Institute for Health and Aging, University of California, San Francisco, 3333 California St, San Francisco, CA 94143-0646, USA.
Pediatrics. 2011 Jul;128(1):20-8. doi: 10.1542/peds.2010-1962. Epub 2011 Jun 13.
Outpatient asthma management remains suboptimal. We previously reported significant improvements in asthma guideline adherence and outcomes in children by using quality-improvement processes and community health workers. We hypothesized that a larger project could achieve comparable outcome improvements with streamlined quality-improvement processes and decreased technical assistance.
Seventeen clinics treating 12 000 children with asthma were evaluated through interviews of a subset of patients with persistent or high-risk asthma (n=761) at baseline and at 12 and 21 months and chart reviews randomly selected from all patients with asthma at baseline and 12 and 24 months (n=2040). Multidisciplinary teams developed data-driven continuous quality-improvement activities. Asthma coordinators provided patient education and were active team members.
Study children were predominantly Hispanic (77%) and black (11%); 60% were enrolled in Medicaid, and 9% were uninsured. Comparing results between baseline and the 21-month follow-up, significantly fewer families reported emergency-department visits (29.6% vs 9.3%), hospitalizations (10.9% vs 3.4%), frequent daytime symptoms (44.0% vs 11.7%), and missed school days (28.7% vs 13.6%); significantly more reported confidence in asthma management (70.6% vs 95.5%); and quality-of-life scores increased significantly for both children and caregivers (all P<.05). Cross-sectional data revealed significant clinic-wide improvements in symptom documentation, health care use, and review of action plans.
On a larger scale, this approach realized impressive changes in provider clinical practice associated with major improvements in health outcomes. It holds great potential for significantly reducing asthma-related morbidity among low-income children.
门诊哮喘管理仍不尽如人意。我们之前曾报道，通过使用质量改进流程和社区卫生工作者，儿童的哮喘指南依从性和结果得到了显著改善。我们假设，通过简化质量改进流程和减少技术援助，可以实现更大规模项目的可比结果改善。
通过对患有持续性或高风险哮喘的患者进行采访，评估了 17 家治疗 12000 名哮喘儿童的诊所，其中有 761 名患者（n=761），并在基线和 12 个月和 21 个月时进行了访谈，以及对所有基线和 12 个月和 24 个月时患有哮喘的患者进行了随机选择的图表审查（n=2040）。多学科团队制定了以数据为驱动的持续质量改进活动。哮喘协调员提供患者教育，并作为团队的积极成员。
研究儿童主要为西班牙裔（77%）和黑人（11%）；60%参加了医疗补助计划，9%没有保险。将基线与 21 个月随访结果进行比较，报告急诊就诊的家庭明显减少（29.6%比 9.3%），住院（10.9%比 3.4%），白天症状频繁（44.0%比 11.7%），缺课（28.7%比 13.6%）；报告对哮喘管理有信心的家庭明显增加（70.6%比 95.5%）；儿童和照顾者的生活质量评分均显著提高（均 P<.05）。横断面数据显示，症状记录、医疗保健使用和行动计划审查方面的诊所整体均有显著改善。
在更大的范围内，这种方法实现了提供者临床实践的显著变化，与健康结果的重大改善相关。它为显著降低低收入儿童的哮喘相关发病率提供了巨大潜力。
