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A knowledge translation approach to improve outcomes after asthma exacerbations

  • Author / Creator
    Villa-Roel, Myriam Ines Cristina
  • Background: A knowledge translation (KT) gap between evidence and action exists in asthma care and this gap may explain the suboptimal quality of care and poor health outcomes after asthma exacerbations. While recently published and widely disseminated asthma guidelines have highlighted the essential role of individualized patient-centered approaches, the following elements of high-quality care have not been well described or deployed: patient education components and key care partnerships; strategies targeting the sustained implementation of various recommendations; and methods to facilitate the transitions in care between the emergency department (ED) and community-based follow-up with primary care providers (PCPs). Methods: The Graham and Straus knowledge to action (KTA) model was used to facilitate and accelerate the use of high-quality asthma evidence into practice settings. Seven steps were followed to support the design, evaluation and implementation of opinion leader (OL) and care manager (CM) -based interventions generated in the ED and directed at community-based PCP and patients, respectively. Results: 1-2) Potential solutions that could help address a problem (Chest. 2015;147:140-9) were targeted through the following research question: In adult patients with acute asthma discharged from the ED, will ED-directed interventions reduce relapses and improve outcomes compared to usual care (UC)? 3) A systematic review of the literature provided conclusive evidence to support the consideration of ED-directed educational interventions targeting either adult patients or providers as effective strategies to increase PCP follow-up visits after asthma exacerbations; 4) Surveys and focus groups involving patients and PCPs helped refine the study interventions to account for local context and identify potential barriers for implementation. 5) Using randomized controlled trial methods, patients were allocated to receive UC (including notification to their PCP of their ED visit), personalized OL-letters faxed to their PCPs (PF; identifying gaps in care and providing guidance on ambulatory management) or OL and patient education by an asthma CM within a week of being discharged from the ED, in an incremental approach. A significant increase in the proportion of PCP follow-up visits within 30 days occurred in the intervention arms when compared to UC; however, this effect was attenuated by 90 days. The interventions did not improve patient-oriented outcomes such as relapses, quality of life and hospitalization; results were counterintuitive and overtreatment was documented at the PCP follow-up visits. 6) Traditional and non-traditional dissemination methods helped make research results available and more useful to stakeholders. 7) Determinants and strategies for the sustained application of this new knowledge were identified and proposed. Conclusions: The use of a KTA conceptual framework favored a reflective and synergistic research process with the engagement of potential end users and the use of high-quality research methods. The costs required to implement these multifaceted and tailored ED-directed interventions would not be warranted given the negative effects on patient oriented health outcomes. Regardless of the results of the comparative effectiveness research, the interpretability of the overall conclusions were facilitated by the previous contact with the practice environment.

  • Subjects / Keywords
  • Graduation date
    2016-06
  • Type of Item
    Thesis
  • Degree
    Doctor of Philosophy
  • DOI
    https://doi.org/10.7939/R3RX93N24
  • License
    This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.
  • Language
    English
  • Institution
    University of Alberta
  • Degree level
    Doctoral
  • Department
    • Department of Public Health Sciences
  • Specialization
    • Epidemiology
  • Supervisor / co-supervisor and their department(s)
    • Majumdar, Sumit R (Medicine)
    • Senthilselvan, Sentil (School of Public Health)
    • Rowe, Brian H (Emergency Medicine)
    • Leigh, Richard (University of Calgary)
  • Examining committee members and their departments
    • Beach, Jeremy (School of Public Health)
    • Gupta, Samir (University of Toronto)
    • Carrol Linda (School of Public Health)
    • Bhutani, Mohit (Medicine)