A study published in the October 5 issue of JAMA shows that emergency department visits or asthma-related readmission rates have not been decreased despite children’s hospitals high-compliance or improvements of asthma care quality measures complying with providing written home management plans upon discharge.

According to background information the Children’s Asthma Care’s (CAC) procedural measures evaluate at hospital level whether patients between the ages of 2 to 17 years who were admitted with an asthma exacerbation were administered with relievers (CAC-1) and systemic corticosteroids (CAC-2) and whether they received a complete home management plan of care (HMPC) (CAC-3) when they were discharged.

The authors wrote:

“Process measures are designed to evaluate compliance with care that is expected and, when provided, should ‘maximize health benefits to patients’ and lead to improved clinical outcomes. Compliance of health care organizations with many hospital-level process measures has improved over time. However, their association with improved outcomes has been variable.”

Rustin B. Morse, M.D., of the Phoenix Children’s Hospital and University of Arizona College of Medicine, and his fellow researchers examined trends in CAC measure compliance at children’s hospitals and its link with improvements in clinical outcomes. The researchers collaborated administrative and CAC compliance data from 30 U.S. children’s hospitals, assessing a total of 27,267 children admitted with asthma between January 2008 and September 2010, who accounted for 45,499 hospital admissions. Follow-up ended in December 2010.

Findings revealed that the minimum quarterly compliance rates reported by a hospital was 97.1% for CAC-1 and 89.5% for CAC-2 measures whilst the average CAC-3 compliance was 40.6% during the first 3 quarters, improving to 72.9% during the last 3 quarters of the study.

The researchers found that the average post-discharge emergency department (ED) visit rates and the average quarterly readmission rates were 1.5% (post discharge ED visits) and 1.4% (readmission) at 7 days, 4.3% and 3.1% at 30 days and 11.1% and 7.6% respectively at 90 days.

According to the authors the high compliance with CAC-1 and CAC-2 with little differences across all hospitals ruled out the need to establish a possible link with the specified outcomes.

The authors write:

“. . . aggregate CAC-3 compliance was initially modest but improved during the study period, with substantial variation in compliance and improvement among the hospitals. We did not find a statistically significant association between aggregate CAC-3 compliance and post discharge ED utilization or asthma-related readmission rates at 7, 30, or 90 days.”

The researchers comment that according to their findings CAC measure set compliance within children’s hospitals on its own does not provide means for evaluating and comparing patients’ quality care for those admitted with asthma exacerbations.

In a concluding statement the authors write:

“Consideration should be given to refining the CAC-3 measure set to ensure that high-quality HMPCs are being developed using evidence-based resources and that they are conveyed to families in an effective manner. Finally, the CAC-3 measure in its current form may not meet the criteria outlined by the Joint Commission for accountability measures. Until CAC-3 compliance can be linked to improved outcomes, the Joint Commission should reconsider whether the CAC-3 component of the measure set is appropriately classified as an ‘accountability measure’ suitable for public reporting, accreditation, or pay for performance.”

Charles J. Homer, M.D., M.P.H., of the National Initiative for Children’s Healthcare Quality at Harvard Medical School and Children’s Hospital Boston writes in an Accompanying Editorial:

“Measurement can play a key role in helping redress the shortcomings of the U.S. health care system, but measures must meet high standards.

The study by Morse et al, highlighting the great value of ‘post marketing surveillance’ of performance measures, demonstrates that the Joint Commission’s Children’s Asthma Care measure 3, an asthma discharge plan, no longer reaches this threshold and should be retired, as should the other components if the nonvariability found in this study is replicated in non-specialty hospitals. Recent public investment in pediatric measurement development and refinement should ensure that children’s health care will not be bereft of high-quality performance measures.”

Written by Petra Rattue