According to the American Lung Association, asthma is one of the most common chronic disorders in childhood affecting an estimated 7 million children under the age of 18. Asthma is the third leading cause of hospitalization among children under the age of 15 and is one of the leading causes of school absenteeism. The annual direct health care cost of asthma is approximately $50 billion; indirect costs (e.g. lost productivity) add another $6 billion, for a total of $56 billion dollars.
Whereas many pediatric practices refer patients with asthma to a pediatric allergist or pulmonologist, Harvard Vanguard Medical Associates, the largest affiliate of Atrius Health, sought to better manage patients with asthma within the pediatrics department. Approximately 15% of Harvard Vanguard pediatric patients are affected by asthma, and the goal was to help children and their families better manage their asthma symptoms so they could enjoy better health and quality of life.
The solution to helping patients with asthma was to implement lung function testing and to work with families to create an Asthma Action Plan (AAP) for each child during the pediatric annual well visit. Both testing and creating AAPs throughout 14 pediatric departments was no small feat, but the well-being of our youngest patients drove the team toward their goal.
The first step in this process was a Lean Rapid Improvement Event (RIE) at the Burlington practice in the summer of 2010. The reason for action was to reduce avoidable asthma-related emergency department (ED) visits and hospitalizations by improving the clinical care year round, not just when there is an acute episode.
The group working on this project determined the best way to reduce avoidable ED visits and hospitalizations was to put well child visit standard work in place for all pediatric patients who have an asthma diagnosis. An asthma control test (ACT) questionnaire, a pulmonary function test (PFT) and a review of the current asthma action plan (AAP) were incorporated as part of the annual visit. This enabled the doctors and nurses to help their patients better recognize early symptoms of an asthma attack, understand the proper use of medication and to seek immediate help when appropriate.
Since asthma control and pulmonary function tests are not typically done and interpreted by pediatricians, wide scale training was necessary for more than 70 pediatricians and their medical teams. Implementation of standard work for conducting ACTs and PFTs for every patient was rolled out across 14 practices over a 15 month time span. This was a massive undertaking and learning process for not only the pediatricians, but also for the nurses and medical assistants who received training to become proficient with these testing procedures.
Monthly reviews of a roster of pediatric patients were also implemented as an ongoing means to ensure the health of these patients is actively being managed between visits. The medical team at each practice reviews the list of all patients with a primary diagnosis of asthma to determine those who are at high risk. Indicators, such as those with an ED visit in the last 12 months or those who had more than 5 rescue inhalers in the past 5 months, are filtered out and an outreach plan is devised. Registered nurses, who specialize in asthma, contact the patient’s family after every ED visit or hospital admission. This outreach includes a skilled assessment with coaching and counseling regarding care, a review of the AAP, and scheduling of a follow up appointment with the pediatrician as appropriate.
The successes of this initiative have been many. First and foremost, the patients are being better monitored and their asthma better managed resulting in a better quality of life. Over the past year, Harvard Vanguard has seen an 8% decrease in emergency department visits by their patients with asthma. When this initiative began, there were AAPs in place for less than 25% of asthmatics. In 2013, there were AAPs in place for 80% of asthmatics, and the goal for 2014 is 85%. With an ongoing emphasis on improving the standard work in place, we expect to continue to improve the health of our patients, to decrease the cost of care and to improve efficiency in our work.