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Restructuring Asthma Care in a Hospital Setting to Improve Outcomes* FREE TO VIEW

Richard Evans, III, MD, MPH; Susan LeBailly, PhD; Karyn K. Gordon, RN, BSN; Anne Sawyer, MA; Katherine Kaufer Christoffel, MD, MPH; Barbara Pearce, MPH
Author and Funding Information

*From the Division of Allergy (Dr. Evans and Ms. Sawyer), Statistical Sciences and Epidemiology Program/Outcomes Research Program (Drs. LeBailly and Christoffel), Pulmonary Unit/Allergy Clinic (Ms. Gordon), and the Division of Quality Improvement (Ms. Pearce), Children’s Memorial Hospital, Chicago, IL.

Correspondence to: Richard Evans III, MD, MPH, Division Head of Allergy, Box 60, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614; e-mail: revans@nwu.edu



Chest. 1999;116(suppl_2):210S-216S. doi:10.1378/chest.116.suppl_2.210S
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Study objectives: To restructure asthma care as the pilot program in hospital-wide redesign aimed at providing better and more standardized care. We chose asthma care to begin our reorganization because it is the highest-volume diagnosis at our hospital and it involves a broad spectrum of services.

Design: Key elements of our restructuring included the following: (1) establishing a pulmonary unit with expanded bed capacity from 8 to 22 beds for asthma patients; (2) standardized treatment protocols; (3) availability of direct admission by primary care physicians who maintained management of their patients with the option of consultation with a specialist; and (4) use of case managers who helped patients and their families overcome obstacles to optimum care.

Setting: A hospital serving a high proportion of Medicaid patients.

Patients/participants: Children with asthma and their families.

Interventions: Standardized care for asthma; use of case managers to facilitate adherence to treatment.

Results: With the restructured asthma care program, parent satisfaction with treatment was sustained; the average length of stay and use of the emergency department (ED) were reduced; observation unit use increased; and there were fewer readmissions to both the inpatient unit and the ED.

Conclusions: We conclude that an inner-city hospital can provide optimum care for asthma patients by standardizing treatment, aggregating asthma patients in one location, and providing education and follow-up through the use of case managers. The protocol shifts some costs from expensive services such as the pediatric ICU and the ED to less costly case management and outreach personnel. In the long run, this allocation of resources should help to lower costs as well as improve quality of care.

In recent years, financial pressures brought about by the proliferation of managed care have forced physicians and provider institutions to reexamine their care delivery practices as they strive to provide optimum care at the lowest possible cost. Most physicians and hospitals have already made some changes to reduce costs while still providing high-quality care. Notably, there has been a movement—mandated in some cases by insurance providers—toward more standardized care for specific diagnoses.

Ironically, while standardized care is deemed desirable by managed-care insurers, another of their policies often works against it. This is the practice of establishing primary care physicians (PCPs), the mainstays of managed health-care delivery, as gatekeepers who decide when referral to a specialist is necessary. Managed-care providers often discourage PCPs in their groups from making such referrals or even penalize them for doing so, and PCPs themselves may be reluctant to make referrals for fear that they will lose access to their patients. Although numerous studies show that specialists’ care for asthma is cost-effective,15 it is also important that PCPs maintain overall management of their patients. The best care for the patient will not emerge from a “turf war” environment. Rather, high-quality care results when all providers who have something to contribute to the patient’s improvement integrate their services seamlessly.

With these considerations in mind, we at Children’s Memorial Hospital (CMH) in Chicago, IL, decided to restructure our health-care delivery system to provide top-quality care more efficiently. Asthma care delivery was chosen as the pilot area for early redesign because it represented the highest-volume diagnosis at admission, and also because asthma care involves a wide spectrum of sites and services, including primary care, emergency department (ED), observation unit, acute-care unit, pediatric ICU (PICU), and the home. Appropriately integrating all these services for a high volume of patients could provide cost savings and, at the same time, rigorously test the new reorganization process.

Objectives

We sought to design a model of care delivery for children and families living with asthma that would permit direct admission of the patient to the ward. Before redesign, we had only eight beds for asthma patients. As the average length of stay (ALOS) in the hospital was 3.4 days, these beds were often filled. When we had to place asthma patients on other patient-care units, there was a logistical problem in providing the level of specialized nursing and education necessary for our asthma patients. To standardize care, we developed a model that all care providers would use at each point of delivery. The attending physician, residents, nurse practitioners, clinical nurse specialists, staff nurses, respiratory therapists, social workers, medical psychologists, patient therapies staff, support services staff, pharmacists, and any other related staff would all use the same protocols.

Our specific objectives were the following: (1) to implement a process that could be integrated with other core processes as redesign progressed to other areas of patient care, (2) to restructure asthma care to treat acute asthma on the ward instead of in the PICU, (3) to design outcome measures to test the restructuring plan, and (4) to develop a mechanism to allow physicians to admit their patients directly to the hospital and to manage their care while in hospital. We also sought to improve and systematize our relationship with community-based physicians through better communication.

By having an integrated plan, we hoped to (1) reduce the ALOS by ≥ 1 day, (2) decrease reliance on the use of the ED, (3) improve patient/family adherence to the patient’s specific medical plan, (4) increase productivity of the clinical staff at each stage of the continuum, (5) reduce the recidivism rate for hospitalization, and (6) develop discharge criteria for each point on the continuum.

Outcomes Measurement

We measured changes and improvements in asthma care delivery by comparing the 1996 asthma season (before redesign) with the 1997 asthma season (after redesign) in several key areas. We compared the overall ALOS and the length of stay on the inpatient pulmonary unit and the PICU; the use of observation status (defined as a stay of < 24 h on the ward) vs the use of the ED; inpatient and observation readmissions within 2 weeks and within 2 months; the number of admissions from the ED; and the average total charge and average total costs.

Initial measurements were made for the quarter including August through October (peak asthma season) for 1996 and 1997. Thereafter, data were collected and analyzed for each quarter. Ongoing measurement monitored care delivery on the inpatient pulmonary unit and overall to ensure a single standard of care for all asthma patients throughout the hospital.

Project Teams

We assembled a multidisciplinary Asthma Redesign Team directed by the Division Head of Allergy and the Director of the Inpatient Pulmonary Unit. This team was charged with evaluating the current process of asthma management, beginning with the entry point in the ED and following the patient up to and including outpatient management. Other members included the Administrator of Critical Care, the ED Director, and two case managers.

A second team, the Asthma Outcomes Management Team, evaluated the effects of redesign on the patient with asthma. This team was directed by the Division Head of Allergy and the Director of the Statistical Sciences and Epidemiology Program/Outcomes Initiative. Other members of the Outcomes Team included six interviewers and a data analyst.

Redesign

To increase efficiency and streamline patient care, we developed standardized orders and patient-care protocols and coordinated asthma patient care among all providers. We also established a pulmonary unit with dedicated allergy/pulmonary coverage. Bed capacity was increased from 8 to 22 beds, with each able to serve all levels of asthma severity.

We established a Command Control Center through which community physicians could admit their asthmatic patients directly to the pulmonary unit. Patients are triaged over the telephone by a nurse. Community physicians continue to manage their own patients, but an asthma-care specialist is available on the floor.

Two asthma nursing case managers follow all asthmatic inpatients and coordinate their care. Case managers monitor the patient through treatment, coordinate discharge planning, and follow up on home health evaluations. They also work with nurses from the pulmonary unit and the allergy clinic to ensure that patients and families receive standardized asthma education. In addition, we have added a certified pediatric nurse practitioner and an asthma respiratory specialist to the staff.

Survey

To track family satisfaction with the changes in protocol, we approached families as they presented for treatment and obtained informed consent for their participation in a survey. The goal was to obtain 50 completed interviews from each site (the inpatient unit, the ED, and the allergy clinic), both before and after redesign. The sample was limited to English-speaking families with at least one custodial parent. Children < 18 months of age were excluded. Families presenting at CMH for asthma care from April through June of 1997 were eligible for inclusion in the baseline group. Families presenting from August through October of 1997 were eligible for inclusion in the post-redesign group. The project was approved by the CMH Institutional Review Board. Table 1 lists the background characteristics of the survey participants.

Survey Instrument

The survey included questions about care delivery, specifically focused on aspects affected by redesign, and outcome measures. Where possible, we used questions from existing surveys with established reliability and validity.68 These items covered demographics, functional status, health-care utilization, medical risk, adherence, parent and child knowledge of asthma, environment, and satisfaction with care. We developed questions involving redesign elements and evaluated them for test-retest reliability. The questionnaire took approximately 30 min to complete. (The questionnaire is available from the corresponding author.)

Table 2 shows the eligibility determination, contact rate, and response rate for the baseline and postredesign samples. Depending on the care site and time period, between 20% and 45% of families did not meet eligibility criteria. Among those eligible, interviewers were able to contact up to 94% of families, again depending on the care site and time period.

Six interviewers interviewed a total of 102 families at baseline (48 in the allergy clinic, 22 in the ED, and 32 on the pulmonary floor). After redesign, 149 families were interviewed, including 52 in the clinic, 50 in the ED, and 47 on the pulmonary floor. Five interviews were completed by telephone after patient discharge.

Hospital Data

We compared data on hospital discharges during August to October 1996 with data from August to October 1997. Data included the number of inpatient asthma discharges for World Health Organization International Classification of Diseases code 493 (asthma) and ALOS. Discharge data were separated into groups of children who received some intensive care during their stay and those who did not require intensive care. Hospital data were extracted from MIDAS and TRENDSTAR databases for CMH and exported to computer software (SigmaStat, version 6.1.4; SPSS Inc; Chicago, IL) for analysis.

For statistical analysis, χ2, t tests, analyses of variance, and one-sample χ2 tests were applied as appropriate. This was true for both survey and hospital data. A p value of < 0.01 was considered significant, while p values of < 0.05 approached significance.

Comparability of Survey Groups

Demographic characteristics of the baseline and postredesign samples were similar overall and at each of the three interviewing sites (clinic, ED, and pulmonary floor), as seen in Table 1.

In the pre- and postredesign groups, children had similar exposure to asthma triggers. There were no significant differences in the proportion living in homes with forced-air heat, gas stoves, dogs, cats, or smokers in the home. Neither were there differences in the average number of reported mold sources or average number of different asthma triggers.

More than one third of families from each site had at least one smoker in the household. Other commonly reported triggers included mold in the home (23% in the baseline group; 26% in the post-redesign group), and use of a gas stove (81% in both groups).

Symptom days/functional status were similar in the baseline and post-redesign groups at each site (Table 1).

Groups were comparable overall and by site for the following: the proportion of children who had a PCP or a physician for asthma; asthma medication use, including inhaled medications, oral steroids, and albuterol; understanding instructions; and number of problems affecting compliance with asthma treatment.

The number of inpatient hospitalizations, unscheduled physician visits, or hospitalizations in the Asthma Care Unit for the prior 2 months did not differ between the baseline and post-redesign groups, either overall or by site.

Results Related to Redesign
Implementing an Integrated Clinical Care Pathway:

We aimed to increase the use of the observation unit, rather than the ED, for the provision of nebulizer treatments. The number of asthmatic children admitted to the observation unit increased from 14 in 1996 to 69 in 1997, an almost fivefold increase.

Another key element was the creation of a pulmonary unit to treat asthma. Before this unit was established, 48% of children hospitalized for asthma were treated on the pulmonary floor. After redesign, the proportion rose to 88%.

Redesign introduced the use of case managers, home health care, and patient assistance liaisons (PALs) to supplement nursing services. These personnel were primarily involved with patients in the inpatient unit, so survey responses reflect the perceptions of parents of 49 inpatients after redesign. Parents did not recognize case managers as a new kind of provider: only four (9%) recalled having someone introduce herself as a case manager. Eleven parents (25%) reported that someone talked about home health care. Thirteen (29%) reported contact with a PAL, whose principal duties were changing bedding, taking vital signs, feeding, talking, and playing with the child. Of those who identified care provided by a PAL, nearly all (92%) were pleased with the care.

Most parents reported having an assigned nurse. After redesign, 67% of parents reported that a nurse visited them more than eight times a day, compared with 8% of inpatients’ parents interviewed at baseline (p < 0.001).

Survey results found no significant differences in the number of parents reporting contact with their child’s PCP during their CMH visit, either overall or by site. At baseline, 93% of parents reported that their child had a PCP. After redesign, the proportion rose slightly, to 96%. However, more parents reported contact with the PCP during the hospital stay after redesign (60% vs 50%).

Another goal of the redesign was to reduce the amount of time spent in the ED to ≤2. Parents interviewed in the inpatient unit who reported waiting in the ED > 2 h before transfer to the pulmonary floor decreased from 48% at baseline to 18% after redesign (p < 0.05).

Increasing Physician Satisfaction:

We hoped that allowing the PCP to directly admit his or her patients to the pulmonary floor would increase physician satisfaction and lead to more referrals. Such admissions were noted on the hospital record. However, data from these records indicate that the proportion of admissions coming from physician referral or self-referral remained stable.

Adherence:

We hoped to reduce recidivism by increasing and systematizing asthma education and counseling about adherence. After redesign, there was no significant difference in the proportion of parents reporting adherence problems, but significantly more parents reported discussing these problems overall (p < 0.001) and in the allergy clinic (p < 0.001). See Table 3 for data on education. The survey included eight topics related to asthma education. Overall (p < 0.01) and in the clinic setting (p < 0.01), parents reported a significant increase in the average number of educational topics discussed. Families of children hospitalized on the pulmonary floor reported an average of 4.5 educational topics discussed after redesign, which was similar to the number reported by those interviewed in the clinic after redesign. Families interviewed in the ED reported discussing the fewest educational topics.

Overall, topics that parents reported discussing significantly more often after redesign included ways to decrease airway obstruction (p < 0.001) and the importance of having a PCP (p < 0.01). Asthma triggers (p < 0.05), ways to avoid triggers (p < 0.05), and steps to take in an emergency (p < 0.05) were discussed more often than before redesign, but not significantly so.

Parents and children completed an asthma knowledge test on the survey. Parental asthma knowledge was relatively high both before and after redesign, with half the parents answering ≥ 75% of questions correctly. An analysis of variance showed that in either time period, the proportion of parents correctly answering ≥ 75% of the questions was significantly higher among families interviewed in the clinic.

Among children able to respond to the survey (40%), asthma knowledge was also relatively high, regardless of the site where the child was interviewed. About 63% of respondents answered ≥ 75% of questions correctly. There were no significant differences in asthma knowledge before and after redesign.

After redesign, survey responses indicated an overall increase in the proportion of children aged ≥ 5 years who reported using a peak flowmeter (PFM) during their CMH visit (p < 0.05). Significantly more parents reported receiving instruction in the use of a PFM (p < 0.01) and in interpreting PFM measurements (p < 0.001). This was particularly true in the clinic setting, where knowledge and use had significantly lagged behind those observed in the ED and the inpatient unit at baseline. In fact, education in the clinic approached the level of the inpatient unit after redesign.

At baseline, 19% of parents overall reported that their children aged ≥ 5 years received a pulmonary function test. After redesign, the proportion rose to 40% overall (p < 0.01). Again, the increase was primarily among clinic patients (17% before vs 75% after redesign; p < 0.001). There were no significant changes in the ED or inpatient groups.

Returns to the ED and Readmissions:

We were concerned that decreases in the ALOS might result in early returns to the hospital if the child had been discharged too early. However, hospital data showed that among 275 discharges in 1996, 11 patients made ED visits within 2 weeks after discharge, compared with two ED visits after 287 discharges in 1997. The proportion of discharges resulting in returns to the ED in 1996 was used as the expected value for ED returns in 1997 in a single-sample χ2 test, which showed a significant decrease in returns to the ED within 2 weeks (p < 0.01). Returns within 2 months also decreased, from 31 of 275 in 1996 to 20 of 287 in 1997 (p < 0.05). There were eight readmissions within 2 weeks in 1996 and three readmissions in 1997 (p < 0.1). In the 1996 period, there were 27 inpatient readmissions within 2 months vs 18 in 1997 (p < 0.05). Although these results were not significant, it appears that reducing the ALOS did not result in increased readmissions.

Parents completed six survey questions about satisfaction with asthma care during their current encounter and rated the quality of their child’s asthma care at CMH during the previous year (Table 4 ). There were no significant differences either in the number of items rated excellent or very good, or in the proportion rating individual items highly. Furthermore, there was no significant difference before vs after redesign in the rating of quality of asthma care during the previous year.

Study Findings

Overall, the results indicate that redesign improved the efficiency and quality of asthma care delivery. We feel that moving patients quickly from the ED to the observation unit was an important factor in the improvement. In our experience, young children with asthma seem to do better in rooms with their own beds than in the ED.

The ALOS dropped significantly, yet ED returns and early readmissions also declined, an indication that patients were well when they left and remained so.

We believe that the use of case managers played a key role in these results. In the past, adherence has been a problem in our patient population. The case managers helped families establish patterns of adherence by scheduling appointments, arranging transportation when necessary, and helping with other problems after the patients went home.

Since we had no control group with which to compare changes, we did not complete a definitive cost analysis, but the available data indicate that the addition of case managers reduced the use of high-priced services. Therefore, as families learn what it takes to keep their children well, the redesign should be cost-effective over the long term.

We are relatively unconcerned that many parents could not identify the case manager as such. Parents were pleased with their child’s care and worked well with the case managers, whether or not they understood the role.

Study Limitations

Because we compared the ALOS in two different asthma seasons, it is possible that factors other than redesign could have influenced the outcome. Comparing our asthma ALOS changes with the ALOS for asthma at other institutions might help to clarify the situation.

We were disappointed that more PCPs did not take advantage of the opportunity for direct admission of their patients. However, we actively recruited only a small sample of PCP practices. In the future, we plan to establish relationships with other community-based PCPs and offer them the opportunity for direct admission. It is also possible that some PCPs were unwilling to try direct admission simply because it was a new protocol with which they were unfamiliar. An upcoming survey of PCPs who did use direct admission should help identify areas for improvement.

Future Plans

To build on the results from this study, we plan to establish a quality-improvement team to identify barriers to adherence to medications; add the use of a spirometer to the current asthma management protocol to facilitate treatment adjustments; and establish a child-advocacy asthma team to bring asthma education and prevention to high-risk children and school nurses. In addition, we plan an 18-month follow-up on the functional status and hospital and ED utilization of our study patients.

Our findings showed asthma redesign met a substantial number of our objectives. Overall ALOS declined significantly without increasing either early ED visits or early readmissions. We were able to shift some patients from the PICU and the ED to the observation unit. Although the ED remained the primary source of admissions, the modest decline in ED admissions represents a trend in the right direction. In our institution, redesign was a positive step toward treating asthma in a more appropriate and cost-effective setting. We believe that our model can be replicated for other specialties and in other institutions for standardized, high-quality, and more- efficient treatment of patients.

Funded by a special allocation of funds from the Office of the Director, Allergy-Immunology Programs, National Institute of Allergy and Infectious Disease (NIAID)/National Institutes of Health (NIH) and sent to the Chicago Asthma Consortium through the Chicago ASU of the National Cooperative Inner-City Asthma Study (NCICAS)/NIAID/NIH.

Abbreviations: ALOS = average length of stay; CMH =Children’s Memorial Hospital; ED = emergency department; PAL = patient assistance liaison; PCP = primary care physician; PFM = peak flowmeter; PICU = pediatric ICU

Table Graphic Jump Location
Table 1. Background Characteristics of the Survey Participants Pre- and Post-redesign*
* 

Pre = before redesign; Post = after redesign.

Table Graphic Jump Location
Table 2. Eligibility, Contact, and Response Among Survey Prospects
Table Graphic Jump Location
Table 3. Asthma Education Pre- and Post-redesign*
* 

See Table 1 for abbreviations.

 

p < 0.001.

 

p < 0.01.

§ 

p < 0.05.

Table Graphic Jump Location
Table 4. Parental Satisfaction With Treatment Pre- and Post-redesign*
* 

MD = physician; RN = registered nurse. See Table 1 for other abbreviations.

 

p < 0.01.

National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, April 1997; Publication No. 97–405.
 
Stempel, DA, Carlson, AM, Buchner, DA Asthma: benchmarking for quality improvement.Ann Allergy Asthma Immunol1997; 79, 517-524
 
Freund, D, Stein, J, Hurley, R, et al The Kansas City asthma care project: specialty differences in the cost of treating asthma.Ann Allergy1988;60,3-8
 
Mayo, PH, Richman, J, Harris, HW Results of a program to reduce admissions for adult asthma.Ann Intern Med1990;112,864-871
 
Vollmer, WM, O’Hollaren, M, Ettinger, KM, et al Specialty differences in the management of asthma: a cross-sectional assessment of allergists’ patients and generalists’ patients in a large HMO.Arch Intern Med1997;157,1201-1208
 
Wade, S, Weil, C, Holden, G, et al Psychosocial characteristics of inner-city children with asthma: a description of the NCICAS psychosocial protocol.Pediatr Pulmonol1997;24,263-276
 
Mitchell, H, Senturia, Y, Gergen, P, et al Design and methods of the National Cooperative Inner-City Asthma Study.Pediatr Pulmonol1997;24,237-252
 
Kattan, M, Mitchell, H, Eggleston, P, et al Characteristics of inner-city children with asthma: the National Cooperative Inner-City Asthma Study.Pediatr Pulmonol1997;24,253-262
 

Figures

Tables

Table Graphic Jump Location
Table 1. Background Characteristics of the Survey Participants Pre- and Post-redesign*
* 

Pre = before redesign; Post = after redesign.

Table Graphic Jump Location
Table 2. Eligibility, Contact, and Response Among Survey Prospects
Table Graphic Jump Location
Table 3. Asthma Education Pre- and Post-redesign*
* 

See Table 1 for abbreviations.

 

p < 0.001.

 

p < 0.01.

§ 

p < 0.05.

Table Graphic Jump Location
Table 4. Parental Satisfaction With Treatment Pre- and Post-redesign*
* 

MD = physician; RN = registered nurse. See Table 1 for other abbreviations.

 

p < 0.01.

References

National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, April 1997; Publication No. 97–405.
 
Stempel, DA, Carlson, AM, Buchner, DA Asthma: benchmarking for quality improvement.Ann Allergy Asthma Immunol1997; 79, 517-524
 
Freund, D, Stein, J, Hurley, R, et al The Kansas City asthma care project: specialty differences in the cost of treating asthma.Ann Allergy1988;60,3-8
 
Mayo, PH, Richman, J, Harris, HW Results of a program to reduce admissions for adult asthma.Ann Intern Med1990;112,864-871
 
Vollmer, WM, O’Hollaren, M, Ettinger, KM, et al Specialty differences in the management of asthma: a cross-sectional assessment of allergists’ patients and generalists’ patients in a large HMO.Arch Intern Med1997;157,1201-1208
 
Wade, S, Weil, C, Holden, G, et al Psychosocial characteristics of inner-city children with asthma: a description of the NCICAS psychosocial protocol.Pediatr Pulmonol1997;24,263-276
 
Mitchell, H, Senturia, Y, Gergen, P, et al Design and methods of the National Cooperative Inner-City Asthma Study.Pediatr Pulmonol1997;24,237-252
 
Kattan, M, Mitchell, H, Eggleston, P, et al Characteristics of inner-city children with asthma: the National Cooperative Inner-City Asthma Study.Pediatr Pulmonol1997;24,253-262
 
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