A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study

Abstract

Background: Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines.

Objective: To evaluate the effectiveness of 2 asthma care improvement strategies in primary care.

Design: Two-year randomized controlled clinical trial.

Setting: Forty-two primary care pediatric practices affiliated with 4 managed care organizations.

Participants: Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations.

Interventions: Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care.

Main outcome measures: Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts).

Results: Six hundred thirty-eight children completed baseline evaluations, representing 64% of those screened and eligible. Mean +/- SD age was 9.4 +/- 3.5 years; 60% were boys. Three hundred fifty (55%) were taking controller medication. Mean +/- SD annualized asthma symptom days was 107.4 +/- 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95% confidence interval [CI], - 16.9 to 3.6), a nonsignificant difference, but had a 36% (95% CI, 11% to 54%) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95% CI, - 24.7 to -2.1) fewer symptom days annually (-12% from baseline; P =.02) and a 39% (95% CI, 11% to 58%) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95% CI, 1.00 to 1.09]).

Conclusions: Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.