Multicenter Analysis of Quality Indicators for Children Treated in the Emergency Department for Asthma

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Studies of the association between process and outcome measures of the quality of acute asthma care for children have been mixed. These studies are limited by small, single-institution settings or by examining the association at the aggregate level. WHAT THIS STUDY ADDS:This first multicenter analysis of the process-outcome association in acute asthma care for children revealed no association. Because the validity of process measures depends on association with outcomes, further study is needed before implementing existing process measures as performance metrics.abstract OBJECTIVE: To test the hypothesis that an association exists between process and outcome measures of the quality of acute asthma care provided to children in the emergency department.METHODS: Investigators at 14 US sites prospectively enrolled consecutive children 2 to 17 years of age presenting to the emergency department with acute asthma. In models adjusted for variables commonly associated with the quality of acute asthma care, we measured the association between 7 measures of concordance with national asthma guideline-recommended processes and 2 outcomes. Specifically, we modeled the association between 5 receipt/nonreceipt process measures and successful discharge and the association between 2 timeliness measures and admission.RESULTS: In this cohort of 1426 patients, 62% were discharged without relapse or ongoing symptoms (successful discharge), 15% were discharged with relapse or ongoing symptoms, and 24% were admitted. The composite score for receipt of all 5 receipt/nonreceipt process measures was 84%, and for timeliness measures, 57% receive a timely corticosteroid and 92% a timely b-agonist. Our adjusted models showed no association between process and outcome measures, with 1 exception: timely b-agonist administration was associated with admission, likely reflecting confounding by severity rather than a true process-outcome association. CONCLUSIONS:We found no clinically significant association between process and outcome quality measures in the delivery of asthma-related care to childreninamulticenterstudy.Althoughthequalityofemergencydepartment care does not predict successful discharge, other factors, such as outpatient care, may better predict outcomes. Pediatrics 2012;129:e325-e332 AUTHORS:

Quality in paediatric emergency medicine: Measurement and reporting

“…For example, while a low chest X‐ray rate in asthma may be an indicator of quality, a much more comprehensive view of quality of care for asthma is gained by combining this measure with measures of admission, steroid administration and representation rates. Similar findings for the management of febrile convulsions and gastroenteritis have been demonstrated …”

“…Many of these measures deteriorate with departmental crowding. Two recent studies have been unable to identify outcome change associated with improvements in process measures of time to bronchodilator and systemic corticosteroid …”

Comparison of US emergency department acute asthma care quality: 1997-2001 and 2011-2012

“…34 This approach has been used in prior studies of both acute and chronic asthma to adjust for this type of confounding. 14,[35][36][37] Lastly, our study population consisted of adults who presented mainly to academic EDs. Therefore our inferences might not be generalizable to children or asthma management in nonacademic EDs, where emergency asthma care might be better or worse than in our participating EDs.…”

Association of Guideline‐concordant Acute Asthma Care in the Emergency Department With Shorter Hospital Length of Stay: A Multicenter Observational Study

“…Process measures are designed to examine concordance with expected care and, when provided, should lead to improved health outcomes . However, previous studies of process–outcome link in the quality of ED acute asthma care have reported inconsistent associations with acute outcomes . For example, a retrospective analysis of Canadian ED‐based data reported that the hospitalization rate of children treated in the EDs with standardized protocols was no different from the rate of children in EDs without these protocols .…”

“…To implement process measures as performance metrics, greater concordance should lead to improved patient outcomes . To date, studies of the process–outcome link in the quality of ED acute asthma care have focused on risks of hospitalization . For instance, several studies have demonstrated that delivery of guideline‐concordant asthma care in the ED is associated with a reduced hospitalization rate .…”