Table 18Future research

PICOT FrameworkObservationRecommendation for Future Research
PopulationInadequate clinical and sociodemographic descriptions of the patient population.Measure asthma control/severity, race/ethnicity, gender, socioeconomic status, etc. in patient populations to more effectively compare effectiveness between studies of interventions.

Test efficacy of multifaceted individualized interventions targeting a specific group of subjects (i.e., young or older age groups, high asthma severity, and high health care utilizers).
InterventionFew studies utilized a randomized, controlled intervention approach.Augment number of studies with RCT design, especially as reviewed RCTs tended to yield more equivocal results.
The reported impact on healthcare provider behaviors (even when illustrating a beneficial effect) was modest, suggesting that certain barriers to provider adherence to asthma guidelines remained unaddressed.Develop/incorporate new strategies or combinations of strategies to increase provider adherence to guidelines.
Develop strategies to incorporate successful interventions into primary care practices that address time constraints, work flow issues and limited resources
Relatively few computer-based interventions.Computerized systems offer an opportunity to increase efficiency in the health care process, thereby potentially improving provider adherence to guidelines. If time constraints pose a barrier to adherence, electronic/computer-based interventions may meaningfully improve delivery of asthma care.
Strategies were generally “passive” (i.e., suggesting care to the provider; discussing asthma management generally, but not for specific patients).Interventions should take a more active role in asthma care process (e.g., provide asthma action plans, patient education, environmental control practices), particularly processes associated with a low risk of harm and those inhibited by specific barriers such as time constraints, poor self-efficiency, lack of awareness. Focus on health care processes impeded by logistical barriers, rather than those barred by provider discord regarding recommendations or lack of outcome expectancy. This also suggests that systems-level interventions that address barriers external to the health care provider would be an important approach to effecting positive changes in health care provider behavior.
Interventions were often narrow in scope and failed to address the comprehensive and complex tasks health care providers must execute in order to be adherent to asthma guideline recommendations (as well as “competing” guidelines including well child care, chronic comorbidities).Test interventions that address all of the elements of the asthma health care process (or as many as is feasible). For example, an intervention that would facilitate/expedite the following elements of care in a single visit might be beneficial: (1) Rx for controller medicine, (2) environmental control practice recommendations, (3) self-management education and asthma action plans, (4) documentation of asthma control/severity, (5) Rx of peak flow meter, (6) schedule of automatic follow-up visits within 3 months of visit.
Specify multifaceted interventions to include provider education + feedback + decision support (or other combinations that seem most potent mixtures of interventions).
Test similar multifaceted models.
Multifaceted interventions are feasible because they are more translatable than interventions limited to one modality.
Caveat: multifaceted interventions are more costly.
Inadequate description or measure of dose.Measure or address intervention “dose.” For example, if only 50 percent of provider participate in intervention, dose is important.
No examination of whether changes in health care provider behavior results in changes in clinical outcomesDesign studies that are more comprehensive in scope to capture changes in health care process measures and determine the strength of association with changes in clinical outcomes.
ComparisonsPre/post designs common. Uncontrolled studies used.Conduct more explicit comparisons of differing results between studies of different designs (i.e. direct comparisons of how results from pre-post studies differ from results from RCTs).
Move beyond pre-post studies; use cluster RCTs; conduct studies with appropriate control groups.
OutcomeHeterogeneity in presentation of the outcome measures.Develop minimum standards for presentation of outcomes (e.g., percent change in prescriptions for inhaled steroids). Other outcomes could be presented, but at minimum, one standard would facilitate comparisons between studies.
Studies failed to link changes in health care process to clinical outcomes.Develop studies that illustrate how specific changes in provision of care manifest improvements in patient outcomes.
Subjectivity/variability in clinical outcome measures including:
Hospitalizations, ED visits
Objective/reliable outcome measures:
Administrative health care utilization data for verification of ED visits, hospitalizations; standardization of cut-points.
Standardize timeframe for measurement of health care utilization outcomes, i.e. 12 months to account for seasonality effects.
Subjectivity/variability in health care process outcomes measures including:
Lack of determination of appropriateness of controller medication prescriptions
Lack of assessment of patient medication adherence as an outcome and/or a modifier of outcomes
Utilize pharmacy data or electronic monitoring of medication use to objectively measure controller medication adherence by patients as a clinical outcome.
Consider additional metrics as indicators of appropriate care, e.g.,
Use of controller meds: >6 fills per 12 months.
Controller-to-total asthma medication ratio: # controller fills in past 12 months/# controller fills + all other asthma med fills. (Cut-point: >0.5).
Lack of use of significance testsDevelop standards for inclusion of significance testing of data presented (e.g., chi-squared for proportions)
CostDevelop standard measures of cost of intervention to determine feasibility for practices to implement
TimeframesNo new recommendations
Settings of careNo new recommendations

From: Discussion

Cover of Interventions to Modify Health Care Provider Adherence to Asthma Guidelines
Interventions to Modify Health Care Provider Adherence to Asthma Guidelines [Internet].
Comparative Effectiveness Reviews, No. 95.
Okelo SO, Butz AM, Sharma R, et al.

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