Quality Improvement Initiative for the Severity Classification of Pediatric Asthma Patients in a Community Health Center Lauren Sheard MD Candidate 2016, University of Illinois at Chicago College of Medicine GE-NMF Primary Care Leadership Program Matthew Walker Comprehensive Health Center- Nashville, TN. August 2013
Asthma in Childhood “ Asthma in childhood is a disease characterized by wide variations over short periods of time in resistance to flow in intrapulmonary airways. Asthma is marked by recurrent attacks of cough or wheeze separated by symptom free intervals varying in length. The airflow obstruction and clinical symptoms are largely or completely reversed by treatment with bronchodilator drugs or steroids.” Godfrey, S. (1985). What is Asthma? Archives of Disease in Childhood. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1777622/pdf/archdisch00716-0009.pdf.
Introduction • More than 22 million Americans have asthma, and asthma is one of the most common chronic diseases of childhood, affecting an estimated 6 million children (*7.1 million) • Asthma related symptoms can gravely impact quality of life and place limits on those affected • Non-Hispanic black children were more likely to have ever been diagnosed with asthma (21%) and to still have asthma (16%) than Hispanic (15% and 10%) or non-Hispanic white (12% and 8%) children. • Children in poor families were more likely to have ever been diagnosed with asthma (18%) or to still have asthma (13%) than children in families that were not poor (12% and 8%). -------------------------------------------------------------------------------------------------------------- National Heart Lung and Blood Institute- NHLBI (2007). Guidelines for Diagnosis and Management of Asthma. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf. US Depart of Health and Human Services: Centers for Disease Control and Prevention (2012). Summary Health Statistics for US Children : National Health Interview Survey 2011, Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/sr10_254.pdf.
NHLBI Guidelines for Diagnosis & Management of Asthma FOUR COMPONENTS OF CARE 1) Assessment and Monitoring • Severity • Control • Responsiveness to treatment 2) Education 3) Control of Environmental Factors and Comorbid conditions 4) Medications / Therapies National Heart Lung and Blood Institute- NHLBI (2007). Guidelines for Diagnosis and Management of Asthma. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf.
Assessment sment of asthma ma severi rity ty is cru rucia ial in properly rly evaluating uating a patient’s experience of asthma and following up with h the clinical ical decisions sions that t will most likely y lead to positi tive health h outcomes. s. How to Assess Asthma Severity:
Background • Importance of lung function test results in most accurate asthma severity classification (Bacharier 2004, Nguyen 1996, Stout 2006) • 2002, Rochester, NY Study: Urban youth more likely to be under classified and under treated when it comes to asthma severity (Halterman 2002)
Objectives • To o com ompare are pedi diat atric ic asthma hma preval alenc ence in a Comm mmuni nity ty Health th Center er (MWCH WCHC) C) to state-wide ide preval alenc ence e of pediat atri ric c asthm hma • To o det eterm ermine ine the propor orti tion on of indivi ividual duals s un under der the e age of 19 with h asthma hma within thin a CHC (MWCH WCHC) C) system m whose ose asthma hma sever erit ity y has been een or can be classif sified ied accor ordin ding to NHLB LBI I asthma hma severit erity y classific icat ation ions for r childr ldren en • To o det eterm ermine ine the incide denc nce rate e of emergen ergency cy depar partm tmen ent t visits ts per patien ent t in the e 12 mon onths ths prior r to the e start t of this s asthm hma Quality ty Impr mprovem ement ent initia iativ tive e for children ldren with h asthma hma being ing treated d at the e CHC under der revie iew (MWCH CHC) C)
Methodology & Results 1 To compare pediatric asthma prevalence in a Community Health Center (MWCHC) to state-wide prevalence of pediatric asthma • Step #1: Using information obtained from the Health Resources and Service Administration Uniform Data System report (HRSA UDS) from 2012, the first goal was to determine the total number of patients under the age of 19 (born during or after the year 1994) seen, for any reason, at either of the three Matthew Walker CHCs across the state of Tennessee • 5 ,034 patie ient nts s under 19 seen, n, for any reason, n, at MWCHC C in 2012 • Step #2: Using this figure, the next goal was to determine how many of those patients possessed an asthma diagnosis • 173 patie ients ts with h asthma hma under r 19 seen at MWCH CHC C in 2012 • Step #3: Calculate the proportion of patients under 19 with asthma seen at MW during 2012 • 173/5, 5,034 34= = 3.5 % of the patie ients ts seen n at MWCHC C in 2012 had an asthma hma diagnos osis s
Methodology & Results 2 To determine the proportion of individuals under the age of 19 with asthma within a CHC (MWCHC) system whose asthma severity has been or can be classified according to NHLBI asthma severity classifications for children • Step #1: To obtain patient info for identified sample set (173) • Step #2: To extract the following information from patient charts • Patient ID # • DOB • Freq. of use of B2 agonist (non-exercise induced usage only) • Reported freq. of symptoms • PFT Results • # of Reported ED visits in the past 12 months • Reported asthma severity classification • Step #3: To determine proportion of patients within the sample set (173) that had asthma severity classified in their charts or had adequate data to be classified according to NHLBI severity guidelines • 29/173= 3= 17% of asth thma ma pati tients ents under er 19 were e clas assif sified ed or class assifiable able based ed on inf nform ormation ation avai vailabl able e in pati tient ent EHR
Methodology & Results 3 To determine the incidence rate of emergency department visits per patient in the 12 months prior to the start of this asthma Quality Improvement initiative for children with asthma being treated at the CHC under review (MWCHC) • Step #1: Extract information regarding total number of ED visits within the past 12 months for the identified sample set (173) • 27/173= 3= 16% of patie ient nt charts ts conta taine ned d infor orma mati tion on regardi ding ng ED visit its s in the past t 12 month th • Responses ponses ranged ed from 0 ED visit its s to 3 ED visit its s and produced ced an average erage of 2.25 ED visit its
Study Limitations • NHLBI has no classification guidelines for patients under the age of 5 • No knowledge of patients’ asthma history/medications • No spirometry results reviewed • Language used was inconsistent • Results from “# of ED visits” inconclusive • No review of data kept in clinic as hard copies
Discussion 173/5, 5,034 34= = 3.5 % of the patie ients ts seen n at MWCHC C in 2012 had an asthma hma diagn gnos osis s • Compared to 9.5% prevalence in Tennessee, analogous to national average (CDC 2013) • Data suggests that asthma is more likely to be diagnosed in non-Hispanic blacks and low income communities; would assume a higher prevalence in a community health center setting
Discussion 29/173= 3= 17% of asthma hma patie ients ts under 19 were class ssif ifie ied d or class ssif ifia iable e based sed on infor orma mati tion on avai ailab able in patien ent t EHR • Since the NHLBI suggests that proper severity classification is essential to optimal treatment and improvement of health outcomes, the inference can be made that the majority of pediatric asthmatic patients within this CHC setting may not be receiving therapies that will lead to ideal health outcomes
Discussion 27/173= 3= 16% of patie ient nt charts ts conta taine ned d infor orma mati tion on regardi ding ng ED visit its s in the past t 12 month th Responses ranged from 0 ED visits to 3 ED visits and produced an average of 2.25 ED visits • Objective was created with the assumption that # of ED visits would negatively correlate with proportion of classified patients • Insufficient data to make such inference
Recommendations • Use of standard form specifically for classifying asthma severity • Standardize the way patient information is collected and stored
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