Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized Controlled Trial

Abstract

PURPOSE The purpose of this study was to assess patient and practice outcomes after introducing the Asthma APGAR (Activities, Persistent, triGGers, Asthma medications, Response to therapy) tools into primary care practices. METHODSWe used a pragmatic cluster-randomized controlled design in 18 US family medicine and pediatric practices to compare outcomes in patients with persistent asthma aged 5 to 45 years after introduction of the Asthma APGAR tools vs usual care. Patient outcomes included asthma control, quality of life, and emergency department (ED), urgent care, and inpatient hospital visits. The practice outcome was adherence to asthma guidelines. RESULTSWe enrolled 1,066 patients: 245 children, 174 adolescents, and 647 adults. Sixty-five percent (692 patients) completed both baseline and 12-month questionnaires, allowing analysis for patient-reported outcomes. Electronic health record data were available for 1,063 patients (99.7%) for practice outcomes. The proportion of patients reporting an asthma-related ED, urgent care, or hospital visit in the final 6 months of the study was lower in the APGAR practices vs usual care practices (10.6% vs 20.9%, P = .004). The percentage of patients with "in control" asthma increased more between baseline and 1 year in the APGAR group vs usual care group (13.5% vs 3.4%, P =.0001 vs P =.86) with a trend toward better control scores and asthma-related quality of life in the former at 1 year (P ≤.06 and P = .06, respectively). APGAR practices improved their adherence to 3 or more guideline elements compared with usual care practices (20.7% increase vs 1.9% decrease, P = .001).CONCLUSIONS Introduction of the Asthma APGAR tools improves rates of asthma control; reduces asthma-related ED, urgent care, and hospital visits; and increases practices' adherence to asthma management guidelines. Ann Fam Med 2018;16:100-110. https://doi.org/10.1370/afm.2179. INTRODUCTIONA sthma is a common chronic condition, [1][2][3] and primary care is the site of most asthma diagnoses and management.2-5 Implementation of asthma guidelines has been challenging, and the burden of asthma remains high with little improvement from 1990 to 2010. [6][7][8][9][10][11][12][13] Use of a metric for assessing asthma control has been suggested for improving asthma care, and several asthma control scores have been developed and validated against allergists' assessments.14-25 But use of these tools remains limited and has not significantly improved asthma outcomes. 23,[26][27][28][29][30][31][32][33][34][35][36] The Asthma APGAR (Activities, Persistent, triGGers, Asthma medications, Response to therapy) (Figure 1) tools were developed not only to provide a score for asthma control, but also to guide further evaluation of inadequate control with a link to a care algorithm (Supplemental Figure 1, available at http://www.annfammed.org/content/16/2/100/suppl/ DC1/). In a small pilot study, use of the Asthma APGAR tools was associated with enhanced asthma guidelines adherence, and focus groups of patients an...

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