Quality of Care Program Reduces Unplanned Health Care Utilization in Patients With Inflammatory Bowel Disease.

INTRODUCTION: There is significant variation in processes and outcomes of care for patients with inflammatory bowel disease (IBD), suggesting opportunities to improve quality of care. We aimed to determine whether a structured quality of care program can improve IBD outcomes, including the need for unplanned health care utilization. METHODS: We used a structured approach to improve adult IBD care in 27 community-based gastroenterology practices and academic medical centers. Patient-reported outcomes (PRO) and health care utilization were collected at clinical visits. Outcomes were monitored monthly using statistical process control charts; improvement was defined by special cause (nonrandom) variation over time. Multivariable logistic regression was applied to patient-level data. Nineteen process changes were offered to improve unplanned health care utilization. Ten outcomes were assessed, including disease activity, remission status, urgent care need, recent emergency department use, hospitalizations, computed tomography scans, health confidence, corticosteroid or opioid use, and clinic phone calls. RESULTS: We collected data prospectively from 20,382 discrete IBD visits. During the 15-month project period, improvement was noted across multiple measures, including need for urgent care, hospitalization, steroid use, and opioid utilization. Adjusted multivariable modeling showed significant improvements over time across multiple outcomes including urgent care need, health confidence, emergency department utilization, hospitalization, corticosteroid use, and opioid use. Attendance at monthly coached webinars was associated with improvement. DISCUSSION: Outcomes of IBD care were improved using a structured quality improvement program that facilitates small process changes, sharing of best practices, and ongoing feedback. Spread of these interventions may facilitate broad improvement in IBD care when applied to a large population.

Impact of environmental tobacco smoke on children admitted with status asthmaticus in the pediatric intensive care unit.

INTRODUCTION: Environmental tobacco smoke (ETS) and allergens are risk factors in children with critical status asthmaticus. Genetic studies support that ETS-associated asthma is a special inflammatory entity, causing significant number of hospital admissions and relapses. Accordingly, the course and outcome of patients with ETS-induced status asthmaticus might also be different. HYPOTHESIS: We hypothesized that the progression, course, and outcome of patients with ETS-induced status asthmaticus would be worse than those of patients without ETS exposure. METHODS: Medical records of children who were admitted to the Pediatric Intensive Care Unit (PICU) with the diagnosis of asthma at the Children's Hospital of Winnipeg, Manitoba, over 10 years were audited after Institutional Review Board (IRB) approval. Two hundred thirty records were reviewed. We extracted data including demographics and analyzed the patient's deterioration defined as clinical asthma score (CAS) drift between the ED and PICU. We computed the treatment response, expressed as length of stay (LOS) in the PICU and in hospital. The risk factors were stratified as none, ETS exposure, allergies, and ETS with allergies. RESULTS: There were 55 (25%) patients with no risk factors, 66 (30%) with ETS exposure only, 46 (21%) with allergies only, and 53 (24%) with both. There was a 25% decrease in CAS deterioration when patients were exposed to ETS (P < 0.05). For patients with or without allergies but with exposure to ETS, both the PICU and overall hospital LOS were ∼15% longer (P < 0.05) than for those not exposed to ETS. Stratifying for gender and race in multivariate analysis did not alter the results. CONCLUSIONS: Patients with ETS-associated critical status asthmaticus deteriorate and recover slower than non-ETS-exposed patients.