Integrating Patient-Reported Outcomes Into Routine Primary Care: Monitoring Asthma Between Visits

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An integrated mobile health (mHealth) application for remote monitoring of asthma symptoms enables primary care clinicians and clinical staff to effectively monitor asthma patient-reported outcomes (PROs) between visits, enhancing patient quality of life by supporting symptom tracking and self-reporting.

Project Details -
Completed

Asthma affects over 25 million people in the United States, with increasing incidence. Poorly controlled asthma severely impacts quality of life and leads to more emergency visits and hospitalizations, especially among Hispanic or Latinx, and low-income individuals. This disparity is linked to low income and health literacy. However, poor outcomes from inadequate asthma control are preventable with timely treatment and adherence to clinical guidelines that adjust treatment based on PROs. Adhering to these guidelines improves health outcomes, and interventions for monitoring symptoms between visits could improve control, quality of life, and reduce healthcare utilization. Despite this, routine intensive symptom monitoring between primary care visits, where most asthma patients are treated, remains rare.

In previous AHRQ-funded work, the research team developed and pilot-tested a patient-facing mHealth application for tracking self-reported asthma symptoms between primary care visits. Additionally, they created a clinician-facing dashboard accessible through the electronic health record (EHR) and inbox messages reminding clinicians to review the dashboard, and established clinic workflows to support symptom monitoring – all seamlessly integrated into routine care to improve asthma symptom management in accordance with guidelines. This follow-up research adapted and scaled the model to seven primary care clinics affiliated with a large academic health center serving a large and diverse asthma population.

The specific aims of the research were as follows:

  • Adapt the existing health information technology (IT)-enabled practice model for asthma symptom monitoring using PROs to a primary care population that includes Spanish-speaking and low-health-literacy patients.
  • Implement the adapted health IT-enabled practice model in seven primary care community clinics, identify a cohort of eligible asthma patients to participate, and train clinicians and clinical staff.
  • Rigorously evaluate the impact of this new health IT-enabled practice model using a randomized controlled trial.

Researchers employed user-centered design and iterative prototyping techniques for both Spanish- and English-speaking patients. They collected quantitative data on mHealth app usage, clinician dashboard engagement, and call-back requests, alongside qualitative insights from participant exit interviews. By addressing EHR integration needs and user requirements for patients, primary care physicians, and nurses, the mHealth app effectively facilitated asthma symptom tracking and reporting in primary care settings. This resulted in a statistically significant improvement in MiniAQLQ scores, indicating enhanced asthma-related quality of life compared to usual care. The integrated model proved feasible for primary care physicians and nurses, achieved robust patient participation rates, and accommodated patients with low health literacy. The success of asthma PRO monitoring between visits suggests that the mHealth app could be scaled up and potentially adopted as the standard of care.

The COVID-19 pandemic began in the United States just as researchers were launching the randomized controlled trial in the initial AHRQ-funded study, disrupting routine asthma care due to social distancing and leading to delays in treatment and medication refills, as many patients avoided seeking care. This prompted the research team to seek AHRQ supplemental funding to better support patients, healthcare providers, and health systems during the pandemic. In the supplemental study, researchers incorporated a publicly available COVID-19 symptom screener into the mHealth application and participants who screened positive for possible COVID-19 were instructed to call the COVID-19 hotline for further evaluation. Findings suggested that integrating a COVID-19 assessment tool as part of a remote patient symptom monitoring intervention was successful, with 81 percent of app users using the COVID-19 symptom screener at least once. Researchers also identified best practices for patient recruitment, including staffing projects with bilingual team members and using a multi-pronged recruitment strategy that employs both digital and non-digital methods to achieve diversity and equity in clinical trial recruitment.

A Simple Mobile Application is Key to Patient Engagement in Reporting and Monitoring of Asthma Symptoms

Key Finding and Impact:

A simple app, designed with input from patients, resulted in 92 percent of patients continuing to report their asthma outcomes at the end of the study. A tool like this simple app may help patients better control their asthma and prevent emergency care.

Seeing value in using PROs data for research purposes, Dr. Robert S. Rudin from the RAND Corporation recognized that PROs data could also be used to improve patient care. People with asthma have better outcomes and fewer flareups when their symptoms are routinely monitored and managed by clinicians. Using mobile applications to report asthma symptoms to clinicians would allow for more timely management of asthma systems.

Dr. Rudin and his research team designed a patient-facing mobile phone app for people with asthma using user-centered design principles and an iterative process that engaged patients and providers. Patients received a weekly prompt to answer five standardized questions about their current asthma symptoms. A care manager, such as a nurse or medical assistant, received notifications if patient-reported symptoms met specific conditions of worsening severity.

User feedback is important to the development of mobile health apps.

Keeping patients engaged is often a challenge in healthcare; therefore, the research team knew they had to develop an app that would be of value to patients so that they would continue to use it. Dr. Rudin commented, “Using a user-centered design process, the patients reveal to you what they want for the design. I’ve yet to have an interaction with a user where I didn’t learn something.” The user-centered design process informed the development of the app and the practice model for the intervention. For instance, physicians invited their patients to use the mobile app, because the researchers found during the formative research that patients are more likely to adhere to recommendations made by their physicians.

The importance of keeping it simple “Too often we try to load up interventions with bells and whistles, and then you don’t know exactly why it works or doesn't work. For this intervention, we discovered that asking patients five simple questions once a week, with the option to call the provider, kept patients engaged in asthma management and made them feel more connected with their physicians.”
- Dr. Robert S. Rudin

A simple solution to engage patients.

Dr. Rudin and his team conducted a 6-month feasibility study in two subspecialty care clinics, analyzing app usage logs and data from interviews conducted with patients and clinical staff. At the end of 6 months, they were surprised and pleased to find high patient engagement: 92 percent of patients were still completing weekly PRO questionnaires. Over 80 percent of patients received at least one call based on their weekly PRO responses. Patients reported that the app was simple and easy to use, increased awareness of their asthma symptoms and flares, made them feel more connected to their provider, and avoided emergency care. Providers reported minimal workflow burden.

Scale and spread of this successful application and model.

Dr. Rudin has been funded for future work by AHRQ to scale and spread this successful app and practice model. For this current research, Dr. Rudin and his team are applying user-centered design processes to enhance and adapt the app in a primary care setting, where much of asthma disease management occurs. The enhancements will include recording peak flows and details on recent symptoms and triggers, which were suggested by patients and providers during the original research project. The enhanced app and model will be rigorously evaluated with a randomized controlled trial to understand the impact of the app on quality of life and asthma-related healthcare utilization.