A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care

Health outcomes of the pediatric asthma care patient outcomes research team II study

Paula Lozano, Jonathan A. Finkelstein, Vincent J. Carey, Edward H. Wagner, Thomas Inui, Anne L. Fuhlbrigge, Stephen B. Soumerai, Sean D. Sullivan, Scott T. Weiss, Kevin B. Weiss

Research output: Contribution to journalArticle

117 Citations (Scopus)

Abstract

Background: Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines. Objective: To evaluate the effectiveness of 2 asthma care improvement strategies in primary care. Design: Two-year randomized controlled clinical trial. Setting: Forty-two primary care pediatric practices affiliated with 4 managed care organizations. Participants: Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations. Interventions: Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care. Main Outcome Measures: Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts). Results: Six hundred thirty-eight children completed baseline evaluations, representing 64% of those screened and eligible. Mean ± SD age was 9.4 ± 3.5 years; 60% were boys. Three hundred fifty (55%) were taking controller medication. Mean ± SD annualized asthma symptom days was 107.4 ± 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95% confidence interval [CI], -16.9 to 3.6), a nonsignificant difference, but had a 36% (95% CI, 11% to 54%) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95% CI, -24.7 to -2.1) fewer symptom days annually (-12% from baseline; P = .02) and a 39% (95% CI, 11% to 58%) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95% CI, 1.00 to 1.091). Conclusions: Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.

Original languageEnglish
Pages (from-to)875-883
Number of pages9
JournalArchives of Pediatrics and Adolescent Medicine
Volume158
Issue number9
DOIs
StatePublished - Sep 2004

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Organizational Innovation
Patient Care
Asthma
Outcome Assessment (Health Care)
Pediatrics
Delivery of Health Care
Physicians
Education
Primary Health Care
Confidence Intervals
Steroids
Managed Care Programs
Health Surveys
Nurses
Organizations
Guidelines
Self Care
Health Status
Teaching
Randomized Controlled Trials

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

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A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care : Health outcomes of the pediatric asthma care patient outcomes research team II study. / Lozano, Paula; Finkelstein, Jonathan A.; Carey, Vincent J.; Wagner, Edward H.; Inui, Thomas; Fuhlbrigge, Anne L.; Soumerai, Stephen B.; Sullivan, Sean D.; Weiss, Scott T.; Weiss, Kevin B.

In: Archives of Pediatrics and Adolescent Medicine, Vol. 158, No. 9, 09.2004, p. 875-883.

Research output: Contribution to journalArticle

Lozano, Paula ; Finkelstein, Jonathan A. ; Carey, Vincent J. ; Wagner, Edward H. ; Inui, Thomas ; Fuhlbrigge, Anne L. ; Soumerai, Stephen B. ; Sullivan, Sean D. ; Weiss, Scott T. ; Weiss, Kevin B. / A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care : Health outcomes of the pediatric asthma care patient outcomes research team II study. In: Archives of Pediatrics and Adolescent Medicine. 2004 ; Vol. 158, No. 9. pp. 875-883.
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abstract = "Background: Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines. Objective: To evaluate the effectiveness of 2 asthma care improvement strategies in primary care. Design: Two-year randomized controlled clinical trial. Setting: Forty-two primary care pediatric practices affiliated with 4 managed care organizations. Participants: Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations. Interventions: Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care. Main Outcome Measures: Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts). Results: Six hundred thirty-eight children completed baseline evaluations, representing 64{\%} of those screened and eligible. Mean ± SD age was 9.4 ± 3.5 years; 60{\%} were boys. Three hundred fifty (55{\%}) were taking controller medication. Mean ± SD annualized asthma symptom days was 107.4 ± 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95{\%} confidence interval [CI], -16.9 to 3.6), a nonsignificant difference, but had a 36{\%} (95{\%} CI, 11{\%} to 54{\%}) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95{\%} CI, -24.7 to -2.1) fewer symptom days annually (-12{\%} from baseline; P = .02) and a 39{\%} (95{\%} CI, 11{\%} to 58{\%}) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95{\%} CI, 1.00 to 1.091). Conclusions: Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.",
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N2 - Background: Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines. Objective: To evaluate the effectiveness of 2 asthma care improvement strategies in primary care. Design: Two-year randomized controlled clinical trial. Setting: Forty-two primary care pediatric practices affiliated with 4 managed care organizations. Participants: Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations. Interventions: Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care. Main Outcome Measures: Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts). Results: Six hundred thirty-eight children completed baseline evaluations, representing 64% of those screened and eligible. Mean ± SD age was 9.4 ± 3.5 years; 60% were boys. Three hundred fifty (55%) were taking controller medication. Mean ± SD annualized asthma symptom days was 107.4 ± 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95% confidence interval [CI], -16.9 to 3.6), a nonsignificant difference, but had a 36% (95% CI, 11% to 54%) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95% CI, -24.7 to -2.1) fewer symptom days annually (-12% from baseline; P = .02) and a 39% (95% CI, 11% to 58%) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95% CI, 1.00 to 1.091). Conclusions: Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.

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