Quality Improvement to Eliminate Disparities in Developmental Screening for Patients Needing Interpreters.

Children from households with a preferred language other than English are less likely to receive timely identification and treatment for developmental delay than children of native English speakers. In dismantling this inequity, the role of primary care pediatrics is to establish equitable systems for screening and referral. This project, conducted in a network of twelve pediatric primary care centers, focused on eliminating a small but systematic disparity in developmental screening rates between families who did and did not require interpreters (86% versus 92%). The specific aim was to increase developmental screen completion among patients needing interpreters from 86% to 92% of age-appropriate well-child visits. Methods: Data were extracted from the electronic health record (EHR) to measure the proportion of 9-, 18-, 24-, and 30-month well-child visits at which developmental screens were completed, stratified by interpreter need (n = 31,461 visits; 7500 needing interpreters). One primary care center tested small changes to standardize processes, eliminate workarounds, and leverage EHR features using the Institute for Healthcare Improvement's Model for Improvement. The QI team plotted screen completion on control charts and spread successful changes to all 12 clinics. Statistical process control evaluated the significance of changes in screening rates. Results: For patients needing interpreters, screen completion rose across all clinics from 86% to 93% when the clinics implemented the new process. Screen completion for patients not needing interpreters remained at 92%. Conclusion: A standardized process supported by the EHR improved developmental screening among patients needing interpreters, eliminating disparities.

Improving Patient-Provider Continuity in a Large Urban Academic Primary Care Network.

OBJECTIVE: Although patient-provider continuity improves care delivery and satisfaction, poor continuity with primary care providers (PCP) often exists in academic centers. We aimed to increase patient empanelment from 0% to 90% and then increase the percent of well-child care (WCC) visits scheduled with the PCP from 25.6% to 50%, without decreasing timely access that might result if patients waited for PCP availability. METHODS: Nationwide Children's Hospital Primary Care Network cares for >120,000 mostly Medicaid-enrolled patients across 13 offices. Before 2017, patients were empaneled to an office, not individual PCPs. We empaneled patients to PCPs, reduced provider floating, implemented continuity-promoting scheduling guidelines, scheduled future WCC visits for patients ≤15 months during check-in for their current one, and encouraged online scheduling. We tracked the percentage of all WCC visits that were scheduled with the patient's PCP and the percentage of subsequent WCC visits for patients ≤15 months that were scheduled during the current visit, and provided feedback to schedulers. We followed emergency department (ED) utilization and visit show rates. WCC visit completion rates were tracked using HEDIS metrics. RESULTS: Patient empanelment increased from 0% to >90% (P < .001). Patient-provider WCC continuity increased from 25.6% to 54.7% (P < .001). A 20.5% decrease in ED utilization rate was associated with continuity project initiation. Empaneled patients demonstrated higher show rates (76.9%) versus unempaneled patients (71.4%; P < .001). WCC completion rates increased from 52.6% to 60.7%. CONCLUSIONS: WCC continuity more than doubled after interventions and was associated with decreased ED utilization, higher show rates, and increased timely WCC completion.

Effect of osteopathic manipulative treatment on pulmonary function testing in children with asthma.

CONTEXT: Asthma is a leading cause of pediatric chronic illness, and poor disease control can lead to decreased quality of life and impaired academic performance. Although osteopathic manipulative treatment (OMT) has been shown to have positive effects on pulmonary function in adult patient populations, less is known about its impact in children. OBJECTIVES: To evaluate changes in pulmonary function testing (PFT) in pediatric patients on the same day they received OMT compared with PFT in those who received usual care. METHODS: We recruited patients between the ages of 7-18 years with a diagnosis of asthma who were receiving routine care at a primary care asthma clinic and had undergone baseline spirometry. Patients were excluded if they met any of the following criteria: clinical indication for pre- and postbronchodilator spirometry on the day of their visit, albuterol use in the last 8 hours, oral steroid use in the previous 2 weeks, or diagnosis of asthma exacerbation in the previous 4 weeks. Eligible patients were then randomized to either an OMT or a control group. Patients in the OMT group were treated with rib raising and suboccipital release in addition to standard asthma care, while control group patients received standard care only. A second PFT was performed for patients in both groups at the end of the visit. OMT was performed by multiple osteopathic pediatric residents specifically trained for this study. Change in spirometry results (forced vital capacity [FVC], forced expiration volume in 1 second [FEV1], FVC/FEV1, and forced expiratory flow 25-75%) were then compared. RESULTS: The study population included 58 patients: 31 (53.4%) were assigned to the OMT group and 27 (46.6%) were assigned to the standard of care group. Patients who received OMT had greater improvement in all spirometry values compared to the usual group; however, these changes were not statistically significant. CONCLUSIONS: The benefits of OMT on short term spirometry results in pediatric asthma patients remain unclear.

Reducing emergency department visits utilizing a primary care asthma specialty clinic in a high-risk patient population.

OBJECTIVE: Asthma is a leading cause of pediatric emergency department (ED) use. Optimizing asthma outcomes is a goal of Nationwide Children's Hospital (NCH) and its affiliated Accountable Care Organization. NCH's Primary Care Network, comprised of 12 offices serving a predominantly Medicaid population, sought to determine whether an Asthma Specialty Clinic (ASC) operated within a single primary care office could reduce ED asthma rates and improve quality measures, relative to all other network offices. METHODS: An ASC was piloted with four components: patient monitoring, provider continuity, standardized assessment, and multi-disciplinary education. A registry was established to contact patients at recommended intervals. At extended-length visits, a general pediatrician evaluated patients and a multi-disciplinary team provided education. Novel educational tools were utilized, guideline-based templates recorded and spirometry obtained. ED asthma rate, spirometry utilization, and controller fills by intervention office patients were compared to all other network offices before and after ASC initiation. RESULTS: At baseline, asthma ED visits by intervention and usual care populations were similar (p = 0.43). After, rates were significantly lower for intervention office patients versus usual care office patients (p < 0.001), declining in the intervention population by 26.2%, 25.2%, and 31.8% in 2013, 2014, and 2015, respectively, from 2012 baseline, versus increases of 3.8%, 16.2%, and 9.5% in the usual care population. Spirometry completion, controller fills, and patients with favorable Asthma Medication Ratios significantly increased for intervention office patient relative to the usual care population. CONCLUSIONS: A primary care-based asthma clinic was associated with a significant and sustainable reduction in ED utilization versus usual care. What's new: This study describes a comprehensive, multi-disciplinary, and innovative model for an asthma management program within the medical home that demonstrated a significant reduction in ED visits, an increase in spirometry utilization, and an increase in controller fills in a high-risk asthma population versus comparison group.

Implementation of the Asthma Control Test in a Large Primary Care Network.

INTRODUCTION: Achieving control in asthma is a primary goal of pediatric care, and assessing the degree of control is a principal step in management. The purpose of this quality improvement project was to implement the Asthma Control Test (ACT) and the Childhood Asthma Control Test (C-ACT) in a large primary care network as a means to reliably and consistently assess asthma control at all visit types. METHODS: A prospective design was used to measure provider documentation of the ACT or C-ACT. Patients (or caregivers) 4 years of age or older with a known diagnosis of asthma were administered the ACT (ages 12 and older) or the C-ACT (ages, 4-11). The quality improvement project, which involved multiple interventions, took place at 11 centers of the Primary Care Network of Nationwide Children's Hospital from November 2013 to December 2014. A goal was set for a 70% completion rate of the ACT/C-ACT at any visit type for patients 4 years of age or older with asthma. RESULTS: Six months after the introduction of the questionnaires, the 70% completion rate was reached. Rates of ACT/C-ACT completion have consistently exceeded 70% through December 2016. CONCLUSIONS: We demonstrated that the ACT/C-ACT can be integrated into a busy primary care network. It is imperative to work toward better asthma care; consistent assessment of asthma control can be the critical first step.