Bruce G. Bender, PhD, Meg Burke, MHSA, Andrew H. Liu, MD, Deborah Fending, RN, Barry Make, MD

Funding source:
This program was funded by an unrestricted educational grant from GlaxoSmithKline
Address correspondence to: Bruce G. Bender, Ph.D.
Professor and Head, Pediatric Behavioral Health
National Jewish Health 1400 Jackson St.
Denver, CO 80206
Telephone: 303 398-1697; Fax: 303 270-2141; E-mail:

Introduction: Programs designed to enhance the diagnosis and management of asthma and chronic obstructive pulmonary disease (COPD) in primary care settings have had variable success and have not been broadly implemented.

The Respiratory Toolkit Program, a two-year program designed to provide primary care training in both asthma and COPD care, was conducted in an urban federally qualified health center with 13 clinics and 87 staff. The program included interactive training with multidisciplinary teams; in-clinic follow- up training visits; electronic medical record (EMR) tools; and patient-centered educational resources.

For asthma patients, use of spirometry increased from 7% of visits before to 43% after training; severity assessment from 13 to 29%; asthma action plans from 2 to 8%; and prescription of inhaled corticosteroids from 33 to 42%. For COPD patients, spirometry use increased from 21 to 35% of visits, and of long-acting beta2-agonist from 19 to 26%. Among undiagnosed smokers, use of the COPD screener increased from 0 to 11% of visits; of spirometry from 4 to 36; and of advice-to-quit from 74 to 79%.

The Respiratory Toolkit program produced significant changes in guidelines-based care for patients with asthma or COPD, including large increases in administration of spirometry.

Many patients with asthma and chronic obstructive pulmonary disease (COPD) present in primary care settings where diagnosis and management may fall short of current national guidelines. In a study of quality of asthma care, 71% of asthma patients seen in primary care were under-treated, typically receiving less controller medication than directed by evidence-based guidelines.1 A survey of primary care providers (PCPs) indicated that only 54% of pediatricians and 51% of family physicians attempted to follow evidence-based National Heart, Lung and Blood Institute (NHLBI) guidelines for prescribing daily controller medication.2 Similarly, only 40% of primary care patients with COPD were receiving medications appropriate for the stage of their disease. 3 Spirometry, which plays a central role in guidelines-directed assessment and management of both respiratory diseases, is under-utilized in primary care. In one survey of PCP practices, only 21% of asthma patients4 and 27% of COPD patients5 received spirometry as a component of routine disease management.

In order for the majority of patients to be accurately diagnosed and treated, educating and supporting PCPs in the diagnosis and management of respiratory diseases is essential. However, interventions designed to enhance care for patients with respiratory diseases in primary care settings have met variable success and have not been implemented broadly. 6 7 8 Comprehensive reviews of provider training programs have concluded that provision of educational materials alone and passive, lecture-format workshops are minimally effective in promoting widespread implementation of evidence-based care. 9 10 One-session,didactic, large-group training programs have had only a small impact.9 10 For example, in a study aiming to improve guidelines adherence in 411 PCPs, those providers randomized to two three-hour group training sessions demonstrated no greater guidelines adoption than those randomized to one of two control groups (abridged training or unrelated training).11 Spirometry uptake has been particularly low, with PCP training programs producing little practice change in use of spirometry for asthma. 12 13 Six hours of group spirometry training in 26 PCP practices did not increase frequency of spirometry use in asthma 13 or COPD. 6 Programs moving toward greater provider engagement show much more promise. A survey of 784 PCPs concluded that CME programs addressing respiratory disease management had not adequately reached primary care practices. Clinicians were less interested in attending out-of-town sessions with opinion leaders, preferring live presentations, information they could access from their office, and content relevant to their daily practice. 14 Tailored approaches that engage providers and include multiple opportunities for interaction and feedback are markedly more likely to change practice behavior.15 We previously reported successful practice change in asthma care following on-site, rural practice coaching. {Bender, 2011 #23}

Few programs have attempted to provide comprehensive respiratory disease training to include both asthma and COPD diagnosis and treatment. The Respiratory Toolkit Program, a two-year performance improvement continuing medical education (PI CME) initiative, was developed to fill this gap. Training particularly targeted a change in the frequency of administration of spirometry, a key practice behavior in both asthma and COPD guidelines-directed disease management. Key components included engagement and survey of providers prior to training; interactive training with multidisciplinary teams; in-clinic follow up training visits; development of electronic medical record (EMR) tools; patient- centered care training; and development of educational materials and web-based resources. Outcomes assessed through EMR databases and provider feedback evaluated the success of guidelines-concordant practice change.

Study Design and Outcome Measures
This PI CME initiative used a three-stage learning model approved by the American Medical Association in 2004. PI CME lends itself to a quasi- experimental design in which outcomes are measured before and after the training program. The primary outcome for both conditions was use of spirometry, with secondary outcomes that included other essential practice behaviors based on key measurable elements of the guidelines for asthma 16 and COPD. 17

National Jewish Health, a non-profit tertiary-care center focused on research, patient care, and education in the areas of respiratory, allergic, and autoimmune diseases, entered into a partnership with Metro Community Provider Network (MCPN) to conduct and assess the Respiratory Toolkit program. MCPN is a non- profit, federally qualified health center that provides primary healthcare to underinsured, uninsured, and low-income working families who cannot afford health services in the Denver, Colorado, metropolitan area. The 13 safety-net outpatient clinics provide care to approximately 35,000 patients, 75% of whom have household incomes below the U.S. poverty level.

Provider Engagement
Preparations for conducting the Respiratory Toolkit program began with engagement with the MCPN leadership and then with health care providers. Surveys of providers and interactive discussions at monthly provider meetings were conducted to assess interest, discuss gaps and priorities, and increase commitment to training. This engagement process led to inclusion of five recommendations to guide the design of the Respiratory Toolkit program (Table 1).


Table 1. Program elements recommended by providers

Training Content
Content focused on asthma and COPD disease-state education, including diagnosis, treatment and management of the disease. Presentation and discussion included elements of patient-centered care and evidence-based strategies for patient engagement and activation, including addressing smoking cessation and medication adherence. Prescribing providers received training in spirometry interpretation and case-based review of treatment decisions while non-prescribing team members received additional spirometry practice. In the asthma program, emphasis was placed on the importance of assessing severity and control and the use of asthma action plans in the ongoing management of patients with asthma (Table 2a).


Table 2a. Targeted guidelines-based practice behaviors for asthma management

Components of the COPD GOLD Guidelines and smoking cessation interventions were emphasized for the management of patients with COPD (Table 2b).17


Table 2b. Targeted guidelines-based practice for COPD management

Training Procedures

The Respiratory Toolkit adopted a team-based approach to asthma and COPD care. Team-based care emphasizes a practice-team approach to coordinated care delivery that typically results in improved outcomes. 18 19 Therefore, education was provided to all members of the practice team, including physicians, nurse practitioners, physician assistants, and medical assistants. The educational interventions were designed to be engaging and interactive. All team members received hands-on training with inhaler devices and spirometry. Role- play and videos demonstrated provider-patient interactions during an asthma or COPD visit. Provider teams received asthma training in year one and COPD training in year two. In each phase, all MCPN participants attended a one-day, seven-hour training session, followed approximately one month later by an in- clinic visit by nurse trainer teams, with a second in-clinic visit approximately one month after the first. Training videos and role-playing sessions were used to demonstrate patient-centered care. Spirometry was demonstrated and practiced repeatedly in small groups with fewer than 10 participants. Discussions focused on incorporation of spirometry into practice flow. At each workshop, all team members received training manuals, one each for asthma and COPD, that included all content from the workshop, action plans, and spirometry instructions. Care and action plan templates were built into the MCPN EMR. A Respiratory Toolkit training website provided access to manuals, patient educational materials, spirometry demonstration videos, answers to frequently asked questions, and links to other web based resources.  Provider Feedback. At the conclusion of both years of the Respiratory Toolkit, providers received Provider Feedback Reports (PFRs) with their individual data that showed their change in performance in comparison to their peers; responded to a survey asking providers to reflect on the program’s impact on their knowledge, competence and performance related to the quality measures and overall program; and gave input on continued barriers and recommendations for program improvement.

MCPN Respiratory Toolkit participants included 35 prescribing providers (physicians, nurse practitioners, physician assistants) and 52 staff (primarily medical assistants). All baseline and post-training practice data were drawn from the MCPN EMR. Data were standardized to represent the percent of patient visits in which specific practice elements occurred.


The total cumulative volume of patients receiving spirometry from the baseline period to the end of both the asthma and COPD programs was extracted. The proportion of patients who had received spirometry, the primary outcome, increased dramatically from the initiation of the asthma training. Spirometry was administered to 85 patients during the baseline year; to 339 patients in the year following the initiation of asthma training; and to 385 patients in the year following COPD training (Figure 1).


The relative proportions of patient visits that included targeted practice behaviors before and after training were tested with Fisher’s exact tests where a p value of <0.05 was considered significant. Significant changes were seen in frequencies of the four targeted guidelines-concordant asthma practice behaviors (Table 3a).


Table 3a. Asthma Visits:

Documentation of spirometry increased from 6.7 to 42.5%; guidelines-based severity assessment from 12.8% to 29.4%; asthma action plan frequency from 1.8% to 7.6%; and prescription of inhaled corticosteroids (ICS) from 33.1 to 41.6% of asthma patient visit from the year before to the year following initiation of training. Despite these increases, more than half of asthma patients seen during the follow up interval did not receive spirometry, severity assessments, action plans, or ICS prescriptions. Action plans were documented in only 7.6% of asthma visits.


Following the COPD training phase, the proportion of patients receiving spirometry rose from 21% to 34.6% of COPD visits. Prescriptions for a long- acting beta2-agonist rose from 19.1 to 25.9% (Table 3b).


Table 3b. COPD Visits

For undiagnosed smokers, use of the COPD screener, spirometry, smoking cessation advice, and prescription of smoking cessation medication were also assessed during baseline and post-intervention visits. The COPD screener, used at 10.6% of undiagnosed smoker visits following the training program, was not used in the MCPN clinics before the Respiratory Toolkit program. Significant increases from pre- to post-training were also seen in spirometry (3.8 to 36.2%) and advice to quit (73.7% to 79%) but not new smoking-cessation medication prescriptions (Table 3c).


Table 3c. Current Smokers Visits, Regardless of Diagnosis

Despite post-intervention increases, fewer than half of visits by current smokers included the COPD screener and spirometry, although the majority of patients were advised of the importance of stopping smoking.

Provider Feedback.

For the asthma program, respondents consistently indicated that time and patient costs posed substantial barriers to their performance in the program. All participants indicated that the program had assisted them in practicing a team-based approach to asthma and that all of the developed program materials were either “extremely” or “somewhat” important when evaluating their confidence in treating their patients. The COPD surveys produced similar results, with 88% of respondents indicating that the program helped them adopt a team-based approach, and 100% responding that they are better able to treat patients with COPD as a result of the program. Similar to the asthma program barriers, the COPD program respondents indicated that time constraints impacted their ability to consistently meet the guidelines-based objectives. Across both programs, providers indicated that repeated spirometry practice, on-site practice coaching, and practice tools including action plans, COPD screeners, and dual-language patient education workbooks were particularly helpful to adopting practice guidelines.

The Respiratory Toolkit program successfully increased provider adherence with evidence-based guidelines for asthma (spirometry, severity assessment, action plan, ICS prescription) and COPD (spirometry, COPD screener, bronchodilator use, advice to quit smoking). Increases in the use of spirometry, the primary outcome for both the asthma and COPD programs, were large. All MCPN prescribing providers who participated in this program began using spirometry in their practice. This uptake of spirometry is particularly meaningful because previous attempts to train PCPs have often seen little change. For example, six hours of group spirometry training in 26 PCP practices did not increase frequency of spirometry use in asthma patients. 13 In another study, an intervention to change practice behavior recruited one clinician from each of six practices to receive guidelines-based training and then systematically introduce changes into the larger practice; most practices demonstrated increases in severity assessment and use of asthma action plans, but not in adoption of spirometry. 12 Spirometry training in primary care management of COPD has fared no better. Following a one-hour workshop on use of spirometry, 21 primary care physicians reported a 59% increase in spirometry tests performed, but also reported continuing doubts about spirometry that included staff unfamiliarity with procedures, uncertainty about interpretation of results, and concerns about reimbursement and excessive time requirements. 6

Successful practice change in this study may be attributed to a number of factors. The program was delivered in the practice community on weekend days when most providers were not seeing patients and were therefor able to participate completely in the training without interruption. Intensive spirometry practice was directed to all staff and occurred on multiple occasions. Following the one-day workshop, two in-practice visits occurred within each of the 13 clinics. This strategy allowed engagement of the multidisciplinary practice team, active practice coaching, and on-site discussion about workflow redesign in their daily environment. These procedures also helped to build practice-specific team-based care plans, an important step toward improved care for chronic health conditions. 18 19 A training website was created to include content presented in the workshops in order to reinforce the training to those who were present at the live meeting, and also to train new practice staff when turnover occurred. Short videos were emailed to providers and also housed on the program website in order to demonstrate patient education and counseling strategies. Opportunities to address gaps encountered during training were identified and addressed. For example, providers requested and received more case-based training in spirometry interpretation. Educational materials were produced in both English and Spanish, and additional training was provided for medical assistants regarding inhaled technique, action plans, and patient education. Flexibility and responsiveness to practice team needs and requests created repeated opportunities to engage providers and reinforce learning.

Clearly, ample room exists for further improvement. More than half of asthma patient visits did not include spirometry, severity assessment, or action plans. Most smokers were advised to quit, but the majority did not complete the COPD screener or receive spirometry. Provider feedback surveys indicated that time constraint barriers impeded their ability to perform better in these categories. Given the high advice-to-quit frequency, low rates of smoking cessation medication intervention may reflect lack of patient acceptance rather than insufficient provider attempts. Despite the success of practice coaching in this program, the search must continue for additional strategies to help providers to address smoking and increase guidelines-based assessment and treatment for both asthma and COPD. As one example, follow-up communication demonstrating how individual practices successfully adopted guideline-based care may provide social modeling that encourages other practices to follow. Finally, a notable limitation to this study was the absence of a randomized controlled trial (RCT) design. However, increasing emphasis has been place on the role of comparative effectiveness research (CER) in the identification of successful strategies for dissemination and implementation of evidence-based guidelines. CER studies often embrace non-RCT designs including observational, cohort, quasi-experimental, and case-control research. Such studies, including the present one, help to determine whether existing therapies work effectively when disseminated into “real world” practice setting with diverse patient populations including patients with multiple comorbidities. 20

Conflict of Interest Statement:
None of the authors has a conflict of interest with content of this manuscript.


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