Great Minds Aren’t Thinking Alike About Asthma Care

While asthma is a common and manageable disease, nine people still die from asthma each day. It is well known that asthma is the leading cause of pediatric hospitalization as well as the most prevalent chronic illness among children under sixteen.

Despite the prevalence of hospital admissions for asthma and the existence of well-established clinical treatment pathways, a new audit published in JAMA Pediatrics in September finds that practice styles in asthma treatment throughout pediatric hospitals are significantly varied.

Of 37 institutions in the Pediatric Hospital Information System (PHIS), the average cost of a hospital stay varied by 87 percent, the length of stay varied by 47 percent and whether a patient was sent to the intensive care unit for treatment varied by 254 percent.

“We may have expected less variation in indicators of resource use if everyone was following the same protocol, but obviously they are not,” says Jeffrey Silber, MD, PhD, director of the Center for Outcomes Research at the Children’s Hospital of Philadelphia and lead author of the audit.

“This study demonstrates the striking need to address the variable care that a patient with asthma receives depending upon what part of the country they live in, or which hospital system they utilize for care,” says David R. Stukus, MD, the director of the Complex Asthma Clinic at Nationwide Children’s Hospital.

Some variation in care is normal, as not every patient admitted for asthma has the same symptoms or severity of the illness. However, the new method of comparison Dr. Silber and his colleagues used – template matching – accounts for this variation, reporting instead variation associated with hospital practice. This method creates templates of patients with similar asthma severity across hospitals and compares their care. This audit analyzed three years of data and compared nearly 49,000 patients’ hospital stays in the PHIS.

“Template matching can be utilized to assess best practices by comparing hospitals’, or groups of hospitals’, performance on any specific outcome of interest. It is a fair test because it consists of similar patients. Hospitals that perform ‘best practices’ should have better outcomes,” explains Dr. Silber, also professor of Pediatrics, Anesthesiology and Critical Care at the Perelman School of Medicine at the University of Pennsylvania. “If not, we may want to re-evaluate what are best practices.”

“I am not surprised by their findings; I’ve witnessed extreme variability in the diagnosis and management of asthma among different providers and institutions, even though evidence-based asthma guidelines exist and have been shown to improve care when implemented,” says Dr. Stukus. “Unfortunately, guideline adoption isn’t universal and can lag years or even decades after publication.”

Dr. Silber hopes that this audit encourages hospital leaders and quality improvement officers to improve and standardize practice styles. “Template matched analysis can be applied to other patient populations and will continue to provide direction for improvement in pediatric health care.”

Reference:

Silber JH, Rosenbaum PR, Wang W, Ludwig JM, Calhoun S, Guevara JP, Zorc JJ, Zeigler A, Even-Shoshan O. Auditing practice style variation in pediatric inpatient asthma care. JAMA Pediatrics. 2016 Sep 1;170(9):878-886.