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  • Pre-post design: the patient/family interviews are done with a subset of kids who are followed longitudinally, while the random chart review samples the entire clinic.
  • A Best Practice Approach to Asthma Disparities in Children
    NAEPP Guidelines for the Diagnosis and Management of Asthma
    National Inner-City Asthma Study
    California Department of Public Health Childhood Asthma Programs:
    Childhood Asthma Initiative
    California Asthma Among the School Aged Program
    Best Practices in Childhood Asthma (BPCA)
    AAP
    Provided and updated annually
    Symptom based
    Clear action steps
    Asthma Education Basics
    Learning about asthma/responding to patient questions
    Understanding medications
    Appropriate use of inhalers, nebulizers
    Recognizing and monitoring symptoms
    Using an asthma action plan to self-manage asthma attacks
    When to seek urgent care
    Identifying and reducing triggers
    HEA
    Based upon EPA Guidelines
    Review of exposures to key triggers:
    Dust mite
    Cockroach
    Mold
    Tobacco Smoke
    Pets
    Assist with measures to reduce or eliminate exposures
    Clinic Visit Flow Sheet
    Recent day/night symptom history
    Recent SABA use
    Urgent care, ED, hospital utilization
    Missed school, work, activities
    Also provides documentation of:
    Asthma meds
    Severity classification
    Recent peak flow/spirometry results
    Specialist referrals
    Allergy tests results
    Patient education
    Home environmental assessment
  • We run the statistical tests at the program-level (across clinics) all results are highly significant (except controller meds Rx).
    The results are not homogeneous across clinics and one shouldn't really give a program-level p value.
    Most clinics improved for most measures (and all improved for at least some of the indicators).
    The following data slides mix interview questions and chart review—one set of results is for the longitudinal interview group, the other for the clinic-wide population.
  • These are the demographics at baseline for the clinic population (chart review), excluding all kids with “unknown” race/ethnicity (most were from Sutter, which did not collect any race data) – n=631
    Total n for all clinics:
    From the chart review populations that the clinics pulled for us to select random charts, we estimate that the 17 clinics serve about 12,000 pediatric asthma patients each year (patients who come in for at least one asthma visit that year).
    Total n for chart reviews
    We asked for 40 charts from each clinic at baseline and f/u (680 charts at each timepoint)
    Total n for interviews
    We asked every clinic to enroll 80 kids into the long interview group (out of the total 250 they were asked to enroll into the program over the 2 years).
    The total number of kids followed up at Y1 was 1053.
    979 Y1 f/u interviews were collected within 4 weeks before and 4 weeks after the anniversary of the baseline interview. Of these 83 (83%) were Hispanic.
  • Total n
    This n is different from the slide before (which was for the whole clinic population). This slide is about the Hispanic kids in the BL-Y1 interview group. Of the 979 kids with a Y1 f/u interview within 4 weeks before and after the anniversary of the baseline interview, 813 were Hispanic (i.e., the denominator for the above graphs) – 83% of the analyzable BPCA interviewees
    Health care details
    Other government subsidized programs include Healthy Families, Healthy Kids, CA Kids, etc.
    CRI information:
    We received a CRI for every child under 6 (after a lot of prodding), since it was an eligibility criterion for 0-5 year olds.
    75% of the Hispanic interviewees had a positive result
    Of the 25% with a negative result (n=93) only 5% did not have an asthma code (493.00-493.92)
  • Chart review items:
    17. For the last asthma visit, does the chart indicate the number of visits the patient has made to a clinic (not including ED visits) and/or doctor’s office because the patient had an asthma ATTACK?
    1 Yes 0 No
     17b. If yes, what was the specified time frame for the acute visits?
    16. For the last asthma visit, does the chart indicate the number of visits the patient has made to the emergency department due to the patient’s asthma?
    1 Yes 0 No
     16b. If yes, what was the specified time frame for the emergency department visits?
    15. For the last asthma visit, does the chart indicate the number of times the patient was hospitalized (overnight or longer) due to his/her asthma?
    1 Yes 0 No
    11. At the last asthma visit, did the practitioner document how often the patient had DAYTIME coughing, wheezing, or shortness of breath?
    1 Yes 0 No
      11b. If yes, what was the specified time frame?
    12. At the last asthma visit, did the practitioner document how often the patient had NIGHTTIME coughing, wheezing, or shortness of breath?
    1 Yes 0 No
      12b. If yes, what was the specified time frame?
    20. Is there documentation that a written Asthma Action Plan was created, updated or reviewed at the last asthma visit?
    1 Yes 0 No
  • Chart review items:
    11. At the last asthma visit, did the practitioner document how often the patient had DAYTIME coughing, wheezing, or shortness of breath?
    1 Yes 0 No
      11b. If yes, what was the specified time frame?
    3 In the past 1 month
    2 In the past 2 weeks
    1 In the past 1 week
    9 Other time frame (Specify):_________________
    99 No time frame was specified
    12. At the last asthma visit, did the practitioner document how often the patient had NIGHTTIME coughing, wheezing, or shortness of breath?
    1 Yes 0 No
      12b. If yes, what was the specified time frame?
  • Interview questions:
    38. Has any health care provider ever asked you about your (or your child’s) exposure to asthma triggers, which are things in your environment that may make your asthma worse?
    1 Yes 0 No 99 Not sure
    39. Has any health care provider ever provided education on your (or your child’s) potential asthma triggers?
    1 Yes 0 No 99 Not sure
    Chart review item:
    20. Is there documentation that a written Asthma Action Plan was created, updated or reviewed at the last asthma visit?
    1 Yes 0 No
     
    20b. If No, was an asthma action plan created or reviewed and updated in the past 12 months or less?
    1 Yes 0 No 9 Not sure (there is no mention in the progress
    note and no asthma action plan in the chart)
  • Interview questions:
    27. Do you (Does your child) have quick-relief medication, in case it is needed to help relieve coughing, wheezing, shortness of breath, or tightness in the chest (First ask the question and, if necessary, describe what quick-relief medication is. If the respondent is still unsure, show poster of quick-relief medications)
    1 Yes (and patient/family know that
    it is quick-relief medication)
    2 Yes, but patient/family do not know that it is quick-relief medication
    (Use this response if a poster was required to prompt the child/family. Go
    to Q. 28)
    3 No
    99 Don’t know
    29. Do you (Does your child) always use a spacer (e.g. aerochamber, aerochamber with mask, inspirease, etc.) with your (his/her) MDI inhaled asthma medications?
    1 Yes 0 No 99 N/A (patient does not have MDI inhaled medications)
  • Interview tool items:
    10. Is controller medication from the following list prescribed for the child’s current use?
    (This question is on the interview tool, i.e., for the longitudinal interview group, but is abstracted from the chart)
    28. Are you (Is your child) currently taking long-term controller medication(s) for asthma? (First ask the question and, if necessary, describe what controller medications are. If the respondent is still unsure, show poster of controller medications)
    1 Yes (and patient/family know
    that it is controller medication)
    2 Yes, but patient/family do not know that it is controller medication
    (Use this response if a poster was required to prompt the child/family. Go
    to Q. 29)
    3 No, has controller medications, but does not take them currently
    4 No, does not have controller medication
    99 Don’t know
  • Interview questions:
    19. In the past 2 WEEKS, how often have you (has your child) had DAYTIME coughing, wheezing, difficulty
    breathing, or shortness of breath? (Choose one answer that BEST describes the child’s daytime symptoms)
    5 Every day, ALL the time
    4 Every day, but NOT all the time
    3 More than twice a week, but NOT everyday
    2 Once or twice a week
    1 Patient did not have DAYTIME coughing, wheezing, or shortness of breath
    [For this question we dichotomized the responses. “Frequent means “more than twice a week”.]
    20. In the past 1 MONTH, how often have you (has your child) had NIGHTTIME coughing, wheezing, difficulty
    breathing, or shortness of breath? (Choose one answer that BEST describes the child’s nighttime symptoms)
    5 Frequently (more than 8 times a month or more than twice a week)
    4 Between 5 and 8 times per month or more than once a week
    3 3 - 4 times per month or less than once a week
    2 Once or twice per month
    1 Patient did not have NIGHTTIME coughing, wheezing, or shortness of breath.
    [“Frequent means “more than twice a month”.]
    27b. If yes, ASK: In the past 2 WEEKS, how often have you (has your child) taken any of the quick-relief medications to help relieve coughing, wheezing, shortness of breath, or tightness in the chest?
    1 Twice a week or less 2 More than twice a week
    [This question was asked only of kids who have rescue meds and know that they are rescue meds]
  • Interview questions:
    25. In the past 6 MONTHS, how many visits have you (has your child) made to a clinic (not including ED visits) and/or doctor’s office because of an asthma ATTACK?
    (no visits = 0)
    24. In the past 6 MONTHS, how many visits have you (has your child) made to the emergency department due to asthma?
    (no visits = 0)
    23. In the past 6 MONTHS, how many times were you (was your child) hospitalized (overnight or longer) due to asthma?
    (no hospitalizations = 0)
  • Interview questions:
    21. In the past 1 MONTH , how many days of school, preschool or daycare have you (has your child) missed because of asthma?
    (no missed days = 0) 99 N/A (child does not go to school or daycare)
    22. In the past 1 MONTH, how many WORK days has a parent, guardian or other caregiver missed because of your (your child’s ) asthma?
    (no missed days = 0) 99 N/A (parents, guardians or other caregivers do not work)
  • QoL Interview:
    Results are derived from Elizabeth Juniper’s child and caregiver quality of life surveys.
    Child survey (age 7+) includes 23 items encompassing 3 domains:
    Activity limitation
    Symptoms
    Emotional function
    Caregiver survey has 13 items on 2 domains:
    Activity limitation
    Emotional function
    Response options (printed on 2 colored cards)that are shown to the child/caregiver) are on a 7-point scale and range from
    All of the time (1) …. None of the time (7)
    Extremely bothered (1)… not bothered (7)
    Very, very worried/concerned … Not worried/concerned (caregiver)
    An average response score is calculated across all items. Scores above 6.0 (out of a possible 7) are categorized by as “very good” QoL
  • Click Here for Power Point Slides

    1. 1. Utilizing Clinical Best Practices to Improve Asthma Care and Outcomes for Hispanic Children in California National Hispanic Medical Association 14th Annual Conference Washington, DC March 25, 2010 David Núñez, MD, MPH California Asthma Public Health Initiative California Department of Public Health
    2. 2. Evidence of Asthma Disparities Affecting Latino/Hispanic Children • Documented care deficiencies: • Fewer prescriptions for controller meds • Fewer follow-up appointments after ED • Fewer specialist referrals • Factors associated with inadequate therapy • Age </= 5 years • Medicaid insurance • Uninsured • Spanish language • Documented disparities in health outcomes • More school absences, activity limitation, sleep difficulty • Increased ED visits • Increased hospitalizations
    3. 3. Potential Contributors to Asthma Disparities in Hispanics • Biologic and Genetic Factors • Environmental Exposures • Social Determinants of Health • Income • Education • Language and culture • Residential segregation • Access and barriers to health care • Quality of care • Fewer than half of Community Health Center (CHC) patients receive appropriate asthma care • California CHCs provide care to a large proportion of Medicaid-insured, Latinos living in underserved areas
    4. 4. Intervention Design • Target Audience: Community Health Centers • Request for Applications  Selection of 17 Community Clinics for 2-year Program (Apr 06- Jun 08), Funded $70K/year • Required Support • Clinic Champion (physician or nurse practitioner) • Clinic Continuous Quality Improvement (CQI) Team • Clinic Administration Support • Pre-Post Evaluation: (1) patient/family interviews and (2) random chart review • State Program technical assistance, training, and evaluation
    5. 5. Components of BPCA • NAEPP Guideline-based care • Clinic-based Care Coordinators • Continuous Quality Improvement (CQI) • Implementation of four best practices: • Asthma Action Plans (AAP) • Basic Asthma Education • Home Environmental Assessment • Clinic Asthma Visit Flow Sheet
    6. 6. Addressing Hispanic Culture and Language • 86% of Hispanic interviewees reported Spanish as the primary language spoken at home • Asthma Care Coordinators • 13/17 bilingual • Health Care providers • 16/17 clinics had providers fluent in Spanish • Translator resources available at clinic sites lacking bilingual staff • All asthma education materials and AAPs available in Spanish
    7. 7. BPCA Findings: Baseline – Year 1 *Data from this presentation is not to be reproduced, published, or presented without written permission from the California Asthma Public Health Initiative, CA Dept. of Public Health. *
    8. 8. Demographics – Race/Ethnicity of BPCA Clinic Populations
    9. 9. Demographics – Hispanic BPCA Program Interviewees
    10. 10. Examples of Insufficient Asthma Documentation at Baseline % ofHispanic Children who have had the Following Measures Documented in their Chartatthe LastClinic Visit: 7.0% 25.6% 23.5% 45.4% 38.6% 17.5% 0% 20% 40% 60% 80% 100% Acute Visits ED Visits Hospitalizations Day Symptoms Night Symptoms AAP Reviewed
    11. 11. Improvements in Chart Documentation of Asthma Symptoms Frequency of Daytime and Nighttime Symptoms Documented in the Chart at the Last Visit 45.4% 38.6% 68.3% 62.9% 0% 20% 40% 60% 80% 100% Daytime Symptoms Nighttime Symptoms Baseline Year 1
    12. 12. Improvements in Care Process – Education Given by Health Care Providers
    13. 13. Self-management Skills – Asthma Medication Use
    14. 14. Self-management Skills – Asthma Medication
    15. 15. Health Outcomes – Asthma Symptoms
    16. 16. Health Outcomes – Healthcare Utilization for Acute Asthma
    17. 17. Health Outcomes – Missed school/work
    18. 18. Quality of Life
    19. 19. Conclusions • A CQI approach guided by patient chart review was essential to improving CHC adherence to asthma clinical best practices. • Overall clinic documentation, quality of clinical asthma care, asthma health outcomes, and quality of life improved significantly in the Hispanic population over the course of the first year of the BPCA program. • Analysis of Year 2 data shows both similar increases and sustained improvements. • Culturally and linguistically appropriate services are an essential component. • Improving the quality of asthma care in California CHC’s could dramatically reduce asthma disparities impacting Hispanic children.
    20. 20. Implications for Policy and Clinical Practice • Quality of asthma care is defined by more than prescriptions for controller medications. • Health care delivery systems (and patients) would benefit from standards of care measuring multiple key components of quality asthma care. • Sustainability and dissemination of asthma care improvements in CHC’s remains a critical concern. • Cost savings/ROI are a consideration. • Timely, consistent quality and health outcome data (including race/ethnicity) are essential for assessing progress.
    21. 21. www.betterasthmacare.org www.cdph.ca.gov/PROGRAMS/CAPHI www.cdph.ca.gov/healthinfo/discond/Pages/Asthma.aspx

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