What approach should be taken when considering new studies and interventions in pediatric care for children under 18 with conditions such as asthma?

Approaching New Studies and Interventions in Pediatric Asthma Care

Core Principle for Implementation

When implementing new interventions to improve pediatric asthma care, decision support systems and clinical pharmacy support demonstrate the strongest evidence for improving controller medication prescribing and self-management education, with moderate strength of evidence supporting their use. 1

Evidence-Based Intervention Framework

Most Effective Interventions

Decision Support Systems:

• Consistently show large magnitude of effect (>30% improvement) for increasing prescription of controller medications 1
• Demonstrate large magnitude of effect for improving self-management education and asthma action plan provision 1
• Show moderate magnitude of effect (10-30% improvement) for reducing ED visits and hospitalizations, with larger effects observed in pre-post studies 1
• Should be prioritized as first-line implementation strategy based on consistent benefits across multiple outcomes 1

Clinical Pharmacy Support:

• Increases controller medication dispensation significantly (OR: 3.80; 95% CI: 1.40-10.32; P = 0.01) 1
• Demonstrates 20% and 6% increases in controller medication prescribing across non-randomized trials (P < 0.05 for both) 1
• Shows moderate strength of evidence for improving self-management education 1
• Involves specialized asthma services including patient appointments, medication needs assessment, and goal-setting 1

Feedback and Audit Combined with Education:

• Increases prescribing of controller medications by 5-12% when using targeted key guideline messages (P = 0.05) 1
• Most effective when combined with prioritized review criteria, benchmarking against peers, or pharmacy monitoring with feedback 1
• Requires individualized feedback on prescribing patterns and decision strategies to be effective 1

Interventions with Limited or No Benefit

Education Alone:

• Shows no benefit for increasing controller medication prescribing (low strength of evidence) 1
• Demonstrates no benefit for reducing ED visits or hospitalizations (insufficient strength of evidence) 1
• Should not be used as a standalone intervention strategy 1

Organizational Change:

• Shows no benefit for reducing ED visits, hospitalizations, or missed school/work days 1
• Restructuring clinical protocols alone (e.g., "3+ visit plan") does not reduce missed school days (OR: 0.8; 95% CI: 0.5-1.2; P = 0.3) 1

Quality Improvement/Pay-for-Performance:

• Demonstrates no significant reduction in ED visits, hospitalizations, or missed school/work days 1
• Insufficient evidence to support routine implementation 1

Pediatric-Specific Considerations

Applicability of Adult Studies to Pediatric Populations

Universal Provider Behaviors:

• Asthma guideline recommendations generally do not distinguish between provider types 1
• Core provider behaviors are universal: assessing asthma control/severity, prescribing controller medications for persistent asthma, providing self-management education 1
• Patient outcome goals are identical across age groups: reducing acute care visits, limiting missed school/work 1
• Mainstay treatments are the same: inhaled corticosteroids and short-acting bronchodilators 1

Pediatric-Specific Factors to Consider:

• Only 25 of 68 studies in the systematic review were conducted in pediatric-only populations 1
• Children have different physiology, disease presentation, natural history, and developmental considerations 1
• Parents are necessary elements in medical decision-making for minors 1
• Despite these differences, intervention effectiveness principles apply across the provider spectrum 1

Critical Outcomes for Pediatric Asthma

Priority Outcomes Endorsed by National Institutes of Health:

• Prescription of asthma controller medicines 1
• Provision of asthma action plans and self-management education 1
• ED visits and hospitalizations 1
• Missed days of school or work 1

Implementation Algorithm

Step 1: Select Evidence-Based Intervention

1. First choice: Implement decision support system with electronic health record integration 1
2. Second choice: Establish clinical pharmacy support program with trained pharmacists 1
3. Third choice: Combine feedback/audit with provider education using targeted guideline messages 1

Step 2: Assess Feasibility

• Evaluate implementation feasibility within your specific practice setting 1
• Consider sustainability of the intervention over time 1
• Ensure intervention addresses both acute and chronic asthma management needs 2

Step 3: Measure Outcomes

• Use validated outcome measures: controller medication prescribing rates, self-management education provision, ED visits/hospitalizations, missed school days 1
• Recognize that pre-post study designs more often report beneficial effects than randomized controlled trials 1
• Account for variable time to onset of symptom relief and different degrees of response among individual patients 3

Common Pitfalls to Avoid

Avoid Education-Only Interventions:

• Education alone consistently fails to improve controller medication prescribing or reduce acute care utilization 1
• Must be combined with decision support, feedback/audit, or pharmacy support to be effective 1

Avoid Organizational Change Without Other Components:

• Restructuring clinical protocols alone does not improve outcomes 1
• Must be paired with decision support or other active interventions 1

Do Not Rely on Quality Improvement Alone:

• Quality improvement strategies without decision support or pharmacy involvement show insufficient evidence for benefit 1

Recognize Study Design Limitations:

• Most studies use pre-post designs which may overestimate treatment effects 1
• Randomized controlled trials show more conservative but reliable effect estimates 1

Research Priorities for Pediatric Asthma

Urgent Need for Pediatric-Specific Studies:

• Long-term studies (minimum 2 years) examining each medication class (inhaled corticosteroids, leukotriene receptor antagonists, anti-IgE) 1
• Studies in young children (under 5 years) where asthma incidence is highest and lung function decline risk is greatest 1
• Research identifying methods for reliably measuring pulmonary function in young children 1
• Studies determining significance of lung function declines and relevance to quality of life, symptom severity, and acute exacerbations 1

Critical Knowledge Gaps:

• Whether early versus delayed intervention with daily long-term-control medication alters the underlying disease course 1
• Most lung function loss in childhood asthma occurs in the first years of life, suggesting intervention timing is critical 1
• Evidence to date is insufficient to conclude that children 5-12 years with mild or moderate persistent asthma have progressive lung function decline preventable by early medication initiation 1