title: A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study.
abstract: BACKGROUND
  Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines.
  
  
  OBJECTIVE
  To evaluate the effectiveness of 2 asthma care improvement strategies in primary care.
  
  
  METHODS
  Two-year randomized controlled clinical trial.
  
  
  METHODS
  Forty-two primary care pediatric practices affiliated with 4 managed care organizations.
  
  
  METHODS
  Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations.
  
  
  METHODS
  Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care.
  
  
  METHODS
  Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts).
  
  
  RESULTS
  Six hundred thirty-eight children completed baseline evaluations, representing 64% of those screened and eligible. Mean +/- SD age was 9.4 +/- 3.5 years; 60% were boys. Three hundred fifty (55%) were taking controller medication. Mean +/- SD annualized asthma symptom days was 107.4 +/- 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95% confidence interval [CI], - 16.9 to 3.6), a nonsignificant difference, but had a 36% (95% CI, 11% to 54%) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95% CI, - 24.7 to -2.1) fewer symptom days annually (-12% from baseline; P =.02) and a 39% (95% CI, 11% to 58%) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95% CI, 1.00 to 1.09]).
  
  
  CONCLUSIONS
  Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.
authors.affiliation: Center for Health Studies, Group Health Cooperative, 1730 Minor Avenue, Seattle, WA 98101, USA. plozano@u.washington.edu
authors.forename: Paula
authors.initials: P
authors.lastname: Lozano
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Finkelstein
authors.forename: Vincent J
authors.initials: VJ
authors.lastname: Carey
authors.forename: Edward H
authors.initials: EH
authors.lastname: Wagner
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Inui
authors.forename: Anne L
authors.initials: AL
authors.lastname: Fuhlbrigge
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Soumerai
authors.forename: Sean D
authors.initials: SD
authors.lastname: Sullivan
authors.forename: Scott T
authors.initials: ST
authors.lastname: Weiss
authors.forename: Kevin B
authors.initials: KB
authors.lastname: Weiss
mesh_terms: D000284:Administration, Oral; D000293:Adolescent; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use; D001249:Asthma / Q000453:epidemiology / Q000628:therapy*; D002648:Child; D002669:Child Welfare; D002675:Child, Preschool; D002908:Chronic Disease; D004502:Education, Medical, Continuing; D005260:Female; D005500:Follow-Up Studies; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008329:Managed Care Programs / Q000458:organization & administration*; D009819:Office Visits; D009936:Organizational Innovation; D010043:Outcome and Process Assessment, Health Care; D010821:Physicians, Family / Q000193:education*; D011320:Primary Health Care; D013256:Steroids / Q000627:therapeutic use; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D018927:Anti-Asthmatic Agents; D013256:Steroids