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Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): A Multicenter, National Study
Sunitha V Kaiser1, Brittany Jennings2, Jonathan Rodean3
1Department of Pediatrics, University of California, San Francisco, San Francisco, California; sunitha.kaiser@ucsf.edu.
Insights
Implementing asthma care pathways in diverse hospitals improved medication use and smoking cessation referrals. While length of stay was unaffected, overall pediatric asthma care quality saw enhancements across various settings.
Area of Science:
- Pediatric pulmonology
- Healthcare quality improvement
- Clinical pathway implementation
Background:
- Clinical pathways enhance evidence-based care for specific conditions.
- Previous studies demonstrated pathway benefits primarily in large, tertiary children's hospitals.
- Generalizability of these benefits to diverse hospital settings remained unclear.
Purpose of the Study:
- To enhance inpatient pediatric asthma care through pathway implementation.
- To assess the impact of clinical pathways in a diverse, national hospital sample.
- To evaluate pathway effectiveness across different healthcare environments.
Main Methods:
- A learning collaborative model was employed for pathway implementation.
- Strategies included local champions, facilitators, seminars, quality improvement, and audit/feedback.
- Outcomes measured: length of stay, inhaler administration, smoking exposure screening/referral, and readmissions.
Main Results:
- 68 of 85 enrolled hospitals completed the study (12,013 admissions).
- Pathways increased early metered-dose inhaler use (OR: 1.18) and smoking cessation referrals (OR: 1.93).
- No significant change in length of stay (RR: 1.00); 65% of hospitals improved at least one outcome.
Conclusions:
- Clinical pathways did not significantly alter length of stay for pediatric asthma admissions.
- Pathways demonstrably improved specific quality metrics in pediatric asthma care.
- Implementation in a diverse national sample suggests broader applicability of asthma care pathways.
Background And Objectives:
Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve inpatient asthma care but mainly in studies at large, tertiary children's hospitals. It remains unclear if these effects are generalizable across diverse hospital settings. Our objective was to improve inpatient asthma care by implementing pathways in a diverse, national sample of hospitals.
Methods:
We used a learning collaborative model. Pathway implementation strategies included local champions, external facilitators and/or mentors, educational seminars, quality improvement methods, and audit and feedback. Outcomes included length of stay (LOS) (primary), early administration of metered-dose inhalers, screening for secondhand tobacco exposure and referral to cessation resources, and 7-day hospital readmissions or emergency revisits (balancing). Hospitals reviewed a sample of up to 20 charts per month of children ages 2 to 17 years who were admitted with a primary diagnosis of asthma (12 months before and 15 months after implementation). Analyses were done by using multilevel regression models with an interrupted time series approach, adjusting for patient characteristics.
Results:
Eighty-five hospitals enrolled (40 children's and 45 community); 68 (80%) completed the study (n = 12 013 admissions). Pathways were associated with increases in early administration of metered-dose inhalers (odds ratio: 1.18; 95% confidence interval [CI]: 1.14-1.22) and referral to smoking cessation resources (odds ratio: 1.93; 95% CI: 1.27-2.91) but no statistically significant changes in other outcomes, including LOS (rate ratio: 1.00; 95% CI: 0.96-1.06). Most hospitals (65%) improved in at least 1 outcome.
Conclusions:
Pathways did not significantly impact LOS but did improve quality of asthma care for children in a diverse, national group of hospitals.
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