Promoting Asthma Guidelines and Management through Technology-Based Intervention and Care Coordination in Clinics and Schools (PRAGMATIC-S)

PROJECT SUMMARY/ABSTRACT There are multiple barriers to guideline-based asthma care, particularly for poor and historically marginalized children who suffer the greatest morbidity burden. These barriers exist at several levels: health system, provider, patient/family, and school/community. To address provider and health system barriers to guideline-based asthma care delivery, we developed decision support prompts in the electronic health records (EHR) to increase provider adoption of asthma care guidelines (R01HL133789, PRAGMATIC trial). We evaluated PRAGMATIC intervention in 18 Bronx, NY Montefiore primary care clinics, where the nursing staff screened for asthma severity and control and providers received a prompt to deliver care based on asthma guidelines. While PRAGMATIC enhanced the delivery of guideline-based asthma care in the office setting, sustained improvement in asthma outcomes depends on ongoing, consistent adherence to prescribed treatments at home and school, places where children spend most of their time. To support consistent adherence, we established and tested our school-based asthma therapy program (R01HL079954) which enhances adherence to guideline-recommended medications for urban children with persistent asthma through school-based directly observed therapy (DOT). However, the long-term success of school-based programs requires innovative partnerships with PCPs to ensure prescription of appropriate preventive medications along with the necessary paperwork and communications with schools, which do not occur consistently. We propose a program called PRAGMATIC-S, which creates an innovative interface between primary care and school-based programs to optimize delivery of guideline-based care to urban children with persistent or uncontrolled asthma. We will conduct a cluster randomized controlled trial, enrolling 420 children, ages 4-12, from 18 Montefiore clinics during office visits. Children in the intervention group (PRAGMATIC-S) will receive updated guideline-based care prompts, with providers completing the medication administration form (MAF), electronically signing it, and routing it directly to the school via the EHR system. Asthma Outreach Worker (AOW) care coordination will support daily adherence to prescribed treatments at home and school. Children in the control group will receive enhanced usual care, which includes EHR prompts for guideline-based care but without the additional PRAGMATIC-S components. This study will (1) assess the effectiveness of PRAGMATIC-S in improving asthma control (Asthma Control Test (ACT), primary outcome), (2) test the impact of PRAGMATIC-S on lung function, quality of life, school attendance, and acute healthcare utilization, (3) examine the impact of PRAGMATIC-S on adherence to guideline-based care, and (4) identify intervention mediators and moderators. PRAGMATIC-S represents a novel approach that addresses multiple barriers to adherence by bridging primary care and schools, ensuring delivery of guideline-based asthma care to urban children across these settings thereby improving adherence to therapy and clinical outcomes.