QI Initiative Reduces Emergency Room Visits for Functional Constipation

Preliminary data from a large accountable care organization’s quality improvement efforts suggest advanced care visits dropped 27% in two years.

Partners For Kids (PFK), the nation’s oldest and largest pediatric accountable care organization, launched a series of quality improvement (QI) projects targeting disease management strategies that could significantly impact healthcare utilization and outcomes for children in the network with some of the most common high-utilization conditions. One of those outcomes was functional constipation, for which gastroenterologists from two of PFK’s anchor hospitals, Nationwide Children’s Hospital and Dayton Children’s Hospital, joined forces to develop and implement a series of initiatives targeting everything from Medicaid drug coverage and clinician education to parent education.

“Historically, constipation is one of the most common childhood gastrointestinal complaints, and it makes up about 40% of our referrals,” says Karla Vaz, MD, motility specialist and gastroenterologist at Nationwide Children’s and the hospital’s medical lead on the QI project. “We are happy to treat it, but if it is managed appropriately and early, children can often avoid long-term medication use, emergency visits and admission to the hospital. Ideally, that management needs to start with the pediatrician.”

The team’s multi-pronged QI efforts have not been in vain; initial data are beginning to show remarkable progress. Before the project started, baseline rates of specialty gastroenterology or emergency department (ED) visits for functional constipation ranged from 12 to 17 per 1,000 members per month (January-June 2021). The latest data (January-May 2023) show rates ranging from 9 to 13 per 1,000 members per month.

The team’s first large-scale change involved collaborating with the Ohio Department of Medicaid to cover chewable senna (Ex-Lax®) so that families could obtain the palatable chocolate laxative without an out-of-pocket expense.

Coupled with increased coverage of this game-changer drug, the team developed a constipation action plan (the SMART Form) for pediatricians to hand out to families for proactive, at-home management of constipation. The tool couples the pediatrician’s care plan with basic educational information to teach families about healthy stooling and appropriate medications and diet/lifestyle adjustments to avoid escalation of the problem.

“We have also created ‘Constipation Guidelines for Primary Care Providers,’ which provides step-by-step advice on managing constipation in the primary care setting. This guideline, provided with the SMART Form, gives  providers all the tools needed to quickly manage constipation from the first visit,” says Dr. Vaz, who discussed the resources in depth during a webinar for network members. “We’ve made them available online, and we have a physician assistant, Jody Wall, PAC, who specializes in nutrition and constipation who visits practices as needed for additional education on the guidelines, workflow, referral recommendations and other resources for providers and families.”

The team has also developed brief educational videos to share on YouTube or other social media in an effort to improve popular understanding of constipation management and to have a resource to share with families after the diagnosis is made. The first one, ”Time to Poop: Constipation in Kids,” will be released this fall, and two more are expected to be released by the end of the calendar year.

“We are layering it in, because we know if we just post a management algorithm and share it at a single webinar, that’s not enough outreach — we need multiple touchpoints and tactics,” says Mary DiOrio, MD, MPH, medical director at PFK. “We have a really engaged group of leaders and subject matter experts for this project who have led the way, always coming up with something to do next. We know that it’s making a difference quantitatively, and qualitatively, we’ve heard that from providers as well.”

The team’s efforts will be further supplemented by electronic medical record-based constipation action plans to be handed out at discharge after initial constipation visits. Dr. Vaz and her Dayton counterpart, Ramakrishna Mutyala, MBBS, are also preparing to lead a 2024 functional constipation-themed Project ECHO, a digital round-Robin-style series of case-based information sessions, to educate additional regional physicians in improved management of this common condition.

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