Michelle M. Cloutier

From theory to practice: improving the impact of health services research

BackgroundWhile significant strides have been made in health research, the incorporation of research evidence into healthcare decision-making has been marginal. The purpose of this paper is to provide an overview of how the utility of health services research can be improved through the use of theory. Integrating theory into health services research can improve research methodology and encourage stronger collaboration with decision-makers.DiscussionRecognizing the importance of theory calls for new expectations in the practice of health services research. These include: the formation of interdisciplinary research teams; broadening the training for those who will practice health services research; and supportive organizational conditions that promote collaboration between researchers and decision makers. Further, funding bodies can provide a significant role in guiding and supporting the use of theory in the practice of health services research.SummaryInstitutions and researchers should incorporate the use of theory if health services research is to fulfill its potential for improving the delivery of health care.

Asthma outcomes: composite scores of asthma control.

BACKGROUND Current asthma guidelines recommend assessing the level of a patients asthma control. Consequently, there is increasing use of asthma control as an outcome measure in clinical research studies. Several composite assessment instruments have been developed to measure asthma control. OBJECTIVE National Institutes of Health institutes and federal agencies convened an expert group to propose the most appropriate standardized composite score of asthma control instruments to be used in future asthma studies. METHODS We conducted a comprehensive search of PubMed using both the National Library of Medicines Medical Subject Headings and key terms to identify studies that attempted to develop and/or test composite score instruments for asthma control. We classified instruments as core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at a National Institutes of Health-organized workshop convened in March 2010 and finalized in September 2011. RESULTS We identified 17 composite score instruments with published validation information; all had comparable content. Eight instruments demonstrated responsiveness over time; 3 demonstrated responsiveness to treatment. A minimal clinically important difference has been established for 3 instruments. The instruments have demographic limitations; some are proprietary, and their use could be limited by cost. CONCLUSION Two asthma composite score instruments are sufficiently validated for use in adult populations, but additional research is necessary to validate their use in nonwhite populations. Gaps also exist in validating instruments for pediatric populations.

Future Research Directions in Asthma. An NHLBI Working Group Report

Asthma is a common chronic disease without cure. Our understanding of asthma onset, pathobiology, classification, and management has evolved substantially over the past decade; however, significant asthma-related morbidity and excess healthcare use and costs persist. To address this important clinical condition, the NHLBI convened a group of extramural investigators for an Asthma Research Strategic Planning workshop on September 18-19, 2014, to accelerate discoveries and their translation to patients. The workshop focused on (1) in utero and early-life origins of asthma, (2) the use of phenotypes and endotypes to classify disease, (3) defining disease modification, (4) disease management, and (5) implementation research. This report summarizes the workshop and produces recommendations to guide future research in asthma.

African ancestry and lung function in Puerto Rican children

BACKGROUND Puerto Rican and African American subjects share a significant proportion of African ancestry. Recent findings suggest that African ancestry influences lung function in African American adults. OBJECTIVE We sought to examine whether a greater proportion of African ancestry is associated with lower FEV(1) and forced vital capacity (FVC) in Puerto Rican children independently of socioeconomic status, health care access, or key environmental/lifestyle factors. METHODS We performed a cross-sectional case-control study of 943 Puerto Rican children aged 6 to 14 years with (n= 520) and without (n= 423) asthma (defined as physician-diagnosed asthma and wheeze in the prior year) living in Hartford, Connecticut (n= 383), and San Juan, Puerto Rico (n= 560). We estimated the percentage of African racial ancestry in study participants using genome-wide genotypic data. We tested whether African ancestry is associated with FEV(1) and FVC using linear regression. Multivariate models were adjusted for indicators of socioeconomic status and health care and selected environmental/lifestyle exposures. RESULTS After adjustment for household income and other covariates, each 20% increment in African ancestry was significantly associated with lower prebronchodilator FEV(1) (-105 mL; 95% CI, -159 to -51 mL; P< .001) and FVC (-133 mL; 95% CI, -197 to -69 mL; P< .001) and postbronchodilator FEV(1) (-152 mL; 95% CI, -210 to -94 mL; P< .001) and FVC (-145 mL; 95% CI, -211 to -79 mL; P< .001) in children with asthma. Similar but weaker associations were found for prebronchodilator and postbronchodilator FEV(1) (change for each 20% increment in African ancestry, -78 mL; 95% CI, -131 to -25 mL; P= .004) and for postbronchodilator FVC among children without asthma. CONCLUSIONS Genetic factors, environmental/lifestyle factors, or both correlated with African ancestry might influence childhood lung function in Puerto Rican subjects.

Organizational culture predicts job satisfaction and perceived clinical effectiveness in pediatric primary care practices

Background: In recent years, there has been a growing understanding that organizational culture is related to an organizations performance. However, few studies have examined organizational culture in medical group practices. Objectives: The purpose of this study was to examine the relationship of organizational culture on provider job satisfaction and perceived clinical effectiveness in primary care pediatric practices. Research Design: This cross-sectional study included 36 primary care pediatric practices located in Connecticut. Participants: There were 374 participants in this study, which included 127 clinicians and 247 nonclinicians. Measures: Office managers completed a questionnaire that recorded staff and practice characteristics; all participants completed the Organizational Culture Scale, a questionnaire that assessed the practice on four cultural domains (i.e., group, developmental, rational, and hierarchical), and the Primary Care Organizational Questionnaire that evaluated perceived effectiveness and job satisfaction. Results: Hierarchical linear models using a restricted maximum likelihood estimation method were used to evaluate whether the practice culture types predicted job satisfaction and perceived effectiveness. Group culture was positively associated with both satisfaction and perceived effectiveness. In contrast, hierarchical and rational culture were negatively associated with both job satisfaction and perceived effectiveness. These relationships were true for clinicians, nonclinicians, and the practice as a whole. Conclusions: Our study demonstrates that practice culture is associated with job satisfaction and perceived clinical effectiveness and that a group culture was associated with high job satisfaction and perceived effectiveness.

Asthma guideline use by pediatricians in private practices and asthma morbidity

OBJECTIVE. We sought to examine whether pediatric clinicians in private, non–health maintenance organization practices could implement the national asthma guidelines and whether, when implemented, these guidelines would decrease medical services utilization and improve asthma care for children. METHODS. A trial of a disease management program (Easy Breathing II) involving 20 private pediatric practices in the greater Hartford, Connecticut area was conducted between January 1, 2001, and December 31, 2003. Demographic data on participating practitioners and patients were obtained from questionnaires. Medical services utilization data from claims were obtained from ConnectiCare, a regional managed care organization. RESULTS. Of the 16750 children enrolled in Easy Breathing II, 2458 were enrolled in ConnectiCare and 490 had asthma. Inhaled corticosteroid use increased in the community overall during the study period. After enrollment in Easy Breathing II, with adjustment for age, gender, ethnicity, asthma severity, season, and calendar year, children with persistent asthma experienced an additional 47% increase in inhaled corticosteroid use, a 56% reduction in outpatient visits, and a 91% decrease in emergency department visits for treatment of asthma. Adherence to national asthma guidelines for prescribing inhaled corticosteroids was 95%. Seventeen of the 20 practices are still using Easy Breathing, 5 years after program implementation. CONCLUSIONS. Pediatric primary care clinicians in private practice settings can implement an asthma management program patterned after the national asthma guidelines. When implemented, this program is successful in reducing medical services utilization for children with asthma. Just as differences in patterns of medical services utilization exist in private practices, compared with urban clinics, the impact of disease management on medical services utilization differs in private practices, compared with urban clinics.

Pulmonary function abnormalities in Prader-Willi syndrome

OBJECTIVE To determine whether individuals with Prader-Willi syndrome (PWS) have abnormalities in pulmonary function as a result of thoracic muscle weakness. DESIGN Testing of spirometry, flow-volume curves, lung volumes, and static respiratory pressures was performed in patients with PWS who are followed at the University of Connecticut. All tests were performed in triplicate on two or more occasions. Only reproducible tests were accepted. Established normative data were applied for all test results. RESULTS A total of 18 male subjects (age, 17.9 +/- 10.2 years (mean +/- SD); range, 5-39 years) and 17 female subjects (age, 23.5 +/- 13.0 years; range, 5-54 years) completed the tests. Forced vital capacity and forced expiratory volume in 1 second were reduced; the forced expiratory volume in 1 second/forced vital capacity ratio was normal, total lung capacity was in the low normal range, and residual volume was elevated. Maximum inspiratory (PImax) and expiratory (PEmax) pressures were markedly reduced in 32 subjects tested. Fifteen subjects had PEmax values and 20 subjects had PImax values < 60 cm H2O, respectively. There was a linear correlation between forced expiratory volume in 1 second and both PImax and PEmax (r = 0.71; r = 0.62, respectively), and between forced vital capacity and both PEmax and PImax (r = 0.62 and r = 0.74, respectively). There was an inverse relationship between both PImax and PEmax, and residual volume (r = 0.47 and r = 0.72, respectively). CONCLUSION Children and adults with PWS have restrictive ventilatory impairment primarily as a result of respiratory muscle weakness. Efforts to improve thoracic muscle strength may be useful in improving pulmonary function in individuals with PWS.

Genome-wide association study of body mass index in 23 000 individuals with and without asthma

Both asthma and obesity are complex disorders that are influenced by environmental and genetic factors. Shared genetic factors between asthma and obesity have been proposed to partly explain epidemiological findings of co‐morbidity between these conditions.

Classifying Asthma Severity: Objective Versus Subjective Measures

National guidelines recommend the use of clinical history and spirometry to determine asthma severity. We examined the usefulness of the six guideline-recommended clinical questions in determining asthma severity and then compared guideline-determined severity to clinician-reported and spirometry-determined severity in a cross-sectional study of 201 children with asthma who were not receiving controller therapy. Four guideline-recommended questions (daytime and nocturnal symptoms, school absenteeism, and exercise impairment) determined asthma severity. Concordance between clinician-reported and spirometry-determined asthma severity was poor (κ = 0.02). Clinical history alone underestimated spirometry-determined disease severity in 27% of children while spirometry results alone underestimated clinician-determined severity in 40% of children.

Effectiveness of an asthma management program in reducing disparities in care in urban children

OBJECTIVE To examine differences in the effectiveness of a program to reduce use of health care services in urban-dwelling black and Hispanic children as a way to understand the origins of disparities. METHODS We examined hospitalization rates, emergency department (ED) visits, outpatient visits (OPVs), and bronchodilator and inhaled corticosteroid (ICS) prescriptions in 2,362 children receiving Medicaid who were enrolled in an asthma management program (Easy Breathing) from June 1, 1998, through May 31, 2001. We used generalized estimating equations to fit multivariate marginal Poisson regression models, controlling for sex, ethnicity, asthma severity, and secular trends. RESULTS Hospitalization rates were high and decreased 53% for black children and 33% for Hispanic children after the intervention. The ED visits decreased for Hispanic children, and OPVs decreased for both black and Hispanic children after Easy Breathing. The ICS prescription rates increased, with a decrease in the bronchodilator to ICS ratio from 5.81 to 2.16 in black children and from 4.74 to 2.17 in Hispanic children. Hispanic children filled more prescriptions for bronchodilators and ICSs (odds ratio, 1.29; 95% confidence interval, 1.05-1.59; P = .01; and odds ratio, 1.55; 95% confidence interval, 1.14-2.11; P = .005; respectively) 3 and 12 months after Easy Breathing. Black children were more likely than Hispanic children not to fill any asthma prescription. A total of 12% of children filled no asthma prescriptions. CONCLUSIONS Hispanic children seek more medical services than black children, whereas black children fill fewer prescriptions for bronchodilators and ICSs than Hispanic children. Easy Breathing reduces overall hospitalizations and OPVs in black and Hispanic children and asthma-specific ED visits in Hispanic children; the benefits of Easy Breathing are different in Hispanic and black children.