Abstract
BACKGROUND: Asthma is the most common chronic disease leading to hospital admissions and readmissions in childhood. Bedside nurses and respiratory therapists are the primary asthma educators, but they may lack time or knowledge to provide comprehensive asthma education and identify barriers to care. Patients and their parent(s) may benefit from comprehensive education and assessment of barriers from a certified asthma educator.
METHODS: A team of certified asthma educators used a quality improvement method to create an in-patient asthma education consulting service. The in-patient pulmonary consult and medical teams referred subjects ≥ 1 y in age with a new or existing diagnosis of asthma who had been admitted to the ICU or identified as having concerns for poor medication adherence to the asthma consult. The asthma consult provided face-to-face education with the subject and parent(s), addressed barriers to the plan of care, and helped facilitate appointments to an asthma specialist after discharge.
RESULTS: There were 126 subjects eligible for the asthma consult pilot implemented October 1, 2018–April 30, 2020. The asthma consult saw 52 subjects. Subjects who received consults had a higher rate of previous health care utilization and existing specialist for asthma. After the in-patient stay, the odds of returning to the emergency department/urgent care (UC) or hospital within the following 12 months did not differ between asthma consult and control group. However, after adjusting for covariates of age, race, ethnicity, previous health care utilization, and existing specialist, there was a significant difference in the odds of readmission and revisits (adjusted odds ratio 0.39 [95% CI 0.16–0.98], P = .04) for the asthma consult group compared to the control group.
CONCLUSIONS: Providing comprehensive, face-to-face asthma education and working with subjects and their parent(s) to address barriers to medication adherence and facilitate specialty follow-up post discharge decreased health care utilization.
- asthma/prevention and control
- patient education
- patient care planning
- patient readmissions
- discharge planning
- hospitalized subjects
- asthma education
- medication adherence
- children’s health
Introduction
Asthma is the most common chronic disease of childhood and one of the most common reasons for children to be admitted to the hospital. Children admitted to the hospital with an asthma exacerbation have a 30% risk of readmission after the first hospitalization and almost a 60% risk after the third.1 Readmissions for asthma exacerbations significantly add to the direct and indirect cost of asthma, which is estimated to be over USD $80 billion per year.2 One of the best predictors of asthma exacerbations is the number of asthma exacerbations requiring prescribed systemic corticosteroids, emergency department utilization, or hospitalizations in the last 12 months.3
Children with asthma are less likely to be admitted to the hospital for asthma when the families fill their β agonist and controller medication prescriptions as prescribed, barriers to care are addressed, discharge education includes the asthma action plan, and a follow-up visit has been scheduled prior to discharge.4-9 Asthma clinical care guidelines standardize and improve the quality of care for children admitted to the hospital for asthma.10 Children’s Hospital Colorado implemented an asthma clinical care guideline/pathway in 2008. The in-patient asthma guideline standardizes medication delivery in the hospital and prompts medications be provided at discharge. The guideline also standardizes the approach to asthma education and completion of the asthma action plan prior to discharge. Data show asthma education that includes an asthma action plan leads to decreased emergency department visits and readmissions to the hospital for asthma.5,11
Unfortunately, despite the asthma clinical guideline, comprehensive asthma education is not always provided prior to discharge because bedside nurses and respiratory therapists, who are the primary asthma educators, also often lack the time or knowledge to provide high-level asthma education. Barriers to care or medication adherence is also associated with hospital admission for asthma but are not always identified or addressed in the hospital.
The goal of this quality improvement (QI) project was to design and pilot a multidisciplinary, multifaceted intervention to decrease the 12-month readmission and revisit rates in children with asthma. Our hypothesis was that children and their parent(s) who had an in-patient asthma education consult with a certified asthma educator would have a decreased rate of hospital readmissions and/or emergency department revisits after the consult when compared to their health care utilization for asthma before and when compared to other children who were eligible for an in-patient education consult but did not receive one.
QUICK LOOK
Current Knowledge
Asthma is one of the most common chronic diseases in children. Providing asthma education and asthma action plans at discharge can decrease hospitalizations and emergency department visits for asthma.
What This Paper Contributes to Our Knowledge
Providing comprehensive, one-on-one, face-to-face asthma education that includes reviewing the asthma action with subjects and their parent(s) and addressing any barriers to medication adherence and follow-up visit post discharge improved subject outcomes.
Methods
Inclusion criteria to participate in the pilot included any patient over the age of 1 y with a new or existing diagnosis of asthma who was admitted to pediatric ICU or the medical surgical floor at main campus (Denver) and who were referred by the in-patient medical team or pulmonary consult service with poor asthma control due to a poor understanding of asthma, medication adherence, and social barriers to care. Patients who had multiple other complex medical conditions (eg, cystic fibrosis, congenital heart disease, chronic lung disease due to prematurity) were excluded from this pilot. The control population consisted of subjects meeting inclusion criteria but did not receive the intervention either because certified asthma educators were not able to meet them or subjects were not referred for an asthma education consult by the medical team. For this study, high utilizers were defined as subjects with > 1 hospitalization or > 2 emergency department visits 12 months before the eligibility.
The pilot ran from October 1, 2018–April 30, 2019. Data were retrospectively collected October 1, 2017–April 30, 2020. Our internal QI review board determined that our project was a QI and, therefore, did not need institutional review board approval. Members from the asthma program met with key stakeholders (nurses, respiratory therapists, providers) to discuss how best to design and implement an in-patient asthma education consult “asthma consult” pilot for children admitted for asthma. Workflow was process mapped, and specific, measurable, attainable, relevant, and time-based goals were created by the asthma consult team then reviewed with key stakeholders. Once the program was designed and implemented, the asthma consult team met regularly to review the process, data, and plan any changes using Plan-Do-Study-Act QI methodology.12 The results of the pilot were reported to the key stakeholders on a regular schedule to elicit feedback.
Referrals to the asthma consult came from the in-patient pulmonary team or pulmonary consult team who saw subjects with asthma in the pediatric ICU or on one of the medical surgical teams. One registered respiratory therapist and 2 advanced practice providers (nurse practitioner and physician assistant) supported the asthma consult pilot Monday through Friday from 8 am to 5 pm, except for holidays. All 3 were certified asthma educators through the National Asthma Educator Certification Board.
Once consulted, one of the asthma consult team members would review the subject’s chart and coordinate a face-to-face visit with the subject and parent(s). During the visit, the asthma consult provided:
Education: Individualized, comprehensive asthma education and review of the asthma action plan with the subject/parent(s) using teach-back methods that included proper inhaled medication device technique.13
Barrier identification: Barriers to care assessed included understanding symptoms, medication adherence, social chaos, multiple caregivers or households, legal concerns, environmental concerns, subject and/or parent(s) engagement, financial limitations, language, subject and/or parent(s) mental health, work/school schedules, health care access, and transportation.14 Social chaos includes relationship(s) between parent and child where family routines and environmental conditions in chaotic homes affect health outcomes.15
The asthma consult then worked with social workers, the medical team, and family navigators to connect the subject and parent(s) to appropriate resources.
Shared decision-making: The asthma consult partnered with the subject/parent(s) to determine the best home management plan and worked with the medical team to approve any adjustments requested by the family.16
Coordinated care: Members of the asthma consult worked with the in-patient medical teams to determine the most appropriate inhaled medications and delivery device based on subject’s age, technique, insurance formulary, and out-of-pocket expense.17
Follow-up: Asthma consult partnered with support staff to arrange follow-up visit with primary care provider and an asthma specialist (ie, pulmonologist, allergist) when appropriate after discharge.18
Documentation: A standardized asthma consult note template (see the supplementary materials at http://www.rc.rcjournal.com) was used to document the visit and any follow-up. The documentation was shared with the in-patient and out-patient care teams as well as community primary care providers. The direct communication was aimed at continuing barrier assessment and education.
Subject-specific data were retrospectively collected by electronic medical record chart review of both the control and intervention group looking at emergency department/UC and hospitalizations 12 months prior and 12 months following the hospital visit when the subject was eligible for the asthma consult. Three subject identifiers were collected (name, medical record number, and date of birth) to assist in retrospective chart reviews. Subject information was placed in a password-protected Excel spreadsheet (Microsoft, Redmond, Washington) and placed on a SharePoint site.
Data Analysis
Subject demographics were summarized overall and by group (asthma consult vs control). Group comparisons were made using t tests, Wilcoxon, chi-square, and Fisher exact as appropriate. Any comparison of baseline clinical characteristics with a P value < .15 was considered potential confounders of the estimated of treatment effect and adjusted for in regression models. Differences in rate of hospitalization before and after identification of eligibility for asthma consult intervention were assessed with McNemar test for paired proportions. Rates across groups by time period were compared with chi-square tests. Multiple logistic regression assessed the primary study question of association of asthma consult with odds of hospitalization during the October 2018–April 2019 period (the time after identification of eligibility for asthma consult intervention). Maximum likelihood estimates with 95% Wald chi-square confidence intervals were estimated before and after adjusting for potentially important baseline clinical and demographic covariates. After univariate analysis, it was determined that age, race, ethnicity, indication of high utilizers, and indication of a previous visit with a specialist would be considered in multivariable regression models. Race and ethnicity were condensed into 2 categories for inclusion into the multivariable model based on quasi-complete separation of data points when including all categories in regression models; race as white and non-white and ethnicity as Hispanic and non-Hispanic. Statistical significance of the test for treatment effect was set at alpha > 0.05. The analysis for this manuscript was generated using SAS software, version 9.4. (SAS Institute, Cary, North Carolina).
Results
A total of 126 subjects met eligibility for the asthma consult pilot, and the asthma consult service completed 52 consults. There was a significant difference between subjects who got a consult and those who did not in age, race, ethnicity, previous health care utilization, and previous specialist. Asthma consult participants had a median age of 4.5 y (interquartile range [IQR] 2–8) compared to the control group of 5 y (IQR 4–8.75). The majority of the asthma consult participants identified as female (53.8%), white (53.8%), and spoke English (84.6%). The majority of participants in the control group also identified as female (64.9%), white (55.4%), and spoke English (95.9%). Both groups had more than half of the participants insured by Medicaid (57.7%). (Table 1) Approximately one-third of the subjects received a new diagnosis of asthma (35% asthma consult and 35% control) at the time of hospitalization. In the asthma consult group, 23 (44.2%) participants had visited an asthma specialist (allergist or pulmonologist) in the prior 12 months. After the asthma consult, 21 (40%) participants received new referrals to an asthma specialist. The control group had a significantly lower rate of prior asthma specialist visits: 7 (9.5%) participants (P < .001). There was a similar rate of new referrals, 17 (23.0%) in the control group.
Demographics and Baseline Asthma Characteristics
Of the total asthma consult subjects, 44 (85%) had a scheduled appointment with an asthma specialist (new referral or existing patient) within 30 business days of discharge, although the asthma consult group had a higher rate of emergency department/UC visits or hospitalizations the previous 12 months (92.3% vs 50.0%, P < .001). The odds of returning to the emergency department/UC or hospital within the follow 12 months did not differ between asthma consult and control group (OR 0.86 [95% CI 0.59–1.22], P = .37).
There was a noted differences in participants’ age, race, and ethnicity (Table 1), which called for a logistical regression analysis. After the logistic regression analysis (Table 2), there was a noted statistical difference in the odds of emergency department/UC visits or hospitalization (adjusted odds ratio 0.39 [95% CI 0.16–0.98], P = .044) for the asthma consult group compared to the control group in the 12 months after the index visit. Age remained the only other statistically significant predictor (type 3 test, P = .03) in the model of future utilization with an estimated decrease in the odds of utilization (adjusted odds ratio 0.90 [95% CI 0.82–0.99], P = .03) for every one-year increase in age. A sensitivity analysis on the subcohort of participants with > 1 emergency department/UC visit or hospitalization in the previous 12 months (n = 85) estimated effect with asthma consult (adjusted odds ratio 0.36 [95% CI 0.14–0.96], P = .04).
Demographics and Baseline Asthma Characteristics in Subcohort of High Utilizers
Discussion
This pilot led to the successful implementation of an in-patient asthma education consult. Comprehensive asthma education and addressing barriers prior to discharge by a certified asthma educator significantly decreased the odds of revisits and readmissions for subjects with asthma who were high utilizers.
More severe asthma is estimated to contribute to 50% of all annual health care costs, and asthma is the leading causes for missed school days.19,20 Children who had an asthma exacerbation the previous year are likely to have 76% more missed school days than other children with asthma.21 Missed school days have the potential to impact a child’s academic performance and parents’ productivity through missed worked days.21
Poorly controlled asthma can cause airway remodeling, potentially leading to persistent air flow obstruction and decline in lung function into adulthood; and in some cases, this obstruction may not be reversable.22,23 Approximately two-thirds of children with an asthma hospitalization had been consistently poorly controlled the previous year.24 Many times patients with poorly controlled asthma have barriers affecting medication adherence and gaps in their understanding of their disease management.24 More comprehensive asthma education and addressing barriers can improve patient outcomes.
The data from this pilot do not explain whether asthma education or barrier identification had more impact on the odds of return to the emergency department/UC or hospital. However, the asthma consult found that having dedicated time to sit with the children and their parent(s) would lead to families sharing barriers to care that they had not previously reported to the medical teams. Many of the barriers to asthma care identified were addressed through education and shared decision-making with the medical team while the subject was still in the hospital. Earlier engagement of social work helped to facilitate discussions with subjects/parents on resources specific to legal concerns, transportation, or financial barriers. In addition, the asthma consult assisted in facilitating appointments with an asthma specialist (ie, pulmonologist, allergist) after the hospitalization.
The rate of hospital readmissions and/or emergency department/UC revisits decreased after the asthma consult. A concomitant decline in health care utilization occurred in the control group. However, the logistic regression analysis indicates a greater decline in the asthma consult group. The sample size is small, resulting in a wide range of potential effects. Nonetheless, evidence supports a reduction in return rates. The observational nature of the QI study limits the ability to quantify the efficacy of the asthma consult service.
In summary, we believe asthma education, addressing barriers to care, facilitating shared decision-making, referring follow-up appointments with a specialist, and creating collaborative relationship between the patient/parent(s) and health care team can decrease health care utilization.25 In hospitals where it is difficult for first-line health care team members to have dedicated time in providing comprehensive asthma education, it may be beneficial to develop a dedicated role to provide a uniform approach to providing asthma education prior to discharge.
Limitations
Limitations to the study include the design and small sample size and retrospective QI data collection at a single site rather than a randomized controlled trial. All observational studies are subject to bias and unmeasured confounders.
Children seen by the asthma consult team had higher number of previous health care utilization rates likely because medical teams referring subjects to the asthma consult recognized these children were greater risk of a future exacerbation, leading to a selection bias for asthma consults.
There is the potential for inherent group differences. However, an attempt to control for this bias was made through statistical adjustment in logistic regression analysis. Care should be used when generalizing results from the study to other centers. It is also possible the in-patient care teams were not familiar with the asthma consult or uncertain how to refer patients.
Newly diagnosed children with asthma were included in the criteria for asthma consult because they were identified as high risk and could benefit from comprehensive asthma education. However, these children did not previously receive standard-of-care discharge education and experience readmission. It is, therefore, not certain that the asthma consult versus standard discharge education would have otherwise improved their readmission and revisit rate. The study did not assess refill or prescription history, emergency department visits, or hospitalizations outside the system. As a result, there is no information on systemic corticosteroid prescription history and pre/post intervention exacerbations.
Future of the In-Patient Asthma Education Consult Service
Study staff felt the QI pilot was successful in helping to enhance the subject/parent(s) experience in receiving more comprehensive asthma education and earlier identification of barriers to care. The asthma education consult service has been extended to all children admitted with a primary or secondary diagnosis of asthma at the main campus. Plans are ongoing to identify ways to extend this service to networks of care and community hospital within the health care system. In addition to the expansion of the service, any patient seen by the in-patient asthma education consult will receive a follow-up telephone call within 2–3 business days after discharge to address any patient/parent(s) questions or concerns, review the asthma action plan with the patient/parent(s), and ensure follow-up communication is provided with primary care providers and asthma specialists to further assist in care coordination. Barriers to follow-up care (transportation, financial, health care access, and health literacy) are being tracked during the telephone calls with the goal to expand our program to best support the needs of our population. In the future, we plan to expand upon our findings to include evaluation of specific barriers and earlier identification to patient outcomes.
As the climate of health care continues to change, this role or similar roles could provide professional growth for a respiratory therapist with a bachelor’s degree to serve as a care coordinator or disease manager in an in-patient or out-patient setting to help facilitate better transitions of care for children, health care team communication, and improved patient outcomes.
Conclusions
Health care utilization the 12 months following asthma education decreased in both the group receiving asthma education consult and those who received standardized asthma education. There were observed differences in age, race, ethnicity, health care utilization, and previous asthma specialist in subjects who were referred for the asthma consult. After adjusting for these factors, there was a significant decrease in the odds of hospital readmissions or emergency department revisits for those subjects who received the asthma education consult.
Providing individualized, comprehensive face-to-face asthma education, earlier identification of barriers to care, implementing a shared decision-making approach to addressing the barriers, facilitate follow-up appointment with a specialist, and creating a collaborative relationship between the patient/parent and health care team can decreases health care utilization.
Footnotes
- Correspondence: Joyce A Baker MBA RRT RRT-NPS AE-C FAARC, Breathing Institute, Children’s Hospital Colorado, 13123 E 16th Ave, Aurora, Colorado 80045. E-mail: joyce.baker{at}childrenscolorado.org
Supplementary material related to this paper is available at http://rc.rcjournal.com.
The authors have disclosed no conflicts of interest.
A version of this paper was presented by Ms Baker at the University of Colorado Denver, Department of Pediatrics Fellowship Research Education and Support: 2020 Virtual Pediatric Spring Poster Session held May 29, 2020; and as an Editors’ Choice abstract at AARC Congress 2020 LIVE!, held virtually on November 18, 2020.
The study was performed at Children’s Hospital Colorado, Aurora, Colorado.
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