How a detailed asthma assessment can reduce future exacerbations

Conducting a more personalized assessment may improve the efficacy of asthma preventive medications and reduce exacerbations requiring hospitalization, according to a new report.

Asthma affects 7 million children in the United States, resulting in nearly 200,000 hospitalizations each year, according to the new data. Controller, or preventive, medications can help reduce hospitalizations, but current guidelines to ensure appropriate dosing and use of these medications is not always followed, the researchers say.

Alexander Hogan, MD, MS, a board-certified pediatrician at Connecticut Children’s Medical Center in Hartford, assistant professor of pediatrics at the University of Connecticut School of Medicine in Farmington, and coauthor of the study, says his team’s report shows that in-depth assessments of patients with status asthmaticus can be used to improve the accuracy of preventive medications. Hogan says the study illustrates the fact that his hospital, probably like many others, was great at managing acute asthma symptoms, but not as good at addressing long-term asthma control that, when used properly, can reduce asthma exacerbations.

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The study, published in Hospital Pediatrics, investigated whether more complete assessments during inpatients stays for asthma could lead to better, more accurate outpatient controller prescriptions.

Collecting data

The research team reviewed medical records for 5 patients discharged from pediatric wards each week throughout 2015 and 2016 following an admission for status asthmaticus. Researchers specifically reviewed documentation of 6 asthma control questions and the accuracy of discharge controller therapy. Nearly 500 charts-240 preintervention and 252 postintervention-were reviewed in all, and the study team found that patients discharged on correct controller therapy improved from 60% in the preintervention group to 80% in the postintervention group.

The 6 questions were asked as a part of the study dealt with the number of asthma symptoms the patients experienced each week; the number of times their symptoms woke them at night each month; the number of times an inhaler was used each week; the degree to which symptoms interfered with normal activity; the number of asthma exacerbations requiring oral corticosteroid medications each year; and the number of doses of current controller therapy that were missed in a given week. At the start of the study, medical personnel were asking these questions just 40% of the time, but that increased to 98% by the close of the study, which investigators tied to the improvements made over the course of the study in discharging those patients on appropriate controller therapies.

More positive results

Throughout the study, use of the 6 assessment questions was positively impacted by the use of flowcharts, smart phrases and smartphones, and electronic medical records (EMR) prompts. In the end, most patients were discharged on the same medications and doses they were on prior to hospitalizations but with which they were noncompliant (48% in the preintervention group and 43% in the postintervention group); started on new controller medications (32% in the preintervention group and 20% in the postintervention group); or had their previous controller medication doses increased (12% in the preintervention group and 17% in the postintervention group). Patients who were discharged on incorrect medication doses also often had inadequate medical documentation to justify their medication orders, the study notes.

It’s difficult to pinpoint which interventions were most effective in increasing the frequency in which assessment questions were asked and documented, Hogan says, but the overall message is that increased engagement and collaboration led to better outcomes.

“As a whole, having a team of frontline providers engaged in quality improvement work is probably the most important factor in our project’s success,” Hogan says. “Through them we found a free iPhone app that told providers which questions to ask and what step of therapy they should be on, we created a paper flowchart that showed the correct way to assess asthma control and which medications to prescribe, and we created smart phrases for our EMR to easily document the control questions into a note. Not having an EMR system that has this functionality would be a barrier to that implementation; however, the rest of the interventions we used were free.”

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More follow-up is needed to assess the long-term success of the interventions, but Hogan says he is hopeful that his team’s work will result in improved clinical practice.

“I hope that inpatient providers will see that they have a unique opportunity to intervene not only in the acute asthma management, but also in the long-term control of their patient’s asthma,” he says.