Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

Importance Readmission rates are used as an indicator of the quality of care that patients receive during a hospital admission and after discharge. Objective To determine the prevalence of pediatric readmissions and the magnitude of variation in pediatric readmission rates across hospitals. Design, Setting, and Patients We analyzed 568 845 admissions at 72 children's hospitals between July 1, 2009, and June 30, 2010, in the National Association of Children's Hospitals and Related Institutions Case Mix Comparative data set. We estimated hierarchical regression models for 30-day readmission rates by hospital, accounting for age and Chronic Condition Indicators. Hospitals with adjusted readmission rates that were 1 SD above and below the mean were defined as having “high” and “low” rates, respectively. Main Outcome Measures Thirty-day unplanned readmissions following admission for any diagnosis and for the 10 admission diagnoses with the highest readmission prevalence. Planned readmissions were identified with procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. Results The 30-day unadjusted readmission rate for all hospitalized children was 6.5% (n = 36 734). Adjusted rates were 28.6% greater in hospitals with high vs low readmission rates (7.2% [95% CI, 7.1%-7.2%] vs 5.6% [95% CI, 5.6%-5.6%]). For the 10 admission diagnoses with the highest readmission prevalence, the adjusted rates were 17.0% to 66.0% greater in hospitals with high vs low readmission rates. For example, sickle cell rates were 20.1% (95% CI, 20.0%-20.3%) vs 12.7% (95% CI, 12.6%-12.8%) in high vs low hospitals, respectively. Conclusions and Relevance Among patients admitted to acute care pediatric hospitals, the rate of unplanned readmissions at 30 days was 6.5%. There was significant variability in readmission rates across conditions and hospitals. These data may be useful for hospitals' quality improvement efforts.

https://jamanetwork.com/journals/jama/articlepdf/1558279/joc120138_372_380.pdf

Pediatric readmission prevalence and variability across hospitals

Asthma Exacerbations: Pathogenesis, Prevention, and Treatment

OBJECTIVES: Prior research has highlighted the importance of psychosocial factors in 'difficult' asthma. This study aimed to review the content, effectiveness and cost-effectiveness of psycho-educational interventions designed to address these factors in patients with severe and difficult asthma. DATA SOURCES: Thirty-two electronic databases and other sources were searched for studies of educational, self-management, psychosocial and multifaceted interventions. REVIEW METHODS: Abstracts were screened in duplicate, against prior definitions, to identify eligible interventions targeted to patients with forms of or risk factors for difficult asthma. Studies were classified by patient group (child, adult) and graded along two dimensions related to study design and relevance in terms of the degree to which they were judged to have targeted difficult asthma. Detailed data were extracted from studies meeting a minimum design and relevance threshold. Characteristics of studies were tabulated and results qualitatively synthesised. Where sufficiently similar studies reported adequate data about comparable outcomes, quantitative syntheses of results were undertaken using a random effects approach to calculate pooled relative risks (RR) or standardised mean differences (SMD), with 95% confidence intervals (CI). RESULTS: Searches identified over 23,000 citations. After initial screening and removal of duplicates, 4240 possibly relevant abstracts were assessed. Papers associated with 188 studies were initially obtained and classified. Fifty-seven studies including control groups and those that were judged to have at least 'possible' targeting of difficult asthma (35 in children, 21 in adults, 1 in both) were selected for in-depth review. The delivery, setting, timing and content of interventions varied considerably even within broad types. Reporting of interventions and methodological quality was often poor, but studies demonstrated some success in targeting and following up at-risk patients. Studies reporting data suitable for calculation of summary statistics were of higher quality than those that did not. There was evidence from these that, compared to usual or non-psycho-educational care, psycho-educational interventions reduced admissions when data from the latest follow-ups reported were pooled across nine studies in children (RR = 0.64, CI = 0.46-0.89) and six studies with possible targeting of difficult asthma in adults (RR = 0.57, CI = 0.34-0.93). In children, the greatest and only significant effects were confined to individual studies with limited targeting of difficult asthma and no long-term follow-up. Limited data in adults also suggested effects may not extend to those most at risk. There was no evidence of pooled effects of psycho-educational interventions on emergency attendances from eight studies in children (RR = 0.97, CI = 0.78-1.21) and four in adults (RR = 1.03, CI = 0.82-1.29). There were overall significant reductions in symptoms, similar in different sub-groups of difficult asthma, across four paediatric studies that could be combined (SMD = -0.45, CI = -0.68 to -0.22), but mixed results across individual adult studies. A few individual studies in children showed mainly positive effects on measures of self-care behaviour, but with respect to all other outcomes in adults and children, studies showed mixed results or suggested limited effectiveness of psycho-educational interventions. No studies of psychosocial interventions were included in any quantitative syntheses and it was not possible to draw clear conclusions regarding the relative effectiveness of educational, self-management and multifaceted programmes. Data on costs were very limited. Of the two well-designed economic evaluations identified, both of multifaceted interventions, one in children suggested an additional cost of achieving health gain in terms of symptom-free days. Provisional data from the other study suggested that in adults the significantly increased costs of providing an intervention were not offset by any short-term savings in use of healthcare resources or associated with improvements in health outcomes. CONCLUSIONS: There was some evidence of overall positive effects of psycho-educational interventions on hospital admissions in adults and children, and on symptoms in children, but limited evidence of effects on other outcomes. The majority of research and greatest effects, especially in adults, were confined to patients with severe disease but who lacked other characteristics indicative of difficult asthma or likely to put them at risk. A lack of good-quality research limited conclusions about cost-effectiveness. Although psycho-educational interventions may be of some benefit to patients with severe disease, there is currently a lack of evidence to warrant significant changes in clinical practice with regard to the care of patients with more difficult asthma. Further research is needed to: (1) standardise reporting of complex interventions; (2) extend and update this review; (3) improve identification of patients at risk from their asthma; (4) develop and test appropriate outcome measures for this group; and (5) design and evaluate, via the conduct of high-quality pragmatic RCTs, more powerful psycho-educational interventions that are conceptualised in terms of the ways in which psychosocial factors and asthma interact.

/pdf/a-systematic-review-to-examine-the-impact-of-psycho-3tjy29fbhg.pdf

A systematic review to examine the impact of psycho-educational interventions on health outcomes and costs in adults and children with difficult asthma.

Transitional care interventions aim to improve care transitions from hospital to home and to reduce hospital readmissions for chronically ill patients. The objective of our study was to examine if these interventions were associated with a reduction of readmission rates in the short (30 days or less), intermediate (31–180 days), and long terms (181–365 days). We systematically reviewed twenty-six randomized controlled trials conducted in a variety of countries whose results were published in the period January 1, 1980–May 29, 2013. Our analysis showed that transitional care was effective in reducing all-cause intermediate-term and long-term readmissions. Only high-intensity interventions seemed to be effective in reducing short-term readmissions. Our findings suggest that to reduce short-term readmissions, transitional care should consist of high-intensity interventions that include care coordination by a nurse, communication between the primary care provider and the hospital, and a home visit within thre...

/pdf/transitional-care-interventions-prevent-hospital-50hzepktvh.pdf

Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.

The largest portion of the cost for asthma healthcare is due to hospitalizations. Improved methods of healthcare delivery for patients with asthma are needed to prevent readmissions. From 1996 to 1999, 96 adult subjects (predominantly young African American women) hospitalized with an asthma exacerbation, who had a history of frequent healthcare use, were randomized to an asthma nurse specialist intervention (n = 50) or a usual care group (n = 46) for 6 months. Our aim was to decrease rates of readmissions within 6 months of hospital discharge, to reduce cost, and to improve health-related quality of life. Our results demonstrate a 60% reduction in total hospitalizations (31 readmissions in the intervention group and 71 in the control group, p = 0.04), with no significant change in emergency department visits. Readmissions for asthma were reduced by 54% (21 vs. 42 in the control group; p = 0.04). We found a marked reduction in lost work or school days: 246 versus 1040 days in the control group (p = 0.02). The intervention resulted in a substantial reduction in direct and indirect healthcare costs, saving US dollars 6462 per patient (p = 0.03). A brief intervention program focusing on high healthcare users with asthma can result in improved asthma control and reduced hospital use with substantial cost savings.

https://www.atsjournals.org/doi/pdf/10.1164/rccm.200208-877OC

Charles Leven

Papers

Asthma Intervention Program Prevents Readmissions in High Healthcare Users