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Learning from a Distance: Effectiveness of Online Spirometry Training in Improving Asthma Care

  • James W. Stout
    Correspondence
    Address correspondence to James W. Stout, MD, MPH, University of Washington, Child Health Institute, Suite 110, 6200 NE 74th Street, Seattle, WA 98115.
    Affiliations
    Departments of Pediatrics and Health Services (Drs Stout, Mangione-Smith, and Zhou), University of Washington, Seattle, Wash; Interactive Medical Training Resources (iMTR) (Drs Stout and Smith), Child Health Institute, University of Washington, Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children’s Hospital Research Institute (Drs Solomon, Mangione-Smith, Zhou, and Garrison), Seattle, Wash; and Department of Pediatrics, New York Medical College, Valhalla, NY (Dr Dozor)
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  • Karen Smith
    Affiliations
    Departments of Pediatrics and Health Services (Drs Stout, Mangione-Smith, and Zhou), University of Washington, Seattle, Wash; Interactive Medical Training Resources (iMTR) (Drs Stout and Smith), Child Health Institute, University of Washington, Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children’s Hospital Research Institute (Drs Solomon, Mangione-Smith, Zhou, and Garrison), Seattle, Wash; and Department of Pediatrics, New York Medical College, Valhalla, NY (Dr Dozor)
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  • Chuan Zhou
    Affiliations
    Departments of Pediatrics and Health Services (Drs Stout, Mangione-Smith, and Zhou), University of Washington, Seattle, Wash; Interactive Medical Training Resources (iMTR) (Drs Stout and Smith), Child Health Institute, University of Washington, Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children’s Hospital Research Institute (Drs Solomon, Mangione-Smith, Zhou, and Garrison), Seattle, Wash; and Department of Pediatrics, New York Medical College, Valhalla, NY (Dr Dozor)
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  • Cam Solomon
    Affiliations
    Departments of Pediatrics and Health Services (Drs Stout, Mangione-Smith, and Zhou), University of Washington, Seattle, Wash; Interactive Medical Training Resources (iMTR) (Drs Stout and Smith), Child Health Institute, University of Washington, Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children’s Hospital Research Institute (Drs Solomon, Mangione-Smith, Zhou, and Garrison), Seattle, Wash; and Department of Pediatrics, New York Medical College, Valhalla, NY (Dr Dozor)
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  • Allen J. Dozor
    Affiliations
    Departments of Pediatrics and Health Services (Drs Stout, Mangione-Smith, and Zhou), University of Washington, Seattle, Wash; Interactive Medical Training Resources (iMTR) (Drs Stout and Smith), Child Health Institute, University of Washington, Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children’s Hospital Research Institute (Drs Solomon, Mangione-Smith, Zhou, and Garrison), Seattle, Wash; and Department of Pediatrics, New York Medical College, Valhalla, NY (Dr Dozor)
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  • Michelle M. Garrison
    Affiliations
    Departments of Pediatrics and Health Services (Drs Stout, Mangione-Smith, and Zhou), University of Washington, Seattle, Wash; Interactive Medical Training Resources (iMTR) (Drs Stout and Smith), Child Health Institute, University of Washington, Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children’s Hospital Research Institute (Drs Solomon, Mangione-Smith, Zhou, and Garrison), Seattle, Wash; and Department of Pediatrics, New York Medical College, Valhalla, NY (Dr Dozor)
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  • Rita Mangione-Smith
    Affiliations
    Departments of Pediatrics and Health Services (Drs Stout, Mangione-Smith, and Zhou), University of Washington, Seattle, Wash; Interactive Medical Training Resources (iMTR) (Drs Stout and Smith), Child Health Institute, University of Washington, Seattle, Wash; Center for Child Health, Behavior, and Development, Seattle Children’s Hospital Research Institute (Drs Solomon, Mangione-Smith, Zhou, and Garrison), Seattle, Wash; and Department of Pediatrics, New York Medical College, Valhalla, NY (Dr Dozor)
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      Abstract

      Objective

      We evaluated the effectiveness of a virtually delivered quality improvement (QI) program designed to improve primary care management for children with asthma.

      Methods

      Thirty-six physicians, nurses, and medical assistants from 14 primary care pediatric practices (7 matched practice pairs) participated in a cluster randomized trial from October 2007 to September 2008. All practices received a spirometer and standard vendor training. A 7-month QI program delivered during the study period included: 1) Spirometry Fundamentals™ CD-ROM, a multimedia tutorial; 2) case-based, interactive webinars led by clinical experts; and 3) an internet-based spirometry quality feedback reporting system. Practice pairs were compared directly to each other, and between-group differences were analyzed with the use of mixed effects regression models. Our main outcome measures were the frequency of spirometry testing, percentage of acceptable quality spirometry tests, asthma severity documentation, and appropriate controller medication prescribing.

      Results

      Participating practices uploaded a total of 1028 spirometry testing sessions, of which 340 (33.1%) were of acceptable quality. During the 7-month intervention period, there was no difference between intervention and control practices in the frequency of spirometry tests performed. Intervention practices were estimated to have significantly greater odds of conducting tests with acceptable quality compared with matched control practices, adjusting for quality in the baseline period (odds ratio 2.85; 95% confidence interval 1.78–4.56, P < .001). Intervention providers also had significantly greater odds of documenting asthma severity during the intervention period (odds ratio 2.9, 95% confidence interval 1.8–4.5; P < .001). Although use of controller medications among patients with persistent asthma approached 100% for both groups, the proportion of asthma patients labeled as persistent increased from 43% to 62% among intervention practices, and decreased from 57% to 50% among controls (NS).

      Conclusions

      A multifaceted distance QI program resulted in increased spirometry quality and improved assessment of asthma severity levels. Successful participation in QI programs can occur over distance.

      Keywords

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      References

        • Expert Panel Report 3 (EPR-3)
        Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007.
        J Allergy Clin Immunol. 2007; 120: S94-138
        • Nair S.J.
        • Daigle K.L.
        • DeCuir P.
        • et al.
        The influence of pulmonary function testing on the management of asthma in children.
        J Pediatr. 2005; 147: 797-801
        • Stout J.W.
        • Visness C.M.
        • Enright P.
        • et al.
        Classification of asthma severity in children: the contribution of pulmonary function testing.
        Arch Pediatr Adolesc Med. 2006; 160: 844-850
        • Wolfenden L.L.
        • Diette G.B.
        • Krishnan J.A.
        • et al.
        Lower physician estimate of underlying asthma severity leads to undertreatment.
        Arch Intern Med. 2003; 163: 231-236
        • Baker J.W.
        • Mellon M.
        • Wald J.
        • et al.
        A multiple-dosing, placebo-controlled study of budesonide inhalation suspension given once or twice daily for treatment of persistent asthma in young children and infants.
        Pediatrics. 1999; 103: 414-421
        • Sears M.R.
        Increasing asthma mortality—fact or artifact?.
        J Allergy Clin Immunol. 1988; 82: 957-960
        • Suissa S.
        • Ernst P.
        • Benayoun S.
        • et al.
        Low-dose inhaled corticosteroids and the prevention of death from asthma.
        N Engl J Med. 2000; 343: 332-336
        • Adams R.J.
        • Fuhlbrigge A.
        • Finkelstein J.A.
        • et al.
        Impact of inhaled antiinflammatory therapy on hospitalization and emergency department visits for children with asthma.
        Pediatrics. 2001; 107: 706-711
        • Buxton M.J.
        • Sullivan S.D.
        • Andersson L.F.
        • et al.
        Country-specific cost-effectiveness of early intervention with budesonide in mild asthma.
        Eur Respir J. 2004; 24: 568-574
        • Weiss K.
        • Buxton M.
        • Andersson F.L.
        • et al.
        Cost-effectiveness of early intervention with once-daily budesonide in children with mild persistent asthma: results from the START study.
        Pediatr Allergy Immunol. 2006; 17: 21-27
        • Legorreta A.P.
        • Christian-Herman J.
        • O’Connor R.D.
        • et al.
        Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience.
        Arch Intern Med. 1998; 158: 457-464
        • Dombkowski K.J.
        • Hassan F.
        • Wasilevich E.A.
        • et al.
        Spirometry use among pediatric primary care physicians.
        Pediatrics. 2010; 126: 682-687
        • Eaton T.
        • Withy S.
        • Garrett J.E.
        • et al.
        Spirometry in primary care practice: the importance of quality assurance and the impact of spirometry workshops.
        Chest. 1999; 116: 416-423
        • Ferguson G.T.
        • Enright P.L.
        • Buist A.S.
        • et al.
        Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program.
        Chest. 2000; 117: 1146-1161
        • Bunik M.
        • Fredrico M.J.
        • Beaty B.
        • et al.
        Quality improvement for asthma care within a hospital teaching clinic.
        Acad Pediatr. 2011; 11: 58-65
        • Mandel K.E.
        • Kotagal U.R.
        Pay for performance alone cannot drive quality.
        Arch Pediatr Adolesc Med. 2007; 161: 650-655
        • Boushon B.
        • Provost L.
        • Gagnon J.
        • et al.
        Using a virtual breakthrough series collaborative to improve access in primary care.
        Jt Comm J Qual Improv. 2006; 32: 573-584
        • Powell H.
        • Stout J.W.
        Spirometry Fundamentals: A Basic Guide to Lung Function Testing (CD-ROM). Version 1.2.
        University of Washington, Seattle, Wash2006
      1. Cisco WebEx. Available at: http://www.webex.com. Accessed October 26, 2011.

      2. University of Washingtion, integrated Medical Training Resources. Our Programs. Spirometry training. Available at: http://www.spirometrytraining.org. Accessed October 26, 2011.

        • Fleiss J.
        • Levin B.
        • Cho Paik M.
        Statistical Methods for Rates and Proportions.
        3rd ed. John Wiley & Sons, New York, NY2003
      3. National Heart, Lung, and Blood Institute. Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma-Update on Selected Topics; 2002. Available at: http://www.nhlbi.nih.gov/guidelines/archives/epr-2_upd/index.htm. Accessed January 11, 2012.

        • Pinheiro J.
        • Bates D.
        Mixed-Effects Models in S and S-Plus.
        Springer Verlag, New York, NY2000
        • R Development Core Team
        R: A Language and Environment for Statistical Computing.
        R Foundation for Statistical Computing, Vienna, Austria2011 (Available at)
        • StatCorp
        Stata statistical software: Release 12.
        StataCorp LP, College Station, Tex2011
        • Levy M.
        • Quanjer P.
        • Booker R.
        • et al.
        Diagnostic spirometry in primary care: proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations.
        Primary Care Respir J. 2009; 18: 130-147