Chapter Quality Network: EQIPP Data Collection Tool
Patient name: __________________________________________Age of patient: __ years __ months
Note: EQIPP does not record any patient identifying information. You may enter it here on the printed copy of the data collection tool for your
own record-keeping purposes, for example, to attach to the patient chart.
Directions: Collectively as a practice use this data collection tool for the next 10 or more patients seen in your office for treatment of asthma.
1. Has this child visited the Emergency Room or Urgent Care Center due to asthma in the past 12 months?
 Yes
 No
2. Has this child been admitted to the hospital due to asthma in the past 12 months?
 Yes
 No
3. Were one or more asthma key indicators present when considering the diagnosis of asthma?
 Yes
 No  Not documented
4. Were lung function measures by spirometry used to establish the asthma diagnosis?
 Yes
 No
 Age inappropriate, younger than 5 years
5. Was a validated instrument (or questions) used to determine the current level of asthma control?
 Yes
 No
6. What is the patient’s current level of control during the past month? (Click to review the National Heart, Lung,
and Blood Institute [NHLBI] Expert Panel Report 3 [EPR-3] control tables.)
 Well controlled
 Not well controlled
 Very poorly controlled
If “not well controlled” or “very poorly controlled”:
6b. Did you identify reason(s) for lack of control? (Examples: exposure to allergens, tobacco smoke,
indoor or outdoor pollutants and irritants, non-adherence to medication regimen)
 Yes
 No
7. Is spirometry currently scheduled to be tested, or have results been obtained within the last 1 or 2 years?
 Yes  No  Age inappropriate, younger than 5 years
8. Have you used the age-appropriate NHLBI EPR-3 stepwise table used to identify treatment options or to
adjust therapy based on asthma control?
 Yes
 No
9. Has a flu shot been administered or a recommendation made within the past 12 months?
 Yes
 No
 Patient younger than 6 months, other contraindications, or vaccine unavailable
10. Does the patient have a written asthma action plan?
 Yes
 No
If yes:
10b. If yes, was the plan updated as needed and reviewed with the patient and/or family at this visit?
 Yes
 No
11. Were asthma self-management education and materials (other than or in addition to the asthma action plan)
provided and explained to the patient and family at any visit? (Examples include correct medication
techniques, avoiding environmental triggers, and getting help to quit smoking. See Figure 3–13, Delivery of
Asthma Education by Clinicians During Patient Care Visits for more information.)
 Yes
 No
12. Was a follow-up appointment scheduled to monitor asthma control?
 Yes
 No
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Chapter Quality Network: EQIPP Data Collection Tool
APPENDIX
<text that displays when previous links are clicked:>
Asthma key indicators:
 History of recurrent wheezing episodes that respond to treatment
 History of any of the following:
- cough, worse particularly at night
- recurrent difficulty in breathing
- recurrent chest tightness
 Direct observation in the clinic of acute wheezing that responds to bronchodilators
 Recurrent respiratory symptoms in a child at high risk for development of asthma (eg, positive asthma
predictive index)
Example validated instruments used to determine the level of asthma control:
 Asthma Therapy Assessment Questionnaire (ATAQ)
 Asthma Control Questionnaire (ACQ)
 Asthma Control Test (ACT)
 Childhood Asthma Control Test (Childhood ACT)
<For NHLBI EPR-3 control tables, display a list of tables that the learner can click on to open the table.>
Assessing Asthma Control



Figure 3-5a, Assessing Asthma Control in Children 0–4 Years of Age
Figure 3-5b, Assessing Asthma Control in Children 5–11 Years of Age
Figure 3-5c, Assessing Asthma Control in Youths 12 Years of Age and Adults
Classifying Asthma Severity to Initiate Treatment



Figure 4-2a, Classifying Asthma Severity and Initiating Therapy in Children 0–4 Years of Age
Figure 4-2b, Classifying Asthma Severity and Initiating Therapy in Children 5–11 Years of Age
Figure 4-6, Classifying Asthma Severity and Initiating Therapy for Youths 12 Years of Age and Adults
Assessing Asthma Control to Maintain or Adjust Therapy



Figure 4-3a, Assessing Asthma Control and Adjusting Therapy in Children 0–4 Years of Age
Figure 4-3b, Assessing Asthma Control and Adjusting Therapy in Children 5–11 Years of Age
Figure 4-7, Assessing Asthma Control and Adjusting Therapy for Youths 12 Years of Age and Adults
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Chapter Quality Network: EQIPP Data Collection Tool
<For NHLBI EPR-3 stepwise tables display a list of tables that the learner can click on to open the table.>
Stepwise Approach



Figure 4-1a. Stepwise Approach for Managing Asthma in Children 0–4 Years of Age
Figure 4-1b. Stepwise Approach for Managing Asthma in Children 5–11 Years of Age
Figure 4-5. Stepwise Approach for Managing Asthma in Youths 12 Years of Age and Adults
Selecting Medication Dosages
For children:
 Figure 4–4a. Usual Dosages for Long-term Control Medications in Children
 Figure 4–4b. Estimated Comparative Daily Dosages for Inhaled Corticosteroids in Children
 Figure 4–4c.Usual Dosages for Quick-Relief Medications in Children
For youths:
 Figure 4–8a. Usual Dosages for Long-term Control Medications for Youths 12 Years of Age and Adults
 Figure 4–8b. Estimated Comparative Daily Dosages for Inhaled Corticosteroids for Youths 12 Years of
Age and Adults
 Figure 4–8c.Usual Dosages for Quick-Relief Medications for Youths 12 Years of Age and Adults
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Chapter Quality Network: EQIPP Data Collection Tool
Figure 3–13
Figure 3–13 continued on next page…
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Chapter Quality Network: EQIPP Data Collection Tool
From the National Asthma Education and Prevention Program (NAEPP)/National Heart, Lung, and Blood Institute (NHLBI).
Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma—Full Report, 2007. Bethesda, MD: NHLBI;
2007: 126-127. Complete reference information for the sources mentioned in the footnote in the original figure is given on
pages 146-164 in the report. Used by permission.
Copyright © 2009. All rights reserved.
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