Evaluation of a practice-based intervention to improve the management of pediatric asthma.

Pediatric asthma remains a significant burden upon patients, families, and the healthcare system. Despite the availability of evidence-based best practice asthma management guidelines for over a decade, published studies suggest that many primary care physicians do not follow them. This article describes the Provider Quality Improvement (PQI) intervention with six diverse community-based practices. A pediatrician and a nurse practitioner conducted the year-long intervention, which was part of a larger CDC-funded project, using problem-based learning within an academic detailing model. Process and outcome assessments included (1) pre- and post-intervention chart reviews to assess eight indicators of quality care, (2) post-intervention staff questionnaires to assess contact with the intervention team and awareness of practice changes, and (3) individual semi-structured interviews with physician and nurse champions in five of the six practices. The chart review indicated that all six practices met predefined performance improvement criteria for at least four of eight indicators of quality care, with two practices meeting improvement criteria for all eight indicators. The response rate for the staff questionnaires was high (72%) and generally consistent across practices, demonstrating high staff awareness of the intervention team, the practice "asthma champions," and changes in practice patterns. In the semi-structured interviews, several respondents attributed the intervention's acceptability and success to the expertise of the PQI team and expressed the belief that sustaining changes would be critically dependent on continued contact with the team. Despite significant limitations, this study demonstrated that interventions that are responsive to individual practice cultures can successfully change practice patterns.

A model-driven approach to qualitatively assessing the added value of community coalitions.

Community-based coalitions are commonly formed to plan and to carry out public health interventions. The literature includes evaluations of coalition structure, composition, and functioning; evaluations of community-level changes achieved through coalition activities; and the association between coalition characteristics and various indicators of success. Little information is available on the comparative advantage or "added value" of conducting public health interventions through coalitions as opposed to less structured collaborative mechanisms. This paper describes a qualitative, iterative process carried out with site representatives of the Controlling Asthma in American Cities Project (CAACP) to identify outcomes directly attributable to coalitions. The process yielded 2 complementary sets of results. The first were criteria that articulated and limited the concept of "added value of coalitions". The criteria included consensus definitions, an organizing figure, a logic model, and inclusion/exclusion criteria. The second set of results identified site-specific activities that met the definitional criteria and were, by agreement, examples of CAACP coalitions' added value. Beyond the specific findings relevant to the added value of coalitions in this project, the use of a social ecological model to identify the components of added value and the placement of those components within a logic model specific to coalitions should provide useful tools for those planning and assessing coalition-based projects.

Decreased physical activity among Head Start children with a history of wheezing: use of an accelerometer to measure activity.

Asthma is a severe problem among inner city children, and recent evidence suggests that both allergen exposure and lifestyle can impact the disease early in childhood. This study was designed to investigate the association between physical activity and wheezing among a population of inner city children enrolling in Head Start. The parents of children aged 3-5 years responded to a questionnaire (N = 144) to determine the presence and severity of wheezing and asthma. Information was also gathered regarding home environment, food frequency, and presence of other allergic diseases. Serum was obtained to measure total IgE and specific IgE levels to common allergens. Height and weight for body mass index were recorded. Lastly, motion sensor wristwatches (Actiwatch) were worn continuously by a subset of these children (n = 54) for 6 or 7 days. Physical activity measured with the motion sensor was decreased among children with a history of wheezing. The significant differences involved those measures of activity relating to prolonged or sustained physical activity. The correlates of asthma associated with decreased levels of physical activity included: 1) a history of wheezing in the last 12 months, 2) the diagnosis of asthma, and 3) presentation to the emergency room in the last 12 months for wheezing or asthma. In a preschool-age population, decreased physical activity was observed among children with a history of asthma or wheezing. Decreased physical activity could contribute to persistence of asthma or put children at higher risk for obesity and other chronic diseases.