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A Systematic Review

Dena M. Bravata, MD, MS; Allison L. Gienger, BA; Jon-Erik C. Holty, MD, MS; Vandana Sundaram, MPH; Nayer Khazeni, MD, MS; Paul H. Wise, MD, MPH; Kathryn M. McDonald, MM; Douglas K. Owens, MD, MS

Arch Pediatr Adolesc Med. 2009;163(6):572-581.

Objective  To evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient pediatric asthma care.

Data Sources  Cochrane Effective Practice and Organisation of Care Group database (January 1966 to April 2006), MEDLINE (January 1966 to April 2006), Cochrane Consumers and Communication Group database (January 1966 to May 2006), and bibliographies of retrieved articles.

Study Selection  Randomized controlled trials, controlled before-after trials, or interrupted time series trials of English-language QI evaluations.

Interventions  Must have included 1 or more QI strategies for the outpatient management of children with asthma.

Main Outcome Measures  Clinical status (eg, spirometric measures); functional status (eg, days lost from school); and health services use (eg, hospital admissions).

Results  Seventy-nine studies met inclusion criteria: 69 included at least some component of patient education, self-monitoring, or self-management; 13 included some component of organizational change; and 7 included provider education. Self-management interventions increased symptom-free days by approximately 10 days/y (P = .02) and reduced school absenteeism by about 0.1 day/mo (P = .03). Interventions of provider education and those that incorporated organizational changes were likely to report improvements in medication use. Quality improvement interventions that provided multiple educational sessions, had longer durations, and used combinations of instructional modalities were more likely to result in improvements for patients than interventions lacking these characteristics.

Conclusions  A variety of QI interventions improve the outcomes and processes of care for children with asthma. Use of similar outcome measures and thorough descriptions of interventions would advance the study of QI for pediatric asthma care.

Author Affiliations: Center for Primary Care and Outcomes Research (Drs Bravata, Khazeni, Wise, and Owens and Mss Gienger, Sundaram, and McDonald), Division of Pulmonary and Critical Care Medicine (Drs Holty and Khazeni), and Department of Pediatrics (Dr Wise), Stanford University, Stanford, and VA Palo Alto Health Care System, Palo Alto (Ms Sundaram), California.

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