Hospital Intervention Defines Strategies for Pediatric Asthma Care

In a national quality improvement (QI) intervention, investigators detailed several strategies for sustained high-quality care for children with asthma that included designating long-term local champions to continue reminders and educational efforts and developing electronic order sets to provide ongoing decision support.

The team, led by Sarah B. Schechter, MD, Department of Pediatrics, University of California, believed prioritizing these strategies would also result in greater returns on QI investments.

Schechter and colleagues cited “critical knowledge gaps” in the prevent delivery of sustained, high-quality hospital care for children with asthma, as well as the hospitalizations rates in the US (100,000 pediatric asthma hospitalizations a year) and the overall direct costs (~$1.6 billion).

Prior to the study, no previous studies had focused on children in community hospital settings.

In this qualitative study, the objective was to study chosen community hospitals to identify strategies associated with sustained, high-quality pediatric asthma care.

The Study

Schechter and colleagues collected data from a national QI intervention called Pathways for Improving Pediatric Asthma Care (PIPA), which was led by the Value in Inpatient Pediatrics Network, the inpatient QI network at the American Academy of Pediatrics.

The intervention included 85 hospitals, 45 of which were community hospitals.

From there, participating hospitals were divided into 2 groups. Half of all sites started in January 2018 and half starting in April 2018.

The QI intervention focused on evidence-based practices such early administration of bronchodilator via metered-dose inhalers,screening for exposure to secondhand tobacco, and referral to smoking cessation resources, as well as decreasing recovery time and/or hospital stay.

From there, investigators interviewed PIPA implementation leaders and other pediatric clinicians from community hospitals with the highest sustainability performance on sustainability strategies.

PIPA implementation leaders from 5 higher-performing and 3 lower-performing community hospitals participated in the study. A total of 19 participants were interviewed.

Higher performers were defined by no significant declines in performance at/after the end of the QI intervention, and long-term improvements in >2 of 4 outcome measures (n=5 hospitals).

Lower performers were defined as those with declines in >3 of 4 outcome measures after the end of the QI intervention, and no significant long-term improvements (n=3 hospitals).

The Findings

Investigators identified 3 promising strategies that were used by community hospitals with higher pediatric QI sustainability performance but were uncommon or inconsistent at hospitals with lower performance.

Higher-performing hospitals had designated local champions that consistently continued using 2 strategies after the end of the QI intervention, which were providing ongoing reminders of evidence-based practices and delivering education on evidence-based pediatric asthma care.

These hospitals also modified/developed EHR tools that remained available to support clinicians after the QI intervention ended, while lower-performing sites reported inability to develop/modify EHR tools, substantial delays in these processes, and/or lack of automation of EHR tools.

Despite most community hospitals lacking robust infrastructure on pediatric QI, Schechter and colleagues’ study confirmed the effectiveness and sustainability of these strategies.

The higher-performing hospitals in this study reported use of these strategies for two years during and after the QI intervention, indicating long-term feasibility, and in their prior study of 104 hospitals that participated in a national pediatric QI intervention, the team found the majority of sites sustained local champions, reminders of evidence-based practices, and electronic order sets.

“To increase feasibility, QI leaders must pro-actively plan for continuing such strategies long-term and initiate this planning at the start of QI interventions,” the team wrote. “Future studies are also needed to prospectively test the effectiveness of these and other potential strategies, as well as quantify the associated costs.”

The study, “Strategies for Sustaining High-quality Pediatric Asthma Care in Community Hospitals,” was published online in Health Services Research.