Heterogeneity in asthma care in a statewide collaborative: the Ohio Pediatric Asthma Repository.

BACKGROUND AND OBJECTIVE: Asthma heterogeneity causes difficulty in studying and treating the disease. We built a comprehensive statewide repository linking questionnaire and medical record data with health outcomes to characterize the variability of clinical practices at Ohio children's hospitals for the treatment of hospitalized asthma. METHODS: Children hospitalized at 6 participating Ohio children's hospitals for asthma exacerbation or reactive airway disease aged 2 to 17 were eligible. Medical, social, and environmental histories and past asthma admissions were collected from questionnaires and the medical record. RESULTS: From December 2012 to September 2013, 1012 children were enrolled. There were significant differences in the population served, emergency department and inpatient practices, intensive care unit usage, discharge criteria, and length of stay across the sites (all P < .0001, total n = 1012). Public insurance was highest in Cleveland and Cincinnati (72 and 65%). In the emergency department, Cincinnati and Akron had the highest intravenous magnesium sulfate use (37% and 33%); Columbus administered the most intramuscular epinephrine (15%). Cleveland and Columbus had the highest intensive care unit admittance (44% and 41%) and proportion of long-stay patients (95% and 85%). Moderate/severe asthma severity classification was associated with discharge prescription for inhaled corticosteroids (odds ratio = 2.7; 95% confidence interval: 1.6-4.5; P = .004) but not stay length. CONCLUSIONS: These data highlight the need for standardization of treatment practices for inpatient asthma care. There is considerable opportunity for personalized care plans that incorporate a patient's asthma impairment, risk, and treatment response history into hospital practices for asthma exacerbation treatment. The Ohio Pediatric Asthma Repository is a unique statewide resource in which to conduct observational, comparative effectiveness, and ultimately intervention studies for pediatric asthma.

The asthma awareness patch program for Girl Scouts: an evaluation of educational effectiveness.

BACKGROUND: Carefully designed educational programs can improve asthma knowledge, management practices, and health outcomes. We used pre-post testing to determine if the curriculum provided in the Girl Scouts of the USA Asthma Awareness Patch Program improved recipients' knowledge of basic respiratory system function, asthma pathophysiology, triggers, and asthma exacerbation recognition and management. We hypothesized that participants would have improved post-test scores following an interactive asthma educational program. METHODS: Girl Scouts ages 5-17 years from a 4-county area in northeastern Ohio were recruited. Educational components were in compliance with the guidelines established by the National Heart, Lung, and Blood Institute's National Asthma Education and Prevention Program. Participants completed a demographic form and pre-test before, and a post-test and program evaluation immediately following, the program. Descriptive statistics were used to report participant demographics. Frequencies and percentages described the participants' responses to pre- and post-test questions. Cronbach's alpha analysis determined internal consistency and reliability of post-test items. T tests assessed differences in pre-post scores. Fishers exact tests determined differences in proportions of responses, between the pre- and post-test time points. A P value of < 0.05 was considered statistically significant. RESULTS: Eighty-six girls, between 5 and 16 years of age (mean ± SD 8.97 ± 2.36 y) participated, 84% of whom were white. Twenty-one percent of the participants were diagnosed and treated for asthma, 48% resided with an asthmatic, and 72% knew someone with asthma. The post-test scores (mean ± SD 89.6 ± 9.0) were significantly higher (P < .001) than the pre-test scores (62.5 ± 20.8). A Cronbach alpha raw score of 0.448 and a standardized score of 0.518 were realized. CONCLUSIONS: The assessment tool demonstrated moderate internal reliability. Participation in the program enhanced participants' knowledge of lung function, trigger identification, asthma pathophysiology, and treatment.

The association of acetaminophen and asthma prevalence and severity.

The epidemiologic association between acetaminophen use and asthma prevalence and severity in children and adults is well established. A variety of observations suggest that acetaminophen use has contributed to the recent increase in asthma prevalence in children: (1) the strength of the association; (2) the consistency of the association across age, geography, and culture; (3) the dose-response relationship; (4) the timing of increased acetaminophen use and the asthma epidemic; (5) the relationship between per-capita sales of acetaminophen and asthma prevalence across countries; (6) the results of a double-blind trial of ibuprofen and acetaminophen for treatment of fever in asthmatic children; and (7) the biologically plausible mechanism of glutathione depletion in airway mucosa. Until future studies document the safety of this drug, children with asthma or at risk for asthma should avoid the use of acetaminophen.

Approach to treating cystic fibrosis pulmonary exacerbations varies widely across US CF care centers.

There is no standard definition of a CF pulmonary exacerbation universally accepted by clinicians. We aimed to investigate the variability of clinical practice among US CF clinicians in the diagnosis and treatment of exacerbations. Using clinical vignettes, we examined if variation in the identification and treatment of CF exacerbations is common, if practice patterns differ between CF care centers and what clinical factors determine treatment. Twenty-eight clinical cases were developed by varying five clinical factors. Participants were given four options for treatment of the patient described in each vignette. Cases were sent via email to a convenience sample of 112 CF clinicians from 13 US CF centers, with 109 clinicians participating (97.3%). 2,792 of the 3,052 cases received a response (91.5%). ANOVA demonstrated variation in rater scores was explained by case scenario and by care center (P < 0.0001). Examining the frequency of each treatment strategy demonstrated no absolute treatment consensus for any given scenario and variability within and between care centers. Direct logistic regression revealed that systemic symptoms (OR = 5.95), decreased O(2) saturation (OR = 4.99) and decreased FEV(1) (OR = 3.78) had a greater effects on the decision to treat a case with IV antibiotics than increased cough/sputum (OR = 2.19) and crackles present on physical examination (OR = 2.10). Similar findings were demonstrated with a cluster analysis. There was surprising variation in the identification and treatment of pulmonary exacerbations by CF clinicians. Variation was present between CF Centers, within each CF center and at the individual clinician level. This study provides additional evidence for the need of a standard definition for a CF pulmonary exacerbation.

Improving care at cystic fibrosis centers through quality improvement.

Quality improvement (QI) using a clinical microsystems approach provides cystic fibrosis (CF) centers the opportunity to make a significant positive impact on the health of their patients. The availability of center-specific outcomes data and the support of the Cystic Fibrosis Foundation are important advantages for these quality improvement efforts. This article illustrates how the clinical microsystems methodology can improve care delivery and outcomes by describing the gradual application of quality improvement principles over the past 5 years by the CF team at the Lewis Walker Cystic Fibrosis Center at Akron Children's Hospital in Akron, Ohio. Using the example of a project to improve the pulmonary function of the pediatric patients at our center as a framework, we describe the QI process from the initial team-building phase, through the assessment of care processes, standardization of care, and developing a culture of continuous improvement. We outline how enthusiastic commitment from physician leadership, clinical managers and central administration, the availability of coaches, and an appreciation of the importance of measurement, patient involvement, communication, and standardization are critical components for successful process improvement.