Asthma Care Measures Don't Reflect Outcomes in Children

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Discharge Measure Doesn’t Measure Up

The findings of Dr. Morse and coauthors demonstrate that the "use of a written discharge management plan no longer meets the criteria for a high-quality measure," Dr. Charles J. Homer said.

The authors showed that the Joint Commission’s CAC-3 measure (a written plan for managing asthma given to the patient at discharge) "should be retired" as a measure of hospital performance.

They also showed that compliance with CAC measures 1 and 2 is nearly universal within a subset of freestanding children’s hospitals. However, more than two-thirds of hospitalizations occur at other types of facilities, and the performance of these measures is yet to be documented in other settings.

Dr. Homer is with the National Initiative for Children’s Healthcare Quality and the department of pediatrics at Harvard Medical School and Children’s Hospital Boston. He reported no financial conflicts of interest. These remarks were adapted from his editorial accompanying Dr. Morse’s report (JAMA 2011;306:1487-8).



Hospital compliance with the Children’s Asthma Care set of process measures did not correlate with asthma patients’ clinical outcomes in a study of more than 37,000 asthma patients who were admitted to 30 U.S. children’s hospitals, according to a study reported in the Oct. 5 issue of JAMA.

Because compliance with these process measures was not associated with improved outcomes, it "cannot serve as a means to evaluate and compare the quality of care provided for patients admitted with asthma exacerbations," said Dr. Rustin B. Morse of Phoenix Children’s Hospital and the University of Arizona, Phoenix, and his associates.

The Joint Commission considers the Children’s Asthma Care (CAC) measure set to be an "accountability measure," appropriate for use in determining accreditation, in public reporting of hospital performance, and in pay-for-performance efforts. But the findings of this study instead suggest that the CAC measure set does not meet the Joint Commission criteria for accountability measures and should be "reconsidered," Dr. Morse and his colleagues said.

They assessed time trends in compliance with the CAC measure set using data on a random sample of 37,267 pediatric inpatients with 45,499 admissions for asthma exacerbations during a 33-month period at 30 freestanding children’s hospitals across the country.

The CAC measure set includes three measures: whether patients received asthma relievers on admission (CAC-1), whether they received systemic corticosteroids on admission (CAC-2), and whether they were discharged with a complete home management plan of care (CAC-3). Compliance is measured quarterly by a review of the medical records of a random sample of patients.

Compliance with CAC-1 and CAC-2 was quite high, exceeding 95% in all but 1 of the 11 quarters assessed, and was consistent across hospitals. Because there were so few cases of poor compliance, no analysis could be performed to examine whether better compliance correlated with improved clinical outcomes.

In contrast, compliance with CAC-3 was not as high and varied substantially among hospitals. Mean CAC-3 compliance was only 41% during the first three quarters of the study and improved to 73% in the final three quarters.

This allowed an analysis of the relationship between compliance with CAC-3 and clinical outcomes. But no significant association was found between CAC-3 compliance and improved outcomes at 7 days, 30 days, or 90 days after discharge, the investigators said (JAMA 2011;306:1454-60).

There also was no association between compliance and clinical outcomes when hospitals in the highest-performing quartile were compared with those in the lowest-performing quartile.

One of Dr. Morse’s associates reported ties to the Robert Wood Johnson Foundation, the National Institute of Allergy and Infectious Diseases, the Child Health Corporation of America, and the Pediatric Research in Inpatient Settings Network. Two reported grants from the Agency for Healthcare ResearcDr. Homer reported no financial conflicts of interest.

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