Pediatricians are required to perform quality improvement for board recertification. We developed an asthma project within the Pediatric Physicians’ Organization at Children’s, an independent practice association affiliated with Boston Children’s Hospital, designed to meet recertification requirements and improve asthma care.
The program was based on the learning collaborative model. We developed practice-based registries of children 5 to 17 years of age with persistent asthma and helped physicians improve processes of asthma care through education, data feedback, and sharing of best practices.
Fifty-six physicians participated in 3 cohorts; 594 patients were included in the project. In all cohorts, improvements occurred in the use of asthma action plans (62.4%–76.8% cohort 1, 50.6%–88.4% cohort 2, 53.0%–79.6% cohort 3) and Asthma Control Tests (4.6%–55.2% cohort 1, 9.0%–67.8% cohort 2, 15.2%–61.4% cohort 3). Less consistent improvements were observed in seasonal influenza vaccines, controller medications, and asthma follow-up visits. The proportion of patients experiencing ≥1 asthma exacerbation within the year declined in all 3 cohorts (37.8%–19.9%, P = .0002 cohort 1; 27.8%–20.7%, P = .1 cohort 2; 36.6%–26.9%, P = .1 cohort 3). For each cohort, asthma exacerbations declined to a greater extent than those of a comparison group.
This asthma quality improvement project designed for maintenance of certification improved processes of care among patients with persistent asthma. The learning collaborative approach may be a useful model for other board-recertification quality improvement projects but requires a substantial investment of organizational time and staff.
Vernacchio et al should be congratulated for conducting an evaluation of the effectiveness of an asthma quality improvement program designed for maintenance of certification.(1) They certainly demonstrated improved processes of care and possibly improved outcomes. Unusually and refreshingly their findings are perhaps understated in the abstract: the project may actually have improved clinical outcomes - even though the authors are rightly cautious about their findings in that regard. The authors mentioned the cost of their approach and mooted the resources needed - including the time of senior staff and quality improvement training. However the costs of sustaining an intervention such as this are likely to account for substantially more than this. They would need to account for the identification of sites or decision points most in need of change, the analysis of the causes of problems, the on-course modification of interventions, the assessment of the implementation of the intervention and the assessment of the outcomes of the intervention, data quality assurance, the drawing of inferences from the results, and the continual sharing of results.(2) Personnel certainly make up a substantial proportion of costs but so also does information technology, facilities, and equipment. All these resources must be put to use to run a quality improvement project and to write it up as a quality improvement report - ideally according to the Squire guidelines.(2) The outcomes will often justify the resources and costs involved - but these costs cannot be discounted.
Yours Sincerely,
Kieran Walsh
1. Vernacchio L, Francis ME, Epstein DM, Santangelo J, Trudell EK, Reynolds ME, Risko W. Effectiveness of an Asthma Quality Improvement Program Designed for Maintenance of Certification. Pediatrics. 2014 Jun 16. pii: peds.2013-2643. [Epub ahead of print]
2. Ogrinc G, Mooney SE, Estrada C et al. The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration. Qual Saf Health Care 2008;17:i13-i32
Conflict of Interest:
None declared