Multilevel Approach Improves Pediatric Asthma Care

Nicola M. Parry, DVM

September 22, 2017

Using a hospital-driven, integrated, multilevel, quality improvement approach that extends into the community leads to improved asthma outcomes among pediatric patients with asthma, a new study shows.

Carolyn M. Kercsmar, MD, from the Cincinnati Children's Hospital Medical Center, Ohio, and colleagues published the results of their study online September 18 in JAMA Pediatrics.

"During the initiative, Medicaid-insured children had a more than 40% relative decrease in asthma-related hospitalizations and [emergency department (ED)] visits, whereas the number of 30-day return visits to the hospital or ED after an index hospitalization decreased by 41%," the authors write.

Successful long-term asthma management continues to be a challenge, the authors say. Only about half of patients with asthma keep appointments or fill prescriptions, and about 40% of children and adolescents hospitalized for asthma require rehospitalizations or ED revisits within 12 months.

The investigators therefore aimed to examine the effect of a hospital-driven improvement collaborative on acute asthma healthcare use in pediatric patients. Using quality improvement methods and the chronic care model, they conducted interventions in three phases: hospital-based inpatient care redesign (phase 1), outpatient-based care enhancements (phase 2), and community-based supports and partnerships (phase 3).

The improvement team comprised a multidisciplinary group of clinicians, including primary care providers, community pediatricians, ED physicians, and pediatric pulmonologists, as well as social workers, nurses, respiratory therapists, pharmacists, quality improvement consultants, and representatives from Medicaid managed care organizations.

The study included an estimated 36,000 children and adolescents (aged 2 - 17 years) with asthma, approximately 13,000 of whom were Medicaid insured and 6000 of whom received care in the medical center's primary care practices.

The investigators evaluated asthma-related hospitalizations and ED visits per 10,000 Medicaid-insured pediatric patients during a 5-year intervention period from January 1, 2010, through December 31, 2015, using data from previous years to establish a baseline.

They found improvements across each of the three phases.

One of the improvement activities implemented in phase 1 was a medications-in-hand program to ensure provision of a 30-day supply of medications to all patients for use at home. Although only 50% of patients were discharged with a 30-day supply of inhaled controller medications in May 2008, this rose to 90% by May 2010. Similarly, the percentage of patients discharged with a short course of oral corticosteroids increased from 0% to 70% by March 2011.

And within 3 years of implementing the phase 1 interventions, the 30-day rate at which hospitalized patients were rehospitalized or revisited the ED also decreased by 41%, dropping from 12% to 7%.

Phase 2 focused on outpatient care, including baseline asthma control of the primary care patients. The study showed that by the end of June 2015, 763 patients with high-risk asthma had been enrolled in asthma care coordination and 394 had graduated after having no hospitalizations or ED visits for 365 consecutive days after enrollment. in addition, 345 patients were offered and received medication home delivery services.

Overall, implementation of phase 2 interventions was associated with improved asthma control, with the percentage of primary care patients with well-controlled asthma increasing from 48% to 54%.

Phase 3 focused on improving connections between the medical center and community-based resources, with interventions aiming to enhance screenings and communication. By the end of the 5-year period, more than 80% of Cincinnati public school students with asthma were evaluated using the Asthma Control Test, and those with suboptimal scores were referred for medical treatment.

According to the authors, by June 30, 2014, this multitiered collaborative approach led to a 41.8% (95% confidence interval [CI], 41.7% - 42.0%) relative reduction in asthma-related hospitalizations (decreasing from 8.1 [95% CI, 7.7% - 8.5%] to 4.7 [95% CI, 4.3% - 5.1%] per 10,000 Medicaid patients per month) and a 42.4% (95% CI, 42.2% - 42.6%) relative reduction in asthma-related ED visits (decreasing from 21.5 [95% CI, 20.6 - 22.3] to 12.4 ([5% CI, 11.5 - 13.2] visits per 10,000 Medicaid patients per month).

These benefits were also sustained during the subsequent 12-month period, the authors add.

As pediatric patients with asthma experience considerable morbidity and disparities, Dr Kercsmar and colleagues conclude that a "multidisciplinary approach to improving family-centered care delivery may reduce the rate of health care utilization for high-risk patients." This approach is not only feasible but also involves cost savings that could help sustain the program, they stress.

In an accompanying editorial, Sean M. Frey, MD, and Jill S. Halterman, MD, both from the University of Rochester School of Medicine and Dentistry, New York, acknowledge the promising nature of these results. This study "is a demonstration of how interdisciplinary care focused within a biopsychosocial model can improve outcomes for vulnerable children," they say.

And although the large number of interventions used in the study prevented the investigators from identifying which specific interventions had the greatest effect on patient outcomes, the editorialists consider the multitiered approach to be a strength of the program and suggest that the improvements were likely a result of the synergistic influence on patients and processes.

"Future efforts to replicate these results in other communities should continue to emphasize this patient-centered, biopsychosocial philosophy, with heightened attention to the challenges that remain for children and families," the editorialists state.

Highlighting the higher background rates of asthma prevalence and morbidity in black and Hispanic children and adolescents than in white children and adolescents, Dr Frey and Dr Halterman also suggest that future analyses from this data set should compare the effect of the program among children and adolescents from different racial and ethnic backgrounds.

This study was supported by grants from the Office of the National Coordinator for Health Information Technology Beacon Program to the Cincinnati Children's Hospital Medical Center, and the National Institutes of Health. One author has reported receiving compensation for serving as the Data Safety Monitoring Committee chair of the US Food and Drug Administration–mandated, GlaxoSmithKline-sponsored Safety and Benefit Study of ADVAIR in Children 4-11 Years Old study. The remaining authors and the editorialists have disclosed no relevant financial relationships.

JAMA Pediatr. Published online September 18, 2017. Article abstract, Editorial extract

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