The SHAKE Study: Sustaining High-quality Asthma care for Kids Everywhere

项目摘要/摘要 医疗保健提供者在坚持循证指导方针方面面临着许多挑战，这导致了贫困 美国每年有10万名哮喘住院儿童的健康状况。成功 已经制定了促进提供者最初采用指南的方法，但到目前为止，几乎没有研究 重点关注了有力地维持准则遵守的方法。粘附性通常在最初的 将删除实施资源。这对患有哮喘的儿童产生了不利影响，因为70%的儿童在 综合医院，那里的资源往往优先分配给成人护理。路径(简明版本 为医疗保健提供者提供直观、循序渐进的指导的指南)提高护理质量 因哮喘住院的儿童。路径实施策略(促进路径的方法 (实施)在综合医院的儿童护理方面取得了短期改善。然而，为了 要从有限的实施资源中获得最大价值，我们必须确定哮喘路径的实施 促进在综合医院持续提供高质量儿童护理的战略。要做到这一点， 目标，这项提议利用“积极偏离”办法，主张识别和 对表现较好和较差的医院进行检查可以促进发现和广泛传播 改善护理的战略。具体目标1将涉及对现有数据进行二次量化分析。多个- 将使用中断时间序列方法的水平回归模型来确定医院级别的因素 与可持续性相关，以及可持续性绩效较高和较低的医院。可持续性将 定义为在路径结束后2年内维持更高的指南遵从性和更高的护理质量 在删除执行资源后，执行(长期效益)不会下降。结果将会 包括住院时间(反映康复时间临床结果)和使用计量吸入器(指南 坚持)。具体目标2将研究目标1中确定的表现较好和较差的综合医院，使用 定性的、恒定的比较方法。实施战略的Eric框架将用于 为参与路径实施的关键人员制定半结构化面试指南。这一分析 将确定促进可持续性的路径实施战略和重要的背景因素 影响他们的成功。这种混合方法将产生一个多维的、全面的 了解综合医院如何促进持续提供高质量的儿童护理 哮喘。这些发现将填补我们对可持续发展理解的关键空白，使综合医院能够 更有效地针对有限的资源，并使我们能够开发一个比较有效的试验 可持续发展干预。因此，这些发现将产生重要的积极影响--它们将推动 临床实践改进的科学性，促进循证指南的持续使用，并改进 儿童的医疗保健质量，是AHRQ优先考虑的人群。

PROJECT SUMMARY/ABSTRACT Healthcare providers' face many challenges adhering to evidence-based guidelines, and this contributes to poor health outcomes for the >100,000 children hospitalized with asthma annually in the United States. Successful methods to promote providers' initial adoption of guidelines have been developed, but to date, little research has focused on methods to robustly sustain guideline adherence. Adherence commonly deteriorates after initial implementation resources are removed. This adversely impacts children with asthma, as >70% are cared for in general hospitals, where resources tend to be preferentially allocated to adult care. Pathways (succinct versions of guidelines that provide visual, step-by-step guidance for healthcare providers) improve quality of care for children hospitalized with asthma. Pathway implementation strategies (methods for promoting pathway implementation) have achieved short-term improvements in care of children in general hospitals. However, to reap maximum value from limited implementation resources, we must identify asthma pathway implementation strategies that promote sustained delivery of high-quality care for children in general hospitals. To achieve that objective, this proposal harnesses the “positive deviance” approach, which asserts that identification and examination of higher- and lower-performing hospitals can facilitate the discovery and wide dissemination of strategies to improve care. Specific aim 1 will involve a secondary quantitative analysis of existing data. Multi- level regression models with an interrupted-time series approach will be used to identify hospital-level factors associated with sustainability and hospitals with higher and lower sustainability performance. Sustainability will be defined as maintenance of higher guideline adherence and higher quality of care at 2 years after pathway implementation (long-term benefit) without declines after implementation resources are removed. Outcomes will include length of stay (clinical outcome that reflects time to recovery) and use of metered-dose inhalers (guideline adherence). Specific aim 2 will study the higher- and lower-performing general hospitals identified in Aim 1 using qualitative, constant comparative methods. The ERIC Framework of implementation strategies will be used to develop a semi-structured interview guide for key personnel involved in pathway implementation. This analysis will identify pathway implementation strategies that promote sustainability and important contextual factors that influence their success. This mixed-methods approach will produce a multi-dimensional, comprehensive understanding of how general hospitals can promote sustained delivery of high-quality care for children with asthma. These findings will fill crucial gaps in our understanding of sustainability, enable general hospitals to more effectively target limited resources, and enable us to develop a comparative-effectiveness trial of sustainability interventions. Thus, these findings will have important positive impacts-- they will advance the science of clinical practice improvement, facilitate sustained use of evidence-based guidelines, and improve health care quality for children, an AHRQ priority population.