PEDIATRICS Vol. 107 No. 3 March 2001, pp. 590-592

COMMENTARY:
Asthma Clinical Pathways: Toward What End?

Clinical pathways are increasingly guiding the care of hospitalized patients. A clinical, or critical, pathway is an operational version of a clinical guideline that designates the timing and sequence of desired care.¹ Clinical pathways are typically developed for inpatient diagnoses for which care is relatively predictable and depends on multidisciplinary inputs. Clinical pathways may pursue several goals: reduction of unintended variation in care delivery, improved patient education, reduction in resource utilization, and improvement in the quality of care.¹ A particular clinical pathway may emphasize some or all of these goals. Only limited evidence supports the efficacy of clinical pathways in achieving these goals despite their growing adoption by hospitals.

Because asthma is a major cause of hospitalization in children, clinical pathways have been developed to guide inpatient management. A growing published literature examines these asthma clinical pathways. The focus of these studies indicates that asthma clinical pathways are being developed primarily to reduce costs rather than improve care and outcomes. We believe this represents an important missed opportunity. A pediatric asthma hospitalization is a sentinel health event in a child's life that both flags unmet chronic illness needs and provides a teachable moment to address these needs.

Kwan-Gett et al² evaluated the impact of an asthma clinical pathway in a academic children's hospital. The pathway included the recommendation to "continue or add maintenance anti-inflammatory medication."² Yet the only clinical outcomes reported were the use of systemic steroids, which was near universal in the preintervention and postintervention groups, and the provision of peak flow meters.² Readmission beyond 2 weeks postdischarge or the percentage of children prescribed a controller medication on discharge also were not evaluated. The pathway did not reduce length of stay or cost.²

Johnson et al³ conducted a randomized trial of an asthma clinical pathway for predominantly minority, low-income, inner-city children. The pathway placed emphasis on a nurse-driven protocol for weaning the frequency of nebulized -agonist treatments. Patients randomized to the pathway unit stayed in the hospital for a 25% shorter length of stay. More than two and one-half times as many children were discharged from the pathway unit within 24 hours of admission.²

The pathway achieved 2 of the aforementioned aims: reduction in unintended variation and reduction in hospital resource utilization. Empowering nursing staff to promote adjustment in the frequency of nebulized -agonist medication may have been the mechanism for achieving shorter hospital stays. This approach makes sense because the patients' respiratory status may be improving rapidly. A nurse assesses a patient several times during each nursing shift whereas a physician may assess an otherwise stable patient once or twice daily. Through reducing variation in this care process Johnson et al have established that an asthma clinical pathway can decrease length of stay without evident short-term adverse effect.

Is the glass half-full or half-empty? Have we done all that we can for the child who is discharged earlier or appropriately diverted to an alternative care setting such as an emergency department observation unit? The children described in the Johnson study serve as a reminder of both the morbidity and undertreatment of many children with asthma, especially those living in inner-city, low-income environments.^4-8 The asthmatic children described in this study had a mean of 1.9 hospital admissions, 3.8 emergency department visits, and 10.5 school days missed attributable to asthma in the year before the index hospitalization.³ However, just over half reported having a controller as a home medication and, of these, less than one third reported having inhaled steroids.³ Just >70% had a follow-up appointment scheduled after discharge³; the percentage actually seen by their primary care provider is not reported.

As demonstrated by the children in the Johnson study, children with an asthma hospitalization are at high risk for subsequent asthma hospitalizations^9-11 and are at increased risk for death from asthma.¹² Researchers and participants from the same institution as the Johnson study reported that 29% of children with an index asthma hospitalization were readmitted within 1 year.¹⁰ One third had either been intubated or had an intensive care unit admission before the index hospitalization.¹⁰ Inner-city children presenting to the emergency department with acute asthma also demonstrate worrisome levels of morbidity and undertreatment.^13-16

An asthma hospitalization is a marker of disease severity; it is not surprising that these children should be at significant risk for readmission.¹⁷ Given this risk, what should be the clinical goals of an asthma hospitalization? Is control of the acute flare-up sufficient or should chronic asthma management be an integral component of inpatient care? Several recent studies have begun to address these questions. A recent multicenter study from Great Britain¹⁸ reported that only 52% of children discharged after an asthma hospitalization were started or continued on a controller medication. Less than one third had inhaler technique assessed, while 28% received inpatient education and 23% were given a written self-management plan.¹⁸

A randomized trial of a nurse-led asthma management training program that included inpatient education, a written symptom-based management plan and follow-up in a nurse-run asthma clinic achieved a reduction in the readmission rate from 25% in the control group to 8% in the treatment group.¹⁹ Another randomized trial of a nurse-led inpatient intervention that involved the development of a written home management plan achieved a comparable reduction of the readmission rate in the intervention group relative to the control group over 6 months (from 37%-15%).²⁰ In a case-control study researchers from Kaiser Permanente found that having a written asthma management plan approximately halved the risk of an asthma hospitalization or emergency department visit.²¹

These data suggest that we evaluate asthma clinical pathways from the perspective of quality improvement. Work-related asthma is considered a sentinel health event in several states.²² Similarly, an asthma hospitalization is a sentinel event in the child's life because, for so many, it is unnecessary. To qualify as a sentinel health event we infer that had "everything gone well, the condition would have been prevented or managed."²³ A sentinel health event "sends a signal or sounds a warning that requires immediate attention" (emphasis added).²⁴ Sentinel events demand root cause analysis, which is an exhaustive investigation of underlying causes. "Ran out of asthma medication before admission," as reported in one study of asthma rehospitalization,¹⁰ is not a root cause. Root cause analysis does not stop at understanding why an adverse event occurred; it must probe deeper to "identify the most obvious opportunities for improvement that will prevent recurrence."²⁴ For an asthmatic child and his family, this analysis may uncover inadequate understanding of the disease, health beliefs that undermine self-monitoring or adherence, parental smoking and allergic triggers in the home, improper inhaler technique, or prescribed therapy that is insufficient for the child's disease severity.

This approach is not compatible with a clinical pathway that primarily targets cost reduction, either through a more structured approach to nebuilzer treatment or identifying children eligible for care in less costly settings.²⁵ An asthma hospitalization is a teachable moment, which may not be easily transferable to the ambulatory clinic. As with diabetes, we need to go beyond reversing the current asthma crisis; we need to teach the patient and family how to manage the underlying chronic illness and prevent the next crisis. And, as with diabetes, making the link from inpatient acute management to comprehensive outpatient care is essential. This coordination is especially crucial as hospitalist models of inpatient care delivery proliferate.²⁶

Clinical pathways that primarily target care process variation and cost reduction are insufficient for asthma. The current asthma epidemic demands a more comprehensive approach. Vulnerable children with a chronic illness require a comprehensive and coordinated system of care delivery. Our current system has not adequately responded to a childhood disease that has increased in prevalence by 5% yearly,²⁷ where hospitalizations have increased by 160%,²⁸ where black asthma mortality is fourfold higher than whites,²⁹ and where black children receive controller medication at half the rate of white children despite worse asthma functional status.⁷

Given the scope of the problem, hospitals should not adopt a silo mentality that accepts treating asthma as an acute illness. Asthma clinical pathways should be inextricably linked with improving the quality of chronic disease management. Controlling cost and improving quality are compatible and should be pursued simultaneously. Kelly et al³⁰ report outcomes of an asthma clinical pathway that support this assertion. Albeit a small sample, they demonstrate that hospitalized children treated on an asthma pathway had a significant reduction in length of stay and cost while increasing the percentage receiving asthma teaching, prescribed a controller, peak flow meter, and spacer device on discharge.³⁰

Clinical pathways are important tools for reducing unintended care variation, controlling cost, and improving the quality of inpatient asthma care. To achieve these goals, we propose that asthma clinical pathways incorporate the following features:

• Asthma education should be provided, addressing the child's and family's concerns and collaboratively developing shared goals for asthma treatment.
• Identify children exposed to environmental tobacco smoke (ETS), in addition to other recognized asthma triggers. Offer smoking parents specific interventions to combat their tobacco addiction. Almost 40% of children are exposed to ETS³¹ in the home; ongoing ETS exposure may impair recovery after an acute asthma hospitalization.³²
• Verify that the child and family demonstrate proper technique in the use of inhaled medication.
• Assess chronic disease severity in addition to reducing the severity of wheezing.
• Start a controller medication in-hospital appropriate to the level of assessed disease severity.
• Develop a personalized written asthma plan, given to the family, which reflects the shared goals that will promote ongoing self-management.
• Direct communication with the child's primary care clinician should occur to coordinate the transition from hospital to ambulatory care settings.
• Identify potential barriers to the child's inclusion in a medical home.³³ Uninsured children should be evaluated for Medicaid or State Child Health Insurance Program eligibility and appropriate social service referrals should be made.³⁴

We have argued that an asthma hospitalization is a sentinel event in a child's life. Viewed as such, the imperative becomes preventing the next event. Asthma clinical pathways should incorporate the evidence-based interventions that make this possible and, in the process, improve the overall health and functioning of children with asthma.

ACKNOWLEDGMENT

This work was supported in part by Grant T32 HS00063 from the Agency for Health Care Policy and Research.

James H. Glauber, MD
Neighborhood Health Plan
Children's Hospital, Boston
Health Services Research
Boston, MA 02115

Harold J. Farber, MD
Department of Pediatrics
Kaiser Permanente
Vallejo, CA 94589

Charles J. Homer, MD, MPH
National Initiative for Children's Healthcare Quality
Boston, MA 02115

FOOTNOTES

Received for publication Dec 18, 2000; accepted Dec 18, 2000.

Reprint requests to (J.H.G.) Medical Director, Pediatric Populations, Neighborhood Health Plan, Children's Hospital, Boston, Health Services Research, 333 Longwood Ave, Second Floor, Boston, MA 02115. E-mail: glauber{at}hub.tch.harvard.edu

ABBREVIATIONS

ETS, environmental tobacco smoke.

REFERENCES

1. Bohmer R Critical pathways at Massachusetts General Hospital. J Vasc Surg 1998; 28:373-377 [CrossRef][Medline]
2. Kwan-Gett , Lozano P, Mullin K, Marcuse EK One-year experience with an inpatient asthma clinical pathway. Arch Pediatr Adolesc Med 1997; 151:684-689 [Abstract/Free Full Text]
3. Johnson KB, Blaisdell CJ, Walker A, Eggleston P Effectiveness of a clinical pathway for inpatient asthma management. Pediatrics 2000; 106:1006-1012 [Abstract/Free Full Text]
4. Eggleston PA, Malveaux FJ, Butz AM, Medications used by children with asthma living in the inner city. Pediatrics 1998; 101:349-354 [Abstract/Free Full Text]
5. Lozano P, Connel FA, Koepsell TD Use of health services by African-American children with asthma on Medicaid. JAMA 1995; 274:469-473 [Abstract/Free Full Text]
6. Halterman JS, Aligne CA, Auinger P, Inadequate therapy for asthma among children in the United States. Pediatrics 2000; 105:272-276 [Abstract/Free Full Text]
7. Lieu TA, Farber HJ, Lozano P, Racial/ethnic variation in asthma status and processes of care among children with managed Medicaid [abstract]. Pediatr Res 2000; 47:152A
8. Finkelstein JA, Lozano P, Farber HJ, Under-use of controller medications among Medicaid-insured asthma patients [abstract]. Pediatr Res 2000; 47:188A
9. Farber HJ Risk of readmission to hospital for pediatric asthma. J Asthma 1998; 35:95-99 [Medline]
10. Minkovitz C, Andrews JS, Serwint JR Rehospitalization of children with asthma. Arch Pediatr Adolesc Med 1999; 153:727-730 [Abstract/Free Full Text]
11. Lieu TA, Quisenberry CP, Sorel ME, Computer-based models to identify high-risk children with asthma. Am J Respir Crit Care Med 1998; 157:1173-1180 [Abstract/Free Full Text]
12. Rea HH, Scragg R, Jackson R, A case-control study of deaths from asthma. Thorax 1986; 41:833-839 [Abstract/Free Full Text]
13. Farber HJ, Johnson C, Beckerman RC Young inner-city children visiting the emergency room for asthma: risk factors and chronic care behaviors. J Asthma 1998; 35:547-552 [Medline]
14. Friday GA, Khine H, Lin MS, Caliguri LA Profile of children requiring emergency treatment for asthma. Ann Allergy Asthma Immunol 1997; 78:221-224 [Medline]
15. Wasilewski Y, Clark NM, Evans D, Factors associated with emergency department visits by children with asthma: implications for health education. Am J Public Health 1996; 86:1410-1415 [Abstract/Free Full Text]
16. Crain EF, Kercsmar C, Weiss KB, Reported difficulties in access to quality care for children with asthma in the inner city. Arch Pediatr Adolesc Med 1998; 152:333-339 [Abstract/Free Full Text]
17. Mitchell EA, Bland JM, Thompson MD Risk factors for readmission to hospital for asthma in childhood. Thorax 1994; 49:33-36 [Abstract/Free Full Text]
18. Hilliard TN, Witten H, Male IA, Hewer SL, Seddon PC Management of acute childhood asthma: a prospective multicentre study. Eur Respir J 2000; 15:1102-1105 [Abstract]
19. Madge P, McColl J, Paton J Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomized controlled study. Thorax. 1997; 52:223-228 [Abstract]
20. Wesseldine LJ, McCarthy , Silverman M Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice. Arch Dis Child 1999; 80:110-114 [Abstract/Free Full Text]
21. Lieu TA, Quesenberry CP, Capra AM, Outpatient management practices associated with reduced risk of pediatric asthma hospitalization and emergency department visits. Pediatrics 1997; 100:334-341 [Abstract/Free Full Text]
22. Jajosky RA, Harrison R, Reinisch F, Surveillance of work-related asthma in selected US states using surveillance guidelines for state health departmentsCalifornia, Massachusetts, Michigan, and New Jersey, 1993-1995. MMWR Morb Mortal Wkly Rep. 1999; 48:1-20
23. Rutstein DD, Berenberg W, Chalmers TC, Measuring the quality of medical care: a clinical method. N Engl J Med 1976; 294:582-588 [Abstract]
24. Joint Commission on Accreditation of Healthcare Organizations. Sentinel Events: Evaluating Cause and Planning Improvement. Oak Brook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1998:7
25. McConnochie KM, Russo MJ, Russo MJ, How commonly are children hospitalized for asthma eligible for care in alternative settings? Arch Pediatr Adolesc Med 1999; 153:49-55 [Abstract/Free Full Text]
26. Bellet PS, Wachter RM The hospitalist movement and its implications for the care of hospitalized children. Pediatrics 1999; 103:474-477
27. Measuring childhood asthma prevalence before and after the 1997 redesign of the National Health Interview SurveyUnited States. MMWR Morb Mortal Wkly Rep 2000; 49:908-911 [Medline]
28. Gergen PJ, Weiss KB. Changing patterns of asthma hospitalization among children: 1979-1987. JAMA. 1990:264:1688-1692
29. Grant EN, Wagner R, Weiss KB Observations on emerging patterns of asthma in our society. J Allergy Clin Immunol 1999; 104:S1-S9 [CrossRef][Medline]
30. Kelly CS, Andersen CL, Pestian JP, Improved outcomes for hospitalized asthmatic children using a clinical pathway. Ann Allergy Asthma Immunol 2000; 84:509-516 [Medline]
31. Gergen PJ, Fowler JA, Maurer KR, et al. The burden of environmental tobacco smoke exposure on the respiratory health of children 2 months through 5 years of age in the United States: third National Health and Nutrition Examination Survey, 1988 to 1994. Pediatrics. 1998;101(2). URL: http://www.pediatrics.org/cgi/content/full/101/2/e8
32. Abulhosn RS, Morray BH, Llewellyn CE, Redding GJ Passive smoke exposure impairs recovery after hospitalization for acute asthma. Arch Pediatr Adolesc Med 1997; 151:135-139 [Abstract/Free Full Text]
33. Kempe A, Beaty B, Englund BP, Quality of care and use of the medical home in a state-funded capitated primary care plan for low-income children. Pediatrics 2000; 105:1020-1028 [Abstract/Free Full Text]
34. Halfon N, Inkelas M, Newacheck PW Enrollment in the State Child Health Insurance Program: a conceptual framework for evaluation and continuous quality improvement. Milbank Q 1999; 77:181-204 [CrossRef][Medline]