Evaluating Emergency Department Asthma Management Practices in Florida Hospitals Alexandra C. H. Nowakowski, PhD, MPH; Henry J. Carretta, PhD, MPH; Julie K. Dudley, BA; Jamie R. Forrest, MS; Abbey N. Folsom, MS rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Objective: To assess gaps in emergency department (ED) asthma management at Florida hospitals. Design: Survey instrument with open- and closed-ended questions. Topics included availability of specific asthma management modalities, compliance with national guidelines, employment of specialized asthma care personnel, and efforts toward performance improvement. Setting: Emergency departments at 10 large hospitals in the state of Florida. Participants: Clinical care providers and health administrators from participating hospitals. Main Outcome Measures: Compliance with national asthma care guideline standards, provision of specific recommended treatment modalities and resources, employment of specialized asthma care personnel, and engagement in performance improvement efforts. Results: Our results suggest inconsistency among sampled Florida hospitals’ adherence to national standards for treatment of asthma in EDs. Several hospitals were refining their emergency care protocols to incorporate guideline recommendations. Despite a lack of formal ED protocols in some hospitals, adherence to national guidelines for emergency care nonetheless remained robust for patient education and medication prescribing, but it was weaker for formal care planning and medical follow-up. Conclusions: Identified deficiencies in emergency asthma care present a number of opportunities for strategic mitigation of identified gaps. We conclude with suggestions to help Florida hospitals achieve success with ED asthma care reform. Team-based learning activities may offer an optimal strategy for sharing and implementing best practices. KEY WORDS: asthma, best practices, emergency departments,
Florida, hospitals
J Public Health Management Practice, 2016, 22(4), E8–E13 C 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Asthma care costs in the United States have totaled close to $60 billion in recent years.1 In the late 1990s, asthma already accounted for a full 1% of all health care spending.2 Investment in preventive care may reduce these costs.3 Likewise, asthma often exerts a “major impact” on health-related quality of life.4 Yet asthma prevalence and care charges continue to rise in many states, including Florida.5 These collective trends suggest that improving asthma management is crucial for Florida and other states. Emergency department (ED) visits are largely avoidable with proper asthma education, medication, and environmental management. Yet in 2010, a total of 90 770 ED visits occurred in Florida with asthma listed as the primary diagnosis—an increase of 12.7% from 2005.5 The total annual charges associated with these visits doubled between 2005 and 2010, rising to $204.1 million.5 Many of these costs stem from repeat visits by people with poorly controlled asthma.6 In Florida, preventable ED visits for asthma accounted for $153.8
Author Affiliations: Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, Tallahassee (Drs Nowakowski and Carretta and Ms Folsom); and Division of Community Health Promotion (Ms Dudley) and Epidemiology and Evaluation (Ms Forrest), Bureau of Chronic Disease Prevention, Florida Department of Health, Tallahassee. The authors thank Kim Streit and other members of the Florida Hospital Association for their outstanding assistance in conceptualizing and implementing this evaluation project. They thank Dr J. Sumerau for additional feedback and assistance with final proofing. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.JPHMP.com). This evaluation was supported by Cooperative Agreement Number 5U59EH000523-03 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. Also, the authors have no conflicts of interest. Correspondence: Alexandra C. H. Nowakowski, PhD, MPH, Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, 1115 W Call St, Ste 3200, Tallahassee, FL 32306 ([email protected]). DOI: 10.1097/PHH.0000000000000231
E8 Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Asthma Management Practices in Florida Hospitals
million in health care charges.5 Asthma partners in Florida thus embarked on an evaluation project to increase knowledge of current practices and illuminate gaps in preventive strategies. Emergency department settings were chosen as a key focus because hospitalizations for asthma can originate with visits to urgent care.7 Prior evaluation of emergency care with ambulatory follow-up as an alternative to hospitalization suggests that effective ED treatment can allow people to return home safely.8 In addition, people who receive structured ambulatory follow-up after discharge from the ED experience better health outcomes over the long-term, with fewer ED visits.9 In spring 2012, the Florida Asthma Program at the Florida Department of Health collaborated with an external evaluation team, the Florida Asthma Coalition, and professionals from the Florida Hospital Association. We developed a qualitative survey to assess asthma management practices in select Florida hospitals. It focused on compliance with National Heart, Lung, and Blood Institute’s Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma (EPR-3 Guidelines). It also captured information about related performance improvement and quality assurance efforts in Florida ED settings. Several recent studies have focused specifically on hospital asthma management practices and improvement efforts in Florida. Hospitals have increasingly made clinical pathways a priority, but more so for inpatient units than EDs.10 These pathways may not significantly impact rates of education or appropriate drug therapy, both key activities for ED asthma management.10 Likewise, most evaluations of clinical pathways in Florida have focused on children; adult Floridians may or may not benefit substantially. Continuity of postdischarge care for childhood asthma has also been a focus for evaluation efforts in Florida. Two thirds of children in Central Florida do not get recommended levels of follow-up care.11 Low maternal education, high maternal age, and high asthma severity all predict lower rates of follow-up care.11 Emergency visits for asthma remain high even among Floridians with substantial socioeconomic privilege.12 Consequently, connecting patients with appropriate follow-up care may help to prevent ED use across diverse socioeconomic groups.12 Other scholars have previously assessed Florida hospitals’ use of national guidelines to inform asthma care practices. Hospitals in the southern states tend to provide lower quality of care for people with asthma who seek treatment in the ED,13 especially if they receive Medicaid benefits.14 People in the southern US may receive ED care less concordant with national guidelines. This represents a high priority for mitigation, as
❘ E9
implementing guidelines can reduce admission risk by 46%.13 Among asthmatic children enrolled in Florida Medicaid, the EPR-3 Guidelines may make a substantial positive difference across multiple domains of care, especially if the level of medication adherence remains high during home follow-up.15 Medication adherence programs can also improve outcomes for asthmatic children enrolled in Medicaid coverage. In addition to national guidelines, efforts to improve care for asthmatic Medicaid patients in Florida have also focused on specific comorbidities and unique service needs.14
● Data and Methods The 20 hospitals with the largest number of combined hospitalizations and ED visits in Florida with asthma listed as the primary diagnosis (International Classification of Diseases, Ninth Revision, code 493) in 2010 were selected for participation using the Florida Agency for Health Care Administration’s discharge files. The FHA reviewed the list and provided contact information for several key informants at each hospital. The partners of FHA then made initial contact with each hospital in mid-June 2012, informing key personnel about the upcoming survey and encouraging participation when contacted by external evaluators from Florida State University. The following week, external evaluators conducted recruitment by contacting the key personnel in each of the 20 hospitals in the sample, with the aim of enrolling 10 or more hospitals to complete the survey. Hospital personnel were given 2 options for completing the survey: telephone interview with one of the evaluators, or writing in answers independently and sending completed surveys to the evaluators. Both methods produced identical data products: copies of the interview script with answers transcribed into text fields below each question. A minimum of 4 follow-up contacts by telephone or e-mail was employed to recruit hospital participants. Data collection concluded in October 2012. A total of 10 hospitals completed the survey, with 3 scheduling interviews and 7 opting to complete the survey on their own. The responding hospitals had a combined total of 19 375 visits, accounting for 15.9% of the 121 680 primary asthma ED visits and hospitalizations in 2010. The responding hospitals had a higher proportion of child asthma visits (72%) than adult asthma visits (27.9%). Table 1 displays size and catchment characteristics of hospitals sampled. Evaluators worked with Florida Asthma Program staff, FHA partners, and the Florida Asthma Coalition Clinical Workgroup to develop an interview script. This
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
E10 ❘ Journal of Public Health Management and Practice TABLE 1 ● Characteristics of Responding and Nonresponding Hospitals
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Facility Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Total ED and Hospital Discharges With Primary Diagnosis of Asthma
Child (0-17) Primary Asthma Discharges
Adult (18+) Primary Asthma Discharges
Completed Survey
3770 3040 2902 2618 2293 2160 1985 1935 1780 1729 1662 1647 1643 1603 1555 1523 1508 1465 1462 1389
2889 1607 1595 1732 2268 950 1072 1151 1768 432 1006 1610 1198 1056 595 1249 730 972 800 886
881 1433 1307 886 25 1210 913 784 12 1297 656 37 445 547 960 274 778 493 662 503
Yes No No Yes No No Yes No Yes No No Yes Yes No Yes Yes No Yes No Yes
instrument covered 5 topics altogether: (1) inpatient care, (2) ED care, (3) performance and quality improvement efforts, (4) community benefit programs, and (5) interest in collaborative activities. The full survey instrument is included in this report as an appendix. This study was approved by the Florida State University Human Subjects Committee in Spring 2012. Interviews lasted between 15 and 30 minutes; selfcompleting hospitals generally returned their surveys within 3 days of receipt. Some respondents reported significant effort to obtain requested information prior to the survey. Written responses and interview transcripts were reviewed using basic content analysis techniques to assess compliance with EPR-3 Guidelines and identify common themes. We focused on domains in which Florida hospitals had success in caring for patients with asthma, as well as challenges these hospitals faced.
● Results All 10 participating hospitals responded to the questions about ED care. Implementation rates for specific care practices are reported in Table 2. Many hospitals reported using some of the same national guidelines mentioned earlier in the inpatient care section. Only
TABLE 2 ● Emergency Department Asthma Care Practices qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Activity Existing formal asthma care protocols for ED Developing formal protocols Asthma education (per EPR-3 recommendations) Sending people home with written plans Providing detailed discharge instructions Prescribing inhaled controllers for persistent asthma Following up with primary care providers Scheduling appointments with specialists Providing written follow-up recommendations Making referrals to case management Employing certified asthma educators Dispensing inhalers for home use Prescribing inhalers for home use Using metered dose inhalers with spacers Allowing people to take spacers home
Percent of Hospitals Reporting 50% 20% 100% 10% 100% 80% 30% 20% 30% 100% 80% 0% 100% 90% 70%
5 of 10 participating hospitals currently had formal ED asthma care protocols/policies in place, though 2 others explicitly reported that they were currently
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Asthma Management Practices in Florida Hospitals
developing formal protocols/policies. Emergency department protocols/policies were generally much less thorough and detailed than inpatient ones. They were implemented mostly on a case-by-case basis, using formal guidelines only as a general foundation. Improving ED care protocols was uniformly reported as a major priority. Table 3 (digital supplement, available at http:// links.lww.com/JPHMP/A141) provides an overview of hospital efforts related to the EPR-3 Guidelines. Adherence to EPR-3 Guidelines remained robust for patient education and medication prescribing but was weaker in other areas. All hospitals reported covering inhaler technique, reviewing medications, recommending environmental controls, and facilitating follow-up. One hospital did report being unsure of how extensively environmental controls were covered, but adherence to the national guidelines for patient education was otherwise uniform. Only one of the participating hospitals reported sending ED patients home with formal Asthma Action Plans/Home Management Plans for Care, but at least 2 additional hospitals were currently working to implement such plans for ED patients upon discharge. However, all 10 hospitals reported providing detailed written discharge instructions for patients to take home, which may include many of the same elements. Eight of 10 participating hospitals reported prescribing inhaled controller medications for patients with a history of persistent asthma. Two of these 8 hospitals noted that this practice was a relatively new component of their ED asthma care procedures. All 10 hospitals reported making referrals to case management and/or community resources as necessary. Likewise, all but 2 of the 10 already had certified asthma educators on staff, though their EDs did not
always have dedicated asthma educators who worked exclusively with emergency patients. Most hospitals indicated making active efforts to train more asthma educators, and also to require certification for existing and new asthma education staff. One hospital reported conducting these efforts in pursuit of a “center of excellence” certification. Only 3 of 10 reported communicating with primary care providers about ED visits for all patients. However, 2 others scheduled patient follow-ups with pulmonology/respiratory specialists, and 3 provided information in discharge instructions about scheduling follow-ups. Two hospitals reported not taking any specific action on follow-up care. One hospital reported mainly using nebulizers for management of acute asthma symptoms; the other 9 reported using metered dose inhalers with valved holding chambers. Seven of the 9 hospitals reported allowing patients to take holding chambers home after use in the ED; the remaining 2 hospitals that used metered dose inhalers did not allow patients to take holding chambers home. As with inpatient care, all 10 hospitals reported discharging patients with prescriptions for reliever medications rather than allowing them to take inhalers home. All 10 answered questions about performance and quality. These questions addressed care delivered in both ED and inpatient units, but respondents were asked to indicate whether the efforts they reported applied to both types of care or only one. Response rates for each item are listed in Table 4 (digital supplement, available at http://links.lww.com/JPHMP/ A142). Seven of these reported currently conducting a
TABLE 4 ● Performance Improvement and Quality Assurance Efforts qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
TABLE 3 ● Emergency Department Efforts Related to the
EPR-3 Guidelines qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Percent of Participating Hospitals Reporting EPR-3 Component Schedule follow-up appointment with primary provider or specialist Provide education prior to discharge from ED Prescribe appropriate controller and/or reliever medications Provide discharge plan and/or Asthma Action Plan
Practice
Protocol/Policy
10%
20%
100%
60%
90%
50%
70%
40%
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Activity Comprehensive PI/QA process Using Joint Commission CAC measures Working from own plans of care to do PI/QA Revised formal care protocols within last 6 months Tracking hospital admissions Tracking repeat visits by specific patients Aware of how hospital compares to others in Florida Tracking education benchmarks from EPR-3 Tracking missed school/work days Developing compliance checklists
Percent of Hospitals Reporting 70% 50% 20% 50% 60% 50% 30% 90% 10% 10%
Abbreviations: CAC, Children’s Asthma Care; EPR-3, Expert Panel Report 3; PI, performance improvement; QA, quality assurance.
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E12 ❘ Journal of Public Health Management and Practice comprehensive performance improvement/quality assurance (PI/QA) process that includes asthma management. The remaining 3 hospitals did not currently have a PI/QA process underway. Of the 7 currently conducting PI/QA efforts, 5 reported using the Joint Commission Children’s Asthma Care measures as guidance. The 2 others reported working from their own Asthma Action Plans/Home Management Plans for Care for guidance on data tracking and reporting. For the 6 hospitals that already had formal asthma care protocols, revisions were usually quite recent. All hospitals reported having revised their protocols for emergency care within the last 6 months, and some were in the process of revision at the time of the interview or survey response. All of these hospitals reported updating their protocols at least once per year. These results were consistent with our findings for inpatient units, but participating hospitals generally noted that their ED protocols were newer and less developed than their inpatient ones. Six hospitals reported actively tracking inpatient readmissions and/or ED visits. Five of these hospitals tracked repeat visits by specific patients and 1 tracked aggregate ED visit and inpatient admission rates over time. Seven of the 10 participating hospitals were unaware of how their hospital was compared with others in the state with respect to asthma management quality and performance indicators. Of the remaining 3, one cited National Association of Children’s Hospitals and Related Institutes as the source for this information, and 2 others cited their own efforts to gather and review statistics from other hospitals. Data tracking was found to be fairly uniform across hospitals for written care plans and patient education. Only 2 participating hospitals reported not tracking education benchmarks from the EPR-3 Guidelines. Seven of 10 reported actively reaching out to community providers and other partners to improve asthma care systems as well as practices within the hospital. Six hospitals reported participating in the National Association of Children’s Hospitals and Related Institutes Children’s Asthma Care Core Measures project. Two of the other hospitals reported not participating despite being eligible. The remaining 2 hospitals were not eligible because they were not children’s hospitals. In addition, 1 hospital reported tracking missed work and school days for patients. Another hospital reported focusing its PI/QA efforts on improving care in the ED. Finally, a third hospital reported developing a checklist for use by both hospitals and private practitioners who see patients in the hospital to ensure compliance with institutional protocols and EPR-3 Guidelines.
● Discussion and Conclusions The quality of ED asthma care in Florida was much less uniform than what we previously found for inpatient units, with some hospitals already having robust formal protocols and others using a more integrative approach with informal review. All hospitals did report using an evidence-based approach and keeping abreast of national guidance. Yet formalization of these approaches was very inconsistent across hospitals, as was data collection on effectiveness. Adherence to EPR-3 Guidelines was more mixed in ED units than in inpatient units we studied at the same hospitals. We found strong adherence for guidelines related to patient education and medication prescribing, but weak adherence for those related to environmental trigger management and follow-up care. However, like inpatient units, use of case management services, community resources, and certified asthma educators is strong for ED units. Review of care practices and development of new protocols is on the rise at many EDs in Florida. However, implementation of EPR-3 recommendations remains inconsistent. Particularly, large gaps exist with respect to written care plans and dispensation of inhaled medications; policy barriers may exacerbate these deficiencies. Responding hospitals were also largely unaware of how other hospitals in the state compared on national quality measures. Our small overall sample size may have introduced limitations. Although Florida has 306 hospitals overall,16 our sampling frame contained only 20 hospitals, of which we interviewed 10. Generalizability of results from our study is further limited by the fact that all 10 hospitals we sampled had relatively high numbers of discharges on a daily basis. Results should not be interpreted as representative of patterns at smaller hospitals. However, restricting sample size also allowed us to collect detailed information from each hospital. We also observed strong similarity in responses. Respondents tended to report the same practices, priorities, and goals. Interviewing additional hospitals thus might not have added substantial value. Getting input from multiple people at many of the sampled hospitals also provided diversity of perspective. Finally, interviewing staff from hospitals with the highest rates of asthma catchment helped identify gaps amenable to strategic mitigation. Broadly speaking, our findings from this evaluation suggest that Floridians with asthma could benefit from increased communication and collaboration among hospital staff in general, and ED staff specifically. These efforts should emphasize overcoming practical and
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Asthma Management Practices in Florida Hospitals
policy barriers to effective implementation of EPR-3 Guidelines in ED settings. Team-based approaches17 could facilitate statewide adoption of policies and practices from hospitals that have successfully increased the thoroughness and overall quality of their ED asthma care. We disseminated these recommendations via pilot learning webinars held in summer 2013 and continue to conduct follow-up activities in collaboration with the Florida Hospital Association. We encourage health care managers to develop participatory learning opportunities of their own, and to share materials and results widely. REFERENCES 1. Barnett SB, Nurmagambetov TA. Costs of Asthma in the United States: 2002-2007. J Allergy Clin Immunol. 2011;127(1):145-152. 2. Bailey R, Weingarten S, Lewis M, Mohsenifar Z. Impact of clinical pathways and practice guidelines on the management of acute exacerbations of bronchial asthma. CHEST J. 1998;113:28-33. 3. Grumbach K, Grundy P. Outcomes of Implementing Patient Centered Medical Home Interventions. Washington, DC: Patient-Centered Primary Care Collaborative; 2010. 4. Adams R, Wakefield M, Wilson D, et al. Quality of life in asthma: a comparison of community and hospital asthma patients. J Asthma. 1976;38:205-214. 5. Forrest J, Dudley J. Burden of Asthma in Florida. Tallahassee, FL: Florida Department of Health, Division of Community Health Promotion, Bureau of Chronic Disease Prevention, Florida Asthma Program; 2012. 6. Meng Y-Y, Babey SH, Hastert TA, Lombardi C. Uncontrolled Asthma Means Missed Work and School, Emergency Department Visits for Many Californians. Loss Angeles, CA: UCLA Center for Health. https://escholarship.org/uc/item/2xp0r5vf. Published 2008. Accessed March 28, 2014.
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7. McCaig LF, Burt CW. National hospital ambulatory medical care survey: 2003 emergency department summary: Citeseer. http://www.ihi.org/resources/Pages/Publications/ NHAMCSurvey2003EDSummaryReport.aspx. Published 2005. Last accessed March 28, 2014. 8. McDermott MF, Murphy DG, Zalenski RJ, Rydman RJ, McCarren M, Marder D. A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma. Arch Intern Med. 1997;157:20552062. 9. Sharieff GQ, Burnell L, Cantonis M, et al. Improving emergency department time to provider, left-without-treatment rates, and average length of stay. J Emerg Med. 2013;45(3): 426-432. 10. Edwards E, Fox K. A retrospective study evaluating the effectiveness of an asthma clinical pathway in pediatric inpatient practice. J Pediatr Pharmacol Ther. 2008;13:233-241. 11. Smith LC. Childhood asthma: ED follow-up determinants. J Emerg Nurs. 2009;35:412-418. 12. Chukmaitov AS, Tang A, Carretta H, Menachemi N, Brooks R. Characteristics of all, occasional, and frequent emergency department visits due to ambulatory care: sensitive conditions in Florida. J Ambul Care Manage. 2012;35(2):149-158. 13. Tsai C-L, Sullivan AF, Gordon JA, et al. Quality of care for acute asthma in 63 US emergency departments. J Allergy Clin Immunol. 2009;123:354-361. 14. Lubell J. Florida Medicaid to focus on care management. Fam Pract News. 2005;35:90. 15. David C. Preventive therapy for asthmatic children under Florida Medicaid: changes during the 1990s. J Asthma. 2004;41:655-661. 16. Florida Hospital Association. Facts and stats about the Florida Hospital Association. Updated June 8, 2012. http:// www.fha.org/reports-and-resources/facts-and-stats.aspx. Accessed March 28, 2014. 17. Mitchell P, Wynia M, Golden R, et al. Core Principles and Values of Effective Team-Based Health Care [discussion paper]. Washington, DC: Institute of Medicine. www.iom.edu/tbc. Published October 2, 2012. Accessed March 28, 2014.
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Objective: To assess gaps in emergency department (ED) asthma management at Florida hospitals. Design: Survey instrument with open- and closed-ended questions. Topics included availability of specific asthma management modalities, compliance with national guidelines, employment of specialized asthma care personnel, and efforts toward performance improvement. Setting: Emergency departments at 10 large hospitals in the state of Florida. Participants: Clinical care providers and health administrators from participating hospitals. Main Outcome Measures: Compliance with national asthma care guideline standards, provision of specific recommended treatment modalities and resources, employment of specialized asthma care personnel, and engagement in performance improvement efforts. Results: Our results suggest inconsistency among sampled Florida hospitals’ adherence to national standards for treatment of asthma in EDs. Several hospitals were refining their emergency care protocols to incorporate guideline recommendations. Despite a lack of formal ED protocols in some hospitals, adherence to national guidelines for emergency care nonetheless remained robust for patient education and medication prescribing, but it was weaker for formal care planning and medical follow-up. Conclusions: Identified deficiencies in emergency asthma care present a number of opportunities for strategic mitigation of identified gaps. We conclude with suggestions to help Florida hospitals achieve success with ED asthma care reform. Team-based learning activities may offer an optimal strategy for sharing and implementing best practices. KEY WORDS: asthma, best practices, emergency departments,
Florida, hospitals
J Public Health Management Practice, 2016, 22(4), E8–E13 C 2016 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Asthma care costs in the United States have totaled close to $60 billion in recent years.1 In the late 1990s, asthma already accounted for a full 1% of all health care spending.2 Investment in preventive care may reduce these costs.3 Likewise, asthma often exerts a “major impact” on health-related quality of life.4 Yet asthma prevalence and care charges continue to rise in many states, including Florida.5 These collective trends suggest that improving asthma management is crucial for Florida and other states. Emergency department (ED) visits are largely avoidable with proper asthma education, medication, and environmental management. Yet in 2010, a total of 90 770 ED visits occurred in Florida with asthma listed as the primary diagnosis—an increase of 12.7% from 2005.5 The total annual charges associated with these visits doubled between 2005 and 2010, rising to $204.1 million.5 Many of these costs stem from repeat visits by people with poorly controlled asthma.6 In Florida, preventable ED visits for asthma accounted for $153.8
Author Affiliations: Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, Tallahassee (Drs Nowakowski and Carretta and Ms Folsom); and Division of Community Health Promotion (Ms Dudley) and Epidemiology and Evaluation (Ms Forrest), Bureau of Chronic Disease Prevention, Florida Department of Health, Tallahassee. The authors thank Kim Streit and other members of the Florida Hospital Association for their outstanding assistance in conceptualizing and implementing this evaluation project. They thank Dr J. Sumerau for additional feedback and assistance with final proofing. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.JPHMP.com). This evaluation was supported by Cooperative Agreement Number 5U59EH000523-03 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. Also, the authors have no conflicts of interest. Correspondence: Alexandra C. H. Nowakowski, PhD, MPH, Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, 1115 W Call St, Ste 3200, Tallahassee, FL 32306 ([email protected]). DOI: 10.1097/PHH.0000000000000231
E8 Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Asthma Management Practices in Florida Hospitals
million in health care charges.5 Asthma partners in Florida thus embarked on an evaluation project to increase knowledge of current practices and illuminate gaps in preventive strategies. Emergency department settings were chosen as a key focus because hospitalizations for asthma can originate with visits to urgent care.7 Prior evaluation of emergency care with ambulatory follow-up as an alternative to hospitalization suggests that effective ED treatment can allow people to return home safely.8 In addition, people who receive structured ambulatory follow-up after discharge from the ED experience better health outcomes over the long-term, with fewer ED visits.9 In spring 2012, the Florida Asthma Program at the Florida Department of Health collaborated with an external evaluation team, the Florida Asthma Coalition, and professionals from the Florida Hospital Association. We developed a qualitative survey to assess asthma management practices in select Florida hospitals. It focused on compliance with National Heart, Lung, and Blood Institute’s Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma (EPR-3 Guidelines). It also captured information about related performance improvement and quality assurance efforts in Florida ED settings. Several recent studies have focused specifically on hospital asthma management practices and improvement efforts in Florida. Hospitals have increasingly made clinical pathways a priority, but more so for inpatient units than EDs.10 These pathways may not significantly impact rates of education or appropriate drug therapy, both key activities for ED asthma management.10 Likewise, most evaluations of clinical pathways in Florida have focused on children; adult Floridians may or may not benefit substantially. Continuity of postdischarge care for childhood asthma has also been a focus for evaluation efforts in Florida. Two thirds of children in Central Florida do not get recommended levels of follow-up care.11 Low maternal education, high maternal age, and high asthma severity all predict lower rates of follow-up care.11 Emergency visits for asthma remain high even among Floridians with substantial socioeconomic privilege.12 Consequently, connecting patients with appropriate follow-up care may help to prevent ED use across diverse socioeconomic groups.12 Other scholars have previously assessed Florida hospitals’ use of national guidelines to inform asthma care practices. Hospitals in the southern states tend to provide lower quality of care for people with asthma who seek treatment in the ED,13 especially if they receive Medicaid benefits.14 People in the southern US may receive ED care less concordant with national guidelines. This represents a high priority for mitigation, as
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implementing guidelines can reduce admission risk by 46%.13 Among asthmatic children enrolled in Florida Medicaid, the EPR-3 Guidelines may make a substantial positive difference across multiple domains of care, especially if the level of medication adherence remains high during home follow-up.15 Medication adherence programs can also improve outcomes for asthmatic children enrolled in Medicaid coverage. In addition to national guidelines, efforts to improve care for asthmatic Medicaid patients in Florida have also focused on specific comorbidities and unique service needs.14
● Data and Methods The 20 hospitals with the largest number of combined hospitalizations and ED visits in Florida with asthma listed as the primary diagnosis (International Classification of Diseases, Ninth Revision, code 493) in 2010 were selected for participation using the Florida Agency for Health Care Administration’s discharge files. The FHA reviewed the list and provided contact information for several key informants at each hospital. The partners of FHA then made initial contact with each hospital in mid-June 2012, informing key personnel about the upcoming survey and encouraging participation when contacted by external evaluators from Florida State University. The following week, external evaluators conducted recruitment by contacting the key personnel in each of the 20 hospitals in the sample, with the aim of enrolling 10 or more hospitals to complete the survey. Hospital personnel were given 2 options for completing the survey: telephone interview with one of the evaluators, or writing in answers independently and sending completed surveys to the evaluators. Both methods produced identical data products: copies of the interview script with answers transcribed into text fields below each question. A minimum of 4 follow-up contacts by telephone or e-mail was employed to recruit hospital participants. Data collection concluded in October 2012. A total of 10 hospitals completed the survey, with 3 scheduling interviews and 7 opting to complete the survey on their own. The responding hospitals had a combined total of 19 375 visits, accounting for 15.9% of the 121 680 primary asthma ED visits and hospitalizations in 2010. The responding hospitals had a higher proportion of child asthma visits (72%) than adult asthma visits (27.9%). Table 1 displays size and catchment characteristics of hospitals sampled. Evaluators worked with Florida Asthma Program staff, FHA partners, and the Florida Asthma Coalition Clinical Workgroup to develop an interview script. This
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
E10 ❘ Journal of Public Health Management and Practice TABLE 1 ● Characteristics of Responding and Nonresponding Hospitals
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Facility Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Total ED and Hospital Discharges With Primary Diagnosis of Asthma
Child (0-17) Primary Asthma Discharges
Adult (18+) Primary Asthma Discharges
Completed Survey
3770 3040 2902 2618 2293 2160 1985 1935 1780 1729 1662 1647 1643 1603 1555 1523 1508 1465 1462 1389
2889 1607 1595 1732 2268 950 1072 1151 1768 432 1006 1610 1198 1056 595 1249 730 972 800 886
881 1433 1307 886 25 1210 913 784 12 1297 656 37 445 547 960 274 778 493 662 503
Yes No No Yes No No Yes No Yes No No Yes Yes No Yes Yes No Yes No Yes
instrument covered 5 topics altogether: (1) inpatient care, (2) ED care, (3) performance and quality improvement efforts, (4) community benefit programs, and (5) interest in collaborative activities. The full survey instrument is included in this report as an appendix. This study was approved by the Florida State University Human Subjects Committee in Spring 2012. Interviews lasted between 15 and 30 minutes; selfcompleting hospitals generally returned their surveys within 3 days of receipt. Some respondents reported significant effort to obtain requested information prior to the survey. Written responses and interview transcripts were reviewed using basic content analysis techniques to assess compliance with EPR-3 Guidelines and identify common themes. We focused on domains in which Florida hospitals had success in caring for patients with asthma, as well as challenges these hospitals faced.
● Results All 10 participating hospitals responded to the questions about ED care. Implementation rates for specific care practices are reported in Table 2. Many hospitals reported using some of the same national guidelines mentioned earlier in the inpatient care section. Only
TABLE 2 ● Emergency Department Asthma Care Practices qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Activity Existing formal asthma care protocols for ED Developing formal protocols Asthma education (per EPR-3 recommendations) Sending people home with written plans Providing detailed discharge instructions Prescribing inhaled controllers for persistent asthma Following up with primary care providers Scheduling appointments with specialists Providing written follow-up recommendations Making referrals to case management Employing certified asthma educators Dispensing inhalers for home use Prescribing inhalers for home use Using metered dose inhalers with spacers Allowing people to take spacers home
Percent of Hospitals Reporting 50% 20% 100% 10% 100% 80% 30% 20% 30% 100% 80% 0% 100% 90% 70%
5 of 10 participating hospitals currently had formal ED asthma care protocols/policies in place, though 2 others explicitly reported that they were currently
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Asthma Management Practices in Florida Hospitals
developing formal protocols/policies. Emergency department protocols/policies were generally much less thorough and detailed than inpatient ones. They were implemented mostly on a case-by-case basis, using formal guidelines only as a general foundation. Improving ED care protocols was uniformly reported as a major priority. Table 3 (digital supplement, available at http:// links.lww.com/JPHMP/A141) provides an overview of hospital efforts related to the EPR-3 Guidelines. Adherence to EPR-3 Guidelines remained robust for patient education and medication prescribing but was weaker in other areas. All hospitals reported covering inhaler technique, reviewing medications, recommending environmental controls, and facilitating follow-up. One hospital did report being unsure of how extensively environmental controls were covered, but adherence to the national guidelines for patient education was otherwise uniform. Only one of the participating hospitals reported sending ED patients home with formal Asthma Action Plans/Home Management Plans for Care, but at least 2 additional hospitals were currently working to implement such plans for ED patients upon discharge. However, all 10 hospitals reported providing detailed written discharge instructions for patients to take home, which may include many of the same elements. Eight of 10 participating hospitals reported prescribing inhaled controller medications for patients with a history of persistent asthma. Two of these 8 hospitals noted that this practice was a relatively new component of their ED asthma care procedures. All 10 hospitals reported making referrals to case management and/or community resources as necessary. Likewise, all but 2 of the 10 already had certified asthma educators on staff, though their EDs did not
always have dedicated asthma educators who worked exclusively with emergency patients. Most hospitals indicated making active efforts to train more asthma educators, and also to require certification for existing and new asthma education staff. One hospital reported conducting these efforts in pursuit of a “center of excellence” certification. Only 3 of 10 reported communicating with primary care providers about ED visits for all patients. However, 2 others scheduled patient follow-ups with pulmonology/respiratory specialists, and 3 provided information in discharge instructions about scheduling follow-ups. Two hospitals reported not taking any specific action on follow-up care. One hospital reported mainly using nebulizers for management of acute asthma symptoms; the other 9 reported using metered dose inhalers with valved holding chambers. Seven of the 9 hospitals reported allowing patients to take holding chambers home after use in the ED; the remaining 2 hospitals that used metered dose inhalers did not allow patients to take holding chambers home. As with inpatient care, all 10 hospitals reported discharging patients with prescriptions for reliever medications rather than allowing them to take inhalers home. All 10 answered questions about performance and quality. These questions addressed care delivered in both ED and inpatient units, but respondents were asked to indicate whether the efforts they reported applied to both types of care or only one. Response rates for each item are listed in Table 4 (digital supplement, available at http://links.lww.com/JPHMP/ A142). Seven of these reported currently conducting a
TABLE 4 ● Performance Improvement and Quality Assurance Efforts qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
TABLE 3 ● Emergency Department Efforts Related to the
EPR-3 Guidelines qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Percent of Participating Hospitals Reporting EPR-3 Component Schedule follow-up appointment with primary provider or specialist Provide education prior to discharge from ED Prescribe appropriate controller and/or reliever medications Provide discharge plan and/or Asthma Action Plan
Practice
Protocol/Policy
10%
20%
100%
60%
90%
50%
70%
40%
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Activity Comprehensive PI/QA process Using Joint Commission CAC measures Working from own plans of care to do PI/QA Revised formal care protocols within last 6 months Tracking hospital admissions Tracking repeat visits by specific patients Aware of how hospital compares to others in Florida Tracking education benchmarks from EPR-3 Tracking missed school/work days Developing compliance checklists
Percent of Hospitals Reporting 70% 50% 20% 50% 60% 50% 30% 90% 10% 10%
Abbreviations: CAC, Children’s Asthma Care; EPR-3, Expert Panel Report 3; PI, performance improvement; QA, quality assurance.
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E12 ❘ Journal of Public Health Management and Practice comprehensive performance improvement/quality assurance (PI/QA) process that includes asthma management. The remaining 3 hospitals did not currently have a PI/QA process underway. Of the 7 currently conducting PI/QA efforts, 5 reported using the Joint Commission Children’s Asthma Care measures as guidance. The 2 others reported working from their own Asthma Action Plans/Home Management Plans for Care for guidance on data tracking and reporting. For the 6 hospitals that already had formal asthma care protocols, revisions were usually quite recent. All hospitals reported having revised their protocols for emergency care within the last 6 months, and some were in the process of revision at the time of the interview or survey response. All of these hospitals reported updating their protocols at least once per year. These results were consistent with our findings for inpatient units, but participating hospitals generally noted that their ED protocols were newer and less developed than their inpatient ones. Six hospitals reported actively tracking inpatient readmissions and/or ED visits. Five of these hospitals tracked repeat visits by specific patients and 1 tracked aggregate ED visit and inpatient admission rates over time. Seven of the 10 participating hospitals were unaware of how their hospital was compared with others in the state with respect to asthma management quality and performance indicators. Of the remaining 3, one cited National Association of Children’s Hospitals and Related Institutes as the source for this information, and 2 others cited their own efforts to gather and review statistics from other hospitals. Data tracking was found to be fairly uniform across hospitals for written care plans and patient education. Only 2 participating hospitals reported not tracking education benchmarks from the EPR-3 Guidelines. Seven of 10 reported actively reaching out to community providers and other partners to improve asthma care systems as well as practices within the hospital. Six hospitals reported participating in the National Association of Children’s Hospitals and Related Institutes Children’s Asthma Care Core Measures project. Two of the other hospitals reported not participating despite being eligible. The remaining 2 hospitals were not eligible because they were not children’s hospitals. In addition, 1 hospital reported tracking missed work and school days for patients. Another hospital reported focusing its PI/QA efforts on improving care in the ED. Finally, a third hospital reported developing a checklist for use by both hospitals and private practitioners who see patients in the hospital to ensure compliance with institutional protocols and EPR-3 Guidelines.
● Discussion and Conclusions The quality of ED asthma care in Florida was much less uniform than what we previously found for inpatient units, with some hospitals already having robust formal protocols and others using a more integrative approach with informal review. All hospitals did report using an evidence-based approach and keeping abreast of national guidance. Yet formalization of these approaches was very inconsistent across hospitals, as was data collection on effectiveness. Adherence to EPR-3 Guidelines was more mixed in ED units than in inpatient units we studied at the same hospitals. We found strong adherence for guidelines related to patient education and medication prescribing, but weak adherence for those related to environmental trigger management and follow-up care. However, like inpatient units, use of case management services, community resources, and certified asthma educators is strong for ED units. Review of care practices and development of new protocols is on the rise at many EDs in Florida. However, implementation of EPR-3 recommendations remains inconsistent. Particularly, large gaps exist with respect to written care plans and dispensation of inhaled medications; policy barriers may exacerbate these deficiencies. Responding hospitals were also largely unaware of how other hospitals in the state compared on national quality measures. Our small overall sample size may have introduced limitations. Although Florida has 306 hospitals overall,16 our sampling frame contained only 20 hospitals, of which we interviewed 10. Generalizability of results from our study is further limited by the fact that all 10 hospitals we sampled had relatively high numbers of discharges on a daily basis. Results should not be interpreted as representative of patterns at smaller hospitals. However, restricting sample size also allowed us to collect detailed information from each hospital. We also observed strong similarity in responses. Respondents tended to report the same practices, priorities, and goals. Interviewing additional hospitals thus might not have added substantial value. Getting input from multiple people at many of the sampled hospitals also provided diversity of perspective. Finally, interviewing staff from hospitals with the highest rates of asthma catchment helped identify gaps amenable to strategic mitigation. Broadly speaking, our findings from this evaluation suggest that Floridians with asthma could benefit from increased communication and collaboration among hospital staff in general, and ED staff specifically. These efforts should emphasize overcoming practical and
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Asthma Management Practices in Florida Hospitals
policy barriers to effective implementation of EPR-3 Guidelines in ED settings. Team-based approaches17 could facilitate statewide adoption of policies and practices from hospitals that have successfully increased the thoroughness and overall quality of their ED asthma care. We disseminated these recommendations via pilot learning webinars held in summer 2013 and continue to conduct follow-up activities in collaboration with the Florida Hospital Association. We encourage health care managers to develop participatory learning opportunities of their own, and to share materials and results widely. REFERENCES 1. Barnett SB, Nurmagambetov TA. Costs of Asthma in the United States: 2002-2007. J Allergy Clin Immunol. 2011;127(1):145-152. 2. Bailey R, Weingarten S, Lewis M, Mohsenifar Z. Impact of clinical pathways and practice guidelines on the management of acute exacerbations of bronchial asthma. CHEST J. 1998;113:28-33. 3. Grumbach K, Grundy P. Outcomes of Implementing Patient Centered Medical Home Interventions. Washington, DC: Patient-Centered Primary Care Collaborative; 2010. 4. Adams R, Wakefield M, Wilson D, et al. Quality of life in asthma: a comparison of community and hospital asthma patients. J Asthma. 1976;38:205-214. 5. Forrest J, Dudley J. Burden of Asthma in Florida. Tallahassee, FL: Florida Department of Health, Division of Community Health Promotion, Bureau of Chronic Disease Prevention, Florida Asthma Program; 2012. 6. Meng Y-Y, Babey SH, Hastert TA, Lombardi C. Uncontrolled Asthma Means Missed Work and School, Emergency Department Visits for Many Californians. Loss Angeles, CA: UCLA Center for Health. https://escholarship.org/uc/item/2xp0r5vf. Published 2008. Accessed March 28, 2014.
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