Surveillance of asthma control in an urban Pediatric Primary Care Center
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INTRODUCTION: Asthma is the most prevalent chronic disease in children, disproportionately affecting children from racial or ethnic minority groups and low-income families. Boston Medical Center’s Pediatric Primary Care Center serves these patient populations predominantly from the surrounding neighborhoods. It has been found that there are gaps in asthma care including diagnosing asthma in infants and young children, under-prescribing of preventive medication in all age groups, and variable management of children with poorly controlled asthma. In alignment with the accountable care organization model, health care professionals at BMC are using evidence-based care and population-based approaches to reduce asthma morbidity and thus improve the quality of life for patients with asthma and their families. METHODS: A quality improvement initiative was conducted at BMC’s Pediatric Primary Care Center. The aim was to develop routine surveillance of asthma control for the clinic population in order to identify and intervene on patients who have poorly controlled asthma. The Asthma Control Test (ACT) and the Test for Respiratory and Asthma Control in Kids (TRACK) were adapted into practice as validated patient-parent-reported tools to use to assess asthma control at all primary care office visits. Process measure included the percentage of visits with a documented asthma control testing in the electronic medical record. Outcome measures included (1) percentage of patients with poorly controlled asthma presenting to the clinic, as indicated by low ACT/TRACK scores, and (2) percentage of visits with a documented provider action in response to low ACT/TRACK scores. Iterative Plan, Do, Study, Act (PDSA) cycles optimized results; process and outcome measures were analyzed on run charts for trends. RESULTS AND CONCLUSIONS: Patient-centered strategies for visits and population-based systems to analyze outcomes are effective at delivering quality care for BMC’s pediatric asthma patient population. Following the implementation of routine asthma control screening in primary care, the percentage of visits with documented ACT/TRACK scores went from a baseline of 8% to 86%. Week to week variation was mostly attributed to higher patient visit volume beginning in the Fall season when epidemiologically there is a substantially increased frequency of asthma exacerbations in children. A median of 23% of patients report poorly controlled asthma during their visit. The percent of visits with documented provider action increased from 87% to 95% during this quality improvement initiative, indicating that patients were receiving targeted care needs including medication management and asthma education in response to low ACT/TRACK scores. However, consistent and timely delivery of preventive care services continues to be a challenge, particularly for a clinic serving high-risk, underserved, and culturally diverse patient populations.