Brief Interventions by Primary Care Physicians Trained in Asthma Management Improve Pediatric Asthma Care
With a grant from the Robert Wood Johnson Foundation (RWJF), a research team from the University of Michigan School of Public Health expanded the Physician Asthma Care Education (PACE) project, which it had developed in the 1990s. The PACE model trains primary care physicians to use a brief clinical intervention to improve pediatric asthma care.
This grant allowed PACE project staff at Michigan to evaluate the PACE training to determine its impact on pediatric asthma patients. Project staff also involved a cadre of clinicians in promoting effective care among their peers.
- Project staff conducted an evaluation at 10 sites in 10 cities, with the participation of 101 primary care providers and 731 patients. Project staff initially trained some 30 "Master Trainers" to provide local PACE training; additional "train-the-trainer" sessions later made PACE training more broadly available.
- The National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health agreed to adopt and disseminate the PACE project. A page on NHLBI's Web site houses all project information and materials, including a training manual, videotapes, slide presentations and participant materials.
- Project staff disseminated more than 1,000 asthma toolkits to clinicians at conferences and meetings throughout the United States.
A year after the training:
- Patients of pediatricians who had PACE training had fewer days every season when their activities were limited by asthma (14.6 days versus 20 days).
- The number of emergency department visits dropped significantly for patients of pediatricians who participated in PACE training (falling by 0.55 visits for the PACE group, compared to a drop of 0.30 visits for the others).
- Using the intervention during a patient office visit did not affect the amount of time that pediatricians spent with patients.
RWJF provided a $2,396,670 grant for this project from September 2000 through December 2006.
Asthma is the most common chronic disease of childhood, according to the National Center for Education in Maternal and Child Health at Georgetown University in Washington. In 1999, more than 5 million children in the United States suffered from asthma, reflecting a dramatic increase in prevalence since 1980.
Despite asthma's potential severity, almost 80 percent of pediatric asthma cases can be successfully managed by general pediatricians in their offices, according to project staff at the University of Michigan School of Public Health.
Replicating an Earlier Model
In the 1990s, project staff developed and tested a project to train general practice pediatricians in delivering effective asthma care to children and their families. The Physician Asthma Care Education (PACE) project was designed to expand this model and evaluate its success when local faculty, rather than national experts, were trained as educators.
The training consisted of two 2.5 hour seminars led by experts who reviewed national asthma guidelines, communication skills and key educational messages. The training included:
- Clinical practice guidelines
- Case discussions on troubling clinical problems
- Examples of long-term asthma action plans
- A video modeling communication techniques
- Topics to cover with patients, including how medicines work and how to identify and avoid asthma triggers.
The approach was modeled on a "brief clinical intervention" format that had been developed and disseminated by the National Cancer Institute for use in tobacco control and was widely considered to be effective.
Physicians received continuing medical education credits for their participation. According to a 1998 paper published in Pediatrics, pediatricians who participated in the PACE seminars were more likely to have:
- Addressed patients' fears about medicines
- Reviewed written instructions with patients
- Explained in writing how patients should adjust medicines at home when their symptoms change.
Patients of these pediatricians were more likely to have:
- Received a prescription for inhaled anti-inflammatory medicine, a practice recommended in National Institutes of Health guidelines
- Fewer nonemergency office visits
- Fewer asthma symptoms.
Parents were more likely to report that their physicians had been reassuring, and that they knew how to manage their children's asthma at home.
Improving the quality of care given to people suffering from chronic health conditions is a key goal of RWJF. In 1998, RWJF staff considered how the Foundation might better focus its efforts on that objective. One recommendation was to explore one or two chronic diseases in depth, developing systems and interventions to improve the clinical care management and outcomes of individuals with those illnesses.
A disease-specific set of programs and projects, in addition to benefiting people suffering from that illness, could potentially produce models of care for other chronic diseases, the staff believed. In recent years, RWJF has increased its focus on improving the quality of chronic care generally and no longer has a focus on any single disease.
Influenced by asthma's increasing prevalence and its status as the most common chronic disease of childhood, RWJF staff recommended pediatric asthma as the focus of the first disease-specific effort. Initiatives on diabetes and depression followed.
The findings of a 1998 national survey (Asthma in America) funded by the pharmaceutical company GlaxoSmithKline were also influential in this decision. The survey of 700 health care providers and 2,509 asthma sufferers indicated that misunderstanding about asthma symptoms and treatment was widespread among patients and that the level of care fell short of National Heart, Lung and Blood Institute guidelines for asthma management.
In 1999, following a scan of asthma-related literature and activities to identify gaps and opportunities in the field, RWJF funded a spectrum of programs and projects to improve asthma treatment (including management of the disease) and policy.
According to Seth Emont, Ph.D, the original RWJF program officer and principal architect of the asthma initiative, the model used—bringing together a set of national programs and projects overlain by a structure to facilitate communication and collaboration—was new to RWJF.
"Each component was responsible for a different part of the wheel. We wanted to bring together clinical and nonclinical [policy] approaches. It was the first initiative to simultaneously address treatment, policy and financing issues at the patient, provider and institutional levels," said Emont. The components included:
- Allies Against Asthma, a $12.5 million, four-year program to support public-private coalitions working to improve the control of pediatric asthma in eight communities across the nation. The University of Michigan School of Public Health managed the program.
- A $228,000 RAND study of policy options for improving pediatric asthma outcomes. (See Grant Results on ID# 037143.)
- Four initiatives aimed at improving management of pediatric asthma in high-risk populations. The overall goal was to reduce asthma-related emergency room visits, hospital admission and costs of asthma care and to increase health-related quality of life for children with asthma:
- Improving Asthma Care for Children—the subject of this report, a $3.25 million program administered by the Center for Health Care Strategies. See Grant Results for more information.
- Managing Pediatric Asthma: Emergency Department Demonstration Program, a $3.5 million program to develop comprehensive interventions to reduce emergency room visits by—and hospitalizations of—children with asthma. The American Academy of Allergy, Asthma and Immunology administered the program. See Grant Results for more information.
- A $495,689 grant (ID# 037659) awarded to the Center for Health Care Strategies under Managing Pediatric Asthma to identify barriers to managing pediatric asthma and to develop new financing models for improved management. See Grant Results for more information
- Pediatric Asthma Care Education (PACE), the subject of this report.
This grant supported a project at the University of Michigan School of Public Health designed to:
- Create a large cadre of opinion leaders and trainers able to influence and educate primary care physicians delivering asthma care.
- Evaluate an approach to training pediatricians and other primary health care providers to determine its impact on the use of health care and the quality of life among pediatric asthma patients.
- Disseminate a toolkit and clinician training across the country.
The project accomplished the following:
- Researchers evaluated the effectiveness of PACE training in improving the outcomes of pediatric asthma patients and the ability of pediatricians to provide appropriate care. Approximately half of the 101 primary care providers who participated in the study, conducted at 10 program sites in 10 cities, attended two-session seminars to learn how to deliver effective care through a brief clinical intervention. The other half served as a control group.
Researchers were able to obtain one-year follow-up outcome data on 731 pediatric asthma patients. Their findings, published in Pediatrics, showed a number of benefits of PACE training (see Findings).
- Staff at the University of Michigan School of Public Health trained some 30 "Master Trainers." These Master Trainers worked in teams—consisting of a local primary care pediatrician, a pediatric subspecialist (a pulmonologist or allergist) and a behavioral scientist or health educator—to train physicians participating in the study. The Master Trainers continued to be available as consultants to sites wishing to develop PACE training.
- Additional "train-the-trainer" sessions enabled several hundred other physicians to conduct PACE training for their colleagues. This training was provided to approximately:
- One hundred local medical leaders from the RWJF Allies Against Asthma national program.
- Forty physicians at an American Academy of Pediatrics continuing medical education conference.
- Forty physicians referred by the U.S. Centers for Disease Control and Prevention (CDC).
- Fifty physicians from the Minnesota chapter of the American Lung Association.
- Each trainer received a package of asthma care training materials including:
- A speaker's manual and training guide.
- Slides and handouts.
- A video demonstrating strategies to improve physician-patient communication.
- A video demonstrating how local physicians can train their peers in PACE.
- Pediatric asthma care guidelines from the National Heart, Blood and Lung Institute (NHLBI).
- Asthma action plans.
- A flip chart from the American Lung Association that can be displayed in a physician's office.
- The National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health formally agreed to adopt and disseminate the PACE project. A page on NHLBI's Web site was created to house all program information and materials, including a training manual, videotapes, slide presentations and participant materials.
- Several national organizations recognized the project:
- The Merck Company Foundation called the PACE project "exemplary" and encouraged organizations funded under its Childhood Asthma Network to provide PACE training.
- The federal Agency for Healthcare Research and Quality recognized it as an effective project for improving quality of care.
- The CDC listed the project as an effective asthma intervention.
- Project staff made presentations about PACE at conferences and meetings throughout the United States. At these venues, staff disseminated to providers more than 1,000 asthma toolkits that included NHLBI's asthma guidelines, informational materials and sample clinical tools.
- Project staff published eight additional papers on aspects of pediatric asthma practice and physician education in peer-reviewed journals during the grant period. (See the Bibliography.)
The project team published a study in Pediatrics (117 : 21492157) of the PACE project's impact, based on one-year follow-up telephone interviews with parents and a self-assessment questionnaire completed by pediatricians (see Appendix 1 for methodology). Among the findings:
- Patients of pediatricians who had PACE training had fewer days every season when their activities were limited by asthma (14.6 days versus 20 days).
- The number of emergency department visits dropped significantly for patients of pediatricians who participated in PACE (falling by 0.55 visits for the PACE group, compared to a drop of 0.30 visits for the others).
- Using the intervention during a patient office visit did not affect the amount of time that pediatricians spent with patients.
- Patients who had more severe asthma symptoms or used the emergency department more frequently, as measured at the baseline interview with their parents, were more likely to benefit from their pediatrician's participation in PACE.
- Pediatricians who participated in the PACE training were more likely to report an increased confidence in their ability to develop a short-term plan for asthma, compared to those who had not participated. They were also more likely to review long-term plans for care with their patients.
- Parents reported that pediatricians who had received the education were more likely to:
- Find out the parent's biggest asthma concern.
- Inform the parent that the child can be fully active.
- Ask if the child met specific goals, including having no daytime symptoms, no nighttime symptoms and no limitation in activity.
See Appendix 2 for key findings from other peer-reviewed published articles, which drew on data collected during the PACE evaluation.
Because there were multiple components to the educational intervention, the researchers note in Pediatrics, "it is not clear which component of the seminar (e.g., communication techniques, reviewing specific asthma message) was most crucial for the success of the educational program. The intervention also attracted physicians who were most likely to be interested in asthma and practice-based research, and, as a result, may not represent primary care providers in general."
- Encourage local faculty to see themselves as asthma "champions" and to assume leadership within their medical communities. (Project Director)
- Arm local physicians with the right tools and training so that they can teach one another. (Project Director)
- Physician communication and counseling are not simply amenities for patients. On the contrary, they are central to achieving positive patient outcomes. "Medicine alone does not do it," said the project director. (Project Director)
- Counseling patients during office visits does not require more time. The evaluation data found that physicians who provide counseling do not have longer office visits. (Project Director)
SIGNIFICANCE TO THE FIELD
Seth Emont, the original RWJF program officer for this grant, reported the following: "The project represents a cost-effective means to broadly deliver training on up-to-date asthma treatment methods; it educates the physician and the patient, and at the same time enhances the notion of patient-centered care."
AFTER THE GRANT
The National Heart, Lung and Blood Institute officially launched a page on its Web site dedicated to the PACE program in conjunction with the spring 2007 release of its updated national asthma guidelines.
A paper on physician-patient communication is scheduled to be published in Clinical Pediatrics in 2008. The project team is preparing a manuscript on the results of a two-year follow-up study.
GRANT DETAILS & CONTACT INFORMATION
Tools and Training to Improve Pediatric Asthma Management by Physicians
University of Michigan School of Public Health (Ann Arbor, MI)
Dates: September 2000 to December 2006
Noreen M. Clark, Ph.D.
Study Implementation and Data Collection
Implementing the Study
To evaluate the effectiveness of the PACE project, researchers from the University of Michigan, School of Public Health:
- Recruited 101 primary care providers (99 pediatricians, one family physician and one nurse practitioner) to participate in a study in 10 U.S. cities.
- Identified 1,418 patients who fit the study criteria in terms of age and health status, drawing from lists of patients supplied by participating providers.
- Matched the 10 cities into five pairs based on factors such as similar size, asthma prevalence and climate. Through a coin toss, chose one city from each pair—a total of five—in which the study clinicians would receive PACE training.
- Recruited a team of three local medical leaders—a primary care pediatrician, a pediatric pulmonologist or allergist and a behavioral scientist or health educator—from each of the five intervention cities and trained them as Master Trainers.
- Master Trainer teams delivered the PACE training at the five intervention sites. (Clinicians in the five comparison cities received the same training after the study was complete, approximately one year later, with Master Trainers trained by project staff.)
To collect the data for the study, the project team:
- Interviewed the parents of participating patients from all 10 cities at the beginning of the study and one year later. (Researchers ultimately completed baseline interviews with parents of 870 patients. The project team was able to re-interview 731 of those parents [84 percent] one year later.)
- Asked all participating physicians to complete a survey at the beginning of the study and one year later. (Some 96 percent of the 101 physicians returned baseline surveys; 76 percent returned surveys one year later.)
Additional Research Findings
Drawing on data collected during the PACE evaluation, the project team published eight additional peer-reviewed articles during the study period (see the Bibliography). Among the key findings from selected publications:
"Pediatrician Attitudes and Practices Regarding Collaborative Asthma Education" (Clinical Pediatrics, 2004):
- More than 90 percent of physicians agreed that patients with asthma should receive asthma counseling and education at every opportunity. Some 78 percent agreed that nurses were just as effective as physicians in delivering this counseling.
"Parental Management of Asthma Triggers Within a Child's Environment" (Journal of Allergy and Clinical Immunology, 2004):
- More than half (51 percent) of the actions that parents of asthma patients initiated to control specific environmental asthma triggers were not likely to be useful for that trigger. The authors suggest that "improving awareness about recognized methods to address triggers may help families use more effective measures."
- Increased contact with physicians and the receipt of asthma education increases the likelihood that parents will take appropriate actions to address environmental asthma triggers.
"Improving Physician Attendance at Educational Seminars Sponsored by Managed Care Organizations" (Managed Care, 2004):
- Physicians were significantly more likely to attend a continuing education seminar when a physician leader solicited their participation. Successful recruitment generally necessitated two points of contact; phone contact appeared to yield greater success than e-mail.
"Asking the Correct Questions to Assess Asthma Symptoms" (Clinical Pediatrics, 2005):
- To determine the frequency of asthma symptoms, physicians need to ask specific questions. Almost all parents (96 percent) described their child's asthma as under "good control" when pediatricians asked them a global assessment question. However, when asked specific questions about a child's symptoms, one-third of parents (34 percent) actually described asthma that was under poor control.
- A number of factors affect the likelihood that parents misinterpret the degree to which a child's asthma is under control. Parents are more likely to provide incongruent answers if English is not the primary household language, the parent has not completed college, the child has Medicaid insurance or a parent smokes.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Cabana MD, Bradley J, Meurer JR, Holle D, Santiago C and Clark NM. "Coding for Asthma Patient Education in the Primary Care Setting." Journal of Medical Practice Management, 21(2): 115119, 2005.
Cabana MD, Brown R, Clark NM, White DF, Lyons J, Wanner-Lang S and Bratton SL. "Improving Physician Attendance at Educational Seminars Sponsored by Managed Care Organizations." Managed Care, 13: 4957, 2004.
Cabana MD, Bruckman D, Meister K, Bradley J and Clark NM. "Documentation of Asthma Severity in Pediatric Outpatient Clinics." Clinical Pediatrics, 42(2): 121125, 2003.
Cabana MD and Clark NM. "Challenges in Evaluating Methods to Improve Physician Practice." Pediatrics, 143: 413414, 2003.
Cabana MD, Slish KK, Brown R and Clark NM. "Pediatrician Attitudes and Practices Regarding Collaborative Asthma Education." Clinical Pediatrics, 43: 269274, 2004.
Cabana MD, Slish KK, Evans D, Mellins RB, Brown R, Lin X, Kaciroti N and Clark NM. "Impact of Physician Asthma Care Education on Patient Outcomes." Pediatrics, 117(6): 21492157, 2006. Abstract available online.
Cabana MD, Slish KK, Lewis TC, Brown R, Nan B, Lin X and Clark NM. "Parental Management of Asthma Triggers Within a Child's Environment." Journal of Allergy and Clinical Immunology, 114: 352357, 2004.
Cabana MD, Slish KK, Nan B and Clark NM. "Limits of the HEDIS Criteria in Determining Asthma Severity in Children." Pediatrics, 114: 10491055, 2004.
Cabana MD, Slish KK, Nan B, Lin X and Clark NM. "Asking the Correct Questions to Assess Asthma Symptoms." Clinical Pediatrics, 44: 319325, 2005.
Clark NM, Cabana MD, Kaciroti N, Gong ZM and Sleeman K. "Long-Term Outcomes of Physician Peer Teaching." Clinical Pediatrics, 47(9): 883890, 2008, Epub 2008 Oct 2. Abstract available online.
Clark NM, Cabana MD, Nan B, Gong ZM, Slish KK, Birk NA and Kaciroti N. "The Clinician-Patient Partnership Paradigm: Outcomes Associated with Physician Communication Behavior." Clinical Pediatrics, 47(1): 4957, 2008. Epub 2007 Sep 27. Abstract available online.
PACE Training Manual and Speaker's Guide. Complete instructions on how to deliver the PACE curriculum, including a detailed program overview, suggested scripts, contact list of Master Trainers and advice for conducting a seminar. Ann Arbor: University of Michigan, 2006. Also available online.
Audio-Visuals and Computer Software
Physician Asthma Care Education (PACE), a 45-minute instructional video for participants demonstrating strategies to improve physician-patient communication and educational messages regarding asthma care. Ann Arbor, MI: University of Michigan, 2001. Instructional video available online.
PACE Train the Trainers, a 20-minute instructional video for facilitators about the PACE program, demonstrating how physicians can train themselves to conduct PACE education programs in their communities. Ann Arbor, MI: University of Michigan, 2006. Instructional video available online.
PowerPoint® Slide Presentation. All PowerPoint slides needed for both training sessions. Ann Arbor, MI: University of Michigan. Slide presentation available online.
Participant Binder Materials. Materials for participant binders, including a review of concepts, sample asthma action plans and coding models. Ann Arbor, MI: University of Michigan. Participant binder materials available online.
Handouts of Slides. Presentation slides in handout format, three per page with space for notes. Ann Arbor, MI: University of Michigan. Handouts of slides available online.
Recruitment and Facilitation Tips. Additional tips to optimize enrollment strategies and session facilitation. Ann Arbor, MI: University of Michigan. Recruitment and facilitation tips available online.
PowerPoint Slide Presentation on Evaluation Methods. Presentation on the most effective and appropriate evaluation methods. Ann Arbor, MI: University of Michigan. Available online.
PowerPoint Presentation on Recruitment. Presentation uses case studies and group discussion to identify effective recruitment strategies. Ann Arbor, MI: University of Michigan. Available online.
PowerPoint Presentation on Facilitation Tips. Provides general facilitation tips as well as tips and guidelines to each group discussion in PACE. Ann Arbor, MI: University of Michigan. Available online.
"Patient-Caregiver Telephone Interview Questionnaire," University of Michigan School of Public Health, fielded July 2001September 2004.
"Physician Questionnaire," University of Michigan School of Public Health, fielded July 2001September 2004.
Physician Survey. Survey used to conduct a pre- and post-program evaluation. Ann Arbor, MI: University of Michigan. Available online.
Presentations and Testimony
Michael D. Cabana and Noreen M. Clark, "Improving Asthma Outcomes: Physician Directed Interventions," at the American Thoracic Society International Conference, May 21, 2002, Atlanta.
Noreen M. Clark, Randall Brown, Niko Kaciroti, Molly Gong, Michael D. Cabana and Juanita Lyons, "Effect of Physician Asthma Education on Health are Utilization of Children at Different Income Levels," at the American Thoracic Society International Conference, May 1922, 2002, Atlanta.
Michael D. Cabana, D. Buckman and Noreen M. Clark, "Assessment of Pediatric Asthma Severity in Outpatient Clinics," at the Pediatric Academic Societies Annual Meeting, May 47, 2002, Baltimore.
Michael D. Cabana, Kathryn K. Slish and Noreen M. Clark, "Effects of Outpatient Follow-up in Preventing Repeat Emergency Department Visits in an American Managed Care Organization," at the European Respiratory Society Annual Congress, September 1418, 2002, Stockholm, Sweden.
Michael D. Cabana, Kathryn K. Slish and Noreen M. Clark, "Which Health Care Professionals Provide Asthma Education in Pediatric Primary Care Offices?" at the American Thoracic Society International Conference, May 1621, 2003, Seattle.
Michael D. Cabana and Noreen M. Clark, "Practical Strategies to Systematically Improve Physician-Patient Communication," at the American Thoracic Society International Conference, May 19, 2003, Seattle.
Michael D. Cabana, Kathryn K. Slish, Xihong Lin and Noreen M. Clark, "Asking the Correct Question: Parent's Description of Their Child's Asthma Severity," at the European Respiratory Society Annual Congress, September 27October 1, 2003, Vienna, Austria.
Michael D. Cabana, Kathryn K. Slish and Noreen M. Clark, "Seasonal Peaks of Asthma Symptoms in Children," at the American Thoracic Society International Conference, May 2126, 2004, Orlando, FL.
Michael D. Cabana, Kathryn K. Slish, Robert B. Mellins, David Evans, Randall W. Brown and Noreen M. Clark, "Impact of Provider Education on the Quality of Pediatric Asthma Care: Results of a Controlled Trial," at the European Respiratory Society Annual Congress, September 48, 2004, Glasgow, Scotland.
Michael D. Cabana, Kathryn K. Slish, Robert B. Mellins, David Evans, Randall W. Brown, Xihong Lin, Kaciroti N and Noreen M. Clark, "Randomized Controlled Trial of Physician Education to Improve Pediatric Outcomes for Asthma," at the American Thoracic Society International Conference, May 25, 2005, San Diego.
Michael D. Cabana, "Translating Research Into Practice: Identifying and Removing Barriers to Changing Physicians' Behaviour," at the European Respiratory Society Annual Congress, September 1721, 2005, Copenhagen, Denmark.
Noreen M. Clark, "Educating Physicians to Improve Physician Practice: A Behavioural View," at the European Respiratory Society Annual Congress, September 1721, 2005, Copenhagen, Denmark.
Report prepared by: Janet Heroux
Reviewed by: Karyn Feiden
Reviewed by: Molly McKaughan
Program Officer: Seth Emont
Program Officer: Anne Weiss