Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Vol. 5: Asthma

Objectives:

Despite the availability of evidence-based guidelines for the management of pediatric and adult asthma, there remains a significant gap between accepted best practices for asthma care and actual care delivered to asthma patients. The purpose of this systematic review was to evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient care for children and adults with asthma.

Data Sources:

We searched four literature sources: the Cochrane Effective Practice and Organization of Care (EPOC) Group database (1/1966 to 4/2006), MEDLINE® (1/1966 to 4/2006), the Cochrane Consumers and Communication Group database (1/1966 to 5/2006), and bibliographies of retrieved articles.

Review Methods:

We sought English language studies of interventions that included one or more QI strategies (e.g., patient education, provider education, audit and feedback) for the outpatient management of children or adults with asthma. Included studies were required to be either randomized controlled trials, controlled before-after trials, or interrupted time series trials. The four primary types of outcomes of interest were:

1. Measures of clinical status (e.g., asthma symptoms, spirometric measures).
2. Measures of functional status (e.g., days lost from work or school).
3. Measures of health services utilization (e.g., hospital admissions).
4. Measures of adherence to guidelines (e.g., number of patients given prescriptions for inhaled corticosteroids).

Results:

We identified 3,843 potentially relevant articles, of which 200 articles describing 171 studies met our inclusion criteria. These studies exhibited substantial variation in terms of the types of strategies evaluated. However, using broad, pragmatic categories for quality improvement strategies, 100 included at least some component of patient education, 94 studies included some component of self-monitoring or self-management, 27 included some component of organizational change, and 19 included provider education, among others. The studies also evaluated heterogeneous patient populations, but these could be broadly categorized into those that targeted children or adolescents with asthma or their families (79 studies) and outpatient populations with asthma comprised typically of adults (92 studies).

Among all studies of pediatric asthma evaluating self-monitoring, self-management, or patient education interventions, those directed at parents or caregivers, as opposed to at the children themselves and not their parents, were more likely to be associated with a statistically significant improvement in clinical outcomes (e.g., improvements in asthma symptoms or spirometric measures (p=0.02)). Self-monitoring, self-management, or patient education interventions for general populations or adults with asthma were associated with improvements in percent predicted forced expiratory volume in one second, or FEV1 (weighted mean difference: 2.92 percent predicted FEV1; 95% CI 0.92, 4.92; p=0.004), and mean peak flow (weighted mean difference: 27.95 L/min; 95% CI 10.75, 45.15; (p=0.01).

QI interventions that are based explicitly on a theoretical framework, provide multiple educational sessions, have longer durations, and use combinations of instructional modalities (e.g., small group teaching with role-playing and handouts) are more likely to result in improvements for patients than interventions lacking these characteristics. When taken as a group, the improvements reported in the included studies were often statistically significant but possibly only of borderline clinical significance.

Conclusions:

A wide variety of types of QI interventions have been found to improve the outcomes and processes of care for children and adults with asthma. Young children with asthma benefit most from QI strategies that also include their caregivers or parents. General populations with asthma can have clinically significant improvements in spirometric measures after participating in self-monitoring, self-management, or patient education interventions-especially interventions that are based on theoretical frameworks, are of relatively long durations, and utilize combinations of educational modalities.