1. Impact of the “Asthma Toolbox” for Improving Documentation of Pediatric Asthma Management in an Urban Community Health Center Presenter: Delaney Gracy, MD, MPH Co-Authors: Alan Shapiro, MD; Ariel Sarmiento, MPH; Wendy Quinones, BSN, RN, MSN, LPNP; Jo Applebaum, MPH Academy Health National Research Meeting Washington DC, June 8, 2008

2. Childhood Asthma Initiative A multidisciplinary program to improve asthma care for severely disadvantaged and under- served pediatric population since 1997 A multidisciplinary program to improve asthma care for severely disadvantaged and under- served pediatric population since 1997 Funded by the Picower Foundation Funded by the Picower Foundation Implemented in Community Pediatric Programs of the Children’s Hospital at Montefiore Implemented in Community Pediatric Programs of the Children’s Hospital at Montefiore South Bronx Health Center for Children and Families (FQHC) South Bronx Health Center for Children and Families (FQHC) New York Children’s Health Project (HCH) New York Children’s Health Project (HCH)

3. Research Objective To evaluate a standardized provider reminder tool developed to document the assessment and treatment of pediatric asthma patients in a primary care setting To evaluate a standardized provider reminder tool developed to document the assessment and treatment of pediatric asthma patients in a primary care setting

4. Population Studied Pediatric patients at the South Bronx Health Center for Children and Families Pediatric patients at the South Bronx Health Center for Children and Families community health center community health center underserved inner-city neighborhood underserved inner-city neighborhood 96% minority 96% minority 27% pediatric asthma prevalence (2006) 27% pediatric asthma prevalence (2006) childhood asthma hospitalization rates in community served twice that of NYC overall (9.6-11.0 vs 5.4/1000) childhood asthma hospitalization rates in community served twice that of NYC overall (9.6-11.0 vs 5.4/1000)

5. Asthma Toolbox Boxed set of questions based on NHLBI guidelines printed on all pediatric medical chart forms (well child, follow-up and walk-in forms) Boxed set of questions based on NHLBI guidelines printed on all pediatric medical chart forms (well child, follow-up and walk-in forms) Prompts providers to consistently and accurately assess and treat pediatric asthma patients in a busy primary care setting Prompts providers to consistently and accurately assess and treat pediatric asthma patients in a busy primary care setting Use of NHLBI guidelines facilitated by streamlined set of questions that can be completed quickly Use of NHLBI guidelines facilitated by streamlined set of questions that can be completed quickly

6. Sample Toolbox

7. Study Design Chart review conducted to determine whether the Asthma Toolbox improved documentation of: Chart review conducted to determine whether the Asthma Toolbox improved documentation of: asthma severity classification asthma severity classification prescribing of controller medications prescribing of controller medications visits to the emergency department (ED) visits to the emergency department (ED) hospitalizations hospitalizations

8. Study Design (cont’d) Sample (N=300) Sample (N=300) 100 patients for each measurement period 100 patients for each measurement period randomly selected randomly selected ages 6 mo to 20 y with a non-urgent visit ages 6 mo to 20 y with a non-urgent visit Measurement periods Measurement periods pre: 11/1/04-10/31/05 pre: 11/1/04-10/31/05 post: 12/1/05-11/30/06 post: 12/1/05-11/30/06 late post: 1/1/07-6/30/07 late post: 1/1/07-6/30/07

9. Study Design (cont’d) Chart review Chart review Last asthma visit in measurement period selected for review Last asthma visit in measurement period selected for review If visit excluded, previous visit reviewed If visit excluded, previous visit reviewed Statistical analysis Statistical analysis Chi-square tests used to compare percentage of patients with variables documented Chi-square tests used to compare percentage of patients with variables documented pre- vs post-; post- vs late post-implementation pre- vs post-; post- vs late post-implementation

10. Findings: Documentation of Assessment and Treatment Chi-square tests used to compare percentage of patients with variables documented at last eligible visit in the measurement period. Percent (%) p=.000 p<.01 p=.000 82 95 100 16 58 84 50 62 90 SeverityOverallPersistent On Controller

11. Findings: Documentation of ED Visits Percent (%) p=.000 all comparisons Prior 4 moPrior 12 mo Chi-square tests used to compare percentage of patients with variables documented at last eligible visit in the measurement period.

12. Findings: Documentation of Hospitalization Percent (%) p=.000 all comparisons Prior 4 moPrior 12 mo Chi-square tests used to compare percentage of patients with variables documented at last eligible visit in the measurement period.

13. Conclusions The Asthma Toolbox significantly improved the documentation of key variables in pediatric asthma management, including asthma severity classification and prescribing of controller medications in persistent asthmatics The Asthma Toolbox significantly improved the documentation of key variables in pediatric asthma management, including asthma severity classification and prescribing of controller medications in persistent asthmatics A standardized brief provider-prompt assisted providers in complying with current asthma guidelines in the context of complex medical encounters A standardized brief provider-prompt assisted providers in complying with current asthma guidelines in the context of complex medical encounters Acceptance of provider-prompt demonstrated by high percentage of usage Acceptance of provider-prompt demonstrated by high percentage of usage

14. Implications for Primary Care Practice and Policy Use of provider-prompts incorporated into the medical record can improve adherence to clinical guidelines Use of provider-prompts incorporated into the medical record can improve adherence to clinical guidelines Assessment, treatment and monitoring of pediatric asthmatics can be improved in a busy primary care setting Assessment, treatment and monitoring of pediatric asthmatics can be improved in a busy primary care setting Consistent documentation in the chart can assist in quality improvement activities by facilitating data collection from the medical record and improve outcome tracking Consistent documentation in the chart can assist in quality improvement activities by facilitating data collection from the medical record and improve outcome tracking

15. Next Steps The Asthma Toolbox has been revised to reflect NHLBI 2007 guidelines The Asthma Toolbox has been revised to reflect NHLBI 2007 guidelines To be incorporated into adult medical record forms To be incorporated into adult medical record forms The Asthma Toolbox has been adapted for and will be incorporated into an electronic health record template The Asthma Toolbox has been adapted for and will be incorporated into an electronic health record template

16. Thank You