The Breathewell Program to Improve Asthma Outcomes

 描述（由申请人提供）：尽管已建立循证治疗，但哮喘治疗存在重大差距，增加了哮喘相关急诊科就诊、住院和口服类固醇爆发的风险。提供者（治疗惰性、时间不足）、患者（依从性差、吸烟）和系统障碍（数据、监测、沟通和药物补充方面的挑战）促成了这些差距。电子健康记录（EHR）的应用有可能降低这些障碍，从而更好地控制哮喘并减少急性发作。本研究的目的是进行一项大型的实用性试验，以评估呼吸良好干预的有效性，成本效益和实施情况，该干预结合了循证EHR干预和基于团队的护理，以改善哮喘的结局。Breathewell采用EpicCare，这是美国使用最广泛的商业EHR，用于识别药物依从性差或未解决的吸烟问题，并自动将患者纳入药物补充或戒烟计划。对于哮喘急性发作或B激动剂吸入器过度使用的患者，EHR向患者发送决策支持工具，并通知护士使用EHR生成的报告与患者进行共享决策讨论，从而制定哮喘护理计划。EHR模板注释和订单集有助于护理计划的执行。该研究将在科罗拉多凯萨医疗机构的26家初级保健诊所进行，采用分组随机实用临床试验设计。超过10,400名哮喘患者将根据他们的诊所被分配到呼吸良好或呼吸护理。该评价评估了临床有效性（哮喘急性发作、生活质量和成本）和实施（干预效果的中介和调节因素、干预障碍和促进因素、患者和提供者印象以及RE-AIM框架转化措施）。这项研究意义重大，因为它可以通过解决循证哮喘护理的差距来大幅降低发病率。这项研究是创新的，因为它1）使用EHR同时解决提供者，患者和循证护理的系统障碍; 2）促进以患者为中心的决策; 3）整合循证EHR和交互式行为改变技术; 4）作为常规临床护理的一部分进行; 5）以英语和西班牙语提供。我们的研究结果可能会通过加速哮喘护理知识转化为实践来影响该领域。Breathewell的成功部署可以作为使用EHR改善许多慢性病护理的实施模式，这是NIH的研究重点和2020年健康人的目标。

 DESCRIPTION (provided by applicant): Despite established, evidence-based therapies, major gaps exist in asthma treatment, increasing the risk of asthma-related emergency department visits, hospitalizations, and oral steroid bursts. Provider (therapeutic inertia, insufficient time, patient (poor adherence, smoking), and system barriers (challenges with data, monitoring, communication, and medication refill) contribute to these gaps. The application of Electronic Health Records (EHRs) has the potential to lower these barriers leading to better asthma control and fewer exacerbations. The objective of this study is to conduct a large pragmatic trial to assess the effectiveness, cost-effectiveness, and implementation of the Breathewell intervention, which combines an evidence-based EHR intervention and team-based care to improve asthma outcomes. Breathewell employs EpicCare, the most widely used commercial EHR in the U.S, to identify poor medication adherence or unaddressed smoking and automatically enroll patients in a medication refill or smoking cessation program. For patients with asthma exacerbations or B-agonist inhaler overuse, the EHR sends the patients a decision support tool and notifies a nurse who uses an EHR-generated report to engage the patient in a shared-decision discussion, leading to development of an asthma care plan. EHR templated notes and order sets facilitate care plan execution. The study will be conducted in 26 primary care clinics of Kaiser Permanente Colorado using a cluster- randomized pragmatic clinical trial design. More than 10,400 asthma patients will be assigned to Breathewell or Usual Care based on their clinic. The evaluation assesses clinical effectiveness (asthma exacerbations, quality of life, and cost) and implementation (mediators and moderators of intervention effect, intervention barriers and facilitators, patient and provider impressions and RE-AIM framework translational measures). This study is significant because it could substantially reduce morbidity by addressing gaps in evidence-based asthma care. This research is innovative because it 1) uses the EHR to simultaneously addresses provider, patient, and system barriers to evidence-based care; 2) facilitates patient-centered decision making; 3) integrates evidence-based EHR and interactive behavioral change technologies; 4) is conducted as part of routine clinical care; and 5) is delivered in English and Spanish. Our results are likely to impact the field by speeding the translation of asthma care knowledge into practice. Successful deployment of Breathewell could serve as an implementation model for using EHRs to improve care for many chronic conditions, an NIH research priority and an objective of Healthy People 2020.