Regional paediatric asthma centre: An intervention model

Abstract

OBJECTIVE:

To evaluate the effectiveness of a multidisciplinary paediatric asthma clinic in reducing the morbidity associated with paediatric asthma.

METHODS:

An initial survey of need was undertaken in the community of Orillia, Ontario and the surrounding area. The clinic was established as a separate entity from the adult model. The multidisciplinary nature of the clinic was a priority. The effectiveness of the clinic was assessed with patient/parent reports and objectively analyzed by assessing the frequency of asthma visits to the emergency room and hospital admissions.

RESULTS:

Comparison was undertaken between the first year and third year of clinic operation. The number of paediatric asthma visits to the emergency room was reduced by 20%. The number of paediatric asthma inpatient visits was reduced by 12%. At the same time, the number of paediatric asthma visits to the asthma clinic increased by 200%.

CONCLUSIONS:

This multidiscipline paediatric asthma clinic model is community friendly and reduces the morbidity of asthma as evidenced by declining visits to the emergency room.

Asthma is characterized by paroxysmal or persistent symptoms such as chest tightness, wheezing, sputum production and cough associated with variable airflow limitation, and a variable degree of hyper-responsiveness of airways to endogenous or exogenous stimuli. Proper patient education is considered essential to achieve adequate control of asthma (1). When asthma is well controlled, one of the best ways to judge severity is to determine the level of treatment needed to maintain adequate control. Education programs have resulted in a decrease in the number of admissions to hospital and emergency rooms in specific subgroups of patients who are frequent users of health resources. Asthma education has also been shown to improve patients’ well-being (1). Asthma education should be aimed at altering patients’ behaviour rather than simply providing knowledge.

The program should involve multiple educational methods. Most importantly, asthma education is unlikely to be effective in the absence of asthma therapy. The key elements of an asthma education program have been identified: control asthma via improved knowledge and change in behaviour; do not rely on written or video taped material alone; provide education at each patient contact; communication between health professionals and coordination of their interventions is essential; and asthma education is effective only in the presence of effective asthma therapy (2–5). The final two points are crucial areas, and the mainstay of the uniqueness of the described multidisciplinary clinic. There is significant support in the literature for the team approach (6–9). Literature review indicates that information alone, without therapy, is relatively ineffective in adults, further supporting the team concept (10–12). To fully meet the needs of the community, outreach programs to homes and schools as well as ‘fun’ adventures are necessary (13). A MEDLINE review covering the period from 1966 to 2003, using the key words “children”, “asthma” and “education” resulted in 11 articles. Four articles described intervention models; however, none involved a multidisciplinary model such as the present model in a secondary level centre (14–17).

METHODS

Design

A survey was carried out in 1998 to identify the scope of the problem of asthma in the community. This survey initially involved a review of the literature and contact with various professional associations (Respiratory Therapy Society of Ontario, Canadian Society of Respiratory Therapists, American Association of Respiratory Care). Questionnaires were developed for physicians (specialists and general practitioners), schools and pharmacies. The physician survey was structured according to the National Heart Lung and Blood Institute of Health’s clinical practice guidelines (18). After analyzing the results of the surveys, the Regional Paediatric Asthma Centre (RPAC) was established in June 2000 as an entity separate from the adult centre. Although the initial seed money originated from private donations, the concept of a multidisciplinary clinic was embraced by the administration of the Orillia Soldiers’ Memorial Hospital as a ‘best practice’ initiative for the children served in the region. Initial staff included a medical director (paediatrician) and certified asthma educator (CAE). All paediatricians at the regional paediatric centre participated fully and joined the team in place of the medical director, if their patients attended the centre.

Shortly after establishing the service, additional personnel joined the team, including a paediatric social worker, a paediatric dietitian and an additional certified asthma educator. After referral of the family by the primary care physician, the CAE schedules a prolonged education visit (1 h to 2 h) at the family’s convenience. The paediatrician then undertakes a consultation with the patient and family with the CAE present. Education regarding the diagnosis and therapy are provided by the physician at that time, an action plan is written out for the patient/family and prescriptions are given. The team meets again with the family at regular intervals (three to four months) until control is achieved. The family physician receives correspondence from the paediatrician at each visit. The family is then referred back to the primary care physician (family doctor) when control is achieved. Primary contact for the family is through the CAE for ongoing education and trouble-shooting with backup available with the consulting paediatrician, always in a team setting.

Outreach programming was initiated through community meetings, school programs and health care professionals’ education sessions.

Assessment of patient/parent satisfaction was carried out. Patient/parent satisfaction forms (Figure 1) were left in the waiting room of the clinic with a request that they be filled out and deposited in a collection box in the room.

Figure 1).

FORM 1 – Patient/parent satisfaction

Quality of life assessments were undertaken to assess the overall impact of the clinic on the child’s asthma (Figure 2). Parents/patient were given the forms on the first visit and asked to return them to the clinic, those who filled out the initial form were given a follow-up form at six months (19).

Figure 2).

FORM 2 – Quality of life assessment form to assess the overall impact of the clinic on the child’s asthma

Setting

Orillia is a small central Ontario community of 25,000 people. The RPAC services a large geographic area, including the counties of Simcoe, Muskoka, Parry Sound and Haliburton (population of 150,000). Four paediatricians work in a network composed of family physicians in five community level 1 hospitals and see patients by referral only. The respiratory therapy department at the Orillia Soldiers’ Memorial Hospital employs six respiratory therapists, of which three are certified asthma educators. One CAE works full time in the RPAC and the other works part time.

Participants

Children attending the clinic were from the traditional catchment area of the regional centre. Families were referred mainly by their family physicians; however, some were referred from walk-in clinics, emergency rooms and inpatient services. None of the participants had previous experience with an asthma centre of this type.

RESULTS

The initial 1998 survey was sent out to 60 physicians, with a return rate of 50% (24 family physicians and six specialists). The survey revealed that 73% of physicians felt time constraints affected their ability to provide asthma education. In this survey, 83% of physicians used peak flow monitoring, but only 13% used an action plan type approach to medication self management. When asked if the development of a hospital-based community asthma care centre would be of benefit in the asthma management of their patients, 83% of the physicians said yes, 3% said no and 14% did not respond. Physicians felt that important aspects of the proposed centre would be rapid access to the centre (87%) and communication with the primary care physicians (70%). The majority of asthma care in Orillia was provided by family physicians. Physicians identified approximately 400 children (aged zero to 16 years) with asthma, and schools identified approximately 150 children with asthma.

The RPAC commenced functioning in June 2000. During that year (April 1, 2000 to March 31, 2001), 228 paediatric patients (aged zero to 18 years) made 303 visits to the emergency room, 52 children had 60 admissions to the paediatric ward and 74 children had 156 visits to the RPAC. The third year of operation encompassed April 1, 2002 to March 31, 2003. Data for emergency visits are available to November 30, 2002 (seven months). Extrapolation of this data for 12 months indicates an expected 273 visits (10% reduction). Extrapolation for inpatient numbers of 40 visits in eight months indicate an expected number of 60 visits in the third year (no change). Data available for the third year of the clinic visits indicate 994 visits (an increase of 200%) (actual data available at October 2003: 242 emergency visits [20% reduction], 53 inpatient visits [12% reduction]).

Quality of life questionnaires were filled out between June 2000 and February 2003. Forty-six assessments were completed for the initial visit and the six month follow-up visit. The number of days lost by the parent due their child’s asthma was reduced by 26%. The number of episodes of wheezing or shortness of breath was reduced by 55%. The degree of concern regarding their child’s asthma was reduced by 15%.

The Patient Program Evaluation form was randomly filled out by patients/parents accessing the clinic in its third year of operation. Twenty-seven forms were available during the third year. All patients/parents indicated that the information was presented in a clear and easy to understand manner, that enough time was available to ask questions, and that the sessions helped the patient/parent to understand and cope with asthma.

The RPAC has been involved in outreach community work with five community meetings and five school initiatives involving both public and separate boards. An innovative camp experience in association with the paediatric diabetic clinic has been established over the last two years. Special day activities including Christmas parties and summer picnics are promoted.

DISCUSSION

The RPAC has been successful in meeting the needs of children with asthma in our catchment area. The reduction in emergency visits supports this claim. The literature supports the concept that education alone, when delivered in isolation without the therapeutic arm, is not as effective as the two components delivered together. We are aware of many clinics that deliver care in the standard medical model, with the physician seeing the patient in the office setting and the educator seeing the patient separately in another setting. Our experience indicates that the described multidisciplinary clinic provides timely, efficient and effective care. The model we have adopted allows the patient/family to meet the team as a whole and allows instant changes of therapy, especially with respect to medication alteration. The support, as evidenced by our referral rate, indicates that this model is family physician friendly. Patient satisfaction with the model of care is high. Significant improvements in quality of life assessments occurred.

CONCLUSION

A multidisciplinary model of paediatric asthma care unique to a secondary level centre, was established and found to be effective in reducing the morbidity associated with childhood asthma.