Inpatient Asthma Research Articles

Clinical Redesign Using All Patient Refined Diagnosis Related Groups

Clinical redesign of processes in hospitals that care for children has been limited by a paucity of severity-adjusted indicators that are sensitive enough to identify areas of concern. This is especially true of hospitals that analyze pediatric patient care using standard Centers for Medicare and Medicaid Services (CMS) diagnosis-related groups (DRGs). The objectives of this study were to determine whether 1) utilization of all-patient refined (APR)-DRG severity-adjusted indicators (length of stay, cost per case, readmission rate) from the National Association of Children's Hospitals and Related Institutions (NACHRI) database could identify areas for improvement at University of Michigan Mott Children's Hospital (UMMCH) and 2) hospital staff could use the information to implement successful clinical redesign. The APR-DRG Classification System (version 20) was used with the NACHRI Case Mix Comparative Database by severity level comparison from 1999 to 2002. Indicators include average length of stay (ALOS), case mix index, cost per case, and readmission rate for low acuity asthma (APR-DRG 141.1). UMMCH cases of 141.1 (n = 511) were compared with NACHRI 141.1 (n = 64,312). Although not part of the standard report, mortality rates were calculated by NACHRI for UMMCH and an aggregate of NACHRI member children's hospitals. Data from 1999 revealed that in noncomplicated asthma cases (level 1 severity), the UMMCH ALOS versus NACHRI ALOS was slightly longer (UMMCH 2.16 days vs NACHRI 2.14 days), and the cost per case was higher (UMMCH $2824 vs NACHRI 2738 dollars), whereas levels 2, 3, and 4 cases (moderate, major, and extreme severity) indicated the ALOS and cost per case were lower than the national aggregate. This showed that the APR-DRG system was sensitive enough to distinguish variances of care within a diagnosis according to severity level. After analysis of internal data and meeting with clinicians to review the indicators, 3 separate clinical processes were targeted: 1) correct documentation of comorbidities and complications, 2) standardized preprinted orders were created with the involvement of the pediatric pulmonologists, and 3) standardized automatic education for parents was started on the first day of admission. Yearly data were reviewed and appropriate adjustments made in the education of both residents and staff. In 2002, the UMMCH ALOS dropped to 1.75 +/- .08 days from 2.16 +/- .09. In 2002, the NACHRI ALOS was 2.00 days +/- 0.01 versus the UMMCH ALOS of 1.75 days +/- 0.0845, indicating that the UMMCH ALOS dropped significantly lower than the NACHRI aggregate database over the 3-year period. Cost per case of UMMCH compared with NACHRI after the 3 years indicated that UMMCH increased 12%, whereas the NACHRI aggregate increased 18%. These data show that length of stay and cost per case relative to the national database improved after clinical redesign. Improvements have been sustained throughout the 3-year period. Readmission rates ranged from 2.97% to 0.80% and were less than the national cohort by the third year. There were no mortalities in the UMMCH inpatient asthma program. This demonstrates that clinicians believed that the data from the APR-DRG acuity-adjusted system was useful and that they were then able to apply classical clinical redesign strategies to improve cost-effectiveness and quality that was sustained over 3 years. Severity-adjusted indicators were useful for identifying areas appropriate for clinical redesign and contributed to the improvement in cost-effective patient care without a detriment in quality indicators. This method of using a large comparative database, having measures of severity, and using internal analysis is generalizable for pediatric hospitals and can contribute to ongoing attempts to improve cost-effectiveness and quality in medical care.

Impact of a comprehensive asthma program on pediatric inpatient admissions

Rationale Children's Medical Center of Dallas developed an inpatient multidisciplinary asthma class in 1997 that alone, was insufficient to significantly reduce asthma-related re-hospitalizations. Subsequently, a comprehensive outpatient Asthma Management Program was implemented in 2001. Elements of the program include in-home education, multidisciplinary asthma class, telephonic follow-up, and care coordination. The program was designed to measure the intervention's impact on healthcare utilization and quality of life indicators. Methods Patients were identified by community physician and insurance provider referrals, as well as internal utilization reports. Eligibility criteria include residence in a five county radius, ages 0-17, and diagnosis of asthma. Pre-enrollment and enrollment period data were available for 45 participants who completed the program. Six-month post-completion data were available for 13 participants. Results Inpatient utilization for pre-enrollment, enrollment period and post-enrollment period were compared. The asthma related Inpatient admissions significantly declined from pre-enrollment (median 0.5) through course of enrollment (median 0.02) (p<.001). Analysis of post-enrollment period suggests that this decrease in inpatient utilization is sustained but the small number of patients limits the generalization of these results. Conclusions The comprehensive intervention decreased asthma-related inpatient admissions during the six-month program. Preliminary evidence supports sustained decreased levels of utilization for six months following participation.

Comparison of racemic albuterol and levalbuterol for treatment of acute asthma

Objective To determine whether levalbuterol resulted in fewer hospital admissions than racemic albuterol when used for treatment of acute asthma. Study design A randomized, double-blind, controlled trial was conducted in the emergency department (ED) and inpatient asthma care unit of an urban tertiary children's hospital. Children age 1 to 18 years (n = 482) provided a total of 547 enrollments. Patients received a nebulized solution of either 2.5 mg racemic albuterol or 1.25 mg levalbuterol every 20 minutes (maximum six doses). Patients admitted to the asthma care unit were treated in a standardized fashion by using the same blinded drug assigned in the ED. Hospitalization rate was the primary outcome. Results Hospitalization rate was significantly lower in the levalbuterol group (36%) than in the racemic albuterol group (45 %, P = .02). The adjusted relative risk of admission in the racemic group compared with the levalbuterol group was 1.25 (95% confidence interval, 1.01-1.57). Hospital length of stay was not significantly shorter in the levalbuterol group (levalbuterol, 44.9 hours; racemic albuterol, 50.3 hours; P = .63). No significant adverse events occurred in either group. Conclusions Substituting levalbuterol for racemic albuterol in the ED management of acute asthma significantly reduced the number of hospitalizations.

Impact of Innovative Model of Inpatient Asthma Disease Management Program on Patient Outcomes

PURPOSE: Asthma disease management (ADM) studies have suggested benefits of improved asthma control and decreased health-resource utilization. Our purpose was to investigate the effectiveness of a new model of asthma disease management for adult inpatients with acute asthma at the University of Michigan Hospital and Health Systems (UMHHS) involving a multidisciplinary team. Team members include: 1. Asthma Educator/Coordinator, 2. Third year medical students on rotation trained in the ADM program at the beginning of every month, 3. Inpatient nursing, and 4. Respiratory Therapists.

Interrater Agreement in the Clinical Evaluation of Acute Pediatric Asthma

Prior studies of observer agreement of the clinical exam of children with asthma have focused on small numbers of specially trained observers, often in the setting of clinical trials. Our objective was to evaluate interobserver reliability in the physical exam of acute pediatric wheezing and asthma among a large group of diverse examiners, in a setting of routine clinical practice, and without prior special training. The setting was a large urban children's hospital. Observers were attending pediatric emergency physicians and fellows; hospital respiratory therapists; and emergency department (ED) nurses. Patients were children receiving nebulized medications for wheezing in the ED or inpatient asthma unit. Pairs of observers simultaneously but independently rated work of breathing, wheeze, decreased air entry, prolonged expiration, breathlessness, respiratory rate, mental status, and global (or overall) severity using a structured exam template. A total score for each exam was also evaluated. A total of 230 pairs of observations were performed; mean patient age was 5.3 years. For all pairs, the weighted kappa statistics for the exam components ranged from 0.61 to 0.74 (moderate or substantial agreement). The global severity category and total score had weighted kappas of 0.80 and 0.82, respectively (excellent agreement). Agreement was generally somewhat lower for unlike (different profession) observer pairs than for like observer pairs, but remained acceptable. Agreement in two age groups (≤3 years old and ≥4) was at least moderate for all exam components analyzed. Spearman rank correlations between individual exam components and the global assessments of patient severity were all greater than 0.5, indicating at least moderate to good correlations. We found substantial interobserver agreement among a broad range of examiners in the components of the clinical examination of acute wheezing in both younger and older children. This is contrary to the commonly held observation that the poor interobserver reliability of physical exam findings in asthma may limit their usefulness as asthma outcome measures. Support for use of a structured respiratory exam format or template in asthma guidelines was also shown.

Ipratropium Bromide Plus Nebulized Albuterol for the Treatment of Hospitalized Children with Acute Asthma

Objective. To ascertain whether the addition of repeated doses of nebulized ipratropium bromide (IB) to standardized inpatient asthma care for children with status asthmaticus would improve clinical outcome. Study Population. A total of 210 children 1 to 18 years old admitted with acute asthma. Methods. This was randomized, double-blind, placebo-controlled trial in which children with acute asthma were assigned to receive either ipratropium or placebo in addition to standard therapy …

Expression of pulmonary lactoferrin in sudden-onset and slow-onset asthma with fatal outcome.

The objective of this forensic autopsy study was to determine the immunohistochemical expression pattern of lactoferrin (LF) in pulmonary tissue sections deriving from fatal slow-onset asthma (time interval between onset of asthma attack and death >2.5 h) and fatal sudden-onset asthma (cases in which death occurred within 1 h of the onset of an asphyxic asthma attack) relative to controls (sudden death due to diseases other than respiratory disorders). LF was applied to paraffin sections using a standard peroxidase-labelled streptavidin-biotin technique. LF immunoreactivity was graded semi-quantitatively in relation to different histoanatomic distribution sites of LF on a five category ordinal scale (maximum score of 15). We found a statistically significant difference between an enhanced expression of LF in both asthma groups relative to the controls (P<0.004 and P<0.001, respectively). When comparing both asthma groups, there was a statistically significant difference in LF immunoreactivity between the slow-onset and sudden-onset asthma group (P<0.001). Since LF immunoreactivity was far less intense in the sudden-onset asthma group (mean expression +/-SD: 7.3+/-1.3) than in the slow-onset asthma group (12.5+/-1), and an absent or weak LF expression pattern was observed in the control group (1.4+/-1.3), we assume that our results permit the following cautious estimations: (1) pulmonary LF expression is enhanced in asthma attacks with fatal outcome relative to controls and (2) a different expression pattern of LF can be observed in fatal sudden-onset asthma compared to slow-onset asthma in so far as the pulmonary expression of LF seems to be positively correlated with the preceding period of time between the asphyxic asthma attack and death. Further clinicopathologic studies including in-patient asthma fatalities with a well-known medical history are required to scrutinize if the pulmonary expression of LF is in fact positively associated with the time span of the asthma attack, thus possibly providing further therapeutic opportunities to intervene in severe asphyxic asthma.

Increasing awareness of asthma and asthma resources in communities on the southwest border.

To provide outpatient asthma education for children and families along the southwest border of the U.S. and to study the effectiveness of a southwest border hospital's in-house asthma educational program. (1) "Increasing the Knowledge Base of Asthmatics and Their Families through Asthma Clubs along the Southwest Border." (2) American Lung Association. (3) National Institutes of Health, National Heart, Lung and Blood Institute. (4) Referrals from a southwest border hospital. Only two of 23 patients referred for asthma follow-up were readmitted to hospital and/or emergency care during the following year. Large group teaching pretest-posttest score means for 3,429 fourth and fifth grade students revealed a 23% increase in asthma knowledge. Small follow-up groups of students received in-depth asthma education. Effectiveness of hospital inpatient asthma education combined with outpatient family follow-up was supported. An additional finding was that southwest border families are more receptive to visits arranged with a school nurse in their children's school than to home visits from primary care clinic nurses.

Inpatient childhood asthma treatment: relationship of hospital characteristics to length of stay and cost: analyses of New York State discharge data, 1995.

There is increasing pressure to optimize asthma treatment efficiency. It is possible that hospital characteristics influence such efficiency. To examine the association of selected hospital characteristics with cost and length of stay (LOS) among pediatric patients with asthma after adjusting for patient characteristics. Secondary analysis of 1995 hospital discharge data in the state of New York. Nineteen thousand six hundred eighty-eight patients aged 1 to 17 years with asthma discharged from 206 acute care hospitals in New York in 1995. Length of stay and hospital cost. Hospitals were described with respect to teaching status and ownership. The differences in the distribution of children within each hospital type were assessed by chi(2) tests. In multivariate analyses, hierarchical models were constructed to analyze cost and LOS, adjusting for both hospital- and patient-level covariance. Asthma severity did not meaningfully differ by hospital ownership and teaching status. Public and teaching hospitals had more minority and Medicaid patients. After adjusting for patient- and hospital-level covariates and for the hierarchical nature of the data, there were no statistically significant differences between public and private hospitals in mean cost or LOS. Adjusted mean LOS in teaching hospitals was not significantly shorter, while costs were significantly but not meaningfully greater ($2459 vs $2271; P<.001). Hospitals providing medical education to pediatricians and safety net care do so without increasing LOS or cost of care for pediatric asthma.

RS4: A MODEL-BASED EVALUATION OF INHALED STEROIDS IN MILD-TO-MODERATE ASTHMA

OBJECTIVE: To forecast the discounted costs and clinical consequences of inhaled corticosteroids (ICS) in a population of adults with mild-to-moderate asthma. METHODS: We developed a Markov, state-transition simulation of asthma patient care and its pharmacoeconomic impact. We employed this framework to compare quick relievers (e.g., b-agonists) on an as-needed basis to quick relievers plus ICS therapy targeted to one of three severity sub-populations. State-space dimensions included patient age, clinical history, and lung dysfunction (measured via forced expiratory volume in one second, FEV1). Risk functions were estimated from symptom, exacerbation, and hospitalization rates obtained from literature reviews and analyses of primary, cross-sectional data. Systematic review of published trials yielded 16 eligible studies and produced the following outcome ranges for sensitivity analysis: 1%–21% improvement in FEV1; monthly costs of $14–$76; and 0%–4% probability of major toxicity. Societal costs were derived from published economic studies of inpatient and outpatient asthma. We collected preference weights (using standard gambles, time trade-offs, and the Health Utilities Index) in a cross-sectional study of 100 adult asthmatics. RESULTS: The table reports outcomes over a 10-year period. Results were driven by the impact of ICS on quality of life, rather than on mortality. Findings were stable over most input data ranges. However, at efficacy levels below 3% and toxicity rates greater than 2.9%, the cost-effectiveness estimate exceeded $100,000/QALY. CONCLUSION: Results suggest that inhaled steroids deliver good comparative value in mild-to-moderate adult asthma. More research is needed, however, on the impact of ICS toxicity on patient preferences. Strategy Cost QALY $QALY Quick Relievers alone $5,185 6.77 — +ICS in moderate disease $5,961 6.84 $10,300 +ICS in mild disease $7,616 6.93 dominated +ICS in mild/mod. disease $8,392 7.00 $15,000

Multidisciplinary education and management program for children with asthma

A multidisciplinary program for managing asthma in a pediatric population is discussed. A coordinated, multidisciplinary program for managing asthma in children was initiated in November 1997 at a U.S. Army medical center. The program, designed to improve care and decrease hospitalizations for asthma, was pharmacist managed and pulmonologist directed and was implemented by pediatricians. Patient education was provided by a pediatric clinical pharmacist or a nurse case manager; providers also received intensive education. Follow-up occurred at predetermined intervals and included asthma education, discussion of expectations and goals, analysis of metered-dose-inhaler and spacer technique, and assessment of compliance. Between November 1997 and January 1999, 210 inpatients were screened for asthma. One hundred seven were believed to have asthma and received inpatient asthma counseling and teaching. Of these 107 patients, 79 were enrolled in the program and monitored in the ambulatory care setting. Seventy-one (90%) of the 79 program enrollees were not rehospitalized during the ensuing two years. The number of children admitted to the hospital for asthma decreased from 147 in 1997 (a rate of 3.2 per 1000 population) to 93 in 1998 (2.1 per 1000) and to 87 in 1999 (1.9 per 1000). A multidisciplinary approach to the management of children with asthma may reduce hospitalizations of such patients.

A clinical pathway reduced use of nebulised β agonists and length of hospital stay in children with asthma exacerbations

Johnson KB, Blaisdell CJ, Walker A , et al. Effectiveness of a clinical pathway for inpatient asthma management. Pediatrics2000 Nov; 106 : 1006 –12 [OpenUrl][1][Abstract/FREE Full Text][2] QUESTION: In children...

Feasibility of a Nurse-Run Asthma Education Program for Urban African-Americans: A Pilot Study

The objective of the study was to assess the feasibility of implementing and evaluating a culturally appropriate in-patient asthma education program specifically targeted for African-Americans. A consecutive sample of 28 African-American patients ages 18–50 who were hospitalized for asthma were randomized to an intervention group, which received three one-on-one sessions on chronic asthma management, or a control group, which received the usual care. Data on symptom frequency, self-management behaviors, quality of life, depression, and health care resource use were collected at baseline and at 3 and 6 months. Although the time required to recruit our sample took longer than anticipated, 28 subjects agreed to be in the study (70% acceptance rate) and complete the baseline interview. We observed no statistically significant differences from baseline or changing trends in frequency of asthma symptoms, self-management behaviors, and health care resource use between the intervention and control groups at 3 and 6 months. However, patients in the intervention group demonstrated a greater average increase in asthma-related quality of life and a greater average decrease in depression than the control group. Feasibility issues included shortened length of stay, which necessitated conducting all three self-management sessions together, multiple interruptions during the sessions, and retention issues at 3- and 6-month follow-ups. The lessons learned from this pilot study are invaluable in that they will enable us to make changes in our existing protocol to ensure the success of a larger clinical trial.

Ipratropium bromide plus nebulized albuterol for the treatment of hospitalized children with acute asthma

Objective: To determine whether the addition of repeated doses of nebulized ipratropium bromide (IB) to a standardized inpatient asthma care algorithm (ACA) for children with status asthmaticus improves clinical outcome. Study design: Children with acute asthma (N = 210) age 1 to 18 years admitted to the ACA were assigned to the intervention or placebo group in randomized double-blind fashion. Both groups received nebulized albuterol, systemic corticosteroids, and oxygen according to the ACA. The intervention group received 250 μg IB combined with 2.5 mg albuterol by jet nebulization in a dosing schedule determined by the ACA phase. The placebo group received isotonic saline solution substituted for IB. Progression through each ACA phase occurred based on assessments of oxygenation, air exchange, wheezing, accessory muscle use, and respiratory rate performed at prescribed intervals. Results: No significant differences were observed between treatment groups in hospital length of stay (P =.46), asthma carepath progression (P =.37), requirement for additional therapy, or adverse effects. Children >6 years (N = 70) treated with IB had shorter mean hospital length of stay (P =.03) and more rapid mean asthma carepath progression (P =.02) than children in the placebo group. However, after adjustment was done for baseline group differences, the observed benefit of IB therapy in older children no longer reached statistical significance. Conclusion: The routine addition of repeated doses of nebulized IB to a standardized regimen of systemic corticosteroids and frequently administered β-2 agonists confers no significant enhancement of clinical outcome for the treatment of hospitalized children with status asthmaticus. (J Pediatr 2001;138:51-8)

Effectiveness of a Clinical Pathway for Inpatient Asthma Management

Clinical pathways for asthma are tools that have the potential to improve compliance with nationally recognized management guidelines, but their effect on patient outcomes has not been documented. To determine the effect of an asthma clinical pathway on patients' length of stay, use of nebulized beta-agonist therapy while hospitalized, and use of acute care clinics for 2 weeks after discharge. The study was a randomized, controlled trial. Patients between the ages of 2 and 18 years admitted with an asthma exacerbation and not under the care of an asthma specialist were eligible for the study. Patients were randomized either to a conventional ward (control group) or to a ward using the clinical pathway (intervention group). For 2 weeks after discharge, we collected data to determine whether patients visited a health care provider for worsening asthma. One hundred ten patients (26%) were enrolled. Control and intervention groups had similar demographic and asthma severity profiles. The intervention group had an average length of stay 13 hours shorter than did the control group. In addition, at every dosing interval, the intervention group received less nebulized beta-agonist therapy. There were no deaths in either group. A clinical pathway for inpatient asthma decreased the length of stay and beta-agonist medication use with no adverse outcomes or increased acute-care encounters through 2 weeks after discharge.

Improved outcomes for hospitalized asthmatic children using a clinical pathway

Although asthma clinical pathways are used with increasing frequency, few controlled studies have evaluated the clinical and cost effectiveness of these pathways. To evaluate the effect of an inpatient asthma clinical pathway on cost and quality of care for children with asthma. One hundred forty-nine children were treated for status asthmaticus using an asthma clinical pathway in a children's hospital between September and December 1997. Thirty-four of 149 children treated with the clinical pathway were randomly selected. A retrospective cohort control group of non-pathway patients (N = 34) was matched with each pathway patient by age, race, gender, co-morbidities, asthma severity score, ICU admission, and time of year admitted. Differences between the two groups in length of stay, total costs, readmission rate, inpatient management, and discharge medications were compared. Length of stay was significantly lower in the clinical pathway group compared with the control group (36 hours versus 71 hours, P < .001) and total costs decreased significantly ($1685 versus $2829, P < .001) as a result of the pathway. Asthmatic children on the clinical pathway were significantly more likely than the control group to complete asthma teaching while hospitalized (65% versus 18%, P < .001), to be discharged with a prescription for a controller medication (88% versus 53%, P < .01), and to have a peak flow meter (57% versus 23%, P < .05) and a spacer device (100% versus 71%, P < .001) for home use. Implementation of this inpatient clinical pathway led to a decrease in length of stay and a reduction in total cost while improving quality of care for hospitalized asthmatic children.

A comprehensive educational programme was effective for inner city patients with asthma

George MR, O'Dowd LC, Martin I , et al. A comprehensive educational program improves clinical outcome measures in inner-city patients with asthma. Arch Intern Med1999 Aug 9/23; 159 : 1710...

Effect of hospital asthma nurse appointment on inpatient asthma care

While asthma nurses are funded by many health authorities within the U.K. National Health Service, for the improvement of clinical management in both inpatient and outpatient settings in secondary care, the effect of asthma nurse appointment on acute asthma care in hospitalized children has been inadequately studied. Here, we test the hypothesis that the employment of a full-time hospital asthma nurse improves quality of care for children admitted to hospital with acute asthma.Prospective in design, the study compares analyses of indicators of good clinical practice for hospitalized asthmatic children (2–16 yrs) before and after the appointment of a hospital asthma nurse.Both management [oxygen saturation check (35/106 vs. 111/126, P<0·05)] and discharge planning [self management plan/asthma education (17/106 vs. 49/126, P<0·05), follow-up arrangements with general practice (8/106 vs. 25/126, P<0·05)] improved. There was, however, no significant change in oral steroid administration, peak flow check, inhaler technique assessment, inhaled drug prophylaxis or arrangements for hospital follow-up at discharge.Employment of a hospital-based children's asthma nurse leads to significant improvement in aspects of routine in-patient asthma management. However, other important areas of in-patient asthma care did not improve following nurse-led interventions. A clearer evidence base may improve compliance with asthma management guidelines, and could make the role of hospital asthma nurse more effective.

Characteristics of Asthma Care Provided by Hospitals in a Large Metropolitan Area: Results From the Chicago Asthma Surveillance Initiative

Little is known of the approaches of United States hospitals to the management of persons with asthma. The purpose of this study is to characterize the extent to which hospitals within a large community have implemented various types of asthma-specific health-care delivery processes. A cross-sectional, self-administered survey was mailed to a "key informant" in asthma care at each of the hospitals in the Chicago area. The survey instrument covered the following content areas: asthma-related inpatient services, asthma-related outpatient services, selected asthma-related quality improvement activities, and asthma-related community outreach. The survey was administered between August 1996 and January 1997. Data were collected from respondents at 59 of the 89 eligible hospitals, yielding a response rate of 66.3%. Of the responding hospitals, 42.4% indicated they had clinical practice guidelines for inpatient asthma management, and 37.3% reported using critical pathways. Four selected aspects of bedside care were also explored. All of the responding hospitals reported routine provision of nebulization therapy at the bedside, and nearly all routinely obtained peak flow measurements (96.6%). In the area of patient instruction, 93.2% provided bedside evaluation of proper inhaler technique, and 86.4% routinely provided instruction on the use of peak flowmeters. Only 54.0% of the hospitals reported routinely administering some type of asthma education program prior to discharge. The hospitals with clinical practice guidelines in place were also more likely to have critical pathways (p < 0.01); to have asthma-specific ICU policies/guidelines/critical pathways (p < 0.01); to provide bedside instruction on the use of peak flowmeters (p < 0.01); to provide an asthma education (p < 0.01) prior to discharge; and to conduct utilization review. Very few hospitals indicated that they had community outreach programs for asthma care. The results of this survey suggest that among Chicago-area hospitals appropriate bedside care for persons with asthma is provided, but there are large variations in other types of asthma services and programs. The hospitals that have adopted asthma clinical practice guidelines are more likely to have other asthma-specific quality improvement activities than hospitals without guidelines. This relationship between use of guidelines and quality of services needs further exploration, as it may prove to be an important marker for hospitals with staff that are interested in improving asthma care.

Maintaining theophylline compliance/adherence in severely asthmatic children: the role of psychologic functioning of the child and family.

Noncompliance with asthma therapy by asthmatic children and their families is a common cause of treatment failure. Psychologic factors have been reported to influence adherence patterns. To evaluate the relationship of psychologic function of severely asthmatic children and families with theophylline compliance during a 1-year follow-up period after inpatient asthma rehabilitation. Thirty-seven severely asthmatic children with a median age of 9 years (range, 2 to 17 years) were treated in an inpatient rehabilitation program (median, 15 days). Established clinical rating scales of psychologic adjustment were used for children (Child Global Assessment Scale) and families (Family Global Assessment Scale) at the time of admission. Patients were defined as noncompliant if 30% or more of theophylline levels obtained during the 1-year follow-up period were less than 5 mg/L (mumol/L). Compliant children had higher scores on the Child Global Assessment Scale than noncompliant children (64 versus 48, P = .09). Families of compliant children had significantly higher scores on the Family Global Assessment Scale than did families with noncompliant children (63 versus 54, P < .05). There was no statistical relationship between compliance status and parent-reported behavior problems, demographic factors (age, race, sex, and number of parents at home), health insurance, specialty referral at admission, measures of medical morbidity (days hospitalized, number of emergency care visits, and number of corticosteroid bursts), or length of rehabilitation stay. Both compliant and noncompliant children had comparable reductions in morbidity (hospital and emergency care, number of corticosteroid bursts required). Psychologic functioning of the child and family may be related to theophylline compliance.