1. The Physician Asthma Care Education (PACE) Study Michael D. Cabana, MD, MPH Implementation Research: Epi 245 October 9, 2008 Department of Pediatrics, Epidemiology and Biostatistics and the Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (UCSF) Funded by the Robert Wood Johnson Foundation (Princeton, NJ)

2. Four Components of NHLBI Guidelines Measures of Assessment and Monitoring Control of Contributing Factors Pharmacologic Therapy Education for a Partnership in Asthma Care

3. Knowledge Attitudes Behavior Lack of Awareness Lack of Agreement External Barriers Lack of Self-Efficacy Lack of Outcome Expectancy Inertia BARRIER Lack of Familiarity

4. Barriers to Effective Communication Visit time is limited Providers have multiple tasks to accomplish in a single visit Patients may have different beliefs, concerns and goals about the treatment plan Communication skills were not previously emphasized in medical education

5. Overview Guideline recommendations for patient communication –Communication skills –Key messages Controlled trial results Next Steps

6. Specific communication techniques have been shown to enhance physician communication and outcomes for patients

7. Key Messages from the Guidelines Set #1 What happens during an asthma attack How to take medicines How to respond to changes in asthma severity Set #2 Safety of medicines Goals of therapy Criteria for successful treatment Set #3 Managing asthma at school Identifying and avoiding triggers Sources of additional asthma education

8. Key Educational Messages Group important concepts into groups of 3 to 4 key messages Spread out the delivery of these groups of key messages over several visits Reinforce key messages over time Use the patient medical record to keep track of which messages have been delivered

9. The PACE Program Pilot Target audience: Primary care pediatricians Purpose: To improve primary care counseling for patients with asthma Faculty: General pediatrician, asthma subspecialist, health educator and coding/billing expert Format: brief lectures, case studies, video modeling effective practices, and tools for self- evaluation and education Two 2.5 hour seminars one week apart

10. Pilot Intervention Design: Controlled trial Participants:83 pediatricians (Ann Arbor and New York) Evaluation:Asthma care of 637 patients (2 year follow-up)

11. Patient Outcomes Patients whose physicians provided education plus inhaled corticosteroids did better than those who received corticosteroids alone: –Reduced emergency room visits –Reduced hospitalizations –Reduced days with symptoms

12. Further Questions Can this program work in other communities in the United States? What additional modifications are needed to successfully disseminate this information to other communities?

13. Bakersfield, CA Corpus Christi, TX Jacksonville, FL New Castle County, DE Omaha, NE St. Paul, MN Nashville, TN Columbus, OH Indianapolis IN Kent County, MI Methods Design: Randomized Controlled Trial in 10 sites in the United States Randomization: 10 sites matched into 5 pairs Subjects: Over 100 physicians with follow-up of 870 of their patients with asthma Follow-up period: 1 year

14. Program Modifications Collaboration with opinion leaders –General pediatrics and asthma subspecialty care –“Train-the-trainer” session Endorsement of local medical organizations Additional segment on documentation, coding and billing for asthma education

15. Program Format Target audience: Primary care providers Faculty: General pediatrician, asthma subspecialist, health educator and coding/billing expert Format: brief lectures, case studies, video modeling effective practices, and tools for self-evaluation and education Two 2.5 hour seminars one week apart

17. Knowledge Attitudes Behavior Lack of Awareness Lack of Familiarity Lack of Agreement Lack of Self-efficacy Lack of Outcome Expectancy Inertia of Previous Practice External Barriers Knowledge Attitudes Behavior Copy of Guidelines Short lectures/discussion Review of Guidelines Handouts Opinion Leaders Local endorsement Teaching & Modeling specific skills Review of Data from previous studies One week test period Documentation, coding & reimbursement Checklists & reminders Placebos & Patient education materials

18. Provider Confidence Provider Confidence Provider Counseling Outcomes Patient Symptoms Asthma Healthcare Utilization Asthma Healthcare Utilization Self-administered physician questionnaires Telephone interviews with parents of asthma patients. Healthcare utilization validated by chart audit.

19. Analysis Plan ‘Intention to treat’ analysis Multivariate regression analyses –We controlled for baseline values, site, demographic characteristics, severity of illness and group assignment –Generalized estimating equation analysis for significant clustering –We included an interaction term for (group) x (baseline asthma utilization)

20. Results 101 primary care providers participated –48 control –53 intervention Patients randomly selected –870 of 1051 (83%) eligible parents interviewed –Median number of patients/provider = 7

21. Communication Technique OR95% CI Finding out the family’s biggest asthma concern 0.910.34, 2.40 Working with the family to develop a short- term asthma plan 3.791.34, 8.10 Working with the family to develop a long- term asthma plan 3.721.17, 11.7 Discussing specific criteria for managing asthma 2.400.74, 5.65 Impact on Provider Confidence Controlling for physician gender

22. Impact on Provider Communication Controlling for patient age, gender, severity of illness, tobacco exposure, insurance and baseline use of communication technique Communication Technique OR95% CI The doctor tried to find out my biggest asthma concern 1.731.17, 2.58 After talking to the doctor, we had a good idea of the short-term asthma plan 1.200.79, 1.82 After talking to the doctor, we knew about the long-term asthma plan 1.711.13, 2.59 The doctor discussed specific criteria about managing asthma 1.501.02, 2.24

23. Days Limited by Asthma Symptoms † ControlIntervention Mean Days/Year 10 30 20 BaselineFollow-up Baseline Follow-up 28.5 20.0 30.2 14.6 † p < 0.05; controlling for patient age, gender, severity of illness, tobacco exposure, insurance, baseline values and the interaction term for (group assignment) x (baseline value)

24. Emergency Department Utilization † ControlIntervention Mean ED visits per Year 10 30 20 BaselineFollow-up Baseline Follow-up † p < 0.05; controlling for patient age, gender, severity of illness, tobacco exposure, insurance, baseline values and the interaction term for (group assignment) x (baseline value) 0.66 0.35 0.85 0.31 0.20 0.40 0.60 0.80

25. Inpatient Asthma Hospitalization ControlIntervention BaselineFollow-up Baseline Follow-up 0.13 0.07 0.12 0.06 0.08 0.04 0.12 Mean Hospitalizations per Year

26. Physician Prescribing Patterns Improving Asthma Corticosteroid Therapy (IMPACT) Design: Randomized Controlled Trial Purpose: To evaluate the effectiveness of physician education for improving prescription of daily inhaled corticosteroids for asthma. Duration: 5 years Source: National Heart, Lung & Blood Institute (NHLBI)

27. Location of Physicians for Pilot Study D.A.L.I Distance Asthma Learning Initiative

28. Implementation Lessons Learned Standardization to make sure the message is consistent –Based on national asthma guidelines –Standard speaker’s guide, slides and video Tailoring the program to the community –Endorsement of professional organizations –Use of opinion leaders as faculty Consider multiple opinion leaders with different areas of expertise Appreciate and understand barriers –Perception that asthma counseling won’t be reimbursed –Perception that asthma counseling takes a lot of time

29. Lessons Learned Difficulty in reaching physicians in isolated communities Intervention may only attract “early adopters” Need to address perceived barriers (e.g., lack of outcome expectancy, reimbursement) Skills-based, interactive programs can be effective in improving physician practice and patient outcomes

30. Thank you