A Multifaceted Prompting Intervention for Urban Children With Asthma

描述（由申请人提供）：不成比例的贫困和少数民族儿童患有哮喘。许多应该接受预防性哮喘药物治疗的儿童没有接受这些药物。在我们之前的工作中，我们发现提供者经常错误地分类哮喘的严重程度，这种错误的分类导致预防药物的处方不足。此外，一旦开了预防性药物，许多儿童的哮喘控制仍然很差。重要的是，大多数临床医生在办公室就诊时不会系统地筛查哮喘症状。本项目的目标是评估在城市初级保健办公室实施的多方面激励干预是否降低了城市哮喘儿童的发病率。这项研究建立在我们在2个城市诊所进行的试点随机试验的经验基础上，我们发现，在办公室就诊时提示临床医生哮喘严重程度和护理指南，可改善预防性护理服务。我们提出了一个全面的集群随机试验，510名儿童年龄2-12岁，在12个不同的做法，从我们的临床和转化科学研究所的实践为基础的研究网络。实践将被匹配成6对，然后随机分配到多方面干预（MPI）或常规护理。对于入组的干预受试者，MPI将包括针对医疗保健提供者的提示和针对护理人员的简化提示，设计用于诊室访视期间，并由经过培训的研究助理在候诊室的平板电脑上准备。这些提示旨在刺激护理人员和提供者之间的沟通，并将包括有关患者哮喘严重程度或控制水平的信息以及基于指南的个性化护理建议。干预实践也将获得实践层面的支持，包括互动研讨会，获得教育计划和资源指南，以及每两年一次对其主要成果表现的反馈。我们将评估干预措施在降低哮喘发病率方面的有效性（包括无哮喘天数作为主要结局，以及其他临床和功能结局），并将评估MPI和常规护理实践中儿童预防性护理提供的程度和性质（定义为索引访视时基于指南的纠正措施的发生率）。在研究完成时，办公室提示的有效性将被更好地定义为一种可持续的手段，以减少高危哮喘儿童的发病率。这种类型的干预措施广泛适用于全国范围内的哮喘护理实践，以及其他慢性病的管理。公共卫生相关性：该项目可能对公共卫生产生深远的影响，因为它提出了一个实际的系统变化，以促进遵守有效的哮喘护理指南。如果它被证明在减轻症状和改善城市哮喘儿童的健康方面是成功的，它有可能成为改善城市社区哮喘护理的典范。

DESCRIPTION (provided by applicant): A disproportionate number of impoverished and minority children suffer from asthma. Many of these children who should receive preventive asthma medications are not receiving them. In our prior work, we found that providers frequently misclassify asthma severity, and this misclassification leads to inadequate prescription of preventive medications. Further, once preventive medications are prescribed, many children continue to have poor asthma control. Importantly, most clinicians do not systematically screen for asthma symptoms at office visits. The goal of this project is to evaluate whether a multifaceted prompting intervention, administered in urban primary care offices, reduces morbidity among urban children with asthma. This study builds on our experience with a pilot randomized trial in 2 urban clinics, in which we found that prompting clinicians about asthma severity and care guidelines at the time of an office visit resulted in improved preventive care delivery. We propose a full scale cluster randomized trial with 510 children ages 2-12 years in 12 different practices from our Clinical and Translational Science Institute's practice-based research network. Practices will be matched into 6 pairs and then randomly assigned to either the Multifaceted Prompting Intervention (MPI) or usual care. For enrolled intervention subjects, the MPI will include a prompt for the health care provider and a simplified prompt for the caregiver, designed for use during the office visit and prepared in the waiting room on a Tablet Personal Computer by a trained research associate. These prompts are designed to stimulate communication between the caregiver and provider and will include information regarding the patient's asthma severity or level of control as well as individualized guideline-based recommendations for care. Intervention practices also will receive practice- level supports, including interactive seminars, access to educational programs and resource guides, and bi- annual feedback on their performance for the primary outcomes. We will assess the effectiveness of the intervention in reducing asthma morbidity (including symptom-free days as the primary outcome, as well as additional clinical and functional outcomes) and will assess the extent and nature of preventive care delivery (defined by the occurrence of guideline-based corrective actions at the index visit) for children in MPI and usual care practices. At study completion, the effectiveness of office-based prompting will be better defined as a sustainable means to reduce morbidity among high-risk asthmatic children. This type of intervention is widely applicable for asthma care in practices nationwide, and for management of other chronic diseases. PUBLIC HEALTH RELEVANCE: NARRATIVE - RELEVANCE This project may have a profound impact on public health because it presents a practical system change to promote adherence to effective asthma care guidelines. Should it prove successful in reducing symptoms and improving the health of urban children with asthma, it has the potential to serve as a model for improved asthma care in urban communities.