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Reattendance not cut by asthma discharge plans

Hospitals’ compliance with asthma protocols did not cut children’s readmissions

Louise Prime

Wednesday, 05 October 2011

Reattendance at A&E and readmissions for asthma in children were not reduced when hospitals improved their compliance with guidelines on managing paediatric asthma exacerbations, found research published in JAMA this week.

Researchers set out to see whether compliance with guidelines had increased over time, and if so whether this had brought any clinical benefits.

They obtained data on 30 US hospitals’ level of compliance with three measures in the Children’s Asthma Care (CAC) guideline. These measures were whether or not 2-17-year-old children admitted with asthma exacerbations received relievers (CAC-1); whether they received systemic corticosteroids (CAC-2); and whether, on discharge, they were given a written ‘complete home management plan of care’ (HMPC) (CAC-3).

During the study period, from January 2008 to September 2010, 37,267 children were admitted across the 30 hospitals – a total of 45,499 admissions. Follow-up continued until the end of December.

The minimum quarterly rate for compliance with CAC-1 was 97.1%, and for CAC-2 it was 89.5%. Between the beginning and end of the study, average level of compliance with CAC-3 rose from 40.6% to 72.9%.

The mean figures for asthma-related attendance at A&E were 1.5% at 7 days after discharge, 4.3% at 30 days, and 11.1% at 90 days. Mean quarterly rates of readmission were 1.4% at 7 days after discharge, 3.1% at 30 days and 7.6% at 90 days.

The researchers examined the relationship between each hospital’s level of compliance with the three CAC measures, and children’s asthma-related attendance at A&E and readmission.

Because levels of compliance with CAC-1 and CAC-2 were already high at the beginning of the study, and there was relatively little difference between hospitals, the authors were unable to look for an association between compliance with these two measures, and clinical outcomes.

On the other hand, compliance with CAC-3 was ‘initially modest’, improved over time, and varied greatly between hospitals – but the researchers were unable to find any statistically significant association between better compliance with CAC-3 and rates of A&E attendance or asthma-related readmission at one week, one month or three months.

The study’s authors conclude that children’s hospitals’ level of compliance with the CAC measures should no longer be used as a marker for their quality of care of children with asthma exacerbations.

They add: “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.”

They conclude: “Until CAC-3 compliance can be linked to improved outcomes, the Joint Commission [on Children’s Asthma Care] 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.”

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