Comparison of US emergency department acute asthma care quality: 1997-2001 and 2011-2012 - 06/01/15

Doi : 10.1016/j.jaci.2014.08.028

Kohei Hasegawa, MD, MPH ^a,^⁎ , Ashley F. Sullivan, MPH, MS ^a, Yusuke Tsugawa, MD, MPH ^b, Stuart J. Turner, BPharm, MPH ^c, Susan Massaro, PharmD, MPH ^c, Sunday Clark, ScD ^d, Chu-Lin Tsai, MD, ScD ^a, Carlos A. Camargo, MD, DrPH ^a
on behalf of the
MARC-36 Investigators^{^∗}
The following individuals were MARC-36 site investigators and collaborators on this article: Annette O. Arthur, PharmD, University of Oklahoma School of Community Medicine–Hillcrest Medical Center, Tulsa, Okla; Jeanne M. Basior, MD, Buffalo General Hospital, Buffalo, NY; Brigitte M. Baumann, MD, MSCE, Cooper Medical School of Rowan University, Camden, NJ; Ronald S. Benenson, MD, York Hospital, York, Pa; Francis L. Counselman, MD, Sentara Norfolk General Hospital, Norfolk, Va; Cameron Crandall, MD, PhD, University of New Mexico Health Sciences Center, Albuquerque, NM; Rita K. Cydulka, MD, MS, MetroHealth Medical Center, Cleveland, Ohio; Michael J. Drescher, MD, Hartford Hospital, Hartford, Conn; Daniel J. Egan, MD, Mount Sinai St Luke's and Mount Sinai Roosevelt Hospitals, New York, NY; Christopher Fee, MD, University of California San Francisco Medical Center, San Francisco, Calif; Theodore J. Gaeta, DO, MPH, New York Methodist Hospital, Brooklyn, NY; Michael G. Gonzalez, MD, Ben Taub General Hospital, Houston, Tex; John E. Gough, MD, East Carolina University, Vidant Medical Center, Greenville, NC; Blanca Grand, DO, St Barnabas Hospital, Bronx, NY; Richard O. Gray, MD, Hennepin County Medical Center, Minneapolis, Minn; Megan Healy, MD, Temple University Hospital, Philadelphia, Pa; Eva Tovar Hirashima, MD, MPH, Massachusetts General Hospital, Boston, Mass; Talmage M. Holmes, PhD, MPH, University of Arkansas for Medical Sciences, Little Rock, Ark; P. Charles Inboriboon, MD, MPH, Truman Medical Center Hospital, Kansas City, Mo; Mark J. Leber, MD, MPH, Brooklyn Hospital Center, New York, NY; Bernard L. Lopez, MD, MS, Thomas Jefferson University Hospital, Philadelphia, Pa; Frank LoVecchio, DO, Maricopa Medical Center, Phoenix, Ariz; Rashid F. Kysia, MD, MPH, John H. Stroger Jr Hospital of Cook County, Chicago, Ill; Mark I. Langdorf, MD, MHPE, University of California Irvine Medical Center, Orange, Calif; Joseph Montibeller, MD, Allegheny General Hospital, Pittsburgh, Pa; Dan Mosely, MD, University of Texas Health Science Center at San Antonio, San Antonio, Tex; Joseph S. Myslinski, MD, Palmetto Health Richland, Columbia, SC; Stephanie A. Nonas, MD, Oregon Health & Science University Hospital, Portland, Ore; Richard M. Nowak, MD, MBA, Henry Ford Hospital, Detroit, Mich; Daniel J. Pallin, MD, MPH, Brigham and Women's Hospital, Boston, Mass; Claire Pearson, MD, MPH, Detroit Receiving Hospital, Detroit, Mich; Veronica Pei, MD, University of Maryland Medical Center, Baltimore, Md; Ava E. Pierce, MD, University of Texas Southwestern Medical Center–Parkland Memorial Hospital, Dallas, Tex; John T. Powell, MD, Christiana Hospital, Newark, Del; Stewart O. Sanford, MD, Albert Einstein Medical Center, Philadelphia, Pa; Nathan Shapiro, MD, Beth Israel Deaconess Medical Center, Boston, Mass; Patrick Shen, MD, Mercy Hospital of Philadelphia, Philadelphia, Pa; Robert A. Silverman, MD, Long Island Jewish Medical Center, New Hyde Park, NY; Howard A. Smithline, MD, MS, Baystate Medical Center, Springfield, Mass; Brian Snyder, MD, University of California San Diego Medical Center, San Diego, Calif; Kirk A. Stiffler, MD, MPH, Akron City Hospital, Akron, Ohio; D. Matthew Sullivan, MD, Carolinas Medical Center, Charlotte, NC; Suzanne S. Teuber, MD, University of California Davis Medical Center, Sacramento, Calif; J. Adrian Tyndall, MD, MPH, Shands Hospital at the University of Florida, Gainsville, Fla; Nancy E. Wang, MD, Stanford University Medical Center, Palo Alto, Calif; Muhammad Waseem, MD, MS, Lincoln Medical and Mental Health Center, New York, NY; and Eric J. Wasserman, MD, Newark Beth Israel Medical Center, Newark, NJ.
^a Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
^b Harvard Interfaculty Initiative in Health Policy, Cambridge, Mass
^c Novartis Pharmaceuticals, East Hanover, NJ
^d Department of Emergency Medicine, Weill Cornell Medical College, New York, NY

^∗Corresponding author: Kohei Hasegawa, MD, MPH, Department of Emergency Medicine, Massachusetts General Hospital, Suite 410, 326 Cambridge St, Boston, MA 02114.

Abstract

Background

It remains unclear whether the quality of acute asthma care in US emergency departments (EDs) has improved over time.

Objectives

We investigated changes in concordance of ED asthma care with 2007 National Institutes of Health guidelines, identified ED characteristics predictive of concordance, and tested whether higher concordance was associated with lower risk of hospitalization.

Methods

We performed chart reviews in ED patients aged 18 to 54 years with asthma exacerbations in 48 EDs during 2 time periods: 1997-2001 (2 prior studies) and 2011-2012 (new study). Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores at the patient and ED levels; these scores ranged from 0 to 100.

Results

The analytic cohort comprised 4039 patients (2119 from 1997-2001 vs 1920 from 2011-2012). Over these 16 years, emergency asthma care became more concordant with level A recommendations at both the patient and ED levels (both P < .001). By contrast, concordance with non–level A recommendations (peak expiratory flow measurement and timeliness) decreased at both the patient (median score, 75 [interquartile range, 50-100] to 50 [interquartile range, 33-75], P < .001) and ED (mean score, 67 [SD, 7] to 50 [SD, 16], P < .001) levels. Multivariable analysis demonstrated ED concordance was lower in Southern and Western EDs compared with Midwestern EDs. After adjusting for severity, guideline-concordant care was associated with lower risk of hospitalization (odds ratio, 0.37; 95% CI, 0.26-0.53).

Conclusions

Between 1997 and 2012, we observed changes in the quality of emergency asthma care that differed by level of guideline recommendation and substantial interhospital and geographic variations. Greater concordance with guideline-recommended management might reduce unnecessary hospitalizations.

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Key words : Acute asthma, emergency department, guideline, concordance, quality of care, hospitalization, regional variation, time trend

Abbreviations used : ED, EMNet, ICU, IQR, MARC, NIH, PEF

Plan

Methods

Study design and setting

ED and patient characteristics

Change in performance on quality measures

ED characteristics and ED-level guideline concordance

Patient-level guideline concordance and risk of hospitalization

Discussion

Potential limitations

Supported by a grant from Novartis Pharmaceuticals Corporation to Massachusetts General Hospital (principal investigator: Camargo). The sponsor had no role in the conduct of the study, nor collection, management, or analysis of the data.

Disclosure of potential conflict of interest: Y. Tsugawa is employed by St Luke's Life Science Institute and has received research support from Harvard University, Honjo International Foundation, and Hoshi General Hospital. S. J. Turner is employed by Novartis. S. Massaro is employed by, has received travel support from, and has stock/stock options in Novartis. S. Clark has received a service agreement from Massachusetts General Hospital for participation in a multicenter study. C. A. Camargo has received research support from Novartis and Teva and has consultant arrangements with GlaxoSmithKline, Merck, Novartis, and Teva. The rest of the authors declare that they have no relevant conflicts of interest.

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Vol 135 - N° 1

P. 73 - janvier 2015 Retour au numéro

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Comparison of US emergency department acute asthma care quality: 1997-2001 and 2011-2012 - 06/01/15

Abstract

Background

Objectives

Methods

Results

Conclusions

Plan

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