A Broad-Based Approach to Social Needs Screening in a Pediatric Primary Care Network.

OBJECTIVE: In 2016, the American Academy of Pediatrics recommended universally screening patients for social needs, and in 2018, a quality measure for social needs screening was included in some Massachusetts Medicaid contracts. However, exact guidelines for screening were not provided. We describe the results and implications from a broad-based health-related social needs (HRSN or "social needs") screening program within our large, pediatric primary care network. METHODS: We adapted items from The Health Leads toolkit to create our network's screening tool: The Health Needs Assessment (HNA). We trained staff to use the tool and provided staff with resources to assist families with their needs. All patients with a primary care physician in the network were eligible to complete an HNA. We calculated descriptive statistics and estimated the risk of identifying a social need using multivariable regression analyses. RESULTS: Between June 2018 and May 2019, 100,097 patients completed an HNA; 8% of patients identified a social need, and 33% of those patients requested assistance with the need(s). The multivariate analysis revealed an association between several patient characteristics-health insurance type, age, median household income by zip code, complex chronic conditions, race/ethnicity-and identifying a social need. CONCLUSIONS: Our large, pediatric primary care network successfully instituted a broad-based HRSN screening program in response to state and national screening recommendations. We observed a low prevalence of reported social needs and a propensity to forego assistance. Additional research is needed to understand the barriers around the disclosure of social needs and requests for assistance.

Variation in asthma care at hospital discharge by race/ethnicity groups.

Objective: While asthma disproportionately affects minorities, little is known about racial/ethnic differences in asthma care at hospital discharge. Methods: Secondary data analysis of multicenter retrospective study using standardized medical record review. A random sample of patients aged 2-54 years, who were hospitalized for asthma at 25 hospitals from 2012 to 2013 was analyzed. We categorized patients into three race/ethnicity groups: non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic. Multivariable logistic regression using generalized estimating equations was used to examine the relationship between race/ethnicity and the provision of guideline-concordant asthma care at hospital discharge including: the provision of asthma action plans, provision of new prescription of an inhaled corticosteroid, and referral to an asthma specialist. Results: Nine hundred thirteen patients (39% children, 71% minorities) hospitalized for asthma were included. In adjusted models, NHB children were significantly less likely to receive a written asthma action plan (OR 0.48; 95% CI 0.31-0.76) than NHW children. In contrast, among adults, we found no statistically significant difference in the provision of asthma action plan. Additionally, we found no difference in the provision of a new inhaled corticosteroid prescription or referral to an asthma specialist among children or adults. Conclusions: NHB and Hispanic patients represent the majority of patients hospitalized for acute asthma in our cohort and were more likely than NHW patients to have increased markers of asthma severity. Despite this, the only significant racial/ethnic difference in asthma care at hospital discharge was among NHB children, who were less likely to receive a written asthma action plan .

"Choosing Wisely" Imaging Recommendations: Initial Implementation in New England Emergency Departments.

INTRODUCTION: In June 2016, the American College of Emergency Physicians (ACEP) Emergency Quality Network began its Reduce Avoidable Imaging Initiative, designed to "reduce testing and imaging with low risk patients through the implementation of Choosing Wisely recommendations." However, it is unknown whether New England emergency departments (ED) have already implemented evidence-based interventions to improve adherence to ACEP Choosing Wisely recommendations related to imaging after their initial release in 2013. Our objective was to determine this, as well as whether provider-specific audit and feedback for imaging had been implemented in these EDs. METHODS: This survey study was exempt from institutional review board review. In 2015, we mailed surveys to 195 hospital-affiliated EDs in all six New England states to determine whether they had implemented Choosing Wisely-focused interventions in 2014. Initial mailings included cover letters denoting the endorsement of each state's ACEP chapter, and we followed up twice with repeat mailings to non-responders. Data analysis included descriptive statistics and a comparison of state differences using Fisher's exact test. RESULTS: A total of 169/195 (87%) of New England EDs responded, with all individual state response rates >80%. Overall, 101 (60%) of responding EDs had implemented an intervention for at least one Choosing Wisely imaging scenario; 57% reported implementing a specific guideline/policy/clinical pathway and 28% reported implementing a computerized decision support system. The most common interventions were for chest computed tomography (CT) in patients at low risk of pulmonary embolism (47% of EDs) and head CT in patients with minor trauma (45% of EDs). In addition, 40% of EDs had implemented provider-specific audit and feedback, without significant interstate variation (range: 29-55%). CONCLUSION: One year after release of the ACEP Choosing Wisely recommendations, most New England EDs had a guideline/policy/clinical pathway related to at least one of the recommendations. However, only a minority of them were using provider-specific audit and feedback or computerized decision support. Few EDs have embraced the opportunity to implement the multiple evidence-based interventions likely to advance the national goals of improving patient-centered and resource-efficient care.

Missed opportunities to transition from nebulizers to inhalers during hospitalization for acute asthma: A multicenter observational study.

OBJECTIVE: Hospitalizations for acute asthma are thought to be highly preventable through the use of efficacious medications, though many patients have poor metered-dose inhaler (MDI) techniques, thus lessening these medications' real-world effectiveness. Teaching MDI techniques during hospitalization may therefore lead to improved outcomes. However, MDIs may be underutilized to deliver short-acting ß-agonists (SABAs) in the inpatient setting, despite equivalent efficacy to nebulizer delivery. We sought to characterize delivery methods of SABAs among hospitalized patients with acute asthma to understand if there are missed opportunities for self-management education. METHODS: In this secondary analysis of a cross-sectional 25-center chart review study of children and adults (ages 2-54 years) hospitalized for acute asthma across 18 states (2012-2013), we studied SABA therapy delivery methods during hospitalization and receipt of action plans and follow-up visits. Unadjusted associations were analyzed using chi-square, Fisher's exact, or Kruskal-Wallis tests. MEASUREMENTS AND MAIN RESULTS: Of 987 patients, 44% received only nebulizer-SABA (children 32% vs. adults 53%; p < 0.001) during hospitalization, and 55% (children 68% vs. adults 47%; p < 0.001) received any MDI-SABA during hospitalization. Children receiving only nebulizer- vs. MDI-SABA were significantly less likely to receive individualized action plans (p < 0.001). Compared to children, adults were overall less likely to receive written plans (47% vs. 78%, p < 0.001) or to have a follow-up appointment (38% vs. 59%, p < 0.001) at discharge. CONCLUSIONS: Opportunities exist to increase the delivery of MDI-SABA during hospitalization, particularly for adult inpatients with asthma. Further studies are needed to determine if increased use of MDI-delivered therapies improves patient education and outcomes.

Smoking status and smoking cessation intervention among U.S. adults hospitalized for asthma exacerbation.

BACKGROUND: In a previous multicenter study during 1999-2000, we found a high prevalence of smoking among patients hospitalized for asthma exacerbations (35%) and suboptimal smoking cessation efforts. There have been no recent multicenter efforts to examine the smoking status and implementation of smoking cessation efforts among patients hospitalized for asthma exacerbation. OBJECTIVE: To investigate the prevalence of cigarette smoking and the proportion and characteristics of patients who received an inpatient smoking cessation intervention. METHODS: We conducted a secondary analysis of a 25-center observational study, which included 597 U.S. adults hospitalized for asthma exacerbation during 2012-2013. RESULTS: Among the analytic cohort, 215 (36%) were current smokers. In the multivariable model, compared with patients with private health insurance, those with public health insurance (odds ratio [OR] 1.71 [95% confidence interval {CI}, 1.06-2.77]) or no health insurance (OR 1.75 [95% CI, 1.02-2.99]) were more likely to be current smokers. By contrast, patients with a previous evaluation by an asthma specialist in the past 12 months (OR 0.49 [95% CI, 0.28-0.86]) and use of inhaled corticosteroids (OR 0.63 [95% CI, 0.43-0.93]) were less likely to be current smokers. Among current smokers, only 55% received smoking cessation interventions during their hospitalization. In the multivariable model, current smokers who had public health insurance (OR 0.25 [95% CI, 0.07-0.82]) or no health insurance (OR 0.26 [95% CI, 0.07-0.94]) were less likely to receive inpatient smoking cessation interventions compared with those with private health insurance. CONCLUSION: Our findings showed a persistently high prevalence of smokers among U.S. patients hospitalized for asthma exacerbations and an underutilized opportunity to provide this at-risk population with smoking cessation interventions.

Improving Quality of Acute Asthma Care in US Hospitals: Changes Between 1999-2000 and 2012-2013.

BACKGROUND: Little is known about the longitudinal change in the quality of acute asthma care for hospitalized children and adults in the United States. We investigated whether the concordance of inpatient asthma care with the national guidelines improved over time, identified hospital characteristics predictive of guideline concordance, and determined whether guideline-concordant care is associated with a shorter hospital length of stay (LOS). METHODS: This study was an analysis of data from two multicenter chart review studies of hospitalized patients aged 2 to 54 years with acute asthma during two time periods: 1999-2000 and 2012-2013. Outcomes were guideline concordance at the patient and hospital levels, and association of patient composite concordance with hospital LOS. RESULTS: The analytic cohort for the comparison of guideline concordance comprised 1,634 patients: 834 patients from 1999-2000 vs 800 patients from 2012-2013. Over these 15 years, inpatient asthma care became more concordant at the hospital-level, with the mean composite score increasing from 74 to 82 (P < .001). However, during 2012-2013, wide variability in guideline concordance of acute asthma care remained across hospitals, with the greatest variation in provision of individualized written action plan at discharge (SD, 36). Guideline concordance was significantly lower in Midwestern and Southern hospitals compared with Northeastern hospitals. After adjusting for severity, patients who received care perfectly concordant with the guidelines had significantly shorter hospital LOS (-14% [95% CI, -23 to -4]; P = .009). CONCLUSIONS: Between 1999 and 2013, the guideline concordance of acute asthma care for hospitalized patients improved. However, interhospital variability remains substantial. Greater concordance with evidence-based guidelines was associated with a shorter hospital LOS.

Opioid-related Policies in New England Emergency Departments.

OBJECTIVES: The opioid abuse and overdose epidemic in the United States has led to the need for new practice policies to guide clinicians. We describe implementation of opioid-related policies in emergency departments (EDs) in New England to gauge progress and determine where further work is needed. METHODS: This study analyzed data from the 2015 National Emergency Department Inventory-New England survey. The survey queried directors of every ED (n = 195) in the six New England states to determine the implementation of five specific policies related to opioid management. ED characteristics (e.g., annual visits, location, and admission rates) were also obtained and a multivariable analysis was conducted to identify ED characteristics independently associated with the number of opioid-related policies implemented. RESULTS: Overall, 169 EDs (87%) responded, with a >80% response rate in each state. Implementation of opioid-related policies varied as follows: 1) use of a screening tool for patients with suspected prescription opioid abuse potential (n = 30, 18%), 2) access state prescription drug monitoring program (PDMP) before prescribing opioids (n = 132, 78%), 3) notify the primary opioid prescriber when prescribing opioids for ED patients with chronic pain (n = 69, 41%), 4) refer patients with opioid abuse to recovery resources (n = 117, 70%), and 5) prescribe naloxone to patients at risk of opioid overdose after ED discharge (n = 19, 12%). EDs located in metropolitan areas and with at least one attending physician on duty 24/7 were less likely to implement opioid policies (incident rate ratio [IRR] = 0.65, 95% confidence interval [CI] = 0.48-0.89; and IRR = 0.78, 95% CI = 0.6-1.0, respectively) while EDs with ≥15% hospitalization rate that used electronic computerized medication ordering and those in Rhode Island were more likely to implement opioid policies (IRR = 1.23, 95% CI = 1.03-1.48; IRR = 1.95, 95% CI = 1.19-3.22; and IRR = 1.30, 95% CI = 1.08-1.56, respectively). CONCLUSIONS: The implementation of opioid-related policies varies among New England EDs. The presence of policies recommending use of screening tools and prescribing naloxone for at-risk patients was low, whereas those regarding utilization of the PDMP and referral of patients with opioid abuse to recovery resources were more common. These data provide important benchmarks for future evaluations and recommendations.

Association of Guideline-concordant Acute Asthma Care in the Emergency Department With Shorter Hospital Length of Stay: A Multicenter Observational Study.

OBJECTIVES: The objectives were to determine whether guideline-concordant emergency department (ED) management of acute asthma is associated with a shorter hospital length of stay (LOS) among patients hospitalized for asthma. METHODS: A multicenter chart review study of patients aged 2-54 years who were hospitalized for acute asthma at one of the 25 U.S. hospitals during 2012-2013. Based on level A recommendations from national asthma guidelines, we derived four process measures of ED treatment before hospitalization: inhaled ß-agonists, inhaled anticholinergic agents, systemic corticosteroids, and lack of methylxanthines. The outcome measure was hospital LOS. RESULTS: Among 854 ED patients subsequently hospitalized for acute asthma, 532 patients (62%) received care perfectly concordant with the four process measures in the ED. Overall, the median hospital LOS was 2 days (interquartile range = 1-3 days). In the multivariable negative binomial model, patients who received perfectly concordant ED asthma care had a significantly shorter hospital LOS (-17%, 95% confidence interval [CI] = -27% to -5%, p = 0.006), compared to other patients. In the mediation analysis, the direct effect of guideline-concordant ED asthma care on hospital LOS was similar to that of primary analysis (-16%, 95% CI = -27% to -5%, p = 0.005). By contrast, the indirect effect mediated by quality of inpatient asthma care was not significant, indicating that the effect of ED asthma care on hospital LOS was mediated through pathways other than quality of inpatient care. CONCLUSION: In this multicenter observational study, patients who received perfectly concordant asthma care in the ED had a shorter hospital LOS. Our findings encourage further adoption of guideline-recommended emergency asthma care to improve patient outcomes.

Underuse of guideline-recommended long-term asthma management in children hospitalized to the intensive care unit: a multicenter observational study.

BACKGROUND: Despite the significant burden of childhood asthma, little is known about prevention-oriented management before and after hospitalizations for asthma exacerbation. OBJECTIVE: To investigate the proportion and characteristics of children admitted to the intensive care unit (ICU) for asthma exacerbation and the frequency of guideline-recommended outpatient management before and after the hospitalization. METHODS: A 14-center medical record review study of children aged 2 to 17 years hospitalized for asthma exacerbation during 2012-2013. Primary outcome was admission to the ICU; secondary outcomes were 2 preventive factors: inhaled corticosteroid (ICS) use and evaluation by asthma specialists in the pre- and posthospitalization periods. RESULTS: Among 385 children hospitalized for asthma, 130 (34%) were admitted to the ICU. Risk factors for ICU admission were female sex, having public insurance, a marker of chronic asthma severity (ICS use), and no prior evaluation by an asthma specialist. Among children with ICU admission, guideline-recommended outpatient management was suboptimal (eg, 65% were taking ICSs at the time of index hospitalization, and 19% had evidence of a prior evaluation by specialist). At hospital discharge, among children with ICU admission who had not previously used controller medications, 85% were prescribed ICSs. Furthermore, 62% of all children with ICU admission were referred to an asthma specialist during the 3-month posthospitalization period. CONCLUSION: In this multicenter study of US children hospitalized with asthma exacerbation, one-third of children were admitted to the ICU. In this high-risk group, we observed suboptimal pre- and posthospitalization asthma care. These findings underscore the importance of continued efforts to improve prevention-oriented asthma care at all clinical encounters.

Prevalence of eosinophilia in hospitalized patients with asthma exacerbation.

BACKGROUND: Recent studies have identified the "eosinophilic phenotype" of asthma that is characterized by persistent eosinophilic inflammation and frequent exacerbations. However, the prevalence of eosinophilia in patients hospitalized for asthma exacerbation is not known. METHODS: We performed a pilot study in two sites participating in a multicenter chart review project of children and adults hospitalized for asthma exacerbation during 2012-2013. The pilot study investigated the prevalence of blood eosinophilia in this patient population. Eosinophilia was defined as a count of ≥300 cells/microliter at some time during the hospitalization. RESULTS: Among 80 patients hospitalized for asthma exacerbation, 47 (59%) underwent CBC with differential and had data on blood eosinophil count. These 47 comprised the analytic cohort. The median patient age was 32 years (IQR, 24-44 years), and 51% were female. Overall, 40% (95% CI, 26%-56%) of patients had eosinophilia. Although statistical power was limited, there were no statistically significant differences in patient characteristics or hospital course between patients with eosinophilia and those without (all P > 0.05). CONCLUSION: Our pilot study showed that 40% of patients hospitalized for asthma exacerbation had eosinophilia. The clinical meaning of this biomarker in the emergency department/inpatient setting requires further study in much larger samples with long-term follow-up; such studies appear feasible.

Children and Adults With Frequent Hospitalizations for Asthma Exacerbation, 2012-2013: A Multicenter Observational Study.

BACKGROUND: Earlier studies reported that many patients were frequently hospitalized for asthma exacerbation. However, there have been no recent multicenter studies to characterize this patient population with high morbidity and health care utilization. OBJECTIVE: To examine the proportion and characteristics of children and adults with frequent hospitalizations for asthma exacerbation. METHODS: A multicenter chart review study of patients aged 2 to 54 years who were hospitalized for asthma exacerbation at 1 of 25 hospitals across 18 US states during the period 2012 to 2013 was carried out. The primary outcome was frequency of hospitalizations for asthma exacerbation in the past year (including the index hospitalization). RESULTS: The cohort included 369 children (aged 2-17 years) and 555 adults (aged 18-54 years) hospitalized for asthma exacerbation. Over the 12-month period, 36% of the children and 42% of the adults had 2 or more (frequent) hospitalizations for asthma exacerbation. Among patients with frequent hospitalizations, guideline-recommended outpatient management was suboptimal. For example, among adults, 32% were not on inhaled corticosteroids at the time of index hospitalization and 75% had no evidence of a previous evaluation by an asthma specialist. At hospital discharge, among adults with frequent hospitalizations who had used no controller medications previously, 37% were not prescribed inhaled corticosteroids. Likewise, during a 3-month postdischarge period, 64% of the adults with frequent hospitalizations were not referred to an asthma specialist. Although the proportion of patients who did not receive these guideline-recommended outpatient care appeared higher in adults, these preventive measures were still underutilized in children; for example, 38% of the children with frequent hospitalizations were not referred to asthma specialist after the index hospitalization. CONCLUSIONS: This multicenter study of US patients hospitalized with asthma exacerbation demonstrated a disturbingly high proportion of patients with frequent hospitalizations and ongoing evidence of suboptimal longitudinal asthma care.