Jennifer Olajos-Clow

Asthma care pathways in the emergency department

Purpose of reviewThe purpose of this review is to describe recent evidence of the efficacy and effectiveness of clinical pathways for the assessment and management of severe acute asthma in children and adults in the emergency department (ED). The review will highlight examples of successful knowledge translation initiatives and their ability to support adherence to Best Practice Guidelines. Recent findingsRecent studies reveal that management of pediatric and adult asthma in the ED setting often differs from that which is recommended in clinical practice guidelines. Single and multicenter North American studies have consistently found care gaps. Barriers to adherence to evidence-based management guidelines are numerous. Care pathways are knowledge translation tools that provide a means of applying knowledge translation principles to overcome these barriers, integrate guidelines into practice and optimize patient outcomes. Evidence from a recent Ontario multicenter asthma clinical pathway initiative is highlighted, demonstrating increased adherence to certain aspects of ED care, improved patient recollection of teaching done in the ED and increased referral rates. These findings strengthen the evidence supporting the development and implementation of standardized evidence-based asthma clinical pathways. SummaryGaps between current and best practices persist for the management of asthma in children and adults in North American EDs. There is robust evidence in support of ED asthma clinical pathways to optimize asthma care and outcomes in this setting.

Comparison of Asthma Control Criteria: Importance of Spirometry

Aims. To compare the measurements of asthma control using Canadian Thoracic Society (CTS) Asthma Management Consensus Summary and Global Initiative for Asthma (GINA) guidelines composite indices with and without spirometry. Methods. Asthma control parameters were extracted from electronic medical records (EMRs) of patients ≥6 years old at two primary care sites. Asthma control ratings calculated according to CTS and GINA criteria were compared. Results. Data were available from 113 visits by 93 patients, aged 6–85 years (38.7 ± 24.8; mean ± SD). The proportion of visits at which individuals’ asthma was completely controlled was 22.1% for CTS symptoms only and 9.7% for CTS with spirometry (p < .01); and 17.7% versus 14.1% for GINA symptoms only versus symptoms with spirometry (p = .125). Conclusions. Asthma control ratings using GINA and CTS criteria are discordant in more than half of the patients deemed “in control” by at least one scale. Differences in the spirometry criterion threshold are primarily responsible for this discordance. Failure to include spirometry as part of the control index consistently overestimates asthma control and may underestimate future risk of exacerbations.

Outcomes of asthma education: results of a multisite evaluation.

BACKGROUND This observational study compared the effectiveness of a standardized adult asthma education program administered in a variety of sites and practice settings on health care utilization, absenteeism, amount of leisure time missed and quality of life (using the Medical Outcomes Study 36-Item Short Form 1.0 [SF-36]). METHODS Seven asthma centres participated in an uncontrolled, multicentre, prospective, observational study using a pre-post design. Variables included hospital- and community-based centres, an academic hospital setting and the presence or absence of physician attendance. Trained asthma educators administered a guided self- management education program, and standardized questionnaires were used for patient assessment at baseline and six months after education. RESULTS Of the 517 patients enrolled at baseline, 396 were eligible for the six-month follow-up. Follow-up data were available for 252 patients. SF-36 data were collected for 241 patients at six sites, with follow-up data available for 103 of 155 eligible patients. Asthma education was associated with substantial improvements in scheduled and unscheduled physician visits, unscheduled specialist visits, emergency department visits, hospital admissions, hospitalized days, missed work or school days and missed days of leisure time. There were also statistically significant improvements in all but one SF-36 domain. These improvements were comparable across all geographical sites and physical settings. CONCLUSIONS Standardized asthma education appears to be effective when administered in a variety of practice settings, and may be associated with significant improvements in patient outcomes. The significant decline in health care utilization implies that substantial health care savings may occur as a result of the implementation of standardized asthma education programs.

Validation of an electronic version of the Mini Asthma Quality of Life Questionnaire

BACKGROUND The Mini Asthma Quality of Life Questionnaire (MiniAQLQ) is a validated disease-specific quality of life (QOL) paper (p) questionnaire. Electronic (e) versions enable inclusion of asthma QOL in electronic medical records and research databases. PURPOSE To validate an e-version of the MiniAQLQ, compare time required for completion of e- and p-versions, and determine which version participants prefer. METHODS Adults with stable asthma were randomized to complete either the e- or p-MiniAQLQ, followed by a 2-h rest period before completing the other version. Agreement between versions was measured using the intraclass correlation coefficient (ICC) and Bland-Altman analysis. RESULTS Two participants with incomplete p-MiniAQLQ responses were excluded. Forty participants (85% female; age 47.7 +/- 14.9 years; asthma duration 22.6 +/- 16.1 years; FEV(1) 87.1 +/- 21.6% predicted) with both AQLQ scores <6.0 completed the study. Agreement between e- and p-versions for the overall score was acceptable (ICC=0.95) with no bias (difference (Delta) p-e=0.1; P=0.21). ICCs for the symptom, activity limitation, emotional function and environmental stimuli domains were 0.94, 0.89, 0.90, and 0.91 respectively. A small but significant bias (Delta=0.3; P=0.004) was noted in the activity limitation domain. Completion time was significantly longer for the e-version (3.8 +/- 1.9min versus 2.7 +/- 1.1min; P<0.0001). The majority of patients (57.5%) preferred the e-MiniAQLQ; 35% had no preference. CONCLUSION This e-version of the MiniAQLQ is valid and was preferred by most participants despite taking slightly longer to complete. Generalizabilty may be limited in younger (12-17) and older (>65) adults.

Development and implementation of an electronic asthma record for primary care: integrating guidelines into practice.

Abstract Rationale: Evidence-based practice may be enhanced by integrating knowledge translation tools into electronic medical records (EMRs). We examined the feasibility of incorporating an evidence-based asthma care map (ACM) into Primary Care (PC) EMRs, and reporting on performance indicators. Methods: Clinicians and information technology experts selected 69 clinical and administrative variables from the ACM template. Four Ontario PC sites using EMRs were recruited to the study. Certified Asthma Educators used the electronic ACM for patient assessment and management. De-identified data from consecutive asthma patients were automatically transmitted to a secure central server for analysis. Results: Of the four sites recruited, two sites using “stand-alone” EMR systems were able to incorporate the selected ACM variables into an electronic format and participate in the pilot. Data were received on 161 visits by 130 patients aged 36.5 ± 26.9 (mean ± SD) (range 2–93) years. Ninety-four percent (65/69) of the selected ACM variables could be analyzed. Reporting capabilities included: individual patient, individual site and aggregate reports. Reports illustrated the ability to measure performance (e.g. number of patients in control, proportion of asthma diagnoses confirmed by an objective measure of lung function), benchmark and use EMR data for disease surveillance (e.g. number of smokers and the individuals with suspected work-related asthma). Conclusions: Integration of this evidence-based ACM into different EMRs was successful and permitted patient outcomes monitoring. Standardized data definitions and terminology are essential in order for EMR data to be used for performance measurement, benchmarking and disease surveillance.

The development and test re-test reliability of a work-related asthma screening questionnaire.

Abstract Objective: Work-related asthma (WRA) is under-recognized and delays in recognition contribute to long-term morbidity. The objective of the project was to develop a WRA screening questionnaire for use by primary care providers in the assessment of individuals with asthma, and to evaluate the respondent burden, test re-test reliability and face validity of the questionnaire. Methods: A literature search was undertaken and an expert advisory committee was convened. A questionnaire was drafted and assessed for feasibility of use and content validity. The study enrolled patients with asthma attending outpatient clinics and an asthma education center. Participants were asked to respond to the questionnaire on two occasions, and comment on the content (face validity) and ease of completion (respondent burden). Ethics approval was obtained from an institutional review board. Results: A 14-item self-administered screening questionnaire was created. Thirty-nine participants were recruited, and 26 participants completed a second administration of the questionnaire. The items on the relation of asthma symptoms to work demonstrated substantial agreement between testings. The workplace exposures items were found to have good reproducibility. The majority of participants denied that items were repetitive, not useful or difficult to understand. Conclusions: We have developed a WRA screening questionnaire designed to aid primary care providers in the recognition of possible WRA. The tool exhibited content and face validity, good test re-test reliability and low respondent burden. Participant feedback is being considered in revisions of the questionnaire.