Inpatient Asthma Research Articles

PREDICTORS AND COMPONENTS OF INPATIENT ASTHMA HOSPITAL COST: A CROSS SECTIONAL STUDY

Asthma, a chronic respiratory condition, continues to impose a significant economic burden on healthcare systems worldwide. Objective: The main objective of the study is to find the predictors and components of inpatient asthma hospital cost. Methods: This cross-sectional study was conducted at a tertiary care hospital from January 2024 to June 2024. Data were collected from 245 patients suffering from asthma. Patients were selected based on the International Classification of Diseases (ICD) codes related to asthma documented in their medical records. Patients aged >18 years with complete medical and billing records available were included in the study. Results: The results show that gender did not significantly affect hospital costs, with males averaging $7,400 and females $7,000 (p = 0.12). Age was a significant predictor, as older patients (65+ years) incurred higher costs ($9,800) compared to younger groups (p < 0.01). Socioeconomic status also impacted costs, with lower-income patients averaging $8,100 compared to $6,200 for higher-income patients (p < 0.05). Age (65+ years) increased costs by $1,800 in univariate analysis and by $1,500 in multivariate analysis (p < 0.01). Asthma severity had the strongest effect, with severe cases adding $5,500 in univariate analysis and $4,800 in multivariate analysis (p < 0.001). Comorbidities increased costs by $4,000 univariately and $3,500 in multivariate models (p < 0.01).Conclusion: It is concluded that asthma severity, comorbidities, and socioeconomic status are the primary predictors of inpatient asthma hospital costs.

Outcomes of a dexamethasone-prednisone combination treatment course for status asthmaticus

Objectives Dexamethasone has become the standard of care for pediatric patients with status asthmaticus in the emergency department (ED) setting. Inpatient providers often must decide between continuing the second dose of dexamethasone or transitioning to prednisone. The effectiveness of receiving dexamethasone followed by prednisone (combination therapy) compared to only prednisone or dexamethasone remains unclear. This study compares patient characteristics and ED reutilization/hospital readmission outcomes of dexamethasone, prednisone, and combination therapy for inpatient asthma management. Methods A retrospective study was conducted at our tertiary children’s hospital of children aged 2 to 18 years hospitalized between March 2016 and December 2018 with a primary discharge diagnosis of asthma, reactive airway disease, or bronchospasm. The differences between steroid groups were compared using Fisher’s exact or Chi-square tests for categorical variables, and a Kruskal-Wallis test for continuous variables. A multivariable logistic regression was performed to analyze ED reutilization and hospital readmission rates. Results 1697 subjects met inclusion criteria. 115 (6.8%) patients received dexamethasone, 597 (35.2%) received prednisone, and 985 (58.0%) received combination therapy. Patients prescribed combination therapy had a lower exacerbation severity than patients prescribed prednisone, but higher severity than patients prescribed dexamethasone (p < .001, p = .001, respectively). Dexamethasone and combination therapy were not associated with increased 30-day ED reutilization/hospital readmissions compared to prednisone (p > .05). Conclusions In our study, most patients hospitalized for status asthmaticus received combination therapy. Despite the differences in severity between steroid groups, outcomes of combination therapy and dexamethasone monotherapy, as measured by frequency of ED reutilizations/hospital readmissions, are comparable to prednisone monotherapy.

Joint associations of air pollutants during pregnancy, infancy, and childhood with childhood persistent asthma: Nationwide database study in Japan

The joint effect of air pollutants at relatively low levels requires further investigation. Here, a database study was performed to evaluate the effects of exposure to mixtures of air pollutants during pregnancy, infancy, and childhood on childhood persistent asthma. We used the Japan Medical Data Center database, which provides access to family linkages and healthcare provider addresses, and included child-mother dyads in which the child was born between January 2010 and January 2017. The exposure of interest was ground-level air pollutants, and the primary outcome was childhood persistent asthma at 45 years of age, as defined based on outpatient and inpatient asthma disease codes and/or asthma medication dispensing claims. The weighted quantile sum (WQS) regression was used to evaluate the effects of air pollutant mixtures on 52,526 child-mother dyads from 1149 of 1907 municipalities (60.3 %) in Japan. The WQS regression models showed that with every 10th percentile increase in the WQS index, ground-level air pollutants during pregnancy, infancy, and childhood increased the risk of childhood persistent asthma by an odds ratio of 1.04 (95 % CI: 1.02–1.05; p<0.001), 1.02 (95 % CI: 1.01–1.03; p<0.001), and 1.03 (95 % CI: 1.01–1.04; p<0.001), respectively. Moreover, particulate matter with an aerodynamic diameter ≤ 2.5 µm was assigned the highest weight across all three exposure periods. Relatively high weights were assigned to suspended particulate matter and photochemical oxidants during pregnancy, carbon monoxide during infancy, and photochemical oxidants during childhood. Our study showed that a mixture of low-level air pollutants has a detrimental association with childhood persistent asthma.

Evaluating Quality of Care for Patients with Asthma in the Readmission Penalty Era.

Rationale: Asthma poses a significant burden for U.S. patients and health systems, yet inpatient care quality is understudied. National chronic obstructive lung disease (COPD) readmission policies may affect inpatient asthma care through hospital responses to these policies because of imprecise diagnosis and identification of patients with COPD and asthma. Objectives: Evaluate inpatient care quality for patients hospitalized with asthma and potential collateral effects of the Medicare COPD Hospital Readmissions Reduction Program (HRRP). Methods: This was a retrospective cohort study of patients aged 18-54 years hospitalized for asthma across 924 U.S. hospitals (Premier Healthcare Database). Results: Care quality for patients with asthma was evaluated before HRRP implementation (n = 20,820; January 2010-September 2014) and after HRRP implementation (n = 26,885; October 2014-December 2018) using adherence to inpatient care guidelines (recommended, nonrecommended, and "ideal care" [all recommended with no nonrecommended care]). Between 2010 and 2018, at least 80% of patients received recommended care annually. Recommended care decreased similarly (rate of 0.02%/mo) after versus before HRRP (P = 0.8). Nonrecommended care decreased more rapidly after HRRP (rate of 0.29%/mo) versus before HRRP (rate of 0.17%/mo; P < 0.001), with changes driven largely by decreased antibiotic prescribing. Ideal care increased more rapidly after HRRP (rate of 0.25%/mo) versus before HRRP (rate of 0.17%/mo; P = 0.02), with changes driven largely by nonrecommended care improvements. Conclusions: Post-HRRP trends suggest asthma care improved with increased rates of guideline concordance in nonrecommended and ideal care. Although federal policies (e.g., HRRP) may have had positive collateral effects, such as with asthma care, parallel care efforts, including antibiotic stewardship, likely contributed to these improvements.

Predictors and components of inpatient asthma hospital cost: A retrospective cohort study. Analysis from a sample of 14 Belgian hospitals.

Addressing the challenges of asthma has involved various approaches, including the examination of costs associated with hospitalization. However, there is a limited number of studies that have investigated the actual expenses incurred by hospital settings in caring for asthma patients. This study aims to describe the costs, predictors, and breakdown of expenditures in different categories. A retrospective cohort study was conducted, involving 314 hospital stays of patients over 12 years old who were admitted for asthma and classified under APR-DRG 141 (asthma). Univariate and multiple linear regression analyses were performed. The median cost, regardless of DRG severity, amounted to 2.314€ (1.550€-3.847€). Significant variations were observed when the sample was stratified based on the severity of DRG, revealing a cost gradient that increases with severity. The length of stay followed a similar trend. Six predictors were identified: age, admission to intensive care, asthma severity, severity level of the DRG, winter admission, and length of stay. The cost breakdown showed that 44% constituted direct costs, 25% were indirect costs, 26% were attributed to medical procedures performed outside the patient unit, and 5% were related to medication administration. This study initiates a discussion on the role of reducing hospital costs in strategies aiming at controlling asthma-related costs. We argue that cost reduction cannot be achieved solely at the hospital level but must be approached from a public health perspective. This includes promoting high-quality outpatient care and addressing factors leading to poor adherence to the care plan.

Impact of Hurricane Harvey on Inpatient Asthma Hospitalization Visits Within Southeast Texas, 2016-2019.

The aim of the study is to estimate inpatient asthma hospital visit rates among impacted Texans in Public Health Region 6/5S during the year of and after Hurricane Harvey. Asthma inpatient hospitalization discharges were collected from the Texas Health Care Information Collection database (2016-2019). Females (age-adjusted rates [AARs] = 4.8-5.0) and Black Texans (AARs = 5.0-8.1) experienced significantly higher AARs compared with males and White Texans during the year of and after Harvey. During the year of Hurricane Harvey, females were 1.49 times as likely to have an inpatient asthma visit compared with males, while Black Texans were 2.78 times as likely to have an inpatient asthma hospitalization compared with White Texans. Findings from this study may assist public health professionals and local officials to allocate future resources to the most impacted subgroups as well as establish effective processes to mitigate consequences.

Identifying asthma-related risks during hospitalization using the child asthma risk assessment tool

Objective: The Child Asthma Risk Assessment Tool (CARAT) identifies risk factors for asthma morbidity. We hypothesized that CARAT-identified risk factors (using a CARAT adapted for inpatient use) would be associated with future healthcare utilization and would identify areas for intervention. Methods: We reviewed CARAT data collected during pediatric asthma admissions from 2010–2015, assessing for risk factors in environmental, medical, and social domains and providing prompts for inpatient (specialist consultation or social services engagement) and post-discharge interventions (home care visit or home environmental assessment). Confirmatory factor analysis identified groups of CARAT-identified risk factors with similar effects on healthcare utilization (latent factors). Structural equation models then evaluated relationships between latent factors and future utilization. Results: There were 2731 unique patients admitted for asthma exacerbations; 1015 (37%) had complete CARAT assessments and were included in analyses. Those with incomplete CARAT assessments were more often younger and privately-insured. CARAT-identified risk factors across domains were common in children hospitalized for exacerbations. Risks in the environmental domain were most common. Inpatient asthma consults by pulmonologists or allergists and home care referrals were the most frequent interventions indicated (62%, 628/1015, and 50%, 510/1015, respectively). Two latent factors were positively associated with healthcare utilization in the year after index stay – social stressors and known/suspected allergies (both p < 0.05). Stratified analyses analyzing data just from those children with prior healthcare utilization also indicated known/suspected allergies to be positively associated with future utilization. Conclusions: Inpatient interventions to address social stressors and allergic profiles may be warranted to reduce subsequent asthma morbidity.

Outcome of Electronic-Consults and Facilitated Follow-up for Inpatient Asthma Exacerbations

Asthma accounts for a large number of observation unit stays and hospitalizations that could potentially be preventable. Timely observation/inpatient evaluations by allergists may improve asthma outcomes in high-risk patients.

Effects of long-term exposure to particle components on inpatient asthma hospitalizations among children and adults in the U.S. using Bayesian kernel machine regression (BKMR)

BACKGROUND: Particulate matter has been documented to adversely affect asthma exacerbation. However, few studies have investigated the long-term exposure of particle components in conjunction with PM2.5 and ozone to assess their individual and additive effects. AIM: We aim to utilize a Bayesian Kernel machine regression (BKMR) to assess the individual and join effects of air pollutants including 15 different particle components such as organic carbon (OC), elemental carbon (EC), copper (Cu), and zinc (Z), along with PM2.5 and ozone, on counts of inpatient asthma hospitalizations for children ages 0 to 18 and adults ages 19 to 64 years. METHODS: Inpatient records were collected from the State Inpatient Databases which included hospitals from 12 U.S. states ranging in years from 2000 through 2016. We also included temperature from Daymet and variables from the U.S. census to control for socio-economic status. All variables were aggregated to the annual level. RESULTS: We observed an increase of 0.44 (95%CI: 0.28,0.59), 1.24 (95%CI: 1.07,1.40), and 2.35 (95%CI: 2.17,2.52) in the number of children asthma inpatient hospitalizations each year at the 25th, 50th, and 75th percentiles of pollutant mixture, respectively. In adults, we observed an increase of 0.84 (95%CI: 0.63,1.04), 1.98 (95%CI: 1.78,2.19), and 3.27 (95%CI: 3.06,3.48) in the number of asthma inpatient hospitalizations each year at the 25th, 50th, and 75th percentiles of the pollutant mixture, respectively. CONCLUSIONS: Our results indicate that long-term exposure to pollutant mixtures result in increased asthma hospitalizations in both children and adults, and daily measurements of particle components data is needed to assess short-term exposure. KEYWORDS: Asthma, PM Components, PM2.5, Ozone, BKMR

New Homogeneous Spatial Areas Identified Using Case-Crossover Spatial Lag Grid Differences between Aerosol Optical Depth-PM2.5 and Respiratory-Cardiovascular Emergency Department Visits and Hospitalizations.

Optimal use of Hierarchical Bayesian Model (HBM)-assembled aerosol optical depth (AOD)-PM2.5 fused surfaces in epidemiologic studies requires homogeneous temporal and spatial fused surfaces. No analytical method is available to evaluate spatial heterogeneity. The temporal case-crossover design was modified to assess the spatial association between four experimental AOD-PM2.5 fused surfaces and four respiratory-cardiovascular hospital events in 12 km2 grids. The maximum number of adjacent lag grids with significant odds ratios (ORs) identified homogeneous spatial areas (HOSAs). The largest HOSA included five grids (lag grids 04; 720 km2) and the smallest HOSA contained two grids (lag grids 01; 288 km2). Emergency department asthma and inpatient asthma, myocardial infarction, and heart failure ORs were significantly higher in rural grids without air monitors than in urban grids with air monitors at lag grids 0, 1, and 01. Rural grids had higher AOD-PM2.5 concentration levels, population density, and poverty percentages than urban grids. Warm season ORs were significantly higher than cold season ORs for all health outcomes at lag grids 0, 1, 01, and 04. The possibility of elevated fine and ultrafine PM and other demographic and environmental risk factors synergistically contributing to elevated respiratory-cardiovascular chronic diseases in persons residing in rural areas was discussed.

Comprehensive In-Patient Education Consult for Asthma Exacerbations.

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. 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. 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. 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.

Interactive Inpatient Asthma Education: A Randomized Controlled Trial.

Inpatient asthma education interventions provide benefit compared with usual care, but evaluation of the most effective educational model is needed. We compared the impact of interactive versus didactic inpatient pediatric asthma education on subsequent emergency department (ED) visits and hospitalizations. Children (aged 2‒16) with asthma admitted to a tertiary care children's hospital with an asthma exacerbation between October 2016 and June 2017 were randomly assigned to interactive or didactic (control) asthma education. The primary outcome was asthma ED visits at 6 and 12 months; secondary outcomes included hospitalizations (6 and 12 months), inhaler technique, asthma knowledge, symptoms, quality of life, and parental management skills at baseline, discharge, and/or 12 months. One hundred forty participants (69 interactive, 71 control) completed the study. There were no differences in ED visits at 6 or 12 months. Compared to controls, the interactive group had fewer hospitalizations (10.1% vs 22.5%; P = .04) at 6 months. Inhaler technique in the interactive group improved at discharge (mean change 4.07 [95% confidence interval (CI): 3.21-4.94]) and remained increased at 12 months (P = .03). Patient-reported asthma symptoms and quality of life were similar in both groups at baseline (19.9 vs 20.62, best possible score 8) and significantly improved in the interactive group at 12 months (least square mean change, 3.52 vs -1.75; P < .01). There were no differences in ED visits; however, the interactive education reduced asthma hospitalizations over a 6-month period. These findings demonstrate that educational delivery methods can play a role in improving clinical outcomes for asthma.

Pediatric Hospital Medicine Needs More Randomized Controlled Trials.

Pediatric Hospital Medicine Needs More Randomized Controlled Trials.

Factors Leading to Reduced Unscheduled Pediatric Asthma Visits During COVID-19

Emergency Department (ED) and inpatient (IP) asthma visits were reduced during 2020 at a tertiary pediatric hospital. This was likely due to measures used to avoid exposure to SARS-CoV-2 virus which led to fewer viral upper respiratory infections (URIs). To determine whether other factors could explain this reduction, we looked for changes in other asthma triggers such as pollen, air pollution and weather.

Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): A Multicenter, National Study

This study was aimed at improving inpatient asthma care in the pediatric population through the implementation of visual evidence-based guidelines, called pathways, in diverse hospital settings.Pediatric patients (ages 2–17) hospitalized with a primary diagnosis of asthma in diverse hospital settings across the United States.From January 2018 through March 2019, clinicians from >250 hospitals that varied in size, location (urban versus rural), ownership (private versus nonprofit), and type (community versus children’s) were recruited to participate in the study. Clinicians were identified through the Value in Inpatient Pediatrics electronic mailing list. Participating hospitals were given evidence-based pathways and order sets as well as various support services for pathway implementation (educational seminars, quality improvement training, and monthly video conferences). Data on hospital characteristics were collected through a survey of implementation leaders. Outcomes data were collected via chart review. The primary outcome was inpatient length of stay (LOS), and secondary outcomes included early administration of bronchodilator via metered-dose inhaler (MDI), screening for secondhand tobacco smoke exposure, referral of caregivers to smoking cessation resources, hospital readmission within 7 days of discharge, and emergency department revisits within 7 days of discharge.A total of 85 hospitals were enrolled in the study, and 68 hospitals completed the study (participated for the full 15-month duration). There was diversity in the types of hospitals that completed the study in terms of size, type, and location. Pathway implementation was not associated with significant changes in LOS, but it was associated with statistically significant increases in early administration of bronchodilators versus MDI as well as caretaker referral to smoking cessation resources. Specific interventions, including implementation of MDI dosing guidance and reminders for smoking cessation resources, were associated with improvements in early administration of MDI and referral to smoking cessation resources, respectively. These improvements were noted with pathway initiation and not just study enrollment. Hospital level analysis revealed that most hospitals (65%) had significant improvements in >1 outcome. Only 2 hospitals had increases in 7-day hospital readmission or emergency department revisits (balancing measures).Overall, pathway implementation was not associated with statistically significant changes in LOS but was associated with improvements in the quality of care being provided, specifically in increasing early administration of bronchodilators via MDI and referring caretakers to smoking cessation resources.Childhood asthma is a major cause of pediatric hospitalization and associated health care costs. Pathways or evidence-based visual guidelines for the treatment of asthma have previously been shown to improve the quality of care of pediatric asthma patients. Large-scale quality improvement projects are extremely difficult to implement because of variations at each site. However, standardization of care can be attained through automated measures, particularly within the electronic medical record. Similar to other large-scale projects across multiple sites, this project did not move the needle overall for their predetermined primary outcome measure, but it did reveal that pathways helped improve other quality care measures, such as early MDI use and provision of smoking cessation resources. Additionally, this study reveals that use of pathways may be beneficial across a diverse array of hospitals, not just large, tertiary care children’s hospitals.

Thirty-day unplanned readmission in hospitalised asthma patients in the USA

IntroductionHospital quality improvement and hospital performance are commonly evaluated using parameters such as average length of stay (LOS), patient safety measures and rates of hospital readmission. Thirty-day readmission (30-DR) rates...

Hospital-Initiated Care Bundle, Posthospitalization Care, and Outcomes in Adults with Asthma Exacerbation

Hospitalization for asthma exacerbation is an opportune setting for initiating preventive efforts. However, hospital-initiated preventive asthma care remains underdeveloped and its effectiveness is uncertain. To examine the effectiveness of a hospital-initiated asthma care bundle on posthospitalization asthma care and clinical outcomes. Prospective multicenter study of adults (18-54 years) hospitalized for asthma exacerbation in 2017 to 2019. During the hospitalization, we implemented an asthma-care bundle (inpatient laboratory testing, asthma education, and discharge care), and prospectively measured chronic asthma care (eg, immunoglobulin E testing, specialist care) and asthma exacerbation (ie, systemic corticosteroid use, emergency department [ED] visit, hospitalizations) outcomes. By applying a self-controlled case series method, we examined within-person changes in these outcomes before (2-year period) and after (1-year period) the bundle implementation. Of 103 adults hospitalized for asthma exacerbation, the median age was 40 years and 72% were female. Compared with the preimplementation period, the postimplementation period had improved posthospitalized asthma care, including serum specific immunoglobulin E testing (rate ratio [RR] 2.18; 95% confidence interval [95% CI] 0.99-4.84; P= .051) and evaluation by asthma specialist (RR 2.66; 95% CI 1.77-4.04; P<.001). Likewise, after care bundle implementation, patients had significantly lower annual rates of systemic corticosteroid use (4.2 vs 2.9 per person-year; RR 0.70; 95% CI 0.61-0.80; P<.001), ED visits (3.2 vs 2.7 per person-year; RR 0.83; 95% CI 0.72-0.95; P= .008), and hospitalizations (2.1 vs 1.8 per person-year; RR 0.82; 95% CI 0.69-0.97; P= .02). Stratified analyses by sex, race and ethnicity, and health insurance yielded consistent results. After hospital-initiated care bundle implementation, patients had improved posthospitalization care and reduced rates of asthma exacerbation.

Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status.

To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities. Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA. We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P=.01), have longer inpatient length of stay (31 vs 29 hours, P=.01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P=.02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures. At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.

Validation of the Hospital Asthma Severity Score (HASS) in children ages 2–18 years old

Introduction The Hospital Asthma Severity Score (HASS) was developed to communicate inpatient asthma severity between providers. The purpose of this prospective study was to validate the HASS against the Pediatric Respiratory Assessment Measure (PRAM) and spirometry for assessment of inpatient asthma exacerbation severity in patients 2–18 years old, at a single point-in-time. Methods This study was registered with clinicaltrials.gov (NCT02782065). Children admitted to a tertiary care, free-standing children’s hospital were assessed for asthma severity using the HASS, PRAM, and pulmonary function by spirometry. Inter-rater agreement of HASS and PRAM scores was assessed between two blinded clinician raters. Spirometry results were obtained by a certified pulmonary laboratory technician and correlated with HASS and PRAM scores. Results The sample included 58 subjects. Allowing for a one-point difference in continuous HASS and PRAM scores, inter-rater agreement was 79% for the HASS and 60% for the PRAM. When the scores were categorized as mild, moderate, and severe, inter-rater agreement was 62% for the HASS and 93% for the PRAM (p < .0001). Additionally, intra-rater agreement between HASS and PRAM severity categories was 71% for Rater 1 and 64% for Rater 2. A weak correlation was noted between both the HASS and FEV1 (r = –0.31; p = 0.11), and PRAM and FEV1 (r = –0.30; p = 0.11) for the 29 subjects with acceptable spirometry results. Conclusions The HASS and PRAM have acceptable inter-rater and intra-rater agreement. These results support validation of the HASS for managing hospitalized patients during asthma exacerbations.

Comparison of Two Assessment Tools for Hospitalized Subjects With Asthma.

Pediatric Asthma Assessment tools used to guide the weaning of inhaled therapies during inpatient hospitalization require further evaluation and validation. This study aimed to compare 2 asthma assessment tools: an asthma scale versus an asthma score. A prospective, physician-blinded, comparison study was conducted in 2 separate 6-week phases of patients > 2 y old admitted to a tertiary care children's hospital with status asthmaticus between July and November 2014. The asthma scale categorized 5 components (oxygen, auscultation, dyspnea, breathing frequency, and pulse oximetry) into 1 of 3 respiratory assessments: mild, moderate, or severe. The asthma score used a sum of the components, resulting in a score of 1-15. Study tool predictability was measured using a metric based on hours on continuous albuterol, with area under the curve ≥ 0.8 indicating good predictability. Agreement between clinicians was measured using the Cohen kappa statistic. Study tool clinical correlation was measured using Spearman coefficient. Usability was evaluated using web-based surveys. Phase 1 included 1,971 assessments (97 unique subjects), whereas phase 2 included 607 assessments (69 unique subjects). Using the continuous albuterol metric, predictability of the asthma scale had an area under the curve of 0.62 versus the asthma score area under the curve of 0.80. Agreement early in hospitalization for the asthma scale was kappa = 0.34 (95% CI 0.18-0.5; n = 84) versus kappa = 0.55 (95% CI 0.35-0.76; n = 44) for the asthma score. Agreement late in hospitalization for the asthma scale was kappa = 0.38 (95% CI 0.17-0.59; n = 66) versus kappa = 0.41 (95% CI 0.13-0.69; n = 33) for the asthma score. Clinical correlation for the asthma scale (no. = 1,908) was r = 0.57 (P < .001) versus r = 0.80 (P < .001) for the asthma score (no. = 558). Mean asthma scale usability was 3.38 versus 3.68 for the asthma score. The asthma score showed better clinical predictability and clinical correlation compared to the asthma scale. Numerical scores provided more objective assessments compared to categorical scores. Validated scoring tools such as the asthma score are crucial to the success of management of inpatient asthma care.