parents at eachvisit and using our modified asthmacontrol score assessed teenagersrsquo
symptoms medication use and confi-dencetomanage their asthma Decision-support tools and frequent feedbackencouraged providers to implementevidence-based practices such as clas-sifying severity developing a writtenasthma management plan and pre-scribing controller medications for per-sistent asthma In 2008 we developedand implemented amoredetailed asthmaassessment and treatment algorithm(see Supplemental Fig 5)52ndash55 based onthe National Heart Lung and Blood In-stitute asthma guidelines13
Care Coordination and ActiveOutreach
In May 2007 the parent of a child witha chronic illness was hired to co-ordinatedata tracking family outreachappointment scheduling and preclinicreminders andassessments Twowidelyavailable electronic databases (DocSiteclinical registry and Care ManagementPlus)wereused tomaintain clinical anddemographic information about thepatients These databases also servedas the primary data source for ourprocessandoutcomesmeasuresPatientsin need of follow-up were tracked Follow-up was performed by different teammembers depending on the specific needFor example the parent coordinatorwould help patients with appointmentscheduling or linking to communityresources The nurse practitioner woulddo clinical reassessment by phone andadjust the treatment plan as needed
From July 2010 through June 2011 wefocused improvement efforts ona group of 58 chronically not-well-controlled patients those with a me-dian score of 9 to 13 over the previousyear on our modified56 asthma controlscore It was discovered through thiseffort that these patients were lesslikely to come to clinic Thereforeinterventions for this group focused onimproving patient contact and follow-up
e420 BRITTO et al
They were called and texted at everyknown telephone number Their schoolswere also contacted If these patientscould be reached their asthma wasassessed over the telephone An in-depthchart review was performed to assesswhat gaps in their care could beaddressed (ie learning needs comor-bidities referrals triggers barriers tocare tobacco exposure) When patients
returned to clinic these gaps wereaddressed This targeted interventionwas evaluated by the proportion ofpatients in the cohort whose score onour modified asthma control ques-tionnaire improved by at least 2 pointsA study consisting primarily of adultsreported a 188-point change in the 25-point Asthma Control Test to be clini-cally important57
Self-management SupportAt the inception of the clinic it was de-termined that self-management supportwas integral to success Initial testingandrefinement of the parent coordinatorrolebegan in2007 In2008all clinical staffand the parent coordinator receivedtraining in motivational interviewing andbehavior change counseling58ndash60 In 2008we designated a team member as
TABLE 1 Interventions
Health systemsbull Delivery system design
s Staff tracker a paper matrix used by staff to track each patientrsquos steps through a clinic visit to ensure they received the care they needed during that visits Asthma and self-management training for residents starting their month-long clinic rotations Parent coordinator the parent of a chronically ill child coordinated data tracking appointment scheduling and preclinic reminders and assessmentss Preclinic plannings Standardized educational brochures Web sites knowledge quiz and checklists developed with patientss Symptom tracker a paper form used by patients to record their asthma symptoms triggers and medication use and reviewed at clinic visitss Individual patient asthma control data plotted on run charts and discussed with patientsfamilies during visitss Contact information updated every 60 days during the clinic visit and numbers and methods prioritized according to patient preference enabled us to obtaininformation that patients sometimes are reluctant to give to registration personnel
s Active follow-up between visitsbull Decision support
s Evidence-based algorithms for asthma allergic rhinitis smoking cessation and gastroesophageal reflux disease were created to standardize cares Prompts and templates developed to guide care decisions and standardize information attained during clinic visit (initially paper later embedded in electronichealth record)
s Standardized previsit planning formsbull Clinical information systems
s Clinic tracker information on completion of patient-entered data self-management support patient community resource needs and patient feedback oninitiatives stored in a spreadsheet database and used during clinic visits
s DocSite Registry a database of all patients and their outcomes used for previsit planning follow-up and monitoring population results (used beforeimplementation of electronic health record)
s Care-Management Plus525355 database patient demographic database used to generate reminder lists of patients needing follow-up (used beforeimplementation of electronic health record)
s Online confidential patient satisfaction questionnaire satisfaction measured on a scale of 0 to 10 with an opportunity for free text commentsSelf-management supportbull Self-management support through tailored mailings and patient brochures based on stage of readinessbull Staff trained to address patient needs and confidence and in behavior change counselingbull Self-management tools (patient self-assessment stage-of-readiness progress checklist and personal action plan) reviewed and documented in medical record ateach clinic visit
bull Reminders for influenza immunization upcoming appointments and need to make a follow-up appointment were sent as text messagesbull Patient illness management questionnaire to identify barriers to self-management61
bull Administration of the StateTrait Anxiety Inventory for Children54 to patients whose asthmawas not well controlled after$3months in clinic patients exceeding thetoolrsquos threshold and possibly anxious or worried were referred to mental health services
bull New patients received a letter providing contact information and describing the Teen Health Center and Asthma Innovation Laboratory and what to expect duringa visit
Communitybull Teen Asthma Advisory Board teenagerswith asthmawho attended the Teen Health Center helped to shape decisions around use of and implementation of Web sitesand documents
bull Asthma camp a weekend camp for children with asthma to promote friendship asthma education and funbull Facilitated mental health referralsbull Emergency prescriptions patientsfamilies without insurance could receive a 1-month supply of medications from the pharmacy at Cincinnati Childrenrsquos and bebilled later
bull Facilitated referrals to financial counseling services to obtain assistance with health carendashrelated financial needsbull Transportation services to and from clinic visits for publicly insured patientsbull Cincinnati Health Department conducted evaluations of rental properties for asthma triggers (mold cockroaches etc) and sent letters to landlordsbull School nurses administered the Asthma Control Test to patients with not-well-controlled asthma who were unresponsive to contact at home or did not attend clinicappointments
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e421
a self-management coach to conductself-assessments61 set goals and de-velop action plans The coach alsocontacted patients between visits toassess progress We tested and even-tually began using 3 self-managementtools a patient self-assessment a stage-of-readiness tool and a personal actionplan The training tools were based onan evidence-based guideline previouslydeveloped at CCHMC62 Starting in 2009resident physicians rotating in the clinicbegan receiving training in the use ofthe self-management tools and behav-ior change counseling using motivationalinterviewing skills
To assess general health concernsworries disease and treatment knowl-edge social stressors and readiness tomakeabehaviorchange thepatientself-management assessment was admin-istered at the beginning of the visit toeverypatientwhohadnotbeenassessedwithin theprevious30days Thestage-of-readiness toolwasusedtodocument thepatientrsquos current stage of readiness tochange and the focus of the behaviorchange counseling at the end of thevisit A personal action plan was com-pleted if the patient was ready to makea behavior change (all tools available onrequest) Follow-up was conducted byphone e-mail or text according to theteenagerrsquos preference
Community Connections
Because many teenagers were failingto achieve optimal asthma control withourevidence-basedcare self-managementand care coordination interventions in2011 we investigated major barriers toachieving good control We interviewedpatients parents and hospital socialworkersanddetermined that themajorpotentially modifiable barriers werelack of transportation to appointmentslack of insurance coverage for medi-cations and untreated mental healthcomorbidities Working with familiessocial services andcommunity agencies
we developed and tested interventions toaddresseachof theseproblems(Table1)
Data Collection
The data to generate the measures andmonthly reports were collected duringclinic or telephone encounters andentered into an electronic patient reg-istry (later the electronic health record)or extracted from hospital administra-tive databases from the start of inter-ventions through June 2011 which wasthe end of the fiscal year in which wetransitionedtoanelectronichealthrecord
Analysis
Statistical process control methodswere used to monitor changes in careprocesses and health outcomes Spe-cifically annotated control or runcharts were developed and updatedmonthly Standard industry criteriawere used to determine if observedchanges in measures were chance ran-dom variation (common cause varia-tion)ordue toaspecificassignable causein thiscase the intervention(specialcausevariation)6364 Some measures werebased on the total population and usedthe most recent data point for each pa-tient Standard statistical process controlcriteria were not used for these cumula-tive measures due to the large degree ofautocorrelation caused by carrying overpatientsrsquo values from the previous datapoint if a new visit did not occur since thedata were collected
Human Subjects Protection
This initiative fell within the CCHMC In-stitutional Review Boardrsquos guidance forquality improvement projects that didnot constitute human subjects research
RESULTS
Overall Innovation LaboratoryMeasures
From June 1 2007 through June 302011 322 unique patients with asthma
were seen in the new clinic The pro-portion of patients with optimally well-controlled asthma (ie highest possiblescore on our modified asthma controlscore) was sim10 at baseline andgradually increased to 20 by June2008 after implementation of stan-dardized evidence-based care andoutreach by a parent coordinator (Fig 1)In August 2009 after the implementationof reliable self-management supportthe proportion of optimallywell-controlledpatients exceeded our goal of 30 andwas maintained
Figure 1 also shows when we con-verted to the electronic health recordand began to use the standard AsthmaControl Test48 as our outcome mea-sure We found that a similar pro-portion of patients had a maximalscore of 25 on the Asthma Control Testas had amaximal score on ourmodifiedasthma score The mean proportion ofpatients with asthma-related ED visitsor hospitalizations was stable at 16(Fig 2) Patient satisfaction also remainedstable at 75 (Fig 3)
Results of Specific Interventions
In September 2006 only 38 of patientsreceived the 3 following elements ofevidence-based care (1) conditionseverity characterized in chart andfor patients with persistent asthma (2)an action plan and (3) controller med-ications at the most recent visit Thevalue increased rapidly and starting inJune 2007 was$94 Between Decem-ber 2010 and June 2011 100 of patientswith asthma received the evidence-based care bundle
After the implementation of self-management interventions in Septem-ber 2007 the proportion of patients andtheir parents who were confident intheir ability to manage their or theiradolescentrsquos asthma (rating of $7 of10) increased from a low of 70 tosim80 This proportion increased againtosim85after the teambegan to increase
e422 BRITTO et al
FIGURE 1Percentage of patients with asthma whose condition was well controlled EPIC our electronic health record FY fiscal year
FIGURE 2Percentage of patients with asthma with asthma-related ED visits andor hospitalizations
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e423
its skill in providing self-managementsupport and planned specific inter-ventions for each adolescent with a lowscore in February 2009
Between July 2008 and August 2009 theproportion of patients receiving the re-quired self-management components (apatient self-assessment a stage-of-readiness tool and a personal actionplan if inaction) rapidly increased from0 to 86 and then remained steady atslightly less than 90 These resultscoincided with the large increase inwell-controlled patients beginning inJune 2008 (Fig 1)
Cohort of Chronically Not-Well-Controlled Patients
Of the 50 chronically not-well-controlledpatients who remained in the practice(8 left the practice ormoved away) 60
had a $2-point improvement in theirmedian modified asthma control scorein the intervention year compared withthe previous year (Fig 4)
Community Connections
Community connections were measuredby identifying patients who needed com-munityservicesandtrackingtheproportionof patients who were either referred orprovidedwith informationduringaclinicvisit By June 2011 we achieved 90reliability in our processes to addressmajor family concerns
DISCUSSION
Our quality improvement initiative isamong the first to show sustained im-provement in asthma control in ado-lescentpatients Byusing theoutcomeof
optimal asthma symptom control wetripled the proportion of patients whoachieved that level of control over thecourse of our initiative In accordancewith the Chronic Care Model4244ndash46 ourmultiple interventions focused on stan-dardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma
We used a high bar to define asthmacontrol thehighest possible scoreonourmodified asthma control score Weoriginally chose to modify the AsthmaControl Test developed by Nathan et al48
because it was not consistent with themost recent asthma guidelines from theNational Heart Lung and Blood In-stitute13 After our transition to use of an
FIGURE 3Percentage of patients with asthma rating the clinic as providing the best possible care
e424 BRITTO et al
electronic health record in March 2011we switched to using the Asthma Con-trol Test to be consistent with otherdepartments in our medical center Ini-tial results after the transition sug-gested that ourmodified score functionedsimilar to the original Asthma Control Test
Several of our interventions focused onimproving teenager and family en-gagement in their asthma care The 3self-management tools (a patient self-assessment a stage-of-readiness tooland a personal action plan) were de-signed to promote self-managementassessment and help providers talkcomfortably and productively with pa-tientsandfamiliesaboutmakingchangesnecessary to improve their health Therole of the parent coordinator served asa relatively low-cost innovation that al-lowed someone familiar with the needsand struggles of families dealing witha chronic illness to help other families
navigate the care system This valuableperson working closely with clinicianswas often able to obtain patient infor-mation that clinicians alone could notget We suspect that the parent coor-dinator herself the parent of a childwith a chronic condition could con-verse with parents as a peer ratherthan as a medical professional
We continue to work with patients whostruggle to control their asthmaWearecurrently testing interventions that usetechnology to promote active outreachand population management We arealsodevelopingnewalgorithms todrivecomanagement approaches with ourspecialist colleagues in PulmonaryMedicine and Psychology
This small group of patients withchronically poor control may also rep-resentagroupwith intrinsically difficult-to-control asthma They are now thefocus of research efforts among our
pulmonarycolleagues Inadditionwearespreadingoursuccessful interventionstoother areas of the medical center thattreat patients with chronic disease Forexample the self-management tools havebeen adapted for use with our electronichealth record and brochures describingthe5stagesofchangereadinessarewidelyused
CONCLUSIONS
Implementing interventions focused onstandardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma resulted insustained improvement in asthmacontrol in adolescent patients Addi-tional interventions are likely neededforpatientswith chronically poorasthmacontrol
FIGURE 4Cumulative percentage of chronically not-well-controlled patients (median score of 9 to 13 on ourmodified asthma control score) whose score improved by 2 points
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e425
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1 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2010 Vital HealthStat 10 2011(250)1ndash80
2 Akinbami LJ Moorman JE Liu X Asthmaprevalence healthcare use and mortalityUnited States 2005ndash2009 Natl Health StatRep 2011(32)1ndash14
3 Akinbami LJ Moorman JE Garbe PL SondikEJ Status of childhood asthma in theUnited States 1980-2007 Pediatrics 2009123(suppl 3)S131ndashS145
4 Bai Y Hillemeier MM Lengerich EJ Racialethnic disparities in symptom severityamong children hospitalized with asthmaJ Health Care Poor Underserved 200718(1)54ndash61
5 Flores G Snowden-Bridon C Torres S et alUrban minority children with asthmasubstantial morbidity compromised qual-ity and access to specialists and the im-portance of poverty and specialty care JAsthma 200946(4)392ndash398
6 Kitsantas P Kornides ML Cantiello J Wu HChronic physical health conditions amongchildren of different racialethnic back-grounds Public Health 2013127(6)546ndash553
7 Forrest CB Starfield B Riley AW Kang M Theimpact of asthma on the health status ofadolescents Pediatrics 199799(2) Availableat wwwpediatricsorgcgicontentfull992e1
8 Global Initiative for Asthma (GINA) Globalstrategy for asthma management andprevention Published 2010 Available atwwwginasthmaorgpdfGINA_Report_2010pdf Accessed February 22 2013
9 British Thoracic Society Scottish In-tercollegiate Guidelines Network Britishguideline on the management of asthmaa national clinical guideline PublishedJanuary 2012 Available at wwwsignacukpdfsign101pdf Accessed February 222013
10 Cincinnati Childrenrsquos Hospital Medical Cen-ter James M Anderson Center for HealthSystems Excellence Management of acute ex-acerbation of asthma in children PublishedSeptember 16 2010 Available at wwwcin-cinnatichildrensorgworkarealinkitaspxlink-identifier=idampitemid=87871amplibid=87559Accessed February 22 2013
11 Department of Veterans Affairs Departmentof Defense VADoD clinical practice guide-line for management of asthma in childrenand adults 2 Published 2009 Available atwwwhealthqualityvagovasthmaast_2_fullpdf Accessed February 22 2013
12 Institute for Clinical Systems ImprovementDiagnosis and management of asthma 9thed Published July 31 2012 Available at httpswwwicsiorgguidelines__morecatalog_guidelines_and_morecatalog_guidelinescatalog_respiratory_guidelinesasthmaAccessed February 22 2013
13 National Heart Lung and Blood InstituteNational Asthma Education and PreventionProgram Expert panel report 3 guidelinesfor the diagnosis and management ofasthma Bethesda MD US Department ofHealth and Human Services 2007 Availableat wwwnhlbinihgovguidelinesasthmaasthgdlnhtm Accessed February 22 2013
14 Registered Nursesrsquo Association of OntarioPromoting asthma control in childrenPublished 2004 Available at httprnaocabpgguidelinespromoting-asthma-control-children Accessed February 22 2013
15 Verloet D Williams AE Lloyd A Clark TJCosts of managing asthma as defined bya derived Asthma Control Test score inseven European countries Eur Respir Rev200615(98)17ndash23
16 Haselkorn T Fish JE Zeiger RS et al Con-sistently very poorly controlled asthma asdefined by the impairment domain of theExpert Panel Report 3 guidelines increasesrisk for future severe asthma exacer-bations in The Epidemiology and NaturalHistory of Asthma Outcomes and Treat-ment Regimens (TENOR) STUDY J AllergyClin Immunol 2009124(5)895ndash902 e891ndashe894
17 Scott L Morphew T Bollinger ME et alAchieving and maintaining asthma controlin inner-city children J Allergy Clin Immu-nol 2011128(1)56ndash63
18 Szefler SJ Zeiger RS Haselkorn T et alEconomic burden of impairment in chil-dren with severe or difficult-to-treatasthma Ann Allergy Asthma Immunol2011107(2)110ndash119e1
19 McMullen A Yoos HL Anson E Kitzmann HHalterman JS Arcoleo KS Asthma care ofchildren in clinical practice do parentsreport receiving appropriate educationPediatr Nurs 200733(1)37ndash44
20 Reeves MJ Bohm SR Korzeniewski SJBrown MD Asthma care and managementbefore an emergency department visit inchildren in western Michigan how welldoes care adhere to guidelines Pediatrics2006117(4 pt 2)S118ndashS126
21 Orrell-Valente JK Jones K Manasse S ThyneSM Shenkin BN Cabana MD Childrenrsquos andparentsrsquo report of asthma education received
from physicians J Asthma 201148(8)831ndash838
22 Cabana MD Chaffin DC Jarlsberg LG ThyneSM Clark NM Selective provision ofasthma self-management tools to familiesPediatrics 2008121(4) Available at wwwpediatricsorgcgicontentfull1214e900
23 Cabana MD Abu-Isa H Thyne SM Yawn BSpecialty differences in prescribing inhaledcorticosteroids for children Clin Pediatr(Phila) 200746(8)698ndash705
24 Rastogi D Shetty A Neugebauer R HarijithA National Heart Lung and Blood Instituteguidelines and asthma management prac-tices among inner-city pediatric primarycare providers Chest 2006129(3)619ndash623
25 Deis JN Spiro DM Jenkins CA Buckles TLArnold DH Parental knowledge and use ofpreventive asthma care measures in twopediatric emergency departments JAsthma 201047(5)551ndash556
26 To T Wang C Dell SD et al PAMG Team Canan evidence-based guideline reminder cardimprove asthma management in theemergency department Respir Med 2010104(9)1263ndash1270
27 Tsai CL Sullivan AF Gordon JA et al Qualityof care for acute asthma in 63 US emer-gency departments J Allergy Clin Immunol2009123(2)354ndash361
28 Knapp JF Simon SD Sharma V Quality ofcare for common pediatric respiratory ill-nesses in United States emergency depart-ments analysis of 2005 National HospitalAmbulatory Medical Care Survey Data Pe-diatrics 2008122(6)1165ndash1170
29 Sawyer S Drew S Duncan R Adolescentswith chronic diseasemdashthe double whammyAust Fam Physician 200736(8)622ndash627
30 Mangione-Smith R DeCristofaro AH SetodjiCM et al The quality of ambulatory caredelivered to children in the United StatesN Engl J Med 2007357(15)1515ndash1523
31 de Benedictis D Bush A The challenge ofasthma in adolescence Pediatr Pulmonol200742(8)683ndash692
32 Howenstine MS Eigen H Medical care ofthe adolescent with asthma Adolesc Med200011(3)501ndash519
33 Couriel J Asthma in adolescence PaediatrRespir Rev 20034(1)47ndash54
34 Staples B Bravender T Drug compliance inadolescents assessing and managingmodifiable risk factors Paediatr Drugs20024(8)503ndash513
35 Desai M Oppenheimer JJ Medication ad-herence in the asthmatic child and ado-lescent Curr Allergy Asthma Rep 201111(6)454ndash464
e426 BRITTO et al
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427
Asthma is the most common chronicdisease of childhood affecting an es-timated 7 million children in the UnitedStates 94 of all children1 The eco-nomic and public health costs relatedto asthma are enormous It results inan estimated 105 million missedschool days 640 000 emergency de-partment (ED) visits and 157 000 hos-pitalizations for children each year2 In2007 there were 185 reported pediat-ric deaths from asthma2 Asthmaprevalence morbidity and mortalityrates appear to be higher in adoles-cents than in younger children3 andhigher in minority and inner-city ado-lescents4ndash6 Adolescents with symp-tomatic asthma have more physicaland emotional symptoms more activitylimitations lower perceived well-beingmore negative behaviors and moreacute recurrent and chronic comor-bidities than adolescents withoutasthma7
The goals of asthma treatment are toachieve andmaintain control of clinicalmanifestations of the disease for ex-tended periods8 When their asthma iscontrolled patients are better able toprevent attacks avoid symptoms andmaintain physical activity Howeverdespite the availability of clinical practiceguidelines and efficacious treatmentoptions9ndash14 asthma is not well controlledfor many patients15 and poorer asthmacontrol is associated with higher costsand increased resource use15ndash18 In ad-dition large gaps still exist between thecare recommended by guidelines andthat actually provided19ndash28 and there isan inadequate focusonself-management29
A study from the Rand Corporation pub-lished in 2007 showed that adherence to 17recommended ambulatory care indicatorsfor children with asthma was only 4630
Using data from 2008 another studyshowed that whereas 96 of children andtheir families were taught how to use aninhaler 72were taught to recognize earlysigns or symptoms of an episode of
asthma and 78 were taught how torespond to an episode only 44 weregiven an asthma management planand 53were advised to change thingsat home school or work to improvetheir asthma2
On average adolescent outcomes areworse than those of younger patients2
The poor outcomes observed for ado-lescents may be related to the intenseemotional psychological developmentaland social changes teenagers charac-teristically undergo during theseyears31ndash34 Many adolescents withasthma particularly those with moresevere disease suffer from anxietydepression and low self-esteem32 Inaddition treatment adherence by adoles-cents is often poor3335ndash38 with rates ofadherence to controller medicationsas low as 2538
In 2003 the Institute of Medicine des-ignated quality improvement in asthmacare as a priority area39 To date qualityimprovement initiatives designed tochange the behavior of patients theircaretakers or health care providershave shown varying degrees of suc-cess A systematic review of controlledtrials found that education inter-ventions for asthma in children led toimprovement in lung function andfeelings of self-control and reducedschool absences days of restrictedactivity and ED use40 Educational inter-ventions were not associated withreductions in hospitalizations A recentsystematic review of 79 quality im-provement interventions for childrenwith asthma found that several types ofinterventions improved process andoutcomes of care although the mag-nitude of improvement was oftenmodest41 Of the 6 studies that exclu-sively enrolled adolescent patientsnone showed significant improvementin key asthma outcomes such asmedication use asthma symptom con-trol or use of health services In addi-tion these studies often did not
quantitate the process improvementsthat were associated with improve-ment in outcomes These results sug-gest the need for additional studies ofquality improvement interventions foradolescents with asthma
We report here on a quality improve-ment initiative guided by the ChronicCare Model42ndash46 to improve asthmacontrol and outcomes for high-riskadolescents treated in a primary caresetting
METHODS
Setting
Cincinnati Childrenrsquos Hospital MedicalCenter (CCHMC) is a large urban pe-diatric academic medical center TheTeen Health Center at CCHMC providesprimary care to 8000 primarily un-derserved and African Americanyouths 12 to 22 years of age Approxi-mately 15 carry a diagnosis ofasthma
To accelerate our learning regardingasthma care improvement in 2007 weinstituted a Tuesday afternoon primarycare clinic where all the patients haveasthma All Teen Health prospectivepatients requesting a new patient ap-pointment are asked if they haveasthma If so they are offered a slot inthe Tuesday clinic If they come to theirnew appointment they are added to thedenominator for the clinic (and for allmeasures included in this article) Theyremain in the targetpopulationwhetherthey come for follow-up visits with thisspecial clinic session or not until theyage out of the Teen Health Center(typically at 22 years of age) inform usthey are receiving care elsewhere ormake no visits to the Teen Health Centerfor 14 months Bringing together an un-selected group of patients with asthmaallows us to more rapidly test and im-plement changes in asthma care Onaverage sim200 patients are in the groupat any time
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e419
Outcomes of Interest
We developed a 3-level system of out-come measures At the highest levelmultifaceted outcome measures weredeveloped to capture the overall aim ofthe team to improve clinical outcomesforadolescentswithasthmaTheprimaryoutcomemeasurewas the percentage ofpatients with optimally well-controlledasthma defined as the best score (16)on our modified asthma control scorequestionnaire47 Our score was based onthe Asthma Control Test48 but wasadapted to be consistent with the 2007National Heart Lung and Blood Instituteasthma guidelines13 When CCHMC tran-sitioned to an electronic health record tobe consistent across the medical centerwe began using the top score of 25 on theoriginal Asthma Control Test48 for ourmeasure of optimally well-controlled and20 for the usual Asthma Control Testcutoff for well controlled Other mea-sures were as follows (1) the percent-age of patients who were hospitalizedandor visited the ED a measure ofhealth care utilization and (2) patientsatisfaction with the clinic visit mea-sured by using a modified ConsumerAssessment of Healthcare Providers andSystems question49 thatmeasures overallsatisfaction with the care patients re-ceived For the satisfaction measurepatients were asked to fill out ananonymous 11-point Likert scale sur-vey at the end of their visit The teammonitors the proportion of patientsgiving their care the highest rating
Within the second level of measureswhich were specific to the inter-ventions the delivery of standardizedandevidence-based carewasevaluatedby using the proportion of patientsreceiving a bundle of care elementsa written asthma action plan severityclassified and controller medicationsprescribed for patients with persistentasthma The overall outcome measurefor self-management support wasthe percentage of patients who were
confident in theirability tomanage theirasthma measured during each clinicvisit by using a Likert scale questiondeveloped and validated by Lorig et al50
for patients with arthritis
The third level of measures were de-veloped to measure the success of thenumerous and targeted Plan-Do-Study-Act cycles51 used in the testing andimplementation of the interventionsFor example while conducting tests toimprove mental health access we de-veloped a process measure of theproportion of patients each weekneeding a mental health referral whoreceived the new standard referralprocess
Interventions
The Chronic Care Model42ndash46 was usedas the evidence-based framework toguide changes in care delivery Duringthe planning phase suggestions andfeedback on proposed changes wereobtained from patients and familiesthrough questionnaires and involvementof the Teen Asthma Advisory Board anadolescent focus group and duringclinic visits The interventions imple-mented included delivery system re-design to provide standardized andevidence-based care productive inter-actions between informed patients andprepared clinicians self-managementsupport community linkages clinicalinformation systems and decisionsupport (Table 1) A quality improve-ment consultant coached the team inquality improvement methods anda data specialist guided the data col-lection process and assisted with thedata analysis
Standardized Evidence-Based Care
In 2007 we began administering theasthma control questionnaires toteenagers and their parents at eachvisit and using our modified asthmacontrol score assessed teenagersrsquo
symptoms medication use and confi-dencetomanage their asthma Decision-support tools and frequent feedbackencouraged providers to implementevidence-based practices such as clas-sifying severity developing a writtenasthma management plan and pre-scribing controller medications for per-sistent asthma In 2008 we developedand implemented amoredetailed asthmaassessment and treatment algorithm(see Supplemental Fig 5)52ndash55 based onthe National Heart Lung and Blood In-stitute asthma guidelines13
Care Coordination and ActiveOutreach
In May 2007 the parent of a child witha chronic illness was hired to co-ordinatedata tracking family outreachappointment scheduling and preclinicreminders andassessments Twowidelyavailable electronic databases (DocSiteclinical registry and Care ManagementPlus)wereused tomaintain clinical anddemographic information about thepatients These databases also servedas the primary data source for ourprocessandoutcomesmeasuresPatientsin need of follow-up were tracked Follow-up was performed by different teammembers depending on the specific needFor example the parent coordinatorwould help patients with appointmentscheduling or linking to communityresources The nurse practitioner woulddo clinical reassessment by phone andadjust the treatment plan as needed
From July 2010 through June 2011 wefocused improvement efforts ona group of 58 chronically not-well-controlled patients those with a me-dian score of 9 to 13 over the previousyear on our modified56 asthma controlscore It was discovered through thiseffort that these patients were lesslikely to come to clinic Thereforeinterventions for this group focused onimproving patient contact and follow-up
e420 BRITTO et al
They were called and texted at everyknown telephone number Their schoolswere also contacted If these patientscould be reached their asthma wasassessed over the telephone An in-depthchart review was performed to assesswhat gaps in their care could beaddressed (ie learning needs comor-bidities referrals triggers barriers tocare tobacco exposure) When patients
returned to clinic these gaps wereaddressed This targeted interventionwas evaluated by the proportion ofpatients in the cohort whose score onour modified asthma control ques-tionnaire improved by at least 2 pointsA study consisting primarily of adultsreported a 188-point change in the 25-point Asthma Control Test to be clini-cally important57
Self-management SupportAt the inception of the clinic it was de-termined that self-management supportwas integral to success Initial testingandrefinement of the parent coordinatorrolebegan in2007 In2008all clinical staffand the parent coordinator receivedtraining in motivational interviewing andbehavior change counseling58ndash60 In 2008we designated a team member as
TABLE 1 Interventions
Health systemsbull Delivery system design
s Staff tracker a paper matrix used by staff to track each patientrsquos steps through a clinic visit to ensure they received the care they needed during that visits Asthma and self-management training for residents starting their month-long clinic rotations Parent coordinator the parent of a chronically ill child coordinated data tracking appointment scheduling and preclinic reminders and assessmentss Preclinic plannings Standardized educational brochures Web sites knowledge quiz and checklists developed with patientss Symptom tracker a paper form used by patients to record their asthma symptoms triggers and medication use and reviewed at clinic visitss Individual patient asthma control data plotted on run charts and discussed with patientsfamilies during visitss Contact information updated every 60 days during the clinic visit and numbers and methods prioritized according to patient preference enabled us to obtaininformation that patients sometimes are reluctant to give to registration personnel
s Active follow-up between visitsbull Decision support
s Evidence-based algorithms for asthma allergic rhinitis smoking cessation and gastroesophageal reflux disease were created to standardize cares Prompts and templates developed to guide care decisions and standardize information attained during clinic visit (initially paper later embedded in electronichealth record)
s Standardized previsit planning formsbull Clinical information systems
s Clinic tracker information on completion of patient-entered data self-management support patient community resource needs and patient feedback oninitiatives stored in a spreadsheet database and used during clinic visits
s DocSite Registry a database of all patients and their outcomes used for previsit planning follow-up and monitoring population results (used beforeimplementation of electronic health record)
s Care-Management Plus525355 database patient demographic database used to generate reminder lists of patients needing follow-up (used beforeimplementation of electronic health record)
s Online confidential patient satisfaction questionnaire satisfaction measured on a scale of 0 to 10 with an opportunity for free text commentsSelf-management supportbull Self-management support through tailored mailings and patient brochures based on stage of readinessbull Staff trained to address patient needs and confidence and in behavior change counselingbull Self-management tools (patient self-assessment stage-of-readiness progress checklist and personal action plan) reviewed and documented in medical record ateach clinic visit
bull Reminders for influenza immunization upcoming appointments and need to make a follow-up appointment were sent as text messagesbull Patient illness management questionnaire to identify barriers to self-management61
bull Administration of the StateTrait Anxiety Inventory for Children54 to patients whose asthmawas not well controlled after$3months in clinic patients exceeding thetoolrsquos threshold and possibly anxious or worried were referred to mental health services
bull New patients received a letter providing contact information and describing the Teen Health Center and Asthma Innovation Laboratory and what to expect duringa visit
Communitybull Teen Asthma Advisory Board teenagerswith asthmawho attended the Teen Health Center helped to shape decisions around use of and implementation of Web sitesand documents
bull Asthma camp a weekend camp for children with asthma to promote friendship asthma education and funbull Facilitated mental health referralsbull Emergency prescriptions patientsfamilies without insurance could receive a 1-month supply of medications from the pharmacy at Cincinnati Childrenrsquos and bebilled later
bull Facilitated referrals to financial counseling services to obtain assistance with health carendashrelated financial needsbull Transportation services to and from clinic visits for publicly insured patientsbull Cincinnati Health Department conducted evaluations of rental properties for asthma triggers (mold cockroaches etc) and sent letters to landlordsbull School nurses administered the Asthma Control Test to patients with not-well-controlled asthma who were unresponsive to contact at home or did not attend clinicappointments
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e421
a self-management coach to conductself-assessments61 set goals and de-velop action plans The coach alsocontacted patients between visits toassess progress We tested and even-tually began using 3 self-managementtools a patient self-assessment a stage-of-readiness tool and a personal actionplan The training tools were based onan evidence-based guideline previouslydeveloped at CCHMC62 Starting in 2009resident physicians rotating in the clinicbegan receiving training in the use ofthe self-management tools and behav-ior change counseling using motivationalinterviewing skills
To assess general health concernsworries disease and treatment knowl-edge social stressors and readiness tomakeabehaviorchange thepatientself-management assessment was admin-istered at the beginning of the visit toeverypatientwhohadnotbeenassessedwithin theprevious30days Thestage-of-readiness toolwasusedtodocument thepatientrsquos current stage of readiness tochange and the focus of the behaviorchange counseling at the end of thevisit A personal action plan was com-pleted if the patient was ready to makea behavior change (all tools available onrequest) Follow-up was conducted byphone e-mail or text according to theteenagerrsquos preference
Community Connections
Because many teenagers were failingto achieve optimal asthma control withourevidence-basedcare self-managementand care coordination interventions in2011 we investigated major barriers toachieving good control We interviewedpatients parents and hospital socialworkersanddetermined that themajorpotentially modifiable barriers werelack of transportation to appointmentslack of insurance coverage for medi-cations and untreated mental healthcomorbidities Working with familiessocial services andcommunity agencies
we developed and tested interventions toaddresseachof theseproblems(Table1)
Data Collection
The data to generate the measures andmonthly reports were collected duringclinic or telephone encounters andentered into an electronic patient reg-istry (later the electronic health record)or extracted from hospital administra-tive databases from the start of inter-ventions through June 2011 which wasthe end of the fiscal year in which wetransitionedtoanelectronichealthrecord
Analysis
Statistical process control methodswere used to monitor changes in careprocesses and health outcomes Spe-cifically annotated control or runcharts were developed and updatedmonthly Standard industry criteriawere used to determine if observedchanges in measures were chance ran-dom variation (common cause varia-tion)ordue toaspecificassignable causein thiscase the intervention(specialcausevariation)6364 Some measures werebased on the total population and usedthe most recent data point for each pa-tient Standard statistical process controlcriteria were not used for these cumula-tive measures due to the large degree ofautocorrelation caused by carrying overpatientsrsquo values from the previous datapoint if a new visit did not occur since thedata were collected
Human Subjects Protection
This initiative fell within the CCHMC In-stitutional Review Boardrsquos guidance forquality improvement projects that didnot constitute human subjects research
RESULTS
Overall Innovation LaboratoryMeasures
From June 1 2007 through June 302011 322 unique patients with asthma
were seen in the new clinic The pro-portion of patients with optimally well-controlled asthma (ie highest possiblescore on our modified asthma controlscore) was sim10 at baseline andgradually increased to 20 by June2008 after implementation of stan-dardized evidence-based care andoutreach by a parent coordinator (Fig 1)In August 2009 after the implementationof reliable self-management supportthe proportion of optimallywell-controlledpatients exceeded our goal of 30 andwas maintained
Figure 1 also shows when we con-verted to the electronic health recordand began to use the standard AsthmaControl Test48 as our outcome mea-sure We found that a similar pro-portion of patients had a maximalscore of 25 on the Asthma Control Testas had amaximal score on ourmodifiedasthma score The mean proportion ofpatients with asthma-related ED visitsor hospitalizations was stable at 16(Fig 2) Patient satisfaction also remainedstable at 75 (Fig 3)
Results of Specific Interventions
In September 2006 only 38 of patientsreceived the 3 following elements ofevidence-based care (1) conditionseverity characterized in chart andfor patients with persistent asthma (2)an action plan and (3) controller med-ications at the most recent visit Thevalue increased rapidly and starting inJune 2007 was$94 Between Decem-ber 2010 and June 2011 100 of patientswith asthma received the evidence-based care bundle
After the implementation of self-management interventions in Septem-ber 2007 the proportion of patients andtheir parents who were confident intheir ability to manage their or theiradolescentrsquos asthma (rating of $7 of10) increased from a low of 70 tosim80 This proportion increased againtosim85after the teambegan to increase
e422 BRITTO et al
FIGURE 1Percentage of patients with asthma whose condition was well controlled EPIC our electronic health record FY fiscal year
FIGURE 2Percentage of patients with asthma with asthma-related ED visits andor hospitalizations
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e423
its skill in providing self-managementsupport and planned specific inter-ventions for each adolescent with a lowscore in February 2009
Between July 2008 and August 2009 theproportion of patients receiving the re-quired self-management components (apatient self-assessment a stage-of-readiness tool and a personal actionplan if inaction) rapidly increased from0 to 86 and then remained steady atslightly less than 90 These resultscoincided with the large increase inwell-controlled patients beginning inJune 2008 (Fig 1)
Cohort of Chronically Not-Well-Controlled Patients
Of the 50 chronically not-well-controlledpatients who remained in the practice(8 left the practice ormoved away) 60
had a $2-point improvement in theirmedian modified asthma control scorein the intervention year compared withthe previous year (Fig 4)
Community Connections
Community connections were measuredby identifying patients who needed com-munityservicesandtrackingtheproportionof patients who were either referred orprovidedwith informationduringaclinicvisit By June 2011 we achieved 90reliability in our processes to addressmajor family concerns
DISCUSSION
Our quality improvement initiative isamong the first to show sustained im-provement in asthma control in ado-lescentpatients Byusing theoutcomeof
optimal asthma symptom control wetripled the proportion of patients whoachieved that level of control over thecourse of our initiative In accordancewith the Chronic Care Model4244ndash46 ourmultiple interventions focused on stan-dardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma
We used a high bar to define asthmacontrol thehighest possible scoreonourmodified asthma control score Weoriginally chose to modify the AsthmaControl Test developed by Nathan et al48
because it was not consistent with themost recent asthma guidelines from theNational Heart Lung and Blood In-stitute13 After our transition to use of an
FIGURE 3Percentage of patients with asthma rating the clinic as providing the best possible care
e424 BRITTO et al
electronic health record in March 2011we switched to using the Asthma Con-trol Test to be consistent with otherdepartments in our medical center Ini-tial results after the transition sug-gested that ourmodified score functionedsimilar to the original Asthma Control Test
Several of our interventions focused onimproving teenager and family en-gagement in their asthma care The 3self-management tools (a patient self-assessment a stage-of-readiness tooland a personal action plan) were de-signed to promote self-managementassessment and help providers talkcomfortably and productively with pa-tientsandfamiliesaboutmakingchangesnecessary to improve their health Therole of the parent coordinator served asa relatively low-cost innovation that al-lowed someone familiar with the needsand struggles of families dealing witha chronic illness to help other families
navigate the care system This valuableperson working closely with clinicianswas often able to obtain patient infor-mation that clinicians alone could notget We suspect that the parent coor-dinator herself the parent of a childwith a chronic condition could con-verse with parents as a peer ratherthan as a medical professional
We continue to work with patients whostruggle to control their asthmaWearecurrently testing interventions that usetechnology to promote active outreachand population management We arealsodevelopingnewalgorithms todrivecomanagement approaches with ourspecialist colleagues in PulmonaryMedicine and Psychology
This small group of patients withchronically poor control may also rep-resentagroupwith intrinsically difficult-to-control asthma They are now thefocus of research efforts among our
pulmonarycolleagues Inadditionwearespreadingoursuccessful interventionstoother areas of the medical center thattreat patients with chronic disease Forexample the self-management tools havebeen adapted for use with our electronichealth record and brochures describingthe5stagesofchangereadinessarewidelyused
CONCLUSIONS
Implementing interventions focused onstandardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma resulted insustained improvement in asthmacontrol in adolescent patients Addi-tional interventions are likely neededforpatientswith chronically poorasthmacontrol
FIGURE 4Cumulative percentage of chronically not-well-controlled patients (median score of 9 to 13 on ourmodified asthma control score) whose score improved by 2 points
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e425
REFERENCES
1 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2010 Vital HealthStat 10 2011(250)1ndash80
2 Akinbami LJ Moorman JE Liu X Asthmaprevalence healthcare use and mortalityUnited States 2005ndash2009 Natl Health StatRep 2011(32)1ndash14
3 Akinbami LJ Moorman JE Garbe PL SondikEJ Status of childhood asthma in theUnited States 1980-2007 Pediatrics 2009123(suppl 3)S131ndashS145
4 Bai Y Hillemeier MM Lengerich EJ Racialethnic disparities in symptom severityamong children hospitalized with asthmaJ Health Care Poor Underserved 200718(1)54ndash61
5 Flores G Snowden-Bridon C Torres S et alUrban minority children with asthmasubstantial morbidity compromised qual-ity and access to specialists and the im-portance of poverty and specialty care JAsthma 200946(4)392ndash398
6 Kitsantas P Kornides ML Cantiello J Wu HChronic physical health conditions amongchildren of different racialethnic back-grounds Public Health 2013127(6)546ndash553
7 Forrest CB Starfield B Riley AW Kang M Theimpact of asthma on the health status ofadolescents Pediatrics 199799(2) Availableat wwwpediatricsorgcgicontentfull992e1
8 Global Initiative for Asthma (GINA) Globalstrategy for asthma management andprevention Published 2010 Available atwwwginasthmaorgpdfGINA_Report_2010pdf Accessed February 22 2013
9 British Thoracic Society Scottish In-tercollegiate Guidelines Network Britishguideline on the management of asthmaa national clinical guideline PublishedJanuary 2012 Available at wwwsignacukpdfsign101pdf Accessed February 222013
10 Cincinnati Childrenrsquos Hospital Medical Cen-ter James M Anderson Center for HealthSystems Excellence Management of acute ex-acerbation of asthma in children PublishedSeptember 16 2010 Available at wwwcin-cinnatichildrensorgworkarealinkitaspxlink-identifier=idampitemid=87871amplibid=87559Accessed February 22 2013
11 Department of Veterans Affairs Departmentof Defense VADoD clinical practice guide-line for management of asthma in childrenand adults 2 Published 2009 Available atwwwhealthqualityvagovasthmaast_2_fullpdf Accessed February 22 2013
12 Institute for Clinical Systems ImprovementDiagnosis and management of asthma 9thed Published July 31 2012 Available at httpswwwicsiorgguidelines__morecatalog_guidelines_and_morecatalog_guidelinescatalog_respiratory_guidelinesasthmaAccessed February 22 2013
13 National Heart Lung and Blood InstituteNational Asthma Education and PreventionProgram Expert panel report 3 guidelinesfor the diagnosis and management ofasthma Bethesda MD US Department ofHealth and Human Services 2007 Availableat wwwnhlbinihgovguidelinesasthmaasthgdlnhtm Accessed February 22 2013
14 Registered Nursesrsquo Association of OntarioPromoting asthma control in childrenPublished 2004 Available at httprnaocabpgguidelinespromoting-asthma-control-children Accessed February 22 2013
15 Verloet D Williams AE Lloyd A Clark TJCosts of managing asthma as defined bya derived Asthma Control Test score inseven European countries Eur Respir Rev200615(98)17ndash23
16 Haselkorn T Fish JE Zeiger RS et al Con-sistently very poorly controlled asthma asdefined by the impairment domain of theExpert Panel Report 3 guidelines increasesrisk for future severe asthma exacer-bations in The Epidemiology and NaturalHistory of Asthma Outcomes and Treat-ment Regimens (TENOR) STUDY J AllergyClin Immunol 2009124(5)895ndash902 e891ndashe894
17 Scott L Morphew T Bollinger ME et alAchieving and maintaining asthma controlin inner-city children J Allergy Clin Immu-nol 2011128(1)56ndash63
18 Szefler SJ Zeiger RS Haselkorn T et alEconomic burden of impairment in chil-dren with severe or difficult-to-treatasthma Ann Allergy Asthma Immunol2011107(2)110ndash119e1
19 McMullen A Yoos HL Anson E Kitzmann HHalterman JS Arcoleo KS Asthma care ofchildren in clinical practice do parentsreport receiving appropriate educationPediatr Nurs 200733(1)37ndash44
20 Reeves MJ Bohm SR Korzeniewski SJBrown MD Asthma care and managementbefore an emergency department visit inchildren in western Michigan how welldoes care adhere to guidelines Pediatrics2006117(4 pt 2)S118ndashS126
21 Orrell-Valente JK Jones K Manasse S ThyneSM Shenkin BN Cabana MD Childrenrsquos andparentsrsquo report of asthma education received
from physicians J Asthma 201148(8)831ndash838
22 Cabana MD Chaffin DC Jarlsberg LG ThyneSM Clark NM Selective provision ofasthma self-management tools to familiesPediatrics 2008121(4) Available at wwwpediatricsorgcgicontentfull1214e900
23 Cabana MD Abu-Isa H Thyne SM Yawn BSpecialty differences in prescribing inhaledcorticosteroids for children Clin Pediatr(Phila) 200746(8)698ndash705
24 Rastogi D Shetty A Neugebauer R HarijithA National Heart Lung and Blood Instituteguidelines and asthma management prac-tices among inner-city pediatric primarycare providers Chest 2006129(3)619ndash623
25 Deis JN Spiro DM Jenkins CA Buckles TLArnold DH Parental knowledge and use ofpreventive asthma care measures in twopediatric emergency departments JAsthma 201047(5)551ndash556
26 To T Wang C Dell SD et al PAMG Team Canan evidence-based guideline reminder cardimprove asthma management in theemergency department Respir Med 2010104(9)1263ndash1270
27 Tsai CL Sullivan AF Gordon JA et al Qualityof care for acute asthma in 63 US emer-gency departments J Allergy Clin Immunol2009123(2)354ndash361
28 Knapp JF Simon SD Sharma V Quality ofcare for common pediatric respiratory ill-nesses in United States emergency depart-ments analysis of 2005 National HospitalAmbulatory Medical Care Survey Data Pe-diatrics 2008122(6)1165ndash1170
29 Sawyer S Drew S Duncan R Adolescentswith chronic diseasemdashthe double whammyAust Fam Physician 200736(8)622ndash627
30 Mangione-Smith R DeCristofaro AH SetodjiCM et al The quality of ambulatory caredelivered to children in the United StatesN Engl J Med 2007357(15)1515ndash1523
31 de Benedictis D Bush A The challenge ofasthma in adolescence Pediatr Pulmonol200742(8)683ndash692
32 Howenstine MS Eigen H Medical care ofthe adolescent with asthma Adolesc Med200011(3)501ndash519
33 Couriel J Asthma in adolescence PaediatrRespir Rev 20034(1)47ndash54
34 Staples B Bravender T Drug compliance inadolescents assessing and managingmodifiable risk factors Paediatr Drugs20024(8)503ndash513
35 Desai M Oppenheimer JJ Medication ad-herence in the asthmatic child and ado-lescent Curr Allergy Asthma Rep 201111(6)454ndash464
e426 BRITTO et al
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427
Outcomes of Interest
We developed a 3-level system of out-come measures At the highest levelmultifaceted outcome measures weredeveloped to capture the overall aim ofthe team to improve clinical outcomesforadolescentswithasthmaTheprimaryoutcomemeasurewas the percentage ofpatients with optimally well-controlledasthma defined as the best score (16)on our modified asthma control scorequestionnaire47 Our score was based onthe Asthma Control Test48 but wasadapted to be consistent with the 2007National Heart Lung and Blood Instituteasthma guidelines13 When CCHMC tran-sitioned to an electronic health record tobe consistent across the medical centerwe began using the top score of 25 on theoriginal Asthma Control Test48 for ourmeasure of optimally well-controlled and20 for the usual Asthma Control Testcutoff for well controlled Other mea-sures were as follows (1) the percent-age of patients who were hospitalizedandor visited the ED a measure ofhealth care utilization and (2) patientsatisfaction with the clinic visit mea-sured by using a modified ConsumerAssessment of Healthcare Providers andSystems question49 thatmeasures overallsatisfaction with the care patients re-ceived For the satisfaction measurepatients were asked to fill out ananonymous 11-point Likert scale sur-vey at the end of their visit The teammonitors the proportion of patientsgiving their care the highest rating
Within the second level of measureswhich were specific to the inter-ventions the delivery of standardizedandevidence-based carewasevaluatedby using the proportion of patientsreceiving a bundle of care elementsa written asthma action plan severityclassified and controller medicationsprescribed for patients with persistentasthma The overall outcome measurefor self-management support wasthe percentage of patients who were
confident in theirability tomanage theirasthma measured during each clinicvisit by using a Likert scale questiondeveloped and validated by Lorig et al50
for patients with arthritis
The third level of measures were de-veloped to measure the success of thenumerous and targeted Plan-Do-Study-Act cycles51 used in the testing andimplementation of the interventionsFor example while conducting tests toimprove mental health access we de-veloped a process measure of theproportion of patients each weekneeding a mental health referral whoreceived the new standard referralprocess
Interventions
The Chronic Care Model42ndash46 was usedas the evidence-based framework toguide changes in care delivery Duringthe planning phase suggestions andfeedback on proposed changes wereobtained from patients and familiesthrough questionnaires and involvementof the Teen Asthma Advisory Board anadolescent focus group and duringclinic visits The interventions imple-mented included delivery system re-design to provide standardized andevidence-based care productive inter-actions between informed patients andprepared clinicians self-managementsupport community linkages clinicalinformation systems and decisionsupport (Table 1) A quality improve-ment consultant coached the team inquality improvement methods anda data specialist guided the data col-lection process and assisted with thedata analysis
Standardized Evidence-Based Care
In 2007 we began administering theasthma control questionnaires toteenagers and their parents at eachvisit and using our modified asthmacontrol score assessed teenagersrsquo
symptoms medication use and confi-dencetomanage their asthma Decision-support tools and frequent feedbackencouraged providers to implementevidence-based practices such as clas-sifying severity developing a writtenasthma management plan and pre-scribing controller medications for per-sistent asthma In 2008 we developedand implemented amoredetailed asthmaassessment and treatment algorithm(see Supplemental Fig 5)52ndash55 based onthe National Heart Lung and Blood In-stitute asthma guidelines13
Care Coordination and ActiveOutreach
In May 2007 the parent of a child witha chronic illness was hired to co-ordinatedata tracking family outreachappointment scheduling and preclinicreminders andassessments Twowidelyavailable electronic databases (DocSiteclinical registry and Care ManagementPlus)wereused tomaintain clinical anddemographic information about thepatients These databases also servedas the primary data source for ourprocessandoutcomesmeasuresPatientsin need of follow-up were tracked Follow-up was performed by different teammembers depending on the specific needFor example the parent coordinatorwould help patients with appointmentscheduling or linking to communityresources The nurse practitioner woulddo clinical reassessment by phone andadjust the treatment plan as needed
From July 2010 through June 2011 wefocused improvement efforts ona group of 58 chronically not-well-controlled patients those with a me-dian score of 9 to 13 over the previousyear on our modified56 asthma controlscore It was discovered through thiseffort that these patients were lesslikely to come to clinic Thereforeinterventions for this group focused onimproving patient contact and follow-up
e420 BRITTO et al
They were called and texted at everyknown telephone number Their schoolswere also contacted If these patientscould be reached their asthma wasassessed over the telephone An in-depthchart review was performed to assesswhat gaps in their care could beaddressed (ie learning needs comor-bidities referrals triggers barriers tocare tobacco exposure) When patients
returned to clinic these gaps wereaddressed This targeted interventionwas evaluated by the proportion ofpatients in the cohort whose score onour modified asthma control ques-tionnaire improved by at least 2 pointsA study consisting primarily of adultsreported a 188-point change in the 25-point Asthma Control Test to be clini-cally important57
Self-management SupportAt the inception of the clinic it was de-termined that self-management supportwas integral to success Initial testingandrefinement of the parent coordinatorrolebegan in2007 In2008all clinical staffand the parent coordinator receivedtraining in motivational interviewing andbehavior change counseling58ndash60 In 2008we designated a team member as
TABLE 1 Interventions
Health systemsbull Delivery system design
s Staff tracker a paper matrix used by staff to track each patientrsquos steps through a clinic visit to ensure they received the care they needed during that visits Asthma and self-management training for residents starting their month-long clinic rotations Parent coordinator the parent of a chronically ill child coordinated data tracking appointment scheduling and preclinic reminders and assessmentss Preclinic plannings Standardized educational brochures Web sites knowledge quiz and checklists developed with patientss Symptom tracker a paper form used by patients to record their asthma symptoms triggers and medication use and reviewed at clinic visitss Individual patient asthma control data plotted on run charts and discussed with patientsfamilies during visitss Contact information updated every 60 days during the clinic visit and numbers and methods prioritized according to patient preference enabled us to obtaininformation that patients sometimes are reluctant to give to registration personnel
s Active follow-up between visitsbull Decision support
s Evidence-based algorithms for asthma allergic rhinitis smoking cessation and gastroesophageal reflux disease were created to standardize cares Prompts and templates developed to guide care decisions and standardize information attained during clinic visit (initially paper later embedded in electronichealth record)
s Standardized previsit planning formsbull Clinical information systems
s Clinic tracker information on completion of patient-entered data self-management support patient community resource needs and patient feedback oninitiatives stored in a spreadsheet database and used during clinic visits
s DocSite Registry a database of all patients and their outcomes used for previsit planning follow-up and monitoring population results (used beforeimplementation of electronic health record)
s Care-Management Plus525355 database patient demographic database used to generate reminder lists of patients needing follow-up (used beforeimplementation of electronic health record)
s Online confidential patient satisfaction questionnaire satisfaction measured on a scale of 0 to 10 with an opportunity for free text commentsSelf-management supportbull Self-management support through tailored mailings and patient brochures based on stage of readinessbull Staff trained to address patient needs and confidence and in behavior change counselingbull Self-management tools (patient self-assessment stage-of-readiness progress checklist and personal action plan) reviewed and documented in medical record ateach clinic visit
bull Reminders for influenza immunization upcoming appointments and need to make a follow-up appointment were sent as text messagesbull Patient illness management questionnaire to identify barriers to self-management61
bull Administration of the StateTrait Anxiety Inventory for Children54 to patients whose asthmawas not well controlled after$3months in clinic patients exceeding thetoolrsquos threshold and possibly anxious or worried were referred to mental health services
bull New patients received a letter providing contact information and describing the Teen Health Center and Asthma Innovation Laboratory and what to expect duringa visit
Communitybull Teen Asthma Advisory Board teenagerswith asthmawho attended the Teen Health Center helped to shape decisions around use of and implementation of Web sitesand documents
bull Asthma camp a weekend camp for children with asthma to promote friendship asthma education and funbull Facilitated mental health referralsbull Emergency prescriptions patientsfamilies without insurance could receive a 1-month supply of medications from the pharmacy at Cincinnati Childrenrsquos and bebilled later
bull Facilitated referrals to financial counseling services to obtain assistance with health carendashrelated financial needsbull Transportation services to and from clinic visits for publicly insured patientsbull Cincinnati Health Department conducted evaluations of rental properties for asthma triggers (mold cockroaches etc) and sent letters to landlordsbull School nurses administered the Asthma Control Test to patients with not-well-controlled asthma who were unresponsive to contact at home or did not attend clinicappointments
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e421
a self-management coach to conductself-assessments61 set goals and de-velop action plans The coach alsocontacted patients between visits toassess progress We tested and even-tually began using 3 self-managementtools a patient self-assessment a stage-of-readiness tool and a personal actionplan The training tools were based onan evidence-based guideline previouslydeveloped at CCHMC62 Starting in 2009resident physicians rotating in the clinicbegan receiving training in the use ofthe self-management tools and behav-ior change counseling using motivationalinterviewing skills
To assess general health concernsworries disease and treatment knowl-edge social stressors and readiness tomakeabehaviorchange thepatientself-management assessment was admin-istered at the beginning of the visit toeverypatientwhohadnotbeenassessedwithin theprevious30days Thestage-of-readiness toolwasusedtodocument thepatientrsquos current stage of readiness tochange and the focus of the behaviorchange counseling at the end of thevisit A personal action plan was com-pleted if the patient was ready to makea behavior change (all tools available onrequest) Follow-up was conducted byphone e-mail or text according to theteenagerrsquos preference
Community Connections
Because many teenagers were failingto achieve optimal asthma control withourevidence-basedcare self-managementand care coordination interventions in2011 we investigated major barriers toachieving good control We interviewedpatients parents and hospital socialworkersanddetermined that themajorpotentially modifiable barriers werelack of transportation to appointmentslack of insurance coverage for medi-cations and untreated mental healthcomorbidities Working with familiessocial services andcommunity agencies
we developed and tested interventions toaddresseachof theseproblems(Table1)
Data Collection
The data to generate the measures andmonthly reports were collected duringclinic or telephone encounters andentered into an electronic patient reg-istry (later the electronic health record)or extracted from hospital administra-tive databases from the start of inter-ventions through June 2011 which wasthe end of the fiscal year in which wetransitionedtoanelectronichealthrecord
Analysis
Statistical process control methodswere used to monitor changes in careprocesses and health outcomes Spe-cifically annotated control or runcharts were developed and updatedmonthly Standard industry criteriawere used to determine if observedchanges in measures were chance ran-dom variation (common cause varia-tion)ordue toaspecificassignable causein thiscase the intervention(specialcausevariation)6364 Some measures werebased on the total population and usedthe most recent data point for each pa-tient Standard statistical process controlcriteria were not used for these cumula-tive measures due to the large degree ofautocorrelation caused by carrying overpatientsrsquo values from the previous datapoint if a new visit did not occur since thedata were collected
Human Subjects Protection
This initiative fell within the CCHMC In-stitutional Review Boardrsquos guidance forquality improvement projects that didnot constitute human subjects research
RESULTS
Overall Innovation LaboratoryMeasures
From June 1 2007 through June 302011 322 unique patients with asthma
were seen in the new clinic The pro-portion of patients with optimally well-controlled asthma (ie highest possiblescore on our modified asthma controlscore) was sim10 at baseline andgradually increased to 20 by June2008 after implementation of stan-dardized evidence-based care andoutreach by a parent coordinator (Fig 1)In August 2009 after the implementationof reliable self-management supportthe proportion of optimallywell-controlledpatients exceeded our goal of 30 andwas maintained
Figure 1 also shows when we con-verted to the electronic health recordand began to use the standard AsthmaControl Test48 as our outcome mea-sure We found that a similar pro-portion of patients had a maximalscore of 25 on the Asthma Control Testas had amaximal score on ourmodifiedasthma score The mean proportion ofpatients with asthma-related ED visitsor hospitalizations was stable at 16(Fig 2) Patient satisfaction also remainedstable at 75 (Fig 3)
Results of Specific Interventions
In September 2006 only 38 of patientsreceived the 3 following elements ofevidence-based care (1) conditionseverity characterized in chart andfor patients with persistent asthma (2)an action plan and (3) controller med-ications at the most recent visit Thevalue increased rapidly and starting inJune 2007 was$94 Between Decem-ber 2010 and June 2011 100 of patientswith asthma received the evidence-based care bundle
After the implementation of self-management interventions in Septem-ber 2007 the proportion of patients andtheir parents who were confident intheir ability to manage their or theiradolescentrsquos asthma (rating of $7 of10) increased from a low of 70 tosim80 This proportion increased againtosim85after the teambegan to increase
e422 BRITTO et al
FIGURE 1Percentage of patients with asthma whose condition was well controlled EPIC our electronic health record FY fiscal year
FIGURE 2Percentage of patients with asthma with asthma-related ED visits andor hospitalizations
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e423
its skill in providing self-managementsupport and planned specific inter-ventions for each adolescent with a lowscore in February 2009
Between July 2008 and August 2009 theproportion of patients receiving the re-quired self-management components (apatient self-assessment a stage-of-readiness tool and a personal actionplan if inaction) rapidly increased from0 to 86 and then remained steady atslightly less than 90 These resultscoincided with the large increase inwell-controlled patients beginning inJune 2008 (Fig 1)
Cohort of Chronically Not-Well-Controlled Patients
Of the 50 chronically not-well-controlledpatients who remained in the practice(8 left the practice ormoved away) 60
had a $2-point improvement in theirmedian modified asthma control scorein the intervention year compared withthe previous year (Fig 4)
Community Connections
Community connections were measuredby identifying patients who needed com-munityservicesandtrackingtheproportionof patients who were either referred orprovidedwith informationduringaclinicvisit By June 2011 we achieved 90reliability in our processes to addressmajor family concerns
DISCUSSION
Our quality improvement initiative isamong the first to show sustained im-provement in asthma control in ado-lescentpatients Byusing theoutcomeof
optimal asthma symptom control wetripled the proportion of patients whoachieved that level of control over thecourse of our initiative In accordancewith the Chronic Care Model4244ndash46 ourmultiple interventions focused on stan-dardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma
We used a high bar to define asthmacontrol thehighest possible scoreonourmodified asthma control score Weoriginally chose to modify the AsthmaControl Test developed by Nathan et al48
because it was not consistent with themost recent asthma guidelines from theNational Heart Lung and Blood In-stitute13 After our transition to use of an
FIGURE 3Percentage of patients with asthma rating the clinic as providing the best possible care
e424 BRITTO et al
electronic health record in March 2011we switched to using the Asthma Con-trol Test to be consistent with otherdepartments in our medical center Ini-tial results after the transition sug-gested that ourmodified score functionedsimilar to the original Asthma Control Test
Several of our interventions focused onimproving teenager and family en-gagement in their asthma care The 3self-management tools (a patient self-assessment a stage-of-readiness tooland a personal action plan) were de-signed to promote self-managementassessment and help providers talkcomfortably and productively with pa-tientsandfamiliesaboutmakingchangesnecessary to improve their health Therole of the parent coordinator served asa relatively low-cost innovation that al-lowed someone familiar with the needsand struggles of families dealing witha chronic illness to help other families
navigate the care system This valuableperson working closely with clinicianswas often able to obtain patient infor-mation that clinicians alone could notget We suspect that the parent coor-dinator herself the parent of a childwith a chronic condition could con-verse with parents as a peer ratherthan as a medical professional
We continue to work with patients whostruggle to control their asthmaWearecurrently testing interventions that usetechnology to promote active outreachand population management We arealsodevelopingnewalgorithms todrivecomanagement approaches with ourspecialist colleagues in PulmonaryMedicine and Psychology
This small group of patients withchronically poor control may also rep-resentagroupwith intrinsically difficult-to-control asthma They are now thefocus of research efforts among our
pulmonarycolleagues Inadditionwearespreadingoursuccessful interventionstoother areas of the medical center thattreat patients with chronic disease Forexample the self-management tools havebeen adapted for use with our electronichealth record and brochures describingthe5stagesofchangereadinessarewidelyused
CONCLUSIONS
Implementing interventions focused onstandardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma resulted insustained improvement in asthmacontrol in adolescent patients Addi-tional interventions are likely neededforpatientswith chronically poorasthmacontrol
FIGURE 4Cumulative percentage of chronically not-well-controlled patients (median score of 9 to 13 on ourmodified asthma control score) whose score improved by 2 points
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e425
REFERENCES
1 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2010 Vital HealthStat 10 2011(250)1ndash80
2 Akinbami LJ Moorman JE Liu X Asthmaprevalence healthcare use and mortalityUnited States 2005ndash2009 Natl Health StatRep 2011(32)1ndash14
3 Akinbami LJ Moorman JE Garbe PL SondikEJ Status of childhood asthma in theUnited States 1980-2007 Pediatrics 2009123(suppl 3)S131ndashS145
4 Bai Y Hillemeier MM Lengerich EJ Racialethnic disparities in symptom severityamong children hospitalized with asthmaJ Health Care Poor Underserved 200718(1)54ndash61
5 Flores G Snowden-Bridon C Torres S et alUrban minority children with asthmasubstantial morbidity compromised qual-ity and access to specialists and the im-portance of poverty and specialty care JAsthma 200946(4)392ndash398
6 Kitsantas P Kornides ML Cantiello J Wu HChronic physical health conditions amongchildren of different racialethnic back-grounds Public Health 2013127(6)546ndash553
7 Forrest CB Starfield B Riley AW Kang M Theimpact of asthma on the health status ofadolescents Pediatrics 199799(2) Availableat wwwpediatricsorgcgicontentfull992e1
8 Global Initiative for Asthma (GINA) Globalstrategy for asthma management andprevention Published 2010 Available atwwwginasthmaorgpdfGINA_Report_2010pdf Accessed February 22 2013
9 British Thoracic Society Scottish In-tercollegiate Guidelines Network Britishguideline on the management of asthmaa national clinical guideline PublishedJanuary 2012 Available at wwwsignacukpdfsign101pdf Accessed February 222013
10 Cincinnati Childrenrsquos Hospital Medical Cen-ter James M Anderson Center for HealthSystems Excellence Management of acute ex-acerbation of asthma in children PublishedSeptember 16 2010 Available at wwwcin-cinnatichildrensorgworkarealinkitaspxlink-identifier=idampitemid=87871amplibid=87559Accessed February 22 2013
11 Department of Veterans Affairs Departmentof Defense VADoD clinical practice guide-line for management of asthma in childrenand adults 2 Published 2009 Available atwwwhealthqualityvagovasthmaast_2_fullpdf Accessed February 22 2013
12 Institute for Clinical Systems ImprovementDiagnosis and management of asthma 9thed Published July 31 2012 Available at httpswwwicsiorgguidelines__morecatalog_guidelines_and_morecatalog_guidelinescatalog_respiratory_guidelinesasthmaAccessed February 22 2013
13 National Heart Lung and Blood InstituteNational Asthma Education and PreventionProgram Expert panel report 3 guidelinesfor the diagnosis and management ofasthma Bethesda MD US Department ofHealth and Human Services 2007 Availableat wwwnhlbinihgovguidelinesasthmaasthgdlnhtm Accessed February 22 2013
14 Registered Nursesrsquo Association of OntarioPromoting asthma control in childrenPublished 2004 Available at httprnaocabpgguidelinespromoting-asthma-control-children Accessed February 22 2013
15 Verloet D Williams AE Lloyd A Clark TJCosts of managing asthma as defined bya derived Asthma Control Test score inseven European countries Eur Respir Rev200615(98)17ndash23
16 Haselkorn T Fish JE Zeiger RS et al Con-sistently very poorly controlled asthma asdefined by the impairment domain of theExpert Panel Report 3 guidelines increasesrisk for future severe asthma exacer-bations in The Epidemiology and NaturalHistory of Asthma Outcomes and Treat-ment Regimens (TENOR) STUDY J AllergyClin Immunol 2009124(5)895ndash902 e891ndashe894
17 Scott L Morphew T Bollinger ME et alAchieving and maintaining asthma controlin inner-city children J Allergy Clin Immu-nol 2011128(1)56ndash63
18 Szefler SJ Zeiger RS Haselkorn T et alEconomic burden of impairment in chil-dren with severe or difficult-to-treatasthma Ann Allergy Asthma Immunol2011107(2)110ndash119e1
19 McMullen A Yoos HL Anson E Kitzmann HHalterman JS Arcoleo KS Asthma care ofchildren in clinical practice do parentsreport receiving appropriate educationPediatr Nurs 200733(1)37ndash44
20 Reeves MJ Bohm SR Korzeniewski SJBrown MD Asthma care and managementbefore an emergency department visit inchildren in western Michigan how welldoes care adhere to guidelines Pediatrics2006117(4 pt 2)S118ndashS126
21 Orrell-Valente JK Jones K Manasse S ThyneSM Shenkin BN Cabana MD Childrenrsquos andparentsrsquo report of asthma education received
from physicians J Asthma 201148(8)831ndash838
22 Cabana MD Chaffin DC Jarlsberg LG ThyneSM Clark NM Selective provision ofasthma self-management tools to familiesPediatrics 2008121(4) Available at wwwpediatricsorgcgicontentfull1214e900
23 Cabana MD Abu-Isa H Thyne SM Yawn BSpecialty differences in prescribing inhaledcorticosteroids for children Clin Pediatr(Phila) 200746(8)698ndash705
24 Rastogi D Shetty A Neugebauer R HarijithA National Heart Lung and Blood Instituteguidelines and asthma management prac-tices among inner-city pediatric primarycare providers Chest 2006129(3)619ndash623
25 Deis JN Spiro DM Jenkins CA Buckles TLArnold DH Parental knowledge and use ofpreventive asthma care measures in twopediatric emergency departments JAsthma 201047(5)551ndash556
26 To T Wang C Dell SD et al PAMG Team Canan evidence-based guideline reminder cardimprove asthma management in theemergency department Respir Med 2010104(9)1263ndash1270
27 Tsai CL Sullivan AF Gordon JA et al Qualityof care for acute asthma in 63 US emer-gency departments J Allergy Clin Immunol2009123(2)354ndash361
28 Knapp JF Simon SD Sharma V Quality ofcare for common pediatric respiratory ill-nesses in United States emergency depart-ments analysis of 2005 National HospitalAmbulatory Medical Care Survey Data Pe-diatrics 2008122(6)1165ndash1170
29 Sawyer S Drew S Duncan R Adolescentswith chronic diseasemdashthe double whammyAust Fam Physician 200736(8)622ndash627
30 Mangione-Smith R DeCristofaro AH SetodjiCM et al The quality of ambulatory caredelivered to children in the United StatesN Engl J Med 2007357(15)1515ndash1523
31 de Benedictis D Bush A The challenge ofasthma in adolescence Pediatr Pulmonol200742(8)683ndash692
32 Howenstine MS Eigen H Medical care ofthe adolescent with asthma Adolesc Med200011(3)501ndash519
33 Couriel J Asthma in adolescence PaediatrRespir Rev 20034(1)47ndash54
34 Staples B Bravender T Drug compliance inadolescents assessing and managingmodifiable risk factors Paediatr Drugs20024(8)503ndash513
35 Desai M Oppenheimer JJ Medication ad-herence in the asthmatic child and ado-lescent Curr Allergy Asthma Rep 201111(6)454ndash464
e426 BRITTO et al
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427
They were called and texted at everyknown telephone number Their schoolswere also contacted If these patientscould be reached their asthma wasassessed over the telephone An in-depthchart review was performed to assesswhat gaps in their care could beaddressed (ie learning needs comor-bidities referrals triggers barriers tocare tobacco exposure) When patients
returned to clinic these gaps wereaddressed This targeted interventionwas evaluated by the proportion ofpatients in the cohort whose score onour modified asthma control ques-tionnaire improved by at least 2 pointsA study consisting primarily of adultsreported a 188-point change in the 25-point Asthma Control Test to be clini-cally important57
Self-management SupportAt the inception of the clinic it was de-termined that self-management supportwas integral to success Initial testingandrefinement of the parent coordinatorrolebegan in2007 In2008all clinical staffand the parent coordinator receivedtraining in motivational interviewing andbehavior change counseling58ndash60 In 2008we designated a team member as
TABLE 1 Interventions
Health systemsbull Delivery system design
s Staff tracker a paper matrix used by staff to track each patientrsquos steps through a clinic visit to ensure they received the care they needed during that visits Asthma and self-management training for residents starting their month-long clinic rotations Parent coordinator the parent of a chronically ill child coordinated data tracking appointment scheduling and preclinic reminders and assessmentss Preclinic plannings Standardized educational brochures Web sites knowledge quiz and checklists developed with patientss Symptom tracker a paper form used by patients to record their asthma symptoms triggers and medication use and reviewed at clinic visitss Individual patient asthma control data plotted on run charts and discussed with patientsfamilies during visitss Contact information updated every 60 days during the clinic visit and numbers and methods prioritized according to patient preference enabled us to obtaininformation that patients sometimes are reluctant to give to registration personnel
s Active follow-up between visitsbull Decision support
s Evidence-based algorithms for asthma allergic rhinitis smoking cessation and gastroesophageal reflux disease were created to standardize cares Prompts and templates developed to guide care decisions and standardize information attained during clinic visit (initially paper later embedded in electronichealth record)
s Standardized previsit planning formsbull Clinical information systems
s Clinic tracker information on completion of patient-entered data self-management support patient community resource needs and patient feedback oninitiatives stored in a spreadsheet database and used during clinic visits
s DocSite Registry a database of all patients and their outcomes used for previsit planning follow-up and monitoring population results (used beforeimplementation of electronic health record)
s Care-Management Plus525355 database patient demographic database used to generate reminder lists of patients needing follow-up (used beforeimplementation of electronic health record)
s Online confidential patient satisfaction questionnaire satisfaction measured on a scale of 0 to 10 with an opportunity for free text commentsSelf-management supportbull Self-management support through tailored mailings and patient brochures based on stage of readinessbull Staff trained to address patient needs and confidence and in behavior change counselingbull Self-management tools (patient self-assessment stage-of-readiness progress checklist and personal action plan) reviewed and documented in medical record ateach clinic visit
bull Reminders for influenza immunization upcoming appointments and need to make a follow-up appointment were sent as text messagesbull Patient illness management questionnaire to identify barriers to self-management61
bull Administration of the StateTrait Anxiety Inventory for Children54 to patients whose asthmawas not well controlled after$3months in clinic patients exceeding thetoolrsquos threshold and possibly anxious or worried were referred to mental health services
bull New patients received a letter providing contact information and describing the Teen Health Center and Asthma Innovation Laboratory and what to expect duringa visit
Communitybull Teen Asthma Advisory Board teenagerswith asthmawho attended the Teen Health Center helped to shape decisions around use of and implementation of Web sitesand documents
bull Asthma camp a weekend camp for children with asthma to promote friendship asthma education and funbull Facilitated mental health referralsbull Emergency prescriptions patientsfamilies without insurance could receive a 1-month supply of medications from the pharmacy at Cincinnati Childrenrsquos and bebilled later
bull Facilitated referrals to financial counseling services to obtain assistance with health carendashrelated financial needsbull Transportation services to and from clinic visits for publicly insured patientsbull Cincinnati Health Department conducted evaluations of rental properties for asthma triggers (mold cockroaches etc) and sent letters to landlordsbull School nurses administered the Asthma Control Test to patients with not-well-controlled asthma who were unresponsive to contact at home or did not attend clinicappointments
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e421
a self-management coach to conductself-assessments61 set goals and de-velop action plans The coach alsocontacted patients between visits toassess progress We tested and even-tually began using 3 self-managementtools a patient self-assessment a stage-of-readiness tool and a personal actionplan The training tools were based onan evidence-based guideline previouslydeveloped at CCHMC62 Starting in 2009resident physicians rotating in the clinicbegan receiving training in the use ofthe self-management tools and behav-ior change counseling using motivationalinterviewing skills
To assess general health concernsworries disease and treatment knowl-edge social stressors and readiness tomakeabehaviorchange thepatientself-management assessment was admin-istered at the beginning of the visit toeverypatientwhohadnotbeenassessedwithin theprevious30days Thestage-of-readiness toolwasusedtodocument thepatientrsquos current stage of readiness tochange and the focus of the behaviorchange counseling at the end of thevisit A personal action plan was com-pleted if the patient was ready to makea behavior change (all tools available onrequest) Follow-up was conducted byphone e-mail or text according to theteenagerrsquos preference
Community Connections
Because many teenagers were failingto achieve optimal asthma control withourevidence-basedcare self-managementand care coordination interventions in2011 we investigated major barriers toachieving good control We interviewedpatients parents and hospital socialworkersanddetermined that themajorpotentially modifiable barriers werelack of transportation to appointmentslack of insurance coverage for medi-cations and untreated mental healthcomorbidities Working with familiessocial services andcommunity agencies
we developed and tested interventions toaddresseachof theseproblems(Table1)
Data Collection
The data to generate the measures andmonthly reports were collected duringclinic or telephone encounters andentered into an electronic patient reg-istry (later the electronic health record)or extracted from hospital administra-tive databases from the start of inter-ventions through June 2011 which wasthe end of the fiscal year in which wetransitionedtoanelectronichealthrecord
Analysis
Statistical process control methodswere used to monitor changes in careprocesses and health outcomes Spe-cifically annotated control or runcharts were developed and updatedmonthly Standard industry criteriawere used to determine if observedchanges in measures were chance ran-dom variation (common cause varia-tion)ordue toaspecificassignable causein thiscase the intervention(specialcausevariation)6364 Some measures werebased on the total population and usedthe most recent data point for each pa-tient Standard statistical process controlcriteria were not used for these cumula-tive measures due to the large degree ofautocorrelation caused by carrying overpatientsrsquo values from the previous datapoint if a new visit did not occur since thedata were collected
Human Subjects Protection
This initiative fell within the CCHMC In-stitutional Review Boardrsquos guidance forquality improvement projects that didnot constitute human subjects research
RESULTS
Overall Innovation LaboratoryMeasures
From June 1 2007 through June 302011 322 unique patients with asthma
were seen in the new clinic The pro-portion of patients with optimally well-controlled asthma (ie highest possiblescore on our modified asthma controlscore) was sim10 at baseline andgradually increased to 20 by June2008 after implementation of stan-dardized evidence-based care andoutreach by a parent coordinator (Fig 1)In August 2009 after the implementationof reliable self-management supportthe proportion of optimallywell-controlledpatients exceeded our goal of 30 andwas maintained
Figure 1 also shows when we con-verted to the electronic health recordand began to use the standard AsthmaControl Test48 as our outcome mea-sure We found that a similar pro-portion of patients had a maximalscore of 25 on the Asthma Control Testas had amaximal score on ourmodifiedasthma score The mean proportion ofpatients with asthma-related ED visitsor hospitalizations was stable at 16(Fig 2) Patient satisfaction also remainedstable at 75 (Fig 3)
Results of Specific Interventions
In September 2006 only 38 of patientsreceived the 3 following elements ofevidence-based care (1) conditionseverity characterized in chart andfor patients with persistent asthma (2)an action plan and (3) controller med-ications at the most recent visit Thevalue increased rapidly and starting inJune 2007 was$94 Between Decem-ber 2010 and June 2011 100 of patientswith asthma received the evidence-based care bundle
After the implementation of self-management interventions in Septem-ber 2007 the proportion of patients andtheir parents who were confident intheir ability to manage their or theiradolescentrsquos asthma (rating of $7 of10) increased from a low of 70 tosim80 This proportion increased againtosim85after the teambegan to increase
e422 BRITTO et al
FIGURE 1Percentage of patients with asthma whose condition was well controlled EPIC our electronic health record FY fiscal year
FIGURE 2Percentage of patients with asthma with asthma-related ED visits andor hospitalizations
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e423
its skill in providing self-managementsupport and planned specific inter-ventions for each adolescent with a lowscore in February 2009
Between July 2008 and August 2009 theproportion of patients receiving the re-quired self-management components (apatient self-assessment a stage-of-readiness tool and a personal actionplan if inaction) rapidly increased from0 to 86 and then remained steady atslightly less than 90 These resultscoincided with the large increase inwell-controlled patients beginning inJune 2008 (Fig 1)
Cohort of Chronically Not-Well-Controlled Patients
Of the 50 chronically not-well-controlledpatients who remained in the practice(8 left the practice ormoved away) 60
had a $2-point improvement in theirmedian modified asthma control scorein the intervention year compared withthe previous year (Fig 4)
Community Connections
Community connections were measuredby identifying patients who needed com-munityservicesandtrackingtheproportionof patients who were either referred orprovidedwith informationduringaclinicvisit By June 2011 we achieved 90reliability in our processes to addressmajor family concerns
DISCUSSION
Our quality improvement initiative isamong the first to show sustained im-provement in asthma control in ado-lescentpatients Byusing theoutcomeof
optimal asthma symptom control wetripled the proportion of patients whoachieved that level of control over thecourse of our initiative In accordancewith the Chronic Care Model4244ndash46 ourmultiple interventions focused on stan-dardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma
We used a high bar to define asthmacontrol thehighest possible scoreonourmodified asthma control score Weoriginally chose to modify the AsthmaControl Test developed by Nathan et al48
because it was not consistent with themost recent asthma guidelines from theNational Heart Lung and Blood In-stitute13 After our transition to use of an
FIGURE 3Percentage of patients with asthma rating the clinic as providing the best possible care
e424 BRITTO et al
electronic health record in March 2011we switched to using the Asthma Con-trol Test to be consistent with otherdepartments in our medical center Ini-tial results after the transition sug-gested that ourmodified score functionedsimilar to the original Asthma Control Test
Several of our interventions focused onimproving teenager and family en-gagement in their asthma care The 3self-management tools (a patient self-assessment a stage-of-readiness tooland a personal action plan) were de-signed to promote self-managementassessment and help providers talkcomfortably and productively with pa-tientsandfamiliesaboutmakingchangesnecessary to improve their health Therole of the parent coordinator served asa relatively low-cost innovation that al-lowed someone familiar with the needsand struggles of families dealing witha chronic illness to help other families
navigate the care system This valuableperson working closely with clinicianswas often able to obtain patient infor-mation that clinicians alone could notget We suspect that the parent coor-dinator herself the parent of a childwith a chronic condition could con-verse with parents as a peer ratherthan as a medical professional
We continue to work with patients whostruggle to control their asthmaWearecurrently testing interventions that usetechnology to promote active outreachand population management We arealsodevelopingnewalgorithms todrivecomanagement approaches with ourspecialist colleagues in PulmonaryMedicine and Psychology
This small group of patients withchronically poor control may also rep-resentagroupwith intrinsically difficult-to-control asthma They are now thefocus of research efforts among our
pulmonarycolleagues Inadditionwearespreadingoursuccessful interventionstoother areas of the medical center thattreat patients with chronic disease Forexample the self-management tools havebeen adapted for use with our electronichealth record and brochures describingthe5stagesofchangereadinessarewidelyused
CONCLUSIONS
Implementing interventions focused onstandardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma resulted insustained improvement in asthmacontrol in adolescent patients Addi-tional interventions are likely neededforpatientswith chronically poorasthmacontrol
FIGURE 4Cumulative percentage of chronically not-well-controlled patients (median score of 9 to 13 on ourmodified asthma control score) whose score improved by 2 points
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e425
REFERENCES
1 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2010 Vital HealthStat 10 2011(250)1ndash80
2 Akinbami LJ Moorman JE Liu X Asthmaprevalence healthcare use and mortalityUnited States 2005ndash2009 Natl Health StatRep 2011(32)1ndash14
3 Akinbami LJ Moorman JE Garbe PL SondikEJ Status of childhood asthma in theUnited States 1980-2007 Pediatrics 2009123(suppl 3)S131ndashS145
4 Bai Y Hillemeier MM Lengerich EJ Racialethnic disparities in symptom severityamong children hospitalized with asthmaJ Health Care Poor Underserved 200718(1)54ndash61
5 Flores G Snowden-Bridon C Torres S et alUrban minority children with asthmasubstantial morbidity compromised qual-ity and access to specialists and the im-portance of poverty and specialty care JAsthma 200946(4)392ndash398
6 Kitsantas P Kornides ML Cantiello J Wu HChronic physical health conditions amongchildren of different racialethnic back-grounds Public Health 2013127(6)546ndash553
7 Forrest CB Starfield B Riley AW Kang M Theimpact of asthma on the health status ofadolescents Pediatrics 199799(2) Availableat wwwpediatricsorgcgicontentfull992e1
8 Global Initiative for Asthma (GINA) Globalstrategy for asthma management andprevention Published 2010 Available atwwwginasthmaorgpdfGINA_Report_2010pdf Accessed February 22 2013
9 British Thoracic Society Scottish In-tercollegiate Guidelines Network Britishguideline on the management of asthmaa national clinical guideline PublishedJanuary 2012 Available at wwwsignacukpdfsign101pdf Accessed February 222013
10 Cincinnati Childrenrsquos Hospital Medical Cen-ter James M Anderson Center for HealthSystems Excellence Management of acute ex-acerbation of asthma in children PublishedSeptember 16 2010 Available at wwwcin-cinnatichildrensorgworkarealinkitaspxlink-identifier=idampitemid=87871amplibid=87559Accessed February 22 2013
11 Department of Veterans Affairs Departmentof Defense VADoD clinical practice guide-line for management of asthma in childrenand adults 2 Published 2009 Available atwwwhealthqualityvagovasthmaast_2_fullpdf Accessed February 22 2013
12 Institute for Clinical Systems ImprovementDiagnosis and management of asthma 9thed Published July 31 2012 Available at httpswwwicsiorgguidelines__morecatalog_guidelines_and_morecatalog_guidelinescatalog_respiratory_guidelinesasthmaAccessed February 22 2013
13 National Heart Lung and Blood InstituteNational Asthma Education and PreventionProgram Expert panel report 3 guidelinesfor the diagnosis and management ofasthma Bethesda MD US Department ofHealth and Human Services 2007 Availableat wwwnhlbinihgovguidelinesasthmaasthgdlnhtm Accessed February 22 2013
14 Registered Nursesrsquo Association of OntarioPromoting asthma control in childrenPublished 2004 Available at httprnaocabpgguidelinespromoting-asthma-control-children Accessed February 22 2013
15 Verloet D Williams AE Lloyd A Clark TJCosts of managing asthma as defined bya derived Asthma Control Test score inseven European countries Eur Respir Rev200615(98)17ndash23
16 Haselkorn T Fish JE Zeiger RS et al Con-sistently very poorly controlled asthma asdefined by the impairment domain of theExpert Panel Report 3 guidelines increasesrisk for future severe asthma exacer-bations in The Epidemiology and NaturalHistory of Asthma Outcomes and Treat-ment Regimens (TENOR) STUDY J AllergyClin Immunol 2009124(5)895ndash902 e891ndashe894
17 Scott L Morphew T Bollinger ME et alAchieving and maintaining asthma controlin inner-city children J Allergy Clin Immu-nol 2011128(1)56ndash63
18 Szefler SJ Zeiger RS Haselkorn T et alEconomic burden of impairment in chil-dren with severe or difficult-to-treatasthma Ann Allergy Asthma Immunol2011107(2)110ndash119e1
19 McMullen A Yoos HL Anson E Kitzmann HHalterman JS Arcoleo KS Asthma care ofchildren in clinical practice do parentsreport receiving appropriate educationPediatr Nurs 200733(1)37ndash44
20 Reeves MJ Bohm SR Korzeniewski SJBrown MD Asthma care and managementbefore an emergency department visit inchildren in western Michigan how welldoes care adhere to guidelines Pediatrics2006117(4 pt 2)S118ndashS126
21 Orrell-Valente JK Jones K Manasse S ThyneSM Shenkin BN Cabana MD Childrenrsquos andparentsrsquo report of asthma education received
from physicians J Asthma 201148(8)831ndash838
22 Cabana MD Chaffin DC Jarlsberg LG ThyneSM Clark NM Selective provision ofasthma self-management tools to familiesPediatrics 2008121(4) Available at wwwpediatricsorgcgicontentfull1214e900
23 Cabana MD Abu-Isa H Thyne SM Yawn BSpecialty differences in prescribing inhaledcorticosteroids for children Clin Pediatr(Phila) 200746(8)698ndash705
24 Rastogi D Shetty A Neugebauer R HarijithA National Heart Lung and Blood Instituteguidelines and asthma management prac-tices among inner-city pediatric primarycare providers Chest 2006129(3)619ndash623
25 Deis JN Spiro DM Jenkins CA Buckles TLArnold DH Parental knowledge and use ofpreventive asthma care measures in twopediatric emergency departments JAsthma 201047(5)551ndash556
26 To T Wang C Dell SD et al PAMG Team Canan evidence-based guideline reminder cardimprove asthma management in theemergency department Respir Med 2010104(9)1263ndash1270
27 Tsai CL Sullivan AF Gordon JA et al Qualityof care for acute asthma in 63 US emer-gency departments J Allergy Clin Immunol2009123(2)354ndash361
28 Knapp JF Simon SD Sharma V Quality ofcare for common pediatric respiratory ill-nesses in United States emergency depart-ments analysis of 2005 National HospitalAmbulatory Medical Care Survey Data Pe-diatrics 2008122(6)1165ndash1170
29 Sawyer S Drew S Duncan R Adolescentswith chronic diseasemdashthe double whammyAust Fam Physician 200736(8)622ndash627
30 Mangione-Smith R DeCristofaro AH SetodjiCM et al The quality of ambulatory caredelivered to children in the United StatesN Engl J Med 2007357(15)1515ndash1523
31 de Benedictis D Bush A The challenge ofasthma in adolescence Pediatr Pulmonol200742(8)683ndash692
32 Howenstine MS Eigen H Medical care ofthe adolescent with asthma Adolesc Med200011(3)501ndash519
33 Couriel J Asthma in adolescence PaediatrRespir Rev 20034(1)47ndash54
34 Staples B Bravender T Drug compliance inadolescents assessing and managingmodifiable risk factors Paediatr Drugs20024(8)503ndash513
35 Desai M Oppenheimer JJ Medication ad-herence in the asthmatic child and ado-lescent Curr Allergy Asthma Rep 201111(6)454ndash464
e426 BRITTO et al
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427
a self-management coach to conductself-assessments61 set goals and de-velop action plans The coach alsocontacted patients between visits toassess progress We tested and even-tually began using 3 self-managementtools a patient self-assessment a stage-of-readiness tool and a personal actionplan The training tools were based onan evidence-based guideline previouslydeveloped at CCHMC62 Starting in 2009resident physicians rotating in the clinicbegan receiving training in the use ofthe self-management tools and behav-ior change counseling using motivationalinterviewing skills
To assess general health concernsworries disease and treatment knowl-edge social stressors and readiness tomakeabehaviorchange thepatientself-management assessment was admin-istered at the beginning of the visit toeverypatientwhohadnotbeenassessedwithin theprevious30days Thestage-of-readiness toolwasusedtodocument thepatientrsquos current stage of readiness tochange and the focus of the behaviorchange counseling at the end of thevisit A personal action plan was com-pleted if the patient was ready to makea behavior change (all tools available onrequest) Follow-up was conducted byphone e-mail or text according to theteenagerrsquos preference
Community Connections
Because many teenagers were failingto achieve optimal asthma control withourevidence-basedcare self-managementand care coordination interventions in2011 we investigated major barriers toachieving good control We interviewedpatients parents and hospital socialworkersanddetermined that themajorpotentially modifiable barriers werelack of transportation to appointmentslack of insurance coverage for medi-cations and untreated mental healthcomorbidities Working with familiessocial services andcommunity agencies
we developed and tested interventions toaddresseachof theseproblems(Table1)
Data Collection
The data to generate the measures andmonthly reports were collected duringclinic or telephone encounters andentered into an electronic patient reg-istry (later the electronic health record)or extracted from hospital administra-tive databases from the start of inter-ventions through June 2011 which wasthe end of the fiscal year in which wetransitionedtoanelectronichealthrecord
Analysis
Statistical process control methodswere used to monitor changes in careprocesses and health outcomes Spe-cifically annotated control or runcharts were developed and updatedmonthly Standard industry criteriawere used to determine if observedchanges in measures were chance ran-dom variation (common cause varia-tion)ordue toaspecificassignable causein thiscase the intervention(specialcausevariation)6364 Some measures werebased on the total population and usedthe most recent data point for each pa-tient Standard statistical process controlcriteria were not used for these cumula-tive measures due to the large degree ofautocorrelation caused by carrying overpatientsrsquo values from the previous datapoint if a new visit did not occur since thedata were collected
Human Subjects Protection
This initiative fell within the CCHMC In-stitutional Review Boardrsquos guidance forquality improvement projects that didnot constitute human subjects research
RESULTS
Overall Innovation LaboratoryMeasures
From June 1 2007 through June 302011 322 unique patients with asthma
were seen in the new clinic The pro-portion of patients with optimally well-controlled asthma (ie highest possiblescore on our modified asthma controlscore) was sim10 at baseline andgradually increased to 20 by June2008 after implementation of stan-dardized evidence-based care andoutreach by a parent coordinator (Fig 1)In August 2009 after the implementationof reliable self-management supportthe proportion of optimallywell-controlledpatients exceeded our goal of 30 andwas maintained
Figure 1 also shows when we con-verted to the electronic health recordand began to use the standard AsthmaControl Test48 as our outcome mea-sure We found that a similar pro-portion of patients had a maximalscore of 25 on the Asthma Control Testas had amaximal score on ourmodifiedasthma score The mean proportion ofpatients with asthma-related ED visitsor hospitalizations was stable at 16(Fig 2) Patient satisfaction also remainedstable at 75 (Fig 3)
Results of Specific Interventions
In September 2006 only 38 of patientsreceived the 3 following elements ofevidence-based care (1) conditionseverity characterized in chart andfor patients with persistent asthma (2)an action plan and (3) controller med-ications at the most recent visit Thevalue increased rapidly and starting inJune 2007 was$94 Between Decem-ber 2010 and June 2011 100 of patientswith asthma received the evidence-based care bundle
After the implementation of self-management interventions in Septem-ber 2007 the proportion of patients andtheir parents who were confident intheir ability to manage their or theiradolescentrsquos asthma (rating of $7 of10) increased from a low of 70 tosim80 This proportion increased againtosim85after the teambegan to increase
e422 BRITTO et al
FIGURE 1Percentage of patients with asthma whose condition was well controlled EPIC our electronic health record FY fiscal year
FIGURE 2Percentage of patients with asthma with asthma-related ED visits andor hospitalizations
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e423
its skill in providing self-managementsupport and planned specific inter-ventions for each adolescent with a lowscore in February 2009
Between July 2008 and August 2009 theproportion of patients receiving the re-quired self-management components (apatient self-assessment a stage-of-readiness tool and a personal actionplan if inaction) rapidly increased from0 to 86 and then remained steady atslightly less than 90 These resultscoincided with the large increase inwell-controlled patients beginning inJune 2008 (Fig 1)
Cohort of Chronically Not-Well-Controlled Patients
Of the 50 chronically not-well-controlledpatients who remained in the practice(8 left the practice ormoved away) 60
had a $2-point improvement in theirmedian modified asthma control scorein the intervention year compared withthe previous year (Fig 4)
Community Connections
Community connections were measuredby identifying patients who needed com-munityservicesandtrackingtheproportionof patients who were either referred orprovidedwith informationduringaclinicvisit By June 2011 we achieved 90reliability in our processes to addressmajor family concerns
DISCUSSION
Our quality improvement initiative isamong the first to show sustained im-provement in asthma control in ado-lescentpatients Byusing theoutcomeof
optimal asthma symptom control wetripled the proportion of patients whoachieved that level of control over thecourse of our initiative In accordancewith the Chronic Care Model4244ndash46 ourmultiple interventions focused on stan-dardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma
We used a high bar to define asthmacontrol thehighest possible scoreonourmodified asthma control score Weoriginally chose to modify the AsthmaControl Test developed by Nathan et al48
because it was not consistent with themost recent asthma guidelines from theNational Heart Lung and Blood In-stitute13 After our transition to use of an
FIGURE 3Percentage of patients with asthma rating the clinic as providing the best possible care
e424 BRITTO et al
electronic health record in March 2011we switched to using the Asthma Con-trol Test to be consistent with otherdepartments in our medical center Ini-tial results after the transition sug-gested that ourmodified score functionedsimilar to the original Asthma Control Test
Several of our interventions focused onimproving teenager and family en-gagement in their asthma care The 3self-management tools (a patient self-assessment a stage-of-readiness tooland a personal action plan) were de-signed to promote self-managementassessment and help providers talkcomfortably and productively with pa-tientsandfamiliesaboutmakingchangesnecessary to improve their health Therole of the parent coordinator served asa relatively low-cost innovation that al-lowed someone familiar with the needsand struggles of families dealing witha chronic illness to help other families
navigate the care system This valuableperson working closely with clinicianswas often able to obtain patient infor-mation that clinicians alone could notget We suspect that the parent coor-dinator herself the parent of a childwith a chronic condition could con-verse with parents as a peer ratherthan as a medical professional
We continue to work with patients whostruggle to control their asthmaWearecurrently testing interventions that usetechnology to promote active outreachand population management We arealsodevelopingnewalgorithms todrivecomanagement approaches with ourspecialist colleagues in PulmonaryMedicine and Psychology
This small group of patients withchronically poor control may also rep-resentagroupwith intrinsically difficult-to-control asthma They are now thefocus of research efforts among our
pulmonarycolleagues Inadditionwearespreadingoursuccessful interventionstoother areas of the medical center thattreat patients with chronic disease Forexample the self-management tools havebeen adapted for use with our electronichealth record and brochures describingthe5stagesofchangereadinessarewidelyused
CONCLUSIONS
Implementing interventions focused onstandardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma resulted insustained improvement in asthmacontrol in adolescent patients Addi-tional interventions are likely neededforpatientswith chronically poorasthmacontrol
FIGURE 4Cumulative percentage of chronically not-well-controlled patients (median score of 9 to 13 on ourmodified asthma control score) whose score improved by 2 points
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e425
REFERENCES
1 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2010 Vital HealthStat 10 2011(250)1ndash80
2 Akinbami LJ Moorman JE Liu X Asthmaprevalence healthcare use and mortalityUnited States 2005ndash2009 Natl Health StatRep 2011(32)1ndash14
3 Akinbami LJ Moorman JE Garbe PL SondikEJ Status of childhood asthma in theUnited States 1980-2007 Pediatrics 2009123(suppl 3)S131ndashS145
4 Bai Y Hillemeier MM Lengerich EJ Racialethnic disparities in symptom severityamong children hospitalized with asthmaJ Health Care Poor Underserved 200718(1)54ndash61
5 Flores G Snowden-Bridon C Torres S et alUrban minority children with asthmasubstantial morbidity compromised qual-ity and access to specialists and the im-portance of poverty and specialty care JAsthma 200946(4)392ndash398
6 Kitsantas P Kornides ML Cantiello J Wu HChronic physical health conditions amongchildren of different racialethnic back-grounds Public Health 2013127(6)546ndash553
7 Forrest CB Starfield B Riley AW Kang M Theimpact of asthma on the health status ofadolescents Pediatrics 199799(2) Availableat wwwpediatricsorgcgicontentfull992e1
8 Global Initiative for Asthma (GINA) Globalstrategy for asthma management andprevention Published 2010 Available atwwwginasthmaorgpdfGINA_Report_2010pdf Accessed February 22 2013
9 British Thoracic Society Scottish In-tercollegiate Guidelines Network Britishguideline on the management of asthmaa national clinical guideline PublishedJanuary 2012 Available at wwwsignacukpdfsign101pdf Accessed February 222013
10 Cincinnati Childrenrsquos Hospital Medical Cen-ter James M Anderson Center for HealthSystems Excellence Management of acute ex-acerbation of asthma in children PublishedSeptember 16 2010 Available at wwwcin-cinnatichildrensorgworkarealinkitaspxlink-identifier=idampitemid=87871amplibid=87559Accessed February 22 2013
11 Department of Veterans Affairs Departmentof Defense VADoD clinical practice guide-line for management of asthma in childrenand adults 2 Published 2009 Available atwwwhealthqualityvagovasthmaast_2_fullpdf Accessed February 22 2013
12 Institute for Clinical Systems ImprovementDiagnosis and management of asthma 9thed Published July 31 2012 Available at httpswwwicsiorgguidelines__morecatalog_guidelines_and_morecatalog_guidelinescatalog_respiratory_guidelinesasthmaAccessed February 22 2013
13 National Heart Lung and Blood InstituteNational Asthma Education and PreventionProgram Expert panel report 3 guidelinesfor the diagnosis and management ofasthma Bethesda MD US Department ofHealth and Human Services 2007 Availableat wwwnhlbinihgovguidelinesasthmaasthgdlnhtm Accessed February 22 2013
14 Registered Nursesrsquo Association of OntarioPromoting asthma control in childrenPublished 2004 Available at httprnaocabpgguidelinespromoting-asthma-control-children Accessed February 22 2013
15 Verloet D Williams AE Lloyd A Clark TJCosts of managing asthma as defined bya derived Asthma Control Test score inseven European countries Eur Respir Rev200615(98)17ndash23
16 Haselkorn T Fish JE Zeiger RS et al Con-sistently very poorly controlled asthma asdefined by the impairment domain of theExpert Panel Report 3 guidelines increasesrisk for future severe asthma exacer-bations in The Epidemiology and NaturalHistory of Asthma Outcomes and Treat-ment Regimens (TENOR) STUDY J AllergyClin Immunol 2009124(5)895ndash902 e891ndashe894
17 Scott L Morphew T Bollinger ME et alAchieving and maintaining asthma controlin inner-city children J Allergy Clin Immu-nol 2011128(1)56ndash63
18 Szefler SJ Zeiger RS Haselkorn T et alEconomic burden of impairment in chil-dren with severe or difficult-to-treatasthma Ann Allergy Asthma Immunol2011107(2)110ndash119e1
19 McMullen A Yoos HL Anson E Kitzmann HHalterman JS Arcoleo KS Asthma care ofchildren in clinical practice do parentsreport receiving appropriate educationPediatr Nurs 200733(1)37ndash44
20 Reeves MJ Bohm SR Korzeniewski SJBrown MD Asthma care and managementbefore an emergency department visit inchildren in western Michigan how welldoes care adhere to guidelines Pediatrics2006117(4 pt 2)S118ndashS126
21 Orrell-Valente JK Jones K Manasse S ThyneSM Shenkin BN Cabana MD Childrenrsquos andparentsrsquo report of asthma education received
from physicians J Asthma 201148(8)831ndash838
22 Cabana MD Chaffin DC Jarlsberg LG ThyneSM Clark NM Selective provision ofasthma self-management tools to familiesPediatrics 2008121(4) Available at wwwpediatricsorgcgicontentfull1214e900
23 Cabana MD Abu-Isa H Thyne SM Yawn BSpecialty differences in prescribing inhaledcorticosteroids for children Clin Pediatr(Phila) 200746(8)698ndash705
24 Rastogi D Shetty A Neugebauer R HarijithA National Heart Lung and Blood Instituteguidelines and asthma management prac-tices among inner-city pediatric primarycare providers Chest 2006129(3)619ndash623
25 Deis JN Spiro DM Jenkins CA Buckles TLArnold DH Parental knowledge and use ofpreventive asthma care measures in twopediatric emergency departments JAsthma 201047(5)551ndash556
26 To T Wang C Dell SD et al PAMG Team Canan evidence-based guideline reminder cardimprove asthma management in theemergency department Respir Med 2010104(9)1263ndash1270
27 Tsai CL Sullivan AF Gordon JA et al Qualityof care for acute asthma in 63 US emer-gency departments J Allergy Clin Immunol2009123(2)354ndash361
28 Knapp JF Simon SD Sharma V Quality ofcare for common pediatric respiratory ill-nesses in United States emergency depart-ments analysis of 2005 National HospitalAmbulatory Medical Care Survey Data Pe-diatrics 2008122(6)1165ndash1170
29 Sawyer S Drew S Duncan R Adolescentswith chronic diseasemdashthe double whammyAust Fam Physician 200736(8)622ndash627
30 Mangione-Smith R DeCristofaro AH SetodjiCM et al The quality of ambulatory caredelivered to children in the United StatesN Engl J Med 2007357(15)1515ndash1523
31 de Benedictis D Bush A The challenge ofasthma in adolescence Pediatr Pulmonol200742(8)683ndash692
32 Howenstine MS Eigen H Medical care ofthe adolescent with asthma Adolesc Med200011(3)501ndash519
33 Couriel J Asthma in adolescence PaediatrRespir Rev 20034(1)47ndash54
34 Staples B Bravender T Drug compliance inadolescents assessing and managingmodifiable risk factors Paediatr Drugs20024(8)503ndash513
35 Desai M Oppenheimer JJ Medication ad-herence in the asthmatic child and ado-lescent Curr Allergy Asthma Rep 201111(6)454ndash464
e426 BRITTO et al
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427
FIGURE 1Percentage of patients with asthma whose condition was well controlled EPIC our electronic health record FY fiscal year
FIGURE 2Percentage of patients with asthma with asthma-related ED visits andor hospitalizations
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e423
its skill in providing self-managementsupport and planned specific inter-ventions for each adolescent with a lowscore in February 2009
Between July 2008 and August 2009 theproportion of patients receiving the re-quired self-management components (apatient self-assessment a stage-of-readiness tool and a personal actionplan if inaction) rapidly increased from0 to 86 and then remained steady atslightly less than 90 These resultscoincided with the large increase inwell-controlled patients beginning inJune 2008 (Fig 1)
Cohort of Chronically Not-Well-Controlled Patients
Of the 50 chronically not-well-controlledpatients who remained in the practice(8 left the practice ormoved away) 60
had a $2-point improvement in theirmedian modified asthma control scorein the intervention year compared withthe previous year (Fig 4)
Community Connections
Community connections were measuredby identifying patients who needed com-munityservicesandtrackingtheproportionof patients who were either referred orprovidedwith informationduringaclinicvisit By June 2011 we achieved 90reliability in our processes to addressmajor family concerns
DISCUSSION
Our quality improvement initiative isamong the first to show sustained im-provement in asthma control in ado-lescentpatients Byusing theoutcomeof
optimal asthma symptom control wetripled the proportion of patients whoachieved that level of control over thecourse of our initiative In accordancewith the Chronic Care Model4244ndash46 ourmultiple interventions focused on stan-dardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma
We used a high bar to define asthmacontrol thehighest possible scoreonourmodified asthma control score Weoriginally chose to modify the AsthmaControl Test developed by Nathan et al48
because it was not consistent with themost recent asthma guidelines from theNational Heart Lung and Blood In-stitute13 After our transition to use of an
FIGURE 3Percentage of patients with asthma rating the clinic as providing the best possible care
e424 BRITTO et al
electronic health record in March 2011we switched to using the Asthma Con-trol Test to be consistent with otherdepartments in our medical center Ini-tial results after the transition sug-gested that ourmodified score functionedsimilar to the original Asthma Control Test
Several of our interventions focused onimproving teenager and family en-gagement in their asthma care The 3self-management tools (a patient self-assessment a stage-of-readiness tooland a personal action plan) were de-signed to promote self-managementassessment and help providers talkcomfortably and productively with pa-tientsandfamiliesaboutmakingchangesnecessary to improve their health Therole of the parent coordinator served asa relatively low-cost innovation that al-lowed someone familiar with the needsand struggles of families dealing witha chronic illness to help other families
navigate the care system This valuableperson working closely with clinicianswas often able to obtain patient infor-mation that clinicians alone could notget We suspect that the parent coor-dinator herself the parent of a childwith a chronic condition could con-verse with parents as a peer ratherthan as a medical professional
We continue to work with patients whostruggle to control their asthmaWearecurrently testing interventions that usetechnology to promote active outreachand population management We arealsodevelopingnewalgorithms todrivecomanagement approaches with ourspecialist colleagues in PulmonaryMedicine and Psychology
This small group of patients withchronically poor control may also rep-resentagroupwith intrinsically difficult-to-control asthma They are now thefocus of research efforts among our
pulmonarycolleagues Inadditionwearespreadingoursuccessful interventionstoother areas of the medical center thattreat patients with chronic disease Forexample the self-management tools havebeen adapted for use with our electronichealth record and brochures describingthe5stagesofchangereadinessarewidelyused
CONCLUSIONS
Implementing interventions focused onstandardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma resulted insustained improvement in asthmacontrol in adolescent patients Addi-tional interventions are likely neededforpatientswith chronically poorasthmacontrol
FIGURE 4Cumulative percentage of chronically not-well-controlled patients (median score of 9 to 13 on ourmodified asthma control score) whose score improved by 2 points
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e425
REFERENCES
1 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2010 Vital HealthStat 10 2011(250)1ndash80
2 Akinbami LJ Moorman JE Liu X Asthmaprevalence healthcare use and mortalityUnited States 2005ndash2009 Natl Health StatRep 2011(32)1ndash14
3 Akinbami LJ Moorman JE Garbe PL SondikEJ Status of childhood asthma in theUnited States 1980-2007 Pediatrics 2009123(suppl 3)S131ndashS145
4 Bai Y Hillemeier MM Lengerich EJ Racialethnic disparities in symptom severityamong children hospitalized with asthmaJ Health Care Poor Underserved 200718(1)54ndash61
5 Flores G Snowden-Bridon C Torres S et alUrban minority children with asthmasubstantial morbidity compromised qual-ity and access to specialists and the im-portance of poverty and specialty care JAsthma 200946(4)392ndash398
6 Kitsantas P Kornides ML Cantiello J Wu HChronic physical health conditions amongchildren of different racialethnic back-grounds Public Health 2013127(6)546ndash553
7 Forrest CB Starfield B Riley AW Kang M Theimpact of asthma on the health status ofadolescents Pediatrics 199799(2) Availableat wwwpediatricsorgcgicontentfull992e1
8 Global Initiative for Asthma (GINA) Globalstrategy for asthma management andprevention Published 2010 Available atwwwginasthmaorgpdfGINA_Report_2010pdf Accessed February 22 2013
9 British Thoracic Society Scottish In-tercollegiate Guidelines Network Britishguideline on the management of asthmaa national clinical guideline PublishedJanuary 2012 Available at wwwsignacukpdfsign101pdf Accessed February 222013
10 Cincinnati Childrenrsquos Hospital Medical Cen-ter James M Anderson Center for HealthSystems Excellence Management of acute ex-acerbation of asthma in children PublishedSeptember 16 2010 Available at wwwcin-cinnatichildrensorgworkarealinkitaspxlink-identifier=idampitemid=87871amplibid=87559Accessed February 22 2013
11 Department of Veterans Affairs Departmentof Defense VADoD clinical practice guide-line for management of asthma in childrenand adults 2 Published 2009 Available atwwwhealthqualityvagovasthmaast_2_fullpdf Accessed February 22 2013
12 Institute for Clinical Systems ImprovementDiagnosis and management of asthma 9thed Published July 31 2012 Available at httpswwwicsiorgguidelines__morecatalog_guidelines_and_morecatalog_guidelinescatalog_respiratory_guidelinesasthmaAccessed February 22 2013
13 National Heart Lung and Blood InstituteNational Asthma Education and PreventionProgram Expert panel report 3 guidelinesfor the diagnosis and management ofasthma Bethesda MD US Department ofHealth and Human Services 2007 Availableat wwwnhlbinihgovguidelinesasthmaasthgdlnhtm Accessed February 22 2013
14 Registered Nursesrsquo Association of OntarioPromoting asthma control in childrenPublished 2004 Available at httprnaocabpgguidelinespromoting-asthma-control-children Accessed February 22 2013
15 Verloet D Williams AE Lloyd A Clark TJCosts of managing asthma as defined bya derived Asthma Control Test score inseven European countries Eur Respir Rev200615(98)17ndash23
16 Haselkorn T Fish JE Zeiger RS et al Con-sistently very poorly controlled asthma asdefined by the impairment domain of theExpert Panel Report 3 guidelines increasesrisk for future severe asthma exacer-bations in The Epidemiology and NaturalHistory of Asthma Outcomes and Treat-ment Regimens (TENOR) STUDY J AllergyClin Immunol 2009124(5)895ndash902 e891ndashe894
17 Scott L Morphew T Bollinger ME et alAchieving and maintaining asthma controlin inner-city children J Allergy Clin Immu-nol 2011128(1)56ndash63
18 Szefler SJ Zeiger RS Haselkorn T et alEconomic burden of impairment in chil-dren with severe or difficult-to-treatasthma Ann Allergy Asthma Immunol2011107(2)110ndash119e1
19 McMullen A Yoos HL Anson E Kitzmann HHalterman JS Arcoleo KS Asthma care ofchildren in clinical practice do parentsreport receiving appropriate educationPediatr Nurs 200733(1)37ndash44
20 Reeves MJ Bohm SR Korzeniewski SJBrown MD Asthma care and managementbefore an emergency department visit inchildren in western Michigan how welldoes care adhere to guidelines Pediatrics2006117(4 pt 2)S118ndashS126
21 Orrell-Valente JK Jones K Manasse S ThyneSM Shenkin BN Cabana MD Childrenrsquos andparentsrsquo report of asthma education received
from physicians J Asthma 201148(8)831ndash838
22 Cabana MD Chaffin DC Jarlsberg LG ThyneSM Clark NM Selective provision ofasthma self-management tools to familiesPediatrics 2008121(4) Available at wwwpediatricsorgcgicontentfull1214e900
23 Cabana MD Abu-Isa H Thyne SM Yawn BSpecialty differences in prescribing inhaledcorticosteroids for children Clin Pediatr(Phila) 200746(8)698ndash705
24 Rastogi D Shetty A Neugebauer R HarijithA National Heart Lung and Blood Instituteguidelines and asthma management prac-tices among inner-city pediatric primarycare providers Chest 2006129(3)619ndash623
25 Deis JN Spiro DM Jenkins CA Buckles TLArnold DH Parental knowledge and use ofpreventive asthma care measures in twopediatric emergency departments JAsthma 201047(5)551ndash556
26 To T Wang C Dell SD et al PAMG Team Canan evidence-based guideline reminder cardimprove asthma management in theemergency department Respir Med 2010104(9)1263ndash1270
27 Tsai CL Sullivan AF Gordon JA et al Qualityof care for acute asthma in 63 US emer-gency departments J Allergy Clin Immunol2009123(2)354ndash361
28 Knapp JF Simon SD Sharma V Quality ofcare for common pediatric respiratory ill-nesses in United States emergency depart-ments analysis of 2005 National HospitalAmbulatory Medical Care Survey Data Pe-diatrics 2008122(6)1165ndash1170
29 Sawyer S Drew S Duncan R Adolescentswith chronic diseasemdashthe double whammyAust Fam Physician 200736(8)622ndash627
30 Mangione-Smith R DeCristofaro AH SetodjiCM et al The quality of ambulatory caredelivered to children in the United StatesN Engl J Med 2007357(15)1515ndash1523
31 de Benedictis D Bush A The challenge ofasthma in adolescence Pediatr Pulmonol200742(8)683ndash692
32 Howenstine MS Eigen H Medical care ofthe adolescent with asthma Adolesc Med200011(3)501ndash519
33 Couriel J Asthma in adolescence PaediatrRespir Rev 20034(1)47ndash54
34 Staples B Bravender T Drug compliance inadolescents assessing and managingmodifiable risk factors Paediatr Drugs20024(8)503ndash513
35 Desai M Oppenheimer JJ Medication ad-herence in the asthmatic child and ado-lescent Curr Allergy Asthma Rep 201111(6)454ndash464
e426 BRITTO et al
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427
its skill in providing self-managementsupport and planned specific inter-ventions for each adolescent with a lowscore in February 2009
Between July 2008 and August 2009 theproportion of patients receiving the re-quired self-management components (apatient self-assessment a stage-of-readiness tool and a personal actionplan if inaction) rapidly increased from0 to 86 and then remained steady atslightly less than 90 These resultscoincided with the large increase inwell-controlled patients beginning inJune 2008 (Fig 1)
Cohort of Chronically Not-Well-Controlled Patients
Of the 50 chronically not-well-controlledpatients who remained in the practice(8 left the practice ormoved away) 60
had a $2-point improvement in theirmedian modified asthma control scorein the intervention year compared withthe previous year (Fig 4)
Community Connections
Community connections were measuredby identifying patients who needed com-munityservicesandtrackingtheproportionof patients who were either referred orprovidedwith informationduringaclinicvisit By June 2011 we achieved 90reliability in our processes to addressmajor family concerns
DISCUSSION
Our quality improvement initiative isamong the first to show sustained im-provement in asthma control in ado-lescentpatients Byusing theoutcomeof
optimal asthma symptom control wetripled the proportion of patients whoachieved that level of control over thecourse of our initiative In accordancewith the Chronic Care Model4244ndash46 ourmultiple interventions focused on stan-dardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma
We used a high bar to define asthmacontrol thehighest possible scoreonourmodified asthma control score Weoriginally chose to modify the AsthmaControl Test developed by Nathan et al48
because it was not consistent with themost recent asthma guidelines from theNational Heart Lung and Blood In-stitute13 After our transition to use of an
FIGURE 3Percentage of patients with asthma rating the clinic as providing the best possible care
e424 BRITTO et al
electronic health record in March 2011we switched to using the Asthma Con-trol Test to be consistent with otherdepartments in our medical center Ini-tial results after the transition sug-gested that ourmodified score functionedsimilar to the original Asthma Control Test
Several of our interventions focused onimproving teenager and family en-gagement in their asthma care The 3self-management tools (a patient self-assessment a stage-of-readiness tooland a personal action plan) were de-signed to promote self-managementassessment and help providers talkcomfortably and productively with pa-tientsandfamiliesaboutmakingchangesnecessary to improve their health Therole of the parent coordinator served asa relatively low-cost innovation that al-lowed someone familiar with the needsand struggles of families dealing witha chronic illness to help other families
navigate the care system This valuableperson working closely with clinicianswas often able to obtain patient infor-mation that clinicians alone could notget We suspect that the parent coor-dinator herself the parent of a childwith a chronic condition could con-verse with parents as a peer ratherthan as a medical professional
We continue to work with patients whostruggle to control their asthmaWearecurrently testing interventions that usetechnology to promote active outreachand population management We arealsodevelopingnewalgorithms todrivecomanagement approaches with ourspecialist colleagues in PulmonaryMedicine and Psychology
This small group of patients withchronically poor control may also rep-resentagroupwith intrinsically difficult-to-control asthma They are now thefocus of research efforts among our
pulmonarycolleagues Inadditionwearespreadingoursuccessful interventionstoother areas of the medical center thattreat patients with chronic disease Forexample the self-management tools havebeen adapted for use with our electronichealth record and brochures describingthe5stagesofchangereadinessarewidelyused
CONCLUSIONS
Implementing interventions focused onstandardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma resulted insustained improvement in asthmacontrol in adolescent patients Addi-tional interventions are likely neededforpatientswith chronically poorasthmacontrol
FIGURE 4Cumulative percentage of chronically not-well-controlled patients (median score of 9 to 13 on ourmodified asthma control score) whose score improved by 2 points
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e425
REFERENCES
1 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2010 Vital HealthStat 10 2011(250)1ndash80
2 Akinbami LJ Moorman JE Liu X Asthmaprevalence healthcare use and mortalityUnited States 2005ndash2009 Natl Health StatRep 2011(32)1ndash14
3 Akinbami LJ Moorman JE Garbe PL SondikEJ Status of childhood asthma in theUnited States 1980-2007 Pediatrics 2009123(suppl 3)S131ndashS145
4 Bai Y Hillemeier MM Lengerich EJ Racialethnic disparities in symptom severityamong children hospitalized with asthmaJ Health Care Poor Underserved 200718(1)54ndash61
5 Flores G Snowden-Bridon C Torres S et alUrban minority children with asthmasubstantial morbidity compromised qual-ity and access to specialists and the im-portance of poverty and specialty care JAsthma 200946(4)392ndash398
6 Kitsantas P Kornides ML Cantiello J Wu HChronic physical health conditions amongchildren of different racialethnic back-grounds Public Health 2013127(6)546ndash553
7 Forrest CB Starfield B Riley AW Kang M Theimpact of asthma on the health status ofadolescents Pediatrics 199799(2) Availableat wwwpediatricsorgcgicontentfull992e1
8 Global Initiative for Asthma (GINA) Globalstrategy for asthma management andprevention Published 2010 Available atwwwginasthmaorgpdfGINA_Report_2010pdf Accessed February 22 2013
9 British Thoracic Society Scottish In-tercollegiate Guidelines Network Britishguideline on the management of asthmaa national clinical guideline PublishedJanuary 2012 Available at wwwsignacukpdfsign101pdf Accessed February 222013
10 Cincinnati Childrenrsquos Hospital Medical Cen-ter James M Anderson Center for HealthSystems Excellence Management of acute ex-acerbation of asthma in children PublishedSeptember 16 2010 Available at wwwcin-cinnatichildrensorgworkarealinkitaspxlink-identifier=idampitemid=87871amplibid=87559Accessed February 22 2013
11 Department of Veterans Affairs Departmentof Defense VADoD clinical practice guide-line for management of asthma in childrenand adults 2 Published 2009 Available atwwwhealthqualityvagovasthmaast_2_fullpdf Accessed February 22 2013
12 Institute for Clinical Systems ImprovementDiagnosis and management of asthma 9thed Published July 31 2012 Available at httpswwwicsiorgguidelines__morecatalog_guidelines_and_morecatalog_guidelinescatalog_respiratory_guidelinesasthmaAccessed February 22 2013
13 National Heart Lung and Blood InstituteNational Asthma Education and PreventionProgram Expert panel report 3 guidelinesfor the diagnosis and management ofasthma Bethesda MD US Department ofHealth and Human Services 2007 Availableat wwwnhlbinihgovguidelinesasthmaasthgdlnhtm Accessed February 22 2013
14 Registered Nursesrsquo Association of OntarioPromoting asthma control in childrenPublished 2004 Available at httprnaocabpgguidelinespromoting-asthma-control-children Accessed February 22 2013
15 Verloet D Williams AE Lloyd A Clark TJCosts of managing asthma as defined bya derived Asthma Control Test score inseven European countries Eur Respir Rev200615(98)17ndash23
16 Haselkorn T Fish JE Zeiger RS et al Con-sistently very poorly controlled asthma asdefined by the impairment domain of theExpert Panel Report 3 guidelines increasesrisk for future severe asthma exacer-bations in The Epidemiology and NaturalHistory of Asthma Outcomes and Treat-ment Regimens (TENOR) STUDY J AllergyClin Immunol 2009124(5)895ndash902 e891ndashe894
17 Scott L Morphew T Bollinger ME et alAchieving and maintaining asthma controlin inner-city children J Allergy Clin Immu-nol 2011128(1)56ndash63
18 Szefler SJ Zeiger RS Haselkorn T et alEconomic burden of impairment in chil-dren with severe or difficult-to-treatasthma Ann Allergy Asthma Immunol2011107(2)110ndash119e1
19 McMullen A Yoos HL Anson E Kitzmann HHalterman JS Arcoleo KS Asthma care ofchildren in clinical practice do parentsreport receiving appropriate educationPediatr Nurs 200733(1)37ndash44
20 Reeves MJ Bohm SR Korzeniewski SJBrown MD Asthma care and managementbefore an emergency department visit inchildren in western Michigan how welldoes care adhere to guidelines Pediatrics2006117(4 pt 2)S118ndashS126
21 Orrell-Valente JK Jones K Manasse S ThyneSM Shenkin BN Cabana MD Childrenrsquos andparentsrsquo report of asthma education received
from physicians J Asthma 201148(8)831ndash838
22 Cabana MD Chaffin DC Jarlsberg LG ThyneSM Clark NM Selective provision ofasthma self-management tools to familiesPediatrics 2008121(4) Available at wwwpediatricsorgcgicontentfull1214e900
23 Cabana MD Abu-Isa H Thyne SM Yawn BSpecialty differences in prescribing inhaledcorticosteroids for children Clin Pediatr(Phila) 200746(8)698ndash705
24 Rastogi D Shetty A Neugebauer R HarijithA National Heart Lung and Blood Instituteguidelines and asthma management prac-tices among inner-city pediatric primarycare providers Chest 2006129(3)619ndash623
25 Deis JN Spiro DM Jenkins CA Buckles TLArnold DH Parental knowledge and use ofpreventive asthma care measures in twopediatric emergency departments JAsthma 201047(5)551ndash556
26 To T Wang C Dell SD et al PAMG Team Canan evidence-based guideline reminder cardimprove asthma management in theemergency department Respir Med 2010104(9)1263ndash1270
27 Tsai CL Sullivan AF Gordon JA et al Qualityof care for acute asthma in 63 US emer-gency departments J Allergy Clin Immunol2009123(2)354ndash361
28 Knapp JF Simon SD Sharma V Quality ofcare for common pediatric respiratory ill-nesses in United States emergency depart-ments analysis of 2005 National HospitalAmbulatory Medical Care Survey Data Pe-diatrics 2008122(6)1165ndash1170
29 Sawyer S Drew S Duncan R Adolescentswith chronic diseasemdashthe double whammyAust Fam Physician 200736(8)622ndash627
30 Mangione-Smith R DeCristofaro AH SetodjiCM et al The quality of ambulatory caredelivered to children in the United StatesN Engl J Med 2007357(15)1515ndash1523
31 de Benedictis D Bush A The challenge ofasthma in adolescence Pediatr Pulmonol200742(8)683ndash692
32 Howenstine MS Eigen H Medical care ofthe adolescent with asthma Adolesc Med200011(3)501ndash519
33 Couriel J Asthma in adolescence PaediatrRespir Rev 20034(1)47ndash54
34 Staples B Bravender T Drug compliance inadolescents assessing and managingmodifiable risk factors Paediatr Drugs20024(8)503ndash513
35 Desai M Oppenheimer JJ Medication ad-herence in the asthmatic child and ado-lescent Curr Allergy Asthma Rep 201111(6)454ndash464
e426 BRITTO et al
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427
electronic health record in March 2011we switched to using the Asthma Con-trol Test to be consistent with otherdepartments in our medical center Ini-tial results after the transition sug-gested that ourmodified score functionedsimilar to the original Asthma Control Test
Several of our interventions focused onimproving teenager and family en-gagement in their asthma care The 3self-management tools (a patient self-assessment a stage-of-readiness tooland a personal action plan) were de-signed to promote self-managementassessment and help providers talkcomfortably and productively with pa-tientsandfamiliesaboutmakingchangesnecessary to improve their health Therole of the parent coordinator served asa relatively low-cost innovation that al-lowed someone familiar with the needsand struggles of families dealing witha chronic illness to help other families
navigate the care system This valuableperson working closely with clinicianswas often able to obtain patient infor-mation that clinicians alone could notget We suspect that the parent coor-dinator herself the parent of a childwith a chronic condition could con-verse with parents as a peer ratherthan as a medical professional
We continue to work with patients whostruggle to control their asthmaWearecurrently testing interventions that usetechnology to promote active outreachand population management We arealsodevelopingnewalgorithms todrivecomanagement approaches with ourspecialist colleagues in PulmonaryMedicine and Psychology
This small group of patients withchronically poor control may also rep-resentagroupwith intrinsically difficult-to-control asthma They are now thefocus of research efforts among our
pulmonarycolleagues Inadditionwearespreadingoursuccessful interventionstoother areas of the medical center thattreat patients with chronic disease Forexample the self-management tools havebeen adapted for use with our electronichealth record and brochures describingthe5stagesofchangereadinessarewidelyused
CONCLUSIONS
Implementing interventions focused onstandardized and evidence-based careself-management support care co-ordination and active outreach linkageto community resources and enhancedfollow-up for patients with chronicallynot-well-controlled asthma resulted insustained improvement in asthmacontrol in adolescent patients Addi-tional interventions are likely neededforpatientswith chronically poorasthmacontrol
FIGURE 4Cumulative percentage of chronically not-well-controlled patients (median score of 9 to 13 on ourmodified asthma control score) whose score improved by 2 points
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e425
REFERENCES
1 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2010 Vital HealthStat 10 2011(250)1ndash80
2 Akinbami LJ Moorman JE Liu X Asthmaprevalence healthcare use and mortalityUnited States 2005ndash2009 Natl Health StatRep 2011(32)1ndash14
3 Akinbami LJ Moorman JE Garbe PL SondikEJ Status of childhood asthma in theUnited States 1980-2007 Pediatrics 2009123(suppl 3)S131ndashS145
4 Bai Y Hillemeier MM Lengerich EJ Racialethnic disparities in symptom severityamong children hospitalized with asthmaJ Health Care Poor Underserved 200718(1)54ndash61
5 Flores G Snowden-Bridon C Torres S et alUrban minority children with asthmasubstantial morbidity compromised qual-ity and access to specialists and the im-portance of poverty and specialty care JAsthma 200946(4)392ndash398
6 Kitsantas P Kornides ML Cantiello J Wu HChronic physical health conditions amongchildren of different racialethnic back-grounds Public Health 2013127(6)546ndash553
7 Forrest CB Starfield B Riley AW Kang M Theimpact of asthma on the health status ofadolescents Pediatrics 199799(2) Availableat wwwpediatricsorgcgicontentfull992e1
8 Global Initiative for Asthma (GINA) Globalstrategy for asthma management andprevention Published 2010 Available atwwwginasthmaorgpdfGINA_Report_2010pdf Accessed February 22 2013
9 British Thoracic Society Scottish In-tercollegiate Guidelines Network Britishguideline on the management of asthmaa national clinical guideline PublishedJanuary 2012 Available at wwwsignacukpdfsign101pdf Accessed February 222013
10 Cincinnati Childrenrsquos Hospital Medical Cen-ter James M Anderson Center for HealthSystems Excellence Management of acute ex-acerbation of asthma in children PublishedSeptember 16 2010 Available at wwwcin-cinnatichildrensorgworkarealinkitaspxlink-identifier=idampitemid=87871amplibid=87559Accessed February 22 2013
11 Department of Veterans Affairs Departmentof Defense VADoD clinical practice guide-line for management of asthma in childrenand adults 2 Published 2009 Available atwwwhealthqualityvagovasthmaast_2_fullpdf Accessed February 22 2013
12 Institute for Clinical Systems ImprovementDiagnosis and management of asthma 9thed Published July 31 2012 Available at httpswwwicsiorgguidelines__morecatalog_guidelines_and_morecatalog_guidelinescatalog_respiratory_guidelinesasthmaAccessed February 22 2013
13 National Heart Lung and Blood InstituteNational Asthma Education and PreventionProgram Expert panel report 3 guidelinesfor the diagnosis and management ofasthma Bethesda MD US Department ofHealth and Human Services 2007 Availableat wwwnhlbinihgovguidelinesasthmaasthgdlnhtm Accessed February 22 2013
14 Registered Nursesrsquo Association of OntarioPromoting asthma control in childrenPublished 2004 Available at httprnaocabpgguidelinespromoting-asthma-control-children Accessed February 22 2013
15 Verloet D Williams AE Lloyd A Clark TJCosts of managing asthma as defined bya derived Asthma Control Test score inseven European countries Eur Respir Rev200615(98)17ndash23
16 Haselkorn T Fish JE Zeiger RS et al Con-sistently very poorly controlled asthma asdefined by the impairment domain of theExpert Panel Report 3 guidelines increasesrisk for future severe asthma exacer-bations in The Epidemiology and NaturalHistory of Asthma Outcomes and Treat-ment Regimens (TENOR) STUDY J AllergyClin Immunol 2009124(5)895ndash902 e891ndashe894
17 Scott L Morphew T Bollinger ME et alAchieving and maintaining asthma controlin inner-city children J Allergy Clin Immu-nol 2011128(1)56ndash63
18 Szefler SJ Zeiger RS Haselkorn T et alEconomic burden of impairment in chil-dren with severe or difficult-to-treatasthma Ann Allergy Asthma Immunol2011107(2)110ndash119e1
19 McMullen A Yoos HL Anson E Kitzmann HHalterman JS Arcoleo KS Asthma care ofchildren in clinical practice do parentsreport receiving appropriate educationPediatr Nurs 200733(1)37ndash44
20 Reeves MJ Bohm SR Korzeniewski SJBrown MD Asthma care and managementbefore an emergency department visit inchildren in western Michigan how welldoes care adhere to guidelines Pediatrics2006117(4 pt 2)S118ndashS126
21 Orrell-Valente JK Jones K Manasse S ThyneSM Shenkin BN Cabana MD Childrenrsquos andparentsrsquo report of asthma education received
from physicians J Asthma 201148(8)831ndash838
22 Cabana MD Chaffin DC Jarlsberg LG ThyneSM Clark NM Selective provision ofasthma self-management tools to familiesPediatrics 2008121(4) Available at wwwpediatricsorgcgicontentfull1214e900
23 Cabana MD Abu-Isa H Thyne SM Yawn BSpecialty differences in prescribing inhaledcorticosteroids for children Clin Pediatr(Phila) 200746(8)698ndash705
24 Rastogi D Shetty A Neugebauer R HarijithA National Heart Lung and Blood Instituteguidelines and asthma management prac-tices among inner-city pediatric primarycare providers Chest 2006129(3)619ndash623
25 Deis JN Spiro DM Jenkins CA Buckles TLArnold DH Parental knowledge and use ofpreventive asthma care measures in twopediatric emergency departments JAsthma 201047(5)551ndash556
26 To T Wang C Dell SD et al PAMG Team Canan evidence-based guideline reminder cardimprove asthma management in theemergency department Respir Med 2010104(9)1263ndash1270
27 Tsai CL Sullivan AF Gordon JA et al Qualityof care for acute asthma in 63 US emer-gency departments J Allergy Clin Immunol2009123(2)354ndash361
28 Knapp JF Simon SD Sharma V Quality ofcare for common pediatric respiratory ill-nesses in United States emergency depart-ments analysis of 2005 National HospitalAmbulatory Medical Care Survey Data Pe-diatrics 2008122(6)1165ndash1170
29 Sawyer S Drew S Duncan R Adolescentswith chronic diseasemdashthe double whammyAust Fam Physician 200736(8)622ndash627
30 Mangione-Smith R DeCristofaro AH SetodjiCM et al The quality of ambulatory caredelivered to children in the United StatesN Engl J Med 2007357(15)1515ndash1523
31 de Benedictis D Bush A The challenge ofasthma in adolescence Pediatr Pulmonol200742(8)683ndash692
32 Howenstine MS Eigen H Medical care ofthe adolescent with asthma Adolesc Med200011(3)501ndash519
33 Couriel J Asthma in adolescence PaediatrRespir Rev 20034(1)47ndash54
34 Staples B Bravender T Drug compliance inadolescents assessing and managingmodifiable risk factors Paediatr Drugs20024(8)503ndash513
35 Desai M Oppenheimer JJ Medication ad-herence in the asthmatic child and ado-lescent Curr Allergy Asthma Rep 201111(6)454ndash464
e426 BRITTO et al
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427
REFERENCES
1 Bloom B Cohen RA Freeman G Summaryhealth statistics for US children NationalHealth Interview Survey 2010 Vital HealthStat 10 2011(250)1ndash80
2 Akinbami LJ Moorman JE Liu X Asthmaprevalence healthcare use and mortalityUnited States 2005ndash2009 Natl Health StatRep 2011(32)1ndash14
3 Akinbami LJ Moorman JE Garbe PL SondikEJ Status of childhood asthma in theUnited States 1980-2007 Pediatrics 2009123(suppl 3)S131ndashS145
4 Bai Y Hillemeier MM Lengerich EJ Racialethnic disparities in symptom severityamong children hospitalized with asthmaJ Health Care Poor Underserved 200718(1)54ndash61
5 Flores G Snowden-Bridon C Torres S et alUrban minority children with asthmasubstantial morbidity compromised qual-ity and access to specialists and the im-portance of poverty and specialty care JAsthma 200946(4)392ndash398
6 Kitsantas P Kornides ML Cantiello J Wu HChronic physical health conditions amongchildren of different racialethnic back-grounds Public Health 2013127(6)546ndash553
7 Forrest CB Starfield B Riley AW Kang M Theimpact of asthma on the health status ofadolescents Pediatrics 199799(2) Availableat wwwpediatricsorgcgicontentfull992e1
8 Global Initiative for Asthma (GINA) Globalstrategy for asthma management andprevention Published 2010 Available atwwwginasthmaorgpdfGINA_Report_2010pdf Accessed February 22 2013
9 British Thoracic Society Scottish In-tercollegiate Guidelines Network Britishguideline on the management of asthmaa national clinical guideline PublishedJanuary 2012 Available at wwwsignacukpdfsign101pdf Accessed February 222013
10 Cincinnati Childrenrsquos Hospital Medical Cen-ter James M Anderson Center for HealthSystems Excellence Management of acute ex-acerbation of asthma in children PublishedSeptember 16 2010 Available at wwwcin-cinnatichildrensorgworkarealinkitaspxlink-identifier=idampitemid=87871amplibid=87559Accessed February 22 2013
11 Department of Veterans Affairs Departmentof Defense VADoD clinical practice guide-line for management of asthma in childrenand adults 2 Published 2009 Available atwwwhealthqualityvagovasthmaast_2_fullpdf Accessed February 22 2013
12 Institute for Clinical Systems ImprovementDiagnosis and management of asthma 9thed Published July 31 2012 Available at httpswwwicsiorgguidelines__morecatalog_guidelines_and_morecatalog_guidelinescatalog_respiratory_guidelinesasthmaAccessed February 22 2013
13 National Heart Lung and Blood InstituteNational Asthma Education and PreventionProgram Expert panel report 3 guidelinesfor the diagnosis and management ofasthma Bethesda MD US Department ofHealth and Human Services 2007 Availableat wwwnhlbinihgovguidelinesasthmaasthgdlnhtm Accessed February 22 2013
14 Registered Nursesrsquo Association of OntarioPromoting asthma control in childrenPublished 2004 Available at httprnaocabpgguidelinespromoting-asthma-control-children Accessed February 22 2013
15 Verloet D Williams AE Lloyd A Clark TJCosts of managing asthma as defined bya derived Asthma Control Test score inseven European countries Eur Respir Rev200615(98)17ndash23
16 Haselkorn T Fish JE Zeiger RS et al Con-sistently very poorly controlled asthma asdefined by the impairment domain of theExpert Panel Report 3 guidelines increasesrisk for future severe asthma exacer-bations in The Epidemiology and NaturalHistory of Asthma Outcomes and Treat-ment Regimens (TENOR) STUDY J AllergyClin Immunol 2009124(5)895ndash902 e891ndashe894
17 Scott L Morphew T Bollinger ME et alAchieving and maintaining asthma controlin inner-city children J Allergy Clin Immu-nol 2011128(1)56ndash63
18 Szefler SJ Zeiger RS Haselkorn T et alEconomic burden of impairment in chil-dren with severe or difficult-to-treatasthma Ann Allergy Asthma Immunol2011107(2)110ndash119e1
19 McMullen A Yoos HL Anson E Kitzmann HHalterman JS Arcoleo KS Asthma care ofchildren in clinical practice do parentsreport receiving appropriate educationPediatr Nurs 200733(1)37ndash44
20 Reeves MJ Bohm SR Korzeniewski SJBrown MD Asthma care and managementbefore an emergency department visit inchildren in western Michigan how welldoes care adhere to guidelines Pediatrics2006117(4 pt 2)S118ndashS126
21 Orrell-Valente JK Jones K Manasse S ThyneSM Shenkin BN Cabana MD Childrenrsquos andparentsrsquo report of asthma education received
from physicians J Asthma 201148(8)831ndash838
22 Cabana MD Chaffin DC Jarlsberg LG ThyneSM Clark NM Selective provision ofasthma self-management tools to familiesPediatrics 2008121(4) Available at wwwpediatricsorgcgicontentfull1214e900
23 Cabana MD Abu-Isa H Thyne SM Yawn BSpecialty differences in prescribing inhaledcorticosteroids for children Clin Pediatr(Phila) 200746(8)698ndash705
24 Rastogi D Shetty A Neugebauer R HarijithA National Heart Lung and Blood Instituteguidelines and asthma management prac-tices among inner-city pediatric primarycare providers Chest 2006129(3)619ndash623
25 Deis JN Spiro DM Jenkins CA Buckles TLArnold DH Parental knowledge and use ofpreventive asthma care measures in twopediatric emergency departments JAsthma 201047(5)551ndash556
26 To T Wang C Dell SD et al PAMG Team Canan evidence-based guideline reminder cardimprove asthma management in theemergency department Respir Med 2010104(9)1263ndash1270
27 Tsai CL Sullivan AF Gordon JA et al Qualityof care for acute asthma in 63 US emer-gency departments J Allergy Clin Immunol2009123(2)354ndash361
28 Knapp JF Simon SD Sharma V Quality ofcare for common pediatric respiratory ill-nesses in United States emergency depart-ments analysis of 2005 National HospitalAmbulatory Medical Care Survey Data Pe-diatrics 2008122(6)1165ndash1170
29 Sawyer S Drew S Duncan R Adolescentswith chronic diseasemdashthe double whammyAust Fam Physician 200736(8)622ndash627
30 Mangione-Smith R DeCristofaro AH SetodjiCM et al The quality of ambulatory caredelivered to children in the United StatesN Engl J Med 2007357(15)1515ndash1523
31 de Benedictis D Bush A The challenge ofasthma in adolescence Pediatr Pulmonol200742(8)683ndash692
32 Howenstine MS Eigen H Medical care ofthe adolescent with asthma Adolesc Med200011(3)501ndash519
33 Couriel J Asthma in adolescence PaediatrRespir Rev 20034(1)47ndash54
34 Staples B Bravender T Drug compliance inadolescents assessing and managingmodifiable risk factors Paediatr Drugs20024(8)503ndash513
35 Desai M Oppenheimer JJ Medication ad-herence in the asthmatic child and ado-lescent Curr Allergy Asthma Rep 201111(6)454ndash464
e426 BRITTO et al
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427
36 Naimi DR Freedman TG Ginsburg KRBogen D Rand CS Apter AJ Adolescentsand asthma why bother with our meds JAllergy Clin Immunol 2009123(6)1335ndash1341
37 McQuaid EL Kopel SJ Klein RB Fritz GKMedication adherence in pediatric asthmareasoning responsibility and behavior JPediatr Psychol 200328(5)323ndash333
38 Rohan J Drotar D McNally K et al Adher-ence to pediatric asthma treatment in eco-nomically disadvantaged African-Americanchildren and adolescents an application ofgrowth curve analysis J Pediatr Psychol201035(4)394ndash404
39 Committee on Identifying Priority Areas forQuality Improvement Board on Health CareServices Priority Areas for National ActionTransforming Health Care Quality Wash-ington DC National Academies Press 2003
40 Wolf FM Guevara JP Grum CM Clark NMCates CJ Educational interventions forasthma in children Cochrane DatabaseSyst Rev 2003(1)CD000326
41 Bravata DM Gienger AL Holty JE et alQuality improvement strategies for chil-dren with asthma a systematic reviewArch Pediatr Adolesc Med 2009163(6)572ndash581
42 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness JAMA 2002288(14)1775ndash1779
43 Bodenheimer T Wagner EH Grumbach KImproving primary care for patients withchronic illness the chronic care modelpart 2 JAMA 2002288(15)1909ndash1914
44 Wagner EH Chronic disease managementwhat will it take to improve care forchronic illness Eff Clin Pract 19981(1)2ndash4
45 Wagner EH Austin BT Davis C HindmarshM Schaefer J Bonomi A Improving chronicillness care translating evidence into ac-tion Health Aff (Millwood) 200120(6)64ndash78
46 Wagner EH Austin BT Von Korff M Orga-nizing care for patients with chronic ill-ness Milbank Q 199674(4)511ndash544
47 Britto MT Munafo JK Schoettker PJ VockellAL Wimberg JA Yi MS Pilot and feasibilitytest of adolescent-controlled text messag-ing reminders Clin Pediatr (Phila) 201251(2)114ndash121
48 Nathan RA Sorkness CA Kosinski M et alDevelopment of the asthma control testa survey for assessing asthma control JAllergy Clin Immunol 2004113(1)59ndash65
49 US Department of Health and HumanServices Agency for Healthcare Researchand Quality Consumer Assessment ofHealthcare Providers and Systems(CAHPS) Available at wwwcahpsahrqgov Accessed February 22 2013
50 Lorig K Chastain RL Ung E Shoor S HolmanHR Development and evaluation of a scaleto measure perceived self-efficacy in peoplewith arthritis Arthritis Rheum 198932(1)37ndash44
51 Langley GJ Moen RD Nolan KM Nolan TWNorman CL Provost LP The ImprovementGuide A Practical Approach to EnhancingOrganizational Performance 2nd ed SanFrancisco CA Jossey-Bass 2009
52 Dorr DA Wilcox A Burns L Brunker CPNarus SP Clayton PD Implementing a mul-tidisease chronic care model in primarycare using people and technology DisManag 20069(1)1ndash15
53 Dorr DA Wilcox A Donnelly SM Burns LClayton PD Impact of generalist caremanagers on patients with diabetes HealthServ Res 200540(5 pt 1)1400ndash1421
54 Spielberger CD State-Trait Anxiety In-ventory for Children Palo Alto CA Consul-ting Psychologists Press 1973
55 Wilcox AB Jones SS Dorr DA et al Use andimpact of a computer-generated patientsummary worksheet for primary careAMIA Annu Symp Proc 2005824ndash828
56 Britto MT Byczkowski TL Hesse EA MunafoJK Vockell AL Yi MS Overestimation ofimpairment-related asthma control byadolescents J Pediatr 2011158(6)1028ndash1030 e1
57 Schatz M Sorkness CA Li JT et al AsthmaControl Test reliability validity and re-sponsiveness in patients not previouslyfollowed by asthma specialists J AllergyClin Immunol 2006117(3)549ndash556
58 Corbin J Strauss A Unending Work andCare Managing Chronic Illness at HomeSan Francisco CA Jossey-Bass 1988
59 Rollnick S Allison J Ballasiotes S et alVariations on a theme motivationalinterviewing and its adaptations InMiller W Rollnick S eds MotivationalInterviewing Preparing People forChange 2nd ed New York NY GuilfordPress 2002270ndash283
60 Rubak S Sandbaek A Lauritzen T ChristensenB Motivational interviewing a systematic re-view and meta-analysis Br J Gen Pract 200555(513)305ndash312
61 Logan D Zelikovsky N Labay L Spergel JThe Illness Management Survey identifyingadolescentsrsquo perceptions of barriers toadherence J Pediatr Psychol 200328(6)383ndash392
62 Cincinnati Childrenrsquos Hospital Medical CenterJames M Anderson Center for Health SystemsExcellence Chronic care self-managementAvailable at wwwcincinnatichildrensorgservicejanderson-centerevidence-based-carerecommendationsdefault AccessedFebruary 22 2013
63 Amin SG Control charts 101 a guide tohealth care applications Qual ManagHealth Care 20019(3)1ndash27
64 Benneyan JC Lloyd RC Plsek PE Statisticalprocess control as a tool for research andhealthcare improvement Qual Saf HealthCare 200312(6)458ndash464
QUALITY REPORT
PEDIATRICS Volume 133 Number 2 February 2014 e427