Health Care Providers
Medical clinics/physicians’ offices
Creating a Medical Home for Asthma
Article Citation:
Evans D, Mellins R, Lobach K, Ramos-Bonoan C, Pinkett-Heller M,
Wiesemann S, Klein I, Donahue C, Burke D, Levison M, Levin B, Zimmerman
B, Clark N. Improving care of minority children with asthma:
Professional education in public health clinics. Pediatrics. Feb
1997;99(2):157-164.
Intervention Setting:
Outpatient clinics
Target Population:
Twenty-two clinics administered by the Bureau of Child Health.
The clinics had an enrolled population 61,652 children.
Program Description:
In response to the lack of continuity of primary care for low-income
children with asthma and of color in New York City, the Creating a
Medical Home for Asthma program was established. The program utilized
the principles of learner-centered teaching and theory-based approaches
to organizational change. The training received by clinic staff was in
accordance with NAEPP guidelines and sought the support and
participation of not only the staff but also the administrators of
pediatric clinics. The program consisted of three components: 1) five
3-hour sessions with staff members discussing the program and their
roles in it; 2) three- hour tutorial sessions for each BCH physician;
and 3) monthly visits to the clinics by a nurse educator.
Evaluation Design:
Clinics were randomly assigned to the intervention or control group.
The control group received only copies of NAEPP guidelines and supplies
of the same medications and devices used by the intervention group. The
control groups received the training once the 2-yr intervention ceased.
Sample Size:
22 clinics
Outcome Measures/Results:
Outcome measures included identification and treatment of asthma
patients, continuity of care, and the use of medication and patient
education by physicians and nurses. Results reveal improvement in all
areas.
Availability of Protocol/Materials:
All information and materials necessary for implementation of this
intervention can be found at
http://www.nyc.gov/html/doh/html/cmha/index.html.
[external link]
Case Study:
None
Physician Asthma Education Program
Article Citation(s):
Brown R, Bratton SL, Cabana MD, Kaciroti N, Clark NM. Physician
asthma education program improves outcomes for children of low-income
families. Chest 2004;126(2):369–74.
This study is a subset of a larger intervention described in two earlier reports:
- Clark NM, Gong M, Schork MA, Evans D, Roloff D, Hurwitz M, et al. Impact of education for physicians on patient outcomes. Pediatrics 1998;101(5):831–6.
- Clark NM, Gong M, Schork A, Kaciroti N, Evans D, Roloff D, et al. Long-term effects of asthma education for physicians on patient satisfaction and use of health services. Eur Respir J 2000;16(1):15–21.
Intervention Setting:
Physicians in the New York, New York, and Ann Arbor, Michigan, areas
were enrolled to receive two asthma seminars lasting 2–3 hours and
spaced over a 2–3 week period.
Target Population:
Children with asthma from low-income families (income < $20,000) who
were treated by physicians taking part in the study. (Note: The
objective of this arm of the larger study was to determine if low-income
child patients of physicians who participated in the intervention also
benefited in health outcomes.)
Program Description:
The study hypothesis was that physicians participating in the
seminars regarding asthma care would improve their patient health
outcomes. Primary care pediatricians were randomized to the interactive
seminars or to a control group. A random sample of patients (children)
from each of the participating physicians was selected to assess the
effectiveness of the program. Children qualified for the study if they
had an asthma diagnosis by a physician, had no other chronic conditions,
and had received emergency care at least once for asthma in the prior
year. Children in the study had frequent asthma symptoms. Parents
reported that 96.1% of all children had persistent symptoms and that
88.2% had moderate-to-severe persistent asthma during at least one
season of the year.
The interactive seminar was based on a previously reported theory of physician self-regulation to enhance their therapeutic skills in treating childhood asthma and to develop their ability to educate and counsel families about asthma self-management. The two main components of the program included optimal clinical practice following National Asthma Education and prevention (NAEPP) guidelines and patient teaching and communication. The program included several activities and materials:
- brief lectures from a local asthma expert,
- a video showing effective clinician teaching and communication behavior,
- case studies that presented clinical problems,
- a protocol by which physicians could assess their oral communication behavior, and
- a review of messages to communicate and materials to distribute to patients and their families.
The first visit that the patient made to the physician within 22 months after the intervention was followed by an interview with the parent. The parent interview consisted of questions related to the children’s asthma symptoms, prescribed medications, use of health care services, and parental observations regarding physicians’ teaching and communication behaviors. The patient then was tracked and evaluated at 12 months and 24 months after the initial visit.
Evaluation Design:
Randomized controlled trial
Sample Size:
The sample included 23 pediatricians and 36 of their patients:
children with asthma from low-income families, ages 1–12 years. This
study is a subset of a larger study involving 74 pediatricians and 637
of their patients.
Outcome Measures:
Health care use for asthma: presenting at emergency departments and
admission to the hospital
Results:
Low-income children in the treatment group were significantly less
likely to be admitted to an emergency department (annual rate, 0.208 vs.
1.44, respectively) or to the hospital (annual rate, 0 vs. 0.029,
respectively) for asthma care compared to low-income children in the
control group during the 2-year assessment period. Low-income children
in the treatment group tended to have higher levels of use of controller
medications, to receive a written asthma action plan, and to miss fewer
days of school. These differences were not statistically significant
compared to low-income children in the control group. This study shows
that the effectiveness of the physicians’ education program is not
reserved merely to those patients with more resources. The greatest
decline in emergency department use was in children from low-income
families, when compared with children of middle- and upper-income
families in the larger study.
Other
Interactive Seminar with Physicians
Article Citation:
Clark NM, Gong M, Schork MA, Evans D, Roloff D, Hurwitz M, Maiman L,
Mellins RB. Impact of Education for Physicians on Patient Outcome.
Pediatrics 1998;101(5)831-836
Intervention Setting:
The intervention was conducted in Ann Arbor, Michigan and New York
City, New York. The meeting space was not further described.
Target Population:
The intervention targeted general practice pediatricians licensed no
earlier than 1960 who provided direct patient care and, through them,
their patients aged 1-12 years who had asthma.
Program Description:
The objective of this study was to assess the impact of an
interactive seminar based on self-regulation theory on treatment,
communication, and education behavior of physicians, the impact on the
physician’s patients, and the satisfaction of the patient’s parents.
Physicians completed a self-administered survey and parents were
interviewed by telephone for baseline data collection. The seminar
comprised two group meetings of the physicians, each lasting
approximately 2½ hours, which were held over a 2- to 3-week period.
Group size was limited to 12 physicians. The seminars were offered three
times in each location. The seminar had two components: 1) optimal
clinical practice and 2) patient teaching and communication. A total of
69 (93%) program and control group physicians completed a follow-up
survey within approximately 5 months of the seminar (or, for controls,
their assigned corresponding date). Parent follow-up occurred within a
22-month timeframe.
Evaluation Design:
Randomized controlled study
Sample Size:
The study participants included 74 general practice pediatricians
assigned to program or control group and 637 of their patients.
Outcome Measures/Results:
Outcome measures included items related to clinical practice,
including the use of particular medicines, procedures for encouraging
self-management by patients, and aspects of patient teaching and
communication behavior. Outcomes from parents included physician
behavior, child’s symptoms, medicines prescribed, use of health care
services, observations of the physicians’ teaching and communication
behavior, and other aspects of physician-patient interaction. Following
the seminar, physicians were significantly more likely than controls to
treat newly diagnosed patients with inhaled corticosteroids, more likely
to address patients fears about medicines, provide written instructions
for medications, provide a sequence of educational messages, and spend
less time with their patients. Parents of children treated by program
physicians were significantly more likely than controls group parents to
report that the physician had been reassuring, urged full activity for
the child, and relieved worries, and the parents knew how to make
disease management decisions at home. The children treated by program
physicians were more likely to have received a prescription for inhaled
anti-inflammatory medicine, have been observed using a metered-dose
inhaler, and had fewer non-emergency office visits and visits for
follow-up after symptoms. There were no differences in emergency
department visits or hospitalizations.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
