Published online October 1, 2007
PEDIATRICS Vol. 120 No. 4 October 2007, pp. e902-e911 (doi:10.1542/peds.2006-1805)
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ARTICLE

Improving Asthma-Related Health Outcomes Among Low-Income, Multiethnic, School-aged Children: Results of a Demonstration Project That Combined Continuous Quality Improvement and Community Health Worker Strategies

Patrick Fox, PhD, Patricia G. Porter, RN, MPH, Sibylle H. Lob, MD, MPH, Jennifer Holloman Boer, MS, David A. Rocha, BA and Joel W. Adelson, MD, PhD, MPH

Integrating Medicine and Public Health Program, Institute for Health & Aging, University of California, San Francisco, California

OBJECTIVE. The purpose of this work was to improve asthma-related health outcomes in an ethnically and geographically disparate population of economically disadvantaged school-aged children by using a team-based approach using continuous quality improvement and community health workers.

PATIENTS AND METHODS. A demonstration project was conducted with 7 community clinics treating ~3000 children with asthma 5 to 18 years of age. The overall clinic population with asthma was assessed for care-process changes through random cross-sectional chart reviews at baseline and 24 months (N = 560). A subset of patients with either moderate or severe persistent asthma or poorly controlled asthma (N = 405) was followed longitudinally for specific asthma-related clinical outcomes, satisfaction with care, and confidence managing asthma by family interview at baseline and at 12 or 24 months. Patient-centered and care-process outcomes included patient/parent assessment of quality of care and confidence in self-management, asthma action plan review, and documentation of guideline-based indicators of quality of care. Direct clinical outcomes included daytime and nighttime symptoms, use of rescue medications, acute care and emergency department visits, hospitalizations, and missed school days. Each clinic site's degree of adherence to the intervention model was evaluated and ranked to examine the correlation between model adherence and outcomes.

RESULTS. Cross-sectional data showed clinic-wide improvements in the documentation of asthma severity, review of action plans, health services use, and asthma symptoms. At follow-up in the longitudinal sample, fewer patients reported acute visits, emergency department visits, hospitalizations, frequent daytime and nighttime symptoms, and missed school days compared with baseline. More patients reported excellent or very good quality of care and confidence in asthma self-management. Linear regression analysis of the clinical sites’ model adherence ranks against site-level combined scores estimating overall outcomes, clinical outcomes, and improvements in clinical care processes showed significant linear correlations with R2 ≥ 0.60.

CONCLUSIONS. The demonstration produced major improvements in asthma-related care processes and clinical outcomes. Closer adherence to the demonstration model was directly associated with better outcomes.

Key Words: asthma • school-aged children • chronic care model • continuous quality improvement • CHW • clinical outcomes • care-process outcomes • model adherence

Abbreviations: CQI—continuous quality improvement • CHW—community health worker • NAEPP—National Asthma Education and Prevention Program • TA—technical assistance

Accepted Mar 3, 2007.


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