Reviews and feature article
Quality of care for acute asthma in 63 US emergency departments

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Background

Little is known about the quality of acute asthma care in the emergency department (ED).

Objectives

We sought to determine the concordance of ED management of acute asthma with National Institutes of Health asthma guidelines, to identify ED characteristics predictive of higher guideline concordance, and to assess whether guideline concordance was associated with hospital admission.

Methods

We conducted a retrospective chart review study of acute asthma as part of the National Emergency Department Safety Study. Using a principal diagnosis of asthma, we identified ED visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at the patient and ED level. These scores ranged from 0 to 100, with 100 indicating perfect concordance.

Results

The cohort consisted of 4,053 subjects; their median age was 34 years, and 64% were women. The overall patient guideline concordance score was 67 (interquartile range, 63-83), and the ED concordance score was 71 (SD, 7). Multivariable analysis showed southern EDs were associated with lower ED concordance scores (β-coefficient, −8.2; 95% CI, −13.8 to −2.7) compared with northeastern EDs. After adjustment for the severity on ED presentation, patients who received all recommended treatments had a 46% reduction in the risk of hospital admission compared with others.

Conclusions

Concordance with treatment recommendations in the National Institutes of Health asthma guidelines was moderate. Significant variations in ED quality of asthma care were found, and geographic differences existed. Greater concordance with guideline-recommended treatments might reduce hospitalizations.

Section snippets

Study design and setting

This retrospective cohort study was part of the NEDSS. Details of the study design and data collection have been published previously.18 In brief, the NEDSS was a large multicenter study that sought to characterize organizational- and clinician-related factors associated with the occurrence of errors in EDs. NEDSS was coordinated by the Emergency Medicine Network (EMNet; www.emnet-usa.org). We recruited EDs mainly by inviting sites affiliated with the EMNet. Because most EMNet sites are

Results

A total of 6,065 visits with a principal diagnosis of asthma were identified on the basis of ICD-9-CM codes, and the charts were reviewed. A total of 2,015 visits were excluded because of age of 13 years or less (n = 712), age of 55 years or greater (n = 490), history of chronic obstructive pulmonary disease (n = 177), no history of chronic asthma (n = 377), visits not prompted by asthma exacerbation (n = 289), and missing information on inclusion/exclusion criteria (n = 7). The final cohort

Discussion

In this study of 4,053 patients presenting to 63 EDs with acute asthma, we found that the overall concordance of emergency care with guideline recommendations was moderate. However, emergency care for asthma was highly concordant with guideline recommendations that are based on the stronger evidence (ie, level A evidence). There were substantial variations in the ED quality of care in different geographic regions, with the widest gap between the South and the Northeast. Our study also showed a

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  • Cited by (0)

    Supported by grant no. 5 R01 HS013099 from the Agency for Healthcare Research and Quality (Rockville, Md). Dr Camargo also is funded by grant HL084401 (Bethesda, Md).

    Disclosure of potential conflict of interest: R. Kaushal received grant support from the Agency for Healthcare Research and Quality, the New York State Department of Health, the Commonwealth Fund, and the United Hospital Fund and has provided legal consultation services/expert witness testimony in cases related to medication errors. D. Blumenthal receives grant support from General Electric and is a member of the Pfizer Health Policy Board and Wellpoint Physician Advisory Committee. C. A. Camargo is a consultant for AstraZeneca, Clinical Therapeutics, and Novartis; is on the speakers' bureau for AstraZeneca, GlaxoSmithKline, and Merck; is on the advisory board for Dey, Genentech, GlaxoSmithKline, Merck, Novartis, and Schering-Plough; and receives grant support from the National Institutes of Health, AstraZeneca, Critical Therapeutics, GlaxoSmithKline, Merck, Novartis, and Respironics. The rest of the authors have declared that they have no conflict of interest.

    Partial results from this study were presented at the 2008 Society for Academic Emergency Medicine Annual Meeting, Washington, DC, May 29–June 1, 2008.

    Reprints will not be available from the authors.

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