Comparative effectiveness of asthma interventions within a practice based research network

Abstract

Background: Asthma is a chronic lung disease that affects more than 23 million people in the United States, including 7 million children. Asthma is a difficult to manage chronic condition associated with disparities in health outcomes, poor medical compliance, and high healthcare costs. The research network coordinating this project includes hospitals, urgent care centers, and outpatient clinics within Carolinas Healthcare System that share a common electronic medical record and billing system allowing for rapid collection of clinical and demographic data. This study investigates the impact of three interventions on clinical outcomes for patients with asthma. Interventions are: an integrated approach to care that incorporates asthma management based on the chronic care model; a shared decision making intervention for asthma patients in underserved or disadvantaged populations; and a school based care approach that examines the efficacy of school-based programs to impact asthma outcomes including effectiveness of linkages between schools and the healthcare providers.

Methods/design: This study will include 95 Practices, 171 schools, and over 30,000 asthmatic patients. Five groups (A-E) will be evaluated to determine the effectiveness of three interventions. Group A is the usual care control group without electronic medical record (EMR). Group B practices are a second control group that has an EMR with decision support, asthma action plans, and population reports at baseline. A time delay design during year one converts practices in Group B to group C after receiving the integrated approach to care intervention. Four practices within Group C will receive the shared decision making intervention (and become group D). Group E will receive a school based care intervention through case management within the schools. A centralized database will be created with the goal of facilitating comparative effectiveness research on asthma outcomes specifically for this study. Patient and community level analysis will include results from patient surveys, focus groups, and asthma patient density mapping. Community variables such as income and housing density will be mapped for comparison. Outcomes to be measured are reduced hospitalizations and emergency department visits; improved adherence to medication; improved quality of life; reduced school absenteeism; improved self-efficacy and improved school performance.

Discussion: Identifying new mechanisms that improve the delivery of asthma care is an important step towards advancing patient outcomes, avoiding preventable Emergency Department visits and hospitalizations, while simultaneously reducing overall healthcare costs.

Figure 1

Study Design. This study will include 95 Practices, 171 schools, and over 30,700 asthmatic patients. Five groups (A-E) will be evaluated to determine the effectiveness of each intervention. Group A is the usual care control group. Group B practices will provide a second control group with an EMR with decision support, Asthma action plans, and Population reports (EAP) at baseline. A time delay design will be used as all practices in Group B will receive the Integrated Approach to Care (IAC) intervention with 10-12 practices receiving the intervention every 2 months over a 1 year period of time. Four practices within Group C will receive the Shared Decision Making (SDM) approach intervention with 1 practice receiving the intervention every 4 months over a 2 year period. Group E will receive School Based Care (SBC) through case management within the schools.

Figure 2

Map of North and South Carolina Showing the Scope of Carolinas Healthcare System (CHS). Each county shaded in green is home to a CHS facility including the 32 hospitals and 95 clinics that will take part in this project.

Figure 3

Development of the Asthma Comparative Effectiveness Research Database (ACER). Data will be collected from 8 sources into the database including: Billing data, clinical data drawn electronically from the EMR, School data, Information collected by the school-based intervention, Medicaid data, clinic data via chart abstraction from control practices without an EMR, Patient level data from surveys and community-level data from the Center for Metropolitan Studies.

Figure 4

Map of Asthma Diagnosis in Mecklenburg County. Map of Mecklenburg County, NC showing Geographic Information Systems (GIS) analysis of the 6,800 patients with a primary diagnosis of asthma seen within the community clinic network over 1 year. The map shows patient density per square mile.