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A Multisite Randomized Trial of the Effects of Physician Education and Organizational Change in Chronic-Asthma Care
Health Outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study
Paula Lozano, MD, MPH;
Jonathan A. Finkelstein, MD, MPH;
Vincent J. Carey, PhD;
Edward H. Wagner, MD, MPH;
Thomas S. Inui, MD;
Anne L. Fuhlbrigge, MD, MS;
Stephen B. Soumerai, ScD;
Sean D. Sullivan, PhD;
Scott T. Weiss, MD;
Kevin B. Weiss, MD
Arch Pediatr Adolesc Med. 2004;158:875-883.
Background Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines.
Objective To evaluate the effectiveness of 2 asthma care improvement strategies in primary care.
Design Two-year randomized controlled clinical trial.
Setting Forty-two primary care pediatric practices affiliated with 4 managed care organizations.
Participants Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations.
Interventions Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care.
Main Outcome Measures Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts).
Results Six hundred thirty-eight children completed baseline evaluations, representing 64% of those screened and eligible. Mean ± SD age was 9.4 ± 3.5 years; 60% were boys. Three hundred fifty (55%) were taking controller medication. Mean ± SD annualized asthma symptom days was 107.4 ± 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95% confidence interval [CI], – 16.9 to 3.6), a nonsignificant difference, but had a 36% (95% CI, 11% to 54%) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95% CI, – 24.7 to –2.1) fewer symptom days annually (–12% from baseline; P = .02) and a 39% (95% CI, 11% to 58%) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95% CI, 1.00 to 1.09]).
Conclusions Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.
From the Center for Health Studies, Group Health Cooperative, Seattle, Wash (Drs Lozano and Wagner); Child Health Institute, Department of Pediatrics (Dr Lozano) and the School of Pharmacy (Dr Sullivan), University of Washington, Seattle; the Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Mass (Dr Finkelstein); the Department of Pediatrics (Dr Finkelstein) and Channing Laboratory (Drs Carey, Fuhlbrigge, S. Weiss, and Soumerai), Harvard Medical School, Boston; Regenstrief Institute for Health Care, Indianapolis, Ind (Dr Inui); Midwest Center for Health Services and Policy Research, Hines VA Hospital, and the Center for Healthcare Studies and the Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill (Dr K. Weiss).
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