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BackgroundAsthma is the most common pediatric illness in the United States, burdening low-income and minority families disproportionately and contributing to high health care costs. Clinic-based asthma education and telephone case management have had mixed results on asthma control, as have eHealth programs and online games. ObjectivesTo test the effects of (1) CHESS+CM, a system for parents and children ages 4–12 years with poorly controlled asthma, on asthma control and medication adherence, and (2) competence, self-efficacy, and social support as mediators. CHESS+CM included a fully automated eHealth component (Comprehensive Health Enhancement Support System [CHESS]) plus monthly nurse case management (CM) via phone. CHESS, based on self-determination theory, was designed to improve competence, social support, and intrinsic motivation of parents and children. MethodsWe identified eligible parent–child dyads from files of managed care organizations in Madison and Milwaukee, Wisconsin, USA, sent them recruitment letters, and randomly assigned them (unblinded) to a control group of treatment as usual plus asthma information or to CHESS+CM. Asthma control was measured by the Asthma Control Questionnaire (ACQ) and self-reported symptom-free days. Medication adherence was a composite of pharmacy refill data and medication taking. Social support, information competence, and self-efficacy were self-assessed in questionnaires. All data were collected at 0, 3, 6, 9, and 12 months. Asthma diaries kept during a 3-week run-in period before randomization provided baseline data. ResultsOf 305 parent–child dyads enrolled, 301 were randomly assigned, 153 to the control group and 148 to CHESS+CM. Most parents were female (283/301, 94%), African American (150/301, 49.8%), and had a low income as indicated by child’s Medicaid status (154/301, 51.2%); 146 (48.5%) were single and 96 of 301 (31.9%) had a high school education or less. Completion rates were 127 of 153 control group dyads (83.0%) and 132 of 148 CHESS+CM group dyads (89.2%). CHESS+CM group children had significantly better asthma control on the ACQ (d = –0.31, 95% confidence limits [CL] –0.56, –0.06, P = .011), but not as measured by symptom-free days (d = 0.18, 95% CL –0.88, 1.60, P = 1.00). The composite adherence scores did not differ significantly between groups (d = 1.48%, 95% CL –8.15, 11.11, P = .76). Social support was a significant mediator for CHESS+CM’s effect on asthma control (alpha = .200, P = .01; beta = .210, P = .03). Self-efficacy was not significant (alpha = .080, P = .14; beta = .476, P = .01); neither was information competence (alpha = .079, P = .09; beta = .063, P = .64). ConclusionsIntegrating telephone case management with eHealth benefited pediatric asthma control, though not medication adherence. Improved methods of measuring medication adherence are needed. Social support appears to be more effective than information in improving pediatric asthma control. Trial RegistrationClinicaltrials.gov NCT00214383; http://clinicaltrials.gov/ct2/show/NCT00214383 (Archived by WebCite at http://www.webcitation.org/68OVwqMPz)

In this article, the authors discuss how a system change framework was developed to change the way a school system worked for students. Decades of reports documented inequitable placement into and completion of remedial mathematics in the University of Wisconsin System (UW System). Incoming "undecided" students often enrolled in college algebra--even if they were unlikely to enter a science, technology, engineering and math (STEM) field requiring the algebra-calculus pathway. Among those perhaps not quite ready for college-level math, the time needed to successfully complete prerequisites often delayed or derailed their progress. A collaborative system change framework and iterative process proved solid and flexible enough to withstand buffeting through stormy seasons of cuts to budgets, threats to shared governance, restructuring of the two-year colleges in UW System, multiple changes in senior leadership, and a 100-year pandemic. Significant impacts on students resulted when institutions embraced structural changes such as math pathways, the use of multiple measures for placement in math, and the development of co-requisite courses. The added focus on pedagogy--including equitable practices in online math instruction--is engaging more math faculty and staff, impacting more students, and contributing to sustainability of UW System Math Initiative progress.

Abstract Background Dissemination is a critical facet of implementing quality improvement in organizations. As a field, addiction treatment has produced effective interventions but disseminated them slowly and reached only a fraction of people needing treatment. This study investigates four methods of disseminating quality improvement (QI) to addiction treatment programs in the U.S. It is, to our knowledge, the largest study of organizational change ever conducted in healthcare. The trial seeks to determine the most cost-effective method of disseminating quality improvement in addiction treatment. Methods The study is evaluating the costs and effectiveness of different QI approaches by randomizing 201 addiction-treatment programs to four interventions. Each intervention used a web-based learning kit plus monthly phone calls, coaching, face-to-face meetings, or the combination of all three. Effectiveness is defined as reducing waiting time (days between first contact and treatment), increasing program admissions, and increasing continuation in treatment. Opportunity costs will be estimated for the resources associated with providing the services. Outcomes The study has three primary outcomes: waiting time, annual program admissions, and continuation in treatment. Secondary outcomes include: voluntary employee turnover, treatment completion, and operating margin. We are also seeking to understand the role of mediators, moderators, and other factors related to an organization's success in making changes. Analysis We are fitting a mixed-effect regression model to each program's average monthly waiting time and continuation rates (based on aggregated client records), including terms to isolate state and intervention effects. Admissions to treatment are aggregated to a yearly level to compensate for seasonality. We will order the interventions by cost to compare them pair-wise to the lowest cost intervention (monthly phone calls). All randomized sites with outcome data will be included in the analysis, following the intent-to-treat principle. Organizational covariates in the analysis include program size, management score, and state. Discussion The study offers seven recommendations for conducting a large-scale cluster-randomized trial: provide valuable services, have aims that are clear and important, seek powerful allies, understand the recruiting challenge, cultivate commitment, address turnover, and encourage rigor and flexibility. Trial Registration ClinicalTrials. govNCT00934141

Continuing education is being provided to professionals in the addiction treatment field to help them develop skills in process improvement and better meet the needs and requests they encounter. Access and retention of individuals seeking addiction treatment have been two of the greatest challenges addiction treatment professionals face. Unfortunately, an estimated 23 million Americans are in need of treatment and many are motivated to become drug free, but when they contact an addiction treatment agency, they often face delays of several days or weeks before they are admitted. As a result, many people lose their motivation to show up for treatment by the time their scheduled intake appointment arrives. Thus, busy agencies have high rates of no-shows, which leads to low admission, empty beds (or places in day treatment), and dropouts. In 2003, the Robert Wood Johnson Foundation (RWJF) and the Federal Center for Substance Abuse Treatment (CSAT) contracted with the College of Engineering at the University of Wisconsin-Madison to be a national program office to improve the delivery of addiction treatment in the United States, due to its prior success in using innovative approaches for organizational change within health and social service agencies. The goal of the Network for the Improvement of Addiction Treatment (NIATx) was to help agencies apply process improvement techniques to: (1) reduce wait time between a potential client's first request for service and actually receiving treatment; (2) reduce no-shows; (3) increase admissions; and (4) increase retention in care. NIATx developed and implemented several educational strategies to advance these goals: (1) a self-directed learning Web site with information about process improvement projects; (2) monthly expert facilitated group teleconferences; (3) coaching for agency-designated change agents; and (4) intensive collaborative learning workshops where agencies learn new strategies for process improvement. It was found that providing agencies with all of the educational resources led to significant improvement on all of the stated goals. However, providing all services was not practical for dissemination on a national level. In this article, the author shares her experience in using adult education principles on a national project to improve operations among drug and alcohol treatment agencies so they can better meet the needs of people who want to become drug-free.

Continuing education is being provided to professionals in the addiction treatment field to help them develop skills in process improvement and better meet the needs and requests they encounter. Access […]