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(Chest. 1999;116:162S-167S.)
© 1999 American College of Chest Physicians

Characteristics of Asthma Care Provided by Hospitals in a Large Metropolitan Area*

Results From the Chicago Asthma Surveillance Initiative

Evalyn N. Grant, MD; Tao Li, PhD; Christopher S. Lyttle, MA; Kevin B. Weiss, MD and for the Chicago Asthma Surveillance Initiative Project Team{dagger}

* From the Department of Immunology/Microbiology (Dr. Grant), Rush-Presbyterian-St. Luke's Medical Center; Center for Health Services Research (Drs. Li and Weiss, and Mr. Lyttle), Rush Primary Care Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL. {dagger} See Appendix for other members of the CASI Project Team.

Correspondence to: Kevin B. Weiss, MD, Director, Center for Health Services Research, Rush Primary Care Institute, Rush-Presbyterian-St. Luke's Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix 1
 References
 
Introduction: Little is known of the approaches of United States hospitals to the management of persons with asthma. The purpose of this study is to characterize the extent to which hospitals within a large community have implemented various types of asthma-specific health-care delivery processes.

Methods: A cross-sectional, self-administered survey was mailed to a "key informant" in asthma care at each of the hospitals in the Chicago area. The survey instrument covered the following content areas: asthma-related inpatient services, asthma-related outpatient services, selected asthma-related quality improvement activities, and asthma-related community outreach. The survey was administered between August 1996 and January 1997.

Results: Data were collected from respondents at 59 of the 89 eligible hospitals, yielding a response rate of 66.3%. Of the responding hospitals, 42.4% indicated they had clinical practice guidelines for inpatient asthma management, and 37.3% reported using critical pathways. Four selected aspects of bedside care were also explored. All of the responding hospitals reported routine provision of nebulization therapy at the bedside, and nearly all routinely obtained peak flow measurements (96.6%). In the area of patient instruction, 93.2% provided bedside evaluation of proper inhaler technique, and 86.4% routinely provided instruction on the use of peak flowmeters. Only 54.0% of the hospitals reported routinely administering some type of asthma education program prior to discharge. The hospitals with clinical practice guidelines in place were also more likely to have critical pathways (p < 0.01); to have asthma-specific ICU policies/guidelines/critical pathways (p < 0.01); to provide bedside instruction on the use of peak flowmeters (p < 0.01); to provide an asthma education (p < 0.01) prior to discharge; and to conduct utilization review. Very few hospitals indicated that they had community outreach programs for asthma care.

Conclusion: The results of this survey suggest that among Chicago-area hospitals appropriate bedside care for persons with asthma is provided, but there are large variations in other types of asthma services and programs. The hospitals that have adopted asthma clinical practice guidelines are more likely to have other asthma-specific quality improvement activities than hospitals without guidelines. This relationship between use of guidelines and quality of services needs further exploration, as it may prove to be an important marker for hospitals with staff that are interested in improving asthma care.


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix 1
 References
 
Asthma accounts for > 450,000 hospitalizations annually in the United States.1 These hospital visits have a significant impact on Untied States health-care expenditures, accounting for an estimated $1.6 billion annually.2 Much of the literature in this area is based on the premise that most asthma hospitalizations are preventable. Therefore, these studies focus on characterizing the risk factors leading up to the event.3 4 5 6 Others focus on follow-up care or patient outcomes after discharge.7 8 9 There have also been studies examining the impact of emergency department practices on the decision to admit10 11 and, more recently, reports on the advantages of standardized care processes—critical pathways—for improving asthma care and reducing costs during hospitalization.12 13

However, there appear to be no studies that have comprehensively examined the overall approaches to asthma care used by hospitals, including bedside care, asthma education activities, asthma quality improvement projects, and asthma outreach services.

The purpose of this study is to characterize the extent to which hospitals in the Chicago area have implemented various types of asthma-specific health-care delivery processes. These characteristics are of particular interest in light of the disproportionately high rate of asthma mortality in this large metropolitan community.14


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 Appendix 1
 References
 
This study used a cross-sectional, self-administered survey of hospital asthma care as reported by a designated asthma expert within each of the hospitals.

Survey Instrument Development
A 98-item, self-administered survey instrument was developed to address the following areas: (1) use of asthma-specific policies or clinical practice guidelines; (2) selected inpatient asthma care practices; (3) selected outpatient asthma care practices; (4) asthma-specific quality improvement activities; and (5) asthma-related community outreach.

Study Population
Hospitals in the six-county Chicago area (including Cook, DuPage, Kane, Lake, McHenry, and Will counties) were identified from the membership list of the American Hospital Association.15 Of the 107 hospitals identified from this source, psychiatric and military hospitals were excluded, leaving a study population of 89 eligible hospitals.

Data Collection
The survey was administered from August 1996 through January 1997. A two-stage survey design was adopted to first identify the best person to complete the survey at each hospital, and then administer the instrument to this individual. For stage one, a brief questionnaire was mailed to the chief of staff or medical director of each of the hospitals. The questionnaire asked them to identify the individual at their institutions who was likely to have the best knowledge of the asthma-related policies and programs in place at that institution. When necessary, telephone follow-up was conducted until a "key informant" was identified for each of the 89 hospitals. Of these, 76.0% of the key informants were either senior administrators or physicians on medical staff. The key informants were subsequently mailed a copy of the written survey instrument along with a cover letter and postage-paid return envelope. Follow-up telephone calls and additional mailings were conducted in an effort to increase the response rate.

Statistical Analysis
The analyses consist of descriptive statistics for hospital-based asthma care practices. Where appropriate, tests of significance were performed using the {chi}2 test or nonparametric analysis of variance. All analyses were conducted using computer software (SAS, version 6.12; SAS Institute; Cary, NC). The response distributions are reported as percentages.

In addition, discharge data for all Chicago-area hospitals were obtained from the 1996 Research-Oriented Dataset of the Illinois Health Care Cost Containment Council.16 This allowed for comparison of the respondent hospitals to the nonrespondents in terms of total annual discharges, total bed days, and average length of stay.

Subanalyses were conducted to determine the relationships between hospitals that were (1) urban vs suburban, (2) academic vs nonacademic, and (3) those reported to use asthma practice guidelines vs those that were not.

Hospitals were classified as urban if they were located within the city of Chicago (based on postal zones), and suburban if they were located outside the city postal zones. Academic status was based on criteria from the 1995 American Hospital Association Guidebook.15 Hospitals were considered academic if they were approved to participate in residency training by the Accreditation Council for Graduate Medical Education, reported medical school affiliation to the American Medical Association, and were a member of Council of Teaching Hospitals of the Association of American Medical Colleges.

This project was conducted under the approval of the Rush-Presbyterian-St. Luke's Medical Center Institutional Review Board.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 Appendix 1
 References
 
General Characteristics of Hospitals
Completed surveys were received from 59 of the 89 eligible hospitals, for a response rate of 66.3%. Using the Illinois Health Care Cost Containment Council data set, the responding hospitals were compared with the nonrespondents for total number of annual discharges, total bed days, and average length of stay. The comparison revealed that the hospitals responding to the survey had more annual total discharges and total bed days (p < 0.05) than the nonrespondents; both groups had similar lengths of stay.

Characteristics of Inpatient Settings
As seen in Table 1 , of the 59 hospitals completing the survey, 42.4% reported using practice guidelines for inpatient asthma management, and 37.3% reported using asthma critical pathways. An additional 18.6% of the hospitals reported that they were developing asthma guidelines, and 15.3% were developing critical pathways.


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  		Table 1. Characteristics of Asthma-Related Inpatient Care Activities in Chicago-Area Hospitals

 
Twenty-six percent of the responding hospitals had policies or guidelines specifically for management of asthma in the ICU, and another 5.2% were in the process of developing them. Only 18.6% of these hospitals had asthma-specific critical pathways for the ICU, and another 8.5% reported that critical pathways were in development.

The survey also explored four aspects of bedside care. All the responding hospitals reported routinely providing nebulization therapy at the bedside, and nearly all obtained peak flow measurements at some time during the patient's hospital stay (96.6%). In the area of patient instruction, 93.2% of the hospitals reported providing instruction on proper inhaler technique, and 86.4% reported routinely providing instruction on the use of peak flowmeters. For nearly all the hospitals, the instruction in peak flow and inhaler technique was provided by respiratory therapists (94.1% and 89.3% respectively). Nursing staffs also provide these services. Approximately 17% of hospitals reported that nursing staffs provide peak flow instruction, and 35.7% reported that nursing staffs provide inhaler technique instruction.

Fifty-four percent of the hospitals also reported routinely administering some type of asthma education program prior to patient discharge. Approximately three of every four hospitals reported that inhaled anti-inflammatory medications were routinely prescribed to asthma patients at time of discharge.

The survey results also revealed information about the effects of guideline use and selected hospital characteristics as they relate to reported inpatient asthma care. The hospitals reporting adoption of clinical practice guidelines for inpatient asthma management were more likely to have critical pathways (p < 0.01) as well as ICU-specific policies/guidelines and critical pathways (p < 0.01). Hospitals with guidelines in place were also more likely to provide bedside instruction on the use of peak flowmeters (p < 0.01) and asthma education prior to discharge (p < 0.01). There were no differences between academic and nonacademic institutions in use of guidelines, critical pathways, or other asthma services.

Urban vs suburban location was significant for only one aspect of hospital asthma care—ICU-specific asthma care policies or guidelines. Where 30.8% of urban hospitals had ICU guidelines, only 9.1% of the suburban hospitals had them (p < 0.05). There were no significant differences among the academic vs nonacademic hospitals for this aspect of care.

Characteristics of Outpatient Settings
Many of the responding hospitals indicated they also deliver outpatient primary care: 40.7% had a general medicine clinic, 30.5% had a family practice clinic, and 32.2% had a pediatric clinic. Nearly 56% of the family medicine clinics were reported to use asthma care guidelines, and 27.8% provided 24-h telephone management for asthma patients. Of the pediatric clinics, 31.6% were reported to use asthma care guidelines, and 26.3% provided 24-h telephone management for asthma patients. Approximately 20% of the general medicine clinics reported using asthma care guidelines, and 25.0% provided 24-h telephone access.

Approximately 20% of the hospitals indicated they had outpatient asthma specialty clinics. Of these specialty clinics, 72.7% provided allergy services, 90.9% provided pulmonary services, and 36.4% provided 24-h telephone access to asthma specialists.

In the outpatient setting, 53.1% of the hospitals reported the ability to provide nebulization therapy, 76.0% of the hospitals routinely provided peak flow monitoring and peak flow instruction, and 88.0% reported routinely providing instruction on inhaler technique. Nearly 36% of the hospitals indicated they conducted formal asthma education programs in the outpatient setting. "Wee wheezers" and "Airpower" were the most common programs used by these hospitals.

Asthma-Specific Quality Improvement Activities and Community Outreach
Approximately 58% of the hospitals indicated that they conducted utilization review for diagnoses of asthma in both the inpatient and outpatient settings. However, as seen in Table 2 , the hospitals with practice guidelines for inpatient asthma management were much more likely to conduct utilization review (p < 0.01).


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  		Table 2. Characteristics of Asthma-Related Quality Improvement and Community-Based Care in Chicago-Area Hospitals

 
Just over one fifth of the responding hospitals had clinical case management programs for asthma, and few hospitals included home visits as part of their asthma management strategy. The frequencies of these activities did not vary by hospital location (urban/suburban) or academic status (see Table 2 ).

Forty-one percent of the hospitals reported conducting one or more of community-based asthma programs within the past 2 years. Figure 1 presents the frequency of each of four types of community-based programs (asthma screening, adult asthma education, pediatric asthma education, and school-based asthma education). The frequency of these community-based activities did not vary by hospital location or by academic status.



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  		Figure 1. Community-based programs for asthma among Chicago-area hospitals (n = 59).

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 Appendix 1
 References
 
In 1996, there were an estimated 11,900 hospital discharges for persons with asthma in the Chicago area, or 42.8 discharges per 10,000 population.17 However, prior to this survey, little was known about the general characteristics of the asthma care delivered by the hospitals in this area. In 1991, the National Asthma Education and Prevention Program released an Expert Panel Report of guidelines for the diagnosis and management of asthma18 ; in 1997, they released a revision of those guidelines.19 These reports provide a national standard for evaluating health-care performance and provide some guidance as to the minimal expectations for asthma care.

In relation to the national guidelines, the Chicago-area hospitals responding to this survey appear to perform well, especially in providing bedside services such as nebulization therapy, patient instruction on peak flow monitoring, and evaluation of inhaler technique. However, just over half of the hospitals routinely provide asthma education to patients prior to discharge. In the future, it would be important to better understand how asthma education in the inpatient setting affects patient outcomes.

Many of the hospitals indicated they have adopted some form of asthma care practice guidelines or critical pathways. The survey results also suggest that the hospitals with guidelines were more likely to have well-developed asthma education programs. As more and more hospitals continue to adopt guidelines and critical paths, it is important to further understand their usefulness. The similarities between the academic and nonacademic institutions in the use of guidelines, critical pathways, or other asthma services may reflect a lack of leadership on the part of the academic institutions to serve as role models for the nonacademic institutions.

While there appear to be no studies of the effects of hospital-based asthma guidelines on patient outcomes, at least two studies have examined the impact of asthma-specific critical pathways. These studies produced mixed results. McDowell et al13 studied the effects of an asthma critical pathway on the hospitalization experience of children with status asthmaticus. Using a quasi-experimental design, the authors reported significantly shorter lengths of stay for children treated via the pathway, with no apparent impact on short-term (72-h) readmission rates, and some important savings in total costs of inpatient care. Alternatively, Kwan-Gett et al,12 using a pre-evaluation and postevaluation analysis to study the effect of asthma critical pathways, found no significant differences in length of stay and similar total charges (with only slightly lower laboratory and radiology charges).

Asthma programs that include a home visit for follow-up after discharge have shown promise as effective strategies to reduce readmission.20 However, very few hospitals provide any type of asthma case management or home visit services. This lack of coordinating services at the hospital level is counter to the emerging interest of managed care to develop comprehensive disease management strategies for this chronic illness.21 22 One potential goal could be the partnering of Chicago-area hospitals and managed care plans for better coordinated and more comprehensive asthma management programs.

This survey also revealed the lack of hospital efforts to reach out to the surrounding community. Less than half of the respondents indicated their hospital had any type of community-based asthma program. Community-based hospital activities are quite common in other areas of health care, such as immunizations, disease screening (eg, cancer, diabetes), and health promotion activities. Expansion of these programs among the Chicago-area hospitals would seem essential if there is to be any community-wide effort to address the public health impact of asthma.

As with all studies, it is important to recognize the limitations of the study design and analysis when interpreting the results. This study was based on self-reported perception of asthma-related activities, some of which are not easily verified by direct observation or chart audit. While it is not possible to determine the true impact of this type of reporting bias, at least one study suggests that positive or socially preferred behaviors tend to be overestimated in self-reported data.23 Also, while the survey process sought to identify the person most knowledgeable about asthma care practices at each of the hospitals, any of the institutions might have had a more optimal person to query regarding this specific topic.

Although there are important limitations, this survey still provides new insights into the asthma care delivered by a large group of hospitals located in one geographical area. Several audits of hospital-based asthma care conducted outside of the United States have been published; however, these studies almost exclusively examine individual hospital performance rather than taking a community-based approach to performance measurement.24 25 26 27 These non-United States audits revealed that while much of the inpatient medical treatment appeared to be adequate, the hospitals demonstrated consistently low performance in the areas of formal patient education programs and objective lung assessment by peak flow. In a multisite study of inpatient pediatric asthma care conducted in Brighton, England, chart audits revealed important variations in asthma care practices. In particular, the study revealed variations in documentation of pulse oximetry, the use of chest radiographs, the use of treatment protocols, documentation of proper inhaler technique prior to discharge, and documentation of written treatment plans given at discharge.28


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
Appendix 1
 References
 
As with the study in England, the findings of the Chicago-area hospital survey bring to light specific areas where there are opportunities to improve hospital-based care for persons with asthma. This Chicago-area study also emphasizes the potential for using practice guidelines as a marker for enhanced asthma-related activities and programs. While a cross-sectional survey design such as this cannot evaluate a causal relationship between the presence of guidelines and quality of asthma programs, it does suggest the need to better understand this relationship. A more detailed, chart-audit–based, community-wide examination of asthma care delivered by hospitals with and without guidelines could be an important next step in motivating change, reducing variation, and improving the quality of asthma care.


   Appendix 1
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix 1
References
 
Other members of the CASI team include (in alphabetical order): Claudia Baier, MPH; Steven Daugherty, PhD; Edward Eckenfels; Anita Malone, MPH; Karen Turner-Roan, MPH; and James Moy, MD, of Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL; and Michael McDermott, MD, of Cook County Hospital, Chicago, IL.


   Acknowledgements
 
The authors would like to thank Ms. Julie Piorkowski for her research assistance in the early phases of this project and Ms. Robin Wagner in her assistance in manuscript preparation.


   Footnotes
 
CASI is funded by a grant from the Otho S.A. Sprague Memorial Institute.

Abbreviation: CASI = Chicago Asthma Surveillance Initiative


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 Appendix 1
 References
 

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K. B. Weiss and E. N. Grant
The Chicago Asthma Surveillance Initiative: A Community-Based Approach to Understanding Asthma Care
Chest, October 1, 1999; 116(suppl_2): 141S - 145S.
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