Gregory Diette, M.D., M.H.S. is Assistant Professor of Medicine and Epidemiology at Johns Hopkins University. He is committed to a career in clinical investigation, with a focus on measuring and improving outcomes and quality of care for patients with asthma. He is a pulmonologist with a clinical practice devoted to asthma, and he has already earned a Master?s degree in Epidemiology. During the proposed study period, career development activities will include one-on-one mentoring, didactic work, relevant clinical work, development and conduct of a research project, presentation of research findings, and learning to teach research skills. Robert A. Wise, M.D. will serve as Dr. Diette?s primary mentor along with co-mentors, Drs. Jonathan Samet, Albert Wu, and Haya Rubin. Dr. Mark Liu will work directly with Dr. Diette in asthma clinic to continue his clinical mentoring. The research project will focus on demonstrating a novel approach to organization of care to improve care and outcomes for a chronic illness: asthma. Asthma is a common respiratory condition that affects approximately 5% of the U.S. population at an annual cost of $6 billion. There are effective medications and treatment strategies, and a systematic approach to asthma care has been recommended through guidelines developed by an expert panel convened by the National Heart, Lung and Blood Institute. However, asthma is becoming more common, and the morbidity, mortality and costs are rising. Research suggests that asthma care is often inconsistent with guidelines. Theoretical reasons for physician non-adherence include lack of awareness and lack of agreement with the guidelines, and limited ability to implement them. Adherence to guidelines also varies by physician specialty. Although generalist physicians provide the majority of asthma care, specialists often provide care that is more consistent with guidelines. Potential reasons for better care by specialists include greater training and experience, and also a practice environment with fewer barriers to high quality care for a given illness. A comprehensive model of determinants of provider behavior can help identify these barriers to adherence and can be used to direct intervention strategies to improve practice.
The specific aims of the proposed project are: 1. To use a customized, assessment method to assess barriers to physician adherence to national asthma guidelines. 2. To develop a generalist physician-run asthma clinic that incorporates interventions to overcome barriers identified in Aim 1 and to improve provider adherence to asthma guidelines. 3. To determine whether adherence to asthma guidelines and outcomes improve in a generalist-run asthma-specific clinic, compared to usual care in a general medical clinic. Phase I of the project is a systematic site-specific assessment of existing barriers to physician adherence to asthma guidelines in medical clinics in inner city Baltimore, MD. To create a practice environment with fewer barriers to guideline adherence, we will develop a new generalist-run asthma clinic designed to overcome the specific barriers identified at the study sites. Phase II is a clinical trial involving 560 adults with asthma, in which their physicians will be assigned to provide asthma care in the new asthma clinic vs. their usual general medical clinic. We will measure changes in adherence to guidelines and outcomes between patients assigned to this new clinic and those seen in the general medical care. This study has the potential to demonstrate: 1) The extent to which guideline adherence can be improved with a site-specific multifactorial intervention to overcome barriers to guideline implementation; 2) The differences in processes and outcomes of care between an improved practice environment for generalists vs. usual generalist care; and 3) How care should be organized for management of chronic diseases.
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