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Utilizing Clinical Best Practices to Improve Asthma

Care and Outcomes for Hispanic Children in California

National Hispanic Medical Association14th Annual Conference

Washington, DC March 25, 2010

David Núñez, MD, MPHCalifornia Asthma Public Health InitiativeCalifornia Department of Public Health

Evidence of Asthma Disparities Affecting

Latino/Hispanic Children• Documented care deficiencies:

• Fewer prescriptions for controller meds• Fewer follow-up appointments after ED• Fewer specialist referrals

• Factors associated with inadequate therapy• Age </= 5 years• Medicaid insurance• Uninsured• Spanish language

• Documented disparities in health outcomes• More school absences, activity limitation, sleep difficulty

• Increased ED visits• Increased hospitalizations

Potential Contributors to Asthma Disparities in

Hispanics• Biologic and Genetic Factors• Environmental Exposures• Social Determinants of Health

• Income• Education• Language and culture• Residential segregation• Access and barriers to health care

• Quality of care• Fewer than half of Community Health Center (CHC) patients receive appropriate asthma care

• California CHCs provide care to a large proportion of Medicaid-insured, Latinos living in underserved areas

Intervention Design

• Target Audience: Community Health Centers• Request for Applications Selection of 17 Community Clinics for 2-year Program (Apr 06-Jun 08), Funded $70K/year

• Required Support• Clinic Champion (physician or nurse practitioner)• Clinic Continuous Quality Improvement (CQI) Team• Clinic Administration Support

• Pre-Post Evaluation: (1) patient/family interviews and (2) random chart review

• State Program technical assistance, training, and evaluation

Components of BPCA

• NAEPP Guideline-based care• Clinic-based Care Coordinators

• Continuous Quality Improvement (CQI)

• Implementation of four best practices:• Asthma Action Plans (AAP)• Basic Asthma Education• Home Environmental Assessment

• Clinic Asthma Visit Flow Sheet

Addressing Hispanic Culture and Language

• 86% of Hispanic interviewees reported Spanish as the primary language spoken at home

• Asthma Care Coordinators• 13/17 bilingual

• Health Care providers• 16/17 clinics had providers fluent in Spanish

• Translator resources available at clinic sites lacking bilingual staff

• All asthma education materials and AAPs available in Spanish

BPCA Findings:Baseline – Year 1

*Data from this presentation is not to be reproduced, published, or presented without written permission from the California Asthma Public Health Initiative, CA Dept. of Public Health.

*

Demographics – Race/Ethnicity of BPCA Clinic

Populations

Demographics –Hispanic BPCA Program Interviewees

Examples of Insufficient Asthma Documentation at Baseline

% of Hispanic Children who have had the Following Measures Documented in their Chart at the Last Clinic Visit:

7.0%

25.6% 23.5%

45.4%38.6%

17.5%

0%

20%

40%

60%

80%

100%

Acute Visits ED Visits Hospitalizations Day Symptoms Night

Symptoms

AAP Reviewed

Improvements in Chart Documentation of Asthma Symptoms

Frequency of Daytime and Nighttime Symptoms Documented in the Chart at the Last Visit

45.4%38.6%

68.3%62.9%

0%

20%

40%

60%

80%

100%

Daytime Symptoms Nighttime Symptoms

BaselineYear 1

Improvements in Care Process –

Education Given by Health Care Providers

Self-management Skills – Asthma Medication Use

Self-management Skills – Asthma Medication

Health Outcomes – Asthma Symptoms

Health Outcomes – Healthcare Utilization for Acute

Asthma

Health Outcomes – Missed school/work

Quality of Life

Conclusions

• A CQI approach guided by patient chart review was essential to improving CHC adherence to asthma clinical best practices.

• Overall clinic documentation, quality of clinical asthma care, asthma health outcomes, and quality of life improved significantly in the Hispanic population over the course of the first year of the BPCA program.

• Analysis of Year 2 data shows both similar increases and sustained improvements.

• Culturally and linguistically appropriate services are an essential component.

• Improving the quality of asthma care in California CHC’s could dramatically reduce asthma disparities impacting Hispanic children.

Implications for Policy and Clinical Practice

• Quality of asthma care is defined by more than prescriptions for controller medications.

• Health care delivery systems (and patients) would benefit from standards of care measuring multiple key components of quality asthma care.

• Sustainability and dissemination of asthma care improvements in CHC’s remains a critical concern.

• Cost savings/ROI are a consideration. • Timely, consistent quality and health outcome data (including race/ethnicity) are essential for assessing progress.

www.betterasthmacare.orgwww.cdph.ca.gov/PROGRAMS/CAPHI www.cdph.ca.gov/healthinfo/discond/Pages/Asthma.aspx