Study Shows Hospital Compliance With Children's Asthma Care Measures Does Not Reduce Returns to ER, Hospital Readmissions; PolicyLab Research Included in Study Findings in JAMA
A study published this week in the Journal of the American Medical Association (JAMA) is the first to look at the association of asthma care quality measures during hospitalization and subsequent asthma-related readmissions or emergency care. Asthma remains the major cause of preventable hospitalizations for children in the U.S.
The three Children’s Asthma Care (CAC) core measures are monitored by the Joint Commission and are meant to evaluate whether patients aged 2 to 17 years with an asthma exacerbation (1) received relievers and (2)systemic corticosteroids during their stay, and whether they (3)were discharged with a complete plan of care for at-home management of asthma.
The study included data from 30 freestanding children’s hospitals in the United States. Researchers found that, while compliance for the three CAC core measures increased over the 2-year study period, improved compliance was not associated with declines in returns to the emergency department or hospital readmission in the 7, 30, and 90 days that followed an initial hospitalization for asthma. While home management plans of care may be an important component of treatment of asthma, the authors conclude that they may not be appropriate to classify as “accountability measures” for hospitals given that hospital-based physicians cannot monitor what happens to a family once they leave the hospital and that so much of what happens to a patient with asthma is influenced by exposures beyond the walls of the hospital.
Although post-discharge education and follow up is an important aspect of care to measure, the lack of an association between this specific measure and readmission highlights an opportunity for further investigation and refinement. The research team recommends that the asthma home management plan of care be re-evaluated as an accountability measure used by the Joint Commission. The team did not recommend that these plans of care not be done. The key is to ensure that evidence-based practices are part of the plan families follow at home and that the plan is communicated effectively to enhance adherence.
Evan Fieldston, MD, MBA, MSHP, a pediatrician and health services researcher at The Children’s Hospital of Philadelphia’s PolicyLab, was one of several researchers to collaborate on this multi-center study. “We are certainly not advising that clinicians stop creating and updating asthma care plans. Of course, it is a good thing to offer patients education about how to manage their care at home and put that in writing,” Dr. Fieldston clarifies. “What we are saying is that we need to consider whether or not this is the right item to use as a hospital accountability measure. Moreover, we need to make sure that care plans are more than just a piece of paper. They need to be effective at communicating information to families after they leave the hospital in order to improve outcomes and decrease readmissions.”
As defined by the Joint Commission, accountability measures are “evidence-based care processes closely linked to positive patient outcomes.” More than 50 quality measures are in place for Joint Commission-accredited hospitals for a number of common diagnoses among adults. However, until recently, no such measures existed for the treatment of hospitalized children. The three Children’s Asthma Care (CAC) core measures remain the only set focused on children, making it particularly important to evaluate them, as the Joint Commission considers implementing similar measures for additional diagnoses.
Commenting on the research in an accompanying editorial in the same issue of JAMA, Charles Homer, MD, MPH, President and CEO of National Initiative for Children's Healthcare Quality, wrote, “Measurement can play a key role in helping redress the shortcomings of the US health care system, but measures must meet high standards. The study by Morse et al, highlighting the great value of ‘postmarketing surveillance’ of performance measures, demonstrates that the Joint Commission's Children's Asthma Care measure 3, an asthma discharge plan, no longer reaches this threshold and should be retired, as should the other components if the nonvariability found in this study is replicated in nonspecialty hospitals.”
Mark Magnusson, MD, PhD, Attending Physician in General Pediatrics, Medical, and Co-chair of the Asthma Care Committee at CHOP, noted, “We are committed to providing the very best care to children and the home management care of plan is a part of that work. Our multi-disciplinary team of inpatient and outpatient professionals seeks to ensure that all asthma care, including the written plans, are effective in terms of improving quality of life for patients and their families.” Dr. Magnusson was recently appointed to the Child Health Corporation of America’s expert panel about asthma care measures, chaired by the lead author of the JAMA study.
The study, “Hospital-Level Compliance with Asthma Care Quality Measures at Children’s Hospitals and Subsequent Asthma-Related Outcomes,” can be read in its entirety at http://jama.ama-assn.org/. An excellent editorial regarding quality and accountability measurement in the hospital setting accompanies the article, and is available at http://jama.ama-assn.org/content/306/13/1487.extract.
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