School-based quality initiative improves childhood asthma outcomes

SAN FRANCISCO - A quality improvement initiative at four school-based health centers in Cincinnati has resulted in significant improvements in outcomes for children with asthma.

The results of the project provide support for the concept of school-based health centers in urban areas and for community partnerships to improve child health, according to researchers from Cincinnati Children's Hospital Medical Center involved in the initiative. They will present their study of the project at 3:15 p.m. Pacific time Saturday, April 29, at the annual Pediatric Academic Societies meeting in San Francisco.

"Improving outcomes through evidence-based care shows that school-based health centers can improve child health," says Mona Mansour, M.D., a physician at Cincinnati Children's and medical director of the school-based health centers. Dr. Mansour co-authored the study with Barbara Rose, M.P.H., who was project manager of the quality improvement initiative.

Rose and Dr. Mansour followed 212 children with asthma who are enrolled in four school-based health centers in Cincinnati that are operated by Neighborhood Health Care, Inc., a federally qualified health center organization. The centers provide comprehensive primary, mental and dental health services to children in grades K-8. Cincinnati Children's provides physicians and nurse practitioners for these centers and collaborates with the Cincinnati Health Department, which provides school nurses; the Cincinnati Public Schools; and, parents of children with asthma.

These individuals and organizations met and engaged in "visioning exercises" to determine what "perfect asthma care" would look like to them. They developed promises and measures to know whether goals were being met. Perfect care became a composite measure of asthma severity classification, a written care plan and appropriate controller medications. Outcomes measures also included minimal restriction in activity and the number of asthma-related emergency department visits.

Between October of 2004 and October of 2005, interventions instituted included a web-based portal that providers can use to support clinical decisions and that families ultimately will be able to access to let them know how their children are doing with their asthma and to get information about asthma resources. Interventions also included a standardized process for identifying children with asthma, standardized forms for data collection during student visits to the school health centers, and improved delineation of staff roles and responsibilities for asthma care.

By October of 2005, the identification of children with asthma had risen from 6.2 percent to 15.8 percent. The prevalence of asthma in urban, African-American communities in Cincinnati is 20.9 percent. In addition, all measures had improved:

The percentage of children receiving perfect care had risen from 24 to 84 percent. Classification by severity had risen from 17 to 90 percent. Controllers prescribed had risen from 18 to 86 percent. A written care plan had risen from 9 to 87 percent. Children reporting never or rarely having activity restriction rose from 20 to 46 percent.

Asthma-related emergency room visits decreased 22 percent between the year prior to the project and the end of the first year of the project.

The project was part of Pursuing Perfection – a national initiative funded by the Robert Wood Johnson Foundation that was a response to two reports from the Institute of Medicine. Those reports questioned the safety, quality, efficiency, effectiveness and fairness of the nation's health care system and suggested that the system is failing America because it is poorly designed and must be fundamentally changed. Pursuing Perfection was intended to be a catalyst for rapid, transformational change. Cincinnati Children's was selected, along with six other health care organizations to be a model for the pursuit of perfect care and was the only pediatric facility among the organizations participating in the initiative.

"The most exciting aspect of this project has been in guiding our community partners in learning about principles of process improvement and seeing them open participate and cooperate to improve asthma care to children at school," says Rose. "They get a lot of credit for their commitment and teamwork over the last two years."

Cincinnati Children's is now planning how best to spread what's been learned to other school environments.

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Cincinnati Children's Hospital Medical Center is a 475-bed institution devoted to bringing the world the joy of healthier kids. Cincinnati Children's is dedicated to transforming the way health care is delivered by providing care that is timely, efficient, effective, family-centered, equitable and safe. Cincinnati Children's ranks third nationally among all pediatric centers in research grants from the National Institutes of Health. It is a teaching affiliate of the University of Cincinnati College of Medicine. The Cincinnati Children's vision is to be the leader in improving child health. Additional information can be found at www.cincinnatichildrens.org.


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