Medical Professional Publications

Assessing Asthma Control in a Large Pediatric Practice

(From the January 2018 Issue of MedStat)

Editor’s Note: This is the first of two articles on the assessment and management of asthma patients in the primary care setting. The second article will describe the building of a comprehensive asthma program in a community private practice.

Written by Dane A. Snyder, MD

Dr. Snyder, pictured here with his family, has been a primary care physician at Nationwide Children's Hilltop Primary Care Clinic since 2008. He was recently appointed as the chief of Nationwide Children's Section of Ambulatory Pediatrics.

As another autumn season has ended, and a new spring is ahead of us, we are reminded of the unpredictability and prevalence of asthma in our pediatric population. The annual fall spike in acute asthma symptoms and the temperamental nature of this disease reinforces the importance of proactive involvement with our patients and their families. In the Nationwide Children's primary care network, we manage over 10,000 patients with asthma, many of whom are at high-risk for asthma morbidity, and optimizing asthma care has been a long-term focus within our primary care offices.

One of the first major steps towards achieving this was assessing asthma control more frequently, and we aimed to evaluate asthma whenever a patient with asthma came to one of our clinics. In 2013, we established a goal to document an Asthma Control Test (ACT) score at 70 percent of all visits by a patient with asthma, regardless of the reason for visit. This afforded us a quick snapshot of symptom control, and if we discovered a patient to be struggling with their asthma, we could address it further. Given the size of our network—we are spread out over 13 primary care sites—we realized that standardization of this process would be challenging. While success did not come immediately—our network only achieved 30 percent adherence during the project’s first month—we were able to surpass our 70 percent goal six months into the initiative. We maintained, and even increased, this goal for several years as we added other interventions to improve the asthma care we provide.

We learned some valuable lessons along the way. Foremost, a project this large takes an entire team—we average over 1,800 encounters with an asthma patient each month across our network. Every member of the clinic team was included, beginning with initial process planning, before any actions were implemented in the clinics. We followed through at quarterly clinic visits (and brought lunch!) and talked with the entire team. We solicited feedback, attempted to find out what worked well, what did not, and attempted to troubleshoot EMR-related issues.

It may seem simple—handing a piece of paper to a patient—but consistently orchestrating this on a large scale is complicated. From alerting the clinic staff that a patient may have asthma, to clinic staff providing the ACT to the patient, to ensuring the provider was aware of the result, and finally the provider documenting the score in the electronic medical record, this process was one that required involvement from all groups in the office. However, by involving everyone, it also became a team-owned process, and made broad buy-in attainable. That’s not to say that everyone initially thought this project was worth the effort. Some of our offices had more success at first. We shared these successes and we provided quarterly feedback that compared each clinic relative to each other (I suspect competitive nature may have taken over). Most importantly, we were able to show the teams that their patients had better outcomes.

Over the course of the next few years, we saw the rate of asthma-related emergency department visits decline approximately 25 percent.This was perhaps the most important factor that led to our ability to not only maintain this process, but build upon it to further improve the quality of asthma care we provide. We are all in this profession to help our patients, and we learned that everyone was willing to do a little extra for their patients if they could see the impact that work was having.

An additional “unofficial” goal of this project was that we hoped our families would change how they viewed their child’s asthma. Prior to this intervention, we would routinely address asthma only if the family initiated the conversation. Usually this was when their child was ill or having asthma-related symptoms. Yet somehow we expected our families to think about asthma in a preventative manner, and not something to solely address when their child was ill. We had to lead this change by changing our practice first. By addressing asthma in a proactive manner, it taught our patients to do the same, and laid the foundation for the improvements we’ve seen in our asthma patients as a whole.

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