Even though there has been high-compliance or improvement by children’s hospitals regarding asthma care quality measures, improved compliance with providing a written home management plan upon discharge has not been associated with subsequent lower emergency department usage or asthma-related readmission rates, according to a study in the October 5 issue of JAMA. 1
The Children's Asthma Care (CAC) set of process measures evaluates at the hospital level whether patients 2 to 17 years of age admitted with an asthma exacerbation received relievers (CAC-1) and systemic corticosteroids (CAC-2) during the admission and whether they were discharged with a complete home management plan of care (HMPC) (CAC-3), according to background information in the article. “Process measures are designed to evaluate compliance with care that is expected and, when provided, should ‘maximize health benefits to patients’ and lead to improved clinical outcomes. Compliance of health care organizations with many hospital-level process measures has improved over time. However, their association with improved outcomes has been variable.”
Rustin B. Morse, M.D., of the Phoenix Children’s Hospital and University of Arizona College of Medicine, and colleagues evaluated trends in CAC measure compliance at children's hospitals and the association between CAC measure compliance and improvements in clinical outcomes. The study included administrative and CAC compliance data from 30 U.S. children's hospitals for a total of 37,267 children admitted with asthma between January 2008 and September 2010, accounting for 45,499 hospital admissions. Follow-up was through December 2010.
The minimum quarterly compliance rates that a hospital reported for CAC-1 and CAC-2 measures were 97.1 percent and 89.5 percent, respectively. Average CAC-3 compliance was 40.6 percent during the initial 3 quarters and improved to 72.9 percent during the final 3 quarters of the study. The researchers found that the average postdischarge emergency department (ED) utilization rates were 1.5 percent at 7 days, 4.3 percent at 30 days, and 11.1 percent at 90 days, while the average quarterly readmission rates were 1.4 percent at 7 days, 3.1 percent at 30 days, and 7.6 percent at 90 days.
The authors write that compliance with CAC-1 and CAC-2 was high, with little variability across hospitals, which precluded examination of their association with the specified outcomes. “… aggregate CAC-3 compliance was initially modest but improved during the study period, with substantial variation in compliance and improvement among the hospitals. We did not find a statistically significant association between aggregate CAC-3 compliance and postdischarge ED utilization or asthma-related readmission rates at 7, 30, or 90 days.”
The researchers add that their findings suggest that within children's hospitals, CAC measure set compliance alone cannot serve as a means to evaluate and compare the quality of care provided for patients admitted with asthma exacerbations.
“Consideration should be given to refining the CAC-3 measure set to ensure that high-quality HMPCs are being developed using evidence-based resources and that they are conveyed to families in an effective manner. Finally, the CAC-3 measure in its current form may not meet the criteria outlined by the Joint Commission for accountability measures. Until CAC-3 compliance can be linked to improved outcomes, the Joint Commission should reconsider whether the CAC-3 component of the measure set is appropriately classified as an ‘accountability measure’ suitable for public reporting, accreditation, or pay for performance,” the authors conclude.
In an accompanying editorial2, Charles J. Homer, M.D., M.P.H., of the National Initiative for Children's Healthcare Quality, Harvard Medical School, and Children’s Hospital Boston, writes that “measurement can play a key role in helping redress the shortcomings of the U.S. 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.”
1. (JAMA. 2011;306:1454-1460.
2. (JAMA. 2011;306:1487-1488.