They were asked about their confidence in using these strategies, how helpful they perceived them to be and the frequency of use during asthma consultations. Following the PACE Australia workshops, participants reported greater confidence in using the 10 key strategies, perceived them as more helpful, and reported using them more often. The doctors gave very positive written and oral feedback about the program content and strategies.
The most useful aspects of the workshops were the sessions on communication strategies, patterns of asthma and the use of devices. The recommendations included extending the duration of the workshops and modifying the video for Australian audiences. The results demonstrate that PACE Australia program can improve the way in which doctors manage asthma consultations and the communication strategies would be equally relevant for other chronic illness consultations.
The impact of the revised PACE program on the processes, costs and outcomes of general practitioners' care of children with asthma is currently being studied as a randomized controlled trial. You can also search for this author in PubMed Google Scholar. Reprints and Permissions. Shah, S. Prim Care Respir J 15, GP were universally enthusiastic and supportive of the workshops.
The most useful elements they reported were communication skills, case studies, device demonstrations and the toolkit provided. The program was delivered through peer teaching by local physicians. Patients of physicians that participated in the program had fewer days affected by asthma symptoms, as well as fewer emergency room visits. PACE physicians spent no more time with their patients than other physicians.
Noreen Clark. Participating and non-participating clinics were similar in that all children were under the public government health plan and in rates of children with asthma attending the clinics. The strata for the random assignment for both experimental conditions were created by matching these eight clinics into four groups of two clinics based on the number of pediatric lives served in each clinic.
Each group of two clinics represented a different strata and one clinic from each strata was assigned to each experimental condition. Potential study participants for both study arms were selected on the basis of a computerized claims data algorithm and on the Health Plan Employer Data and Information Set HEDIS criteria for classifying children with persistent asthma [ 28 ].
Inclusion criteria required that the child have at least one claim with a diagnostic code for asthma or reactive airway disease International Classification of Diseases ICD 9 diagnostic code All children were enrolled in the government insurance plan funded with Medicaid funds. Using the HEDIS criteria, children were identified through the claims data and were referred, either by other participants or by the clinics, for a total of potential eligible cases.
Of these, were screened by phone after obtaining oral informed consent See Figure 1. The remaining cases were not screened since the desired number of participants had been reached. Eligibility criteria for selection during phone screening were: 1 families with a child between the ages of 5 to 12 years of age, 2 poor asthma control, as defined by any of the following: a use of any asthma medication more than once a week in the last four weeks b experiencing asthma symptoms such as wheezing, because of asthma either daily or continuously in the last four weeks , c using the ED two or more times during the last year, d using oral steroids or having been hospitalized during the last year.
Exclusion criteria were: 1 currently participating in another asthma study and, 2 no appropriate address for follow-up in the claims data. At the time of screening, the caregiver was defined as the adult legally responsible for the child and was the only person authorized to complete the screening procedure.
Of the children phone screened, 64 were not eligible for a total of eligible children. Both study Arms 1 and 2 used an evidence based asthma intervention called CALMA previously tested and described elsewhere [ 11 ]. Briefly, asthma counselors or lay interviewers were trained to deliver eight asthma education modules that were administered over the course of two home visits.
Home assignments, and a telephone booster for reinforcement of recommended plan s also comprised the intervention. The CALMA modules were designed to help families with managing the child's asthma in the following areas: nature of asthma, barriers to treatment, types of medications, follow-up appointments, action plans, asthma triggers and environmental avoidance techniques, identification of onset of symptoms and early management, communication with the provider, and stressors related to psychological well being.
The intervention was culturally adapted using a collaborative participatory research approach described in detail elsewhere that involved all affected partners in the research process [ 29 ]. Similar to the PACE program, physicians in the CALMA-plus intervention were offered training in three interactive seminars lasting an hour and aimed at enhancing their clinical skills to diagnose, manage and treat asthma according to the NAEPP guidelines.
The training provided opportunities to practice the skills learned, and used multifaceted educational tools. The seminars included brief lectures from local pediatric pulmonologists, case studies that presented clinical problems, and distribution to providers of materials for patients that addressed the advantages of visiting the clinic instead of the ED, the importance of adhering to treatment, and how to use controller medications.
This form was designed to aid physicians to make an asthma diagnosis, and improve prescription practices based on the NAEPP guidelines [ 20 ]. The ARF included a patient treatment plan to aid the patient in adhering to the prescribed treatment see online supplement for copy of these forms. The form also consisted of a checklist to aid the physician in making an asthma diagnosis and or determining asthma control according to guidelines.
The ARF contained NAEPP [ 20 ] recommended medications that were in the formula of the government health plan for step up or step down medications according to the patient's severity or asthma control level. Research staff conducted bi-weekly visits to the clinic for a period of 18 months for administration of these four first questions and for documentation of the number of asthma review forms completed by PCPs.
Pediatric pulmonologists visited the clinics periodically to motivate practicing physicians from clinics that had the lowest compliance with the asthma review form. The adaptation of the PACE program and asthma review form to our culture and the context in which physicians were practicing was done using a collaborative participatory research CPR approach [ 30 ] that involved several focus groups and a weekend workshop with PCPs, and administrators.
Training of the physicians and other staff was performed in each clinic. Training was done prior to initial assessment of participants. Not more than a month elapsed between training of physicians and implementation of the provider intervention. Re-certification of asthma counselors was required if the audiotape and or checklists revealed poor fidelity to the standardized intervention.
Fidelity of the provider intervention was checked by visits to the Clinics to check if asthma forms had been completed by physicians, and by reminding them of the need to fill out the forms. All measures were adapted for use among Spanish-speaking populations using multi-stage, state-of-the-art methods for cross-cultural adaptation [ 31 ]. Controller medication use was evaluated retrospectively by asking the mother whether the child had used prescribed asthma medication in the last six months by the child's physician.
If the parent said the child was using medication then the interviewer asked the parent to bring the medication for an in-home physical observation of the medication itself in the face to face interviews baseline, and 12month follow up. Rescue medications or short acting beta agonists assessed were: albuterol, metaproterenol, pibuterol and terbutaline. The medication use questions did not inquire about frequency or adherence to medication.
Therefore, medication use in this study does not refer to daily use of controller medication, since it is possible that the child could have used it only once. Symptom days is an index of asthma morbidity estimated by caregivers' reports of symptoms during the day or night during the past 30 days prior to the follow-up interview.
Improvements of two to three symptom days or nights are clinically meaningful [ 32 ]. Controller medication use and symptom days were analyzed as secondary outcomes for the six month and 18 month follow up telephone interviews.
We also examined parental reports of 12 month ED visits and hospitalizations in addition to asthma control. Asthma control was assessed with the Pediatric Asthma Therapy Assessment Questionnaire ATAQ [ 33 , 34 ] that measures asthma symptoms and consequences within the last 4 weeks in children 4 to 11 years. Control domains are scored from 0 to 7 with 0 indicating no asthma control problems and higher scores indicating higher asthma control problems with not well controlled, poorly controlled.
Emergency Department visits and number of hospitalizations was measured with items that assessed the number of ED visits or hospitalizations in the last 6 and 12 months. Demographic Information includes the family's income and educational level, perception of poverty, Medicaid status, marital status, and household composition.
After some differences were discovered, we made adjustments using inverse probability weights IPW that were based on estimated propensity scores [ 35 - 37 ]. Propensity scores were estimated using a logistic regression model that included the following predictors: child's gender, primary caretaker's education, caretaker's marital status, household income, social assistance, and perception of poverty. Primary analyses took into account the cluster-randomized design using mixed models that recognized the multilevel structure of the data where individual patients were nested within one of the eight clinics [ 38 ].
Three primary outcomes were analyzed at the twelve months follow up: a binary indicator of whether a controller had been used in the past 6 months, a count of days in the past 30 days when asthma symptoms were present, and a count of nights in the past 30 days when symptoms were present.
The first of these outcomes was modeled with a logit link using a binomial distribution, and the last two were modeled with a log link using a negative binomial distribution. The pattern of missing data was very similar for all primary and secondary outcome variables. Comparison of missing data by treatment groups did not reveal any consistent pattern of missing data being more frequent on any of the two treatment groups.
Rather than restricting the analysis to those with complete data, we used multiple imputation 20 imputed data sets to adjust for effects of missingness assuming missing at random [ 39 ]. An a priori power analysis was conducted when funding was sought, but we were unable to implement the original design which would have involved a larger number of clinics because of changes in health administration policies.
These changes resulted in there being more insurance companies and fewer clinics within each company. As a result we were only able to obtain eight clinics near the university within an insurance company to randomize.
We calculated post-hoc power estimates that take into account the number of clinics and patients recruited, the adjustment for clustering and the multiple imputation.
Table 1 summarizes the demographic characteristics of the two treatment arms after IPW adjustment. Before adjustment, the two groups were very similar on most baseline covariates with the exception of statistically significant differences on household income, receiving social assistance and perception of poverty.
After IPW adjustment these differences were no longer evident. However, groups showed high mean rates 7. Percentages are shown after Inverse Probability Weight adjustment based on estimated propensity scores.
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