While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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.
A year after the training:
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.
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:
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:
Patients of these pediatricians were more likely to have:
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:
This grant supported a project at the University of Michigan School of Public Health designed to:
The project accomplished the following:
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:
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."
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."
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.
Tools and Training to Improve Pediatric Asthma Management by Physicians
University of Michigan School of Public Health (Ann Arbor, MI)
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:
To collect the data for the study, the project team:
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):
"Parental Management of Asthma Triggers Within a Child's Environment" (Journal of Allergy and Clinical Immunology, 2004):
"Improving Physician Attendance at Educational Seminars Sponsored by Managed Care Organizations" (Managed Care, 2004):
"Asking the Correct Questions to Assess Asthma Symptoms" (Clinical Pediatrics, 2005):
(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.
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.
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
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