Impact of patient-centered decision support on quality of asthma care in the emergency department.
OBJECTIVE
Communication barriers between parents of children with asthma and clinical emergency department (ED) providers and subsequent underrecognition of chronicity and severity impede improvements in disease management for patients with asthma in the ED setting. The asthma kiosk, a novel patient-driven decision-support tool, provides ED clinicians with tailored recommendations for guideline-based treatment. We evaluated the impact of the asthma kiosk on measures of quality during ED care, specifically, parent-reported satisfaction with dimensions of care related to communication and providers' adoption of guideline-endorsed processes of care.


METHODS
A clinical trial composed of a baseline and an intervention period was conducted at a single tertiary care pediatric ED. Eligible participants were English- or Spanish-speaking parents of children who were 1 to 12 years of age and had a respiratory complaint and history of asthma. Parents used the kiosk to report children's symptoms, current medications, and unmet needs. During a 2-month baseline, no output from the kiosk was shared, and usual care proceeded. During a 3-month intervention that followed a 1-week run-in period, the output was shared with ED clinicians. All parents completed a telephone follow-up interview 1 week after discharge. Primary outcomes were (1) prescription of controller medication to patients who had persistent asthma symptoms and were not on controllers and (2) mean problem scores for 2 specific dimensions of care: information-sharing and partnership.


RESULTS
Over 5 months, 1090 parent-child dyads were screened and 430 were eligible. A total of 286 (66.5%) of 430 parents enrolled in the trial. The kiosk generated severity classifications for 264 (92.3%) of 286 children. A total of 131 parents enrolled during baseline, 13 during a 1-week test phase, and 142 during intervention. Baseline participants were older (mean age: 5.3 years) compared with intervention (4.4 years) but did not differ on chronic severity, current use of controllers, or race. The total number of prescribed inhaled corticosteroids did not vary significantly between intervention and baseline (9 of 50 vs 4 of 43). Providers did prescribe inhaled fluticasone to eligible patients more often during intervention than baseline (9 of 50 vs 2 of 43). The number of reported information problems was unchanged between the baseline and intervention periods. The mean number of partnership problems increased from a mean of 1.5 (SD: 1.9) at baseline to a mean of 1.9 (SD: 1.4) during the intervention. This difference was marginally significant after adjustment for child gender, age, and severity category. When ED providers acted on kiosk data, reports of information problems were fewer (0.6 +/- 0.8) than when no action was taken (1.1 +/- 1.1).


CONCLUSIONS
The asthma kiosk demonstrated small and variable impact on quality. Physicians' nonuse of kiosk-generated recommendations may explain the limited impact of the intervention.
Porter
Stephen C
SC
Department of Medicine, Children's Hospital Boston, Boston, MA 02115, USA. stephen.porter@childrens.harvard.edu
Forbes
Peter
P
Feldman
Henry A
HA
Goldmann
Donald A
DA
D001249:Asthma / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D003201:Computers; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D006801:Humans; D007223:Infant; D010287:Parent-Child Relations; D010290:Parents / Q000193:education* / Q000523:psychology; D017060:Patient Satisfaction; D018802:Patient-Centered Care; D011787:Quality of Health Care