Improving Improvement for Childhood Asthma

The health care system in the United States delivers much good high-quality care but also causes unnecessary harm. This harm has many guises—some visible, such as hospital-acquired infections, and others more subtle, such as failure to prescribe indicated treatment or communicate effectively.^{1 - 2} Individuals with chronic conditions may be particularly vulnerable to the shortcomings of the delivery system. The care of these individuals crosses organizational boundaries—primary care and subspecialty, hospital and community. Although defects certainly occur within systems, the likelihood and severity of errors increase substantially at the crevasses between systems.

All of these concerns apply equally to health care for children. The quality of ambulatory care for children and the levels of harm in hospitals differ only slightly between children and adults.^{3 - 4} Chronic illness in childhood is increasing; a subset of children with chronic conditions incurs a large proportion of overall child health care costs.^{5 - 6}

Measurement is one lynchpin for improving quality. Measures—when coupled with the capacity for organizational improvement—can lead to better care either through “accountability” (ie, by having the measures publicly available or connected to tangible incentives) or through enabling delivery organizations to identify and prioritize shortcomings and then track improvement.⁷ The bar for using a measure should be high. Measurement is costly and burdensome. If organizational leadership uses measures to shift priorities and affect care or if external entities use them to determine payment or accreditation, these parties should be confident that they are measuring the right thing and that outcomes will be better. Well-accepted criteria for high-quality measures include that the indicator shows opportunity for improvement (either low performance, high variability, or both) and that any process being assessed is clearly linked to a desired outcome.⁸

It is in this context that the study reported in this issue of JAMA by Morse and colleagues⁹ informs efforts to measure and improve quality of care in several ways. Frustrated by reporting on matters of tangential relevance to children, several organizations developed a set of measures for one of the most common medical diagnoses for which a well-accepted guideline exists—acute exacerbations of asthma. The measurement set has 3 components—use of relievers, use of systemic corticosteroids, and use of a written home asthma management plan.

Using administrative data from 2 sources and 30 children's hospitals, the authors examined the rates of performance on these indicators over time (2008-2010) and across hospitals and also sought to correlate performance with accepted proxy outcome measures for asthma care—emergency department (ED) visits and rehospitalizations. They found that levels of performance were extremely high for the first 2 measures, with little variation across sites, whereas performance on the third measure, a written home management plan, was lower, with modest variability, improving from 41% use to 73% in 3 years. However, the use of a plan was not associated with reductions in subsequent ED visits or rehospitalizations.

The study also has several limitations. It included only a subset of freestanding children's hospitals, where technical quality is expected to be high. More than two-thirds of hospitalizations for children occur outside children's hospitals.⁶ Documentation of levels of performance in community hospital settings is necessary before the findings about consistently high rates for these 2 measures can be generalized. In addition, the likelihood that an individual child was given a management plan was not directly captured in the data but was inferred from the rate reported by the hospital for a separate sample of patients. Also, only revisits (ED visits or asthma rehospitalizations) to the same hospital were counted. Nonetheless, multiple analyses by the authors failed to reveal even a suggestion that the presence of a written home management plan influenced the likelihood of an ED visit or rehospitalization.

Should clinicians be surprised by this finding? Having high hopes that a management plan would prove helpful was reasonable when the measure was developed based on the evolving understanding of chronic care management.¹⁰ Yet what was reasonable then can be viewed as naive now. Perhaps the best known and best tested model to improve the hospital discharge/transition process is the Care Transitions Intervention (CTI).¹¹ In the CTI program (which focuses on a sicker and more complex population than most of the patients in the study by Morse et al), geriatric patients receive coaching in self-management skills, learn which “red flags” merit concern and specific actions, undergo timely follow-up, and are taught to understand their medication management. The current National Quality Forum care transition measure asks whether patients understood what they were responsible to do, whether their preferences were considered, and whether they understood the purpose of their medications.¹² The gulf between these patient-centered approaches and the simple presence of a written plan is wide. The Cochrane Airways Group recently withdrew its systematic review on written management plans for asthma in children and adults, noting that “written action plans are now viewed as a component of asthma self-management rather than a standalone intervention.”¹³

Based on the findings of Morse et al,⁹ use of a written discharge management plan no longer meets the criteria for a high-quality measure. Nonetheless, asthma remains the major cause of preventable hospitalizations in childhood in the United States (even if hospitalization rates have declined modestly over the past several years), and children with chronic conditions overall are frequently hospitalized and readmitted.¹⁴ Are there other performance measures that would be more suitable? With the increasing adoption of electronic health records and health information exchanges, a risk-adjusted, community-based asthma readmission or asthma-specific ED use measure for childhood asthma may soon become feasible; such an outcome measure would be highly appropriate in an accountability context. Use of such a measure would require shared accountability across settings—consistent with the rationale for the creation of accountable care organizations and the priorities of the National Quality Strategy (better care, better health, greater affordability).

Researchers should also develop and test measures related to pediatric acute care transitions that are more patient- and family-centered. Such a patient-centered transition measure would be suitable for organizational and community improvement activities. Both measures would be excellent areas of focus for the new Agency for Healthcare Research and Quality/Centers for Medicare & Medicaid Services Pediatric Quality Measures Program Centers of Excellence, a major federally supported program included as part of the Child Health Insurance Program Reauthorization Act of 2009.¹⁵ Fortunately, developing measures of readmission for children and refining measures of ED use for children with asthma are already priority areas for this new program.

Should hospitals stop providing written management plans when sending a child home with asthma? It seems likely that although written plans alone are insufficient, they may be a valuable part of a more comprehensive transition program. Organizations should develop and test the effects of such programs not only on revisits and readmissions for children with asthma but also on other outcomes important to families, including ongoing symptoms and functional impairment among patients and consequences for other family members (eg, missed work).

Measurement can play a key role in helping redress the shortcomings of the US health care system, but measures must meet high standards. The study by Morse et al, highlighting the great value of “postmarketing surveillance” of performance measures, demonstrates that the Joint Commission's Children's Asthma Care measure 3, an asthma discharge plan, no longer reaches this threshold and should be retired, as should the other components if the nonvariability found in this study is replicated in nonspecialty hospitals. Recent public investment in pediatric measurement development and refinement should ensure that children's health care will not be bereft of high-quality performance measures.