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Presenter: Delaney Gracy, MD, MPH

Impact of the “Asthma Toolbox” for Improving Documentation of Pediatric Asthma Management in an Urban Community Health Center. Presenter: Delaney Gracy, MD, MPH Co-Authors: Alan Shapiro, MD; Ariel Sarmiento, MPH; Wendy Quinones, BSN, RN, MSN, LPNP; Jo Applebaum, MPH Academy Health

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Presenter: Delaney Gracy, MD, MPH

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  1. Impact of the “Asthma Toolbox” for Improving Documentation of Pediatric Asthma Management in an Urban Community Health Center Presenter: Delaney Gracy, MD, MPH Co-Authors: Alan Shapiro, MD; Ariel Sarmiento, MPH; Wendy Quinones, BSN, RN, MSN, LPNP; Jo Applebaum, MPH Academy Health National Research Meeting Washington DC, June 8, 2008

  2. Childhood Asthma Initiative • A multidisciplinary program to improve asthma care for severely disadvantaged and under-served pediatric population since 1997 • Funded by the Picower Foundation • Implemented in Community Pediatric Programs of the Children’s Hospital at Montefiore • South Bronx Health Center for Children and Families (FQHC) • New York Children’s Health Project (HCH)

  3. Research Objective • To evaluate a standardized provider reminder tool developed to document the assessment and treatment of pediatric asthma patients in a primary care setting

  4. Population Studied • Pediatric patients at the South Bronx Health Center for Children and Families • community health center • underserved inner-city neighborhood • 96% minority • 27% pediatric asthma prevalence (2006) • childhood asthma hospitalization rates in community served twice that of NYC overall (9.6-11.0 vs 5.4/1000)

  5. Asthma Toolbox • Boxed set of questions based on NHLBI guidelines printed on all pediatric medical chart forms (well child, follow-up and walk-in forms) • Prompts providers to consistently and accurately assess and treat pediatric asthma patients in a busy primary care setting • Use of NHLBI guidelines facilitated by streamlined set of questions that can be completed quickly

  6. Sample Toolbox

  7. Study Design • Chart review conducted to determine whether the Asthma Toolbox improved documentation of: • asthma severity classification • prescribing of controller medications • visits to the emergency department (ED) • hospitalizations

  8. Study Design(cont’d) • Sample (N=300) • 100 patients for each measurement period • randomly selected • ages 6 mo to 20 y with a non-urgent visit • Measurement periods • pre: 11/1/04-10/31/05 • post: 12/1/05-11/30/06 • late post: 1/1/07-6/30/07

  9. Study Design(cont’d) • Chart review • Last asthma visit in measurement period selected for review • If visit excluded, previous visit reviewed • Statistical analysis • Chi-square tests used to compare percentage of patients with variables documented • pre- vs post-; post- vs late post-implementation

  10. p=.000 p=.000 100 95 90 84 82 p<.01 p=.000 62 58 Percent (%) 50 16 Severity Overall Persistent On Controller Findings: Documentation of Assessment and Treatment Chi-square tests used to compare percentage of patients with variables documented at last eligible visit in the measurement period.

  11. p=.000 all comparisons Percent (%) Prior 4 mo Prior 12 mo Findings: Documentation of ED Visits Chi-square tests used to compare percentage of patients with variables documented at last eligible visit in the measurement period.

  12. p=.000 all comparisons Percent (%) Prior 4 mo Prior 12 mo Findings: Documentation of Hospitalization Chi-square tests used to compare percentage of patients with variables documented at last eligible visit in the measurement period.

  13. Conclusions • The Asthma Toolbox significantly improved the documentation of key variables in pediatric asthma management, including asthma severity classification and prescribing of controller medications in persistent asthmatics • A standardized brief provider-prompt assisted providers in complying with current asthma guidelines in the context of complex medical encounters • Acceptance of provider-prompt demonstrated by high percentage of usage

  14. Implications for Primary Care Practice and Policy • Use of provider-prompts incorporated into the medical record can improve adherence to clinical guidelines • Assessment, treatment and monitoring of pediatric asthmatics can be improved in a busy primary care setting • Consistent documentation in the chart can assist in quality improvement activities by facilitating data collection from the medical record and improve outcome tracking

  15. Next Steps • The Asthma Toolbox has been revised to reflect NHLBI 2007 guidelines • To be incorporated into adult medical record forms • The Asthma Toolbox has been adapted for and will be incorporated into an electronic health record template

  16. Thank You

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