ABSTRACT: Interventions to Modify Health Care Provider Adherence to Asthma Guidelines [Internet].
OBJECTIVES:To synthesize the published literature on the effect of interventions designed to improve health care providers’ adherence to asthma guidelines on: (1) health care process outcomes (Key Question 1); (2) clinical outcomes (Key Question 2); (3) health care processes that subsequently impact clinical outcomes (Key Question 3).DATA SOURCES:Reports of studies from MEDLINE®, Embase®, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL®), Educational Resources Information Center (ERICsm), PsycINFO®, and Research and Development Resource Base in Continuing Medical Education (RDRB/CME), up to July 2012.REVIEW METHODS:Paired investigators independently reviewed each title, abstract, and full-text article to assess eligibility. Only comparative studies were eligible. Investigators abstracted data sequentially and independently graded the evidence.RESULTS:A total of 73 studies were eligible for review. A slight majority of studies were conducted in the U.S. (n=38). We classified studies as assessing eight types of interventions: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement (QI)/pay-for-performance, multicomponent, and information only. Half of the studies were randomized trials (n=34), 29 were pre-post, and the remaining 10 were a variety of nonrandomized study designs. The studies took place exclusively in primary care settings. The most frequently cited health care process outcome was prescription of asthma controller medication (n=41), followed by provision of an asthma action plan (n=18), prescription of a peak flow meter (n=17), and self-management education (n=12). Common clinical outcomes included emergency department (ED) visits (n=30) and hospitalizations (n=27), followed by use of short-acting β2 agonists (n=9), missed school days (n=8), lung function tests (n=6), symptom days (n=6), quality of life (n=5), and urgent doctor visits (n=5). We identified 4 critical outcomes for which 68 studies provided information. There was moderate evidence for increased prescriptions of asthma controller medications using decision support, feedback and audit, and clinical pharmacy support interventions and low grade evidence for organizational change, multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans; for the same outcome, low grade evidence supports the use of organizational change, feedback and audit, education only, quality improvement, and multicomponent interventions. Moderate grade evidence supports use of decision support tools to reduce ED visits/hospitalizations while low grade evidence suggests there is no benefit associated with organizational change, education only, and QI/pay-for-performance. Organizational change interventions provided no benefit for lost days of work/school. The evidence for the remainder of interventions was insufficient or low in strength.CONCLUSIONS:There is low to moderate evidence to support the use of decision support tools, feedback and audit, and clinical pharmacy support to improve the adherence of health care providers to asthma guidelines, as measured through health care process outcomes, and to improve clinical outcomes. There is a need to further evaluate health care provider-targeted interventions with a focus on standardized measures of outcomes and more rigorous study designs.
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