By: Shilpa J. Patel, MD, Lora Bergert, MD, Christopher A. Longhurst, MD, MS, Paul J. Sharek, MD, MPH Six years after initiation of the CAC measure set, we can reflect on the effectiveness of these three core measures, the challenges associated with compliance, and the approaches to reducing barriers to compliance. We will use the four criteria for accountability measures outlined by Chassin et al. (2) to assess these asthma performance measures: The first two measures, use of relievers (short-acting bronchodilator agents) (CAC-1) and administration of systemic corticosteroids (CAC-2), easily fulfill all four of Chassin’s accountability criteria. First, an overwhelming preponderance of evidence supports the use of both relievers and systemic corticosteroids for acute asthma symptoms. (3) Second, a patient’s medication administration record enables accurate tracking of administration of relievers and systemic corticosteroids. Third, improvement of the patient’s symptoms is closely linked to administration of both relievers and systemic corticosteroids. And fourth, administering relievers and low dose corticosteroids to pediatric patients with asthma is known to be safe in the short term. Compliance with both measures is very high in the literature, (4,5,6) likely due to the standardization of care through hospital-based treatment guidelines, utilization of order sets, and the positive reinforcement provided by observed treatment benefit. Although some experts argue that compliance is so consistently high across United States hospitals that these two metrics are rendered inadequate to identify quality improvement opportunities, (4,5) we believe that their use as accountability measures for national transparency or payment programs remains relevant as they both ensure a high level of performance and capture any outliers in compliance. (7) In addition, full compliance for the HMPC measure requires documentation that the completed asthma action plan was given to the caregiver and that the patient medical record includes a copy. (1)
In 2007, The Joint Commission announced the first pediatric core measure set on Children’s Asthma Care (CAC). This set includes the following 3 measures in eligible children (defined as hospitalized, between the ages of 2 and 17 years old, and admitted with a primary discharge diagnosis of asthma):
The third asthma process measure, the HMPC or “asthma action plan” (CAC-3), which stipulates that a complete HMPC be given to the caregiver prior to discharge, has been shown in the literature to be the most difficult asthma core measure with which to comply. (4,5,6) In addition, the data linking compliance with the HMPC measure and improved outcomes (as measured by emergency department [ED] utilization or readmissions) is conflicting, (4,5) and, therefore, the utility of this process measure deserves more scrutiny.
For compliance with the HMPC measure, the asthma action plan must explicitly document all five of the following subcomponents:
In terms of Chassin’s accountability criteria for the HMPC, the literature supports the use of home/self-care monitoring and initiation of treatment, as well as the benefit of asthma action plans for the prevention of severe asthma exacerbations. (3,8,9,10,11) This satisfies the first accountability criterion in the small subset of patients categorized with severe asthma. Compliance with the HMPC accurately depicts the intent of providing a completed action plan to families upon discharge, thus satisfying Chassin’s second criterion. Completion of the multiple steps, however, can prove extremely challenging and is described in more detail below. (5,6) The third accountability criterion, which states that few intervening steps should occur before an improvement can be realized, is more difficult to satisfy and is also discussed further below. Finally, the HMPC measure satisfies the fourth accountability criterion as the HMPC does not appear likely to produce harm to the patient.
Since the HMPC contains several different required elements, it is helpful to address each of these separately in relation to Chassin’s third accountability criterion. HMPC-1 stipulates scheduling of a follow-up appointment prior to discharge or inclusion of information on how to make the appointment (provider’s name and phone number) on the HMPC document. This subcomponent is the most difficult with which to comply, as it requires several steps to occur. (4) Fortunately, however, the value of a follow-up appointment after hospitalization to ensure continuity of care is well-supported in the literature for chronic illnesses in general, specifically for asthma. (10,12,13,14,15,16)
Recent evidence demonstrating that the HMPC measure is associated with improved patient outcomes is conflicting and few data describe compliance with HMPC-generated follow-up appointments or the effect of this follow-up on the outcomes of ED utilization and readmission rates. One multicenter study showed no improvement in outcomes with relatively low compliance with the follow-up appointment subcomponent, (4) while a single site study showed improvement in readmissions. (5) More information regarding patient compliance with the CAC-3 subcomponents would allow the process measure to be more closely tied to the patient outcome, thereby satisfying the third accountability criterion. Anecdotally, at the primary author’s (SP) institution (Kapi’olani Medical Center for Women and Children [KMCWC] in Honolulu, Hawaii), 84% of Asthma Core Measure eligible patients attended the HMPC-scheduled follow-up appointment; during the associated timeframe significant decreases in readmissions have been seen.
The second subcomponent of the HMPC measure (HMPC-2) stipulates inclusion of information regarding triggers and trigger avoidance in the HMPC. Substantial evidence supports reduction of trigger exposure as a preventive measure for acute asthma flares. (3) Including the triggers on the HMPC prompts the in-patient medical team to review it with the patient/caretakers at discharge. HMPC measure subcomponents HMPC-3 and HMPC-5 refer to recognition of asthma symptoms and the corresponding actions in response to increasing severity of symptoms. As noted above, the literature supports the use of self-monitoring and self-care to prevent asthma exacerbations, including the early initiation of relievers to reduce lower airway obstruction. (3) As perhaps the most familiar component of the asthma action plan, the step-wise response to symptom severity refers to the traditional green/yellow/red approach to recognizing and treating increasing asthma symptoms and is closely tied to improved outcomes in asthma patients. (3,9) Finally, subcomponent HMPC-4 refers to controller medication use, also strongly supported by the literature for its effectiveness in persistent asthma. (3)
Aside from subcomponent HMPC-1, the subcomponents of the HMPC measure are directly supported as accountability measures because they fulfill the criteria set forth by Chassin et al. as effective process measures. Data supporting the value of subcomponent HMPC-1 is mixed. Morse et al. concluded that no improved outcomes occurred despite high compliance with CAC-3 overall, while Fassl et al. demonstrated decreased readmission rates post-discharge in a single site study. Unpublished data from Honolulu’s KMCWC is consistent with Fassl’s conclusions that arrangement for follow-up care is, indeed, a useful measure.
The electronic medical record (EMR) can play a substantial role in supporting compliance for the three asthma core measures. First, an effectively used EMR clearly supports standardized approaches to routinely administering relievers (CAC-1) and systemic steroids (CAC-2) in all eligible patients. Second, the EMR supports compliance with several of the subcomponents of the HMPC (CAC-3). For example, the HMPC-1 subcomponent can be pre-populated with the primary provider’s name, contact information, and follow-up appointment date/time, and can also be utilized for patient self-scheduling upon deployment of a robust patient portal. The EMR also facilitates inclusion of important information by providing cognitive and workflow support to providers with drop down menus (e.g., tying common triggers to exposure-reduction strategies). Furthermore, the EMR can be configured to ensure that the completed HMPC automatically faxes or electronically transmits to the patient’s outpatient provider to maintain continuity of care and consistently reinforce the asthma education message. Most importantly, both homegrown and vendor EMRs can be configured to create a true forcing function to prevent discharge of pediatric inpatients with asthma until the HMPC’s full completion. Use of computerized alerts and reminders as tools to facilitate compliance with protocols when appropriately integrated in workflow is well documented. (17) Also, a recent meta-analysis shows that providing decision support to patients in addition to providers is significantly more effective than delivering it to the providers alone. (18) At Lucile Packard Children’s Hospital at Stanford University, for example, this bundle of EMR-enabled interventions was associated with an increase from 65% to 94% HMPC compliance on eligible patients. (6) At KMCWC, when failures in compliance were noted, solutions were often found by utilizing the EMR (e.g., best practice alerts, pre-populated fields, forcing functions).
In summary, we believe that CAC-1 (relievers) and CAC-2 (systemic corticosteroids) should continue to be utilized as Joint Commission Core Measures in pediatric asthma inpatients, as they ensure compliance with best practice, are closely linked to improved outcomes in patients, and satisfy the four criteria for effective accountability measures proposed by Chassin. Data regarding CAC-3 (HMPC) is more controversial since the relationship of the HMPC to outcomes improvements is conflicting in the literature. Despite this lack of conclusive evidence, we believe in the continued inclusion of the HMPC in the core measure set, as it serves as a tool to ensure the facilitation of follow-up with primary providers and reinforcement of asthma education and self-management. However, further studies linking follow-up appointment compliance with improved outcomes are necessary. The EMR plays a critical role as a tool to support implementation of this measure, since appropriate configuration of both home-grown and vendor EMRs appear effective in promoting efficient operationalization of the process measures.
Authors
Shilpa J. Patel, MD
Assistant Professor, University of Hawaii John A. Burns School of Medicine; Pediatric Hospitalist, Kapi’olani Medical Center for Women and Children
Lora Bergert, MD
Assistant Professor, University of Hawaii John A. Burns School of Medicine; Pediatric Hospitalist, Kapi’olani Medical Center for Women and Children
Christopher A. Longhurst, MD, MS
Associate Professor of Clinical Pediatrics, Stanford University School of Medicine; Chief Medical Information Officer, Lucile Packard Children’s Hospital
Paul J. Sharek, MD, MPH
Associate Professor of Pediatrics, Stanford School of Medicine; Medical Director, Center for Quality and Clinical Effectiveness; Chief Clinical Patient Safety Officer, Lucile Packard Children’s Hospital
Disclaimer
The views and opinions expressed are those of the author and do not necessarily state or reflect those of the National Quality Measures Clearinghouseâ„¢ (NQMC), the Agency for Healthcare Research and Quality (AHRQ), or its contractor ECRI Institute.
Potential Conflicts of Interest
Drs. Patel, Bergert, Longhurst, and Sharek state no financial, personal, business, or professional conflicts of interest with respect to this expert commentary.
References
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