Published online October 31, 2008
PEDIATRICS Vol. 122 No. 5 November 2008, pp. 1055-1063 (doi:10.1542/peds.2007-2399)
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ARTICLE

Quality of Care for Children Hospitalized With Asthma

Flory L. Nkoy, MD, MS, MPH, Bernhard A. Fassl, MD, Tamara D. Simon, MD, MSPH, Bryan L. Stone, MD, Rajendu Srivastava, MD, FRCP(C), MPH, Per H. Gesteland, MD, MS, Gena M. Fletcher, MS and Christopher G. Maloney, MD, PhD, FAAP

Division of Inpatient Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES. The goals were (1) to identify evidence-based clinical process measures that are appropriate, feasible, and reliable for assessing the quality of inpatient asthma care for children and (2) to evaluate provider compliance with these measures.

METHODS. Key asthma quality measures were identified by using a modified Rand appropriateness method, combining a literature review of asthma care evidence with a consensus panel. The feasibility and reliability of obtaining these measures were determined through manual chart review. Provider compliance with these measures was evaluated through retrospective manual chart review of data for 252 children between 2 and 17 years of age who were admitted to a tertiary care children's hospital in 2005 because of asthma exacerbations.

RESULTS. Nine appropriate, feasible, reliable, clinical process measures of inpatient asthma care were identified. Provider compliance with these measures was as follows: acute asthma severity assessment at admission, 39%; use of systemic corticosteroid therapy, 98%; use of oral (not intravenous) systemic corticosteroid therapy, 87%; use of ipratropium bromide restricted to <24 hours after admission, 71%; use of albuterol delivered with a metered-dose inhaler (not nebulizer) for children >5 years of age, 20%; documented chronic asthma severity assessment, 22%; parental participation in an asthma education class, 33%; written asthma action plan, 5%; scheduled follow-up appointment with the primary care provider at discharge, 22%.

CONCLUSIONS. Nine appropriate, feasible, reliable, clinical process measures of inpatient asthma care were identified. Provider compliance across these measures was highly variable but generally low. Our study highlights opportunities for improvement in the provision of asthma care for hospitalized children. Future studies are needed to confirm these findings in other inpatient settings.

Key Words: asthma • pediatrics • inpatient care • quality of care • quality measures • provider compliance

Abbreviations: ED—emergency department • PCMC—Primary Children's Medical Center • RCT—randomized, controlled trial

Asthma is the most common chronic illness in children and is a leading cause of childhood hospitalizations1–3 in the United States. The inpatient burden4,5 for asthma includes ~190000 hospital admissions per year,6 $2 billion in direct medical expenditures per year,7 and a readmission rate of 10% to 30%.8,9 Previous studies of the quality of asthma care focused mostly on outpatient and emergency department (ED) settings,10–13 and the quality of asthma care in the inpatient setting has not been well described. Few quality measures exist for quality-of-care assessments for hospitalized children.14,15

Quality of health care was defined by the Institute of Medicine as "the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."16 Quality of health care can be assessed on the basis of structure (minimal standards or characteristics of providers and hospitals), process (clinical services that adhere to agreed-on good practices), and outcomes (resultant changes in health status) of care.17 Structure-based measures provide minimal information for patient care. Outcome-based measures are arduous to establish in pediatrics.18 In contrast, process-based quality measures might be feasible, informative, and sensitive to differences in the quality of care.19 Use of process-based quality measures also might highlight specific provider actions and system deficiencies that, if changed, could improve patient outcomes.20

The safety and quality of pediatric medical care represent an increasing concern shared by government agencies, health care consumers, and third-party payers.21,22 Substantial efforts are being made to develop quality measures to assess the quality of care provided to children.23 The objectives of this study were to identify evidence-based clinical process measures that are appropriate, feasible, and reliable for assessing the quality of care provided to children hospitalized with asthma exacerbations and to evaluate provider compliance with these measures.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Project Design
The project was divided into 3 phases. In phase 1, evidence-based, inpatient, asthma care process measures were identified by using a modified Rand24 appropriateness method. This method combined a literature review of existing asthma care evidence with a consensus panel. In phase 2, the feasibility and reliability of obtaining the measures identified in phase 1 were assessed through manual chart review. In phase 3, provider compliance with the measures identified in phases 1 and 2 was evaluated through retrospective manual chart review of records for children with asthma exacerbations who were admitted to a tertiary care children's hospital in 2005. The study was approved by the University of Utah and Primary Children's Medical Center (PCMC) institutional review board.

Setting
The study took place at PCMC, an academic children's hospital in Salt Lake City, Utah, affiliated with the Department of Pediatrics at the University of Utah School of Medicine. PCMC is a level 1 trauma center and serves as both the community pediatric hospital for Salt Lake County and the tertiary care pediatric hospital for Utah and 4 surrounding states (Wyoming, Nevada, Idaho, and Montana). It has 232 licensed beds and is owned and operated by Intermountain Healthcare, a regional, not-for-profit, integrated, health care delivery system.25 More than 400 providers have admitting privileges at PCMC.

Phase 1: Literature Review and Consensus Process
Literature Review
A detailed literature search of journals featured in PubMed and the Cochrane database was conducted to identify studies published up to 2006 relevant to asthma care of children <18 years of age. The literature search was centered on the following topics: (1) medical care of asthma exacerbations, (2) evidence-based interventions to decrease admissions and readmissions, and (3) monitoring and scoring during the care path progression. Search terms included asthma, children, hospitalized, and 1 or a combination of the following: outcome, corticosteroids, β2 agonists, severity assessment, chronic symptom control, readmission prevention, controller medication, and inhaled corticosteroids. Only the search term asthma was used in Medical Subject Heading format. The rest of the search terms were text words, to yield the greatest number of citations.

One of the authors (Dr Fassl) examined article titles, abstracts, and reviewed, full-text articles that met our search criteria. Related articles from PubMed were included. Dr Fassl also reviewed the following national and international guidelines, to identify evidence-based asthma care recommendations: Global Initiative for Asthma guidelines, 2005 and 2006; National Asthma Expert Panel Reports, 1991, 1997, 2002, and 2006; American Academy for Asthma, Allergy, and Immunology guidelines, 2005 and 2006; British Thoracic Society guidelines, 2005; and European Respiratory Society guidelines. On the basis of this literature search and review of the evidence-based guidelines, 2 authors (Drs Nkoy and Fassl) drafted a preliminary list of potential quality measures.

The validity of each potential measure was assigned by using the evidence-level classification described by Jadad et al.26 This classification categorizes evidence from the medical literature into 5 different levels on the basis of the strength associated with the evidence, as follows: level A, randomized, controlled trials (RCTs) with a rich body of data; level B, RCTs with small sample sizes, subgroup analyses of RCTs, or meta-analyses of RCTs; level C, evidence from outcomes of uncontrolled trials or observational studies; level D, panel consensus judgment; level E, expert consensus.

After assignment of the level of evidence supporting these potential measures, measures with lower evidence levels (levels D and E) were excluded, leaving only measures with higher evidence levels (levels A, B, and C). A summary sheet containing the remaining potential measures, including the rationale for the measures and the level of evidence associated with each measure, was then generated. The summary sheet with these measures was presented to a consensus panel for review.

Consensus Process
A local consensus panel was recruited and consisted of 6 physicians, including 5 pediatric hospitalists from the hospitalist division and 1 of the 2 pediatric pulmonologists from the pulmonology division in the department of pediatrics. The panel was a convenience sample of pediatricians interested in standardizing care to reduce clinical variation. The consensus process was led by Dr Nkoy, who had previous experience with the development and implementation of quality measures through collaborative works with the National Committee for Quality Assurance.27 Most panelists, including Dr Nkoy, had formal training and experience in both health services research (Drs Maloney, Gesteland, and Srivastava) and quality improvement (Drs Stone, Maloney, Srivastava, and Gesteland) through the Intermountain Healthcare Institute for Health Care Delivery Research, led by Brent C. James, MD, MStat, an internationally recognized leader and educator in quality measurement and improvement.28 The role of the consensus panel was to review, to rate, and to select from the list of preliminary measures a set of quality measures appropriate for assessing the quality of asthma inpatient care. The consensus process involved a single round of measurement rating followed by a face-to-face consensus panel meeting. An anonymous e-mail survey was sent to the panelists, for review of the potential measures listed on the summary sheet. Panelists were asked to rate individually the appropriateness of the proposed measures for assessing the quality of inpatient asthma care, on a Likert scale from 1 (not at all important) to 4 (essential). A measure was declared appropriate for assessing the quality of inpatient care if it addressed an important clinical process in the provision of inpatient asthma care that had been shown to be associated with improved outcomes. In the case of 2 equally effective and safe treatments, as assessed with the measure, panelists considered other factors, such as cost, resource utilization, and patient discomfort with the 2 alternatives, to decide.29 The average rating for each measure was calculated from the individual responses.

A face-to-face meeting of the panelists was then convened, to select a final set of process-based measures appropriate for assessing the quality of inpatient asthma care. On the day of the meeting, each panelist was given a copy of the summary sheet containing the potential measures, including the rationale for the measure, the associated evidence level, and the average panel rating. Each measure was reviewed and discussed individually. The panelists also were given the opportunity to refine measure descriptions on the basis of their personal clinical experience. After discussion, the panel was asked to decide whether the measure was appropriate for assessing the quality of inpatient asthma care. Quality measures for which ≥5 (≥83%) of 6 panelists agreed were deemed appropriate and were selected.

Phase 2: Feasibility and Reliability
Data elements necessary to generate each measure were determined and were used to develop a standardized data collection template30 for chart review. Data elements were extracted from the ED medical record, hospitalization progress notes, medication list, and discharge summary. Feasibility was defined as using measures that could be generated from information typically found in the medical record. Reliability was defined as the extent to which measures were reproducible, meaning that 2 independent raters agreed on the measurement.31

Two trained chart abstractors independently collected data elements from a sample of 30 charts. Agreement statistics were calculated for the sample of 30 charts. A measure had acceptable reliability if the {kappa} value was 0.70. We had 90% power to detect significant differences between the chart abstractors at {alpha} = .05 and {kappa} = 0.70.

Phase 3: Provider Compliance
The last phase of the study was to determine provider compliance with the final set of quality measures that were found to be appropriate, feasible, and reliable. A provider was compliant with a measure if the information assessed by the measure was documented in the medical record. The study population included 252 children 2 to 17 years of age who were discharged from PCMC in 2005, the year preceding the study, with a primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for asthma (code 493.xx). Children <2 years of age were excluded to avoid inclusion of patients with wheezing related to other causes, such as bronchiolitis. Patients were identified through the enterprise data warehouse, an electronic database that links clinical, financial, and administrative data.32 Provider compliance with these measures was evaluated through retrospective manual chart review and was reported as the proportion of patients for whom providers, as a group, complied with each measure.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Phase 1: Literature Review and Consensus Process
Figure 1 summarizes the overall measure identification and selection process. The literature review yielded 80 potential measures. Thirty-seven measures with lower levels of evidence (levels D and E) were excluded, leaving 43 potential measures with higher levels of evidence (levels A, B, and C) (Table 1). Of the 43 potential measures, 11 process measures were found by the consensus panel to be appropriate for assessing the quality of inpatient asthma care.


Figure 1
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  		FIGURE 1 Identification of measures and selection process.

 

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  		TABLE 1 Potential Quality Measures Presented to the Expert Consensus Panel

 
Phase 2: Feasibility and Reliability
Of the 11 process measures selected by the panel, 2 measures were excluded because of feasibility concerns. These measures (measures 18 and 19 in Table 1) were excluded because data on chronic asthma severity, which lacks standardized methods for assessment, were rarely available in the medical record and therefore were not feasible to obtain.

The final set of quality measures included 9 appropriate, feasible, reliable, evidence-based process measures for inpatient asthma care. The interrater {kappa} values for obtaining these 9 measures through chart review ranged from 0.70 to 0.96 (Table 2). Table 2 also lists studies supporting selection of each of the 9 quality measures. Five measures were specific to inpatient asthma care, and 4 were related to reexacerbation/readmission prevention.


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  		TABLE 2 Reliability of and Provider Compliance With Evidence-Based Inpatient Asthma Quality-of-Care Measures

 
Phase 3: Provider Compliance
Provider compliance with these measures is depicted in Table 2; results represent the overall compliance of 109 providers who admitted ≥1 patient at PCMC in 2005. Compliance with treatment recommendations for the acute exacerbation (use of corticosteroids, ipratropium bromide, and β2-receptor agonists) was higher than compliance with evidence-based interventions aimed at achieving better chronic asthma symptom control and preventing readmissions.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Nine appropriate, feasible, and reliable, clinical process measures of inpatient asthma care were identified by using a combination of evidence-based literature review and consensus panel methods. These measures could be used for inpatient asthma care quality monitoring and improvement in pediatric hospital settings. Provider compliance across these measures was highly variable but generally low.

Despite the fact that asthma is associated with significant inpatient burden, previous studies of asthma quality of care focused on outpatient and ED settings.10–13 In contrast, our study focused solely on inpatient care and attempted to describe the quality of asthma care in this setting. Our study was conducted between 2005 and 2006 and preceded the publication of Joint Commission inpatient asthma measures. Encouragingly, 2 of 3 measures (use of systemic corticosteroid therapy for inpatient asthma and documentation of home management plan of care) recommended by the Joint Commission as quality indicators for children's asthma care33 were also selected by our consensus panel. In addition, our study identified 7 more measures. The variable but overall low level of provider compliance with our measures is consistent with previous studies of adults and children that reported suboptimal quality of asthma care in outpatient and ED settings.34–38

Although our measures were targeted to the inpatient setting, they included measures addressing prevention of reexacerbations and readmissions. Similar to previous work on quality of care in the ED setting,12 the quality of inpatient care affects the quality of outpatient care and vice versa. In addition, for many children hospitalization represents an opportunity to reevaluate the adequacy of asthma care received in outpatient settings. We think that an inpatient encounter is an opportunity for collaboration with outpatient providers in intensifying asthma education, as well as developing asthma action plans to prevent future urgent care/ED visits and hospital admissions.

Compliance with evidence-based interventions aimed at control of chronic asthma symptoms was concerning. Inadequate chronic asthma symptom control not only contributes to high readmission rates but also has a direct impact on the quality of life of children and their families.39 Several factors have been described in the literature for this treatment gap, including skewed parental and physician perceptions of chronic asthma severity,40,41 lack of user-friendly tools for standardized symptom assessment and treatment modification, and deficiency in ongoing care arrangements.42

There are several limitations inherent in our study, including potential measure selection bias, alteration of the Rand appropriateness method, potential patient selection bias, and burdens related to chart review. Measure selection bias might have been introduced by our literature review and panel composition. Our literature review was current to 2006 and did not include more-recent evidence on asthma care. The final set of quality measures was selected through a consensus panel. These measures represent the opinions of the panelists, which might have varied with a different panel composition; that is, members of the consensus panel were from a single institution, and selection of measures might have been different if the consensus panel had been independent of PCMC. Members of the consensus panel were not recognized asthma experts, and consensus and interpretation of the evidence might reflect the group's practices rather than general expert consensus. Furthermore, the consensus panel did not include an allergist, because the few allergists at PCMC are available only for outpatient consultations and not for inpatient consultations. Results might have been different if an allergist was part of the consensus panel. Finally, provider compliance with our measures was evaluated at 1 site, and the results might not be generalizable to other hospital institutions. Provider compliance with our measures was evaluated with children 2 to 17 years of age. However, studies supporting these measures did not always provide evidence of the value of these measures across this age range, and members of the consensus panel extrapolated the evidence beyond the ages identified by the individual studies.

We used a modified Rand appropriateness method to select our measures. In contrast to the standard Rand method, which includes 2 rounds of measurement rating followed by a face-to-face consensus panel meeting, our method included only 1 round of measurement rating followed by a face-to-face panel meeting. Our rating scale ranged from 1 through 4 instead of 1 through 9, as in the standard Rand appropriateness method. The final selection of measures was based exclusively on the consensus panel decision and not on the rating of each measure. Despite these limitations, we think that our measures address important aspects of inpatient asthma care, because we incorporated in our selection process both research evidence and input from providers. In addition, previous studies reported that there is no single standard method for developing, rating, and analyzing the results of performance measures.43–46

Patient selection bias also is possible. Our study population was identified electronically and included only patients with a primary discharge International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of asthma. It did not include patients for whom an asthma discharge diagnosis was placed in the second position or lower. Therefore, provider compliance with our measures may not represent the actual quality of inpatient asthma care provided at our institution. Furthermore, we did not take into account eligibility criteria for the second, third, and fifth measures listed in Table 2. Specifically, we did not exclude patients for whom systemic corticosteroid therapy was contraindicated (second measure), patients with vomiting (third measure), or patients who were unable to use a metered-dose inhaler (fifth measure). Provider compliance with these measures might have improved if we had used detailed inclusion and exclusion criteria. However, we think that, even if we had accounted for inclusion and exclusion criteria, the results would not have been significantly different, for the following reasons: provider compliance with respect to systemic corticosteroid therapy was 98% even without accounting for inclusion and exclusion criteria, asthmatic patients do not typically present with vomiting, and children >5 years of age are more likely to cooperate and to be able to used a metered-dose inhaler.

Finally, provider compliance with the final set of our measures was evaluated through manual chart review. Chart review is labor-intensive and is associated with significant costs, which may limit the use of these quality measures for general application. We think that, with the increasing adoption of electronic medical records,47,48 standard data elements necessary to generate these measures could be incorporated into an electronic medical record, to collect data at the point of care and to decrease the burden associated with manual chart review.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
We identified 9 evidence-based, appropriate, feasible, and reliable process measures for assessing the quality of inpatient asthma care for children. Low provider compliance with these process-based measures highlights a potential problem in the quality of asthma care in the inpatient setting, as well as several opportunities for improvement. Motivated providers and managed-care organizations can use these measures to initiate targeted interventions to address shortcomings and to improve asthma outcomes. Future studies will need to demonstrate the link between these process measures and outcomes, that is, to demonstrate that increased compliance with these measures is associated with improved outcomes (ie, predictive validity).49

Our study represents the first 3 of 5 steps for improving asthma care in the inpatient setting, that is, (1) identification of specific, evidence-based, inpatient asthma care measures amenable to provider actions; (2) use of these measures to evaluate provider compliance; (3) identification of opportunities for improvement and development of targeted interventions; (4) establishment of an ongoing mechanism for collecting and sharing quality data with providers; and (5) assessing effects of these measures on patient outcomes. We think that this work represents a first step in developing a model for improvements in quality of care and research on health services for hospitalized children.


   ACKNOWLEDGMENTS
 
Dr Srivastava was supported by grant K 23 HD052553 from the National Institute for Child Health and Human Development. This study was supported in part by the Children's Health Research Center at the University of Utah and the Primary Children's Medical Center Foundation.

Technical assistance was provided by Brent James, MD, MStat, executive director of the Institute for Health Care Delivery Research at Intermountain Healthcare. We express gratitude to Derek Uchida, MD, Pediatric Pulmonology Division, and Armand Antommaria, MD, PhD, Pediatric Inpatient Division at PCMC, for their expertise in the selection of inpatient asthma quality measures during the consensus panel meeting. We also thank Alice Dowling, MD, and Julie Ballard, RT, for the excellent support provided during data collection.


   FOOTNOTES
 
Accepted Feb 29, 2008.

Address correspondence to Flory L. Nkoy, MD, MS, MPH, Division of Pediatric Inpatient Medicine, Primary Children's Medical Center, University of Utah School of Medicine, 100 North Medical Dr, Salt Lake City, UT 84113. E-mail: flory.nkoy{at}hsc.utah.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


What's Known on This Subject

Asthma is the most common chronic illness in children and is a leading cause of childhood hospitalizations in the United States. Few quality measures exist for assessing quality of care for hospitalized children.

 

What This Study Adds

This study identified evidence-based clinical process measures that are appropriate, feasible, and reliable for assessing the quality of care provided to children hospitalized with asthma exacerbations, and it evaluated provider compliance with these measures.

 


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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