Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

For patients with chronic diseases where large numbers of physicians do not follow guideline based care, such as with asthma-the most common chronic disease, what are the most and least effective interventions to modify physician and other health care provider practice.

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Educational programs, policy changes, pay for quality care versus decrease in pay for average or poor care, effectiveness of guideline versus non-guideline care on patient outcomes such as morbidity, mortality, cost of total care.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Although my interest is people with asthma, any group with chronic diseases, or health disparities. There seems to be more research with the pediatric asthma population than with adults although morbidity exceeds Healthy People 2010 goals for asthma in every age category.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Disadvantaged groups in asthma are African Americans, Hispanics, those in low socio-economic conditions, those with less education, and rural groups. Additionally, children 0-4 have a higher incidence of hospitalization and adult women 25-44 have a higher incidence of ED visits, hospitalizations, and death. (Death rates are low for asthma but all are considered unnecessary.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Decrease in numbers of ED visits. Decrease in hospitalizations. Decrease in asthma episodes. Increase in numbers of patients who receive: an asthma action plan, are classified by stage and risk level, an inhaled corticosteroid (including being discharged on and ICS following ED or hospitalization, receive self management education.

Describe any health-related risks, side effects, or harms that you are concerned about.

Physician barriers to guideline-based managment of patients, patient barriers to adherence, any intervention that does not decrease morbidity. Patients are having actual morbidity and mortality already and in some ways there is no where to go than to improve.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

no

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Pulmonary disease/asthma

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare
• State Children's Health Insurance Program (SCHIP)

Importance

Describe why this topic is important.

Asthma currently affects about 10% of the population in the U.S. and is increasing. Also, there is evidence that climate change may put many more people at risk of asthma development. About 40-50% of people with asthma do not receive guideline based care in the U.S. and we do not seem to be improving that level. While it is possible to control asthma and improve quality of life with current methodologies for most patients, many do not have the skills or the resources to control their disease because of healthcare deficits. We need to find sustainable ways to modify health care practice to improve patient outcomes and costs to families, individuals, and the health care system.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

I coordinate the asthma program at the Ohio Department of Health. In that role I staff the Ohio Asthma Coalition and the Clinical Initiative of the coalition. The Clinical Initiative plans to identify a group of interventions to replicate across the state of Ohio to improve asthma care and outcomes. There is such a plethora of information that it is difficult to sort out what is actually effective and replicable.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

From a certain perspective this does represent uncertainty for clinicians. There are those who are not planning to change what they do and others who just can't seem to get through the 460+ page 2007 Expert Panel Report 3 on asthma. There is the controversy between the big picture folks and the more detail oriented folks in what constitutes quality and effective care. Self Care Management is not part of the playbook form many physician.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

The answer to this question will assist the committee and the entire coalition to identify the most effective interventions for physician practice change. It is our view that simple education does not change practice but we need to know what is the most effective way to work with practices, federally qualified healthcare centers and small primary care practices to make the biggest changes.

Describe the timeframe in which an answer to your question is needed.

Of course, sooner is better. Although we would like to have something ready to go by September, I know that is an unreasonable timeframe since I just saw the opportunity to ask this question. I would like to see an answer early in 2011 if that is possible.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

We are committed to work with populations with disparities as our primary targets. We currently have about 14.4% of our children with current asthma and 11+% of our adults. We have now exceeded the national numbers. The most vulnerable of out populations are children and the elderly. In children asthma is more likely to be accompanied by allergies but not as often accompanied by other comorbidities. In older adults, the range of comorbidities is significant and there may be adult onset work related asthma which may or may not have an allergic component.

The low income, low educational levels of some populations are also particularly vulnerable as are people of color and hispanic origin. Also, there is some evidence that rural and inner city populations are more affected.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

The answer to this question will assist the committee and the entire coalition to identify the most effective interventions for physician practice change. It is our view that simple education does not change practice but we need to know what is the most effective way to work with practices, federally qualified healthcare centers and small primary care practices to make the biggest changes.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

I signed up to recieve news release from AHRQ and stumbled on the link for the program.