Improving Improvement for Childhood Asthma

Abstract

THE HEALTH CARE SYSTEM IN THE UNITED STATES DElivers much good high-quality care but also causes unnecessary harm. This harm has many guises— some visible, such as hospital-acquired infections, and others more subtle, such as failure to prescribe indicated treatment or communicate effectively. Individuals with chronic conditions may be particularly vulnerable to the shortcomings of the delivery system. The care of these individuals crosses organizational boundaries—primary care and subspecialty, hospital and community. Although defects certainly occur within systems, the likelihood and severity of errors increase substantially at the crevasses between systems. All of these concerns apply equally to health care for children. The quality of ambulatory care for children and the levels of harm in hospitals differ only slightly between children and adults. Chronic illness in childhood is increasing; a subset of children with chronic conditions incurs a large proportion of overall child health care costs. Measurement is one lynchpin for improving quality. Measures—when coupled with the capacity for organizational improvement—can lead to better care either through “accountability” (ie, by having the measures publicly available or connected to tangible incentives) or through enabling delivery organizations to identify and prioritize shortcomings and then track improvement. The bar for using a measure should be high. Measurement is costly and burdensome. If organizational leadership uses measures to shift priorities and affect care or if external entities use them to determine payment or accreditation, these parties should be confident that they are measuring the right thing and that outcomes will be better. Well-accepted criteria for highquality measures include that the indicator shows opportunity for improvement (either low performance, high variability, or both) and that any process being assessed is clearly linked to a desired outcome. It is in this context that the study reported in this issue of JAMA by Morse and colleagues informs efforts to measure and improve quality of care in several ways. Frustrated by reporting on matters of tangential relevance to children, several organizations developed a set of measures for one of the most common medical diagnoses for which a wellaccepted guideline exists—acute exacerbations of asthma. The measurement set has 3 components—use of relievers, use of systemic corticosteroids, and use of a written home asthma management plan. Using administrative data from 2 sources and 30 children’s hospitals, the authors examined the rates of performance on these indicators over time (2008-2010) and across hospitals and also sought to correlate performance with accepted proxy outcome measures for asthma care— emergency department (ED) visits and rehospitalizations. They found that levels of performance were extremely high for the first 2 measures, with little variation across sites, whereas performance on the third measure, a written home management plan, was lower, with modest variability, improving from 41% use to 73% in 3 years. However, the use of a plan was not associated with reductions in subsequent ED visits or rehospitalizations. The study also has several limitations. It included only a subset of freestanding children’s hospitals, where technical quality is expected to be high. More than two-thirds of hospitalizations for children occur outside children’s hospitals. Documentation of levels of performance in community hospital settings is necessary before the findings about consistently high rates for these 2 measures can be generalized. In addition, the likelihood that an individual child was given a management plan was not directly captured in the data but was inferred from the rate reported by the hospital for a separate sample of patients. Also, only revisits (ED visits or asthma rehospitalizations) to the same hospital were counted. Nonetheless, multiple analyses by the authors failed to reveal even a suggestion that the presence of a written home management plan influenced the likelihood of an ED visit or rehospitalization. Should clinicians be surprised by this finding? Having high hopes that a management plan would prove helpful was reasonable when the measure was developed based on the evolving understanding of chronic care management. Yet what was reasonable then can be viewed as naive now. Perhaps