The Science Journal of the American Association for Respiratory Care

1997 OPEN FORUM Abstracts

A Cost-Effective Program for Children Hospitalized with Asthma

Timothy R. Myers, BS, RTT, Tuesday, December 9, 1997.

Asthma is one of the most common chronic diseases of childhood, affecting between five and ten percent of children in the United States, and recent data reveal that its prevalence is increasing.[1,2] Asthma is now the most common discharge diagnosis for patients admitted to pediatric hospitals.[2,3] Forty three percent of the annual health care expenditures for asthma are spent on emergency visits, hospitalizations and costs associated with death.[4]

Because asthma is so common and hospitalization so frequent, an effective predetermined algorithm could have enormous economic impact by decreasing treatment variation and improving outcomes. A major impediment to critical evaluation of acute care strategies for management of pediatric asthma is the lack of standardization of care. Although the number of medications for treatment of the hospitalized patient with asthma is relatively limited, there is substantial variation in the use of those medications. Choice of drugs, doses, timing of administration, duration of treatment and assessment measures vary widely; plans often are not formulated on the basis of data showing efficacy, but rather on local availability, physician experience and preference. Elimination of treatment which adds cost but not improved quality of care can be an effective strategy.

We developed an intensive, assessment-driven algorithm for treating children hospitalized with asthma. The Asthma Care Algoform (ACA), an intensive regimen of standard therapy for asthma driven by the patient's condition, has been universally applied for the past 18 months to all hospitalized with asthma. Chest assessments are used to make treatment decisions and determine the frequency of therapy. Specific criteria are outlined for decreasing treatment, augmenting treatment for patients who failed to respond, and transferring patients to the intensive care unit. Criteria for discharge are also specified.

The frequency of assessment and treatment decreases in a step-wise fashion as indicated by improvement on chest assessment measures. Patients in the ACA move through all four phases of assessment, but the amount of time spent at any particular phase, and the amount of treatment given is determined by individual patient assessment. Patients are allowed a maximum of 12 hours at any level. Advanced to the next phase (less frequent level of assessment), before the 12 hour maximum, is permitted as soon as meeting "discharge" criteria. If, after 12 hours at a particular phase of therapy, patient condition is no worse as indicated by chest assessment, the patient advances to the next level of treatment even without meeting the "discharge" criteria on chest assessment measures. The maximum interval allowed between treatments is 6 hours. Thus, a patient could spend as little as 12 hours in the ACA. If patient condition deteriorates at any point, an intensification protocol is implemented. Failure to improve on this treatment requires transfer to the intensive care unit.

Cost reductions resulting from the use of the ACA have led to substantial savings. Our institution, with approximately 900 asthma admissions annually saves over $1 million in hospital costs and over $1.4 million in patient charges each year. Prior to using the ACA, our hospital had the longest mean LOS (3.2 days) for asthma among a consortium of 20 children's hospitals whose average LOS for asthma was 2.4 days. Our LOS is now the shortest among consortium hospitals. Both short-term (72 hours) and long term (30 day) readmission rates decreased using the ACA.

References

1. Morbidity and Mortality Weekly Report, May 3, 1996; 45(17): 350-53.

2. Gergen PJ, Weiss KB. Changing patterns of asthma hospitalization among children: 1979-1987. JAMA, 1990; 264: 1688-92.

3. Gergen PJ, Mullally DI, Evans R. National survey of prevalence of asthma among children in the United States, 1976 to 1980. Pediatrics, 1988; 81: 1-7.

4. Weiss, KB, Gergen PJ, Hodgson TA. An economic evaluation of asthma in the United States. N Engl J Med, 1992; 326: 862-6.

AARC 50th Anniversary, December 6 - 9, 1997, New Orleans, Louisiana.

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