Improving Post-Hospital Transitions and Ambulatory Care for Children with Asthma (Utah)

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Summary:

Asthma is the most common chronic illness in children and their most frequent reason for preventable hospital and emergency department admissions. Children hospitalized for asthma are at increased risk for readmission. There are several reasons for readmission due to asthma, including: 1) hospital provider’s noncompliance with evidence-based asthma preventive measures at patient discharge; 2) poorly managed transitions from hospital care to primary care; 3) failure of primary care providers (PCPs) to monitor and manage chronic asthma; 4) patient noncompliance with asthma home therapy; and 5) failure to establish ongoing monitoring of asthma chronic symptoms. Preventing asthma-related hospitalization and emergency department use can improve quality of life, reduce health care use, and reduce health care costs among children with chronic asthma.

This project worked to develop and implement two health information technology (IT) applications to improve care transitions from the hospital setting to the ambulatory and home settings. The primary objectives of this project were to:

  • Develop an asthma-specific Reminder and Decision Support (RADS) system to help hospital providers at discharge: 1) comply with evidence-based asthma preventive measures; determine the patient’s chronic asthma severity level; and determine severity appropriate asthma preventive medications, and 2) establish effective care transitions to PCPs in the ambulatory setting. 
  • Develop a Web-based Asthma Home Monitoring System (AHMS -- also called the electronic Asthma Symptom Tracking and Exacerbation Response system, e-ASTER) to: 
    • Enable at-home ongoing assessment of patients' level of asthma control and promptly respond to early deteriorations of asthma control, and 
    • Support PCPs in monitoring and managing chronic asthma symptoms. 

Secondary objectives included evaluating attitudes, acceptability, use, as well as effectiveness of these IT applications in reducing asthma readmissions.

This project supports effective care transitions and continuity post-hospital discharge, and enhances the quality of ambulatory care for children with asthma to reduce the risk of asthma readmissions. The result of the project serves as a new model for enhancing management of patients with asthma in particular and chronic diseases in general.

Improving Post-Hospital Transitions and Ambulatory Care for Children with Asthma - 2012

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018678
  • Project Period: 
    April 2011 – March 2014
  • AHRQ Funding Amount: 
    $1,191,501
  • PDF Version: 
    (PDF, 259.26 KB)

Summary: Asthma is the most common chronic illness in children and can have a significant impact on quality of life for both children and their families. Asthma is also the most frequent reason for preventable hospital and emergency department (ED) admissions among children in the United States. Children hospitalized for asthma are at increased risk for readmission for several reasons, including: 1) hospital provider’s non-compliance with evidence-based asthma preventive measures at patient discharge; 2) poorly-managed care transitions from the hospital to the ambulatory setting; 3) failure of primary care providers (PCPs) to monitor and manage chronic asthma; 4) patient non-compliance with asthma home therapy; and 5) failure to establish ongoing monitoring of asthma chronic symptoms in the ambulatory setting. Preventing asthma-related hospitalization and ED use can improve quality of life and reduce health care-related costs among children with chronic asthma.

This project is developing and evaluating two applications of health information technology (IT) to improve care transitions from the hospital to the ambulatory and home settings for children with asthma. The first application, an asthma-specific Reminder and Decision Support (RADS) system, has been developed and implemented to help hospital providers accomplish the following at discharge: 1) comply with evidence-based asthma preventive measures; 2) determine a patient’s chronic asthma severity level; 3) determine severity-appropriate asthma preventive medications; and 4) establish effective care transitions to PCPs. The second application, a Web-based Asthma Home Monitoring System (AHMS), also called the electronic Asthma Symptom Tracking and Exacerbation Reduction (e-ASTER), is being used to enable care continuity through continuous (weekly) at-home self-assessment of patients’ asthma control, and support of PCPs in monitoring and managing chronic asthma symptoms. A paper-based version of the AHMS, known as the Asthma Symptom Tracker or AST, has also been developed and the questionnaire validated prior to the AHMS implementation.

The RADS system was built from an existing electronic discharge order and discharge instruction (DOADI) tool. The DOADI is currently used throughout Primary Children’s Medical Center (PCMC) in
Salt Lake City, Utah, by health care providers to facilitate the discharge process for all patients admitted with a medical diagnosis of asthma. The RADS system was designed to automate the multiple functions of the paper-based discharge process. It uses the DOADI as a platform and automatically faxes asthma discharge information to the patient’s identified PCP, including the patient’s asthma action plan and preventive medications recommended by the hospital provider based on asthma guidelines. The DOADI automatically transfers discharge information to PCPs in an accurate and timely manner.

The e-ASTER application was designed to: 1) engage patients in weekly self-monitoring and self-management of chronic asthma control by prompting compliance with therapy and appropriate and timely physician visits; and 2) support physicians with longitudinal data to assess the effectiveness of asthma therapy and prompt adjustments. The application includes an active real-time feedback and alerting system for patients and their parents to prompt early response to deteriorations in asthma control status.

The e-ASTER application has been developed, programmed, and pilot-tested. Children between the ages of 2 and 18 admitted to PCMC for asthma are invited to participate in the study to evaluate the utility of e-ASTER. Surveys will be administered to hospital providers, PCPs, and patients and their caregivers to evaluate the attitudes, acceptability, and use of the both the RADS and the e-ASTER applications. Qualitative questionnaires and quantitative data (e.g., Web page views, and log-in and log-out times) will be used to determine factors associated with effective use of the health IT applications. Readmission rates within 6 months of the index hospitalization discharge will be assessed to determine the impact of the two health IT applications.

Specific Aims:

  • Develop two IT applications to improve post-hospital care transitions and ambulatory care. (Ongoing)
  • Evaluate the attitudes, acceptability, and use of the new IT applications. (Ongoing)
  • Determine factors associated with effective use of new IT applications by hospital providers, PCPs, and patients. (Upcoming)
  • Determine the effect of implementing new IT applications by measuring specific process measures at the hospital provider, PCP, and patient levels, and on readmissions. (Upcoming)

2012 Activities: The AST (AHMS paper-based version) was pilot tested among 210 people. Findings demonstrate the AST to be a valid and reliable tool for weekly monitoring and self-management of asthma symptoms. Dissemination of these findings included presentations at two annual meetings and a paper submitted to Pediatrics.

Development of e-ASTER was completed. The project team conducted 2 rounds of usability testing and integrated user feedback into the tool before finalizing it. A manuscript reporting these results was published as part of the American Medical Informatics Association Annual Symposium – Development of a novel tool for engaging children and parents in asthma self-management. The Web site for e-ASTER was launched in July 2012, and recruitment into the e-ASTER pilot test is underway. Additional clinic sites have been added to the study to bolster enrollment, which will continue into 2013. Currently, patients access the e-ASTER through a Web portal. A mobile Web version is being developed and is expected to be implemented in 2013.

In light of the findings from the AST pilot test (paper-based version), there has been a high demand from primary care providers in the region about using e-ASTER as part of a quality improvement initiative.

Dr. Nkoy and his team added to the e-ASTER a Maintenance of Certification (MOC) function for providers. This will allow providers to obtain MOC credits, offering an incentive to providers to use this tool. An application for the MOC was approved by the American Academy of Pediatrics the end of 2012.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track, and project spending is on target.

Preliminary Impact and Findings: Frequent users of the AST have significantly less acute health care utilization (e.g., emergency department and hospital admissions) than non-frequent users. These findings were presented at the 2012 Pediatric Academic Societies Annual Meeting and the 2012 Academy Health Annual Research Meeting.

Target Population: Asthma, Chronic Care*, Pediatric*, Teenagers

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

*This target population is one of AHRQ’s priority populations.

Improving Post-Hospital Transitions and Ambulatory Care for Children with Asthma - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology (IT) to Improve Health Care Quality (R18)
  • Grant Number: 
    R18 HS 018678
  • Project Period: 
    April 2011 - March 2014
  • AHRQ Funding Amount: 
    $1,191,501
  • PDF Version: 
    (PDF, 201.2 KB)

Summary: Asthma is the most common chronic illness in children and can have a significant impact on quality of life for both children and their families. Asthma is also the most frequent reason for preventable hospital and emergency department (ED) admissions among children in the United States. Children hospitalized for asthma are at increased risk for readmission for several reasons, including; 1) hospital provider's non-compliance with evidence-based asthma preventive measures at patient discharge; 2) poorly-managed care transitions from the hospital to the ambulatory setting; 3) failure of primary care providers (PCPs) to monitor and manage chronic asthma; 4) patient non-compliance with asthma home therapy; and 5) failure to establish ongoing monitoring of asthma chronic symptoms in the ambulatory setting. Preventing asthma-related hospitalization and ED use can improve quality of life and reduce health care-related costs among children with chronic asthma.

This project is developing and evaluating two applications of health information technology (IT) intended to improve care transitions from the hospital to the ambulatory and home settings for children with asthma. The first application, an asthma-specific Reminder and Decision Support (RADS) system, has been developed and implemented to help hospital providers accomplish the following at discharge: 1) comply with evidence-based asthma preventive measures; 2) determine the patient's chronic asthma severity level; 3) determine severity-appropriate asthma preventive medications; and 4) establish effective care transitions to PCPs in the ambulatory setting. The second application, a Web-based Asthma Home Monitoring System (AHMS), also called the electronic Asthma Symptom Tracking and Exacerbation Reduction (e-ASTER), is being finalized to enable care continuity through continuous at-home selfassessment of patients' chronic asthma control, and support of PCPs in monitoring and managing chronic asthma symptoms.

The RADS system was built from an existing electronic discharge order and discharge instruction (DOADI) tool. The DOADI is currently used throughout Primary Children's Medical Center (PCMC) in Salt Lake City, Utah, by health care providers for all patients discharged with a medical diagnosis. The DOADI automatically transfers discharge information to PCPs in an accurate and timely manner. The RADS system was designed to automate the multiple functions of the paper-based discharge process. It uses the DOADI as a platform and automatically faxes asthma discharge information to the patient's identified PCP, including the patient's asthma action plan and preventive medications recommended by the hospital provider based on asthma guidelines.

The e-ASTER application was designed to: 1) engage patients in self-monitoring and self-management of chronic asthma control by prompting compliance with therapy and appropriate and timely physician visits and; 2) support physicians with longitudinal data to assess the effectiveness of asthma therapy and prompt adjustments. The application includes an active real-time feedback and alerting system for patients and their parents to prompt early response to deteriorations in asthma control status. For patients without Internet access, an interactive voice response system will be used. These patients will receive real-time feedback upon entering information on their level of asthma control over the phone.

The e-ASTER application has been developed, programmed, and pilot-tested. Children admitted to PCMC for asthma between the ages of 2 and 18 will be invited to participate in a study to evaluate the utility of e-ASTER for ongoing asthma self-monitoring and self-management. Surveys will be administered to hospital providers who care for children admitted to PCMC during the project period, PCPs whose patients are enrolled in the study, and patients enrolled in the study and their caregivers to evaluate the attitudes, acceptability, and use of the both the RADS and the e-ASTER applications. Qualitative questionnaires and quantitative data (e.g., Web page views, log-in, and log-out times) will be used to determine factors associated with effective use of the health IT applications. Readmission rates within 6 months of the index hospitalization discharge will be determined for the overall study population and compared to results after implementation of the two health IT applications using time series analysis.

These health IT applications and the study findings will promote effective care transitions and continuity post-hospital discharge, and will enhance the quality of care for children with asthma.

Specific Aims:

  • Develop two IT applications to improve post-hospital care transitions and ambulatory care. (Ongoing)
  • Evaluate the attitudes, acceptability, and use of the new IT applications. (Ongoing)
  • Determine factors associated with effective use of new IT applications by hospital providers, PCPs, and patients. (Upcoming)
  • Determine the effect of implementing new IT applications by measuring specific process measures at the hospital provider, PCP, and patient levels, and on readmissions. (Upcoming)

2011 Activities: Development of the RADS system was completed and all major components of the system have been implemented at PCMC. The RADS system is now being used as part of the standardized asthma discharge process, and is successfully auto-generating and auto-faxing the patient's action plan, discharge instruction, and discharge summary to the PCP.

The AHMS was developed in a paper-based version (Asthma Symptom Tracker [AST]) and a Webbased version (e-ASTER). The AST was pilot-tested and determined valid and reliable. Two iterative usability testing sessions were conducted for the e-ASTER application and changes are being made based on feedback received to finalize the application. Development of the patient interface of the e-ASTER application is complete, while the clinic (PCP office) interface is in progress. The research team anticipates launching e-ASTER by March 2012 upon completing the security test of the Web site server.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track. The project budget funds are somewhat underspent because the study team is not fully staffed and outstanding subcontract invoices have yet to be received and processed.

Preliminary Impact and Findings: The research team pilot-tested the paper-based version of the AHMS, and determined it to be valid and reliable for monitoring asthma control. A manuscript is being written to publish preliminary findings.

Target Population: Asthma, Chronic Care*, Pediatric*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Synthesis and Dissemination

* This target population is one of AHRQ's priority populations.

Improving Post-Hospital Transitions and Ambulatory Care for Children with Asthma - Final Report

Citation:
Nkoy, F. Improving Post-Hospital Transitions and Ambulatory Care for Children with Asthma - Final Report. (Prepared by the University of Utah under Grant No. R18 HS018678). Rockville, MD: Agency for Healthcare Research and Quality, 2015. (PDF, 1.81 MB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
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