Quality Improvement Initiative for the Severity Classification of - - PowerPoint PPT Presentation

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
• ne 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

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.

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

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
• com
• mpare

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
• det

eterm ermine ine the propor

• rti

tion

• n 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

• se asthma

hma sever erit ity y has been een or can be classif sified ied accor

• rdin

ding to NHLB LBI I asthma hma severit erity y classific icat ation ions for r childr ldren en

• To
• 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

• nths

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

• sis

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

• rmation

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

• rma

mati tion

• n 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

• sis

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

• rma

mati tion

• n 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

• utcomes, 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

• rma

mati tion

• n 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

What has worked elsewhere?

• For decreasing asthma severity: “Asthma Care Training [ACT] for Kids”
• Children under 12 w/ Severe, Persistent asthma assigned to Intervention
• vs. Control group
• Goal of study: patient and parent education
• Results: decreased ED visits & increased compliance behaviors for

intervention group

• For implementation of NHLBI guidelines: “Asthma Guideline

Implementation Steps & Tools”

• National Asthma Control Initiative (NACI) & Asthma Initiative of Michigan
• “To get the most from your practice’s GIST implementation: GIST materials

can be implemented in an electronic or paper office system”

• To imp

mprove e asthma hma-re relat lated ed health th outc tcom

• mes

es in minori

• rity

ty populat ulation

• ns of
• f

economi nomically cally disadvanta antage ged d school-aged ged childre ren

• Goal: Staged an intervention for seven clinics in California with high

proportion of moderate to severe persistent asthma cases or poorly controlled asthma cases

• Assessed correlation between adherence to intervention model and

patient centered outcomes + clinical outcomes

Conclusions

• Assessment of asthma severity is crucial in properly

assessing a patient’s experience of asthma and following up with the clinical decisions that will most likely lead to positive health outcomes for patients.

• This assessment should include careful analysis of

symptom frequency, frequency of treatment, daily limitations, urgent care visits and lung function testing results in order for the most accurate evaluation.

• Aside from obtaining a patient’s self report and performing

appropriate lung function tests, it may be beneficial to standardize the way patient data is collected and filed

References

• Bacharier, L. (2004). Classifying Asthma Severity in Children Mismatch Between Symptoms,

Medication Use, and Lung Function. American Journal of respiratory and Critical Care Medicine, Vol. 170, No. 4, pp. 426-432.

• Bureaus of Primary Health Care- BPHC (2012). Health Resources and Services Administration

Uniform Data System report 2012- Matthew Walker Comprehensive Health Center.

• Centers for Disease Control and Prevention- CDC (2013). CDC/ National Center for Health

Statistics: Asthma. Retrieved from USA.gov.

• 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.

• Fox, P. (2007). Improving Asthma-Related Health Outcomes Among Low-Income, Multiethnic,

School-aged Children: Results of a Demonstration Project That Combined Continuous Quality Improvement and Community Health Worker Strategies. Journal of the American Academy of Pediatric. Retrieved from http://pediatrics.aappublications.org/content/120/4/e902.full.pdf.

• Godfrey, S. (1985). What is Asthma? Archives of Disease in Childhood.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1777622/pdf/archdisch00716-0009.pdf.

• Halterman, J. (2002). Providers Underestimate Symptom Severity Among Urban Children With
• Asthma. Archives of Pediatrics and Adolescent Medicine/ JAMA Pediatrics. Retrieved From

http://archpedi.jamanetwork.com/article.aspx?articleid=191527.

• Lewis, CE. (1984). Children with Asthma: Randomized Trial for A.C.T. (Asthma Care

Training). Retrieved from http://www.cdc.gov/asthma/interventions/children_medicalclinics.htm.

• National Asthma Control Initiative (2010). Asthma Guideline Implementation Steps and Tools

(GIST). Retrieved from http://www.getasthmahelp.org/gist-asthma-guideline-implementation-steps-and-tools.aspx.

• 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.

• Nguyen, B. (1996). Patients' Perceptions Compared with Objective Ratings of Asthma Severity.

Elsevier: Annals of Allergy, Asthma and Immunology. Volume 77, Issue 3. Retrieved From http://www.sciencedirect.com/science/article/pii/S1081120610632577.

• Stout, J. (2006). Classification of asthma severity in children: the contribution of pulmonary

function testing. Archives of Pediatrics and Adolescent Medicine/ JAMA Pediatrics. Retrieved from http://archpedi.jamanetwork.com/article.aspx?articleid=205379.

Photo credits

• Photo 1/ Title Page:

http://epa.gov/sciencematters/oct2012/asthmagap.htm

• Photo 2/ Asthma in Childhood:

http://babygooroo.com/wp- content/uploads/2012/02/iStock_000011165828Small- e1329851680634-450x250.jpg

• Photo 3/ Introduction:

http://i.telegraph.co.uk/multimedia/archive/01349/asthma_1349 714c.jpg

• Photo 4/ NHLBI Guidelines:

http://www.tc.umn.edu/~town0045/images/NHLBI%20Logo.jpg

• Photo 5/ Background:

http://shrp.rutgers.edu/Faculty/Research/images/books.jpg

Acknowledgements

• National Medical Fellowships
• Primary Care Leadership Program scholars @ MWCHC
• I. Michele Williams, MD
• Consuelo Wilkins, MD, MSCI
• Michael DeBaun, MD, MPH
• Brandi McClain, RN, MSN, PCNS-BC, PNP-BC
• Valencia Bryant, CRT
• Robin Dean, MHSA
• Markeith Braden, MSPH