Evans D, Mellins R, Lobach K, Ramos-Bonoan C, Pinkett-Heller M, Wiesemann S, Klein I, Donahue C, Burke D, Levison M, Levin B, Zimmerman B, Clark N
Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
Pediatrics. 1997 Feb;99(2):157-64. doi: 10.1542/peds.99.2.157.
Recent studies have shown that lack of continuing primary care for asthma is associated with increased levels of morbidity in low-income minority children. Although effective preventive therapy is available, many African-American and Latino children receive episodic treatment for asthma that does not follow current guidelines for care. To see if access, continuity, and quality of care could be improved in pediatric clinics serving low-income children in New York City, we trained staff in New York City Bureau of Child Health clinics to provide continuing, preventive care for asthma.
We evaluated the impact of the intervention over a 2-year period in a controlled study of 22 clinics. Training for intervention clinic staff was based on National Asthma Education and Prevention Program guidelines for the diagnosis and management of asthma, and included screening to identify new cases and health education to improve family management. The intervention included strong administrative support by the Bureau of Child Health to promote staff behavior change. We hypothesized that after the intervention, clinics that received the intervention would, compared with control clinics, have increased numbers of children with asthma receiving continuing care in the clinics and increased staff use of new pharmacologic and educational treatment methods.
In both the first and second follow-up years, the intervention clinics had greater positive changes than control clinics on measures of access, continuity, and quality of care. For second year follow-up data these include: for access, greater rate of new asthma patients (40/1000 vs 16/1000; P < .01); for continuity, greater percentage of asthma patients returning for treatment 2 years in a row (42% vs 12%; P < .001) and greater annual frequency of scheduled visits for asthma per patient (1.85 vs .88; P < .001); and for quality, greater percentage of patients receiving inhaled beta agonists (52% vs 15%; P < .001) and inhaled antiinflammatory drugs (25% vs 2%; P < .001), and greater percentages of parents who reported receiving patient education on 12 topics from Bureau of Child Health physicians (71% vs 58%; P < .01) and nurses (61% vs 44%; P < .05).
We conclude that the intervention substantially increased the Bureau of Child Health staff's ability to identify children with asthma, involve them in continuing care, and provide them with state-of-the-art care for asthma.
近期研究表明，低收入少数族裔儿童缺乏持续的哮喘初级护理与发病率上升有关。尽管有有效的预防性治疗方法，但许多非裔美国人和拉丁裔儿童接受的哮喘间歇性治疗并不遵循当前的护理指南。为了了解纽约市为低收入儿童服务的儿科诊所能否改善医疗服务的可及性、连续性和质量，我们对纽约市儿童健康局诊所的工作人员进行培训，使其能够提供持续的哮喘预防性护理。
我们在一项对22家诊所的对照研究中评估了为期两年的干预措施的影响。对干预诊所工作人员的培训基于国家哮喘教育和预防计划关于哮喘诊断和管理的指南，包括筛查以识别新病例以及开展健康教育以改善家庭管理。干预措施包括儿童健康局提供强有力的行政支持，以促进工作人员行为的改变。我们假设，干预后，与对照诊所相比，接受干预的诊所中接受持续护理的哮喘儿童数量会增加，工作人员对新的药物和教育治疗方法的使用也会增加。
在第一年和第二年的随访中，干预诊所在医疗服务的可及性、连续性和质量指标方面的积极变化均大于对照诊所。第二年随访数据包括：在可及性方面，新哮喘患者的比例更高（40/1000对16/1000；P <.01）；在连续性方面，连续两年复诊的哮喘患者比例更高（42%对12%；P <.001）以及每位患者每年哮喘定期就诊的频率更高（1.85对.88；P <.001）；在质量方面，接受吸入型β受体激动剂治疗的患者比例更高（52%对15%；P <.001）以及接受吸入型抗炎药物治疗的患者比例更高（(25%对2%；P <.001），并且报告从儿童健康局医生处接受12个主题患者教育的家长比例更高（71%对58%；P <.01）以及从护士处接受教育的家长比例更高（61%对44%；P <.05）。
我们得出结论，该干预措施大幅提高了儿童健康局工作人员识别哮喘儿童、让他们接受持续护理并为其提供最新哮喘护理的能力。
