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Bravata DM, Sundaram V, Lewis R, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 5: Asthma Care). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jan. (Technical Reviews, No. 9.5.)
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 5: Asthma Care).
Show detailsAsthma* 1, 2 is one of the most common chronic medical conditions in the U.S. It affects 16 million adults and 6.1 million children and results in two million visits to emergency departments, 70,000 hospitalizations, and 5,000 deaths annually.3 Children aged 5 to 17 years have the highest prevalence of asthma among all age groups in the U.S. (Figure 1). Among children with chronic medical conditions, asthma is the most common reason for hospitalization and school absence.4 The burden of asthma disproportionately affects patients of lower socioeconomic status: they are more likely to be limited by asthma symptoms, to use an emergency department as their usual source of care, and to be hospitalized for asthma care.3, 5–7 Asthma has serious economic consequences: in 1994, slightly more than half of the estimated $10.7 billion in asthma-related costs were for direct costs, while the rest were indirect costs, including those associated with caregiver costs, travel and waiting time, and premature death.6 The Pew Environmental Health Commission estimated that totals costs associated with asthma care could increase to $18 billion by 2020.7
Figure
Figure 1. U.S. asthma prevalence. Source: CDC, NCHS. Surveillance for Ashthma—United States, 1960-1995. Mortality Weekly Report 47 (SS-1);1–28, 1998
In an effort to reduce the burden of asthma on patients, their families, and the U.S. healthcare system, the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute (NHLBI) has published comprehensive guidelines for diagnosis and management of asthma.8, 9 Because asthma can neither be prevented nor cured, current management objectives are to monitor symptoms and objective measures of lung function, to encourage the use of medications that control and prevent symptoms with the fewest adverse effects possible, to control the triggers of asthma symptoms to which a patient is sensitive (such as house dust mite, tobacco smoke, animal dander, and pollens), and to educate the patient and provider for a partnership in asthma care.6, 10–12 Specifically, the reduction of airway inflammation and asthma symptom control is based largely on the use of inhaled corticosteroids, inhaled long-acting β-agonists, and leukotriene pathway inhibitors. Breakthrough asthma symptoms are treated with inhaled bronchodilators, which relax bronchial smooth muscle.9 In general, inhaled corticosteroids, leukotriene receptor antagonists, cromolyn, sustained release theophylline, and long acting inhaled β-agonists combined with inhaled corticosteroids are used to prevent daily symptoms and recurring exacerbations. Short-acting inhaled β-agonists, and, if necessary, oral corticosteroids are used as needed to treat symptoms and exacerbations when they occur. Effective asthma management has been demonstrated to reduce symptoms, hospitalizations, and urgent care visits.6, 7
The Quality Gap
Despite the availability of evidence-based guidelines for the management of pediatric and adult asthma, there remains a significant gap between accepted best practices for asthma care and actual care delivered to asthma patients in the U.S.7, 8 For example, although the National Committee for Quality Assurance has found that more patients with asthma are prescribed appropriate asthma mediations in recent years (71% in 2003 versus 63% in 2000),13 many patients with asthma and their caregivers do not use preventive medications or know how to prevent and treat asthma attacks.7 Diette and colleagues evaluated the rate of adherence of asthma care with the National Asthma Education and Prevention Program Guidelines for 318 pediatric patients.14 They found that 55% of patients used long-term controller medications daily, 49% had written instructions for handling asthma attacks, 44% had instructions for adjustment of medication before exposures, 56% had undergone allergy testing, and 54% had undergone pulmonary function testing.14 Other research has shown similarly poor guideline adherence among adults with asthma.15, 16 Even simple preventive measures are often neglected for asthma patients: patients with asthma are at high risk of developing complications after influenza-related illness, yet only one-third of adults and one-fifth of adults younger than 50 years with asthma receive the flu vaccine annually.17
A RAND report, “Improving Childhood Asthma Outcomes in the United States: A Blueprint for Policy Action” describes three primary barriers to effective management of asthma: the complexity of asthma care (i.e., it requires an understanding of the variety of symptoms, triggers, and use of multiple medications by clinicians, patients, and caregivers); the costliness of asthma care (e.g., patients may not have health insurance or other means to pay for preventive services and medications; schools may lack the resources to provide comprehensive asthma prevention and treatment services); and the lack of comprehensive strategies to improve asthma prevention in health care settings and the community.7
Given the prevalence of asthma, its considerable economic effects, the demonstrated gaps between high-quality care and demonstrated practice, and the disproportionate effect of poor care on lower socioeconomic populations, the Institute of Medicine (IOM) has designated quality improvement in asthma care as a priority area.18 Specifically, the IOM report notes that persons with mild/moderate persistent asthma often do not receive appropriate treatment.18 The objective of this Report is to evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient care for children and adults with asthma.
Key Research Questions
The specific research questions addressed in this review are:
Research Question 1: What is the evidence that QI strategies improve the processes and outcomes of outpatient care for pediatric and adult populations with asthma? Specifically, which QI strategies are effective for improving processes and outcomes of asthma care for specific patient populations (e.g., adults, children, low SES, racial groups, urban/rural)? Also, does the setting of the QI intervention (e.g., home, school, clinic) determine its effectiveness for improving processes and outcomes of asthma care?
Research Question 2: Are QI interventions for asthma care that incorporate multiple strategies more effective than those that employ a single strategy?
Footnotes
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Historical note: References to asthma symptoms have been found in the Nei Ching, a Chinese medicine text written between 2500 and 1000 BC and in the Ebers Papyrus, an Egyptian medical reference from around 1550 BC. The word asthma is derived from the Greek verb aazein, meaning to exhale with open mouth, to pant, to take a “sharp breath.” The word first appears in Homer's Iliad and Hippocrates first used the word to describe the medical condition. Hippocrates wrote that asthma symptoms were more likely to occur in tailors, anglers, and metalworkers. Six centuries later, Galen was the first to describe it clinically and noted that it was caused by partial or complete bronchial obstruction. Moses Maimonides, a prominent medieval philosopher and physician, wrote a treatise on asthma diagnosis, prevention, and treatment. In the 17th century, Bernardino Ramazzini recognized an association between asthma and organic dust. The use of bronchodilators started in 1901, but it was not until the 1960s that the inflammatory component of asthma was recognized and anti-inflammatories were added to treatment regimens.
- Introduction - Closing the Quality Gap: A Critical Analysis of Quality Improveme...Introduction - Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 5: Asthma Care)
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