Asthma disproportionately affects low-income, minority children residing in inner cities such as the Bronx, NY. The use of national guidelines reduces asthma morbidity by 70%; yet, these guidelines are not consistently implemented by health care providers. Although several interventions to improve provider adherence to asthma guidelines have been described, few studies have addressed translation of guidelines into routine care. This study builds on our experience evaluating a multifaceted prompting intervention (MPI) in 12 urban clinics (R01HL091835, PI Halterman). Although effective in the short-term, this intervention must be modified to translate into routine practice. We will enhance MPI in several ways: (1) use clinic rather than research staff to facilitate assessment for prompts at every visit; (2) ensure prompting for guideline-based care for all children ages 2-12 with persistent or uncontrolled asthma, rather than just a research sample; (3) routinely deliver prompts to the provider via Electronic Health Record (EHR); (4) offer telephone-based care coordination, education and support to children with the highest morbidity via a dedicated Outreach Worker (OW); and (5) provide practice-level supports (e.g. clinic champions, on-going performance feedback and participatory problem solving) to promote full adoption of guidelines. The enhanced MPI program (eMPI) consists of innovative multi-level and team-based strategies to enable providers to effectively and efficiently adopt asthma care guidelines. In response to PAR-15-279, this study will address the guideline-to-practice gap by evaluating eMPI in real-world primary care settings. We will conduct a cluster randomized trial comparing eMPI to enhanced usual care (eUC) in 22 Bronx practices serving over 5,000 children ages 2-12 years with persistent or uncontrolled asthma. Practices will join the study in 4 waves over 4 years. Lessons learned about facilitators and barriers to eMPI implementation in earlier study waves will be used to improve the implementation in later clinics. Eleven eUC practices will receive guideline information and assess children's asthma severity and control, but active intervention components will not be provided. This study will (1) test the impact of eMPI on provider adoption of asthma management guidelines (primary outcome measure is the proportion of visits with >1 guideline-based corrective actions taken by the provider); (2) determine whether consistent use of eMPI leads to both short- and long-term improvements in clinical outcomes (measured by the symptom-free days); and (3) evaluate the process of program implementation using RE-AIM framework. We will also evaluate group differences in the extent of healthcare utilization and resources used (i.e., adherence to follow-up visits, specialty referrals, emergency and in-patient care, referrals to OW). The proposed research will provide critical new knowledge about how to implement guideline-based asthma care in routine pediatric practice, in order to facilitate widespread dissemination and adoption across the U.S.

Public Health Relevance

National asthma guidelines are rarely universally implemented in routine clinical practice likely contributing to preventable illness. This study will evaluate a program consisting of multi-level, team-based strategies to improve provider adoption of asthma management guidelines in real-world clinical practices using a rigorous cluster randomized trial design. 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 ultimately improving clinical outcomes of urban children with asthma.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Freemer, Michelle M
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Albert Einstein College of Medicine
United States
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