• The Association of Integrated Management of Childhood Illness' Asthma Management Protocol and Asthma Control in Omani Children 2-5 years Old

      Al Amri, Warda; Ogbolu, Yolanda; Johantgen, Mary E. (2018)
      Background: Oman had the highest asthma prevalence and severity in children among Eastern Mediterranean countries. Despite national implementation of Integrated Management of Childhood Illness (IMCI) asthma protocol, reports show no improvement in asthma-related hospital admissions among children aged 1-4 years. IMCI asthma treatment protocol implementation and factors affecting asthma control are understudied. Purpose: Describe characteristics of IMCI asthma management protocol implementation (medication, counselling, and specialist referral); explore multilevel factors associated with asthma control in children attending IMCI clinics; and analyze trends in acute care visits (emergency department [ED] and hospital admissions) by asthmatic children and their characteristics during one year follow-up. Methods: Retrospective cohort study of Omani children aged 2-5 years in Muscat was conducted using electronic health data (2012-2015). Asthma control was measured by number of exacerbations requiring visits to the health center, emergency care or hospitalization within one year of asthma index diagnosis. Generalized linear mixed-effects modelling was used to account for the clustering of children within health centers. Results: Mean age was 2.8 years, predominantly male (63.2%) and originally from Muscat (96.2%). On index diagnosis day, 61.2% were given reliever medications, and on discharge 47.1% were prescribed controller medications. Most (74%) children had well-controlled asthma that was highly associated with being treated in a health center with higher proportion of IMCI training (Adj. OR= 3.0; 95% CI =1.34, 6.73; p <0.01), and receiving short acting β2-agonists for acute management at index diagnosis (Adj. OR=2.4; 95% CI=1.38-4.09). There was limited data for specialist referrals and counselling. Majority of children with ED visits were infrequent attenders (94.1%), however, a small percentage had high acute care utilization (e.g. 21 visits/year). Conclusion: IMCI is designed to improve health outcomes of young children. A high proportion of children treated in IMCI clinics achieved well-controlled asthma. Training of physicians improved asthma outcomes, but specific components in the IMCI asthma management protocol need more reinforcement and further exploration. Utilizing prevention quality indicators to screen for implementation of IMCI components is recommend. Longitudinal investigation of multilevel factors (patient, family, practice, and health care system) associated with childhood asthma control in Oman is needed.
    • Improving Provider Compliance with Glycemic Guidelines in Children with Type 1 Diabetes

      Burr, Mary S. (2016)
      The serum glycated hemoglobin or hemoglobin A1c (HbA1c) measurement is the most important long-term measurement of glycemic control and treatment effect when caring for the child with Type 1 diabetes mellitus (T1DM). The goal of treatment in diabetes is to maintain the patient’s blood glucose within a specific therapeutic range. A team of specialized providers is typically responsible for the care of these children, and continuity of the treatment among providers has been shown to improve glycemic control. Additionally, provision of guideline driven care has been shown to have positive outcomes in terms of therapeutic HbA1c measurement. In January 2015, The American Diabetes Association (ADA) released revised HbA1c guidelines for children with T1DM. Their recommendation was all children with T1DM should have an HbA1c level of < 7.5%. The goal of this quality improvement (QI) project was to promote and measure the level of provider compliance with current (2015) ADA glycemic guidelines using a standardized phrase for documentation in the electronic medical record (EMR). Methods: There were three phases to the implementation of the project. The initial phase was the completion of an EMR audit to assess the current HbA1c measurements of the pediatric patients in the clinic. The second phase was performance of a survey to assess provider knowledge of current ADA guidelines and the third phase was the creation and implementation of a “smart phrase” for EMR documentation, which confirmed that the HbA1c measurement and the recommendations of the ADA had been addressed with the patient and family. At the completion of the intervention phase, the project leader performed a manual retrospective chart review, which provided the nominal data needed to measure provider compliance in the use of the EMR smart phrase. Results: The project took place in a Diabetes and Endocrinology Center of a large urban academic medical center. The convenience sample of providers consisted of 9 pediatric diabetes care providers who currently practice at the center: three pediatric endocrinologists, three pediatric nurse practitioners and three certified diabetes educators. Data collection for the project was conducted over a six-week period, capturing 122 patient visits. Overall there was a 59% provider compliance rate with smart phrase usage; the group most compliant in smart phrase usage was the group of APRN providers, who used the phrase in 70% of patient visits. Conclusions: The standardized EMR phrase was helpful in identifying provider compliance with discussing current ADA guidelines when utilized. Consistent use of the smart phrase reflects guideline-driven care by diabetes providers and sends a clear message to families of patients with T1DM regarding the importance of glycemic control and improved patient outcomes.