Putting guidelines into practice: Improving documentation of pediatric asthma management using a decision-making tool

Objective: To assess improvement in documentation of asthma indicators using the Asthma Toolbox, an asthma decision-making tool developed in accord with National Asthma Education and Prevention Program guidelines. Design: Retrospective medical record review using cross-sectional, independent, random samples. Reviews were conducted for 1-year periods before and after implementation and after revision reflecting 2007 guideline modifications. Setting: Two inner-city, federally qualified health center programs providing pediatric primary care to housed and homeless populations. Participants: A total of 1246 patients aged 6 months to 18 years with at least 1 asthma visit to a community health center using paper records (n=600) or a mobile medical program serving family homeless shelters using an electronic health record (EHR; n=646). Intervention: Implementation of the Asthma Toolbox incorporated into paper encounter forms and embedded in the EHR to guide providers (ie, physicians and nurse practitioners) through pediatric asthma assessment and management. Main Outcome Measures: Documentation of a subset of asthma severity/control measures, emergency department visits, hospitalizations, and percentage of persistent asthmatic patients prescribed controller medications. Results: Documentation of each asthma indicator increased significantly after implementation (χ² tests; P<.001 all comparisons) for both programs. Documentation of severity/control increased from 25.5% to 77.5% in paper records and from 11.7% to 85.1% in the EHR (P<.001). Increases were sustained after Asthma Toolbox revision for all indicators. The percentage of patients with persistent/uncontrolled asthma prescribed controller medications reached 96% to 97% in both programs. Conclusion: Use of the Asthma Toolbox, an asthma decision-making tool, significantly increased documentation of pediatric asthma management among providers working in high-disparity, urban primary care settings.