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。这些应该接受预防性哮喘药物治疗的儿童中，有许多人并没有得到这些药物。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，大多数临床医生在就诊时没有系统地筛查哮喘症状。该项目的目标是评估在城市初级保健办公室实施的多方面提示干预是否能降低城市哮喘儿童的发病率。本研究建立在我们在2个城市诊所进行的随机试验的基础上，在试验中我们发现，在门诊就诊时提示临床医生哮喘的严重程度和护理指南，可以改善预防性护理的提供。我们建议在临床与转化科学研究所基于实践的研究网络的12种不同实践中对510名2-12岁的儿童进行全规模集群随机试验。实践将被匹配成6对，然后随机分配到多方面提示干预（MPI）或常规护理。对于已登记的干预受试者，MPI将包括针对卫生保健提供者的提示和针对护理人员的简化提示，设计用于办公室访问期间，并由训练有素的研究助理在候诊室的平板电脑上准备。这些提示旨在促进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，以及个性化的基于指南的护理建议。干预实践也将得到实践层面的支持，包括互动式研讨会，获得教育计划和资源指南，以及一年两次的主要结果表现反馈。我们将评估干预措施在降低哮喘发病率方面的有效性（包括无症状天数作为主要结果，以及额外的临床和功能结果），并将评估MPI儿童和常规护理实践中预防性护理提供的程度和性质（由指标就诊时基于指南的纠正措施的发生来定义）。在研究结束时，基于办公室的提示的有效性将被更好地定义为降低高危哮喘儿童发病率的可持续手段。这种类型的干预在全国范围内广泛适用于哮喘护理实践，以及其他慢性疾病的管理。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用的系统变革，以促进对有效哮喘护理指南的遵守。如果证明它能成功地减轻城市哮喘儿童的症状并改善其健康状况，它就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.