Improved quality of asthma care has not reduced readmission rates to hospitals, ED

Homer CJ. JAMA. 2011;doi:10.1001/jama.2011.1422.

Morse RB. JAMA. 2011;doi:10.1001/jama.2011.1385.

Despite improved asthma care quality measures by children’s hospitals, including increased use of a written home management plan upon discharge, rates of subsequent ED visits and asthma-related readmissions did not decline, according to results of a new study.

“We did not find an association between hospital-level measure compliance and patient outcomes. This doesn’t mean implementing these measures is not helpful on an individual patient level. For example, we know that prescribing inhaled corticosteroids for children with chronic asthma reduces subsequent asthma attacks and is good long term for the child. But when you measure aggregate compliance, it’s worrisome we didn’t see benefit,” Samir S. Shah, MD, MSCE, senior researcher of the study and associate professor of pediatrics at Cincinnati Children’s Hospital Medical Center, told Infectious Diseases in Children. “It may be that we have to collect more information in a more detailed manner.”

The researchers evaluated trends in Children’s Asthma Care (CAC) measure compliance at children’s hospitals and the association between CAC measure compliance and improvements in clinical outcomes.

The study included administrative and CAC compliance data from 30 US children’s hospitals that included 37,267 children admitted with asthma between January 2008 and September 2010, accounting for 45,499 hospital admissions. Follow-up was through December 2010, according to a press release.

The CAC set of process measures evaluates whether patients aged 2 to 17 years who are admitted with an asthma exacerbation received relievers (CAC-1) and systemic corticosteroids (CAC-2) during admission and whether they were discharged with a complete home management plan of care (CAC-3), according to the study investigators.

They found that there was a level of hospital compliance with CAC-1 and CAC-2 quality measures and moderate compliance with the CAC-3 measure for children admitted to pediatric hospitals for asthma, but no association between CAC-3 compliance and subsequent ED visits and asthma-related readmissions.

“I view our findings as a great opportunity to highlight the importance of ongoing efforts to continue to develop, refine and evaluate pediatric quality measures,” lead researcher of the study, Rustin B. Morse, MD, of the Phoenix Children’s Hospital and University of Arizona College of Medicine, told Infectious Diseases in Children.

Rustin B. Morse

According to the study results, the minimum quarterly compliance rates that a hospital reported for CAC-1 and CAC-2 measures were 97.1% and 89.5%, respectively. Average CAC-3 compliance was 40.6% during the initial three quarters and increased to 72.9% during the final three quarters of the study. The average post-discharge ED utilization rates were 1.5% at 7 days, 4.3% at 30 days and 11.1% at 90 days, whereas the average quarterly readmission rates were 1.4% at 7 days, 3.1% at 30 days and 7.6% at 90 days.

The researchers said CAC compliance alone cannot serve as a means to evaluate and compare the quality of care provided for patients admitted to children’s hospitals with asthma exacerbations.

They concluded that the CAC-3 measure in its current form may not meet the criteria outlined by the Joint Commission for accountability measures and that the Joint Commission should reconsider whether the CAC-3 component of the measure set is appropriately classified as an “accountability measure” suitable for public reporting, accreditation or pay for performance.

“In the end, this is all about doing what is right for ill or injured children. We need to continue to develop measures that ensure children are consistently receiving high-quality care in all health care settings,” Morse said.

In an accompanying editorial, Charles J. Homer, MD, MPH, of the National Initiative for Children’s Healthcare Quality, Harvard Medical School, and Children’s Hospital Boston, wrote that measurement can help with the shortcomings of the US health care system, but that measures must meet high standards.

Shah said he also believes that measuring compliance with certain measures is an important strategy to improve the quality of care.

“However, it is important to ensure that the quality measures reflect quality of care as defined by patient outcomes,” he said. “Part of the challenge is that we’re not able to measure care after hospital discharge. Once a child feels better, it’s human nature that taking extra steps, such as making a follow-up appointment, seems less urgent from the family perspective.” – Cassandra A. Richards

Disclosure: Drs. Morse, Shah and Homer report no relevant financial disclosures.

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