Promoting Asthma Guidelines and Management through Technology-Based Intervention and Care Coordination (PRAGMATIC)

项目摘要/摘要 哮喘对居住在纽约布朗克斯等市中心的低收入少数族裔儿童的影响不成比例。 国家指南的使用将哮喘发病率降低了70%；然而，这些指南并不一致 由医疗保健提供者实施。尽管有几种干预措施可以提高服务提供商对 哮喘指南已被描述，但很少有研究涉及将指南转化为常规护理。 这项研究建立在我们评估12家城市诊所多方面激励干预(MPI)的经验基础上 (R01HL091835，派·哈特曼)。尽管这种干预在短期内有效，但必须加以修改，以 转化为例行公事。我们将在几个方面增强MPI：(1)使用诊所而不是研究人员来 促进评估每次就诊时的提示；(2)确保提示所有儿童以指导方针为基础的护理 2-12岁，患有持续性或未控制的哮喘，而不仅仅是一个研究样本；(3)常规提供 通过电子健康记录(EHR)向提供者提示；(4)提供基于电话的护理协调， 通过专职外展工作者(OW)向发病率最高的儿童提供教育和支持；以及(5) 提供实践层面的支持(例如，诊所冠军、持续的绩效反馈和参与式 解决问题)，以促进指南的全面采用。增强的MPI计划(EMPI)包括 创新的多层次和基于团队的战略，使提供者能够有效和高效地采用哮喘 护理指南。作为对PAR-15-279的回应，本研究将通过评估 EMPI在现实世界的初级保健环境中。我们将进行一项整群随机试验，将empi与 在22个布朗克斯诊所加强日常护理(EUC)，为5,000多名2-12岁儿童提供持续护理 或是失控的哮喘。实践将在4年内分4波加入这项研究。从促进者身上学到的教训 在前面的研究浪潮中，实施Empi的障碍将在以后的研究中用于改进实施 诊所。11个EUC实践将收到指南信息并评估儿童哮喘的严重程度和 控制，但不会提供主动干预组件。这项研究将(1)测试人力资本投资对 提供者采用哮喘管理指南(主要结果衡量标准是就诊的比例 &gt；1供应商采取的基于指南的纠正措施)；(2)确定是否一致地使用MPI 导致临床结果的短期和长期改善(以无症状天数衡量)； (3)使用RE-AIM框架对项目实施过程进行评估。我们还将评估小组 医疗保健利用程度和使用的资源的差异(即坚持跟踪访问， 专科转介、急诊和住院护理、转诊至OW)。拟议的研究将提供关键的 关于如何在儿科常规实践中实施以指南为基础的哮喘护理的新知识，以便 促进在美国各地的广泛传播和采用。

PROJECT SUMMARY/ABSTRACT Asthma disproportionately affects low-income, minority children residing in inner cities such as the Bronx, NY. The use of national guidelines reduces asthma morbidity by 70%; yet, these guidelines are not consistently implemented by health care providers. Although several interventions to improve provider adherence to asthma guidelines have been described, few studies have addressed translation of guidelines into routine care. This study builds on our experience evaluating a multifaceted prompting intervention (MPI) in 12 urban clinics (R01HL091835, PI Halterman). Although effective in the short-term, this intervention must be modified to translate into routine practice. We will enhance MPI in several ways: (1) use clinic rather than research staff to facilitate assessment for prompts at every visit; (2) ensure prompting for guideline-based care for all children ages 2-12 with persistent or uncontrolled asthma, rather than just a research sample; (3) routinely deliver prompts to the provider via Electronic Health Record (EHR); (4) offer telephone-based care coordination, education and support to children with the highest morbidity via a dedicated Outreach Worker (OW); and (5) provide practice-level supports (e.g. clinic champions, on-going performance feedback and participatory problem solving) to promote full adoption of guidelines. The enhanced MPI program (eMPI) consists of innovative multi-level and team-based strategies to enable providers to effectively and efficiently adopt asthma care guidelines. In response to PAR-15-279, this study will address the guideline-to-practice gap by evaluating eMPI in real-world primary care settings. We will conduct a cluster randomized trial comparing eMPI to enhanced usual care (eUC) in 22 Bronx practices serving over 5,000 children ages 2-12 years with persistent or uncontrolled asthma. Practices will join the study in 4 waves over 4 years. Lessons learned about facilitators and barriers to eMPI implementation in earlier study waves will be used to improve the implementation in later clinics. Eleven eUC practices will receive guideline information and assess children's asthma severity and control, but active intervention components will not be provided. This study will (1) test the impact of eMPI on provider adoption of asthma management guidelines (primary outcome measure is the proportion of visits with >1 guideline-based corrective actions taken by the provider); (2) determine whether consistent use of eMPI leads to both short- and long-term improvements in clinical outcomes (measured by the symptom-free days); and (3) evaluate the process of program implementation using RE-AIM framework. We will also evaluate group differences in the extent of healthcare utilization and resources used (i.e., adherence to follow-up visits, specialty referrals, emergency and in-patient care, referrals to OW). The proposed research will provide critical new knowledge about how to implement guideline-based asthma care in routine pediatric practice, in order to facilitate widespread dissemination and adoption across the U.S.