THEME 2: Changing Physician Practices

    • October 6, 2008

Physician Training Highlights Needs of Children With Asthma
The typical 15-minute appointment does not give physicians much time to learn about the challenges facing pediatric asthma patients and their parents in their everyday lives.

"It's really hard in that amount of time to get a picture of what's going on with the child and family outside of those four [clinic] walls," says Cynthia S. Kelly, MD, director of pediatric allergy and immunology at Children's Hospital of The King's Daughters in Norfolk, Va.

The Allies Against Asthma project in Virginia's Hampton Roads area—run by a regional coalition named Consortium for Infant and Child Health—tried to bring the real-world asthma picture into tighter focus for local physicians, especially those with low-income Medicaid patients. The project was part of the Robert Wood Johnson Foundation (RWJF) Allies Against Asthma national program.

A key example, says Kelly, who co-directed the Allies project, was the effort to change the way doctors write prescriptions for spacers—tube-shaped chambers that significantly improve the delivery of asthma medication into a child's airways.

Kelly, who is also an associate professor of pediatrics at Eastern Virginia Medical School in Norfolk, says a child needs two spacers: one at home and one at school.

Expecting a youngster to carry a single device back and forth is unrealistic, she says. "I can't even get my kids to bring home their dirty PE [gym] clothes every couple of weeks."

Through feedback from school nurses, project personnel learned that, in fact, many youngsters did not have a second spacer for school, and that their asthma care suffered as a result.

A little investigation showed the reason: families were getting only one spacer through their Medicaid coverage. Any additional devices were out of pocket, and at about $50 a piece, that effectively meant many poor families in the urban centers of sprawling southeast coastal Virginia had only one.

By working with insurance company representatives, project personnel discovered that the Medicaid plans would cover two spacers provided the prescribing doctor labeled them as "medically necessary." "Those were the two key buzz words," says Kelly.

So it was, as it turned out, not a problem of insurance coverage but of education, says Frances D. Butterfoss, PhD, a professor at Eastern Virginia Medical School and project co-director with Kelly. And education was the approach the project took.

Through PACE (for Physician Asthma Care Education program) and other training mechanisms, the Consortium for Infant and Child Health made local physicians aware of the medical need for children to have a separate spacer for school—and the need to write prescriptions accordingly, explains Butterfoss, the consortium's founder.

PACE is a continuing medical education program to improve pediatricians' skills in asthma therapy and communications. The national program office at the University of Michigan developed it with RWJF support.

Four PACE sessions sponsored by the Hampton Roads consortium reached 32 pediatricians and 15 pediatric nurse practitioners. Additional educational initiatives focused on nurses and other support staff. Altogether, the educational efforts involved at least one representative (including physicians, nurses and nursing assistants) from 75 percent of the local pediatric practices, the consortium reported.

In addition, Kelly included the spacer story in presentations to various health care provider groups—an opportunity she also used to pass on real-world insights gained by project outreach workers from their in-home asthma education visits.

For example, says Kelley, a mother may tell the doctor that her child has medicine and a spacer at home. However, the full story is that the medicine is expired and the spacer unused. In one home, a project worker found the child's spacer on top of the refrigerator, full of roach droppings.

"People on the whole want to do the right thing for their children," says Kelly. But for many families, she adds, asthma is just one of a multitude of difficulties they must contend with everyday.

Other Allies Against Asthma sites also conducted PACE sessions to improve physicians' compliance with national asthma care guidelines.

For example, the Long Beach Alliance for Children with Asthma, the coalition that ran the Allies project in Long Beach, Calif., oversaw PACE training for 179 providers. Doctors who took the course got priority in signing up their patients for the alliance's in-home education service.

Linking PACE with the project's outreach component was intentional, explains Elisa Nicholas, MD, MSPH, the project director and founder of the alliance. She wanted to build a collaborative relationship between medical professionals and the community health workers who dealt with the families in their homes.

Nicholas, a PACE trainer, praises the curriculum for teaching doctors how to communicate more effectively with patients. "That is something they don't get in medical school," she says. "Many doctors think they are great communicators, but if you ask their patients, they aren't." Nicholas is chief of staff of Miller Children's Hospital and CEO of the free-standing Children's Clinic.

Collaborative Learning Helps Safety-Net Clinics Improve Asthma Care
The Allies project in Seattle took another approach to improving clinical quality. The King County Asthma Forum, the local coalition funded by RWJF's Allies program, instituted a collaborative learning process that helped four clinics serving low-income patients make changes in their delivery of pediatric asthma care.

Using a modified version of the collaborative change model developed by the Institute for Healthcare Improvement in Cambridge, Mass., the clinics instituted new procedures to manage pediatric asthma patients and link them to community resources.

Before "all we did was 'treat 'em and street 'em.' We didn't have any follow-up that was organized," says Gwen Marcus, MD, a pediatrician at the Roxbury Family Health Center, which serves a low-income, predominantly minority community just south of the city limits.

Aided by a computerized registry developed with technical assistance from the Allies project, the clinic staff now tracks the condition of its pediatric asthma patients and sets statistical benchmarks for gauging the clinic's quality of asthma care.

Also, the staff links families to asthma educators and collaborates with a county community health worker to address environmental problems in the home. Mold—an asthma trigger—is a particular problem in rainy Seattle, notes Marcus, who led the clinic's improvement push. (Other common triggers are secondhand tobacco smoke, dust mites, cockroaches, family pets and outdoor air pollution.)

At a medical clinic operated by Sea Mar Community Health Centers in a Spanish-speaking section of south Seattle, the asthma team leader was Cor Van Niel, MD. He says the learning collaborative—which included quarterly meetings with the teams from the other participating clinics—got the Sea Mar staff "to think about treating asthma as a chronic disease instead of a series of acute illnesses."

One challenge, the pediatrician explains, was getting parents with an asthmatic child to come to the clinic to discuss asthma management when their child was well. A conversation about smoking and other environmental issues is unlikely to be productive during a sick visit, Van Niel says.

The answer was Asthma Day. Now, as a result of the Allies project, three or four times a year staff invites the clinic's asthma patients and their families to come after closing hours for a special program that is part serious, part fun.

"We try to make it more of a social occasion," Van Niel says. Staff members test the children's lung function with a spirometer—a diagnostic tool that tests lung function—and parents get education in triggers and asthma management strategies.

There are also games for children and dinner for everyone, including siblings who do not have asthma. There are even raffles, the winners getting mattress covers, approved cleaning products and the like.

"Concentrating on asthma, thinking about it as a chronic disease and getting families to come in when their children are well has made a difference to our patients," Van Niel says.

The Roxbury clinic instituted a similar educational program for its patients as a result of the project.