The San Diego Pediatric Asthma Provider Education Initiative

Asthma affects not only the health and daily life of children with asthma but also their families, friends, schools, businesses and taxpayers. The prevalence of asthma over the past decade has been rising and is one of the leading causes of chronic diseases and hospitalizations in San Diego. According to the 2001 California Health Interview Survey, 14.7 percent of San Diego County children (ages 1–17) have been diagnosed with asthma compared to 10.8 percent of adults (i). At 14.7 percent, San Diego County has the second-highest childhood asthma prevalence rates in southern California, exceeding the state average of 13.6 percent (ii). Statistics also show disproportionate rates of asthma symptoms and hospitalization and emergency room use, based on income, race and ethnicity.

Asthma is one of the chronic diseases that define a pediatric practice. Many challenges are faced in asthma’s diagnosis and management. Undoubtedly, medicine has come a long way with asthma management, since residency training in the 1970s, when theophylline was the drug of choice for home therapy and every child admitted received intravenous aminophylline and steroids. Now, more is known about the molecular basis of asthma, exposures can be assessed, and a wide array of available therapies can be chosen with molecular pathophysiology in mind. To help bridge the gap between current knowledge and practice, in 1997, the National Heart, Lung, and Blood Institute (NLHBI) released guidelines for the diagnosis and treatment of asthma to improve the quality of care for children with asthma.

Physicians play a key role in implementing evidence-based recommendations to improve outcomes, but compliance is generally low. A recent quality improvement study, conducted in San Diego, showed that only 30 percent of patients had documented disease severity; steroids were generally under-prescribed; many patients received inadequate education; few patients were asked to demonstrate proper inhaler use technique; and not many patients utilized disease monitoring devices such as peak flow meters. Moreover, no written asthma treatment plans were found in charts of children with asthma. There are barriers to the implementation and adherence of these guidelines. Focus groups suggested that physicians face varying barriers to the implementation of the guidelines such as a lack of familiarity or agreement with the NLHBI guidelines, economic disincentives, patient non-compliance, and inadequate time or resources (iii).

To overcome barriers to implementation of the guidelines, the County of San Diego Health and Human Services Agency, in partnership with the American Academy of Pediatrics (AAP), implemented the San Diego Pediatric Provider Education Asthma Initiative (SDPAPEI). This initiative has provided specific changes at the individual physician practice level — through targeted physician education — that positively impact the health of children with asthma in San Diego. SDPAPEI implemented a modified Institute for Healthcare Improvement (IHI) breakthrough quality improvement series, adapted for the medical setting, to introduce physicians to goal setting, self-evaluation, chart review, and other essential elements of the physician practice change model.

SDPAPEI sought to reduce the gaps in asthma care through the implementation of the NHLBI guidelines for asthma. SDPAPEI focused on key factors known to improve asthma management: 1) the use of correct classification of asthma severity; 2) appropriate use of controller medications; 3) proper techniques for medication delivery and disease monitoring devices; 4) written Asthma Action Plan; and 5) education of individuals who provide care or supervise the child. SDPAPEI targeted medical practices that served areas where children have high rates of asthma hospitalizations and emergency room use.

Results showed that 73 percent of responding SDPAPEI participants stated that, to a great extent, the program helped them classify asthma severity in their practice; 59 percent noticed a decrease in asthma exacerbations, sick visits, or ER visits in their patients. Responses to the survey conducted to determine physician behavior change were positive, as 100 percent of respondents stated that participation in the program changed the way they treat children with asthma. Our experience shows that targeted physician education is effective in changing physician behavior and is an alternative to the traditional learning approach.

Physicians interested in learning or implementing asthma SDPAPEI tools should contact Dr. Cureg at (619) 692-8808, Dr. Pradeep Gidwani at (858) 576-1700, ext. 4133, or Matt Wimmer at (858) 576-1700, ext. 4478. Resources, including the San Diego Asthma Report Card and many of the SDPAPEI tools are also available at www.lungsandiego.org and www.sdrac.org.

References: 1. California Health Interview Survey, 2001, Los Angeles, CA: UCLA Center for Health Policy Research, July 2002. 2. San Diego Asthma Regional Asthma Coalition. Asthma Report Card 2004. 3. Unpublished report.

San Diego County Health Stats:

• Asthma hospitalization rates for children ages 0–4 in San Diego County were 309.4 (age-adjusted rates/100,000 population). The highest rate was 458.9 in central San Diego followed by 346.8 in the south region and 318.4 in the east region of San Diego County. The north inland region was 271.1, the north central region was 265.7, and the north coastal was the lowest rate at 192.7. (1)
• In San Diego County, 33% of all youth ages 13–17 with asthma are African-American. (2)
• May is Asthma and Allergy Awareness Month. For more information, go to the Asthma and Allergy Foundation of America website at www.aafa.org.
• To request additional health statistics describing health behaviors, diseases, and injuries for specific populations, health trends, and comparisons to national targets, please call the County’s Community Health Statistics Unit at (619) 515-4318. To access the latest data and data links, including the 2004 Core Public Health Indicator document, go to www.sdhealthstatistics.com.

Refernces: 1. California Office of Statewide Health Planning and Development, 2002. 2. California Health Interview Survey, 2001, Los Angeles, CA: UCLA Center for Health Policy Research, July 2002.