Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized Controlled Trial

Abstract

Purpose: The purpose of this study was to assess patient and practice outcomes after introducing the Asthma APGAR (Activities, Persistent, triGGers, Asthma medications, Response to therapy) tools into primary care practices.

Methods: We used a pragmatic cluster-randomized controlled design in 18 US family medicine and pediatric practices to compare outcomes in patients with persistent asthma aged 5 to 45 years after introduction of the Asthma APGAR tools vs usual care. Patient outcomes included asthma control, quality of life, and emergency department (ED), urgent care, and inpatient hospital visits. The practice outcome was adherence to asthma guidelines.

Results: We enrolled 1,066 patients: 245 children, 174 adolescents, and 647 adults. Sixty-five percent (692 patients) completed both baseline and 12-month questionnaires, allowing analysis for patient-reported outcomes. Electronic health record data were available for 1,063 patients (99.7%) for practice outcomes. The proportion of patients reporting an asthma-related ED, urgent care, or hospital visit in the final 6 months of the study was lower in the APGAR practices vs usual care practices (10.6% vs 20.9%, P = .004). The percentage of patients with "in control" asthma increased more between baseline and 1 year in the APGAR group vs usual care group (13.5% vs 3.4%, P =.0001 vs P =.86) with a trend toward better control scores and asthma-related quality of life in the former at 1 year (P ≤.06 and P = .06, respectively). APGAR practices improved their adherence to 3 or more guideline elements compared with usual care practices (20.7% increase vs 1.9% decrease, P = .001).

Conclusions: Introduction of the Asthma APGAR tools improves rates of asthma control; reduces asthma-related ED, urgent care, and hospital visits; and increases practices' adherence to asthma management guidelines.

Trial registration: ClinicalTrials.gov NCT01446315.

Keywords: asthma; asthma control; asthma management; asthma tool; guideline; implementation; outcomes; practice-based research; pragmatic research; primary care; protocol; randomized clinical trial.

Figure 1

Asthma APGAR patient form.

Figure 2

CONSORT diagram for cluster-randomized trial of APGAR tools implementation in primary care. APGAR = Activities, Persistent, triGGers, Asthma medications, Response to therapy; CONSORT = Consolidated Standards Of Reporting Trials.

Figure 3

Primary outcomes: asthma-related ED, urgent care, and hospital visits, and asthma control (rates of “in control”). ACT = Asthma Control Test; APGAR = Activities, Persistent, triGGers, Asthma medications, Response to therapy; ED = emergency department. ^a ACT score ≥20. Note: Rates of asthma-related ED, urgent care, and hospital visits compared with χ² test. Rates of asthma control compared with McNemar test.