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

项目概要/摘要 哮喘不成比例地影响低收入，少数民族儿童居住在内城，如布朗克斯，纽约州。 使用国家指南可将哮喘发病率降低70%;然而，这些指南并不一致。 由卫生保健提供者实施。虽然有几项干预措施，以提高供应商遵守 虽然哮喘指南已经被描述，但是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的经验，评估了多方面的激励干预（MPI）在12个城市诊所 （R01HL091835，PI Halterman）。虽然这种干预措施在短期内有效，但必须加以修改， 转化为日常实践。我们将从以下几个方面加强MPI：（1）使用诊所而不是研究人员， 促进每次就诊时对提示的评估;（2）确保提示所有儿童接受基于指南的护理 2 - 12岁持续性或不受控制的哮喘，而不仅仅是研究样本;（3）定期交付 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， 通过专门的外展工作者向发病率最高的儿童提供教育和支助;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性 解决问题），以促进准则的全面采用。增强型MPI程序（eMPI）包括 创新的多层次和基于团队的策略，使供应商能够有效地采用哮喘 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。我们将进行一项群集随机试验，比较eMPI与 在22个布朗克斯诊所中，为5,000多名2 - 12岁的儿童提供了增强型常规护理（eUC）， 或者哮喘失控实践将在4年内分4波加入研究。关于促进者的经验教训 早期研究浪潮中eMPI实施的障碍将用于后期的改进实施 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， 控制，但不会提供主动干预组件。本研究将（1）测试eMPI对 提供者采用哮喘管理指南（主要结局指标是 > 1提供商采取的基于指南的纠正措施）;（2）确定是否一致使用eMPI 导致临床结果的短期和长期改善（以无瘤天数衡量）; （3）利用RE-AIM框架对项目实施过程进行评估。我们还将评估组 保健利用程度和所用资源的差异（即，坚持后续访问， 专科转诊、急诊和住院护理、OW转诊）。这项研究将提供关键的 关于如何在常规儿科实践中实施基于指南的哮喘护理的新知识， 促进在美国的广泛传播和采用。

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.