A disproportionate number of impoverished and minority children suffer from asthma. Many of these children who should receive preventive asthma medications are not receiving them. In our prior work, we found that providers frequently misclassify asthma severity, and this misclassification leads to inadequate prescription of preventive medications. Further, once preventive medications are prescribed, many children continue to have poor asthma control. Importantly, most clinicians do not systematically screen for asthma symptoms at office visits. The goal of this project is to evaluate whether a multifaceted prompting intervention, administered in urban primary care offices, reduces morbidity among urban children with asthma. This study builds on our experience with a pilot randomized trial in 2 urban clinics, in which we found that prompting clinicians about asthma severity and care guidelines at the time of an office visit resulted in improved preventive care delivery. We propose a full scale cluster randomized trial with 510 children ages 2-12 years in 12 different practices from our Clinical and Translational Science Institute's practice-based research network. Practices will be matched into 6 pairs and then randomly assigned to either the Multifaceted Prompting Intervention (MPI) or usual care. For enrolled intervention subjects, the MPI will include a prompt for the health care provider and a simplified prompt for the caregiver, designed for use during the office visit and prepared in the waiting room on a Tablet Personal Computer by a trained research associate. These prompts are designed to stimulate communication between the caregiver and provider and will include information regarding the patient's asthma severity or level of control as well as individualized guideline-based recommendations for care. Intervention practices also will receive practice- level supports, including interactive seminars, access to educational programs and resource guides, and bi- annual feedback on their performance for the primary outcomes. We will assess the effectiveness of the intervention in reducing asthma morbidity (including symptom-free days as the primary outcome, as well as additional clinical and functional outcomes) and will assess the extent and nature of preventive care delivery (defined by the occurrence of guideline-based corrective actions at the index visit) for children in MPI and usual care practices. At study completion, the effectiveness of office-based prompting will be better defined as a sustainable means to reduce morbidity among high-risk asthmatic children. This type of intervention is widely applicable for asthma care in practices nationwide, and for management of other chronic diseases.
This project may have a profound impact on public health because it presents a practical system change to promote adherence to effective asthma care guidelines. Should it prove successful in reducing symptoms and improving the health of urban children with asthma, it has the potential to serve as a model for improved asthma care in urban communities.
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