Improving Quality of Acute Asthma Care in US Hospitals: Changes Between 1999-2000 and 2012-2013

Evaluating Quality of Care for Patients with Asthma in the Readmission Penalty Era

Rationale: Asthma poses a significant burden for U.S. patients and health systems, yet inpatient care quality is understudied. National chronic obstructive lung disease (COPD) readmission policies may affect inpatient asthma care through hospital responses to these policies because of imprecise diagnosis and identification of patients with COPD and asthma. Objectives: Evaluate inpatient care quality for patients hospitalized with asthma and potential collateral effects of the Medicare COPD Hospital Readmissions Reduction Program (HRRP). Methods: This was a retrospective cohort study of patients aged 18-54 years hospitalized for asthma across 924 U.S. hospitals (Premier Healthcare Database). Results: Care quality for patients with asthma was evaluated before HRRP implementation (n = 20,820; January 2010-September 2014) and after HRRP implementation (n = 26,885; October 2014-December 2018) using adherence to inpatient care guidelines (recommended, nonrecommended, and "ideal care" [all recommended with no nonrecommended care]). Between 2010 and 2018, at least 80% of patients received recommended care annually. Recommended care decreased similarly (rate of 0.02%/mo) after versus before HRRP (P = 0.8). Nonrecommended care decreased more rapidly after HRRP (rate of 0.29%/mo) versus before HRRP (rate of 0.17%/mo; P < 0.001), with changes driven largely by decreased antibiotic prescribing. Ideal care increased more rapidly after HRRP (rate of 0.25%/mo) versus before HRRP (rate of 0.17%/mo; P = 0.02), with changes driven largely by nonrecommended care improvements. Conclusions: Post-HRRP trends suggest asthma care improved with increased rates of guideline concordance in nonrecommended and ideal care. Although federal policies (e.g., HRRP) may have had positive collateral effects, such as with asthma care, parallel care efforts, including antibiotic stewardship, likely contributed to these improvements.

Cost variation and revisit rate for adult patients with asthma presenting to the emergency department

BACKGROUND

Asthma is common, resulting in 53 million emergency department (ED) visits annually. Little is known about variation in cost and quality of ED asthma care.

STUDY OBJECTIVE

We sought to describe variation in costs and 7-day ED revisit rates for asthma care across EDs. Our primary objective was to test for an association between ED costs and the likelihood of a 7-day revisit for another asthma exacerbation.

METHODS

We used the 2014 Florida State Emergency Department Database to perform an observational study of ED visits by patients ≥18 years old with a primary diagnosis of asthma that were discharged home. We compared patient and hospital characteristics of index ED discharges with and without 7-day revisits, then tested the association between ED revisits and index ED costs. Multilevel regression was performed to account for hospital-level clustering.

RESULTS

In 2014, there were 54,060 adult ED visits for asthma resulting in discharge, and 1667 (3%) were associated with an asthma-related ED revisit within 7 days. Median cost for an episode of ED asthma care was $597 with an interquartile range of $371-980. After adjusting for both patient and hospital characteristics, lack of insurance was associated with higher odds of revisit (OR 1.42, 95% CI 1.18-1.71), while private insurance, female gender, and older age were associated with lower odds of revisit. Hospital costs were not associated with ED revisits (OR = 1.00; 95% CI 1.00-1.00).

CONCLUSION

Hospital costs associated with ED asthma visits vary but are not associated with odds of ED revisit.

Association of Asthma Exacerbation Risk and Physician Time Expenditure With Provision of Asthma Action Plans and Education for Pediatric Patients

OBJECTIVE

To provide information about factors underlying provision of asthma action plans (AAPs) to a minority of pediatric patients with asthma, assess whether risk of exacerbation acts on provision of AAP and asthma education directly, suggesting targeting to highest-risk patients, or indirectly by influencing physician-patient interaction time.

METHODS

This study was a retrospective cross-sectional analysis of a nationally representative sample of physician office visits that consisted of patients aged 2 to 18 years with asthma. Exacerbation risk comprised proxy indicators of control and severity. Direct and time-mediated effects of exacerbation risk on provision of AAP and education were calculated from logistic regression models.

RESULTS

Asthma action plans were provided in 14.3% of visits, education in 23.9%. Total direct effects of exacerbation risk (ORs = 3.88-4.69) far exceeded indirect, time-mediated effects (both ORs = 1.03) on AAPs. Direct effects on education were similar but smaller. After adjusting for risk, physician time expenditure of ≥30 minutes was associated with nearly doubled odds of providing AAP or education (ORs = 1.90-1.99). Visits that included allied health professionals alongside physician care were significantly associated with all 4 outcomes in multivariate analyses (ORs = 3.06-5.28).

CONCLUSIONS

Exacerbation risk has a strong, direct association with AAP provision in pediatric asthma, even controlling for physician time expenditure. Provision of AAP and education to pediatric patients with asthma may be facilitated by increasing available time for office visits and involving allied health professionals.

Strategies for sustaining high-quality pediatric asthma care in community hospitals

OBJECTIVE

To identify strategies associated with sustained guideline adherence and high-quality pediatric asthma care in community hospitals.

DATA SOURCES

Primary qualitative data from clinicians in hospitals across the United States (collected December 2019-February 2021).

STUDY DESIGN

Pathways for Improving Pediatric Asthma Care (PIPA) was a national quality improvement (QI) intervention. In a prior quantitative study, data from 23 community hospitals in PIPA were analyzed to identify sites with the highest and lowest performance in sustaining improvements for 2 years. In this qualitative study, we conducted semi-structured interviews with multidisciplinary clinicians from these hospitals to identify strategies associated with sustainability.

DATA COLLECTION/EXTRACTION METHODS

We purposefully sampled and interviewed participants involved in clinical care of children hospitalized with asthma at the identified hospitals (those with the highest/lowest sustainability performance). We transcribed and analyzed interview data using constant comparative methods.

PRINCIPAL FINDINGS

Clinicians (n = 19) from five higher- and three lower-performing hospitals participated. In higher-performing hospitals, dedicated local champions more consistently provided reminders of evidence-based practices and delivered ongoing education. They also modified/developed electronic health record (EHR) tools (e.g., order sets with decision support). Higher-performing hospitals had a collaborative culture receptive to practice change and set firm expectations that evidence-based practices would be followed without exception. In lower-performing hospitals, participants described unique barriers, including delays in modifying the EHR and lack of automation of EHR tools (requiring clinicians to remember new EHR tasks without automated prompts). Barriers to sustainability for all hospitals included challenges with quality monitoring, decreasing focus of local champions over time, and ongoing difficulties developing consensus around evidence-based practices.

CONCLUSIONS

To better ensure sustained high-quality care for children with asthma and greater returns on QI investments, QI leaders should prioritize: designating long-term local champions to continue reminders and educational efforts and developing electronic order sets to provide ongoing decision support.

Real-world treatment patterns and clinical outcomes for inpatients with COVID-19 in the US from September 2020 to February 2021

The objective of this retrospective cohort study was to describe pre-treatment characteristics, treatment patterns, health resource use, and clinical outcomes among adults hospitalized with COVID-19 in the United States (US) who initiated common treatments for COVID-19. The Optum^® COVID-19 electronic health records database was used to identify patients >18 years, diagnosed with COVID-19, who were admitted to an inpatient setting and received treatments of interest for COVID-19 between September 2020 and January 2021. Patients were stratified into cohorts based on index treatment use. Patient demographics, medical history, care setting, medical procedures, subsequent treatment use, patient disposition, clinical improvement, and outcomes were summarized descriptively. Among a total of 26,192 patients identified, the most prevalent treatments initiated were dexamethasone (35.4%) and dexamethasone + remdesivir (14.9%), and dexamethasone was the most common subsequent treatment. At day 14 post-index, <10% of patients received any treatments of interest. Mean (standard deviation [SD]) patient age was 65.6 (15.6) years, and the most prevalent comorbidities included hypertension (44.8%), obesity (35.4%), and diabetes (25.7%). At the end of follow-up, patients had a mean (SD) 8.1 (6.6) inpatient days and 1.4 (4.1) days with ICU care. Oxygen supplementation, non-invasive, or invasive ventilation was required by 4.5%, 3.0%, and 3.1% of patients, respectively. At the end of follow-up, 84.2% of patients had evidence of clinical improvement, 3.1% remained hospitalized, 83.8% were discharged, 4% died in hospital, and 9.1% died after discharge. Although the majority of patients were discharged alive, no treatments appeared to alleviate the inpatient morbidity and mortality associated with COVID-19. This highlights an unmet need for effective treatment options for patients hospitalized with COVID-19.

Hospital-Initiated Care Bundle, Posthospitalization Care, and Outcomes in Adults with Asthma Exacerbation

BACKGROUND

Hospitalization for asthma exacerbation is an opportune setting for initiating preventive efforts. However, hospital-initiated preventive asthma care remains underdeveloped and its effectiveness is uncertain.

OBJECTIVE

To examine the effectiveness of a hospital-initiated asthma care bundle on posthospitalization asthma care and clinical outcomes.

METHODS

Prospective multicenter study of adults (18-54 years) hospitalized for asthma exacerbation in 2017 to 2019. During the hospitalization, we implemented an asthma-care bundle (inpatient laboratory testing, asthma education, and discharge care), and prospectively measured chronic asthma care (eg, immunoglobulin E testing, specialist care) and asthma exacerbation (ie, systemic corticosteroid use, emergency department [ED] visit, hospitalizations) outcomes. By applying a self-controlled case series method, we examined within-person changes in these outcomes before (2-year period) and after (1-year period) the bundle implementation.

RESULTS

Of 103 adults hospitalized for asthma exacerbation, the median age was 40 years and 72% were female. Compared with the preimplementation period, the postimplementation period had improved posthospitalized asthma care, including serum specific immunoglobulin E testing (rate ratio [RR] 2.18; 95% confidence interval [95% CI] 0.99-4.84; P = .051) and evaluation by asthma specialist (RR 2.66; 95% CI 1.77-4.04; P < .001). Likewise, after care bundle implementation, patients had significantly lower annual rates of systemic corticosteroid use (4.2 vs 2.9 per person-year; RR 0.70; 95% CI 0.61-0.80; P < .001), ED visits (3.2 vs 2.7 per person-year; RR 0.83; 95% CI 0.72-0.95; P = .008), and hospitalizations (2.1 vs 1.8 per person-year; RR 0.82; 95% CI 0.69-0.97; P = .02). Stratified analyses by sex, race/ethnicity, and health insurance yielded consistent results.

CONCLUSIONS

After hospital-initiated care bundle implementation, patients had improved posthospitalization care and reduced rates of asthma exacerbation.

Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative

BACKGROUND

Community hospitals, which care for most hospitalised children in the USA, may be vulnerable to declines in paediatric care quality when quality improvement (QI) initiatives end. We aimed to evaluate changes in care quality in community hospitals after the end of the Pathways for Improving Paediatric Asthma Care (PIPA) national QI collaborative.

METHODS

We conducted a longitudinal cohort study during and after PIPA. PIPA included 45 community hospitals, of which 34 completed the 12-month collaborative and were invited for extended sustainability monitoring (total of 21-24 months from collaborative start). PIPA provided paediatric asthma pathways, educational materials/seminars, QI mentorship, monthly data reports, a mobile application and peer-to-peer learning opportunities. Access to pathways, educational materials and the mobile application remained during sustainability monitoring. Charts were reviewed for children aged 2-17 years old hospitalised with a primary diagnosis of asthma (maximum 20 monthly per hospital). Outcomes included measures of guideline adherence (early bronchodilator administration via metered-dose inhaler (MDI), secondhand smoke screening and referral to smoking cessation resources) and length of stay (LOS). We evaluated outcomes using multilevel regression models adjusted for patient mix, using an interrupted time-series approach.

RESULTS

We analysed 2159 hospitalisations from 23 hospitals (68% of eligible). Participating hospitals were structurally similar to those that dropped out but had more improvement in guideline adherence during the collaborative (29% vs 15%, p=0.02). The end of the collaborative was associated with a significant initial decrease in early MDI administration (81%-68%) (adjusted OR (aOR) 0.26 (95% CI 0.15 to 0.42)) and decreased rate of referral to smoking cessation resources (2.2% per month increase to 0.3% per month decrease) (aOR 0.86 (95% CI 0.75 to 0.98)) but no significant changes in LOS or secondhand smoke screening.

CONCLUSIONS

The end of a paediatric asthma QI collaborative was associated with concerning declines in guideline adherence in community hospitals.

Improving asthma care with Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE)

BACKGROUND

Emergency departments (ED) are important providers of asthma care, particularly after-hours. We identified gaps for quality improvement such as suboptimal adherence rates to three key recommendations from the Global Initiative for Asthma (GINA) guidelines for discharge management asthma guidelines. These were: the prescription of oral and inhaled corticosteroids (OCS and ICS) and issuance of outpatient follow-up for patients discharged from the ED.

AIM

To achieve an adherence rate of 80% to GINA guidelines for ED discharge management by providing after-hours asthma counselling services.

METHODS

We implemented Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE) according to the Plan-Do-Study-Act (PDSA) framework to provide after-hours asthma counselling and clinical decision support to ED physicians three nights a week. Data on adherence rates to the GINA guidelines were collected and analysed on a run chart.

RESULTS

After 17 months' follow-up, a sustained improvement was observed in patients reviewed by A-CARE in the median adherence rates to OCS prescription (58% vs 86%), ICS initiation (27% vs 67%) and issuance of follow-up (69% vs 92%), respectively. The overall impact was, however, limited by a suboptimal referral rate to A-CARE (16%) in a clinical audit of all ED patients with asthma. Nonetheless, in this audit, attendance rates for patients referred to our respiratory department for follow-up were higher in those receiving asthma counselling compared with those who did not (41.7% vs 15.9%, p=0.0388).

CONCLUSION

Sustained improvements in the adherence rates to guidelines were achieved for patients reviewed by A-CARE but were limited in overall impact due to suboptimal referral rate. We plan to improve the quality of asthma care by implementing further PDSA cycles to increase the referral rates to A-CARE.

Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): A Multicenter, National Study

BACKGROUND AND OBJECTIVES

Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve inpatient asthma care but mainly in studies at large, tertiary children's hospitals. It remains unclear if these effects are generalizable across diverse hospital settings. Our objective was to improve inpatient asthma care by implementing pathways in a diverse, national sample of hospitals.

METHODS

We used a learning collaborative model. Pathway implementation strategies included local champions, external facilitators and/or mentors, educational seminars, quality improvement methods, and audit and feedback. Outcomes included length of stay (LOS) (primary), early administration of metered-dose inhalers, screening for secondhand tobacco exposure and referral to cessation resources, and 7-day hospital readmissions or emergency revisits (balancing). Hospitals reviewed a sample of up to 20 charts per month of children ages 2 to 17 years who were admitted with a primary diagnosis of asthma (12 months before and 15 months after implementation). Analyses were done by using multilevel regression models with an interrupted time series approach, adjusting for patient characteristics.

RESULTS

Eighty-five hospitals enrolled (40 children's and 45 community); 68 (80%) completed the study (n = 12 013 admissions). Pathways were associated with increases in early administration of metered-dose inhalers (odds ratio: 1.18; 95% confidence interval [CI]: 1.14-1.22) and referral to smoking cessation resources (odds ratio: 1.93; 95% CI: 1.27-2.91) but no statistically significant changes in other outcomes, including LOS (rate ratio: 1.00; 95% CI: 0.96-1.06). Most hospitals (65%) improved in at least 1 outcome.

CONCLUSIONS

Pathways did not significantly impact LOS but did improve quality of asthma care for children in a diverse, national group of hospitals.

Nursing intensity scores did not correlate well with reimbursement claims for infant bronchiolitis

AIM

We retrospectively evaluated the hospital reimbursement rates for inpatient bronchiolitis treatment and then compared them to the RAFAELA^® nursing intensity scores.

METHODS

We selected all 44 bronchiolitis patients treated in the paediatric intensive care unit (PICU) and then for each PICU-treated patient two patients treated on the ward (n = 88) under 12 months of age in 2010-2015. The data included medical histories, hospital reimbursement rates using the Nordic Diagnosis Related Groups (NordDRG) or expense categories and the RAFAELA^® scores.

RESULTS

Reimbursement claims were mostly based on expense categories for PICU admissions and NordDRG categories for ward admissions. The median (range) was €6352 (€1330-30 554) and €2009 (€768-6027) per episode for the PICU and ward cases, respectively. The median lengths of hospital stay were 8.5 days (3-18) and 3 days (1-8), respectively. Higher RAFAELA^® scores were associated with nasal continuous positive airway pressure therapy and mechanical ventilation in the PICU and oxygen supplementation and nasogastric tube feeding on the ward. The correlation coefficients between RAFAELA^® scores and hospital reimbursement claims ranged from 0.121-0.450.

CONCLUSION

Hospital reimbursement claim for a PICU admission was three times as much as a ward admission and reimbursement claims for bronchiolitis did not match with nursing intensity scores.

Nationwide pulmonary function test rates in South Korean asthma patients

BACKGROUND

Previous studies have shown that pulmonary function tests (PFTs) are performed at considerably lower rates than would be expected if standard guidelines were followed. The goal of this study was to evaluate the current status of PFT performance in the Republic of Korea.

METHODS

We analysed quality assessment data from a nationwide Health Insurance Review and Assessment Service database collected from July 2013 to June 2014. PFT performance rates were compared among types and specialties of medical institutions. PFT performance rates were also measured by patient gender, age, and insurance type. Possession rates of PFT equipment and performance rates of each type of PFT were also evaluated.

RESULTS

A total of 16,804 institutions and 831,613 patients were included in this study. The mean overall PFT performance rate was 22.67%. The performance rate in tertiary hospitals was 78.00%, while PFTs were performed in only 20.87% of asthma patients at primary health clinics. Male and elderly patients received PFTs more frequently than did female and younger patients. Also, patients who were covered by the Korean Veterans Health Service received a PFT more frequently than those covered by other insurance services. The possession rate of PFT equipment was significantly higher in tertiary hospitals than in primary health clinics. Of all PFT types, spirometry with flow-volume curve was performed for most patients.

CONCLUSIONS

The PFT performance rate was significantly lower than would be expected if guidelines were followed. Average performance rates were higher in tertiary hospitals and for male and elderly patients.

Comparing Ran-Out Status of Inhaled Short-Acting Beta-Agonists in Emergency Department Patients with Acute Asthma: 1996-1998 versus 2015-2017

BACKGROUND

Medication nonadherence, including running out of inhaled asthma medications, is an important problem.

OBJECTIVE

The objective of this study was to examine the changes in the proportion of adults with acute asthma who ran out of their short-acting beta-agonist (SABA) inhalers before presenting to the emergency department (ED) between 1996--1998 and 2015-2017.

METHODS

We analyzed data from prospective multicenter observational cohort studies of ED adult patients (aged 18-54 years) with acute asthma. Within the same 3 EDs, we performed a structured interview during 2 time periods: 1996-1998 and 2015-2017. We fitted multivariable models to compare ran-out status between the 2 periods, adjusting for the baseline patient demographics, socioeconomic status, chronic asthma factors, and health care utilization factors. We further adjusted for the presence of a written action plan-an intervenable factor.

RESULTS

The analytic cohort comprised 353 patients (150 from the 1996-1998 studies and 203 from the 2015-2017 study). Over the approximately 20-year period, the proportion of patients who ran out of SABA inhalers increased (18% in 1996-1998 vs 26% in 2015-2017). In the multivariable model, compared with patients in 1996-1998, those in 2015-2017 had a significantly higher risk of running out of their SABA inhalers (adjusted odds ratio [OR] 2.01; 95% confidence interval [CI] 1.06-3.81; P = .03). With further adjustment for the presence of a written action plan, this difference attenuated (adjusted OR 1.66; 95% CI 0.75-3.68; P = .21).

CONCLUSIONS

Between 1996 and 2017, the proportion of ED patients with asthma who ran out of SABA inhalers significantly increased. The increase was explained, at least partially, by a lack of a written action plan.

Severe Asthma Phenotypes - How Should They Guide Evaluation and Treatment?

Although patients with "severe" asthma tend to be characterized by ongoing symptoms and airway inflammation despite treatment with high doses of inhaled and systemic corticosteroids, there is increasing recognition of marked phenotypic heterogeneity within affected patients. Although "precision medicine" approaches for patients with severe asthma are needed, there are many hurdles that must be overcome in daily practice. The National Heart, Lung and Blood Institute's Severe Asthma Research Program (SARP) has been at the forefront of phenotype discovery in severe asthma for the past decade. SARP, along with other international groups, has described clinical severe asthma phenotypes in both adults and children that can be evaluated in the clinical setting. Although these clinical phenotypes provide a good "starting point" for addressing disease heterogeneity in severe asthma in everyday practice, more efforts are needed to understand how these phenotypes relate to underlying disease mechanisms and pharmacological treatment responses. This review highlights the clinical asthma phenotypes identified to date, their associations with underlying endotypes and potential biomarkers, and remaining knowledge gaps that must be addressed before precision medicine can become a reality for patients with severe asthma.

Management of acute asthma exacerbations

PURPOSE OF REVIEW

Herein, we review the current guidelines for the management of children with an acute asthma exacerbation. We focus on management in the emergency department, inpatient, and ICU settings.

RECENT FINDINGS

The most recent statistics show that the prevalence of asthma during childhood has decreased in certain demographic subgroups and plateaued in other subgroups. However, acute asthma accounts for significant healthcare expenditures. Although there are few, if any, newer therapeutic agents available for management of acute asthma exacerbations, several reports leveraging quality improvement science have shown significant reductions in costs of care as well as improvements in outcome.

SUMMARY

Asthma is one of the most common chronic conditions in children and the most common reason that children are admitted to the hospital. Nevertheless, the evidence to support specific agents in the management of acute asthma exacerbations is surprisingly limited. The management of acute exacerbations focuses on reversal of bronchospasm, correction of hypoxia, and prevention of relapse and recurrence. Second-tier and third-tier agents are infrequently used outside of the ICU setting. Reducing the variation in treatment is likely to lead to lower costs and better outcomes.