EFFECTS OF A SELF-CARE DEFICIT NURSING THEORY-DESIGNED NURSING SYSTEM ON SYMPTOM CONTROL IN CHILDREN WITH ASTHMA A Dissertation presented to the Faculty of the Graduate School University of Missouri-Columbia In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy by KARENR. COX Dr. Marilyn J. Rantz. Dissertation S~pervisor DECEMBER 2001 UMI Number: 3036817 Copyright 2001 by Cox, Karen Rose All rights reserved. ' ,lJMI~ UMI Microform 3036817 Copyright 2QQ2 by ProQuesUnformation and Leaming Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17. United States Code. ProQuest Information and Leaming Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346 0 copyright by Karen R. Cox 200 I All Rights Reserved The undersigned, appointed by the Dean of the Graduate School, have examined the dissertation entitled EFFECTS OF A SELF-CARE DEFICIT NURSING THEORY- DESIGNED NURSING SYSTEM ON SYMPTOM CONTROL IN CHILDREN WITH ASTHMA presented by Karen R. Cox a candidate for the degree of Doctor of Philosophy and hereby certify that in their opinion it is worthy of acceptance. , ACKNOWLEDGEMENTS The late Met-Carnahan. our Missouri governor during the 1990s, had a heart that ', \ . burned with a fire of advocacy for children. At the core of this fire was a desire to provide Missouri's children with a strong and solid educational foundation. Mel Carnahan's focus was on children because he believed passionately that our children are Missouri's future. Mel Carnahan understood that, when children were sick, his goal could not be achieved. Sick children cannot effectively learn when illnesses cause concentration interference or school absences. Therefore, with diligence and determination, he searched for and hired a health care leader who shared his passion for achieving healthy outcomes for all of Missouri's children. Mel Carnahan hired Coleen K.ivlahan, M.D., M.S.P.H., to be the Director of Missouri's Department of Health at a time when health policy was shifting. Dr. Coleen K.ivlahan understood health care systems and financing, measurement of clinical outcomes, promotion of humanity, and the challenges associated with poverty. Mel Carnahan and Dr. K.ivlahan spearheaded the design of a public insurance program that would promote access to health cue for all children. As the results of this study suggest, we will not let Mel c~•s fire of advocacy for Missouri's children go out. i Health outcomes can be significantly improved when children are provided with access to a health care system in which the team members use scientific evidence to make the best treatment decisions. While this dilsertatian has only one author, it truly reflects a group effort. I would like to thank my committee members who encouraged me, yet demanded a quality product. Dr. Susan G. Taylor,. who retired before I completc,fmy fonnal studies, has il , . steadfastly pointed the way since 1985. Dr. Marilyn Rantz has been a great facilitator, always assuring forward progress. Dr. Larry Ganong has provided hours of meaningful teaching and advic~ now I understand his mono: .. research is not for sissies". Dr. Alice Kuehn has shared a great deal of enthusiasm regarding Dorthea Orem' s nursing theory. Dr. Timothy Patrick spent hours preparing me. for next steps and reflecting with me on lessons learned. Dr. Daryl Hobbs has inspired a revolution in my heart. At this point, I am not exactly sure where this revolution is leading, but I do know that it starts with Paulo Freire. As· I began the design and implementation of the nursing system, I was introduced to a treasure chest of special health care professionals with tremendous expertise, caring and compassion. All of these individuals, volunteering countless hours on the Pediatric Asthma Continuous Quality Improvement Team, have proven time and again to be very special people with a single focus for making children's lives as orderly and normal as possible. These colleagues have become friends and have willingly shared their expertise across a variety of content areas to include respiratory pathology and treatment, health plan organization, research and evaluation, continuous quality improvement, and child development. This work could not have been done without each and every one of them. They include Dr. Bernard Ewigman, Ben Francisco, Dr. Peter Konig, Dr. Gavin Graff, Dr. Tom Cheek, Dr. Tom Selva, Dr .. Steve Scott, Dr. Kay Davis, Donna Checkett, Gwen Burley, and Ryan Grueber. My professional colleagues within the Office of Clinical Effectiveness are also my friends and, we share a common vision: to design health care processes that improve iii clinical outcomes for patients. This vision is being achieved as we integrate scientific e'lridence into our delivery systems. These friends and colleagues are responsible for my personal and prof~nal growth over the last four years. Coleen K.ivlahan inspires me while teaching me about leadership, humanity, comfort. medicine, poverty, and quality. Kay Davis initially challenged me to work on an improvement project for ~hildren with asthma because she wanted me to pursue scholarly inquiry relative to Orem's nursing theory. Kay was behind me all the way. Among many other things, Kathryn Nelson has taught me 'customer' advocacy. Pattie Malone has been a mentor.for inquiry and scholarship. In addition to macro and micro editing, Jennifer Buddenbaum has helped me with patience, professionalism and logic. Betty Nikodim and Lori Wilcox have been personal anchors, specifically during data preparation and analytic phases. Louise Whitener has been, and continues to be, my cheerleader. Lastly, I want to thank my husband Ted Cox and my daughter Jesse Alice Reinhold from the bottom of my heart. Jesse was in 6th grade when I started on this journey. Now she is a freshman at MU: Jesse has made my busy life very fulfilling because she chose to take con~i of her life and to team skills surrounding personal organization, goal direction and responsibility. Ted provided support and space so that I could grow. Ted has optimi7.cd my scholarship through a great deal of personal sacrifice. You are all incredibly valuab~ to me and, from the bottom Qf my heart, I want to thank you for letting me l~ from you. lV EFFECTS OF A SELF-CARE DEFICIT NURSING THEORY-DESIGNED NURSING SYSTEM ON SYMPTOM CONTROL IN CHILDREN WITH ASTHMA Karen R. Cox ' Dr. Marilyn J. Rantz, Dissertation Supervisor ABSTRACT Asthma is the most frequent J'C!LSOn for preventable hospital admissions among children regardless of race or socio-economic status. Since asthma hospitalizations are preventable, an implicit assumption is that parents are not optimally managing the illness condition. Using Orem's Self-Care Deficit Nursing Theory, 14 antecedent conditions necessary for competent action by dependent-care agents (usually parents) were uncovered in the pediatric asthma literature. All but two of the 14 antecedent conditions are influenced by factors partly or comple!ely controlled by the health care system. Given this new understanding, a unique partnership between a health care system and a Medicaid managed care health plan was forged to remove health care system barriers that interfere with dependent-care agent competency for the management of asthma. A nursing system was designed and implemented to improve health care system factors associated with optimal symptom control: accurate diagnosis, appropriate treatment, continuity, access, and parent/child teaching. The multi-faceted nursing system was implemented across three professional groups (physicians, nurses, and respiratory therapists) within one ER, three hospital units, and six outpatient clinic sites. One component of the nursing ~tern involved formal annual training of participants on appropriate diagnosis and optimal treatment. Other nursing system components focused attention on children who had failed outpatient management. Specifically, between V October 1, 1998, and March 31, 2001, 753 children were brought to one emergency room or three hospital units for treatment of an asthma exacerbation. The nursing system was successfully implem)nted on behalf of 75% of these children. Using Medicaid managed care enrollment files and claims data for asthma care, the effects of the nursing system on symptom control were compared before and after the nursing system intervention, and between two groups of health care providers who had either been maximally or minimally impacted by the nursing system. Rates for asthma claims used to proxy symptom control included ER. hospital, and clinic visits for asthma. Children who had providers in the maximally involved group were one-half as likely to be hospitalized for an asthma exacerbation as children with providers in the minimally involved group. The results of this study confirm that when nursing theory guides practice, patient outcomes improve. vi LIST OFT ABLES TABLES Page 1. Actions Required to Regulate Asthma .... .. .... .. ..... ... ................................... ... ....... .. 4 2. Antecedent Conditions Known To Influence Asthma Symptom Control Competency ...... .... ............. .. ......... .... ... .. .. .. .. .... .. .... .................................... ... ... ... . 51 3. Nursing System Indicators ............................................................................ .... ... 80 4. Principle and Secondary ICD-9 Diagnostic Codes Defining Asthma Utilization ... • ······························································································· ·· ················· ············87 5. All CPT Codes 'Allowed' In the Count of Facility Utilization By Site of Visit. 88 6. Swnmer/Winter Data Comparison Intervals ...... ......... ... ... .. ............ ......... .. ... ... .... 89 7. Demographic Trends from Children Included in the Nursing System ................ 95 8. Results of Emergency Room Monitoring .... .. .. ................................. .... ............... 99 9. Children's Hospital Unit Results ... .. ... .. ........ .. ... ..... ... .. ........... .. ........ ................. 101 10. Follow-Up Clinic Results ... ........... .. ............. ... ........ ........... ............................. .. 103 11. Prevalence and Visits for Asthma By Study Year ............................................. 112 12. Unduplicated Asthma Prevalence and Visits for All Y elrs Combined ......... ... , 112 13. Results from the Logistic Regression Analysis for ER Visits ........................... 115 14. Results from the Logistic Regression Analysis for Hospital Visits .................. . 117 15. RA:5ults from the Logistic Regression Analysis for Clinic Visits ...................... 118 16. Asthma Facility Visit Volume By Maximally and Minimally Involved Providqr Groups ............................................................................................................... . 1\0 17. Crude Utiliution Rates By Provider Group Per 1,000 Members ..... ...... .......... . 121. vii 18. Relative ~ of Asthma Outcomes Between Two Groups of Providers .... ... .. . 121 \ J 1. Demographics from Children Enrolled Between April 1, 1998, and March 31, 2001 ... ...... .... ....... ....... .... ........... .. ........................... .... ......................................... 151 J2. Total Enrollment Days for Chi.ldren Without Gaps In Enrollment... .. .. ... .. ... .. .. . 153 _ J3. Total Enrollment Days for Children With Gaps In Enrollment ....... ... .. ...... .. .... . 154 J4. Total Gap Days for Children With Enrollment Gaps ... .... .. ..... .. .......... .. .. .......... 154 KI . All CPT Codes 'Allowed' In the Count of Facility Utilization By Site of Visit ..... ... ..... .... ......... .. ........ ... ... ... ........... .......... .. ... ...... ... ... .... ..... .. ...................... 160 K.2. Results of Validity Comparisons Between Known Utilization and Billing Codes for Clinics, ER, and Hospital Visits In 70 Children .. .... .. ..... ............... .... .... ... .. . 161 :• ..... viii LIST OF FIGURES FIGURES Page I.. 1. Symptom Control Outcomes Expected to Improve When a SCDNT-Designed Nursing System Is Implemented .... ........................................................................ 7 2. Meeting the Therapeutic Self-Care Demand .. ...... ......... ... ...... .. ..... ........ ... ... ........ 14 3. Self-Care Operations Resulting in a System of Self-Care/Dependent-Care Actions .. .. ... .... ... .......... ....... .. .... .. ........... .................... ............... ..... ... ............ .. ...... 15 4. Symptom Management Self-Care Operations ..................................................... 22 5. Medication Management Self-Care Operations ....... ... ..... ...... .. ... .... .... ... ..... ....... .. 33 6. Trigger Control Self-Care Operations ................................................................. 40 7. Seeking Medical Advice Self-Care Operations ................................................... 44 8. Participating Health Plan, Providers, and Service Sites ............ .. .... ... ... ...... ........ 57 9. Summary of the Nursing System .. .. ..... ....... .......... .... ... ... .. .. .... ... .... .. ......... ...... .. ... 75 I 0. Conceptual Model for Nursing System Evaluation ............................................. 83 11. Enrollment Growth During First Three Years of Missouri Care Health Plan ... I 08 12. Age Box Plots For Each Month ......................................................................... 109 13. Children Enrolled By Provider Group By Month of Study ....... .............. .. .... .... 110 14. Annual Rates for Asthma Utilization ........ .. ................................. ...................... 113 15. Semi-Annual Rates for Asthma Emergency Visits ............................................ 114 16~ Semi-Annual Rates for Asthma Hospital Visits ................................................ 116 17. Semi-Annual Rates for Asthma Clinic Visits .................................................... 117 18. Volume Of 'Asthmatic' Children and Comparison Interval Between Maximally and Minimally Involved Provider Groups ......................................................... 119 .. ix TABLE OF CONTENTS ' ACKNOWLEOOEMi;:NTS ...... .. .. .............. .. ... .. .. .. .. .... .. .... .... .. ....... ....... ... ......... .. ... ..... ..... .. ii ABSTRACT ... .. ... .. ..... .... ...... ... .... .... .... .. ... ... .. .. ... ........ .... ..... ....... ... ..... ... ... .... .... .. .. ..... .. ........ v LIST OF TABLES ... ..... .... .... ...... ... .. ... .. ..... .. ... ... ....... ..... .. .. .. ... ... ...... ..... ............. ...... ... ... ... vii LIST OF FIGURES ... ... .. ..... ... ........ ...... ......... ....... ... .. ....... .. ........ ... ......... .. ......... ..... ........... . ix CHAPTERS 1. INTRODUCTION ........... ..... ... ......... .... .... ... ....... .. ... .... ..... ... ........ ..... ...... .. ... .... .. ...... .. , ... l • Problem Statement .............. ..... .. ... .. .... .... ... .. .... .... .. ...... ....... ..... .. .. .. ..... .. ..... .... .. ....... l Purpose .. .... .... ... .... ... .... ... ... ....... ... .. .. .. .. .. .. ... ... .... .... ...... .. ...... .... ...... .. .... .. ...... ... .... .. ... 6 Research Questions ... .. ............... ... ... ........... ..... ... .. ..... ... ............ .... .... .. ...... ...... ....... . 8 AssUD1ptions ... .... ...... .. .... ... .... ....... ..... .... ...... ... .. ... ..... ....... .. ..... ......... .. ....... ..... ........ .. 8 Significance of the Study .. ... ........ ...... ... ... ... .. .... ..... ..... ... ....... ..... .. .. ... .. .... .... .. .. ... ..... 9 2. REVIEW OF THE LITERATURE ... ....... ........ .. .. .. ... .. ....... ..... ...... .. ....... .. ........... .. ..... . 10 Orem's Self-Care Deficit Nursing Theory ....... .... ... .. ... ... ..... .. .. ... ..... .. ... .... ... .... .. ... l 0 Knowledge & Experience Required For Action ... ............... .. ....... ...... ... .. . 11 Therapeutic Self-Care Actions ........ ... ........ .... ... ... .. .. .... ... .. .. ... ... .. .. .... ..... ... 12 Self-Care Operations ........ .. ... .. ... ... ... .. .... ........ .......... ......... .......... .... ..... .... . 15 Orem's Investigational Matrix ............. .... .. ........... ....... ........ .. ............... .. ... 16 Application of SCDNT to The Pediatric Asthma Literature .. ......... .. .... .. .... .... .. .... 17 Prevalence of Asthma in Children ............. ......................................... .. ... . 17 OptimUD1 Asthma Outcome ........... ...... ... ................... .......... ........ .. ..... .... .. 19 Necessary Actions For Achieving The OptimUD1 Outcome .... .... .. ..... ..... .. 20 Action Theme #I: Detecting, Interpreting and Monitoring SYIJlptoms ... . 22 Dependent-Care Agent Believes the Diagnosis Of Asthma is Relevant. .. .............................. ...... .... ... ........... .............................. ......... ...... .. .... .. 24 Dependent-Care Agent Has The Cognitive Ability to Appraise ......... 26 Dependent-Care Agent is Aware of and Able To Discriminate Meaningful Asthma Symptoms .............. ....... ...... ..... .. ... .. ......... .. ..... ... 27 Dependent-Care Agent Keeps Time Available To Assess And To Take Action ........................................................... ....... ... ............... ...... ...... .. 31 Action Theme #2: Regulation and Administration Of Medications ......... 3 2 Dependent-Care Agent Has Appropriate Medications Prescribed ...... 34 Dependent-Care Agent Has Medications ·and Supplies Available At All Times .................................... .. ............. ................................ ... ............ . 36 Dependent-care Agent Is Skilled In Medication Administration ........ 36 X Dependent-Care Agent ls Knowledgeable In Asthma Medications, Their Purpose, Duration of Action, Dosing, And When It Is )\ppropriate To Repeat Doses ......................................................... .. .. 38 Acti~ Theme #3: Identification and Avoidance of Environmental Triggers .............................. ......................................................... .. ... ......... 39 Dcpcndcnt-Care Agent ls Aware of Relevant Triggers ...................... 40 Dependent-Care Agent Pays Attention To Symptoms Associating With Confounding Illnesses That Trigger Asthma Exacerbations .............. 41 Dependent-Care Agent Understands, Identifies, And Avoids Triggers. ··············•····················· ············ ·· ··· ····· ··· ········· ········ ······ ······················· · 41 Dependent-Care Agent Understands Protective Strategies That Minimize Trigger Exposure ..... .. ......................... ... .. ... ......... .. ... ......... . 43 Action lbeme #4: Appropriately Seeking Medical Advice in a Timely Manner······ ··········· ·················································-· ································ · 43 Dependent-Care Agent Has Access To Medical Treatment. .............. 44 Dependent-Care Agent Has a Relationship With a Health Care Provider Who ls Available For Medical Concerns ......................... .. .. 47 Design of a Nursing System to Improve Asthma Symptom Control .................... 49 Assessment of Nursing System Need at MUHC ....... ......... .. ... .. ............................ 52 3. METHODS .................................................... ... ....................................................... ..... 55 Methodology for Implementing the Nursing System ...... ................................ .. ... . 56 Participants ........... ......... ... ... .. ..... ............... ....... .... .... .......... .... ... .. .... .... .. .. .. 57 Health Plan ..... .. .................. ... .................. .. .......................................... 5 8 Providers ............ ......................................................... .............. ... ....... 59 Sites ................................................................................ .... ...... ........... 59 Methodology ....................................... .......... ....... ...... .............. .... ............. 61 Continuous Quality Improvement .................................................... ... 61 Pediatric Asthma Continuous Quality lmprove"1ent Team ................ 62 Materials .......................................................... ..... ... .................... ... .......... 63 Appropriate Diagnosis and Treatment ........................................ ........ 64 Access ...................................... .............. ............................................. 69 Dependent-Care Agent and Child Education ...................................... 70 Continuity ........................................................................................... 7 4 Procedure .................................................... .............................................. 7 4 Inclusion Criteria. ................................................................................ 75 Exclusion Criteria ........ , .................................................................... .. 76 EJDcraency ROOln Procedure ........ ........ .................... .... ... .................... 77 Hospital Unit Procedure ...................................................................... 77 , Post ER/Hospitll Clinic Procedure ..................................................... 77 xi Data Collection Methodology ................................................................... 77 Case Finding ......... ..... .. ....... ... .. .. ......................................... ........ ......... ..... 78 Datil Collection ........... ....................................... ...... .. .. ... ... ....................... 78 Methodo~::~~·s~~~~·c~~~i·i~·cbi·i~~·wi~·A~~·::::::::: :: ::::::: :~ Research Questions ............. .... .......... ... .... ...... .... ; ... ......................... .. ... ... .. 84 Hypotheses ... .. ......... .... ... ..... .. .. ... ... .......... ....... .... .... ............................ ....... 85 Data Source ............................................... .......... ... .. .......... ... ... .. .. ........ ... .. 85 [)efinition of Terms ... .... .......... .... .. ........... .... .... .. .... ... ... .. .... ........................ 86 Population of Children .................. .... .. .. .. .... .......... ..... ......................... 86 Asthma ...... .. .... ... ......... ................ ............. .................... ......... .... .......... 87 Health Care Utilization ............ ............. ....... ... ... .... ...... ........ .... .... ....... 88 Before and After Implementing a Nursing System .... .. ..... ..... .. .. ... ... .. . 89 Maximally and Minimally Involved Providers .... ..... .......... ...... .. .. .. .... 89 Analysis Plan ...... .. .. .... ....... .. · ... .. ..... ........... .. ....... .. ... .... .. ....... ..... ... .... .... ... ... 90 4. RES UL TS ... ...... ..... .. .... ............. .. ... ......... ........ .... ....... .. ... .. ......... .... ... .. ..... ... ... ........ ....... 94 Results [)efining the Penetration of The Nursing System ...... .. ... ......................... 94 [)emographic Results About Health Care System Participation ....... .. ..... . 94 UH Emergency Room Visits ... .... ... .... ..... ............ ..... .. ... ... ......... ......... .... ... 98 Children's Hospital Stays ............... .. ... ... ...... ... .......... ..... ......................... 100 Post ER/Hospital Clinic Visits .. ............. .............. ...... ..... ......... ............... 102 Results [)etermining the Extent To Which Symptoms Were Controlled ........... 107 Aim 1: Describe Missouri Care Enrollrr Patterns Between April 1, 1998, and March 31, 2001 ............ ............................... .............................. 108 Aim 2: Determine if Asthma Utilization Rates In the Missouri Care Population Ctwiged Following Nursing System Implementation .. 111 Aim 3: [)etermine If Utilization Rates Differed in Children With Asthma Who Had Maximally Involved Providers and Those With Minimally Involved Providers ... ................ ...................... ..... ................... ...... .. .. 119 5. DISCUSSION ........................ ................................. ............. ....................... ................ 123 Limitations ............................................................... ......... ......... .......... .. .. ........... 130 Implications ..................................................................................................... .... 132 APPENDIXES A. Outpatient Asthma Guidelines .............................. .................................. ... .... .. . 134 B. Emergency Astluna Guidelines ........................................... ......................... .. .. . l.,JQ C. Pediatric Asthma Utilization Summary (PCP Version) .................................... tle- D. Pediatric Asthma Utiliz.ation Summary (Parent Version) ................................. 139 E. Asthma Symptom Diary .................................................................................... 140 F. Asthma Manlplnent Plan .............................................................................. ... 141 G. List of Asthma Instructional Sheets and Self-Monitoring Tools ....................... 143 xii H. Missouri Care Data Analysis Agreement ... ........... ..... .......... ........ ..................... 145 I. IRB Approval of Study ........ ..................... ... ... ... .... .. .. ............................... ........ . 147 J. Preparatio_p oftbe Enrollment Table for Statistical Analysis ... .... .... .... ............. 148 K. Billing~ Validity Study to Differentiate Specific Sites of Care for Facility Visits ... .......... ...... .. ..... ... ... .............. .. ..... .. .... ... .. ......... .. .... ... ..... ... .. .. ... ......... ....... . 157 REFERENCE LIST ........... ............ .... ............. ..... .... ... .................. ... .. ... ..... ... .... ..... ...... .. . 163 VITA ................................. .. ............. ...... .... ... .. .. ......... ......... .. .. .. ... ..... .. .............. .. ........... . 172 ..... xiii CHAPTER 1 INTRODUCTION This study demonstrates that when nursing theory guides practice, patient outcomes improve. Specific nursing theories have been used to guide activities within professional practice and to frame important questions within that theoretical perspective (Meleis, 1991 ). As clinical questions are posed, nursing theory can guide scholarly synthesis and organiz.ation of current knowledge. Once that knowledge is synthesized and organized, the specific theoretical approach can be used to guide further knowledge development for the profession, specifically through scientific inquiry, description, measurement, and evaluation. This study applies Self-Care Deficit Nursing Theory (SCDNT; Orem, 2001) to current knowledge of children with asthma. The scholarly application of SCDNT to a population of children with asthma is intended to validate the proposition that when nursing theory guides practice, population-based outcomes improve. Problem Statement Asthma is a chronic inflammatory disorder of the airways characterized by hyperactivity of the trachea and bronchi to various stimuli, resulting in airflow obstruction that is reversible either spontaneously or ~ a result of treatment (National Asthma Education and Prevention Program, 1997a). Two factors cause airway narrowing, thus airflow obstruction: bronchospasm and inflammation. Bronchospasm is caused by bronchial smooth muscle constriction, resulting in a decreasing diameter of the airway · 1umen. Inflammation causes both edema of the mucous membranes lining the airways and . • I Effects of a SCDNT Nursing System on Children With Asthma 2 an increase in the ~tion of mucous. Airflow obstruction may be persistent or fluctuate " ' widely during the cowsc of the day, week, and year (Weinberger, 1990). Primary symptoms of airflow obstruction include wheezing, shortness of breath. dyspnea. and/or cough, particularly at night and in the _early morning (National Asthma Education and Prevention Program, 1997a). In March 1989, the National Heart. Lung, and Blood Institute (NHLBI), part of the National Institutes of Health (NIH), implemented the National Asthma Education and Prevention Program (NAEPP). The goal of the program was to establish management guidelines for clinicians and to develop a comprehensive asthma education campaign for health professionals and patients in the United States. By 1991, the first Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (NAEPP, 1991) set forth the first national standard on asthma diagnosis and management. This standard was revised in 1997 due to increased understanding about the role of inflammation in the pathogenesis of asthma, new phannacologic additions, revised diagnostic considerations, improvements in monitoring devices, advances in environmental management, and improvements in patient education strategies (NAEPP, 1997a). Goals of the 1997 national standard included: (a) raising awareness that asthma is a serious chronic disease, (b) helping ensure that patients recognize symptoms of asthma and that health professionals correctly diagnose asthma, and (c) ensuring effective control of asthma by encouraging a partnership amona patients, physicians, and other health professionals by using updated treatment regimens and education programs. Effects of a SCDNT Nursing System on Children With Asthma 3 Given 'best-p_rttetice' guidelines and a clear national priority to control asthma morbidity and monali~ in children and adults (U.S. Department of Health and Human Services, 2000), current practices at University of Missouri-Columbia Health Care (MUHC) were compared with ideal childhood asthma practices. This 'gap analysis' . revealed that systematic processes to support asthma symptom control were not in place. A one-year MUHC fiscal analysis determined that mean hospital charges for asthma care of children enrolled in Medicaid were 55% higher than the national Medicaid average (Elixhauser, Duffy, & Sommers, 1996; C. Kivlahan, personal communication, February 3, 1998). As a result of the gap analysis, MUHC and a managed Medicaid health plan developed a collaborative partnership in early 1998 with the specific aim to improve symptom control in children with asthma. SCDNT (Orem, 2001) guided the design of the intervention that resulted from this partnership. Following design completion, the intervention was implemented across the entire MUHC system. Claims data submitted to the Medicaid health plan for asthma-related health care services were used to measure intervention effectiveness in the study population. lbe literature review presented in Chapter 2 identifies and articulates actions that must be taken by parents IO regulate the asthma condition on behalf of children. Four • ideal sets of action' were identified. Theoretically, these four ideal sets of actions, when accomplished at the right time and in the right amount, are expected to result in successful regulation of the asthma condition as evidenced by symptom control (see Table 1). The four ideal sets of action identified from examining the literature from a Effects of a SCDNT Nursing System on Children With Asthma 4 SCDNT perspective arc (a) detection. interpretation and monitoring of meaningful symptoms. (b) rcgul~on and administration of asthma medications. ( c) identification and avoidance of environmental triggers. and ( d) appropriately seeking medical advice in a timely manner. Table I Actions Required To Regulate Asthma OUTCOME: Adequate Control of Asthma Symptoms PROCESS: Dependent-care agent takes appropriate. sequenced. and timely actions. Four sets of action taken by a competent dependent-care agent to achieve the outcome: l . Detects. interprets and monitors meaningful symptoms. 2. Regulates and administers medications. 3. Identifies and avoids environmental triggers. 4. Appropriately seeks medical advice in a timely manner. According to SCDNT (Orem. 2001), once ideal sets of action are made known, the professional nurse assesses the capacity of the individual to competently carry out required actions. If there arc gaps in the individual's ability to perform required actions. the professional nurse designs a nursing system. According to Orem, a nursing system is a plan to bridge the identified gaps between action demands and action limitations. In some cases, the nurse can intervene by designing a nursing system focused on developing the parent's ability to successfully perform all required actions (action demands). In other Effects of a SCDNT Nursing System on Children With Asthma 5 cases. the nursing system must be designed so that required actions ( action demands) arc performed by another ~mpetent and willing person or persons. According to SCDNT (Orem. 2001). the person who takes care-giving actions on behalf of another is referred to as the dependent-are agent (DCA). In order to achieve adequate control of asthma symptoms, a competent DCA must take appropriate. sequenced. and timely actions with regard to the four ideal sets of action. There is ample evidence to suggest that simply working with DCAs to develop competency is a prudent intervention for improving symptom control in children with asthma. Many studies have documented improved outcomes such as better symptom control and reduced emergency room (ER) visits for asthma after implementing educational programs (Brook. Mendelberg. & Heim. 1993; Charlton. Gharlton. Broomfield. & Mulee. 1990; Gillies et al., 1996; Ignacio-Garcia & Gonzalez-Santos, 1995; Lewis, Rachclcfsky, Lewis, de la Sota, & Kaplan, 1984; Madge, McColl, & Paton, 1997; Mesters, Meertens, Kok, & Parcel, 1994; Pedersen, 1992; Wilson ct al., 1996). &iucational programs designed to increase DCA competency arc completely consistent with SCDNT, and these programs arc necessary, but not sufficient for developing DCA competency. Other necessary conditions, antecedent to DCAs developing competence, were uncovered unexpectedly while framing the pediatric asthma Ii~ from Orem's (2001) theoretical perspective. Specifically, the review of the literature (Chapter 2) presents the argument that competency development is directly influenced by facton completely or partially controlled by the health care system. Despite health care system facton that interfere with development of DCA competency, Effects of a SCDNT Nursing System on Children With Asthma 6 expensive ER visits and hospitalizations are often presumed to result from the failure of OCAs to take effective actions to control symptoms in their children. ln fact, asthma costs have shown dramatic decreases when persons are correctly diagnosed, medically managed, and effectively educated (Buchner et al ., 1998; DuMont, 1998; Hughes, McLeod, Barr, & Goldbloom, 1991; Lieu et al, 1997; Marosi, Stiesmeyer, & FacuJjak, I 998; Volsko, I 998) . The development of competency to achieve symptom control continually and skillfully does not occur by chance. Specific knowledge, skills and anention to the asthma condition are required to perform ideal actions competently. From the nursing theoretical perspective presented in Chapter 2, symptom control in children can be achieved through development of DCA competency; however, symptom control will not be achieved until health care system barriers interfering with competency development are removed. The five health care system barriers that interfere with successful regulation of the asthma condition by DCAs are illustrated in Figure l . Figure I also illustrates symptom control outcomes that would be expected to change if health care system barriers known to interfere with development of DCA competency are reduced or eliminated. Purpose The purpose of this study is to evaluate the impact of an intervention, a nursing system, explicitly designed according to Orem' s (200 l) theoretical constructs and implemented across a health care system to benefit a population of children with asthma. The evaluation is designed to quantify changes in measures of asthma symptom control across the population of children. The evaluation will compare measures of asthma Effects of a SCDNT Nursing System on Children With Asthma 7 Nursing System Reduce or remove health care system factors that interfere with: 1. Appropriate Diagnosis 2. Optimum Trcabnent 3. Development ofOCA Competency 4. Access 5. Continuity Children With Asthma Expected Symptom Control Outcomes I Hospitalizations for Asthma I Emergency Room Visits for Asthma f Clinic Visits for Asthma Figure 1. Symptom control outcomes expected to improve when a SCDNT- designed nursing system is implemented. symptom control in a population of children before and after implementation of the nursing system and between two groups of children. The comparison of two groups of children with asthma will be in children who were treated by health care providers who had been maximally involved in the nursing system and children with providers who were minimally involved in the nursing system. Measurement of symptom control is from health plan claims for asthma utilimtion (ER. hospital and clinic visits for asthma). If the nursing system is successful in controlling asthma symptoms in a population of children, a before and-after nursing system comparison will result in reduced ER visits and Effects of a SCDNT NW'Sing System on Children With Asthma 8 hospitalizations for asthma with a concWTCDt increase in asthma clinic visits. Further, a comparison between two groups of children with asthma (those treated by maximally involved [in the nursing system] providers and those treated by minimal~y involved providers) will result in improved symptom control by children with maximally involved providers. Research Questions The two research questions to be answered in this study are: 1. Is there a statistically significant difference in asthma health care utiliz.ation before and after implementing a nursing system to benefit a population of children with asthma? 2. Is there a statistically significant difference in asthma health care utiliz.ation when comparing a group of children with asthma who have providers maximally involved in the nursing system and a group of children with asthma who have providers who were minimally involved in the nursing system? Assumptions There are three assumptions in-this study. First. the intervention can be implemented across an entire health care system so that children actually 'receive' the intervention. Second. the intervention health plan has enrolled a sufficient number of children who have asthma and the range of symptom control in these children is no different than that reported in the litel'atUre. Third, if the nursing system is implemented across the health care system. changes in symptom control can be detected using asthma- related claims &om the health plan. Effects of a SCDNT Nursing System on Children With Asthma 9 Significance of the Study Symptom col\_trol significantly improves when national asthma treatment guidelines are followed (Buchner et al., 1998; DuMont, 1998; Hughes et al ., 1991; Lieu et al, I 997; Taggert et al, 1991; Volsko, I 998). Failure to implement national guidelines and failure to control symptoms in children with asthma is disturbing. Against a backdrop of known treatment modalities, the prevalence of childhood asthma has been rising dramatically for 20 years, outpacing adult rates (Centers for Disease Control and Prevention [COC], 1998). Deaths, hospitaliz.ations and ER visits for children with asthma have consistently risen (Crain, Weiss, & Fagan, 1995; COC, 1996). Identifying and altering obstacles across health care delivery sites that interfere with asthma symptom control is an enormous challenge. Children with asthma usually rely on at least one other person to take appropriate, sequenced and timely action on their behalf to control asthma symptoms. DCAs who have children with asthma must know what action to take and have the skills to take required actions. This study presents, examines, and answers the SCDNT-based argument that development of OCA competency is heavily influenced by factors partially or completely controlled by the health care system. This study will significantly impact nursing practice and conswnen of health care if implementation of a theoretically based nursing system improves symptom control in children with asthma. CHAPTER2 REVIEW OF THE LITERA TIJRE This chapter begins by describing those constructs and relationships from Orem's SCDNT (2001) that are salient to this s~y. These theoretical constructs and relationships are then applied to the scientific literature of the population of children with asthma to describe the asthma condition, optimal outcomes resulting from competent DCA action, four ideal action sets that must be taken to control symptoms, and antecedent conditions that influence development of care-giver competency. Chapter 2 then raises the argument that there are two 'centers of accountability' impacting the extent to which DCAs are successful in controlling the asthma condition on behalf of the child. These centers of accountability are the DCA and the health care system. Health care system factors are then grouped into five themes. Chapter 2 concludes with the results from a needs assessment to determine if health care system changes were needed to benefit the pediatric asthma population served by MUHC. Orem's Self-Care Deficit Nursing Theory As early as 1959, Dorthea E. Orem began publishing scholarly work defining "the nature and structure of nursing" (Orem, 1996, p. 2). To this day, she and others have continued to develop constructs and concepts that fonn three inter-related theoretical frameworks that constitute the general SCDNT. The three theories, Theory of Self-Care, Theory of Self-Care Deficit, and Theory of Nursing System, articulate to fonn the expression ofSCDNT (Orem, 2001). The Theory of Self-Care proposes that humans have an ability to take deliberate action for regulating life, health, and well being. The capacity 10 Effects of a SCDNT Nursing System on Children With Asthma 11 and ability of an individual to take action in order to regulate life, health, and well being is termed self-care ag~ncy. The Theory of Self-Care Deficit proposes that, in order to maintain life, health, and well-being, each person must take many actions in an adequate and timely manner throughout the course of each day. A self-care deficit exists when the relationship between a human' s ability to perform the required actions is not adequate to meet all or part of the total need for self-care action. The Theory of Nursing System proposes that properly educated and experienced nurses are needed to identify and design a plan of care for individuals whose demands for self-care exceed their ability to perform required actions. Thus, a nursing system is the design and implementation of a plan that bridges the identified gap between the action requirements necessary for the regulation of life, health, and well being and the individual's inability to accomplish required actions. Knowledge & Experience Required For Action Action as a construct is clearly foundational to the three theories that form SCDNT (Orem, 2001). In her general nursing theory construction, Orem studied MacMurray's ( 1957) and others' work concerning deliberate human action. Deliberate action is a behavior by an individual intended to bring about a goal (MacMurray). For Orem, human actions that are deliberately taken to achieve the goal of health promotion or illness prevention are defined as self-care actions. Both MacMurray and Orem name the individual taking deliberate action the 'agent'. Since Orem's interest in deliberate human action is narrower than MacMurray's, she has named this individual the 'self-care Effects of a SCDNT Nursing System on Children With Asthma 12 agent' . Deliberate self-care actions are taken by the self-care agent in order to bring about goal achievement or i,nprovement in life, health, and well being. In order to choose specific actions, knowledge is required (MacMurray, 1957). When a self-care agent has no knowledge about a particular situation, that person does not know how to act optimally. Knowledge is developed over time particularly as an agent reflects on results achieved from prior action(s). Post-experience reflection is an intellectual process that influences future plans for deliberate action. A thoughtful plan for future deliberate action is called intention. Prior to deliberate action, the agent intellectually develops ideas about what needs to be accomplished and decides which actions ought to be taken. Even though thinking is commonplace prior to and following deliberate action, thinking about acting but never taking action is not considered deliberate action (MacMurray). Knowledge is derived from experiences as one plans action, acts, and reflects on results achieved. As new knowledge is gained from each situation, more choices or alternatives become evident. With trial and error experiences, agents learn to make a selection among possible (known) action sequences. Eventually, from the newly fonned knowledge base, one approach is selected as the best approach and, with 'practice makes perfect', patterned action sequences, or habits, result (MacMurray, 195 7). Therapeutic Self-Care Actions Ideal self-care actions for each individual arc based upon specific life, health, and well-being situations. The term used to describe all actions required for an individual to Effects of a SCDNT Nursing System on Children With Asthma 13 maintain life, health, and well being is termed therapeutic self-care demand (TSCD; Orem, 2001 ). 1bc TS~_D "stands for a specification of the kinds and numbers of care measures that arc known or presumed to be regulatory of an individual's human functioning and development within some time frame" (Orem, 1995, p. 187). The ability of a person to accurately assess, judge, and act in a timely manner for the accomplishment of all actions within the TSCD is termed self-care agency. In like manner, the term dependent-care agent is used to refer to the person who takes action on behalf of an individual who does not have the capacity or ability to take required (self-care) action. Like self-care agency, the term dependent-care agency is used to describe the dependent- care agent's ability to provide appropriate and timely actions for individuals whose self- care agency is undeveloped (i .e., infants and children), inoperable (i .e., persons under general anesthesia) or inadequate (i.e., physically unable to perform required actions) (Orem, 2001). Nursing practice that is grounded in SCDNT requires the nurse to assess an individual's ability to meet his or her TSCD (see Figure 2). The nursing assessment consists of both the action requirements demanded by a specific illness or situation (action demands) and the agent's ability to perform the required actions (identification of action limitations). Since self-care and dependent-care actions are learned behavior, the nurse &uides and monitors development of self-care and/or dependent-care agency (Orem, 2001 ). Self-care/dependent-care agency is acquired from knowledge about situations and is developed through post-experience reflection. When an individual confronts unfamiliar Effects of a SCDNT Nursing System on Children With Asthma 14 Malnta.ln a ONT Concept: nceBetw•n Figure 2. Meeting the therapeutic self-care demand (TSCD). health situations, he or she may not have any experiences from which to select actions. Knowledge and experience in managing requirements for action expands the known choices for action. In order to gain maximum insight, new experiences should be followed by thoughtful reflection (MacMurray, 1957). Nurses can guide purposeful reflection so that patients increase their knowledge base by thinking about results achieved through previous action (reflection) and planning (intention) what kinds of actions should be taken in the future. Over time, an individual's action system should result in the establishment of habitual self-care patterns that meet the ~CD. Effects of a SCDNT Nursing System on Children With Asthma 15 Self-Care Operations With regard to taking action, Orem (200 I) outlines three phases that occur in the production of deliberate action. Orem's three phases of deliberate action are termed self- care operations (see Figure 3). Estimative self-care operations include the cognitive processes such as the thinking, assessing, and deliberating that take place as an agent appraises his or her choices about actions to take. Transitional self-care operations also include cognitive processes such as judgments and decision-making as the agent chooses one course of action over others. The third and final phase, productive self-care operations, is the actual engagement in action (Orem). As a result of the estimative, transitional, and productive self-care operations, a system of self-care ( or dependent-care actions) is achieved. When the system of actions is appropriate, sequenced, and timely, the goal of regulating health care demands is met (Orem, 200 I). The appropriateness, sequence, and timeliness of self-care actions are influenced by knowledge about, and Figure 3. Self-care operations resulting in a system of self-care/dependent-care actions. Effects of a SCDNT Nursing System on Children With Asthma 16 experiences with, the-.ituation of interest. When an individual confronts unfamiliar health situations, the individual may not have any knowledge or experiences from which to select actions. As knowledge and experience grow over time, known action choices expand. Orem 's Investigative Matrix From Orcm's (2001) perspective, effective self-care is based on the balance between required demands for action and self-care abilities to perform required actions. lbeoretically driven nursing practice uncovers action limitation gaps and guides the design of nursing systems to restore a balance between demands for action and abilities to meet these demands. For nurse researchers, SCDNT establishes an investigative matrix, directing tests of theory-based practice. Specifically, a researcher could measure the extent to which a nurse accurately calculated specific action limitation gaps, or measure the extent to which the nursing system restored a balance between the demands and limitations. In order to begin testing the theory for a specific patient population, the theoretical action demands (the work to be done to manage the specific health condition) must be defined. After defining the theoretical action demands, the design, implementation, and evaluation of a nursing system follows. If the nursing theory guides the design and implementation of nursing interventions, and these interventions improve outcomes for patients, the value of professional nursing practice is revealed. The testing of Orcm's ,irivestigational matrix on a population of children with asthma begins with a listing of the Effects of a SCDNT Nursing System on Children With Asthma 17 'theoretical' demands. for action. The scientific literature from children with asthma is the data source to detennibc necessary demands for action. Application of SCDNT to the Pediatric Asthma Literature With background about integral components of SCDNT (Orem's, 2001), an investigative matrix can proceed for a population of children with asthma. The results from the theoretical application of SCDNT with the asthma literature will be the organiz.ation of what is currently known about asthma from a nursing perspective. In addition, a theoretical listing of appropriate and timely action sequences that are necessary (ideal) for competent asthma management will be defined. Prevalence of Asthma in Children Asthma is a chronic inflammatory disorder of the airways characterized by hyperactivity of the trachea and bronchi to various stimuli, resulting in airflow obstruction that is reversible either spontaneously or as a result of treatment (NAEPP, 1997a). There are two factors that cause airway narrowing, thus obstruction to airflow: bronchospasm and inflammation. Bronchospasm is caused by bronchial smooth muscle constriction, resulting in rapid clwlges in the diameter of the airway lumen. Inflammation causes both edema of the mucous membranes lining the airways and an increase in the secretion of mucous. Airflow obstruction may be persistent or fluctuate widely during the course of the day, week, and year (Weinberger, 1990). Primary symptoms of airflow obstruction include wheezing, shortness of breath, dyspnca, and/or cough, particularly at night and in the early morning (NAEPP). Effects of a SCDNT Nursing System on Children With Asthma 18 Despite improved understanding about asthma and a decade-long articulation of national goals, effecti~e management of children with asthma remains an elusive goal. Pediatric asthma continues to be a common problem in the United States and elsewhere. One in every 14 children bas asthma (CDC, 1998). This 7% prevalence rate has been rising dramatically since 1980 (CDC, 1998). Of all age cohorts, asthma mortality is lowest among children younger than 14. However, this rate is double that of the 1980 rate for children ages 5-14 (CDC, 1996). Deaths, hospitalizations and ER visits for children with asthma have consistently risen. In a 1991 survey of U.S. emergency departments, it was estimated that 1.6 million pediatric visits were for asthma care; representing 17% of all pediatric ER visits (Crain et al., 1995). Admissions to the hospital for children with asthma ages 0-14 has increased 74% in the past 20 years while the overall hospitalization rate during this same time only increased 17% (CDC, 1996). Poor children are 40% more likely to be hospitalized for an asthma exacerbation than children from more affluent families, and African-American children are three times more likely to be hospitalized than white children (CDC, 1998). Asthma is the most frequent reason for preventable hospital admissions among all children regardless of race or socio-economic status (Billings et al., 1993; Weissman, Gatsonis, & Epstein, 1992). Asthma is common in children across all ages and presents various challenges depending on the age group. The diameters of the young child's airways are quite small, thus diseases causing airway narrowing such as asthma have a much greater impact (McWilliams, 1995). Triggers, such as respiratory infections, play a much larger role in Effects of a SCDNT Nursing System on Children With Asthma 19 asthma exacerbations for young children compared with older children (Weinberger, 1990). One of the earliest warning signs of an asthma exacerbation is night-time coughing or dyspnca that causes awakening (NAEPP, 1997a). Parents may sleep through such an episode, thus missing an early warning ~ign of an impending respiratory crisis. There are limitations in available asthma medications for children less than six, and there are various different, more complex strategics for delivering the medications to the airways of young children (Weinberger, 1990). The volume of children seen in hospitals suggests either complicated medical requirements, extraordinary management challenges for DCAs, or both. Since a young child's capacity for declaring illness symptoms or reporting effectiveness of medical interventions is undeveloped, the care-giver demand for astute symptom detection and effective, timely action is critical. Knowing which symptoms should be attended to and having the ability to perform actions competently to treat and relieve symptoms is critical for ideal management. Diseases in children presents physiologic, pharmacologic, and human experiential differences that complicate ideal management. Optimum Asthma Outcome Adequate control of symptoms requires deliberate self-care or dependent-care actions. Specifically, adequate control of symptoms occurs when appropriate, sequenced and timely actions are taken before and during an asthma exacerbation. Adequate control of symptoms is evidenced by (a) being able to sleep at night, free from waking due to coughing, (b) being able to work or play hard without breathing problems, ( c) not Effects of a SCDNT Nursing System on Children With Asthma 20 requiring w-gent or enacrgcnt care for an asthma exacerbation. and ( d) having a medication regime that results in good symptom control without side effects (NAEPP, 1997a). Specific knowledge, skills and attention to the asthma condition are required to perform ideal actions competently. Necessary Actions For Achieving The Optimum Oulcome In order to define action demands for children with asthma based on the literature, a template analysis was done (Crabtree & Miller, 1999). The primary objective for wing this qualitative technique was to create an evidence-based listing of all actions required to achieve the optimal outcome of asthma symptom control. As a result of applying the template analysis process, four general action themes emerged. A template was created to perform four discrete but iterative cognitive and analytical stages; each stage reflects relevant theoretical constructs. The first stage involved listing specific outcomes that could be expected when appropriate dependent- care actions were taken. Then. for each of these defined outcomes, all actions required to achieve the outcomes were defined. Third, each action required to achieve the outcome was categorized as estimative self-care operations (thoughts), transitional self-care operations (judgements/decisions) or productive self~are operations (actions). In the final stage, questions were created that could be asked of DCAs in order to assess competency with regard to each of the outcomes and self-care operations. The data source for this process was the scientific literature and local experts from MUHC Pediatric Pulmonary Department (physicians and a pediatric nurse practitioner). Effects of a SCDNT Nursing System on Children With Asthma 21 The template analysis IWBS completed during multiple lengthy sessions over approximately three months. During this phase, an iterative process occurred as developments and modifications were discussed with locat-experts in both asthma and Orcm's (2001) theory. From the 'near-final' template analysis listing, outcomes were named as, and grouped into, one of four ideal action demand themes. The ideal action demand themes arc (a) detecting, interpreting and monitoring symptoms, (b) regulating and administering medications, (c) identifying and avoiding environmental triggers, and (d) appropriately seeking medical advice in a timely manner. For each of the four ideal action demand themes, the flow of the self-care operations (estimative, transitional, and productive) required for competent asthma management was then formulated and illustrated. Once each of the four illustrations had been completed, the self-care operations defined in the template analysis process did not express all that was necessary for asthma symptom control. If fact, certain conditions must be present in order for the DCA to have the capacity to think, judge, and take competent action appropriately. 1besc conditions were named, and they were antecedent to a DCA performing appropriate estimative, transitional, or productive self-care operations. If any of the antecedent conditions were not present, even the best intentioned DCA would not be able to control asthma symptoms successfully. The four action themes and their antecedent conditions were then validated with local clinicians. The four action theme illustrations were modified so that the antecedent conditions were included with the estimative, transitional, and productive self-care operations defined during the Effects of a SCDNT Nursing System on Children With Asthma Z2 template analysis. Each theme, to include the antecedent conditions and the self-care operations, is now described and illustrated according to supporting literature. Action Theme # 1: Detecting, Interpreting and Monitoring Symptoms In order to control symptoms adequately, symptom detection, interpretation and I) monitoring are critical. Symptoms can be characterized by type (wheeze, cough, shortness of breath, labored breathing), pattern (intermittent, continuous, seasonal, exercise induced), associated conditions (viral respiratory infection, ,rhinitis, sinusitis, fever), and precipitating factors (trigger exposure) (Weinberger, 1990). Detecting, Interpreting and Monitoring SYMPTOMS SYMPTOMS SUGGESTING EXACERBATION • A~ ofprael!C)C ofmcaaingful symplOIIIS • Severity of symplOIIU • Progmsion of symptoms over time I will seek treallllcnt fiom • facility with lrliDed providcn Figure 4. Symptom management self-care operations. I will lake DO action at Ibis time but,i:mtinue to appraise for wonening symptoms Effects of a SCDNT Nursing System on Children With Asthma 23 Figure 4 illusirates symptom-related estimative, transitional, and productive self- care operations and the four antecedent conditions identified as necessary for competeot action. When symptoms are assessed (estimative self-care operations), there are four possible decisions (transitional self-care operations) for actioo (productive self-care operations). These decisions include independent tfflltlnent; seeking treatment advice by contacting a member of the health care team; traveling to a treatment facility; or taking no action except to reappraise symptoms at a later time. When seeking advice from a member of the health care system either by phone or by traveling to a facility, the DCA intentionally transfers care decisions to someone believed to be more competent or to access treatment methods not available to the DCA. If the DCA chooses either to act independently or to continue to appraise for worsening symptoms, the agent 'loops' back through this assessment, judgement, decision-making cycle (self-care operations) until the symptoms are judged to be resolved or the care is delegated to a member of the health care system. With either the decision to independently treat or to reappraise symptoms at subsequent intervals, two additional self-care operations are required. One is selecting the appropriate time intervals between reassessments. The second is a judgement about the child's direction of change: improving, worsening, or unchanged. An accurate assessment of symptom severity, frequency, and control is critical in determining what additional actions should be taken. With regard to antecedent conditions, one should not expect a DCA to be able to detect, interpret or monitor symptoms if the agent docs not believe, or has not been told, Effects of a SCDNT Nursing System on Children With Asthma 24 the diagnosis of asthma is relevant. A second, much more obvious, antecedent condition is that the DCA must have the ~c cognitive capacity to appraise the child's symptoms. Third, the DCA must be able to discriminate between those symptoms that arc asthma related and those that arc not. Finally, the DCA needs to have sufficient time to think through, decide, and take action on behalf of the child needing care. The asthma literature is now presented according to the four antecedent conditions necessary for competent thoughts, decisions, and actions relative to detecting, interpreting and monitoring symptoms. DependenJ-care agenl believes the diagnosis of asthma is relevant. Before an agent can begin learning how to manage asthma, the provider has to diagnose the condition in the child and begin appropriate medication therapy. The literature clearly documents an international concern about under-diagnosis of asthma and under- estimation of disease severity leading to under-treatment (Duran-Tauleria, Rona, Chinn, & Burney, 1996; Ehrlich et al., 1995; Kaur et al., 1998; Mostgaard, Siersted, Hansen, Hyldebrandt, & Oxhoj, 1997; Sennbauser & Kuhni, 1995; Siersted, Bolutpaticn&Clinics •UP Pedialrics in Columbia •UP Pedialric Pulmonary •UP Family Practice (F P) in Columbia •UP FP in Fayette •UP FP in Fulton •Family Health Center Figure 8. Participating health plan. providers, and service sites. Effects of a SCDNT Nursing System on Children With Asthma 58 Health Plan As described earlier, access to the Medicaid MC+ health care coverage was expanded significantly in 1997 and 1998. In central Missouri at that time, Medicaid eligible children could choose from among three insurance plans who had contracts with the state to provide MC+ coverage for children ages 0-17. The three plans were Healthcare USA, Missouri Care, and Care Partners (D. Checkett, personal communication, September 5, 1998). Only Missouri Care contracted with MUHC and UP as network providers so Missouri Care was a logical participant. The partnership with Missouri Care proved critical in alignment of health plan incentives that directly and indirectly influence asthma symptom control. A partnership agreement with the largest commercial insurance health plan in mid-Missouri was also sought, but this offer was declined. The rationale for declining participation was that, as a national health plan, relevant services had already been contracted (telephone consultations to persons with expensive claims for asthma care). No other commercial health plan was approached to participate as a partner in the intervention. Providers In terms of the estimated 9,000 children with asthma in the MUHC service region, some provider groups were maximally involved in the intervention while others were either minimally involved, or not involved at all. UP and Family Health Center (FHC) providers were maximally involved. Effects of a SCDNT Nursing System on Children With Asthma 59 UP is mid-Missouri's largest group practice with over 300 physicians in '1most 70 specialties. UP also staffs University Hospital, Children's Hospital, and outpatient clinics located throughout Columbia and surrounding communities (University of Missouri- Columbia. 2001d). UP providers from·both Family and Community Medicine (family practice), Child Health (pediatrics) and Emergency Service (ES) agreed to maximal participation. Although not affiliated with UP, physician and nurse practitioners at FHC in Boone County enthusiastically requested to be included as maximally involved participants due to the high-risk population that FHC serves and their strong commitment to evidence-based medicine. Minimal involvement occurred when providers, not affiliated with UP or FHC, contracted with Missouri Care as a PCP for children members. The specific 'minimal involvement' (and 'maximal involvement') activities arc described in a later section. Siles Prior to site selection, the MUHC gap analysis was presented to site-specific leaders who then enthusiastically agreed to participate. Within each care delivery site, these leaders began to seek agreement from medical providers, nursing and respiratory therapy professionals. Within six months, full suppor:1 and agreement to participate was obtained from four hospital areas and six outpatient clinic sites. The four hospital areas selected were University Hospital (UH) ER, and Children's Hospital Pediatric Unit, Adolescent Unit and Pediatric Intensive Care unit. The UH ER is the only Level I Trauma Center in mid-Missouri and serves as a tertiary Effects of a SCDNT Nursing System on Children With Asthma 60 care referral center and a regional resource center. More Jhan 25,000 patients seek treatment at UH ER annually (University of Missouri-Columbia, 2001c). Children's Hospital, a hospital within University Hospital, is mid-Missouri's largest and most comprehensive pediatric health-care fw.ility. Dedicated exclusively to meeting the health- care needs of children, the hospital has more than 115 beds. The Pediatric Unit is a 29- bed unit specially designed for medical and surgical pediatric patients. The Adolescent Unit in Children's Hospital is a 16-bed adolescent unit designed to meet the unique needs of teen-age patients. The Pediatric Intensive Care Unit is an 11-bcd unit in which management of critically ill and injured children takes place within the context of a full range of high-tech services, including ventilatory support and invasive and noninvasive hemodynamic monitoring (University of Missouri-Columbia, 2001 a). The six outpatient clinic sites participating in the intervention consisted of five UP clinics and one community health clinic. Two UP Pediatric clinics, both in Columbia, represent generalist care ("Green Meadows Pediatrics") and specialist care ("Pediatric Pulmonary/ Allergy Clinic"). Green Meadows Pediatrics has an average visit volume exceeding 20,000 visits annually (T. Nations, personal communication, October 17, 2001 ); Pediatric Pulmonary Clinic has approximately 1,700 visits annually (A. Painter, personal communication, October 24, 2001). Family and Community Medicine UP providers manage three outpatient clinics with approximately 80,000 visits annually (University of Missouri-Columbia, 2001 b ). Two of the three FP clinics serve rural populations in Fayette and Fulton; one serves the Columbia area. The FHC, located in Effects of a SCDNT Nursing System on Children With Asthma 61 Columbia. serves qualified families in Boone and surrounding counties. This federally qualified community\llcalth center primarily serving Medicaid and uninsured persons has approximately 26,000 outpatient visits annually (C. Kivlahan, personal communication, October 14, 2001 ). FHC providers arc not UP providers, but were maximally involved in the nursing system. Methodology Because implementation of a multi-faceted interventioQ was planned across a large volume of participants and service sites, the continuous quality improvement (CQI) approach was taken to operationaliu the nursing system across participants and sites. CQI is a method of continuously examining processes and making them more effective (Deming. 1993 ). Continuous Quality Improvement CQI was developed in a business environment where solving problems was common (Deming. 1993). The CQI methodology resulted from the application of specific sciences to understand, adapt. and ultimately achieve improvements in daily work (Blumenthal & Scheck. 1995). The theoretical foundation of CQI is based on systems theory and involves hwnan and non-hwnan sciences, as the focus has been on understanding and resolving processes that influence production quality. Hwnan sciences directly affecting the practical application of CQI include psychology and the science of learning. Specifically, these sciences inform systems production when factors such as group dynamics, conflict resolution, motivation, and creativity arc considered. The use of Effects of a SCDNT Nursing System on Children With Asthma 62 mathematical sciences for understanding variation. prediction. and experimentation are examples of the applications of non-human sciences. In summary, CQI was initially developed from a business model with the purpose of achieving improvements in outputs from daily work (Deming, 1993). Pediatric Asthma Continuous Quality Improvement Team In December 1997, before a team was assembled, this study' s principal investigator (Pl) was hired full-time to serve as the program manager. Shortly thereafter, asthma expert professionals were sought for voluntary team membership and two physician champions, one representing family practice and one representing pediatrics, volunteered to co-lead the team. Two nationally renowned pediatric pulmonologists and one pediatric nurse practitioner within the MUHC Child Health Department also agreed to join the team. These MUHC experts had been providing specialty ambulatory services to more than 1,100 children in mid-Missouri (B. Francisco, personal communication, August 5, 1998). Other team member volunteers were added between March and October 1998 when various program design decisions unfolded and key representatives were needed to assure successful implementation. In addition to adding team members who represented and had 4irect authority over certain participating sites, membership selection decisions were hued upon proven leadership skills, enthusiasm, and commitment to improving care for children. Team membership was voluntary and only secured after each potential member was oriented to expected roles and contributions. Effects of a SCDNT Nursing System on Children With Asthma 63 Prior to implementation of the nursing system on October 1, 1998, team membership includcd'. attending and resident leaders in Child Health, Family and Community Medicine, Pediatric Pulmonary, Family Health Center, Emergency Medicine. and Missouri Care. The team also included professional and nurse leaders representing administration across the participating sites to include the 24-Hour Telephone Triage Line and Missouri Care representation of case management services. Twelve of the original 18 CQI team members remain on the team 36 months after implementation. Between March and November 1998 (six months before and two months after nursing system implementation), team meetings were held almost every week. During this time, all activities centered around creating, integrating, and building an infrastructure to bridge the health care system gaps identified from the literature. Team meetings were reduced from weekly to every other week between December 1998 and August 1999. During this time, lessons were continually learned and adjustments made to program components. By the end of the first year, program components rarely required revision. Thus, beginning in September 1999, one year after implementation, monthly team meetings primarily consisted of oversight. Malerials The MUHC gap analysis (refer to Chapter 2) revealed that systematic processes to support asthma symptom control were not in place. For example, not one generalist physician surveyed admitted to using AMPs, but each agreed to adopt an AMP template if one was developed for them. Although UH and Children's Hospital had a pre- Effects of a SCDNT Nursing System on Children With Asthma 64 established strategy for standardizing and documenting population-specific patient education. there was 'not a pre-established education plan for either adults or children with asthma. There was no process in either the UH ER or Children's Hospital for routinely communicating treatment plans back to the child's provider after an ER visit or a hospital stay. There was no established process to schedule next business day appointments for persons discharged from the ER. Pulmonary consultations bad only occurred for the most complex cases, usually reserved for children admitted to the Pedia,.tric Intensive Care Unit. In summary, the gap analysis identified the specific materials and processes to be created and showed the team that significant behavioral and system level changes would be necessary for successful implementation. Materials and processes created and implemented to optimize asthma diagnosis, treatment, access, education, and continuity are now described. Appropriate Diagnosis and Trealmen/ Team consensus for best asthma practices was expedited due to the availability of the 1997 NHLBI Guidelines/or the Diagnosis and Managemenl of Asthma (NAEPP, 1997a). However, the NHLBI guidelines are almost 150 pages in length and, an official excerpt of the original guidelines, the Practical Guideline for the Diagnosis and Manag,menJ of Asthma, were also quite long at 50 pages (NAEPP, 1997b ). A pediatric- specifi~ version of the guidelines, although using large font and colorful pictures, was 150 pages (American Academy of Allergy, Asthma & Immunology, 1999). In order for clinicians to have access to and follow the guidelines, the CQI team distilled the Effects of a SCDNT Nursing System on Children With Asthma 65 guidelines down to two single page, two-sided reference documents. One version guided outpatient. or preventive, management (see Appendix A); the other addressed emergency, or crisis, management (see Appendix 8). Pre-printed physician orders for UH ER and Children's Hospital were created to trapslate these guidelines into practical hour-to-hour patient care activities. Once the one-page guidelines were approved, an overall asthma curriculum was developed for educational sessions with (maximally) participating providers. Curriculwn emphasis was on diagnostic criteria and appropriate medication therapies. Beginning in September and October 1998 and repeated annually through 200 I, the CQI team members used this curriculum for multiple group training sessions until over l 00 providers across all participating sites were trained. Unexpectedly, this massive training effort resulted in the emergence of site leaders (providers) who tried various approaches to systematizing asthma care. For example, in one outpatient clinic, some patients were scheduled for up to four follow-up appointments over a six-week period after an exacerbation. During these appointments, the DCA was asked to return with completed symptom diaries. Follow-up visits allowed the provider to assess the effectiveness of the prescribed medications and to reinforce education about asthma manaaement. Beyond translation of the guidelines and provider education, the nuning system also •required' pulmonary consultation in those children whose asthma exacerbation was so severe the child was hospitalized. Ordering the pulmonary consultation was left to the Effects of a SCDNT Nursing System on Children With Asthma 66 admitting physician. Pediatric pulmonary consultation for inpatients was an unpopular intervention as many of-the residents and attendings felt they had sufficient medical preparation to provide the same standard of care achieved from pulmonary consultations. Many meetings and educational sessions were held to air these concerns. Ultimately, the non-pulmonologist physicians began to recognize the value of the consultation report (specific diagnoses and treatment regimen). Dissemination of the one-page guidelines to the minimally involved providers occurred through the leadership of the Missouri Care medical director. In 1999, a Missouri Care-sponsored mailing was targeted to all providers who had been assigned to children members 'suspected' of having asthma. The designation of 'suspected' was determined after a very purposeful process of 'case finding'. The case finding method identified suspected children using three data mining approaches. These approaches included (a) the identification of billed claims for either asthma specific utilization or home nebulizer rental, (b) using initial member registration information where the parent had given a docwnentcd history of asthma. or ( c) manually programmed asthma alerts that had been entered into the child's membership file by case managers (usually after phone consultations with parents in which asthma care questions had been asked and answered). Using these case finding approaches during the winter of 1999, over 700 children were labeled as possibly having asthma. PCPs of these children (both maximally and mioimaJly involved providers) received a cover letter, signed by the Missouri Care medical director, emphasizing an evidenced-based approach to managing c:hildren with Effects of a SCDNT Nursing System on Children With Asthma 67 asthma. The letter introduced five attachments. The five attachments included (a) one copy of the abbreviated (50 page) national guideline (NAEPP, 1997b), (b) one copy of both preventative and crisis one-page MUHC asthma consensus guidelines, (c) names and dates of birth of children assigned to the PCPs who were identified as having a ·suspected' asthma condition from the case finding methods, (d) copies of blank AMPs and ( e) symptom diaries for each child on the case finding list. PCPs were informed in the letter that the parents of these children would receive sent an informational letter stating that asthma symptoms could be controlled, especially when an individualized AMP was developed between the provider and parent. The providers were told these parents were being sent a blank AMP and that parents were encouraged to make appointments with their provider to complete the AMP. The provider letter included Missouri Care contact names, phone numbers, and email addresses for questions or to schedule training about either evidence-based asthma management or how to individualize an AMP. At the same time, a similar letter was prepared by the Missouri Care medical director and mailed to the parents of the 700 children. The letter was intended to be educational, informing parents that if their child had recurrent wheezing or a diagnosis of asthma, an AMP was the best way to control symptoms. The letter informed parents that they could make an appointment with their PCP, at no charge, to individualize an AMP for their child. A blank copy of the AMP and a Missouri Care magnet was included in the mailing. Effects of a SCDNT Nursing System on Children With Asthma 68 The third mailing was sent to some maximally involved PCPs in the fall of 2000. Prior to this mailing, \all children with UP and FHC providers and health care claims for asthma during a one-year period were identified. Twenty percent of identified children (n = 74) were singled out after ranking total asthma clwges during that year from highest to lowest. The claims from the 20% of children with the highest clwges were translated into a succinct and meaningful patient profiling report for provider use. The format for the profile, the Pediatric Asthma Utilization Summary (PAUS), was ~ one-page document with colorful graphics. This format was intended to attract the PCPs attention and to quickly convey symptom control recommendations. In addition to symptom control recommendations, the PAUS included information about demographics, utiliz.ation, continuity, missed appointments, and medication refill patterns (see Appendix C). A parent-friendly version was also printed and mailed to the child's parent with specific messages about what the parent could do to improve their child• s symptoms ( see Appendix D). This mailing also included three asthma symptom diaries, one AMP, and, for those children older than S years, a peak flow meter. In summary, strategies to promote appropriate diagnosis and treatment over the 30 months of the nursing system involved UP and FHC providers in a maximal way (regular asthma educational sessions, reminders, meetings, email correspondence, and results of ~ monitorin&). But, for non-UP and non-FHC Missouri Care providers, informative mailings were intended to influence adoption, translation, and dissemination of the Effects of a SCDNT Nursing System on Children With Asthma 69 national asthma guidelines. so these providers were at least 'minimally involved' in the nursiag system. Access The partnership with Missouri Care allowed for dialogue surrounding health plan- specific barriers interfering with optimal care, such as payment for certain medications and treatments. One concern involved the Missouri Care fonnulary. A fonnulary is a list of medications and supplies that arc reimbursed by the health plan when prescribed. In addition to fonnulary restrictions, health plans can limit the number of prescriptions covered during health plan defined intervals. All recommendations for revision were ultimately approved by the Missouri Care medical director and included removing and adding certain asthma medications to the fonnulary, as well as changing certain allowable 'limits' on the number of medication refills and adding coverage for aerosol delivery c!wnbcrs (spacers). These revision approvals resulted in the availability of multiple asthma medication refills and nebulizcrs in different households for children who lived in more dwl one location (e.g., divorced parents who share custody). The availability of a 24-hour telephone triage nurse line, staffed by MUHC registered nurses. was mandated as part of the Missouri regulations for Medicaid MC+ plans. This regulation was intended to assure access·to trained persons who could assist the DCA to make trcatment decisions during, in this case, asthma exacerbations. Before implementation of the nursing system, general asthma triage telephone protocols were Effects of a SCDNT Nursing System on Children With Asthma 70 reviewed and modified to be consistent with the emergency guidelines adopted by MUHC providers. For those children who presented to the ER with an asthma exacerbation, a new system was created so that. prior to discharge from the ER. a •next-business day' appointment could be scheduled for UP providers. For non-UP providers, DCAs were instructed to contact their primary provider at 8 am the next-business day after the ER visit to make an appointment. In order to maximize continuity in the plan of care, DCAs were also given time-limited AMPs that detailed every action to take during the time following ER discharge up to the time of the next business day appointment. In summary, the literature provided evidence that a nwnber of access barriers interfered with development of DCA competency to control asthma symptoms. The design of the nursing system addressed these access barriers through several processes and activities. These included (a) the overall minimi7.ation of financial access barriers that MC+ provides, (b) Missouri Care formulary revisions, (c) consistently written MUHC asthma messages for the 24-Hour •advice' lines to deliver, and (d) the immediate availability of a next bu.tines., day appointment following an exacerbation requiring an ER visit. Depeunl-Cart Agtnl and Child &luca1ion Durin& the pp analysis (prior to nursing system design), a large variety and volume of non-standardized asthma educational materials were found at the participating ER, hoapital, and clinic sites. This finding prompted a team goal to develop and use Effects of a SCDNT Nursing System on Children With Asthma 71 standardized asthma educational materials across participating sites. Since MUHC baseline data for ti~ year 1997 revealed that 73% of the children treated for asthma and enrolled in Medicaid were younger than six years, materials needed to be relevant for parents with young children (C. K.ivlahan, personal communication, February 3, 1998). Educational materials needed to be structured for simplicity in medical terminology, graphics, and use interactive games where content allowed. Because there are a variety of age-specific medications and delivery devices, separate educational materials that could be used to 'mix and match' an individualiz.ed treatment plan for different medications, delivery devices, and triggers were developed. A task force had been established to develop standardized asthma materials. The task force decided that the format of educational materials should be one or two page sheets, with lots of white space and graphics, and each material should focus on distinct topics. A total of 26 unique instructional sheets were developed. The task force then determined that all children with asthma (or suspected asthma) had common learning needs, and 8 of the 26 instructional sheets would meet common learning needs. To this end, the task force designed a folder to contain these eight instructional sheets, and it is called the 'Basic 8'. Even though the 26 standardized instructional materials seemed thorough, from a SCDNT (Orem, 2001) perspective, two other tools were needed to develop DCA wmpetency. The first, the Asthma Symptom Diary, was intended to serve as a self- monitoring tool to build skills and habits in regular monitoring, quantifying and documenting the child's symptoms (see Appendix E). The daily symptom diary Effects of a SCDNT Nursing System on Children With Asthma 72 documentation is valuable to PCPs because total days of asthma symptoms are obviously a quantifiable marker Qf severity. As asthma severity increases or decreases, asthma medications are adjusted. Symptom diaries facilitate accurate medication adjustments (NHLBI, 1997a). The second tool combines self-monitoring instructions about the four ideal sets of action onto an AMP (see Appendix F). OCAs are encouraged to keep the AMP in an easy-to-find location. One side of the plan categom.cs symptoms according to the traffic signal metaphor with 'green light' indicating 'a good day'; 'yellow light' is a 'caution day', and 'red light' is a 'stop and call day'. Terms used for symptom monitoring across these three traffic signal categories were intentionally created to be simple, m~ingful, and memorable for a variety of age groups. For assessment term examples, moving from green, to yellow, to red, AMP wheezing tenns are ''no wheezing", "some wheezing", and "lots of wheezing". The coughing tenns are ''no coughing", "some coughing", and "lots of coughing'. Relative to the parent's assessment of the child's activity level, AMP tenns are "active and breathing well", "less active or playful", and "too short of breath to run or play". Once the OCA has assessed the symptom category (green, yellow, or red light), the AMP guides decision-making. MUHC added the AMP and symptom diary to the Basic 8 folder. The titles of all 26 Caring/or Kids With Asthma instructional sheets and the two self-monitoring tools, grouped according to the four ideal sets of action, are listed in Appendix G. A system for stocking and replenishing Basic 8 supplies was established in all participating sites. In the Effects of a SCDNT Nursing System on Children With Asthma 73 30 months between October 1, 1998, and March 31, 2001, over 3200 Basic 8 folders were produced and distrihl,tcd (A. Rebeny, personal communication. April 3, 2001). Competency based training for staff in participating sites was scheduled dwing September and October of 1998 and has been repeated annually through 2001. The specific training objective was to develop staff skills to train parents and children effectively in self-assessment, trigger avoidance, medication knowledge/delivery skills and when/how to contact a provider. The training fonnat included multiple small group sessions educating over 150 nurses and respiratory therapists across participating sites each year. Staff competency based training, however, was not enough to ensure the DCA and child received adequate asthma education. Participating sites designed approaches to identify those DCAs who would benefit from asthma teaching. For children presenting to the ER with an asthma exacerbation. the respiratory therapists (Rn took the lead in notifying providers and nurses of parents/children who should be taught. For hospitalized children, nurses have been arc primarily responsible for teaching and documenting learning outcomes according to the newly created DCA teaching plan, the Asthma (Ages 0-17) Patienl Teaching Record. For children treated in the ER or hospital for an asthma exacerbation, outpatient clinics were notified of an 'asthma follow-up appointment' using an alert. An alert was entered into the scheduling software when the appointment was scheduled. Thus, the alert was printed on clinic schedules to remind staff of the need to reinforce asthma learning Effects of a SCDNT Nursing System on Children With Asthma 74 objectives and skills development. The alert also served as a reminder to locate and review ER and bospilal post-discharge faxes prior to the patient-provider encounter. Responsibility for outpatient teaching is shared between clinic providers and nurses with documentation of teaching on AMPs. Continuity The fifth and final potential health care system gap addressed by the nursing system was continuity. Missouri Care members must select. or be assigned to, a PCP in the Missouri Care network. This 'gate-keeper' model was built into the Missouri Care structure because the establishment of a relationship between an accountable PCP and his or her assigned members is theoretically fostered, allowing precise management and anticipation of typical health care needs and prevention services (Gill & Mainous, 1998). Although the gate-keeper model has been designed to foster continuity, MUHC clinics are staffed by UP providers who have research, teaching and clinical obligations. For children who rapidly develop urgent symptoms, it is difficult to schedule a same-day or urgent appointment with their PCP. Since the CQI team recogniz.ed provider continuity was a challenge, the team detennined that a reasonable substitute was for the outpatient clinic provider to receive aJaxed copy of all asthma-related treatment records after the ER or hospital visit, but before the pre-scheduled follow-up appointment. Procedure Fiau,re 9 illustrates a summary of the nursing system implemented on October 1, 1998. The nursing system was simultaneously adopted by IO participating sites and by Effects of a SCDNT Nursing System on Children With Asthma 75 Nursing System Interventions UeD fduSDfw GJ■ l.~o.,wts 2.0pd,la,w~ •Emergency and Oulpetient Guidelines and Pre-printed (!lders •Pulmonary Consult Oil Hospitaliz.ed Childrea "' •Provider UtiliDtion Summaries 3.Acasr •Heahh Pl• Contract and Fonnulary Changes •24° Nurse Triage "'°'1e Linc •~ F/U Appointments 4.~u.c.do,r •Basic a (& other patient education 11 materials) •AMP •Symptom Diary •Patient Teaching Record •Parent UtiliDtion Summaries 5. ColdbudtJ •Treatment plans faxed Participating Sites b Olltpatie■t Chics Figure 9. Summary of the nursing system. Participating Providers Univenity Physicians and Family Health Center three groups of health care professionals. The procedures established for day-to-day activities necessary to ensure satisfactory implementation of the nursing system are now described. Inclusion Criteria Inclusion criteria for implementation of the nursing system were for: (a) children ages 0-17, (b) presenting to either the University Hospital (UH) ER or to any of three Children's Hospital Units (Pediatrics, Pediatric Intensive Care, or Adolescent Unit), (c) treated with albuterol by either nebulizer or metered dose inhaler; and ( d) satisfied exclusion criteria From these, children who had a previous or current diagnosis of Effects of a SCDNT Nursing System on Children With Asthma 76 asthma or who bad a history of at least one other wheezing episode (as determined by history or home medications that included albuterol) were included. Also, children without an asthma diagnosis but who would be going home on prescriptions for inhaled anti-inflammatory medications were included. Exclusion Criteria Children with significant chronic respiratory or neurologic disorders were not included. These exclusion criteria were adopted because, while these severe chronic conditions often have an asthma component. these DCAs receive significant training and assistance to manage their home-bound children. Examples of excluded conditions included children with cystic fibrosis, bronchopulmonary dysplasia. or cerebral palsy. Emergency Room Procedure When a child was identified as meeting the inclusion criteria in the UH ER, physicians, nurses, and respiratory therapists followed certain steps prior to the child's discharge from the ER. Specifically, children who were treated in the ER and discharged home should have received (a) education about asthma using the Basic 8, (b) a time- limited AMP, and (c) pre-scheduled next business day appointment. This time-limited AMP was completed by both nurse and physician to include (a) the scheduled follow-up visit date, time, location, (b) follow-up provider name, and ( c) medication instructions to follow until the next business day appointment. For children who were treated and admitted to the hospital, the ER should have faxed all relevant treatment documents to the child's provider. Effects of a SCDNT Nursing System on Children With Asthma 77 Hospilal Unil Procedure For children meeting the inclusion criteria and who were placed on any of the three hospital units (Pediatrics, Pediatric Intensive Care, or Adolescent), several steps should have been initiated by the physician, nurse, or respiratory therapist who determined the child met inclusion criteria. These processes were designed so that, prior to discharge, the child would receive (a) a Pediatric Pulmonary consultation, (b) asthma teaching, (c) an AMP, and (d) a follow-up appointment within seven days of discharge. Additionally, the pulmonary consultation and treatment plan should have been faxed to the child's PCP prior to the follow-up appointment. Posl ER/Hospilal Clinic Procedure. There were three monitored processes for children who had received care from UH ER or Children's Hospital units. They were: (a) arrival of faxes prior to the follow-up visit. (b) follow-up appointments kept. and ( c) revision of AMP during the next business day appointment. Da1a Colleclion Melhodology By October I, 1998, indicators bad been developed and tested to measure the extent to which the nursing system was implemented by the participating ER, hospital units, and clinics sites. Thirteen indicators were ultimately selected for the following reasons: (a) meaningful data could be collected after the child had been discharged, (b) each directly represented specific nursing system components deemed pivotal for Effects of a SCDNT Nursing System on Children With Asthma 78 promoting symptom control (e.g., parent/child education), and (c) each provided reliable evidence of nursing ~stem implementation. Case Finding Prior to October 1998, the PI worked with the MUHC Respiratory Therapy (RT) Department to develop an accurate case finding methodology. Since RT provides, docwnents and bills for all respiratory treatments in the ER and Children's Hospital, the daily treatment schedule was a reliable source for finding new nebulizer and metered- dose inhaler doses given to patients. All new orders were easily located because they are handwritten additions to a daily computerized activity log. On business days (non-holiday Monday through Friday), the PI examined all handwritten additions to the treatment schedule for children treated in the UH ER or admitted to any of the three Children's Hospital units from the previous day. Monday case finding identified new orders for children treated with albuterol anytime between 6:00 am Friday and 6:00 am Monday. The medical record from all newly treated children was screened to determine the nature of the presenting medical condition. Regardless of whether the nursing system components had been initiated for the child on the date the child was treated with albuterol, if inclusion criteria had been met, data collection procedures were initiated. Data Collection Following positive case finding, data on the extent of implementation of the nursing system components were tabulated on the data collection fonn. There were two sources of data for the 13 nursing system indicators: medical record review and personal Effects of a SCDNT Nursing System on Children Wit,h Asthma 79 (phone or email) contact with providers or sites of care. Scores were either 'yes' (the indicator was prcsenti 'no' (the indicator was not present), or 'N/A' (the indicator was not applicable; or scoring of the indicator was not relevant for that case, that time; or the score could not be obtained for the indicator that time). The data collection process occurred after the child had been discharged. Table 3 lists the 13 nursing system indicators by monitored sites of care. Four of the 13 indicators were scored following an ER visit, four were scored following hospitaliz.ation, and five were scored after the child was seen during the clinic follow-up appointment. Three of the four ER indicators were only relevant for children who were treated and released from the ER (as opposed to being treated and admitted). Asthma education was scored 'yes' if there was documentation of any kind that DCA educational outcomes had been met. AMP was scored 'yes' if the chart contained a completed copy of the time-limited AMP. Next business day appointment was scored 'yes' if the UP electronic scheduling system listed a next business day appointment. For providers not on this scheduling system, if there was clear documentation in the record the DCA was instructed to contact the child's provider the following morning to schedule a next business day appointment, the next business day appointment was scored 'yes'. Faxes from the ER visit were scored 'yes' if the medical record contained a copy of a completed pediatlic asthma fax transmittal memo. Effects of a SCDNT Nursing System on Children With Asthma 80 Table 3 Nursing System Jndicqlors ERlndicaaors Hospital Unit lndicalors I . Asthma plan S. Pulmonary consultation . 2. Teaching 6. Asthma plan 3. F /U appt made 7. Teaching 4. Faxes sent 8. F/U appt made Note. F/U appt"' follow-up appointment Clinic Indicators 9. ER faxes received I 0. Hospital faxes received I I . Post ER appt kept 12. Asthma plan 13. Post hospital appt kept For hospitalized children. pulmonary consultation was scored 'yes' if there was a docwnented order for pulmonary consultation in the medical record or if a pulmonary physician made progress note entries. Asthma education was scored 'yes' when the medical record contained a completed MUHC Asthma (Ages 0-17) Patient Teaching Record. AMP was scored 'yes' if a copy of the plan was contained in the medical record, and it was not blank. Pre-scheduled follow-up appointments (within seven days of discharge) was scored 'yes' if the UP electronic scheduling system listed an appointment within seven days of discharge, or if a non-UP appointment had been set and the specific appointment date, time, and provider had been docwnented as part of the discharge orders and parent instructions. For children who initially presented to the UH ER and were admitted, and those children directly admitted to the hospital, the five clinic indicators were scored as follows. Both ER fax and hospital fax indicators were scored as 'yes' when a clinic staff member Effects of a SCDNT Nursing System on Children With Asthma 81 confirmed receipt of the faxes. In some cases, this information could not be retrieved. For these cases, the data ¢0llection tool was scored as N/ A. Two of the outpatient indicators were scored as •yes• when either the child presented to the clinic for their pre-scheduled next business day appoinbnent or when the child presented for their post-hospital discharge appoinbnent. For UP patients, this follow-up appoinbnent confinnation was available by accessing the clinic scheduling software. For non-UP providers, telephone or fax contact was attempted to confirm follow-up appoinbnents were kept. The final clinic indicator was for the use of AMPs during next business day appointments. This was obtained for children (a) who were treated and released from the ER, and (b) who were scheduled for a next business day appointment, and ( c) who came to the next business day appointment. The indicator was scored 'yes' when either clinic staff or the provider affinned use of an AMP during follow-up. Reporting Data from the completed check sheets for every child who bad met the inclusion criteria were entered into the PJ's pediatric asthma data registry. Rates for all indicators were calculated at least monthly. 1be denominator for each indicator rate was the total of all •yes' and 'no' entries. 1be numerator for each indicator rate was the total of all •yes' entries. •N/A' entries were ignored for all numerators·and denominators. , Timely communicating of failures to accountable individuals was required regularly throughout the 30 intervention months. Aggregate results were reported each month to the CQI team. comparing the current month rates with prior months. 1be Effects of a SCDNT Nursing System on Children With Asthma 82 primary business of monthly CQI team meetings was to plan improvements when reported rates were ~inting. Prior to joining the CQI team, each member had agreed to be accountable for a particular implementation site or provi~ group. Formal discussions and group problem solving occurred to address system factors that could be modified to promote successful implementation of the nursing system. The CQI methodology and team activities were essential for this complex and broad based nursing system implementation. If the nursing system design and the CQI methodology were successful across health care system providers and sites, improvement in symptom control for children with asthma could be expected. The data analysis plan to measure and compare symptom control before and after implementation of the nursing system is now described. Methodology to Detect Symptom Control in Chil~n With Asthma lbis research proposes that, if specific health care system factors known to influence the development of DCA competency for managing symptom control in children with asthma are optimiz.ed. asthma symptom control will improve. Fourteen antecedent conditions known to influence a DCA's ability to control asthma symptoms were identified from the literature (Chapter 2). Twelve of the 14 antecedent conditions are under complete or partial control of the health care system. The 12 health care system antecedent conditions were grouped into five categories, and a nursing system was -, designed and implemented to reduce health care system gaps within these five categories. The nursina system was monitored for 30 months across a population of children with Effects ofa SCDNT Nursing System on Children With Asthma 83 asthma in mid-Missouri. Because this intervention was applied across a population, the analysis of intervention effectiveness was from population data, specifically health plan claims data. Figure IO illustrates the conceptual model and expected outcomes. The expected outcomes represent a belief that symptom control improvements can be detected from a population using claims data (Halfon & Newacheck. 1993; Marosi et al., 1998; Stempel, Carlson, & Buchner, 1997; Weissman, Gatsonis, & Epstein, 1992; Wennergren, ~---- --- --- '1erso1tlll Facto CYII Clianderilda •• ..... • race o ........ ea... ~ •lbleti> ........ .......... lymplaml •llbltillleto-lDd ..... .,...... •nd;c•-- ' Imtit11tio1tal · Factors a ..... ,... •acca11 UllplVWd • primary CIN provider -.blilhed for Ill mroUecs •ftamcial baricn modified ( CIO-pl)'I ' ' \ for vilia, med.ic:ationa, tnDlportllioo I eliminaod) -daiml dala CM ldelllify M. rilk" ~ IDd primary pn,vidcn •tea.atoM•rilk"pll'IIIIIIDd providln reprdiaa 1Y11111101D coatrol •formullry ....... for medicalica lllddlliwry claval •availlbility of cw .............. •pideliw dlYeloped IDd dill --~dilpoeric crillrialDd•imimm I meal •c-, •••cr...t.+liClllion'DI ..................... .......................... •..-cllild ....... pimcl9\1IIJPICI ._of,ympe.dillilladlllbml · .......... .,.. •lollow-up.....,....,. ICbeduled ¾wiflt fall of lCUII viii& 1ml to PCP / ftrr!d 1 1 •Dilplllilllllde . •Approprillc medica&icm pracribcd I •Teedlina lbcllll symptoms. trigen, medicaliom, IDd wbea IO contact the provider completed •AllbmtlDINplDC!Mplw CCllllplllled •Follow-up office vilill 1Cbedi11ed -CClllliauily •eticwhip •INilbed providlr IDd ,._,,c:bild I eetPrt · 1 t 'IC !ts,.. .£.IRrillll t ....... Figure I 0. Conceptual model for nursing system evaluation. Effects of a SCDNT Nursing System on Children With Asthma 84 Kristjansson. & Stranncgard, 1996). As has been described, the nursing system was designed to shift the focus of asthma care from crisis to preventive management. From a claims perspective, when a child's asthma symptoms are well controlled, there will be reduced emergency visits and hospitalizations for asthma exacerbations with a concurrent increase in asthma clinic visits. Thus, a· shift in care from crisis to prevention would be detectable using asthma claims for health care utiliz.ation. Comparison of ER, hospital and clinic utilization for asthma before and after implementation of the nursing system is one component of the analysis plan. The analysis plan also includes a comparison of ER, hospital, and clinic utilization between the group of children who had been assigned to maximally involved providers and those assigned to minimally involved providers. This chapter will conclude after a discussion of the research questions, hypotheses, definition of terms, analytic aims, and analytic procedures. Research Questions Two research questions are derived from the data analysis plan. 1. Is there a statistically significant difference in asthma health care utilization before and after implementing a nursing system to benefit a population of children with asthma? 2. Is there a statistically significant difference in asthma health care utilization between a group of children with asthma who are assigned to providers maximally Effects of a SCDNT Nursing System on Children With Asthma 85 involved in the nursing system and a group of children with asthma who are assigned to providers minimally involved in the nursing system? Hypotheses For comparisons in this study,~ null hypothesis (there is no difference in asthma health care utiliz.ation) was tested against a one-sided alternative hypothesis (that the nursing system is associated with improved health care utilization). Specifically, Ho1: There is no statistically significant difference between asthma health care utiliz.ation before and after implementation of the nursing system. HA 1: There is a statistically significant difference between asthma health care utilization before and after implementation of the nursing system, with utilization improving after the nursing system was implemented. Ho2: There is no statistically significant difference in health care utilization between a group of children with asthma who have maximally involved providers and a group of children with asthma who have minimally involved providers. HA2: There is a statistically significant difference in health care utilization between a group of children with asthma who have maximally involved providers and a group of children with asthma and minimally involved providers in the nursing system, with utilization improving for the group of maximally involved providers. DataSow-ce Missouri Care prepared a confidentiality agreement allowing the PI to proceed with the claims analysis (see Appendix H). The PI submitted a request for exemption to Effects of a SCDNT Nursing System on Children With Asthma 86 the U Diversity of Missouri's Health Sciences Institutional Review Board (IRB; see Appendix I); this was approved for an exemption because all Missouri Care identifiers were eliminated prior to analyses. A document was then prepared by the PI to direct Missouri Care staff in the specific queries needed to calculate symptom control rates. The ~tabase provided by Missouri Care contained enrollment and claims data from children (born on or after April 1, 1980) between April 1, 1998 and March 31, 2001 From the database, tables were prepared and sent for statistical analysis. All data preparation decisions were made consistent with the following definition of terms used in the research questions. Definition o/Terms Population of Children Although the nursing system had been designed to improve care for all children with asthma who sought treatment from participating providers and sites, the population of children available for data analysis was limited to children enrolled in Missouri Care. Appendix J presents a discussion of the enro!lment table variables, the checking and cleaning of errors inherent in the data, decisions about children who were included in the analyses, and file preparation for statistical analysis. In terms of meeting the definition for 'population of children', children with more than 180 total enrollment days were included in the .analyses. For each of the 19,252 children meeting this criterion, a dichotomous entry was prepared for each of the 36 months: 'Y' for positive enrollment on the 15th (mid-point) of the month, or 'N' for negative enrollment on the 15111 of the month. Effects of a SCDNT Nursing System on Children With Asthma 87 Asthma All claims s~bmined to Missouri Care for asthma services were the basis for counting facility visits (ER. hospital and clinic). To determine the nature of each claim, principle and secondary discharge diagnosis ~odes from the International Classification of Diseases Coding Manual (9111 version; 2000; lCD-9) were used. These standardized codes are submitted by the facility based on the provider' s description of the primary (and secondary) reason(s) the patient required treatment. The specific JCD-9 codes that defined asthma utilization is this study are listed in Table 4. Table 4 Principle and Secondary ICD-9 Diagnostic Codes Defining Asthma Utilization ICD-9: 493.00-493 .99 - Asthma as principle diagnostic code ICD-9: 493 .00-493. 99 - Asthma as secondary diagnostic code if any of the following were principle diagnostic codes: 461 Acute sinusitis 462 Acute pharyngitis 464.4 Croup 465.9 Acute upper respiratory infection NOS 466.0 Acute bronchitis 466.19 Bronchiolitis organism NEC 473 .9 Chronic sinusitis NOS 480.9 Viral pneumonia NOS 485 Bronchopnewnonia organism NOS 486 Pneumonia; organism NOS 490 Bronchitis NOS 511.11 Respiratory failure 7999 Viral infection NOS 716.2 Cough Note. Codes listed match specific ICD-9 "Hospital and Payer ICD-9-CM" by International Classification of Diseases Codin& Manual, (2000), Salt Lake City: St. Anthony's Medicode. NOS • not otherwise specified; NEC • not ellewbere classified. Effects of a SCDNT Nursing System on Children With Asthma 88 Health Care Utilization In this study,\thc term 'health care utilization• refers to specific facility utilization for asthma in any of three sites of care: ER. hospital, and clinic. In order to differentiate which site was utiliz.ed, procedure codes, called Current Procedural Terminology (CPT) codes were used (American Medical Association, 2000a). Specific CPT codes are submitted for provider visits. Within the range of provider payment codes, there are CPT codes for provider visits in the ER. hospital, and clinic. These codes 'count' utiliz.ation by site of care. To determine the most accurate site of care counts, a study comparing known asthma utilization with CPT codes was completed. Appendix K discusses the methodology and results from study. The CPT codes defining a valid 'count' of ER, hospital and clinic health care utiliz.ation for asthma are specified in Table 5. Table 5 All CPT Codes 'Allowed· In the Count of Facility Utilization By Site of Visit 5-Digit CPT Codes Textual description ofCPT code Clinic visits 99201, 99202, 99203, 99204, 99205, 99211, 99212, "Office or other outpatient visit for evaluation and 99213, 99214, 99215, 99241, 99243, 99244 management ofa patient" or "Office consultation for a new or established patient" 9928l,99212,99283,99214,99285 Emergency visit "Emergency department visit for the evaluation and management of a patient" Hospital visit 99211, 99219, 99220, 99221 , 99222, 99223, 9925 I, "Initial observation can:, per day, for the evaluation 99252, 99253, 99254, 99255 and management" or "Initial patient consultation for a new or established patient" NOi•. 23° obeervation visits were counted II hospitalization visits. Effects of a SCDNT Nursing System on Children With Asthma 89 Before and After Implementing a Nursing System Because of the seasonal nature of asthma exacerbations, the ideal pre- and post- comparison would be the immediate 12 months before and after nursing system implementation. However, the Missouri Care Health Plan did not open enrollment until January 1998. 1be nursing system was implemented on October I, 1998. This allowed only a maximum eight-month comparison interval before October 1, 1998. Because of the short baseline period, the only suitable 'pre' period was the summer months between April I, 1998, and September 30, 1998. The 'post' period was defined as October I, 1998, through March 31, 2001 (Table 6). Table 6 Summer/Winter Data Comparison Intervals 1998-1999 1999-2000 2000-2001 Spring/Summer (PRE) (POSn (POsn 04/1/98-09/30/98 04/1/99-09/30/99 04/1/00-09/30/00 FalVWintcr (POsn (POSn (POSn 10/1/98-03/31/99 10/1/99-03/31/00 10/1/00-03/31/01 Maximally and Minimally Involved Provi (■ • U/35) (D • 147/258) % data collection 99" 87% 83% 91% (n =- 1261117) (n"" 9711/2) (n = 35141) (n "' 2581281) 11. Poat ER Appt Kept 79% 75•1. 80•1. 11•1. (D • 130/164) (D • 90/120) (D • '3/54) (D • 263/338) % data collection JOO'¼ 100% 100% /{)()'Yo (n = /641/64) (n .. 1101110) (n • 54154) (n "" 3381338) 12. Altllaa Pia• 27% 55% 41% 39-;. <• • 23/15) (D •36/66) (D • 11/27) (D • 70/178) % data collection 65% 73% 63% 68% (n • 851/ JO) (n = 66190) (n =- 27143) (n "' I 781163) 13. Poet Hoap Appt Kept a•At 91% 114•,.{. a•;. <• • 19/101) <• - 6'171) (D • 21/25) (D • 174/197) % data collection ~ 87% 8/% 92% (n • /0///02) (n .. 71181) (n • 15131) (n = 1971115) Indicator #9 reports the sample of clinic rep~ntatives who confirmed, when asked by email or telephone call, that faxes from the ER were received. The sample of ', children eligible for data collection about Indicator #9 is actually the numerator of Indicator #4 (refer to Table 8). Specifically, data collection was possible for Indicator #9 from children initially presenting to UH ER (n = 588 [refer to Table 7]) and for whom Effects of a SCDNT Nursing System on Children With Asthma 104 data about ER faxes was available (n = 536 [refer to Indicator #4 of Table 8]) and for whom ER faxes were.sent (n = 473 [refer to the numerator for Indicator #4 of Table 81). In terms of the cumulative results for Indicator #9, 86% of clinic staff confirmed receipt of faxes from the ER prior to the child's follow-up visit. For the 14% in which the ER had documented evidence of faxing bui in which the clinic denied receipt of faxes before the follow-up clinic visit, two main problems were identified and addressed. First, for a few clinics, the ER had incorrect fax numbers. Second, when ER faxes was correctly sent, clinic processes broke down and the faxed documents were not placed in the child's medical record prior to the child's arrival for the follow-up appointment. Indicator # 10 reports the findings from the eligible 281 hospitalized children in whom the follow-up clinic confirmed receipt of post-discharge faxes. The specific hospital records that should have been faxed included the history and physical, pulmonary consultations, asthma management plan, and discharge orders/instructions. Cumulatively, clinic representatives confirmed receipt of these faxes in only 147 of the 258 (57%) children for whom data collection was possible. These cumulative results reflect a downward trend from 61 % compliance in the Months 1-12 to 40% compliance in Months 25-30. Both Indicators #11 and 12 apply only to those children who were treated and released from the ER (n = 472). For determining the rates of post-ER discharge follow-up appointments kept, Indicator #11 reflects monitoring activity already reported for Indicator #3 (Table 8). Specifically, of the 472 children who were treated and released from UH ER, data about scheduling follow-up appointments before ER discharge was Effects of a SCDNT Nursing System on Children With Asthma 105 only collected fro~37 children (Indicator #3, Table 8). In this cumulative sample, 338 \ children (7-r/o) bad appointments scheduled for them. This sample of 338 children with appointments scheduled was used to determine the proportion who •kept' their scheduled visit. Cumulatively, 78% of these children kept the appointment. This finding of a high . rate of kept appointments was surprising given the common perception that lower socio- economic persons prefer treatment in the ER. A proxy of low socio-economic status is Medicaid eligibility. In this nursing system, one-half of children who presented for an asthma exacerbation were enrolled in Medicaid. Indicator # 12 was collected from the 263 children treated and released from UH ER, with follow-up scheduled, and who kept their follow-up appointment (the numerator from Indicator # 11 ). In the 263 children, data collection about whether or not an AMP was developed ( or revised) with the PCP was only attempted for UP and FHC providers. Among those providers, a response was provided for only 178 children. Cumulatively, only 70 of the 178 children (39%) bad AMPs developed during the post-ER follow-up visit. Indicator # 13 was collected from the group of children discharged from the hospital (direct admits [n = 165) and ER treated and admitted [n = 116)) who were also scheduled for follow-up appointments within one week of discharge (the numerator from Indicator #8, Table 9 [n"" 215/277)). From these 215, data could be collected from follow-up clinic offices representing 197 children. From the 197 children, 88% (n = 174) did arrive for the post-hospital discharge follow-up appointment. These unexpectedly high results clearly document that, at least for asthma, DCAs value post-exacerbation Effects of a SCDNT Nursing System on Children With Asthma 106 access with their PCP . The timing of these appointments may be ideal for forging a continuity rclationshiJtbetween DCAs and the child's PCP. This concludes the ' results' from the 13 nursing system process indicators. With the exception of one indicator, AMPs C';)mpleted during the follow-up appointment after an ER visit, 12 nursing system processes were successfully adopted throughout panicipating sites between October 1, 1998, and March 31, 200 l . One purpose for daily monitoring of these 13 nursing system indicators on behalf of all children (both Medicaid and non-Medicaid) who sought treatment for an asthma exacerbation at UH ER or the three Children's Hospital units, was to solidify specific health care system changes. These health care system changes were designed to be consistent with national asthma standards (NHLBI, 1997a). Throughout the 30 months, these 13 nursing system indicators were monitored daily, with ongoing results reported regularly through monthly CQI team meetings. However, these 13 nursing system indicators were measured from children interfacing with the changed system. Measurements from these 753 children only reflected three of five identified health care system gaps, specifically access, continuity, and parent/child education. Measurements were not obtained from PCPs regardins knowledse or skills surrounding 'under-diagnosis' and 'under-treatment'. However, multiple provider educational interventions were undertaken during these same 3Q months with maximally involved UP and FHC PCPs (and their staffs). All maximally involved provider and staff educational sessions included content on appropriate asthma diagnosis and optimum medical therapies. Effects of a SCDNT Nursing System on Children With Asthma 107 Results ~termining the Extent To Which Symptoms Were Controlled A true test ofthe effectiveness of this multi-faceted nursing system was completed using quantifiable measures of asthma symptom control, specifically claims data from one health plan for asthma utilization. This final section reports the results ' from three specific analytic aims designed to determine the effectiveness of the nursing system in controlling asthma symptoms. All three analytic aims use Missouri Care enrollment records and asthma utilization claims over the three year period between April 1, 1998, and March 31, 2001 . The first aim is descriptive in nature and only uses enrollment records from all Missouri Care children, ages 0 to 18. This aim defines Missouri Care's enrollment growth and characteristics prior to and during nursing system implementation. The second aim uses enrollment files and asthma utilization claims to compare asthma ER, hospital, and clinic visit rates before and after nursing system implementation. The third aim uses only those children with one or more asthma claim for ER. hospital or clinic to compare utilization claim rates between the group of children assigned to maximally involved providers with the group of children assigned to minimally involved providers. The results of each of these three aims are now presented. Of the 753 children who presented to either the UH ER or three Children's Hospital pediatric units, and who were exposed to the nursing system, 367 (49%) were Missouri Care members. The results from the analyses run using Missouri Care - , enrollment and claims data to achieve the three data analysis aims are now presented and discussed. Effects of a SCDNT Nursing System on Children With Asthma l 08 Aim l : Describe Missouri Care Enrollee Panerns Between April l, 1998 and March 31, 200 l As of March 31, 2001, there were 27,649 children (unique identifiers) in the Missouri Care membership files. Plan growth over the three years was 150%. For pwposes of the three analytic aims, only children with a minimum of six months were included. When considering this inclusion criterion, 19,252 children were enrolled at least 181 days. Plan growth in these children was 121 % (see FigU{C 11 ). 1 20,000 I C 15,000 w ~ lZ 10,000 :c u 0 5,000 · J I 0 z 1 4 7 10 13 16 19 22 25 28 31 34 Months 1-38 [-Total Enrollment - Included In Analy~~] Figure I I. Enrollment growth during first three years of Missouri Care Health Plan. Of the I 9.2S2 different children who were enrolled in Missouri Care for at least six months during the 36-month interval, the proportions of males in each month of the study hardly varied, ranging from 0.496 to 0.504. ... II 11 II " 14 II II II .. I I 1 I Ii 4 I I • -• Effects of a SCDNT Nursing System on Children With Asthma I 09 \ . I I I I I • .. It 40 _ ... Figure 1 2. Age box plots for each month. Using box plots, Figure 12 graphs ages for the 19,252 children enrolled in each of the 36 months. In the data cleaning stage, instances where enrollment dates were set before birth dates was not considered, so the output did have some instances where birth date had negative values. Other than one birth date in which there was a five-month 'negative' age, all negative ages were less than l month. The bottom of the box plots conespond to the 25• percentile while the top corresponds to the 1s• percentile. The line in the middle joins the medians. All box plots slant mildly upward over the duration of Effects of a SCDNT Nursing System on Children With Asthma 110 the study. The mean starts at approximately 7 years 4 months and ends at approximately 8 years 2 months. or a. 10-month difference in mean age over the 36-month interval. The provider group summary. for children 'enrolled' for a given month, is illustrated in Figure 13 . Provider group counts are presented as four trend lines for 'Maximal PCPs', 'Minimal PCPs, 'Both' (maximally and minimally involved providers), and 'None' (for cases where no provider information was available). J 10,000 l C 8,000 w ~ 6,000 l2 :c 4,000 (.) '8 J 2,000 I 0 z 1 4 7 10 13 16 19 22 25 28 31 34 Montha1-36 [-Maximal PCPs -Minimal PCPs -Both -~j Figure I 3. Children enrolled by provider group by month of study. By Month 10 (December 1998), growth of 'Minimal PCPs' surpasses that of 'Maximal PCPs'. According to the Missouri Care medical director, this growth is comistent with a marketing emphasis to expand plan enrollment in all 18 counties served by Missouri Care, thus an increase in 'Minimal PCPs' (non-UP and non FHC providers; T. Check, penonal ~mmunication, October 31, 2001 ). Effects of a SCDNT Nursing System on Children With Asthma 111 Aim 2: Determine if Asthma Utilizalion Rales In the Missouri Care Population C~ged Following Nursing System lmplemenlation Descriptive findings relative to • Aim 2' are presented. These are followed by the results from the logistic regression tests to determine if there was a statistically significant change in asthma utilization visits after the nursing system was implemented. For each of the three years, Table 11 reports change over time in terms of annual enrollment for the 19,252 children included in the analysis. Average enrollment increased sharply over the three-year study period from 8,467 to 14,029. Table 11 also reports the number of children with one or more asthma claims (' asthmatic children•) during each of the three 12 month-intervals. The 7% asthma prevalence is consistent with CDC estimates for children with asthma (CDC, 1998). Table 11 then reports a count of asthma visits (ER, hospital, and clinic) for each of the three years and the average number of visits in children with asthma claims. Table 12 displays the results of combining the 36 months for a report of unduplicated asthma prevalence and visits. There were a total of 1,730 children with one or more asthma utilization claims from the 19,252 children included in the logistic regression for Aim 2. Effects of a SCDNT Nursing System on Children With Asthma 112 Table 11 Prevalence and Visits for Asthma By Study Year Year of study' Asthmatic children' Average enrollment' Prevalenci Year I ( '91 - '99) 633 8,467 -,.;. Year 2 ('99 - '00) 820 12, 194 7¾ Year 3 ('00- '01) 931 14,029 1e;. Year of study" Total# asthma visits' Asthmatic children' Average visits' Year I ('91 - '99) 1,407 633 2.22 Year 2 ('99 - '00) 2,124 120 2.59 Year 3 ('00 - '01) 2,005 931 2. 15 "Year I - April I, I 991 - March 31 , 1999; Year 2 ""April I, 1999 '": March 31 , 2000; Year 3 "" April I, 2000 - March 31, 200 I . ~ Asthmatic children "" number of children with at least one visits (ER, hospital. or clinic) during the measurement year. 'Average enrollment "" the number of children with more than 180 total enrollment days and who were enrolled at the mid-point day of the measurement year ( on July I). 4Prevalence ,. 'average enrollment' divided by number 'asthmatic children' . 'Total# of asthma visits "" total count of • child months• in which there wu at least one claim during the measurement year. When there wu more than one visit for a specific child in a month (e.g., two or more clinic visits for one child in one month), the count of the outcome variable (e.g. clinic visits) was one. For the ' clinic ' variable, there were IO-IS% of'child months' in which multiple clinic visits were counted as one. ' Average visits "" ' total # asthma visits' divided by 'asthmatic children' . Table 12 Unduplica1ed Asthma Prevalence and Visits/or All Years Combined All years combined" Children enrolled' Asthmatic children' Prevalence' Y._ean l .3 ('91 - •o 1) 19,252 1,730 9-/o "Y cars I - 3 • April I , 1991 - March 31, 200 I . 1Children enrolled • a count of children with more than 180 toeal enrollment day1. c Althmatic children • number of children with u leut one asthma visits (ER, bolpital, or clinic). 'Prevalence• children enrolled' divided by number 'asthmatic children' . Effects of a SCDNT Nursing System on Children With Asthma 113 Figure 14 prelCllts the annual population-based rates for the three outcomes (ER. hospital, clinic asthma 'visits). When comparing Year 3 with Year 1, there were 21. 7 ER visits per 1,000 Missouri Care members compared with 19.7 ER visits per 1,000 members. This reflects a 10% increase t,y the end of the study period. Clinic visits decreased by 17%. Asthma hospitalizations decreased by 11 o/o to 6.3 visits per 1,000 members (Year 3) from 7.1 visits per 1,000 members (Year 1). Yr1 Yr 2 Yr3 • ER 19.7 23.1 21 .7 Hosp 7.1 9.9 6.3 • Clinic 139.4 141 .1 115.0 160 -.-------------------, 140 Clinic visits J, 17% I! J 120 I .. I 0 0 • - -.. -• CIC 100 - · 80 60 40 20 ER visits t I 0% ■■------a■t--------■ Hospital J. 11 % · 0 -+--------------.---------,-----' Yr 1 Yr2 Yr3 Figure 14. Annual rates for asthma utilization. As stated in the methods section for Aim 2, only the first baseline summer interval (Year 1) could be statistically compared with summer post-intervals (Year 2 and 3 ). Figures 15-17 display illustrations of semi-annual summer and winter rates for ER, Effects of a SCDNT Nursing System on Children With Asthma 114 hospital, and clinic visits for asthma. Each chart has three lines, each representing a different year. Figure 15 displays semi-annual rates for ER visits. During the three six-month summer intervals available for statistical analysis, there were 215 instances where a unique identifier ( child)I ....... ) STIP.l M ....... ,....._, (l)ajlySya,.._.) STU4 ............... (CNdaMI s,,., .... ) No daily medications nccdcd PRN usc of bronchodilalors (Albutcrol and/or Atrovenl) Rqular usc of anli-intlamma&orics ... ~5: qid ncbuliz.cd Cromolyn x I month (can I to q4°). If controlled after I month • can I to lid ... > 5: qid MDI Cromolyn 2 puffs x I month (can I to q4°). If controlled at I month, I to lid QI if aae > 12: qid MDI Ncdocromil 2 puffs qid x I month; then 2 puffs bid can be given instead of Cromolyn If ABOVE TREATMENT f AILS TO CONTROL SYMPTOMS: Inhaled Steroids- Low l>Gle (sec page 2) Consider specialty consultation CromolynQB lnbalcd Staoids - Mid.I■• 0... (sec paae 2) lf1p>l2,Nedocromi1Mfl lnbalod Staoida- MNI ... DIN Spocialty COCllllltatioo n,commcndcd Comider Thoophyllinc. Salmdcrol, Nedocromil*, or l)'llemic steroids for additive effect lnbalod Staolcb - MNIJ■a te llJp DIN (1C1Cpap2) Oblain apociality QOIIIUltatioo QutcK-Rl:UU sec STEP 2 Quick-Relief qe~5: q 4-6°- USC pre-mixed Albut.crol or mix Albutcrol 0.5% by ncbulizcr 0.03 mllk&/ dose (min of0.25 mUdosc - max of0.5 mUdose) AND Atrovcnt 1.25 mL ( 1~ vial) by ncbulizcr (For offu:e tlwrapy only. may re,,.a, q 20 lflimlles .r / howr. Hmrw lflOIIQgemenJ slto,Jd flOI uceed q 4-6, qe > 5 widl alld to....._ .. attack: q 4-6° - Albut.crol MDI 2 puffs AND Atrovcnt MDI 2 puffs aae > 5 widl severe attack: q 4-6° - mix Albut.crol 0.5% by ncbulizcr 0.5 ml AND Atrovcnt u follows : If aae 5-12 = 1.25 mL (Ya vial); If age> 12 • 2.5 mL ( I vial) IF ABOVE TREATMENT f AILS TO CONTROL SYMPTOMS: Systemic steroids prcdnisonc or prcdnisolonc 2 ma/k&f day with a maximum of 60 mg/day in 2-4 divided doses for 5-7 days (Close follow-up by plw,w or offu:e visit withiff a wed as 16 V anccril • 42 BID puffs/day puffs/day . mcglpuff VancerilDS"' 4 puffs/day 14 mcglpuff 2 puffs 4-1 BID puffs/day Fluticuone propionate Flovent • 110 4 puffs/day 2 puffs I puffs/day > 8 puffs mcglpuff BID Triamcinolone acetonide Azmacon .. 8 puffs/day 4 puffs 8-12 > 12 puffs IOOnqlpuff BID puffs/day Budesooide Pubnicor1 - 1-2 I doseQD 2-4 >4 200 mcwdose doses/day or BID doses/day doses/day lpdjgliops for rmml le apg;jalj1t· l. Uollrisfw:tnfy coaaol (u defined above) on non-sacroidal anti-inflammatory drugs (cromolyn or ncdocromil) or low dolC iobalcd conicollasoids. 2. Dilpolil of 8llbma uncertain. 3. CliDicll entities QOIDPlicatioa Ulbma; sinusitis, severe chronic rhinitis, nasal polyps, aspcrgillosis 4. Neod b ftu1her diapolric tcltioa: skin lCIIS for allcr&Y, complete pulmonary function tests. provocation tests ( cxacilc or medlacholinc ). 5. Compliance problems, cnvironmcnlal c:oatrol problems, complications of therapy 6. Two or more counca of prodnilonc per year SpiromcUy lhould be performed II lcalt ~ in children over 5 years. If values of FEV I arc less than 80% of prodicted or ifFEFn lea than 70% prodidCld (II mblc llllC, not in 111 cucerbalion), the pllicnt should also be referred to llfM"ialill care. Rcfcralcc; Nllioaal Allbma F.dUCllion and Prevention Propwn. Expert Panel Report II: Guidelines for the diagnosis and mana,ancot of llduna. Nl&ioaal lnslituta of Health, Nllional Heart, Luna, and Blood lnslitutc, Pub. no. 97-4051 . Bclbad1, MO; 1997. ',, Offlc:c of Clinical Effectivcneu Univcnity of Mia>uri, Heallb Scicnca Center Copyriaht 1998 by the curaton of the University of Missouri, 1 Public Corporation. 1t•'1•I .1,1 I H l1 ! I :JJ r,.1• . ~ rdl• I ttJ, tll : a l,.t IS I ,~ 1 =l •a : . r ~ ,J , .i5 ~ rt , 1 , I l1 .. l . as r ._ I f ~ z I I l - ' i .. I !. --- ---- -- -- ·-- ·-- -- . • na - I , rt 1 uuh 1 "fli I ,Ii ~•is lf! - r I I • ~- - ~- ff .. . . . . :Jlim . i~ ! . _ _. _ _ _ .. _ u~•tflU Pi ·~~!I• ! 1~1 -· ~11•1111 ltlfl I ,,t, 1,1 .. t , iii [ -~ O if • ~i!il"' I · 1,.e - ""I, ll f'v,. i ~ I Si j i I ~1 l i i } ~ -~ l 1 ! ' a< s ~- I g i ~} - ! - - - -~ °' Effects of a SCDNT Nursing System on Children With Asthma 13 7 DOSAGES OF DRUGS FOR ASTIIMA EXACERBATIONS IN DfERGENCY MEDICAL CARE OR HOSPITAL ·, DOSAGES Nebuliz:cr solution (5 ma/ml) MDI (90 mca/puff) 0.15 me/kl (minimum dose 2.5 ma) every 20 min. for 3 doses, then 0.15- 0.3 me/kl up 10 10 ma every 1-4 hows as nccdcd. or by continuous ncbulizltiOII II 5 ffll/hr, IO ffll/hr OR 15 ffll/hr. 4-1 puffs every 20 min. for 3 doses, then every 1-4 hows as nccdcd. SyataaJc (lajeded) beta 2 - apa■tl Epinephrine - I : I 000 ( I m,/mL) 0.0 I mg/kg up to 0.3-0.5 mg every 20 min. for 3 doses sq. Terbutaline (I m,/mL) A■dcNllaerpa 0.0 I mg/kg every 20 min. for doses, then every 2-6 hours as needed sq. lpratropium bromide - 0.25 mg every 20 min. Nebuliz.er solution (0.25 fflW'mL) for 3 dosea, then every 2 to 4 hows. MDI ( 11 mcwpuff) 4-8 puffs as needed. I mw'k& every 6° for 41° then 1-2 ma/k&fday (maximum"" 60 mat'day) in 2 divided doses maximum 60 m,Jday) for 3-10 days. until PEF 70% of predided or penonal bat. Only selective beta 2 - l&()llisls arc rccommc:ndcd. For optimal delivery. dilulC aerosols 10 minimum of 4 ml II ps flow of 6-1 Umin. As effective as ncbulmd thcnpy if patient is Ible 10 coordinalc inhalation maneuver. Use spacer/ holdin& chamber. No proven advantage of systemic therapy over aerosol. No proven advantaae of systemic therapy over aerosol. May mix in same nebulizer with albuterol. Should not be used as first line therapy; should be added to beta 2-agonist therapy. Dose delivered from MDI is low as has Not been studied in asthma exacerbations. For outpatient "burst", use 40-60 roam in sina(e or 2 divided doses (children• 1-2 mg/kg/day) Nole: No .......... biM b ....... ~ ia-.. ...._......._., aor ii lhcn •Y adva&IF b iln,•a. ......... OWII cnl 11111-,y ~- ' M llwil lall or llilorptim ia DOC impaired. The 1111111 ...... ii ID ODalilla dill .......... dlil)' .... .-irdlll ,._ ldlinll • FEV, or PEF of 50 pcrtmt of ........ Of .......... 1M .. ..,_dill .. ID twicll aly. Tbia lllllllly OOCWI wilUI 41 liloun. n..py followmg 1 halfh+!•ICi e o. w...., d pl1 Hilit aay i.. tam l ID 10 dllys. II,.._ .. dllll ltll1IDd oa inbllod ~ .._ __.. ._. ia • wd lDtlplr dill~~ .... 111111 followup a)'llanic dllrlpy ia ID be Ii-- daily. cmc -,Y _... il may Ill - cliDcillly cfflctiv, ID live the lk>lc in Untvenlty of Mluowt Health Sdencel Center ~ die l8nooa a lRUld 3:00 p.m. (8- 11 II. 1992). Clillicll 0.C-. 1M Mldicll Mm I WM UnmnilyotMillouri, HNldl~C.. CCopyrialM 19971,ythcCIIIIIOn ofdll Unmnity ofMiuouri I l'\lbllc Corponlion. Appendix C PEDIA TRI , ASTHMA UTIUZA TION SUAIIIARY 1'1/N-&l30IH These data represent claims submitted to Missouri Care which were coded as asthma visits. For clinical concerns reprdiJI& information in this report, you may wish to consult the medical record. Name: A. ALPHA MR Number: 0 Primary Provider: PURPLE. DR DOB: 05121/1987 S.a,:g of Utilmtioa Ideal Utillzatioa 12 rnonltll • MINoufi C... eM>IIN 5 ER villa b ..etwna .... .. . . ... 0 ER vilila 3 "cllplllll .. • b ..etwna ... .. .... ...... 0 hoeplwetioN O..,_CXNlnl (lllla, V-rtl tal ..... Olllt,_ ~, ....... , 138 8 c:lnlc ~ kapL . . .. ....... . high continuity 12 ---------- - -~ 1 did not kaep c:lnlc appoil ...... (ON4/19N 0&'01119N OQI03/19N OQI03/19N 09'25/1- 09125/1- 1CW2/1- 111QW1- 111QW1- 12JOW1- 12108i1- 01/22/11119 01/22/11119 02J03/1999 02J03/11119 UCOMMENDATIONS • le 1Ur1 IN patient hel Ill ..etllN management plan and knowa how to UN I .PIWlft».....,..-.CONTROl.medlcalllol• Po4PPMsdPlkm ALBUTEROL ALBUTEROL SULFATE ATROVENT FLOVENT SEREVENT SEREVENT FLOVENT FLOVENT SEREVENT FLOVENT SEREVENT seREVENT FLOVENT SEREVENT FLOVENT SEREVENT FLOVENT SEREVENT ALBUTEROL SULFA TE IPRATROPtUM BROMIDE • FOf mu111p11 ER villa Of ~lltioNI. cone.- contacting MINoun ca,. (573) 441.2100 to epeak with one ot the caeemen.,. ,-.Uais,MO,PW> c.-~ a.;w.-,,_,. h ■- 1H: -,,.ed.. (171) 111.-11 ........ G . 1....-- MD, MSPH Co-~ F..i,Pnaim ••• ,a 1➔ -...-n.­ I. QUICK-REUEF (or RESCUE) dr\115 such as Albulsol can 11op MduDa aa.:b. CONTllOL Chp aucb u Flovena, BocloWlllt, Pulmicon or VIDCa'il uep yow- dlild hm llaviaa problcma in tbe fuh.n. ANGIE HAD 13 QUICK- RELIEP llUILLS AND ONLY 7 CONTROL RUILLS IN ONE YEAR. mEALLY, 11IUE SHOULD Bl MORE CONTllOL REFILLS THAN QUICK-RELIEF REFILLS . ✓ la o■e year, Aqie uw fCMlr diffaat docton for lier utllaL Ideally, Aqie 1bo11ld 1ft ber prtaary can doctor for ro11d■e .-. .. vilib but we do uadersta■d tllat tllis is DOI always poatble d■riq a■ IIClllc eucerlledoa. ✓ Aqie .... IIOt keep I dale Y1lit. MAiiia& vilib ca■ llurt llow weU we keep Aqie'• u1bma la coatroL U yo■ IINd lleip wtcll tnuportado• to cllllk •Alita. pleue caU Mlaourt Care al 441-2111. ✓ Ev.y dlild wida Mduu abould have an AJduna Actioo Plan. Tbe Allbma Act.ion Plan cells what to do far yow- dlild'1 udlm■. U A..- does ■ot llave u Altlaaa AcdN Pl■■• please schedule •• .,,...._, wtcll .. lty calJIIII& 112-4730. We'U develop •• Altlaaa AdJoa Pia■ tllal we ■Ucaa-. ./ You ca beJp coatrol yow- dlild'• udlm■. Koep An&ie away from lbinp dial make her asthma worNIIICbacipreae -,keordull. .t Wida daia ..... an ...... .,....,. diary and peak flow mccer. For at leut one monlh, write doWII Altpl'11ymp10m1 and pllk Clow mets rewlb each day. Brin& this with )'OIi lhe next lime youYilit•. If you have queatiom. pleue IChcdule a routine appoinlment to 10 over this by calliaa 112-1730. Briq tlall naaary ud Aqle'1 l)Wpto• diary to Aaste'• am vtdt, ud we will dllau ways to better coatrol ber utbmL -~~Ir:'@ PatPwplc.MD Pi:.l>IATMI<: AsTIIMA CoNTINUOl'S QUALITY IMl'Mov1-·.M1'.NT ASTHMA SYMPTOM DIARY Name: -------- Medlcal Record Number: ____ _ Date of Birth: Month: ------------------------ DATE: 1.c..i .... .. .. . . . .. . . . 0 Om11111 ..... . .. 1 ,__ .. .... ' .. 2 1- .... . . . , . . . ... . . 0 Ult . ... ........ . 1 PSI f .... .... 2 .... ...... .. .. . s S.Adlflr QIIIINDIIIII ...... 0 c...-. ..... 1 LJIIIINID ... .. 2 Olldloal•llldoorl 3 . . ..... f/1 ... Noni 0 On11tlll . . . ... . , PIIICIIO., ..... .. 2 llllldDlw .. . .. . . J I . ..,Dllull,aMIDODUgll, \ ................ Noni . . . . . . . . . . . . 0 Hllld,dollnot ... . 1 MIIII ........ ... 2 UIIIIIIIDSlllp .... s l,_fw ..... ,,.ldloal 7. D11111 (No . ., Clllllll24 lloull) . 1. 1 . ,. Appendix F ASTHMA ACTION PLAN FOR: 1 Dale ofbinh _____ _ Medical Record Number ________ _ Goals of Asthma Care "YOW" Clldwno can be mncroled expect nodtinf less. .. - N.I.H. tf8e tr. from severe breachin& pi oblans day & nilht; sleep not bochered by asduna ef8e able to run or play hard wichout bradq pi oblems; not rniuln& school or work efNo need for WTMllplC)' care or holpkal mys due co asthma efUNs udwna medicines correaly wtch ,ood results and no side effeas 141 ef AVOID TOBACCO SMOKE Tobacco smoke worsens udvna and puts you at risk for wious lnathin& pi oblen'ls. Stay away from ALL tobacco smoke at home & In the earl ef Watch for chirlp dlU make your udllna worse. Stay away from chae trigen: a house dust & coda aach O 'Viral inleaio,11 & colds a very cold air 0 Indoor animals O .,-. pollen □ weadler dw,aes a mo1c1 and mildew a IUffllMI" a fall po11en a _____ _ Dally Control Medldnes to Prevent Breathln1 Problems (HUST be tabn EVERY day u obn u Ol del eel to be effeaive!) name of medidHe how mud, ID rate wnen to use it Quick Relief for Couch, WhNH, or Shortness of Breath name of medidl'ie how mud, ID 1111b When ID &.se Ir Medicine to be Uwl Before RLmnlns or Playtn1 Hard name of medidnt ,_, mud, ID Mb when ID use Ir I THIA MIDICINII AM TO .. Cll¥IN ■Y, 0 ·-' pp Cl lta'NASE Cl AaOCHN11ER I Tac:1•11QWDIIIONITIATIDACC18 •-»U_-___________ _ Pleue, CAI I If you IINd quick,..._, medlc:lnel more often than every 4 houri or for more than 5 cta,s In a row. (See wamlna stans on next pap.) as-, ...... ».ail • ..-..J 0 A mne plan for Ulhml canll'Ol II needld & w •Xllll:lred to Iha family. SN rwM aide. °'WIIIIAl...,a_..,....,..,..._._.pc, 142 AEl:N • NOd Doy YELLOW • Ccution RED • Stop 4 Call UN ally Dally eon,, ol Madicsnu UscQuickA&liefMedidnu UN Quick leliaf Mldiciftu '· 6c.lboctor \ ,.. Flaw above Paak Flaw to Peek Flow below '"ND.t.aing •s-whaezing 91..ouof.tlauing "N.COlightrlg •s...coughing '"Lotaofeo1ighiltg •Actiwa and breathing W&ll 9L&a actiwa or playful *Too ahort of bNath to run or play •s-,ingW&II *Hcwil'lbrathifttllfob ..... •c:.n,t steep Gia 'to breathing ..._..,_ rate of breathing (count *Cough or breathing problau wale& problems breaths per iuute when your child you up •Might have rapid breathing at ii Nltillf or .._,): *Eating less or not hungry Nit if rate ii 11111N than: Infant: 20-40 bNatha/lftinute 50 breathl/lftinute-Infant T...,.: 11-JO bNatha/lllilute 40 bruthsllllinute-Toddlcr Olild: 16-25 breathl/lllilute JO bruths/lllinuta- Quick...._, ■Idle.,_ *kvar&IN_,...,p,,b.._ *c:.ldl c....- , .... atery illfectillll) bllCUS5 wrtM YOUR DOCTOR & YOUR DOCTOR 10 TO THE EMENeNCY A00M TOOAY ORCAU.~U• Appendix G Asthma Instructional Sheets and Self-Monitoring Tools A. Detecting, f nlerp(eting and Monitoring SylllplOIIU •Questions and Answers About Breathing and Lungs •what is Asthma? •How to Know If You're Having An Asthma Episode •What to Do If You Have An Asthma Episode B. Regula/ion and Administration of Medicatio,u •Albuterol Asthma Medicines: Medicines You Swallow To Prevent Airway Swelling Asthma Medications: Control Medicines that PREVENT Airway Swelling Asthma Medications: Control Medicines that REDUCE Airway Swelling Asthma Medications: Control Medicines that REVERSE Airway Swelling lpratropium Bromide Theopbylline Salmc1crol lnspirease How to Use Your Metered Dose Inhaler How To Use Your Nebulizer How To Use Your Peak Flow Meter C. Jt:kn11jica1ion and Avoidance of Environmenlal Trlaen •Wbaa Maka Asthma Worse? How to Control Trigen: Animals How to Control Trigers: Cockroacbes How to Control Trigen: Cold Air How to Control Trigen: Dust Mites •How to Control Trigen: Infections 143 Effects of a SCDNT Nursing System on Children With Asthma 144 How to Control Triggers: Mold & Mildew How to Contml Triggers: Pollens ' •How to Control\.Triggers: Smoke, Fumes & Strong Odon How to Control Triggers: Strong Feelings D. Appropriately Seeking Metllctll Adwce in a Timely Manner • Asthma Sympcom Diary • Asthma Action Plan NOi•. The cipl inslructional nwcrials and the two self-monitoring tool contained in the Basic 8 folder arc denoccd by an asterisk before the title. Appendix H 145 LETTER Of AGREEMENT This Ag I eement is entered into this I st day of March , 1998 by and between Missouri Care. LLC. The Curators of the University of Missouti. on behalf of the university of Missour1 ·Columbia Heath Sciences Center, and family Health Center . WITNESSETH: WHEREAS. Missouti Care, LLC. and The Curators of the University of Missouti, on behalf of the University of Missouri -Columbia Health Sciences Center (MUniversityw) have co-sponsored a Continuous Ouality Imptovement Initiative fot the putpose of improving th' quality of cate to children with asthma; and WHEREAS, Family Health Center ("the Center") pt·ovides medical cate aetvices to pediatric asthma patients who are members of the health plan sponsored by Missouri Care, LLC; NOW, THEREFORE, in consideration of the mutual ptomises contained herein, the parties hereto agree as follows: A, lMJLJ QALTI CW!il BMP 180 days (six months). Using this definition, 55% (9,145) of children without gaps met this criterion. Interestingly, at least 35% of children without gaps would have met the HEDIS definition for continuous enrollment. TableJ2 Total Enrollment Days For Children Without Gaps In Enrollment Total enrollment days # Unique identifiers o/e of total (n .. 16,S91) 1-7 days 199 lo/e l-4S days 2,497 IS% 46-90days 1,947 12% 91-llO days 2,103 I 7o/e 111-270 days 1,103 11% 271-364 days 1,423 10% >- 365 days 5,919 35% NOi•. A venp enrollment wu 351 days; median WU 217 days. Children With Enrollment Gaps There were 11,058 children with gaps in enrollment. These 11,058 children had 18,595 gaps in enrollment, or an average of 1.68 gaps per child. Table J3 documents the distribution for total enrollment day ranges. The average enrollment duration for these Effects of SCDNT Nursing System on Children With Asthma 154 children was 246 days, with a median of 177 days. Ninety-two percent of children with gaps (n = 10, I 07) bad enrollment durations longer than six months. TableJ3 Total Enroll~nl Days for Children Wilh Gaps in Enrol/men/ Total enrollment days # Unique identifiers "'• oftoeal (n = 11,051) 1-7 days 0 0% 8-45 days 51 lo/• 46-90 days 219 2% 91-110 days 615 691. 111-270 days 777 7% 271-364 days 968 9% >• 365 days 8,362 76o/. Note. Average enrollment days were 246 with a median of 177. For children with enrollment gaps, Table J4 documents the total gap day distribution. TableJ4 Total Gap Days for Children With Enrollmenl Gaps Total pp days # Unique identifiers %oftoeal (n • 11,051) 1-7 days 5,964 S4% 1-45 days 1,637 15% 46-90 days 1,171 11% 91-llO days 175 1% t'll-270 days 429 4% 271-364 days 293 3% >- 365 days 619 6% Not•. Aventp pp days wu 44 with a median of I pp day. Effects of SCDNT Nursing System on Children With Asthma 155 The total gap "8Y average was 44; but the median was 1 day. More than one-half of the gaps were less than a week. Shon gaps such as these reflect administrative terminations from the plan with almost overnight re-enrollment. For children with gaps, various inclusion/exclusion decisions, considering total enrollment days and total gap days, were examined. Actual enrollment table scenarios were tested. Enrollment scenarios were : "if total enrollment days are at least X and total gap days exceet½ Y, keep or remove unique ID". After studying several dozen index cases, it was determined that total enrollment days were the most meaningful indicator of whether or not the child had access to preventive care than enrollment gaps, since most gaps were one day long. Given this understanding, gaps were ignored and inclusion criterion for children with gaps was also set at total enrollment days of greater than 180. In the final enrollment table prepared for statistical analysis, 19,252 children were included. This volume represented 70% of the original unique identifiers from the October 3rd enrollment table. Membership File Prepared for Statistical Analysis Three spreadsheets, each identical in layout and representing a 12 month interval between April 1 and March 31 were prepared. Each spreadsheet contained 19,252 rows that documented unique identifier enrollment and PCP activity relevant to the statistical analysis. Spreadsheet variables were: 1. UNIQUE_ID - The unique identifier for each child. 2. GENDER- 'F' for female; 'M' for male. Effects of SCDNT Nursing System on Children With Asthma 156 3. 008 - Month, day, and year of birth. 4. ENROLLED_'MonthX' - For each month (e.g., Month 1, Month 2, Month 3, etc.), this variable was coded '1' if the child was enrolled on the 15111 day of the specific month; otherwise the cell was left blank. 5. PROV _X'MonthX' - For each month, a set of four variables were prepared to define the PCP group on the 15111 day of the specified month. The 'PROV _A'MonthX' variable was set to' l' if the unique identifier had a PCP assignment with a maximally involved provider from Group A; otherwise PROV _A'MonthX was left blank. These same rules applied to the variable for the minimally involved Group B PCPs (PROV _B'MonthX). When, because of Missouri Care database errors, both Group A and B providers had been listed on the 15111 of a specific month, PROV _BOTH'MonthX, was reported as '1 '. When membership files did not list a provider for the child on the 15111 of the month, the code' I' was used for the variable PROV NONE'MonthX. APPENDIX K BILLING CODE VALIDITY STUDY TO DIFFERENTIATE SPECIFIC SITES OF CARE FOR FACILITY VISITS The purpose of Appendix K is to discuss the background, methodology, and results from a study conducted to deriv~ valid 'counts' for asthma ER, hospital and clinic health care utili:zation. Billing Code Background For facility utili:zation, every claim with a principle diagnosis of asthma (493 .00- 493 .99) was obtained in one file. Missouri Care did not have specific identifying codes to differentiate between the three sites of care (clinic, ER, or hospital). The Missouri Care medical director and PI contacted a national Medicaid analyst, Neil West, M.D., for assistance. West recommended a range of provider payment codes to calculate site- specific utili:zation rates, but could not provide literature citations for this recommendation (N. West, personal communication, May 4, 2001). The recommended provider payment codes come from five-digit Curren/ Procedural Terminology (CPT) codes (American Medical Association, 200 lf) or Health Care Procedure Codes (HCPC; American Medical Association, 2001b). These codes are submitted with claims when specific activities arc performed during the visit. Many health plans base payments and make judgements about medical necessity from these CPT/HCPC codes. When a provider files for payment after seeing a patient, there arc 58 possible CPT payment codes; all 58 with the first two digits of"9" (99--). The 58 CPT 99-- codes are used to define both site of care and visit complexity. One child may be 157 Effects of SCDNT Nursing System on Children With Asthma 158 seen (and billed) during one clinic visit by more than one provider, each provider filing a different CPT '99-' code, resulting in two CPT 99- codes for a single visit. In another ' example, a three day hospital visit can generate at least two distinct CPT 99-- codes; one for the initial day of hospital treatment and one for the two subsequent days, resulting in a minimwn of three CPT 99--- codes for a three day hospitalization. Consequently, when using 99-- CPT codes for counting facility utilization, precautions must be taken so that over counting of facility utilization does not occur. In order count facility visits from claims data as accurately as possible, a validity study comparing true facility utiliz.ation with the filed CPT 99--- code claims was completed. Known Groups Technique For a one year period, all Missouri Care billing activity involving children with asthma claims who had been assigned to UP or FHC PCPs were studied for true facility utiliz.ation. Between July I, 1998, and June 30, 1999, there were 367 children with asthma claims (for UP and FHC providers). The total billed amounts for each child was summed and the total amount for each child ranked from highest to lowest. The highest total charges for 20% of children (n :a: 70) were selected for validity comparisons. All claim dates were matched with known MUHC and FHC activity. This matching activity was accomplished by locating the actual site of care for each claim date by reviewing medtcal ~rds. dictated reports, and electronic scheduling infonnation. For the 70 children assigned to UP or FHC PCPs in one year, there were a total of 432 total visits in Elu, hospitals or clinics. Effects of SCDNT Nursing System on Children With Asthma 159 As part of the validity procedures, claims from the 70 children were split into two comparable groups. -Qne group was used to study and learn about commonly used CPT 99--- coding patterns, and to ultimately propose final query rules. The other group was used to 'blindly' calculate validity of the coding rules after they had been established in the first group. For group assignment, the children were ranked according to the total sum of asthma charges. Those children who had been assigned an odd number in the ranking (every other child; n = 35) were the group from whom all CPT 99--- data was viewable and studied against known utilization. The children who had been assigned an even number in the ranking (n = 35) had all their CPT 99--- codes and known utiliution set aside until the proposed queries from the first 35 children were ready for testing. Coding Decisions for Determining Site of Care To determine the most valid query rules, a number of possible CPT 99--- code queries were tested. Table KI represents the most valid CPT 99--- codes selected to count each type of facility visit. All queries were grouped by 'date of service' so that over- counting of multiple 'allowable' CPT 99--- codes would be avoided. But multiple visits among the three sites of care on the same date were allowed. Referring to Table KI, two examples of queries and their results are now given. If two claims had been submitted for the same visit by two providers, one with a CPT 99--- code of 99204 (clinic) and the other with a CPT code of 99244 (clinic), both clinic codes • .. would be combined and counted as one clinic visit because site-specific visits were grouped together by date of service to avoid double-counting. In another example, two Effects of SCDNT Nursing System on Children With Asthma 160 claims from different sites had been received for the same date of service, one with a CPT code of 99214 (clinic) and the other with a CPT code of99254 (hospital). Each would count; one for a clinic visit and one for a hospital visit, even though these occurred on the same date of service. Using CPT 99--- codes, the validity comparisons ranged between 61%and 93%. Table Kl All CPT Codes 'Allowed' In the Count of Facility Utilization By Site of Visit S-Digit CPT Codes Textual description of CPT code Clinic visits 99201, 99202, 99203, 99204, 99205, 99211, 99212, "Office or other outpatient visit for evaluation and 99213, 99214, 9921S, 99241, 99243, 99244 management ofa patient" or "Office consultation for a new or established patient" Emergency visit 99211,99212,99213,99284,99215 "Emergency department visit for the evaluation and management of a patient" Hospital visit 99211,99219,99220,99221,99222,99223,992SI, 992S2,99253,992S4,992SS "Initial observation care, per day, for the evaluation and management" or "Initial patient consultation for a new or established patient'' Note. 23° observation visits were counted u hospitalimion visits. During the validity tests, meaningful codes other than CPT codes were identified. 'Location' codes had been assign~ during the billing process and reflected specific sites of care. These codes were also tested for validity. Location codes in the Missouri Care '-, utilwation tables were contained in three columns. The three columns were "Bill Class Code", "Facility Code", and "ER Code". A clinic visit location was given a '3 1-' code Effects of SCDNT Nursing System on Children With Asthma 161 (3 on variable "Bill Class Code" and 1 on "Facility Code"). A hospital location code was '1 1 - ' ( 1 on "Bill C~ Code" and 1 on "Facility Code"). An ER location code was '3 l l' ( 1 on "Bill Class Code", 1 on "Facility Code", and 1 on "ER Code"; S. Koenig, personal communication, June 20, 2001 ). The results from the final validity tests are presented in Table K.2. CPT only code accuracy ranged between 61 % and 93%. Location only code accuracy ranged between 33% and 86% accurate. When combining CPT 99--- codes with location codes (using "or" and controlling by date of service), the validity comparisons ranged between 78% and 104% accurate. It is not clear why there was known facility visits without provider payment CPT 99--- codes, but it suggests 'under-billing' for provider visits. It is also not clear if this finding reflects specific administrative issues for UP and FHC providers, but since very different UP and FHC 'billing systems' were tested, both with CPT 99--- 'misses', this finding may, in fact, be generalizable. Table K2. Results of Validity Comparisons Between Known Utilization and Billing Codes/or Clinics, ER, and Hospital Visits In 70 Children Known Visits for CPTCodes Location Codes CPT and Location Asthma Codes Development of rules Clinic (n • 144) 134 (93%) 69 (48¥e) ISO (104%) a,oup(na35) ER(n • 29) 26 (90%) 25 (86%) 28 (97%) Hospital (n • 18) II (61%) 6 (33'/e) 14 (78%) Validity test aroup (n Clinic (n • 184) 163 (89%) 76 (41%) 186 (101%) • 35) ER(n • 30) 24 (80%) 24 (80%) 29 (9'79/4) Hospital (n • 18) ~) 13 (72%) 18 ( I 00-/4) Effects of SCDNT Nursing System on Children With Asthma 162 F~ility Utilization File Prepared/or Statistical Analysis For calculation of facility utilization (hospital, ER, and clinic visits), one Microsoft Excel file, containing three spreadsheets was prepared. Each of the three spreadshccts were identical in layout. ~h representing a 12 month interval between April 1 and March 31. Like the enrollment file, each row in a spreadsheet contained utilii.ation data for one unique identifier. Unlike the enrollment file, the utiliz.ation file only contained information from unique identifiers with at least one asthma facility claim during the specific 12 month interval. The following variables were defined for each unique identifier in the utilization file: 1. UNIQUE_ID - An identical match to the UNIQUE ID from the enrollment file. 2. HOSP'MonthX' - The sum of all asthma hospital claims by month. When HOSP cells arc blank., there were no hospital asthma claims for that month. 3. ER'MonthX' -The sum of all asthma ER claims by month. When ER cells were blank., there were no ER asthma claims for that month. 4. CLINIC'MonthX' - The sum of all asthma clinic visit claims by month. When CLINIC cells are blank., there were no clinic visit claims for that month. REFERENCES American AcademY"Of Allergy Asthma and Immunology. ( 1999). Pediatric asthma: Promoting bestf!ractice. New York: Author. American Medical Association. (2000a). Current procedural terminology 200/. Chicago: Author. American Medical Association. (2000b). Health Care Financing Administration common procedure coding system: Medicare's national level II 2001 codes (13111 ed.). Atlanta. GA: Author. Bauman, A., Cooper, C., Bridges-Webb, C., Tse, M., Miles, D., Bhasale, A., et al. (1995). Asthma management and morbidity in Australian general p~tice: The relationship between patient and doctor estimates. Respiratory Medicine, 89, 665-672. Bartter, T., & Pratter, M. R. (1996). Asthma: Better outcome at lower cost? The role of the expert in the care system. Chest, I I 0, 1589-1596. Billings, J., Kretz. S. E., Rose, R., Rosenbaum, S., Sullivan, M., Fowles, J., et al. (1996). National Asthma Education and Prevention Program working group report on the financing of asthma care. Ameri"1n Journal of Respiratory and Critical Care Medicine, I 54, S 119-130. Billings, J ., Zeitel, L., Lukomnik, J ., Carey, T. S., Blank, A. E., & Newman, L. ( 1993 ). Impact of socioeconomic status on hospital use in New York City. Health Affairs, /2, 162-173. Blumenthal, D., & Scheck, A. C. ( 1995). Improving clinical practice: Total quality management and the physician. San Francisco: Jossey-Bass. Brook, U., Mendelberg, A., & Heim, M. (1993). Increasing parental knowledge of asthma decreases the bospitaliz.ation of the child: A pilot study. Journal of Asthma, 30, 4S-49. Buchner, D. A., Butt, L. T., DeStefano, A., Edgren, 8., Suarez, A., & Evans, R. M. ( 1998). Effects of an asthma manaaement program on the asthmatic member: P.atient-centered results of a 2-year study in a managed care organization. The American Journal of Managed Care, 4, 1288-1297. Centers for Disease Control and Prevention. (1990, July 27). CDC surveillance summaries: Asthma- United States, 1980-1987. Morbidity and Mortality Weekly Report, 39, 493-497. 163 Effects of a SCDNT Nursing System on Children With Asthma 164 Centers for Disease Control and Prevention. (1996, May 3). CDC surveillance summaries: A$hma mortality and hospitalization among children and young adults - United States', 1980-1993. Morbidity and Mortality Weekly Report, 45; 350-353. Centers for Disease Control and Prevention. ( 1998, April 24 ). CDC surveillance summaries: Surveillance for asthma - United States, 1960-1995. Morbidity and Mortality Weekly Report, 47, 1-28. Charlton, I, Gharlton, G., Broomfield, J., & Mulee, M.A. (1990). Evaluation ofpealc flow and symptoms only self management plans for control of asthma in general practice. British Medical Journal, 301, 1355-1359. Chilmonczyk, 8 . A., Salmwi, L. M., Megathlin, K. N., Neveux, L. M., Palomaki, G. E., Knight. et al. ( 1993). Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. New England Journal of Medicine, 328, 1665-1669. Crabtree, 8. F ., & Miller, W. L. ( 1999). Doing qualitative research (2nd ed.). Thousand Oates, CA: Sage. Crain. E. F., Weiss, K. 8., & Fagan, M. J. (1995). Pediatric asthma care in U.S. emergency departments. Current practice in the context of the National Institutes of Health guidelines. Archives of Pediatrics and Adolescent Medicine, 149, 893-901. Dales, R. E., Kerr, P. E., Schweitzer, I., Reesor, K., Gougeon, L., & Dickinson, G. (1992). Asthma management preceding an emergency department visit. Archives of Internal Medicine, 152, 2041-2044. Dawod, S. T., Ehlayel, M. S., & Osundwa, V. M. (1996). Acute asthma: Treatment and outcome of2000 consecutive pediatric emergency room visits in Doha, Qatar. Journal of Asthma. 33, 131-13 5. Dawson, K. P., Van Aspcren, P., Hiagins, C., Sharpe, C., & Davis, A. (1995). An evaluation of the action plans of children with asthma. Journal of Paediatrics and Child Health. 3/, 21-23. Dekker, C., Dales, R., Bartlett. S., Brunekreef, 8 ., & Zwanenburg, H. (1991). Childhood " asthma and the indoor environment. Chest, 100, 922-926. Deming, W. E. ( 1993). 'The new economics for indwtry, educaJion and government. Cambridp: Massachusetts Institute of Technology, Center for Advanced Engineering Study. Effects of a SCDNT Nursing System on Children With Asthma 165 Dinkevich. E. I., Cunningham, S. J., & Crain, E. F. (1998). Parental perceptions of access to care and quality of care for inner-city children with asthma. Journal of Asthma, 35, 63-71. Donnelly, E. ( 1994 ). Parents of children with asthma: An examination of family hardiness, family stressors, and family functioning. Journal of Pediatric Nursing. 9, 398-408. Du.Mont, J. (1998). Asthma program targets patient and physician compliance; wins first disease management excellence award. Demand and Disease Management, 4, 181- 184. Du.ran-Tauleria, E., Rona, R. J., Chinn, S., & Burney, P. (1996). Influence of ethnic group on asthma treatment in children in 1990-1991 : National cross ·sectional study. British Medical Journal, 313(7050), 148-152. Ehrlich. R. I., Du Toit, D., Jordaan, E., Volmink, J. A., Weinberg, E. 0 ., & Zwarenstein, M. (1995). Prevalence and reliability of asthma symptoms in primary school children in Cape Town. International Journal of Epidemiology, 24, 1138-1145. Elixhauser, A., Duffy, S. Q., & Sommers, J. P. (1996). Most frequent diagnoses and procedures for DRGs, by insurance status. Healthcare Cost and Utilization Project (HCUP-3) Research Nore 4 (No. 97-0006). Rockville, MD: Agency for Health Care Policy and Research. Engel, W., Freund, D. A., Stein, J. S., & Fletcher, R.H. (1989). The treatment of patients with asthma by specialists and generalists. Medical Care, 27, 306-314. -. Farber, H. J. ( 1998). Risk of readmission to hospital for pediatric asthma. Journal of Asthma. 35, 95-99. Farber, H.J., Johnson, C., & Beckerman, R. C. (1998). Young inner city children visiting the emergency room for asthma: Risk factors and chronic care behaviors. Journal of Asthma. 35, 547-552. Flocke, S. A., Strange, K. C., & Zyanski, S. J. (1997). The impact of insurance type and forced discontinuity of the delivery of primary care. Journal of Family Practice, 45, ,__ 129-135. Effects of a SCDNT Nursing System on Children With Asthma 166 Gergen., P. J., Fowler, J. A., Maurer, K. R., Davis, W.W., & Overpeck, M. D. (1998). The burden of environmental tobacco smoke exposure on the respiratory bcalth of children two months through five years of age in the United States: Third National Health and NutJ\tion Examiniaton Survey, 1988 to 1994. Retrieved November 4, 2001, from The American Academy of Pediatrics Web Site: http://www.pediatrics. org/cgi/content/abstract/ IO l /2/e8 Gibson, N. A., Ferguson, A. E., Aitchison, T. C., & Paton, J. Y. (1995). Compliance with inhaled asthma medications in preschool children. Thorax, 50, 1274-1279. Gill, J.M., & Mainous, A. G. (1998). The role of provider continuity in preventing hospitaliz.ations. Archives of Family Medicine, 7, 352-357. Gillies, J., Barry, D., Crane, J., Jones, 0., Maclennan, L., Pearce, et al . ( 1996). A community trial of a written self management plan for children with asthma. New aaland Medical Journal, 109, 30-33. Gottlieb, D. J., Beisc;r, A. S., & O'Connor, G. T. ( 1995). Poverty, race and medication use are correlates of asthma hospitaliz.ation rates: A small area analysis in Boston. Chest, 108, 28-35. Greincder, D. K., Loane, K. C., & Parks P. (1995) Reduction in resource utiliz.ation by an asthma outreach program. Archives of Pediatric and Adolescent Medicine, I 49, 415-420. Halfon, N., & Newachcck, P. W. (1993). Childhood asthma and poverty: Differential impacts and utiliz.ation of health services. Pediatrics, 9 I . 56-61 . Health Care Financing Administration. ( 1997). Missouri statewide health reform demonstration/act sheet. Retrieved October 30, 2001, from http://www.hcfa.gov/ mcdicaid/1115/mofact.htm Health Care Financing Administration. ( 1998). HHS approves Missouri plan to insure more children. Retrieved October 30, 2001, from http://www.hcfa.gov/init/ 980428mo.htm Herzlinger, R. E. ( 1997). Market driven health care. Reading, Massachusettes: Addison Wesley. Hughes, D., McLeod, M., Barr, 8 ., & Goldbloom, R. (1991). Controlled trial of a home and ambulatory program for asthmatic children. Pediatrics, 87, 54-61. Effects of a SCDNT Nursing System on Children With Asthma 167 Ignacio-Garcia, J.M., & GoD2Jllez-Santos, P. (1995). Asthma self-management education program by h