Integrating Patient-Reported Outcomes into Routine Primary Care: Monitoring Asthma Between Visits (California)

Project Details - Ongoing

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Uncontrolled asthma impairs quality of life and is associated with utilization of high-cost healthcare services. Current clinical guidelines recommend frequent monitoring of asthma symptoms in the ambulatory setting to avoid clinical deterioration and the need for emergency care. However, adherence to guidelines is poor, and tools and practice models for intensive symptom monitoring are needed. The project team previously developed and successfully pilot tested a simple mobile health (mHealth) application (app) that tracks patients’ self-reported asthma symptoms, and a practice model to monitor the symptoms as part of routine care.

This project will adapt and scale the app-enabled practice model to the primary care setting, the setting where most asthma patients are treated, at an accountable care organization that serves a large and diverse population of patients with asthma. The Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework, which emphasizes the importance of simplicity in designing and scaling technology, will guide the project. A rigorous evaluation will be conducted to understand the impact on quality of life and asthma-related healthcare utilization.

The specific aims of this project are as follows:

  • Adapt the existing health information technology (IT)-enabled practice model for asthma symptom monitoring using PROs to a primary care population that includes Spanish-speaking and low-health-literacy patients. 
  • Implement the adapted health IT-enabled practice model in four primary care community clinics, identify a cohort of eligible asthma patients to participate, and train clinicians and clinical staff. 
  • Rigorously evaluate the impact of this new health IT-enabled practice model using a randomized controlled trial. 

The findings of the project will inform strategies for implementing a health IT-enabled practice model that incorporates the collection of asthma-related PROs into routine primary care. Furthermore, a set of best practices will be developed to scale and spread this, or similar, health IT-enabled practice models for between-visit collection of PROs for patients with asthma and other conditions.

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