Study focuses on asthma discharge outcomes

Standardization is needed

One of the key discharge priorities in care for children involves asthma. Poor patient compliance with medication and self-care can lead to acute episodes and extra emergency room visits and hospitalizations.

Asthma episodes result in about 200,000 hospital admissions in the United States each year, and their treatment costs more than $3 billion. Previous studies have shown that inappropriate treatment is a major contributor to acute episodes, so various national organizations have developed asthma guidelines, but too few hospital emergency department employees have heard of these.1

The Joint Commission has made the Children’s Asthma Care (CAC) measures its only core measures applicable to evaluate care for hospitalized children.1

So researchers at Phoenix Children’s Hospital used the three CAC measures in a study of hospital compliance, based on data for 30 U.S. children’s hospitals. Data came from more than 37,000 hospital visits by children with asthma, and taking place between 2008 and 2010. The CAC measures include CAC-1 which refers to relievers for inpatient asthma; CAC-2, which are systemic corticosteroids for asthma; and CAC-3, which is a home management plan of care.1

They found that there was a high hospital-level compliance with CAC-1 and CAC-2 quality measures, but more moderate compliance with having a home management plan of care. The study also found no association between CAC-3 compliance and emergency department visits and asthma-related readmissions.1

"Compliance with CAC-3 started at approximately 40% initially and topped off at 73% over three years," says Rustin B. Morse, MD, medical director for quality at Phoenix Children’s Hospital, University of Arizona College of Medicine in Phoenix, AZ.

"There was no difference in readmission rates in that period of time," Morse says.

Despite the findings, home management plans of care for asthma patients represent an important part of the hospital discharge process, he says.

"It’s hard to evaluate interventions performed at the hospital level to see who is doing better," he adds.

So researchers work with the tools and data they have available, and these include the readmission rates.

"Our 30-day readmission rate for asthma in this population is lower than the typical readmission rate quoted in the adult literature," Morse says. "But more needs to be done to evaluate readmission as a measure of quality in pediatrics."

Intuitively, health care providers would think that compliance with CAC-1 and CAC-2 would lead to better outcomes and care, but this cannot be proven in a study until data are available from hospitals that demonstrate poor compliance with these measures. Obtaining such data would be difficult because adult hospitals do not have to collect these particular core measures, he notes.

"Hospitals that are Joint Commission accredited have to choose core measures, but not that many nonpediatrics are choosing asthma core measures," Morse says. "So how do we measure the quality of care in community hospitals to make sure they’re providing the same level of care as the children’s hospitals?"

Morse and co-authors wanted to see if trends noted in the literature about adult chronic illnesses proved to be true for children and asthma. Among these was the trend of low compliance and whether compliance was associated with outcomes. However, for the measures involving treatment, the hospitals were highly compliant. So they measured the compliance with the home management plan of action, which was less than ideal, and compared that with readmissions and ED visits.

"There are challenges with quality measurement and proving improved health or outcomes," Morse notes.

"If a hospital gives an aspirin to a heart attack patient, then the patient will have an improved mortality rate, but is this plan of care equivalent to that aspirin?" he explains. "Does it improve their clinical outcomes in some fashion, and should everyone be doing it? That was the challenge we faced."

What they found was that compliance for CAC-1 and CAC-2 was very high at all 30 children’s hospitals, but compliance with CAC-3 was not. Nonetheless, they discovered no difference in hospital utilization.

"The home management plan of care makes perfect sense," Morse says. "Patients should be able to measure asthma and know what happens, so we’re not saying they shouldn’t do those things."

But the way this standard was measured, it did not appear to be linked to improved outcomes, he adds.

One thing hospital discharge planners should keep in mind is that children’s hospitals already have very good outcomes in asthma care, and they demonstrate overall fairly high compliance in the three core measures.

"What’s important to me is the flip side of that coin where there is plenty of care for children outside of children’s hospitals, and whether these children were receiving these high levels of care," Morse says.

"Compliance in children’s hospitals was so high that we could not determine whether improvements in compliance would be associated with improvements in outcomes," he adds. "But we should make sure that every child admitted to community hospitals is receiving the same level of care."

The next step from an asthma home management plan of care perspective would be to find out which parts of the plans of care are of greatest value, Morse says.

One part requires some type of arrangement for follow-up care, including a scheduled appointment or giving patients and families the name of a provider they can call, he says.

"Perhaps, as we think about the appropriate transition of care as we move from inpatient to outpatient, that bar should be raised higher," Morse says. "Hospital discharge staff might actually make the appointments for patients and make follow-up calls to them about the appointment."

This is improving the connection between inpatient and outpatient care and optimizing the patient’s potential to get the same quality on the outside as on the inside, he adds.

Another point is that emergency department and hospital utilization might not be the only or best outcomes to be evaluated in asthma care for children, Morse says.

"There are plenty of other potential outcome measures than readmission rates," Morse says. "The exciting part of what we’re doing now is beginning to think about what are the right outcome measures to think about quality of care at the hospital level for children."

For example, quality of life and productivity outcomes might be used.

"We need measures like the number of days of school a patient misses or days of work missed because the parent is taking care of the child," he says. "What types of functional measures can we implement in a reasonably feasible manner to identify who is providing the best quality of care, and that is not easy."

Measuring readmission rates is far easier.

"It’s very difficult to sit down with a seven-year-old and ask them how they feel when they are running around the playground, so that’s the next challenge," Morse says. "How do you balance time and the cost element and measure the process of care in the hospital and outcomes after discharge?"


1. Morse RB, Hall M, Fieldston ES, et al. Hospital-level compliance with asthma care quality measures at children’s hospitals and subsequent asthma-related outcomes. JAMA. 2011;306(13):1454-1460.