Quality of care for acute asthma in 63 US emergency departments

Abstract

Background Little is known about the quality of acute asthma care in the emergency department (ED). Objectives We sought to determine the concordance of ED management of acute asthma with National Institutes of Health asthma guidelines, to identify ED characteristics predictive of higher guideline concordance, and to assess whether guideline concordance was associated with hospital admission. Methods We conducted a retrospective chart review study of acute asthma as part of the National Emergency Department Safety Study. Using a principal diagnosis of asthma, we identified ED visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at the patient and ED level. These scores ranged from 0 to 100, with 100 indicating perfect concordance. Results The cohort consisted of 4,053 subjects; their median age was 34 years, and 64% were women. The overall patient guideline concordance score was 67 (interquartile range, 63–83), and the ED concordance score was 71 (SD, 7). Multivariable analysis showed southern EDs were associated with lower ED concordance scores (β-coefficient, −8.2; 95% CI, −13.8 to −2.7) compared with northeastern EDs. After adjustment for the severity on ED presentation, patients who received all recommended treatments had a 46% reduction in the risk of hospital admission compared with others. Conclusions Concordance with treatment recommendations in the National Institutes of Health asthma guidelines was moderate. Significant variations in ED quality of asthma care were found, and geographic differences existed. Greater concordance with guideline-recommended treatments might reduce hospitalizations.

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

“…This differs from the findings of the previously cited adult EMNet study, 8 as well as 2 of the 4 previous studies of this issue in children. 3,4,9,10 The process measures used in the adult study were the same 5 level A recommendations as in our study; the study revealed that 100% guideline concordance (in 12 level A and B measures) was associated with a 46% lower admission rate.…”

“…14 Employing methods similar to those in an EMNet multicenter study of adults with acute asthma, 8 we derived 7 process measures of asthma care quality from the NIH asthma guidelines 2 ( Table 1).…”

“…The 5 level A process measures, the same 5 used in the adult EMNet study, 8 assess receipt of inhaled b-agonists, inhaled anticholinergics, and systemic corticosteroids; nontreatment with methylxanthines; and prescription of oral corticosteroids at discharge. The 2 level B processes both involve timeliness of medication administration: receipt of a corticosteroid treatment and an inhaled b-agonist in the first hour in the ED.…”

“…2 We selected the 1-hour threshold for corticosteroid administration based on a Cochrane review recommending dosing of systemic corticosteroids within the first hour. 15 For each process and outcome measure, we defined an eligible population by adapting the eligible population definitions used in the adult EMNet study, which derived them from the NIH guidelines 8 (Table 1). For 2 measures, nontreatment with methylxanthines and treatment with a b-agonist in the first hour, the eligible population definitions were identical to those in the adult EMNet study.…”

“…[3][4][5] The quality of care for children with acute asthma, as measured by guideline concordance, varies among ED providers. [5][6][7] For adults, better guideline concordance of ED processes of care has been shown to reduce hospital admissions by 46% in a multicenter study 8 ; however, little is known about how guideline concordance affects acute asthma outcomes in children. Studies of the association between process and outcome measures in ED asthma care for children are either small, single-institution studies or do not examine the association at the patient level.…”