Better Asthma Control and Fewer Visits Using an Online Clinical Process Support System

From the 2019 HVPAA National Conference

Dr. Barbara Howard (Johns Hopkins U School of Medicine), Dr. Raymond Sturner (Johns Hopkins U School of Medicine), Ms. Genevieve Vullo (Total Child Health), Mr. Paul Bergmann (Foresight Logic)

Background

Asthma affects 8% of US children and is a leading cause of ED visits, hospitalization, missed school, suffering and death. This project sought to facilitate implementation of national asthma guidelines including improving controller adherence. Patient generated data can aid clinical care but is not yet used routinely and the potential to facilitate clinical processes has not been realized.

Objective

1. To explore impact of an online Asthma Intervention Module (AIM) using a cluster randomized control study with regard to control and healthcare utilization. 2. To use this study as one of several examples to illustrate the use of patient generated data to trigger patient specific: decision support; patient education; and QI metrics including statistical process control charts.

Design/Methods

24 pediatric practices were randomized to control or use of AIM in CHADIS. Parents of 4860 children under 18 years with asthma completed the Pediatric Asthma Control and Communication Instrument (PACCI) (Okelo, et al., 2013) online before visits. The AIM group was also asked to complete the PACCI monthly from home.  PACCI assesses asthma severity/control symptoms, controller use and adherence, medical visits, perceived trajectory and burden. AIM clinicians had access to decision support including NHLBI guideline tips, a teleprompter for problem solving counseling specific to barriers to adherence, medication suggestions, as well as remote monitoring alerts about uncontrolled patients and MOC-4 credit and families had online access to individualized patient education and Action Plans.

Data was assessed for children who had at least one PACCI showing persistent asthma severity plus had a PACCI 30+ days after the intervention began. For the AIM group, “Post” was defined as the last PACCI 30+ days after starting use of AIM and “Pre” as the first PACCI showing persistent asthma 14+ days prior to Post (n=444). For controls, Post was the last completed PACCI and Pre was first PACCI with persistent asthma 14+ days prior to Post (n=313).

This type of clinical process support will be illustrated for Social Determinants of Health and ADHD.

Results

The AIM group had significantly more days of no quick relief medication use and fewer steroid bursts for exacerbations. Those “poorly controlled” at Pre were significantly more likely to be on controller at Post in the AIM group (100% vs. 81%). Mean number of acute asthma visits in the past 3 months was significantly lower in the AIM group. Patients in the AIM condition tended to have fewer hospitalizations, fewer ED or urgent care visits and tended to have larger Pre-Post drops in utilization.

Conclusion(s)

1. Use of this asthma online clinical process support system by pediatricians showed some benefits with less rescue medicine and steroid burst use suggesting less need for care for exacerbations and also fewer acute asthma visits. In addition, children in the AIM group with initially “poorly controlled” asthma were more often appropriately treated with controller medication.

2. A clinical process support system using patient generated data triggering “patient specific templates”; options for post visit education and monitoring; and metrics for QI/MOC-4 efforts holds promise for improvements in care resulting in improved outcomes.

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