A qualitative study of perspectives on the acceptability and feasibility of "virtual home visits" for asthma.

BACKGROUND: Asthma home-visit programs delivered by community health workers (CHWs) are an effective way to improve asthma outcomes and cost of care, through performing home environmental inspections, delivering education and hands-on demonstrations, and providing personalized behavior change support. During the COVID-19 pandemic, many in-person asthma CHW programs have been adapted to be delivered virtually, but it is unclear whether this is acceptable or feasible for clients with asthma. This qualitative study sought to identify perspectives of prior clients of the Public Health-Seattle & King County Asthma Program on acceptability and feasibility of a hypothetical virtual asthma program. METHODS: We performed semi-structured interviews with participants speaking English, Spanish, and Somali. An a priori codebook was developed based on the Theoretical Framework of Acceptability and was revised iteratively during coding. Intra-rater reliability was established, and thematic analysis was used to determine major themes. RESULTS: A total of 19 individuals participated (9 speaking English, 8 Spanish, and 2 Somali). Krippendorf's alpha was 0.848, indicating high intra-rater reliability. Our results demonstrated that many participants felt positively about the prospect of completing the program virtually, but they also expected a variety of challenges, the most important of which were lack of engagement with the CHW and lack of confidence in the accuracy of a virtual home inspection. Participants also varied widely in their comfort level with videoconferencing platforms and their access to adequate internet connectivity. CONCLUSIONS: Acceptability and feasibility of virtual programming varies widely between participants, indicating that there may be no "one-size-fits-all" approach. We present several recommendations for adapting in-person asthma home visit programs to a virtual format, including considering a hybrid approach to delivery, making concerted efforts to build rapport when using videoconferencing, and deliberately evaluating the effectiveness of new adaptations, especially if a virtual environmental assessment is attempted.

Defining and Promoting Pediatric Pulmonary Health: Assessing Lung Function and Structure.

Lifelong respiratory health is rooted in the structural and functional development of the respiratory system in early life. Exposures and interventions antenatally through childhood can influence lung development into young adulthood, the life stage with the highest achievable lung function. Because early respiratory health sets the stage for adult lung function trajectories and risk of developing chronic obstructive pulmonary disease, understanding how to promote lung health in children will have far reaching personal and population benefits. To achieve this, it is critical to have accurate and precise measures of structural and functional lung development that track throughout life stages. From this foundation, evaluation of environmental, genetic, metabolic, and immune mechanisms involved in healthy lung development can be investigated. These goals require the involvement of general pediatricians, pediatric subspecialists, patients, and researchers to design and implement studies that are broadly generalizable and applicable to otherwise healthy and chronic disease populations. This National Institutes of Health workshop report details the key gaps and opportunities regarding lung function and structure.

Text2Breathe: Text-Message Intervention for Parent Communication and Pediatric Asthma.

OBJECTIVE: Mobile health technology offers promise for reducing disparities in pediatric asthma care and outcomes by helping parents more effectively communicate with their children's primary care providers and manage their children's asthma. This study tested the impact of a text messaging program on emergency department utilization and asthma morbidity. METHODS: A randomized controlled trial enrolled 221 parents of Medicaid-insured children visiting the emergency departments of 2 urban children's hospitals in the Pacific Northwest for an asthma-related concern between September 2015 and February 2019. Standardized surveys were administered to parents at baseline and 12 months later to assess the primary outcomes of emergency department utilization and morbidity as well as primary care utilization, parent communication self-efficacy, and asthma self-management knowledge. The intervention group received brief in-person education on partnering with primary care providers, followed by 3 months of educational text messages. RESULTS: Participants were mostly female, English speakers, of minority race and ethnicity, and living below 200% of the federal poverty level. Negative binomial and linear regressions indicated no significant group differences in annual number of emergency department visits, morbidity, parent communication self-efficacy, or asthma self-management knowledge at 12 months' follow-up, adjusting for baseline covariates. Average annual rate of primary care visits for asthma was 35% higher in the intervention group compared to control group at follow-up (95% confidence interval 1.03-1.76, P = .03). CONCLUSIONS: This parent-focused text message intervention did not impact emergency department utilization or asthma morbidity; however, results suggest its potential for enhancing use of primary care for management of pediatric chronic conditions.

Stakeholder engagement in eight comparative effectiveness trials in African Americans and Latinos with asthma.

BACKGROUND: The effects of stakeholder engagement, particularly in comparative effectiveness trials, have not been widely reported. In 2014, eight comparative effectiveness studies targeting African Americans and Hispanics/Latinos with uncontrolled asthma were funded by the Patient-Centered Outcomes Research Institute (PCORI) as part of its Addressing Disparities Program. Awardees were required to meaningfully involve patients and other stakeholders. Using specific examples, we describe how these stakeholders substantially changed the research protocols and in other ways participated meaningfully as full partners in the development and conduct of the eight studies. METHODS: Using the method content analysis of cases, we identified themes regarding the types of stakeholders, methods of engagement, input from the stakeholders, changes made to the research protocols and processes, and perceived benefits and challenges of the engagement process. We used summaries from meetings of the eight teams, results from an engagement survey, and the final research reports as our data source to obtain detailed information. The descriptive data were assessed by multiple reviewers using inductive and deductive qualitative methods and discussed in the context of engagement literature. RESULTS: Stakeholders participated in the planning, conduct, and dissemination phases of all eight asthma studies. All the studies included clinicians and community representatives as stakeholders. Other stakeholders included patients with asthma, their caregivers, advocacy organizations, and health-system representatives. Engagement was primarily by participation in advisory boards, although six of the eight studies (75%) also utilized focus groups and one-on-one interviews. Difficulty finding a time and location to meet was the most reported challenge to engagement, noted by four of the eight teams (50%). Other reported challenges and barriers to engagement included recruitment of stakeholders, varying levels of enthusiasm among stakeholders, controlling power dynamics, and ensuring that stakeholder involvement was reflected and had true influence on the project. CONCLUSION: Engagement-driven modifications led to specific changes in study design and conduct that were felt to have increased enrollment and the general level of trust and support of the targeted communities. The level of interaction described, between investigators and stakeholders in each study and between investigator-stakeholder groups, is-we believe-unprecedented and may provide useful guidance for other studies seeking to improve the effectiveness of community-driven research.

The goal of comparative clinical effectiveness research is to compare healthcare options and learn which work best for patients depending on their preferences and circumstances. Research efforts can be more effective when researchers engage stakeholders, such as patients, healthcare providers, and other members of the community­especially those communities or groups targeted by the planned research. Stakeholders can give their input throughout the research process to make sure the study will address questions and concerns that are most important and useful for participants. In 2014, the PCORI funded eight research studies that evaluated various ways to help African Americans and Hispanics/Latinos with poorly controlled asthma. These groups are underrepresented in asthma research but have higher rates of and more severe asthma for reasons that are poorly understood. The goal of this report is to show how stakeholders­including patients with asthma from these underrepresented groups, healthcare providers who care for patients with asthma, key representatives from the communities and others­participated as full partners in the eight studies and helped to improve the overall quality of the research and the relationship between the researchers and the community.

Performance and usability of a new mobile application for measuring respiratory rate in young children with acute lower respiratory infections.

OBJECTIVES: Respiratory rate (RR) measurement is critical to diagnosing pneumonia in resource-constrained settings, but accurate RR measurement is challenging. The acute lower respiratory illness treatment and evaluation (ALRITE) mobile phone application (app), designed to help healthcare workers (HCWs) manage pediatric respiratory illnesses, includes a semiautomated RR counter. This study aimed to evaluate the accuracy and usability of the ALRITE RR counter and a commercially available RR counter app, RRate, with a reference standard. METHODS: This was a cross-sectional observational study of HCWs. Participants used both apps to measure the RR of pediatric patients from standardized videos. The reference standard was determined by consensus of a manual 1-min count by two providers. We assessed agreement using Spearman's rank correlation coefficient and constructed Bland-Altman plots to determine bias and limits of agreement. Participants completed a usability survey. RESULTS: Thirty-nine HCWs participated. The agreement between the apps and reference standard (Spearman's coefficient) was 0.83 (95% confidence interval [CI]: 0.78-0.87) for ALRITE and 0.62 (95% CI: 0.52-0.70) for RRate. ALRITE had a bias of -2 breaths/min (lower limit of agreement [LoA] -16 to +12) and RRate had a bias of -0.4 breaths/min (LoA -24 to +23) compared to the reference standard. Both apps had a poorer agreement at higher RRs. Based on usability survey responses, 95% found ALRITE easy to use. CONCLUSIONS: The ALRITE RR counter has acceptable accuracy for counting RR in infants with respiratory distress, appears to be more accurate than a commercially available option, and was user-friendly. The ALRITE RR counter is a promising tool for meriting evaluation in real-world settings.

Fidelity evaluation of the dialogue around respiratory illness treatment (DART) program communication training.

OBJECTIVE: To evaluate receipt fidelity of communication training content included in a multifaceted intervention known to reduce antibiotic over-prescribing for pediatric acute respiratory tract infections (ARTIs), by examining the degree to which clinicians implemented the intended communication behavior changes. METHODS: Parents were surveyed regarding clinician communication behaviors immediately after attending 1026 visits by children 6 months to < 11 years old diagnosed with ARTIs by 53 clinicians in 18 pediatric practices. Communication outcomes analyzed were whether clinicians: (A) provided both a combined (negative + positive) treatment recommendation and a contingency plan (full implementation); (B) provided either a combined treatment recommendation or a contingency plan (partial implementation); or (C) provided neither (no implementation). We used mixed effects multinomial logistic regression to determine whether these 3 communication outcomes changed between baseline and the time periods following each of 3 training modules. RESULTS: After completing the communication training, the adjusted probability of clinicians fully implementing the intended communication behavior changes increased by an absolute 8.1% compared to baseline (95% Confidence Interval [CI]: 2.4%, 13.8%, p = .005). CONCLUSIONS: Our findings support the receipt fidelity of the intervention's communication training content. PRACTICAL IMPLICATIONS: Clinicians can be trained to implement communication behaviors that may aid in reducing antibiotic over-prescribing for ARTIs.

Sociodemographic Differences in Asthma Self-Management Knowledge of Parents Seeking Asthma Care for their Children in Pediatric Emergency Departments.

To effectively support asthma self-management among children most at risk for poor outcomes, it is important to examine potential disparities in parents' asthma-related knowledge. This study draws on baseline data collected from a randomized controlled trial to analyze how knowledge of asthma self-management varies by sociodemographic characteristics in a racially and economically diverse sample of Medicaid-insured children seeking emergency asthma care (N=221). Multivariable linear regression revealed that parent race/ethnicity, preferred language, and education were independently associated with scores on the Asthma Self Management Knowledge Questionnaire, and there was a significant interaction between parent race/ethnicity and education. In analyses stratified by parent education level, Latinx race/ethnicity was associated with lower-self-management knowledge among parents with higher education level, but not among those with a lower level of education. Our findings call for further research to understand and address the unique barriers to improving asthma self-management knowledge among Latinx parents and parents with limited English proficiency.

Development of an Asthma Home-Visit Training Program for Community Health Workers and Their Supervisors in Washington State.

The community health worker (CHW) asthma home-visiting model developed by Public Health-Seattle & King County (PHSKC) is an evidence-based approach proven to improve health outcomes and quality of life. In addition, it has been shown to be an effective and culturally appropriate approach to helping people with asthma understand the environmental and behavioral causes of uncontrolled asthma, while acquiring the skills they need to control their asthma. This paper describes the development and implementation of training curricula for CHWs and supervisors in the asthma home visiting program. To facilitate dissemination, this program took advantage of the current healthcare landscape in Washington State resulting from Centers for Medicare & Medicaid Services (CMS) approval of the 1115 Medicaid Waiver project. Key aspects of the training program development included: (1) Engagement: forming a Community Advisory Board with multiple stakeholders to help prioritize training content; (2) Curriculum Development: building the training on evidence-based home-visit protocols previously developed at PHSKC; (3) Implementation of the training program; (4) Evaluation of the training; and (5) Adaptation of the training based on lessons learned. We describe key factors in the training program's improvement including the use of a community-based participatory approach to engage stakeholders at multiple phases of the project and ensure regional adaption; combining in-person and online modules for delivery; and holding learning collaboratives for post-training and technical support. We also outline our training program evaluation plan and the planned evaluation of the home visit program which the trainees will deliver, both of which follow the RE-AIM framework. However, because the COVID-19 pandemic has curtailed training activities and prohibited the trainees from implementation of these CHW home visit practices, our evaluation is currently incomplete. Therefore, this case study provides insight into the adaptation of the training program, but not the delivery of the home visit program, the outcomes of which remain to be seen.

Health workers' perspectives of a mobile health tool to improve diagnosis and management of paediatric acute respiratory illnesses in Uganda: a qualitative study.

OBJECTIVES: Mobile health tools have potential to improve the diagnosis and management of acute lower respiratory illnesses (ALRI), a leading cause of paediatric mortality worldwide. The objectives were to evaluate health workers' perceptions of acceptability, usability and feasibility of Acute Lower Respiratory Illness Treatment and Evaluation (ALRITE), a novel mobile health tool to help frontline health workers diagnose, treat and provide education about ALRI in children <5 years. DESIGN: A qualitative study including semistructured interviews with health facility administrators and focus groups with primary care health workers. SETTING: Two federally funded Ugandan primary care health facilities, one peri-urban and one rural. PARTICIPANTS: We enrolled 3 health administrators and 28 health workers (clinical officers and nurses). INTERVENTION: The ALRITE smartphone application was developed to help frontline health workers adhere to ALRI guidelines and differentiate wheezing illnesses from pneumonia in children under 5 years of age. ALRITE contains a simple decision tree, a partially automated respiratory rate counter, educational videos and an adapted respiratory assessment score to determine bronchodilator responsiveness. We performed a demonstration of ALRITE for participants at the beginning of interviews and focus groups. No participant had used ALRITE prior. RESULTS: Themes impacting the potential implementation of ALRITE were organised using individual-level, clinic-level and health-system level determinants. Individual-level determinants were acceptability and perceived benefit, usability, provider needs and provider-patient relationship. Clinic-level determinants were limited resources and integration within the health centre. Systems-level determinants included medication shortages and stakeholder engagement. CONCLUSIONS: Incorporation of these themes will ready ALRITE for field testing. Early engagement of end users provides insights critical to the development of tailored mHealth decision support tools.

2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group.

The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders:A rigorous process was undertaken to develop these evidence-based guidelines. The Agency for Healthcare Research and Quality's (AHRQ) Evidence-Based Practice Centers conducted systematic reviews on these topics, which were used by the Expert Panel Working Group as a basis for developing recommendations and guidance. The Expert Panel used GRADE (Grading of Recommendations, Assessment, Development and Evaluation), an internationally accepted framework, in consultation with an experienced methodology team for determining the certainty of evidence and the direction and strength of recommendations based on the evidence. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups. To assist clincians in implementing these recommendations into patient care, the new recommendations have been integrated into the existing Expert Panel Report-3 (EPR-3) asthma management step diagram format.

Correction: Diagnosis and treatment of acute respiratory illness in children under five in primary care in low-, middle-, and high-income countries: A descriptive FRESH AIR study.

[This corrects the article DOI: 10.1371/journal.pone.0221389.].

Diagnosis and treatment of acute respiratory illness in children under five in primary care in low-, middle-, and high-income countries: A descriptive FRESH AIR study.

BACKGROUND: Respiratory disease and, specifically, pneumonia, is the major cause of mortality and morbidity in young children. Diagnosis of both pneumonia and asthma in primary care rests principally on clinical signs, history taking, and bronchodilator responsiveness. This study aimed to describe clinical practices in diverse global primary care settings concerning differential diagnosis of respiratory disease in young children, especially between pneumonia and asthma. METHODS: Health professionals in Greece, Kyrgyzstan, Vietnam, and Uganda were observed during consultations with children aged 2-59 months, presenting with cough and/or difficult breathing. Data were analyzed descriptively and included consultation duration, practices, diagnoses and availability/use of medications and equipment. The study is part of the European Horizon 2020 FRESH AIR project. RESULTS: In total, 771 consultations by 127 health professionals at 74 facilities in the four countries were observed. Consultations were shorter in Vietnam and Uganda (3 to 4 minutes) compared to Greece and Kyrgyzstan (15 to 20 minutes). History taking was most comprehensive in Greece. Clinical examination was more comprehensive in Vietnam and Kyrgyzstan and less in Uganda. Viral upper respiratory tract infections were the most common diagnoses (41.7% to 67%). Pneumonia was diagnosed frequently in Uganda (16.3% of children), and rarely in other countries (0.8% to 2.9%). Asthma diagnosis was rare (0% to 2.8%). Antibiotics were prescribed frequently in all countries (32% to 69%). Short acting ß-agonist trials were seldom available and used during consultations in Kyrgyzstan (0%) and Uganda (1.8%), and often in Greece (38.9%) and Vietnam (12.6%). CONCLUSIONS: Duration and comprehensiveness of clinical consultations observed in this study seemed insufficient to guide respiratory diagnosis in young children. Appropriate treatment options may further not be available in certain studied settings. Actions aiming at educating and raising professional awareness, along with developing easy-to-use tools to support diagnosis and a general strengthening of health systems are important goals.

Automatic characterization of user errors in spirometry.

Spirometry plays a critical role in characterizing and improving outcomes related to chronic lung disease. However, patient error in performing the spirometry maneuver, such as from coughing or taking multiple breaths, can lead to clinically misleading results. As a result, spirometry must take place under the supervision of a trained specialist who can identify and correct patient errors. To reduce the need for specialists to coach patients during spirometry, we demonstrate the ability to automatically detect four common patient errors. Creating separate machine learning classifiers for each error based on features derived from spirometry data, we were able to successfully label errors on spirometry maneuvers with an F-score between 0.85 and 0.92. Our work is a step toward reducing the need for trained individuals to administer spirometry tests by demonstrating the ability to automatically detect specific errors and provide appropriate patient feedback. This will increase the availability of spirometry, especially in low resource and telemedicine contexts.

Use of a Smartphone App to Assess Neonatal Jaundice.

BACKGROUND: The assessment of jaundice in outpatient neonates is problematic. Visual assessment is inaccurate, and more exact methodologies are cumbersome and/or expensive. Our goal in this study was to assess the accuracy of a technology based on the analysis of digital images of newborns obtained using a smartphone application called BiliCam. METHODS: Paired BiliCam images and total serum bilirubin (TSB) levels were obtained in a diverse sample of newborns (<7 days old) at 7 sites across the United States. By using specialized software, data on color values in the images ("features") were extracted. Machine learning and regression analysis techniques were used to identify features for inclusion in models to predict an estimated bilirubin level for each newborn. The correlation between estimated bilirubin levels and TSB levels was calculated. In addition, the sensitivity and specificity of the estimated bilirubin levels in identifying newborns with high TSB levels were calculated by using 2 recommended decision rules for jaundice screening. RESULTS: Estimated bilirubin levels were calculated and compared with TSB levels in a diverse sample of 530 newborns (20.8% African American, 26.3% Hispanic, and 21.2% Asian American). The overall correlation was 0.91, and correlations among white, African American, Hispanic, and Asian American newborns were 0.92, 0.90, 0.91, and 0.88, respectively. The sensitivities of BiliCam in identifying newborns with high TSB levels were 84.6% and 100%, respectively, by using 2 decision rules; specificities were 75.1% and 76.4%, respectively. CONCLUSIONS: BiliCam provided accurate estimates of TSB values, demonstrating that an inexpensive technology that uses commodity smartphones could be used to effectively screen newborns for jaundice.

Effectiveness of the Spirometry 360 Quality Improvement Program for Improving Asthma Care: A Cluster Randomized Trial.

OBJECTIVE: To determine the effectiveness of the Spirometry 360 distance learning quality improvement (QI) program for enhancing the processes and outcomes of care for children with asthma. METHODS: Cluster randomized controlled trial involving 25 matched pairs of pediatric primary care practices. Practices were recruited from 2 practice-based research networks: the Slone Center Office-based Research Network at Boston University, Boston, Mass, and the Puget Sound Pediatric Research Network, Seattle, Wash. Study participants included providers from one of the 50 enrolled pediatric practices and 626 of their patients with asthma. Process measures assessed included spirometry test quality and appropriate prescription of asthma controller medications. Outcome measures included asthma-specific health-related quality of life, and outpatient, emergency department, and inpatient utilization for asthma. RESULTS: At baseline, 25.4% of spirometry tests performed in control practices and 50.4% of tests performed in intervention practices were of high quality. During the 6-month postintervention period, 28.7% of spirometry tests performed in control practices and 49.9% of tests performed in intervention practices were of high quality. The adjusted difference-of-differences analysis revealed no intervention effect on spirometry test quality. Adjusted differences-of-differences analysis also revealed no intervention effect on appropriate use of controller medications or any of the parent- or patient-reported outcomes examined. CONCLUSIONS: In this study, the Spirometry 360 distance learning QI program was ineffective in improving spirometry test quality or parent- or patient-reported outcomes. QI programs like the one assessed here may need to focus on practices with lower baseline performance levels or may need to be tailored for those with higher baseline performance.

Enrolling African-American and Latino patients with asthma in comparative effectiveness research: Lessons learned from 8 patient-centered studies.

BACKGROUND: African-American and Latino patients are often difficult to recruit for asthma studies. This challenge is a barrier to improving asthma care and outcomes for these populations. OBJECTIVES: We sought to examine the recruitment experiences of 8 asthma comparative effectiveness studies that specifically targeted African-American and Latino patients, and identify the solutions they developed to improve recruitment. METHODS: Case report methodology was used to gather and evaluate information on study design, recruitment procedures and outcomes from study protocols and annual reports, and in-depth interviews with each research team. Data were analyzed for themes, commonalities, and differences. RESULTS: There were 4 domains of recruitment challenges: individual participant, institutional, research team, and study intervention. Participants had competing demands for time and some did not believe they had asthma. Institutional challenges included organizational policies governing monetary incentives and staff hiring. Research team challenges included ongoing training needs of recruitment staff, and intervention designs often were unappealing to participants because of inconveniences. Teams identified a host of strategies to address these challenges, most importantly engagement of patients and other stakeholders in study design and troubleshooting, and flexibility in data collection and intervention application to meet the varied needs of patients. CONCLUSIONS: Asthma researchers may have greater success with recruitment by addressing uncertainty among patients about asthma diagnosis, engaging stakeholders in all aspects of study design and implementation, and maximizing flexibility of study and intervention protocols. However, even with such efforts, engagement of African-American and Latino patients in asthma research may remain low. Greater investment in research on engaging these populations in asthma research may ultimately be needed to improve their asthma care and outcomes.

Learning from a distance: effectiveness of online spirometry training in improving asthma care.

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.

Identifying children with lifelong chronic conditions for care coordination by using hospital discharge data.

BACKGROUND: Children with lifelong chronic conditions (LLCC) are costly, of low prevalence, and a high proportion of patients at children's hospitals. Few methods identify these patients. OBJECTIVES: We sought to identify children with LLCC in hospital discharge data for care coordination by using clinical risk groups (CRGs), to evaluate the accuracy of this methodology compared with a chart review and to investigate accuracy according to condition groups. METHODS: CRG software identified LLCC children who receive care at a primary care clinic, Odessa Brown Children's Clinic, by using Seattle Children's Hospital discharge data. RESULTS: There were 5356 active Odessa Brown Children's Clinic patients with at least 1 clinic encounter in 2006-2007. Six hundred two (11.2%) patients were admitted to Seattle Children's Hospital, and 1703 (31.8%) were seen only in the emergency department over 7 years (2001-2007). One hundred sixty-four (7%) were identified to have a LLCC. In a blind review of 200 (33.2%) children with inpatient encounters, the specificity of the CRG designation to LLCC was 95.0% (95% confidence interval [CI], 90.0%-98.0%), sensitivity 76.3% (95% CI, 63.4%-86.4%). Mental health conditions formed the largest group that was chart-review positive and CRG negative (7 of 14). Children hospitalized before 13 months of age were the second largest group (3 of 14). Clinical review placed the 164 patients in these condition groups: sickle cell disease, 43 (26.2%), neurological, 37 (22.6%), mental health, 22 (13.4%), malignancies, 4 (2.4%), other 52 (31.7%), and no chronic condition 6 (3.7%). CONCLUSION: This study demonstrates a unique way to identify children with LLCC for care coordination by using hospital administrative data.

Randomized trial of teaching brief motivational interviewing to pediatric trainees to promote healthy behaviors in families.

HYPOTHESIS: That pediatric resident trainees would demonstrate increased counseling skill following training in brief motivational interviewing (MI). DESIGN: Randomized controlled trial. SETTING: University of Washington Pediatric Residency. PARTICIPANTS: Pediatric residents (N = 18), including residents in postgraduate years 1, 2, 3, and 4. INTERVENTIONS: Collaborative Management in Pediatrics, a 9-hour behavior change curriculum based on brief MI plus written feedback on communication skills (based on a 3-month Objective Standardized Clinical Evaluation [OSCE]). MAIN OUTCOME MEASURE: The percentage of MI-consistent behavior (%MICO), a summary score for MI skill, was assessed via OSCEs in which standardized patients portray parents of children with asthma in 3 clinical scenarios (stations). The OSCEs were conducted at baseline and 3 and 7 months. Blinded coders rated videotaped OSCEs using a validated tool to tally communication behaviors. Training effects were assessed using linear regression controlling for baseline %MICO. Global ratings of counseling style served as secondary outcome measures. RESULTS: Trained residents demonstrated a trend toward increased skill (%MICO score) at 3 months compared with control residents. At 7 months, %MICO scores increased 16% to 20% (P < .02) across all OSCE stations after the combined intervention of Collaborative Management in Pediatrics training plus written feedback. The effect of training on global ratings supported the main findings. CONCLUSIONS: Pediatric trainees' skills in behavior change counseling improved following the combination of training in brief MI plus personalized feedback.

The effects of visual acuity on target discrimination and shooting performance.

PURPOSE: To explore the effects of visual acuity on target discrimination and marksmanship. METHODS: A randomized, single-blind, repeated measures study was conducted to evaluate the effect of visual acuity on target discrimination and marksmanship. Subjects were examined for inclusion criteria and equivalent plus lens over-refractions necessary to obtain the five test visual acuity ranges. Qualified subjects fired at randomized target presentations from 50 to 300 m while wearing customized spectacles to yield the visual acuity levels being evaluated. Subjects then rotated foxholes for target discrimination sequences. Randomized targets marked as friend or enemy were presented in like manner for each of the five visual acuity levels. RESULTS: Subjects at acuities better than 0.2 LogMAR were significantly more likely to hit the target than those with acuities equal to or worse than 0.7 LogMAR. Target discrimination results show subjects with acuities between -0.2 and 0.6 LogMAR were significantly more likely to correctly identify the target than those with acuities equal to or worse than 0.7 LogMAR. In addition, those at acuities of 0.0 LogMAR or better performed significantly better than those with acuities between 0.3 and 0.6 LogMAR. CONCLUSIONS: Visual acuity significantly affects target discrimination and marksmanship performance. Results of this study closely mirror expected findings based on visual angles with acuities in the range 0.3 to 0.4 LogMAR (20/40-20/50) being the transition zone where performance begins to deteriorate. This performance-based evidence fully supports a vision classification system that mandates eyewear to maximize visual performance for deployable military members. Based on the results of this study, the current U.S. Army, U.S. Navy, and U.S. Marine Corps vision readiness standards of 20/40 or better uncorrected or corrected vision seems to be a valid choice because it is the transition point for performance in both target discrimination and marksmanship ability.