A Team-Based Approach to Providing Asthma Action Plans

• Asthma
• Delivery of Health Care
• Health Care Team
• Patient Education

National guidelines for treatment of asthma include recommendations for providing written asthma action plans (AAPs) to support patient self-management.¹ However, research indicates that AAP completion rates often remain low despite such recommendations.^2–4 Proactive, clinic-based approaches to asthma management have shown promise in increasing the use and ownership of AAPs, but they involve extensive provider training and/or health care worker time commitments.^1,5

During the period 2005 to 2006, our academic health center reported low AAP completion rates (7.5%; 884 of 11,785 patients) despite existing guidelines, AAP templates, and feedback from a quality improvement team. With no formal process in place for implementing clinic practice change, we piloted a team-based approach to increase the number of patients with written AAPs at 5 community-based family medicine clinics. The clinics handled 1300 to 2500 patient visits per month with staffing levels of 8 to 17 physicians and 2 to 4 registered nurses (RNs). A clinical quality management system (CQMS, Crimson Care Registry, Ann Arbor, MI) provided reminders to the physician at the time of the office visit. The system was capable of monitoring management for patients with chronic conditions, producing lists of patients with persistent asthma, delivering evidence-based reminders for asthma management, and tracking provider-generated responses.

Results

From 2006 to 2009, we educated 14 RNs, 30 residents, and 56 faculty. RNs wrote ∼98% of the AAPs based on physician and RN reports. Inclusion criteria for persistent asthmatics in the PGIP database somewhat differed over time because of changes in the reporting criteria of our internal health system, with a total of 10,071 to 11,686 recorded per year during the study period. Physician responses to the CQMS reminders remained high, ranging from 78% (993 of 1276) in 2007 to 90% (1481 of 1647) in 2009 (P = .121). Responses to AAP reminders included “completed today” (26%), “ordered for upcoming visit” (9%), “did not address due to more pressing health concern at visit” (13%), “discussed/deferred” (49%), and “refused” (3%).

From June 2007 to December 2009, the total number of patients provided with written AAPs increased significantly over time at most family medicine clinics, and at a level that exceeded other primary care clinics within the health system (Figure 1). Clinic 3 served as the pilot site, and AAP rates remained highest there for the majority of the study period, only showing a slight decline in late 2009 after reaching saturation.

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Figure 1.

Asthma action plan rates (cumulative %) for patients with persistent asthma. Results are based on the Physician Group Incentive Program chart review. Physician Group Incentive Program data from December 2008 was not available. Average-Other represents cumulative asthma action plan completion rates for the departments of internal medicine and pediatrics.

• Received for publication April 29, 2011.
• Revision received September 1, 2011.
• Accepted for publication September 6, 2011.