Skip to main content
NCBI home page
HHS Author Manuscripts logoLink to HHS Author Manuscripts
. Author manuscript; available in PMC: 2021 Dec 13.
Published in final edited form as: J Pediatr. 2018 Feb 1;195:175–181.e2. doi: 10.1016/j.jpeds.2017.11.062

Impact of Discharge Components on Readmission Rates for Children Hospitalized with Asthma

Kavita Parikh 1, Matt Hall 2, Chén C Kenyon 3, Ronald J Teufel II 4, Grant M Mussman 5,6, Amanda Montalbano 7, Jessica Gold 8, James W Antoon 9, Anupama Subramony 10, Vineeta Mittal 11, Rustin B Morse 11, Karen M Wilson 12, Samir S Shan 13,6
PMCID: PMC8666980  NIHMSID: NIHMS1759488  PMID: 29395170

Abstract

Objectives

To describe hospital-based asthma-specific discharge components at children’s hospitals and determine the association of these discharge components with pediatric asthma readmission rates.

Study design

This is a multicenter retrospective cohort study of pediatric asthma hospitalizations in 2015 at children’s hospitals participating in the Pediatric Health Information System. Children ages 5 to 17 years were included. An electronic survey assessing 13 asthma-specific discharge components was sent to quality leaders at all 49 hospitals. Correlations of combinations of asthma-specific discharge components and adjusted readmission rates were calculated.

Results

The survey response rate was 92% (45 of 49 hospitals). Thirty-day and 3-month adjusted readmission rates varied across hospitals, ranging from 1.9% to 3.9% for 30-day readmissions and 5.7% to 9.1% for 3-month readmissions. No individual or combination discharge components were associated with lower 30-day adjusted readmission rates. The only single-component significantly associated with a lower rate of readmission at 3 months was having comprehensive content of education (P < .029). Increasing intensity of discharge components in bundles was associated with reduced adjusted 3-month readmission rates, but this did not reach statistical significance. This was seen in a 2-discharge component bundle including content of education and communication with the primary medical doctor, as well as a 3-discharge component bundle, which included content of education, medications in-hand, and home-based environmental mitigation.

Conclusions

Children’s hospitals demonstrate a range of asthma-specific discharge components. Although we found no significant associations for specific hospital-level discharge components and asthma readmission rates at 30 days, certain combinations of discharge components may support hospitals to reduce healthcare utilization at 3 months.

Asthma exacerbations are a leading cause of hospitalization in children and a leading cause of potentially preventable pediatric admissions.1–3 Despite reductions in the rates of potentially preventable pediatric asthma admissions between 2003 and 2012,4 asthma hospitalizations remain high in certain populations and account for almost one-third of childhood asthma costs, resulting in $1.5 billion in hospital charges annually in the US.5 As hospitals and health systems take on increasing risk in their contracts with insurance companies, they face increasing financial pressure to reduce rates of readmissions.

Children hospitalized for asthma have approximately a 20% chance of repeat hospitalization in the subsequent year and 3-month readmission rates vary widely among hospitals, ranging from 3% to 14%.6–8 With this increased risk and wide variation in outcomes, children hospitalized for asthma are an important population on which hospitals and health systems should focus. There is an ongoing debate regarding how much inpatient management and discharge planning influence asthma readmission rates and whether readmission rates are truly a measure of high inpatient quality care.6,9 That said, ideal inpatient care for asthma results in a successful transition back to the community with sustained improvement in the child’s underlying illness, reducing the need for future hospitalization.

Currently, there is no standardized asthma discharge process across children’s hospitals. Evidence-based guidelines published by the National Institutes of Health (NIH) recommend asthma education, medication education, environmental mitigation, and coordination of care with the primary provider as part of the discharge planning process.10 The objectives of the present study were to describe current hospital-based asthma-specific discharge components at children’s hospitals across the US, and to study the association of specific discharge components with asthma readmission rates to identify and better understand the discharge practices that may reduce readmissions.

Methods

This is a retrospective cohort study of children 5–17 years of age hospitalized with an acute asthma exacerbation in a US children’s hospital from January 1, 2015 to December 31, 2015. We used data from the Pediatric Health Information System (PHIS) database, which is an administrative database containing clinical and billing data from tertiary care children’s hospitals in the US. Data quality is ensured through a joint effort between the Children’s Hospital Association (Lenexa, Kansas) and participating hospitals, as previously described.11 For this study, PHIS data were supplemented with data collected from an electronic survey distributed to quality leaders at each participating PHIS hospital.

Among the PHIS hospitals, children who were hospitalized with an asthma exacerbation (inpatient or observation) were eligible for inclusion if they were between 5 and 17 years of age, and were discharged between January 1, 2015 to December 31, 2015 with an All Patient Refined Diagnosis Related Group (APR-DRG) diagnosis of asthma (APR-DRG 141). We excluded children with complex chronic conditions using a previously reported classification scheme.12

An electronic survey (Appendix 1; available at www.jpeds.com) was distributed to quality leaders at each of the PHIS hospitals. The survey focused on 13 different asthma-specific discharge components adapted from previously identified interventions to reduce rehospitalization,13,14 and key components as identified by the National Heart Lung Blood Institute asthma expert guidelines.10 The survey asked respondents to report the frequency (never, rarely, sometimes, often, and always) by which their hospital group performed each discharge practice. The survey highlighted 4 broad discharge practice categories: (1) Inpatient asthma education (specifically, dedicated individual to conduct education, multiple formats of education (group class, one-to-one teaching, videos, written materials, etc), and content areas of asthma education); (2) Medications and devices in-hand at discharge (specifically, spacer, beta-agonist, controller medication, and oral steroids for current or future exacerbation); (3) Contact with the primary medical doctor (PMD) (specifically, communication with the PMD, and scheduled follow-up PMD appointment); and (4) Postdischarge components (specifically, postdischarge phone call to caregivers, home visit referrals, and environmental mitigation program referrals).

Through group consensus, each hospital’s provision of a discharge component was classified by intensity and given a score of 1 (low), 2 (middle), and 3 (high) (Appendix 2; available at www.jpeds.com). For example, in the content of education discharge component, the survey asked about 7 specific topic areas that the educator discussed with the patient and/or caregiver based on the NIH asthma guidelines, including asthma pathophysiology, symptom identification, trigger assessment/ avoidance strategies, role of medications, inhaler/spacer technique demonstration, inhaled corticosteroid adherence, and home-asthma management plan.10 There was also an option to write-in additional education components. A hospital was classified as low (score 1) for content of education if they reported less than the 7 content areas, middle (score 2) if they reported 7 of 7 content areas, and high (score 3) if they reported all 7 content areas plus additional content; a high score for this discharge component was considered comprehensive content of education. As another example, for the communication with PMD at discharge component, the hospital was classified as low (score 1) if the reported frequency was never/ rarely, middle (score 2) if the reported frequency was sometimes/often, and high (score 3) if the reported frequency was always.

The primary outcomes were the adjusted same-cause readmission rates at 30 days and 3 months. We counted readmissions (inpatient or observation) if the patient returned for asthma (APR-DRG 141) or other respiratory APR-DRGs.15 The additional respiratory APR-DRGs were included as outcomes to capture readmissions that may have been related to asthma, but not coded specifically as asthma. Readmission rates were adjusted for patient characteristics (age, sex, race, and payer status), severity of asthma illness (number of hospitalizations for asthma in prior year [2014]), severity of exacerbation (any encounter in the intensive care unit [ICU]), length of stay, disposition, seasonal variation, and hospital characteristics (case-mix index and hospitals’ percentage of admissions that are for asthma).

Statistical Analyses

Categorical variables were summarized with frequencies and percentages, and comparisons were made across groups using χ2 statistics. Continuous variables were summarized with median and IQRs, and compared across groups with Wilcoxon rank-sum statistics. We risk-adjusted hospital readmission rates using generalized linear mixed effects models with a random hospital effect and the following covariates: age, ARP-DRG severity of illness, sex, race, payor, disposition, length of stay, receipt of ICU care, and the hospital-level percentage of asthma discharges to total discharges. From these models, we performed a covariance test to determine if there was significant variation in risk-adjusted readmission rates across hospitals. Hospital-level 30-day and 3-month readmissions rates were compared across levels of the discharges components using Kruskal-Wallis tests. Because of the number of discharge components relative to the number of observations, we employed a data reduction technique using Classification and Regression Trees. This suggested several possible combinations of components that might be related to adjusted 3-month readmission rates. The concept of combining components into bundles is supported in the literature as an important tool to improve care, as often, single interventions are not successful.13,16 We identified potentially effective bundles of 2–4 different components, and tested these combinations for their association with readmission rates using the Spearman correlation coefficient. All statistical analyses were performed using SAS v 9.4 (SAS Institute, Cary, North Carolina) except the Classification and Regression Trees analysis that was performed using the “PARTY” package in R v 3.2 (R Core Team, Vienna, Austria), and P values of <.05 were considered statistically significant. Significance levels were adjusted for multiple comparisons using Bonferonni corrections when assessing bundles.

The Institutional Review Board at Children’s National Medical Center approved this study.

Results

The survey response rate was 92% (45 of 49 hospitals completed the survey). For the 45 hospitals completing the survey, the median number of asthma discharges was 349 per year (Table). Demographic information and comparisons between responder and nonresponder hospitals and cases can be found in Table. Readmission rates varied significantly by hospital; the median 30-day adjusted readmission rate for all PHIS hospitals was 2.6%, with a range of 1.9% to 3.9% (P = .005), and the median 3-month adjusted readmission rate was 6.6%, with a range of 5.7% to 9.1% (P = .002).

Table.

Demographics of survey responders and nonresponders by hospital and asthma characteristics

Characteristics Overall Survey nonresponders Survey responders P value
Hospital characteristics
 N hospitals 49 4 45
 N discharges: median [IQR] 16457 [12043, 21464] 10538 [8653.5, 16105.5] 17115 [13532, 22642] .093
 N asthma discharges: median [IQR] 321 [209, 435] 164.5 [111, 227] 349 [220, 436] .024
 Region
  Midwest 12 (24.5) 1 (25) 11 (24.4) .855
  Northeast 7 (14.3) 0 (0) 7 (15.6)
  South 19 (38.8) 2 (50) 17 (37.8)
  West 11 (22.4) 1 (25) 10 (22.2)
Asthma discharge characteristics
 N asthma discharges 17,397 676 16,721
 Age, y
  a. 5–6 5422 (31.2) 234 (34.6) 5188 (31) .140
  b. 7–11 8496 (48.8) 312 (46.2) 8184 (48.9)
  c. 12–17 3479 (20) 130 (19.2) 3349 (20)
 Sex
  a. Male 10437 (60) 406 (60.1) 10031 (60) .960
  b. Female 6958 (40) 270 (39.9) 6688 (40)
 Race
  a. Non-Hispanic white 4256 (24.5) 131 (19.4) 4125 (24.7) <.001
  b. Non-Hispanic black 8424 (48.4) 80 (11.8) 8344 (49.9)
  c. Hispanic 3279 (18.8) 311 (46) 2968 (17.8)
  d. Other 1438 (8.3) 154 (22.8) 1284 (7.7)
 Payer status
  a. Government 11872 (68.2) 455 (67.3) 11417 (68.3) <.001
  b. Private 5079 (29.2) 220 (32.5) 4859 (29.1)
  c. Other 446 (2.6) 1 (0.1) 445 (2.7)
 Length of stay (d)
  a. 0–1 9475 (54.5) 331 (49) 9144 (54.7) .001
  b. 2–3 6579 (37.8) 270 (39.9) 6309 (37.7)
  c. 4+ 1343 (7.7) 75 (11.1) 1268 (7.6)
 ICU care provided
  No 14947 (85.9) 514 (76) 14433 (86.3) <.001
  Yes 2450 (14.1) 162 (24) 2288 (13.7)
 30-d readmission rate: median [IQR] 2.6 [1.9, 3.9] 2.4 [2.3, 2.5] 2.6 [2.4, 2.9] .136
 3-mo readmission rate: median [IQR] 6.6 [5.7, 9.1] 6.6 [6.2, 6.6] 6.6 [6.3, 7.2] .395
Open in a new tab

The asthma-specific discharge components that were most used across hospitals included having a dedicated individual to provide education (76%), providing a spacer at discharge (67%), and communication with the PMD at discharge (58%) (Figure 1). The components that were least used across hospitals were providing in-hand medications at discharge; specifically, oral steroids for future exacerbations and oral steroids for completion of treatment course after discharge from hospital. Even though a majority of hospitals communicated with the PMD (58%), only about one-quarter of hospitals scheduled a PMD appointment (24%). In addition, only 16% of hospitals consistently make postdischarge phone calls to their patients after an asthma exacerbation, and 33% and 31% consistently provided referrals to environmental mitigation or home visit programs, respectively. Given the potential for colinearity of environmental mitigation and home visit referrals, we calculated the correlation, which was 0.28 (P = .06), so these 2 components approached correlation. When all the discharge components were analyzed individually, there were no significant relationships at 30 days for single-discharge component bundles. The only single-component significantly associated with lower rate of readmission at 3 months was having comprehensive content of education (P < .029), specifically, the group with the least comprehensive content of education had a 3-month readmission rate of 7.2% (6.7, 7.3) compared with 6.4% (6.3, 6.6) in the most comprehensive content of education group.

Figure 1.

Figure 1.

Open in a new tab

Asthma-specific discharge components at surveyed hospitals by intensity. Scaled representation of discharge practice intensity across all surveyed hospitals.

When evaluating combinations of discharge bundles, increasing intensity of the asthma-specific discharge components was associated with reducing readmission rates at 3 months, but this did not reach statistical significance. Figure 2 depicts one 2-discharge component and one 3-discharge component bundle focusing on key components of education, communication, medications in-hand, and environmental mitigation. On Figure 2, A, the intensity of the bundle combination of content of education and communication with PMD (x-axis, ranges from score of 2 to 6 for 2-discharge component bundle combinations because each component can be scored between 1 and 3) has a relationship with the lower adjusted readmission rates at 3 months (y-axis) (P = .033). As noted in Figure 2, the slope of the relationship is -0.24, which implies that if a hospital were to increase their intensity of this bundle combination (content of education with communication with PMD by 1 point, their 3-month adjusted readmission rate would be expected to decrease by 0.24, and if they increase their score by 2, their 3-month adjusted readmission rate would be expected to decrease by 0.48. For example, if the 3-month adjusted readmission rate at that hospital is 5%, an increase in their discharge component intensity by 2 points would drop the readmission rate to 4.52%. Figure 2, B depicts the relationship with adjusted readmission percent with a 3-discharge component bundle (content of education and environmental mitigation and medications in hand) (P = .05) and the slope of the relationship is -0.18. In this situation, if the 3-month adjusted readmission rate at the hospital is 5%, an increase in their discharge component intensity by 3 points (perhaps increasing the intensity of each of the 3 components) would drop the readmission rate to 4.46%.

Figure 2.

Figure 2.

Open in a new tab

Association of discharge bundles by intensity with reduction in 3-month adjusted readmission rates. Relationship of discharge bundles with 3-month readmission rate where each circle represents a single surveyed hospital. X-axis represents discharge component intensity because each component was scored as 1 (low intensity) to 3 (high intensity), so range for 2-discharge component is 2 to 6 and range for 3-discharge component is 3 to 9.

Appendix 3 (available at www.jpeds.com) presents discharge component bundles and association to lower adjusted readmission at 3 months. The magnitude of the decrease in readmissions with increasing intensity was similar across bundles though none reached statistical significance after adjusting for multiple comparisons. Seven discharge components contributed to the successful bundles: having a dedicated individual performing asthma education, communicating with the PMD at time of discharge, home visits, environmental mitigation, comprehensive content of education, having steroids in hand for future exacerbation, and having inhaled corticosteroid medication in hand at time of discharge.

Discussion

In this national sample of tertiary-care children’s hospitals, we identified the range and intensity of discharge components for children hospitalized for acute asthma exacerbation. Though none of the discharge bundles was associated with a statistically significant reduction in 30-day readmission rates, there was the suggestion of decreasing 3-month readmission rates with increasing intensity of discharge components. The range of readmission rates at 30 days is quite small and narrow so it is difficult to detect change in this shorter readmission window, which reflects more directly care during the index hospitalization for the acute asthma exacerbation. However, by 3 months, there is more variability in readmission rates and, thus, a greater opportunity to make improvements in this period, which is may be more reflective of comprehensive care management for asthma as a chronic condition. Our work highlights that increasing the intensity of currently implemented asthma-specific discharge components may help hospital systems reduce 3-month readmission rates for asthma. For example, we show that an increase in intensity of 4 points— or stated in practical terms, ensuring that medications are in-hand and PMD communication is done consistently, rather that occasionally—would reduce asthma readmissions from 20 to 17 per year at a single typical hospital.

Despite the variation in discharge components and their intensity, the only single component associated with lower adjusted 3-month readmission rates was more robust content of education. In addition to the single component of comprehensive education, several combinations of discharge components were associated with improved outcomes, consistent with the evidence supporting that bundles of different practices or interventions can improve other healthcare outcomes.16,17 We identified 7 key discharge components associated with reductions in readmission rates that represent four distinct categories: (1) comprehensive asthma education (including content and use of dedicated asthma educator), (2) communication with PMD at discharge, (3) environmental mitigation or home visits, and (4) medications in-hand at discharge.

Bundling of these components involves using multiple strategies to incrementally improve outcomes; in this study, the bundled components may offer the opportunity for multiple contacts with the patient and family to educate and to evaluate determinants of asthma control post discharge, including at a primary care physician appointment and home environment assessment with referral to environmental mitigation programs. Another potential benefit of bundles of asthma discharge components may be that it allows for different mechanisms of education: didactic, visual, and interactive tailored to different styles and levels of adult learners. These strategies are aligned with the NIH asthma recommendations using multimodal educational strategies when interacting with patients and families to promote self-management and provide repetition and reinforcement.10 In addition, the bundle elements improve patient access to care if symptoms develop at home, by making it easy to connect with a primary care provider and to have access to oral steroids for a future exacerbation.

Comprehensive Asthma Education: Content of Education and Dedicated Asthma Educator

The only individual discharge component in our study noted to reduce readmissions at 3 months was content of asthma education, and it was also the only common discharge component in all successful bundles. Specific elements of the NIH guidelines mirror the elements included in our gradation of the content of education, reinforcing the importance of comprehensive education, including education on self-management for asthma.10 Although we found an association with education components and 3-month readmission rate, a prior study showed that higher asthma knowledge among caregivers was associated with higher rates of readmission for their children.18 However, that study focused on asthma knowledge based on asthma facts and roles of medications, but no clear focus on self-management strategies, such as how to administer medications appropriately or self-monitor symptoms.19 This highlights the potential risk of over-focusing on asthma knowledge as opposed to skills and behaviors which are central to the self-management of a chronic illness. A systematic review of randomized clinical trials focusing on asthma self-management education demonstrated that self-management programs increased feelings of self-control and lung function, and reduced school absences, days of restricted activity, and emergency department utilization.20 In addition, an education-oriented strategy that has been associated with lower asthma readmission in several studies is the use of a dedicated nurse to provide both individualized inpatient education as well as some degree of outpatient follow-up.21–23 Our study supports the need for a comprehensive education approach, which includes content on self-management strategies that function in concert with other tangible supports.

Communication with PMD

Communicating with the PMD at the time of discharge to link the patient back to the medical home or connecting a patient with a high-functioning medical home has been shown to decrease readmission rates. In one study, increasing follow-up appointments with primary care providers was associated with decreased readmission rates.24 In addition, other studies have shown that poor access to medical homes was associated with increased asthma readmissions.25,26 Visits to the PMD are another opportunity to reinforce education and assess asthma control.

Environmental Mitigation and Home Visits

Although it is not precisely clear the extent to which patient and caregiver environmental factors drive repeat utilization, it is widely accepted that social determinants contribute to asthma outcomes and morbidity. In a recent study, poor housing quality was independently and strongly associated with asthma morbidity.27 Two large, multicenter initiatives have identified important modifiable environmental factors associated with asthma control and demonstrated the efficacy of home-based, comprehensive environmental remediation for urban children with allergic asthma.28,29 Further, asthma coalitions have been shown to be effective in improving asthma outcomes across the clinical spectrum by leveraging home visits or use of a community health-worker model that includes education and patient/family activation for self-management as well as environmental risk modification.30 Future work should focus on effectively linking high-risk inpatients with evidence-based outpatient and community programs that include environmental mitigation.31,32

Medications in Hand at Discharge: Inhaled Corticosteroid or Oral Steroids for Future Exacerbation

Another crucial evidence-based aspect of the hospital to home transition is assuring that children with asthma have medications necessary to manage acute and chronic symptoms. Patients who fill prescriptions for a short-acting beta agonist, oral corticosteroid, and inhaled corticosteroid within 3 days of discharge had lower readmission rates within 90 days.33 In addition, a recent quality improvement effort reported that providing medications in-hand at the time of discharge could reduce pediatric asthma emergency department revisits.34 Our study demonstrated that very few hospitals gave steroids for future use, and yet this discharge component may be particularly beneficial for preventing readmission.35

Limitations

This study has several limitations. First, only children’s hospitals were included in the sample and the children’s hospitals that responded to the survey were different from those did not in several ways. Relative to hospitals that responded, nonrespondent hospitals tended to have lower volumes of asthma discharges, different racial/ethnic compositions (less non-Hispanic black, more Hispanic and “other” patients), longer lengths of stay, and higher proportion of ICU stays. These differences in volume, length of stay, and ICU admission may indicate response bias on the part of hospitals with higher inpatient asthma volume and, thus, more established inpatient and discharge care processes for asthma patients. Our high response rate, however, makes it likely that our findings are generalizable to most children’s hospitals. Only tertiary care, freestanding children’s hospitals were included, so these findings may not be generalizable to other pediatric inpatient care settings. Second, we were only able to identify readmissions to the same hospital as the index admission. If a large proportion of readmissions occurred at other hospitals. we would underestimate readmission rates, although the impact of this limitation on association between intensity of discharge components and readmission rates is unclear. Of note, a recent study of pediatric readmissions showed that only 13.9% of all-cause readmissions were to a different hospital than the index admission.36 Also, the narrow range of readmission rates may have limited our ability to detect variation based on discharge practices. Third, discharge component information was solicited from quality leaders at participating hospitals, so may be subjective and not include all factors that impact readmission rate (for example, patient-level factors such as medication adherence). To minimize this limitation, care was taken to obtain hospital process information from the most informed provider knowledgeable of asthma discharge components at the hospital. However, although we aimed to survey providers knowledgeable about asthma care at the particular hospital, responses may not have complete fidelity to what is actually happening in the hospitals. In addition, because this is an administrative database, we did not have access to some potential readmission confounders, such as second-hand smoke exposure.

As children’s hospitals and healthcare systems take on increasing accountability for the readmissions of the populations they serve, identifying care practices that prevent potentially avoidable readmissions such as repeat asthma hospitalizations will become increasingly important. This study demonstrates that isolated discharge components are likely insufficient when it comes to preventing readmissions of certain common and chronic conditions such as asthma. Prospective studies are necessary to confirm these findings, but the current study highlights key discharge components that should be bundled and optimized to reduce readmission rates. ■

Acknowledgments

K.P. is supported by the Agency for Healthcare Research and Quality (K08HS024554). The other authors declare no conflicts of interest.

Glossary

APR-DRG

All Patient Refined Diagnosis Related Group

ICU

Intensive care unit

NIH

National Institutes of Health

PHIS

Pediatric Health Information System

PMD

Primary medical doctor

Appendix 1. Children with Asthma Readmissions Evaluation Study

Inpatient admission for asthma exacerbations is a discrete event and may serve as a “teachable moment” for some patients or caregivers to initiate behavior change. We will ask about management strategies for children hospitalized with asthma during hospitalization (inpatient component) as well as after hospitalization (outpatient component). Please refer to current practice at your hospital while you answer the following questions.

Inpatient Component

  1. At your hospital, are there unique components for discharging a child with asthma compared to other diagnoses? Yes/No

  2. Do patients receive different discharge processes based on severity of illness and/or utilization? For example, patients who required ICU care or patients with multiple hospitalizations for asthma?

    Yes/No

    If yes, please explain [Free text]

  3. Is there a dedicated individual or group of individuals, who coordinate discharge for children with asthma, for example, do you have a specific asthma educator(s)? Yes/No

  4. What is the background of this individual or team? Check all that apply.
    1. Nurse
    2. Respiratory therapist
    3. Social worker
    4. Case manager
    5. Generalist physician
    6. Specialists physician (for example, pulmonary or allergist)
    7. Medical student
    8. Health worker not employed by the hospital
    9. Pharmacist
    10. Other [Free text box]
    11. Not applicable
  5. What is the format of the asthma-specific education that patients and caregivers receive while hospitalized? Check all that apply.
    1. 1-on-1 education
    2. Group class of patients and/or caregivers
    3. Asthma-specific videos
    4. Asthma-specific reading materials
    5. Internet-based tools
    6. Asthma specific-apps
    7. Other [Free text box]
    8. Not applicable
  6. What is the content of the education? Check all that apply.
    1. Asthma pathophysiology
    2. Symptom identification
    3. Trigger assessment and avoidance strategies
    4. Role of medications
    5. Inhaler/spacer technique demonstration
    6. Inhaled corticosteroid adherence (ICS)
    7. Asthma action plan
    8. Other
    9. Not applicable
  7. Are the following medications or equipment in-hand for patient at the time of discharge?
    5-point scale
    Medication/equipment Never Rarely Sometimes Often Always
    Spacer
    Nebulizer
    Oral steroids for current exacerbation
    Oral steroids for future exacerbation
    Beta-agonist (for example, albuterol)
    ICSs controller medication
    Other controller medications
    Open in a new tab
    ICS, Inhaled corticosteroid.

Outpatient component

  1. Are there postdischarge communications to patients or caregivers after patient’s admission for an asthma exacerbation?
    5-point scale
    Communication types Never Rarely Sometimes Often Always
    Phone call
    Text message
    Email message
    Mailings to home address
    Open in a new tab
  2. Are there postdischarge communications to health workers after the patient’s admission for an asthma exacerbation?
    5-point scale
    Medications/equipment Never Rarely Sometimes Often Always
    Primary doctor
    School nurse
    Community health worker
    Pharmacist
    Open in a new tab

  3. Are the following performed for patients with asthma at discharge?

    Are there specific programs that address the following?
    5-point scale
    Asthma care Never Rarely Sometimes Often Always
    Recommended appointment with primary doctor
    Scheduled appointment with primary doctor
    Asthma specific follow-up clinic
    Specialty follow-up clinic (pulmonary/allergy)
    Case/care management services
    Asthma education programs
    Home visits
    Medical-legal partnerships
    Environmental mitigation (removal of carpets, give pillow covers, bed covers)
    Partnership with schools
    Open in a new tab

  4. Are there other aspects of asthma discharge management at your hospital that was not addressed in this survey? If yes, please explain.

    [Free text box]

Appendix 2.

Discharge components Bundle 1: low Bundle 2: middle Bundle 3: high
Dedicated individual No Yes Yes
Content of education <7 7 of 7 7 +
Format of education 1 format 2–3 formats >3 formats
Medications in hand: spacer Sometimes Often Always
Medications in hand: beta-agonist Sometimes Often Always
Medications in hand: oral steroids for current exacerbation Never/rarely Sometimes/often Always
Medications in hand: oral steroids for future exacerbation Never Rarely/sometimes Often/always
Medications in hand: ICS controller medication Never/rarely Sometimes/often Always
Scheduled PMD appointment Never/rarely Sometimes/often Always
Communication with PMD at discharge Never/rarely Sometimes/often Always
Postdischarge phone call Never/rarely Sometimes/often Always
Home visits Not applicable/never Rarely/sometimes Often/always
Environmental mitigation Not applicable/never Rarely/sometimes Often/always
Open in a new tab

Appendix 3.

The 2-component and 3-component discharge bundles associated with reduction in 3-month adjusted readmission rates

Discharge components Change in readmission rate per increase in discharge component intensity slope (95% CI) P value*
Two-discharge component bundles
 Bundle 1 Content of education
Environmental mitigation		 −0.33 (−0.56, −0.03) .029
 Bundle 2 Content of education
Communication with PMD at discharge		 −0.32 (−0.55, −0.02) .033
Three-discharge component bundles
 Bundle 1 Content of education
Communication with PMD at discharge
Environmental mitigation		 −0.35 (−0.58, −0.06) .019
 Bundle 2 Content of education
Medications in hand: ICS
Environmental mitigation		 −0.32 (−0.56, −0.02) .034
 Bundle 3 Content of education
Homes visits
Environmental mitigation		 −0.30 (−0.55, −0.01) .042
 Bundle 4 Content of education
Communication with PMD at discharge
Homes visits		 −0.30 (−0.55, −0.01) .044
 Bundle 5 Content of education
Medications in hand: steroids for future
Environmental mitigation		 −0.30 (−0.54, −0.01) .046
 Bundle 6 Dedicated individual
Content of education
Homes visits		 −0.30 (−0.54, 0) .049
Open in a new tab
*

Statistical significance was defined as P < .025 for the 2-discharge component bundles and P < .01 for the 3-discharge component bundles to account for multiple comparisons.

References

  • 1.Moorman JE, Akinbami LJ, Bailey CM, Zahran HS, King ME, Johnson CA, et al. National surveillance of asthma: United States, 2001–2010. Vital Health Stat 3 2012;1–67. [PubMed] [Google Scholar]
  • 2.Akinbami LJ, Moorman JE, Bailey C, Zahran HS, King M, Johnson CA, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001–2010. NCHS Data Brief 2012;1–8. [PubMed] [Google Scholar]
  • 3.Gay JC, Agrawal R, Auger KA, Del Beccaro MA, Eghtesady P, Fieldston ES, et al. Rates and impact of potentially preventable readmissions at children’s hospitals. J Pediatr 2015;166:613–9, e5. [DOI] [PubMed] [Google Scholar]
  • 4.Fingar K, Washington R. Potentially preventable pediatric hospital inpatient stays for asthma and diabetes, 2003–2012: statistical brief #192. Rockville (MD): Healthcare Cost and Utilization Project (HCUP) Statistical Briefs; 2006. [PubMed]
  • 5.Kamble S, Bharmal M. Incremental direct expenditure of treating asthma in the United States. J Asthma 2009;46:73–80. [DOI] [PubMed] [Google Scholar]
  • 6.Nakamura MM, Toomey SL, Zaslavsky AM, Berry JG, Lorch SA, Jha AK, et al. Measuring pediatric hospital readmission rates to drive quality improvement. Acad Pediatr 2014;14(5 Suppl):S39–46. [DOI] [PubMed] [Google Scholar]
  • 7.Kenyon CC, Melvin PR, Chiang VW, Elliott MN, Schuster MA, Berry JG. Rehospitalization for childhood asthma: timing, variation, and opportunities for intervention. J Pediatr 2014;164:300–5. [DOI] [PubMed] [Google Scholar]
  • 8.Parikh K, Berry J, Hall M, Mussman GM, Montalbano A, Thomson J, et al. Racial and ethnic differences in pediatric readmissions for common chronic conditions. J Pediatr 2017;186:158–64, e1. [DOI] [PubMed] [Google Scholar]
  • 9.Morse RB, Hall M, Fieldston ES, McGwire G, Anspacher M, Sills MR, et al. Hospital-level compliance with asthma care quality measures at children’s hospitals and subsequent asthma-related outcomes. JAMA 2011;306:1454–60. [DOI] [PubMed] [Google Scholar]
  • 10.National Asthma Education and Prevention Program. Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol 2007;120(5 Suppl):S94–138. [DOI] [PubMed] [Google Scholar]
  • 11.Mongelluzzo J, Mohamad Z, Ten Have TR, Shah SS. Corticosteroids and mortality in children with bacterial meningitis. JAMA 2008;299:2048–55. [DOI] [PubMed] [Google Scholar]
  • 12.Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr 2014;14:199. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med 2011;155:520–8. [DOI] [PubMed] [Google Scholar]
  • 14.Auger KA, Kenyon CC, Feudtner C, Davis MM. Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review. J Hosp Med 2014;9:251–60. [DOI] [PubMed] [Google Scholar]
  • 15.Berry JG, Toomey SL, Zaslavsky AM, Jha AK, Nakamura MM, Klein DJ, et al. Pediatric readmission prevalence and variability across hospitals. JAMA 2013;309:372–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Krupp NL, Fiscus C, Webb R, Webber EC, Stanley T, Pettit R, et al. Multifaceted quality improvement initiative to decrease pediatric asthma readmissions. J Asthma 2017;54:911–8. [DOI] [PubMed] [Google Scholar]
  • 17.Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line-associated bloodstream infections by implementation of a postinsertion care bundle. Am J Infect Control 2010;38:430–3. [DOI] [PubMed] [Google Scholar]
  • 18.Auger KA, Kahn RS, Davis MM, Simmons JM. Pediatric asthma readmission: asthma knowledge is not enough? J Pediatr 2015;166:101–8. [DOI] [PubMed] [Google Scholar]
  • 19.Cabana MD, Bardach NS. A little bit of knowledge is a dangerous thing. J Pediatr 2015;166:10–1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Wolf FM, Guevara JP, Grum CM, Clark NM, Cates CJ. Educational interventions for asthma in children. Cochrane Database Syst Rev 2003;(1):CD000326. [DOI] [PubMed] [Google Scholar]
  • 21.Madge P, McColl J, Paton J. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Thorax 1997;52:223–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Wesseldine LJ, McCarthy P, Silverman M. Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice. Arch Dis Child 1999;80:110–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Ng DK, Chow PY, Lai WP, Chan KC, And BL, So HY. Effect of a structured asthma education program on hospitalized asthmatic children: a randomized controlled study. Pediatr Int 2006;48:158–62. [DOI] [PubMed] [Google Scholar]
  • 24.Bergert L, Patel SJ, Kimata C, Zhang G, Matthews WJ Jr. Linking patient-centered medical home and asthma measures reduces hospital readmission rates. Pediatrics 2014;134:e249–56. [DOI] [PubMed] [Google Scholar]
  • 25.Auger KA, Kahn RS, Davis MM, Beck AF, Simmons JM. Medical home quality and readmission risk for children hospitalized with asthma exacerbations. Pediatrics 2013;131:64–70. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Sills MR, Hall M, Colvin JD, Macy ML, Cutler GJ, Bettenhausen JL, et al. Association of social determinants with children’s hospitals’ preventable readmissions performance. JAMA Pediatr 2016;170:350–8. [DOI] [PubMed] [Google Scholar]
  • 27.Hughes HK, Matsui EC, Tschudy MM, Pollack CE, Keet CA. Pediatric asthma health disparities: race, hardship, housing, and asthma in a national survey. Acad Pediatr 2016;17:127–34. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Morgan WJ, Crain EF, Gruchalla RS, O’Connor GT, Kattan M, Evans R 3rd, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med 2004;351:1068–80. [DOI] [PubMed] [Google Scholar]
  • 29.Evans R III, Gergen PJ, Mitchell H, Kattan M, Kercsmar C, Crain E, et al. A randomized clinical trial to reduce asthma morbidity among inner-city children: results of the National Cooperative Inner- City Asthma Study. J Pediatr 1999;135:332–8. [DOI] [PubMed] [Google Scholar]
  • 30.Findley S, Rosenthal M, Bryant-Stephens T, Damitz M, Lara M, Mansfield C, et al. Community- based care coordination: practical applications for childhood asthma. Health Promot Pract 2011;12(6 Suppl 1):52S–62S. [DOI] [PubMed] [Google Scholar]
  • 31.Krieger JW, Takaro TK, Song L, Weaver M. The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health 2005;95:652–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Bryant-Stephens T, Kurian C, Guo R, Zhao H. Impact of a household environmental intervention delivered by lay health workers on asthma symptom control in urban, disadvantaged children with asthma. Am J Public Health 2009;99(Suppl 3):S657–65. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Kenyon CC, Rubin DM, Zorc JJ, Mohamad Z, Faerber JA, Feudtner C. Childhood asthma hospital discharge medication fills and risk of subsequent readmission. J Pediatr 2015;166:1121–7. [DOI] [PubMed] [Google Scholar]
  • 34.Hatoun J, Bair-Merritt M, Cabral H, Moses J. Increasing medication possession at discharge for patients with asthma: the meds-in-hand project. Pediatrics 2016;137:e20150461. [DOI] [PubMed] [Google Scholar]
  • 35.Bhogal SK, McGillivray D, Bourbeau J, Benedetti A, Bartlett S, Ducharme FM. Early administration of systemic corticosteroids reduces hospital admission rates for children with moderate and severe asthma exacerbation. Ann Emerg Med 2012;60:84–91, e3. [DOI] [PubMed] [Google Scholar]
  • 36.Khan A, Nakamura MM, Zaslavsky AM, Jang J, Berry JG, Feng JY, et al. Same-hospital readmission rates as a measure of pediatric quality of care. JAMA Pediatr 2015;169:905–12. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES