Performance Feedback Improves Pediatric Residents’ Adherence to Asthma Clinical Guidelines

• Objective: To determine the impact of a monthly peer-comparison report on pediatric residents’ adherence to asthma guidelines. • Design: Preand post-intervention study. • Participants and setting: 21 residents working in a pediatric clinic in a military teaching hospital in Hawaii. • Methods: Residents were trained on the use of asthma guidelines and an ambulatory pathway. Guideline adherence was subsequently measured by asking residents to document in an ambulatory data system whether they had performed 4 pathway tasks when treating asthma patients: assess and classify asthma severity, provide or review an asthma action plan, provide direct patient education, and order spirometry at the visit or within 6 months. Use of controller medications in patients with persistent or unclassified asthma severity was also measured. Monthly reports showing the rate at which individual providers performed each task relative to their peers were generated and provided to the house staff without comment. Individual rates for the 5 measures were averaged monthly and the means compared across 6 months to detect an effect of the reports on resident behavior. • Results: Of 373 patients with asthma at baseline, 36.0% had asthma severity classified, 13.4% of patients had an asthma action plan documented, 28.5% had patient education documented, 4.7% had spirometry ordered, and 37.2% of patients with persistent asthma were on controller medications. At 6 months, rates of documenting of an asthma action plan, severity classification, patient education, and ordering of spirometry increased significantly (P < 0.001) compared to baseline. Appropriate use of a controller medication did not increase significantly. • Conclusion: Pediatric resident adherence to asthma guidelines improved for 4 of 5 parameters with monthly peer-comparison feedback. The management of childhood asthma consumes a large portion of health care resources, with direct costs estimated at more than $5 billion per year [1]. In the Military Health Care System, diagnosis-related group (DRG) 98 (bronchitis and asthma) is the most common reason for admission in the pediatric age-group. Most of the expense for asthma management results from hospitalizations and emergency department visits or other unscheduled acute care [1,2]. The use of clinical practice guidelines in caring for children with asthma has been shown to decrease hospitalization and improve patient outcomes [3–15]. Unfortunately, physicians frequently fail to adhere to clinical guidelines for a variety of reasons, including lack of familiarity with the guidelines or lack of motivation to change practice behavior [16–18]. While there have been many different approaches to improving physician adherence, no one method has been demonstrated to be consistently effective [19,20]. Physician profiling, the process of comparing the performance of a physician to that of his or her peers, is an approach that has shown some promise [21,22]. The medical informatics branch of our information management division has developed a robust clinical data repository that is populated with pertinent clinical data from our hospital information systems. A Web-based front end on our intranet “mines” data from the systems for use by the medical center’s clinical leaders and clinicians. Recent programming developments allow our clinicians to monitor their practice patterns and compare their treatment and patient outcomes with that of their peers. We used specially designed reports from this system to provide monthly peercomparison feedback to pediatric residents in our training program who regularly care for children with asthma. The purpose of this study was to determine whether the regular distribution of these reports to the house staff had an effect on their performance in caring for children with asthma. From the Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI.