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The Hospital Readmissions Reduction Program and COPD: More Answers, More Questions
Many provisions of the Affordable Care Act (ACA) have served to support the hospitalized patient. The expansion of Medicaid and the creation of state and federal insurance exchanges for the individual insurance market both significantly lessened the financial burden of hospital care for millions of Americans. Other aspects have proven more controversial, as many of the ACA’s health policy interventions linked to cost and quality in new ways, implementing untested concepts derived from healthcare services research on a national scale.
The Hospital Readmissions Reduction Program (HRRP) was no exception. Based on early research examining readmissions,1 the ACA included a mandate for the Centers for Medicare and Medicaid Services (CMS) to establish the HRRP. Beginning in Fiscal Year 2013, the HRRP reduced payments for excessive, 30-day, risk-standardized readmissions covering six conditions and procedures. As the third leading cause of 30-day readmissions, chronic obstructive pulmonary disease (COPD) was included in the list of designated HRRP conditions.
This inclusion of COPD in HRRP was not without controversy; analysis of Medicare data from before the ACA’s implementation demonstrated that only half of all readmissions for acute exacerbations of COPD were respiratory-related and only a third were directly related to COPD.2 Unsurprisingly, the high proportion of readmissions due to non-COPD-related causes is considered to be one of the leading factors for the failure of COPD readmission reduction programs to find significant reductions in readmissions.3 In this month’s issue of the Journal of Hospital Medicine, Buhr and colleagues explore differential readmission diagnoses following acute exacerbations of COPD using a validated, national, all-payer database.4
Like many analyses of payer datasets, this study has several limitations. First, although a large area of the US was included, the data did not include all US states. Further, as the study used multiple cross-sectional data using pooling techniques, it was not truly a longitudinal study. It was additionally limited to 10 months out of the calendar year, missing December and January, which have a high seasonal prevalence of viral respiratory illness. Finally, due to the nature of the data, COPD diagnoses were identified through administrative data known to be highly unreliable for fully capturing admissions for acute exacerbation of COPD.
Despite these limitations, the analysis by Buhr and colleagues provides additional value. They found an overall readmission rate of 17%, with just under half (7.69%) due to recurrent COPD. Patients with COPD-related readmissions were younger, had a higher proportion with Medicaid as the payer, were more frequently discharged home without services, had a shorter length of stay, and had fewer comorbidities.
Most critically, Buhr and colleagues—with a multipayer database—confirmed what researchers found in uni-payer5 and site-specific6 datasets: over half of readmissions are due to diagnoses other than COPD or respiratory-related causes. Patients readmitted due to other, unrelated diagnoses had a higher mean Elixhauser Comorbidity Index score along with higher rates of congestive heart failure and renal failure. To the practicing hospitalist, this finding supports what our internal clinical voice tells us: sicker patients are readmitted more often and more frequently with conditions unrelated to their index admission diagnosis.
The reaffirmation of the finding that the majority of readmissions are due to nonrespiratory-related causes suggests that perhaps we have a different problem than physicians and policymakers originally thought when adding COPD to the HRRP. Many COPD patients suffer from a polychronic disease, requiring a more holistic approach rather than a traditional, disease-driven, siloed approach focused solely on improving COPD-related care. It may also be true that for other subpopulations of patients with COPD, additional in-hospital and transition of care interventions are required to address patients’ multimorbidity and social determinants of health.
As physicians on the front lines of the readmitted patient, hospitalists are uniquely situated to see the challenges of populations with increasing disease complexity and disease combinations.7 The HRRP policy remains controversial. This is due in large part to recent work suggesting that while the HRRP may have helped reduce readmissions, its implementation may have driven the unintended consequence of increased mortality.8 Thus, our profession faces an existential challenge to traditional care delivery models targeting diseases. What has not been well parsed by the hospital industry or policymakers is what to do about it.
Readmission of the multimorbid patient, coupled with the challenges of the HRRP, focuses our attention on the need to transition care delivery to a model that is better suited to our patients’ needs: mass-customized, mass-produced service delivery. As physicians, we know that care delivery must be oriented around patients who have many diseases and unique life circumstances. It is our profession’s greatest challenge to collaborate with researchers and administrators to help do this with scale.
The authors thank Mary Akel for her assistance with manuscript submission.
1. Jencks SF, Williams MV, Coleman EA. Rehospitalization among patients in the Medicare Fee-for-Service Program. N Engl J Med. 2009;360(14):1418-1428. https://doi.org/10.1056/NEJMsa0803563.
2. Shah T, Churpek MM, Coca Perraillon M, Konetzka RT. Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion. Chest. 2015;147(5):1219-1226. https://doi.org/10.1378/chest.14-2181.
3. Press VG, Au DH, Bourbeau J, Dransfield MT, Gershon AS, Krishnan JA, et al. An American thoracic society workshop report: reducing COPD hospital readmissions. Ann Am Thorac Soc. 2019;16(2):161-170. https://doi.org/10.1513/AnnalsATS.201811-755WS.
4. Buhr R, Jackson N, Kominski G, Ong M, Mangione C. Factors associated with differential readmission diagnoses following acute exacerbations of COPD. J Hosp Med. 2020;15(4):252-253. https://doi.org/10.12788/jhm.3367.
5. Sharif R, Parekh TM, Pierson KS, Kuo Y-F, Sharma G. Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Annals ATS. 2014;11(5):685-694. https://doi.org/10.1513/AnnalsATS.201310-358OC.
6. Glaser JB, El-Haddad H. Exploring novel Medicare readmission risk variables in chronic obstructive pulmonary disease patients at high risk of readmission within 30 days of hospital discharge. Ann Am Thorac Soc. 2015;12(9):1288-1293. https://doi.org/10.1513/AnnalsATS.201504-228OC.
7. Sorace J, Wong HH, Worrall C, Kelman J, Saneinejad S, MaCurdy T. The complexity of disease combinations in the Medicare population. Popul Health Manag. 2011;14(4):161-166. https://doi.org/10.1089/pop.2010.0044
8. Wadhera RK, Joynt Maddox KE, Wasfy JH, Haneuse S, Shen C, Yeh RW. Association of the hospital readmissions reduction program with mortality among medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA. 2018;320(24):2542-2552. https://doi.org/10.1001/jama.2018.19232.
Many provisions of the Affordable Care Act (ACA) have served to support the hospitalized patient. The expansion of Medicaid and the creation of state and federal insurance exchanges for the individual insurance market both significantly lessened the financial burden of hospital care for millions of Americans. Other aspects have proven more controversial, as many of the ACA’s health policy interventions linked to cost and quality in new ways, implementing untested concepts derived from healthcare services research on a national scale.
The Hospital Readmissions Reduction Program (HRRP) was no exception. Based on early research examining readmissions,1 the ACA included a mandate for the Centers for Medicare and Medicaid Services (CMS) to establish the HRRP. Beginning in Fiscal Year 2013, the HRRP reduced payments for excessive, 30-day, risk-standardized readmissions covering six conditions and procedures. As the third leading cause of 30-day readmissions, chronic obstructive pulmonary disease (COPD) was included in the list of designated HRRP conditions.
This inclusion of COPD in HRRP was not without controversy; analysis of Medicare data from before the ACA’s implementation demonstrated that only half of all readmissions for acute exacerbations of COPD were respiratory-related and only a third were directly related to COPD.2 Unsurprisingly, the high proportion of readmissions due to non-COPD-related causes is considered to be one of the leading factors for the failure of COPD readmission reduction programs to find significant reductions in readmissions.3 In this month’s issue of the Journal of Hospital Medicine, Buhr and colleagues explore differential readmission diagnoses following acute exacerbations of COPD using a validated, national, all-payer database.4
Like many analyses of payer datasets, this study has several limitations. First, although a large area of the US was included, the data did not include all US states. Further, as the study used multiple cross-sectional data using pooling techniques, it was not truly a longitudinal study. It was additionally limited to 10 months out of the calendar year, missing December and January, which have a high seasonal prevalence of viral respiratory illness. Finally, due to the nature of the data, COPD diagnoses were identified through administrative data known to be highly unreliable for fully capturing admissions for acute exacerbation of COPD.
Despite these limitations, the analysis by Buhr and colleagues provides additional value. They found an overall readmission rate of 17%, with just under half (7.69%) due to recurrent COPD. Patients with COPD-related readmissions were younger, had a higher proportion with Medicaid as the payer, were more frequently discharged home without services, had a shorter length of stay, and had fewer comorbidities.
Most critically, Buhr and colleagues—with a multipayer database—confirmed what researchers found in uni-payer5 and site-specific6 datasets: over half of readmissions are due to diagnoses other than COPD or respiratory-related causes. Patients readmitted due to other, unrelated diagnoses had a higher mean Elixhauser Comorbidity Index score along with higher rates of congestive heart failure and renal failure. To the practicing hospitalist, this finding supports what our internal clinical voice tells us: sicker patients are readmitted more often and more frequently with conditions unrelated to their index admission diagnosis.
The reaffirmation of the finding that the majority of readmissions are due to nonrespiratory-related causes suggests that perhaps we have a different problem than physicians and policymakers originally thought when adding COPD to the HRRP. Many COPD patients suffer from a polychronic disease, requiring a more holistic approach rather than a traditional, disease-driven, siloed approach focused solely on improving COPD-related care. It may also be true that for other subpopulations of patients with COPD, additional in-hospital and transition of care interventions are required to address patients’ multimorbidity and social determinants of health.
As physicians on the front lines of the readmitted patient, hospitalists are uniquely situated to see the challenges of populations with increasing disease complexity and disease combinations.7 The HRRP policy remains controversial. This is due in large part to recent work suggesting that while the HRRP may have helped reduce readmissions, its implementation may have driven the unintended consequence of increased mortality.8 Thus, our profession faces an existential challenge to traditional care delivery models targeting diseases. What has not been well parsed by the hospital industry or policymakers is what to do about it.
Readmission of the multimorbid patient, coupled with the challenges of the HRRP, focuses our attention on the need to transition care delivery to a model that is better suited to our patients’ needs: mass-customized, mass-produced service delivery. As physicians, we know that care delivery must be oriented around patients who have many diseases and unique life circumstances. It is our profession’s greatest challenge to collaborate with researchers and administrators to help do this with scale.
The authors thank Mary Akel for her assistance with manuscript submission.
Many provisions of the Affordable Care Act (ACA) have served to support the hospitalized patient. The expansion of Medicaid and the creation of state and federal insurance exchanges for the individual insurance market both significantly lessened the financial burden of hospital care for millions of Americans. Other aspects have proven more controversial, as many of the ACA’s health policy interventions linked to cost and quality in new ways, implementing untested concepts derived from healthcare services research on a national scale.
The Hospital Readmissions Reduction Program (HRRP) was no exception. Based on early research examining readmissions,1 the ACA included a mandate for the Centers for Medicare and Medicaid Services (CMS) to establish the HRRP. Beginning in Fiscal Year 2013, the HRRP reduced payments for excessive, 30-day, risk-standardized readmissions covering six conditions and procedures. As the third leading cause of 30-day readmissions, chronic obstructive pulmonary disease (COPD) was included in the list of designated HRRP conditions.
This inclusion of COPD in HRRP was not without controversy; analysis of Medicare data from before the ACA’s implementation demonstrated that only half of all readmissions for acute exacerbations of COPD were respiratory-related and only a third were directly related to COPD.2 Unsurprisingly, the high proportion of readmissions due to non-COPD-related causes is considered to be one of the leading factors for the failure of COPD readmission reduction programs to find significant reductions in readmissions.3 In this month’s issue of the Journal of Hospital Medicine, Buhr and colleagues explore differential readmission diagnoses following acute exacerbations of COPD using a validated, national, all-payer database.4
Like many analyses of payer datasets, this study has several limitations. First, although a large area of the US was included, the data did not include all US states. Further, as the study used multiple cross-sectional data using pooling techniques, it was not truly a longitudinal study. It was additionally limited to 10 months out of the calendar year, missing December and January, which have a high seasonal prevalence of viral respiratory illness. Finally, due to the nature of the data, COPD diagnoses were identified through administrative data known to be highly unreliable for fully capturing admissions for acute exacerbation of COPD.
Despite these limitations, the analysis by Buhr and colleagues provides additional value. They found an overall readmission rate of 17%, with just under half (7.69%) due to recurrent COPD. Patients with COPD-related readmissions were younger, had a higher proportion with Medicaid as the payer, were more frequently discharged home without services, had a shorter length of stay, and had fewer comorbidities.
Most critically, Buhr and colleagues—with a multipayer database—confirmed what researchers found in uni-payer5 and site-specific6 datasets: over half of readmissions are due to diagnoses other than COPD or respiratory-related causes. Patients readmitted due to other, unrelated diagnoses had a higher mean Elixhauser Comorbidity Index score along with higher rates of congestive heart failure and renal failure. To the practicing hospitalist, this finding supports what our internal clinical voice tells us: sicker patients are readmitted more often and more frequently with conditions unrelated to their index admission diagnosis.
The reaffirmation of the finding that the majority of readmissions are due to nonrespiratory-related causes suggests that perhaps we have a different problem than physicians and policymakers originally thought when adding COPD to the HRRP. Many COPD patients suffer from a polychronic disease, requiring a more holistic approach rather than a traditional, disease-driven, siloed approach focused solely on improving COPD-related care. It may also be true that for other subpopulations of patients with COPD, additional in-hospital and transition of care interventions are required to address patients’ multimorbidity and social determinants of health.
As physicians on the front lines of the readmitted patient, hospitalists are uniquely situated to see the challenges of populations with increasing disease complexity and disease combinations.7 The HRRP policy remains controversial. This is due in large part to recent work suggesting that while the HRRP may have helped reduce readmissions, its implementation may have driven the unintended consequence of increased mortality.8 Thus, our profession faces an existential challenge to traditional care delivery models targeting diseases. What has not been well parsed by the hospital industry or policymakers is what to do about it.
Readmission of the multimorbid patient, coupled with the challenges of the HRRP, focuses our attention on the need to transition care delivery to a model that is better suited to our patients’ needs: mass-customized, mass-produced service delivery. As physicians, we know that care delivery must be oriented around patients who have many diseases and unique life circumstances. It is our profession’s greatest challenge to collaborate with researchers and administrators to help do this with scale.
The authors thank Mary Akel for her assistance with manuscript submission.
1. Jencks SF, Williams MV, Coleman EA. Rehospitalization among patients in the Medicare Fee-for-Service Program. N Engl J Med. 2009;360(14):1418-1428. https://doi.org/10.1056/NEJMsa0803563.
2. Shah T, Churpek MM, Coca Perraillon M, Konetzka RT. Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion. Chest. 2015;147(5):1219-1226. https://doi.org/10.1378/chest.14-2181.
3. Press VG, Au DH, Bourbeau J, Dransfield MT, Gershon AS, Krishnan JA, et al. An American thoracic society workshop report: reducing COPD hospital readmissions. Ann Am Thorac Soc. 2019;16(2):161-170. https://doi.org/10.1513/AnnalsATS.201811-755WS.
4. Buhr R, Jackson N, Kominski G, Ong M, Mangione C. Factors associated with differential readmission diagnoses following acute exacerbations of COPD. J Hosp Med. 2020;15(4):252-253. https://doi.org/10.12788/jhm.3367.
5. Sharif R, Parekh TM, Pierson KS, Kuo Y-F, Sharma G. Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Annals ATS. 2014;11(5):685-694. https://doi.org/10.1513/AnnalsATS.201310-358OC.
6. Glaser JB, El-Haddad H. Exploring novel Medicare readmission risk variables in chronic obstructive pulmonary disease patients at high risk of readmission within 30 days of hospital discharge. Ann Am Thorac Soc. 2015;12(9):1288-1293. https://doi.org/10.1513/AnnalsATS.201504-228OC.
7. Sorace J, Wong HH, Worrall C, Kelman J, Saneinejad S, MaCurdy T. The complexity of disease combinations in the Medicare population. Popul Health Manag. 2011;14(4):161-166. https://doi.org/10.1089/pop.2010.0044
8. Wadhera RK, Joynt Maddox KE, Wasfy JH, Haneuse S, Shen C, Yeh RW. Association of the hospital readmissions reduction program with mortality among medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA. 2018;320(24):2542-2552. https://doi.org/10.1001/jama.2018.19232.
1. Jencks SF, Williams MV, Coleman EA. Rehospitalization among patients in the Medicare Fee-for-Service Program. N Engl J Med. 2009;360(14):1418-1428. https://doi.org/10.1056/NEJMsa0803563.
2. Shah T, Churpek MM, Coca Perraillon M, Konetzka RT. Understanding why patients with COPD get readmitted: a large national study to delineate the Medicare population for the readmissions penalty expansion. Chest. 2015;147(5):1219-1226. https://doi.org/10.1378/chest.14-2181.
3. Press VG, Au DH, Bourbeau J, Dransfield MT, Gershon AS, Krishnan JA, et al. An American thoracic society workshop report: reducing COPD hospital readmissions. Ann Am Thorac Soc. 2019;16(2):161-170. https://doi.org/10.1513/AnnalsATS.201811-755WS.
4. Buhr R, Jackson N, Kominski G, Ong M, Mangione C. Factors associated with differential readmission diagnoses following acute exacerbations of COPD. J Hosp Med. 2020;15(4):252-253. https://doi.org/10.12788/jhm.3367.
5. Sharif R, Parekh TM, Pierson KS, Kuo Y-F, Sharma G. Predictors of early readmission among patients 40 to 64 years of age hospitalized for chronic obstructive pulmonary disease. Annals ATS. 2014;11(5):685-694. https://doi.org/10.1513/AnnalsATS.201310-358OC.
6. Glaser JB, El-Haddad H. Exploring novel Medicare readmission risk variables in chronic obstructive pulmonary disease patients at high risk of readmission within 30 days of hospital discharge. Ann Am Thorac Soc. 2015;12(9):1288-1293. https://doi.org/10.1513/AnnalsATS.201504-228OC.
7. Sorace J, Wong HH, Worrall C, Kelman J, Saneinejad S, MaCurdy T. The complexity of disease combinations in the Medicare population. Popul Health Manag. 2011;14(4):161-166. https://doi.org/10.1089/pop.2010.0044
8. Wadhera RK, Joynt Maddox KE, Wasfy JH, Haneuse S, Shen C, Yeh RW. Association of the hospital readmissions reduction program with mortality among medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA. 2018;320(24):2542-2552. https://doi.org/10.1001/jama.2018.19232.
© 2020 Society of Hospital Medicine
Critical Errors in Inhaler Technique among Children Hospitalized with Asthma
Many studies have shown that improved control can be achieved for most children with asthma if inhaled medications are taken correctly and adequately.1-3 Drug delivery studies have shown that bioavailability of medication with a pressurized metered-dose inhaler (MDI) improves from 34% to 83% with the addition of spacer devices. This difference is largely due to the decrease in oropharyngeal deposition,1,4,5 and therefore, the use of a spacer with proper technique has been recommended in all pediatric patients.1,6
Poor inhaler technique is common among children.1,7 Previous studies of children with asthma have evaluated inhaler technique, primarily in the outpatient and community settings, and reported variable rates of error (from 45% to >90%).8,9 No studies have evaluated children hospitalized with asthma. As these children represent a particularly high-risk group for morbidity and mortality,10,11 the objectives of this study were to assess errors in inhaler technique in hospitalized asthmatic children and identify risk factors for improper use.
METHODS
As part of a larger interventional study, we conducted a prospective cross-sectional study at a tertiary urban children’s hospital. We enrolled a convenience sample of children aged 2-16 years admitted to the inpatient ward with an asthma exacerbation Monday-Friday from 8 AM to 6 PM. Participants were required to have a diagnosis of asthma (an established diagnosis by their primary care provider or meets the National Heart, Lung, and Blood Institute [NHLBI] criteria1), have a consenting adult available, and speak English. Patients were excluded if they had a codiagnosis of an additional respiratory disease (ie, pneumonia), cardiac disease, or sickle cell anemia. The Institutional Review Board approved this study.
We asked caregivers, or children >10 years old if they independently use their inhaler, to demonstrate their typical home inhaler technique using a spacer with mask (SM), spacer with mouthpiece (SMP), or no spacer (per their usual home practice). Inhaler technique was scored using a previously validated asthma checklist (Table 1).12 Certain steps in the checklist were identified as critical: (Step 1) removing the cap, (Step 3) attaching to a spacer, (Step 7) taking six breaths (SM), and (Step 9) holding breath for five seconds (SMP). Caregivers only were also asked to complete questionnaires assessing their literacy (Brief Health Literacy Screen [BHLS]), confidence (Parent Asthma Management Self-Efficacy scale [PAMSE]), and any barriers to managing their child’s asthma (Barriers to Asthma Care). Demographic and medical history information was extracted from the medical chart.
Inhaler technique was evaluated in two ways by comparing: (1) patients who missed more than one critical step with those who missed zero critical steps and (2) patients with an asthma checklist score <7 versus ≥7. While there is a lot of variability in how inhaler technique has been measured in past studies, these two markers (75% of steps and critical errors) were the most common.8
We assessed a number of variables to evaluate their association with improper inhaler technique. For categorical variables, the association with each outcome was evaluated using relative risks (RRs). Bivariate P-values were calculated using chi-square or Fisher’s exact tests, as appropriate. Continuous variables were assessed for associations with each outcome using two-sample t-tests. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression analyses. Using a model entry criterion of P < .10 on univariate tests, variables were entered into a multivariable logistic regression model for each outcome. Full models with all eligible covariates and reduced models selected via a manual backward selection process were evaluated. Two-sided P-values <.05 were considered statistically significant.
RESULTS
Participants
From October 2016 to June 2017, 380 participants were assessed for participation; 215 were excluded for not having a parent available (59%), not speaking English (27%), not having an asthma diagnosis (ie, viral wheezing; 14%), and 52 (14%) declined to participate. Therefore, a total of 113 participants were enrolled, with demonstrations provided by 100 caregivers and 13 children. The mean age of the patients overall was 6.6 ± 3.4 years and over half (55%) of the participants had uncontrolled asthma (NHLBI criteria1).
Errors in Inhaler Technique
The mean asthma checklist score was 6.7 (maximum score of 10 for SM and 12 for SMP). A third (35%) scored <7 on the asthma checklist and 42% of participants missed at least one critical step. Overall, children who missed a critical step were significantly older (7.8 [6.7-8.9] vs 5.8 [5.1-6.5] years; P = .002). More participants missed a critical step with the SMP than the SM (75% [51%-90%] vs 36% [27%-46%]; P = .003), and this was the most prominent factor for missing a critical step in the adjusted regression analysis (OR 6.95 [1.71-28.23], P = .007). The most commonly missed steps were breathing normally for 30 seconds for SM, and for SMP, it was breathing out fully and breathing away from the spacer (Table 1). Twenty participants (18%) did not use a spacer device; these patients were older than those who did use a spacer (mean age 8.5 [6.7-10.4] vs 6.2 [5.6-6.9] years; P = .005); however, no other significant differences were identified.
Demographic, Medical History, and Socioeconomic Characteristics
Overall, race, ethnicity, and insurance status did not vary significantly based on asthma checklist score ≥7 or missing a critical step. Patients in the SM group who had received inpatient asthma education during a previous admission, had a history of pediatric intensive care unit (PICU) admission, and had been prescribed a daily controller were less likely to miss a critical step (Table 2). Parental education level varied, with 33% having a high school degree or less, but was not associated with asthma checklist score or missing critical steps. Parental BHLS and parental confidence (PAMSE) were not significantly associated with inhaler proficiency. However, transportation-related barriers were more common in patients with checklist scores <7 and more missed critical steps (OR 1.62 [1.06-2.46]; P = .02).
Nearly half of the participants in this study missed at least one critical step in inhaler use. In addition, 18% did not use a spacer when demonstrating their inhaler technique. Despite robust studies demonstrating how asthma education can improve both asthma skills and clinical outcomes,13 our study demonstrates that a large gap remains in proper inhaler technique among asthmatic patients presenting for inpatient care. Specifically, in the mouthpiece group, steps related to breathing technique were the most commonly missed. Our results also show that inhaler technique errors were most prominent in the adolescent population, possibly coinciding with the process of transitioning to a mouthpiece and more independence in medication administration. Adolescents may be a high-impact population on which to focus inpatient asthma education. Additionally, we found that a previous PICU admission and previous inpatient asthma education were associated with missing fewer critical steps in inhaler technique. This finding is consistent with those of another study that evaluated inhaler technique in the emergency department and found that previous hospitalization for asthma was inversely related to improper inhaler use (RR 0.55, 95% CI 0.36-0.84).14 This supports that when provided, inpatient education can increase inhaler administration skills.
Previous studies conducted in the outpatient setting have demonstrated variable rates of inhaler skill, from 0% to approximately 89% of children performing all steps of inhalation correctly.8 This wide range may be related to variations in the number and definition of critical steps between the different studies. In our study, we highlighted removing the cap, attaching a spacer, and adequate breathing technique as critical steps, because failure to complete them would significantly reduce lung deposition of medication. While past studies did evaluate both MDIs and discuss the devices, our study is the first to report difference in problems with technique between SM and SMP. As asthma educational interventions are developed and/or implemented, it is important to stress that different steps in inhaler technique are being missed in those using a mask versus mouthpiece.
The limitations of this study include that it was at a single center with a primarily urban and English-speaking population; however, this study population reflects the racial diversity of pediatric asthma patients. Further studies may explore the reproducibility of these findings at multiple centers and with non-English-speaking families. This study included younger patients than in some previous publications investigating asthma; however, all patients met the criteria for asthma diagnosis and this age range is reflective of patients presenting for inpatient asthma care. Furthermore, because of our daytime research hours, 59% of patients were excluded because a primary caregiver was not available. It is possible that these families have decreased access to inpatient asthma educators as well and may be another target group for future studies. Finally, a large proportion of parents had a college education or greater in our sample. However, there was no association within our analysis between parental education level and inhaler proficiency.
The findings from this study indicate that continued efforts are needed to establish that inhaler technique is adequate for all families regardless of their educational status or socioeconomic background, especially for adolescents and in the setting of poor asthma control. Furthermore, our findings support that inhaler technique education may be beneficial in the inpatient setting and that acute care settings can provide a valuable “teachable moment.”14,15
CONCLUSION
Errors in inhaler technique are prevalent in pediatric inpatients with asthma, primarily those using a mouthpiece device. Educational efforts in both inpatient and outpatient settings have the potential to improve drug delivery and therefore asthma control. Inpatient hospitalization may serve as a platform for further studies to investigate innovative educational interventions.
Acknowledgments
The authors thank Tina Carter for her assistance in the recruitment and data collection and Ashley Hull and Susannah Butters for training the study staff on the use of the asthma checklist.
Disclosures
Dr. Gupta receives research grant support from the National Institutes of Health and the United Healthcare Group. Dr. Gupta serves as a consultant for DBV Technology, Aimmune Therapeutics, Kaleo & BEFORE Brands. Dr. Gupta has received lecture fees/honorariums from the Allergy Asthma Network & the American College of Asthma, Allergy & Immunology. Dr. Press reports research support from the Chicago Center for Diabetes Translation Research Pilot and Feasibility Grant, the Bucksbaum Institute for Clinical Excellence Pilot Grant Program, the Academy of Distinguished Medical Educators, the Development of Novel Hospital-initiated Care Bundle in Adults Hospitalized for Acute Asthma: the 41st Multicenter Airway Research Collaboration (MARC-41) Study, UCM’s Innovation Grant Program, the University of Chicago-Chapin Hall Join Research Fund, the NIH/NHLBI Loan Repayment Program, 1 K23 HL118151 01, NIH NLBHI R03 (RFA-HL-18-025), the George and Carol Abramson Pilot Awards, the COPD Foundation Green Shoots Grant, the University of Chicago Women’s Board Grant, NIH NHLBI UG1 (RFA-HL-17-009), and the CTSA Pilot Award, outside the submitted work. These disclosures have been reported to Dr. Press’ institutional IRB board. Additionally, a management plan is on file that details how to address conflicts such as these which are sources of research support but do not directly support the work at hand. The remaining authors have no conflicts of interest relevant to the article to disclose.
Funding
This study was funded by internal grants from Ann and Robert H. Lurie Children’s Hospital of Chicago. Dr. Press was funded by a K23HL118151.
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2. Hekking PP, Wener RR, Amelink M, Zwinderman AH, Bouvy ML, Bel EH. The prevalence of severe refractory asthma. J Allergy Clin Immunol. 2015;135(4):896-902. doi: 10.1016/j.jaci.2014.08.042. PubMed
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8. Gillette C, Rockich-Winston N, Kuhn JA, Flesher S, Shepherd M. Inhaler technique in children with asthma: a systematic review. Acad Pediatr. 2016;16(7):605-615. doi: 10.1016/j.acap.2016.04.006. PubMed
9. Pappalardo AA, Karavolos K, Martin MA. What really happens in the home: the medication environment of urban, minority youth. J Allergy Clin Immunol Pract. 2017;5(3):764-770. doi: 10.1016/j.jaip.2016.09.046. PubMed
10. Crane J, Pearce N, Burgess C, Woodman K, Robson B, Beasley R. Markers of risk of asthma death or readmission in the 12 months following a hospital admission for asthma. Int J Epidemiol. 1992;21(4):737-744. doi: 10.1093/ije/21.4.737. PubMed
11. Turner MO, Noertjojo K, Vedal S, Bai T, Crump S, Fitzgerald JM. Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med. 1998;157(6 Pt 1):1804-1809. doi: 10.1164/ajrccm.157.6.9708092. PubMed
12. Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med. 2011;26(6):635-642. doi: 10.1007/s11606-010-1624-2. PubMed
13. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003;326(7402):1308-1309. doi: 10.1136/bmj.326.7402.1308. PubMed
14. Scarfone RJ, Capraro GA, Zorc JJ, Zhao H. Demonstrated use of metered-dose inhalers and peak flow meters by children and adolescents with acute asthma exacerbations. Arch Pediatr Adolesc Med. 2002;156(4):378-383. doi: 10.1001/archpedi.156.4.378. PubMed
15. Sockrider MM, Abramson S, Brooks E, et al. Delivering tailored asthma family education in a pediatric emergency department setting: a pilot study. Pediatrics. 2006;117(4 Pt 2):S135-144. doi: 10.1542/peds.2005-2000K. PubMed
Many studies have shown that improved control can be achieved for most children with asthma if inhaled medications are taken correctly and adequately.1-3 Drug delivery studies have shown that bioavailability of medication with a pressurized metered-dose inhaler (MDI) improves from 34% to 83% with the addition of spacer devices. This difference is largely due to the decrease in oropharyngeal deposition,1,4,5 and therefore, the use of a spacer with proper technique has been recommended in all pediatric patients.1,6
Poor inhaler technique is common among children.1,7 Previous studies of children with asthma have evaluated inhaler technique, primarily in the outpatient and community settings, and reported variable rates of error (from 45% to >90%).8,9 No studies have evaluated children hospitalized with asthma. As these children represent a particularly high-risk group for morbidity and mortality,10,11 the objectives of this study were to assess errors in inhaler technique in hospitalized asthmatic children and identify risk factors for improper use.
METHODS
As part of a larger interventional study, we conducted a prospective cross-sectional study at a tertiary urban children’s hospital. We enrolled a convenience sample of children aged 2-16 years admitted to the inpatient ward with an asthma exacerbation Monday-Friday from 8 AM to 6 PM. Participants were required to have a diagnosis of asthma (an established diagnosis by their primary care provider or meets the National Heart, Lung, and Blood Institute [NHLBI] criteria1), have a consenting adult available, and speak English. Patients were excluded if they had a codiagnosis of an additional respiratory disease (ie, pneumonia), cardiac disease, or sickle cell anemia. The Institutional Review Board approved this study.
We asked caregivers, or children >10 years old if they independently use their inhaler, to demonstrate their typical home inhaler technique using a spacer with mask (SM), spacer with mouthpiece (SMP), or no spacer (per their usual home practice). Inhaler technique was scored using a previously validated asthma checklist (Table 1).12 Certain steps in the checklist were identified as critical: (Step 1) removing the cap, (Step 3) attaching to a spacer, (Step 7) taking six breaths (SM), and (Step 9) holding breath for five seconds (SMP). Caregivers only were also asked to complete questionnaires assessing their literacy (Brief Health Literacy Screen [BHLS]), confidence (Parent Asthma Management Self-Efficacy scale [PAMSE]), and any barriers to managing their child’s asthma (Barriers to Asthma Care). Demographic and medical history information was extracted from the medical chart.
Inhaler technique was evaluated in two ways by comparing: (1) patients who missed more than one critical step with those who missed zero critical steps and (2) patients with an asthma checklist score <7 versus ≥7. While there is a lot of variability in how inhaler technique has been measured in past studies, these two markers (75% of steps and critical errors) were the most common.8
We assessed a number of variables to evaluate their association with improper inhaler technique. For categorical variables, the association with each outcome was evaluated using relative risks (RRs). Bivariate P-values were calculated using chi-square or Fisher’s exact tests, as appropriate. Continuous variables were assessed for associations with each outcome using two-sample t-tests. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression analyses. Using a model entry criterion of P < .10 on univariate tests, variables were entered into a multivariable logistic regression model for each outcome. Full models with all eligible covariates and reduced models selected via a manual backward selection process were evaluated. Two-sided P-values <.05 were considered statistically significant.
RESULTS
Participants
From October 2016 to June 2017, 380 participants were assessed for participation; 215 were excluded for not having a parent available (59%), not speaking English (27%), not having an asthma diagnosis (ie, viral wheezing; 14%), and 52 (14%) declined to participate. Therefore, a total of 113 participants were enrolled, with demonstrations provided by 100 caregivers and 13 children. The mean age of the patients overall was 6.6 ± 3.4 years and over half (55%) of the participants had uncontrolled asthma (NHLBI criteria1).
Errors in Inhaler Technique
The mean asthma checklist score was 6.7 (maximum score of 10 for SM and 12 for SMP). A third (35%) scored <7 on the asthma checklist and 42% of participants missed at least one critical step. Overall, children who missed a critical step were significantly older (7.8 [6.7-8.9] vs 5.8 [5.1-6.5] years; P = .002). More participants missed a critical step with the SMP than the SM (75% [51%-90%] vs 36% [27%-46%]; P = .003), and this was the most prominent factor for missing a critical step in the adjusted regression analysis (OR 6.95 [1.71-28.23], P = .007). The most commonly missed steps were breathing normally for 30 seconds for SM, and for SMP, it was breathing out fully and breathing away from the spacer (Table 1). Twenty participants (18%) did not use a spacer device; these patients were older than those who did use a spacer (mean age 8.5 [6.7-10.4] vs 6.2 [5.6-6.9] years; P = .005); however, no other significant differences were identified.
Demographic, Medical History, and Socioeconomic Characteristics
Overall, race, ethnicity, and insurance status did not vary significantly based on asthma checklist score ≥7 or missing a critical step. Patients in the SM group who had received inpatient asthma education during a previous admission, had a history of pediatric intensive care unit (PICU) admission, and had been prescribed a daily controller were less likely to miss a critical step (Table 2). Parental education level varied, with 33% having a high school degree or less, but was not associated with asthma checklist score or missing critical steps. Parental BHLS and parental confidence (PAMSE) were not significantly associated with inhaler proficiency. However, transportation-related barriers were more common in patients with checklist scores <7 and more missed critical steps (OR 1.62 [1.06-2.46]; P = .02).
Nearly half of the participants in this study missed at least one critical step in inhaler use. In addition, 18% did not use a spacer when demonstrating their inhaler technique. Despite robust studies demonstrating how asthma education can improve both asthma skills and clinical outcomes,13 our study demonstrates that a large gap remains in proper inhaler technique among asthmatic patients presenting for inpatient care. Specifically, in the mouthpiece group, steps related to breathing technique were the most commonly missed. Our results also show that inhaler technique errors were most prominent in the adolescent population, possibly coinciding with the process of transitioning to a mouthpiece and more independence in medication administration. Adolescents may be a high-impact population on which to focus inpatient asthma education. Additionally, we found that a previous PICU admission and previous inpatient asthma education were associated with missing fewer critical steps in inhaler technique. This finding is consistent with those of another study that evaluated inhaler technique in the emergency department and found that previous hospitalization for asthma was inversely related to improper inhaler use (RR 0.55, 95% CI 0.36-0.84).14 This supports that when provided, inpatient education can increase inhaler administration skills.
Previous studies conducted in the outpatient setting have demonstrated variable rates of inhaler skill, from 0% to approximately 89% of children performing all steps of inhalation correctly.8 This wide range may be related to variations in the number and definition of critical steps between the different studies. In our study, we highlighted removing the cap, attaching a spacer, and adequate breathing technique as critical steps, because failure to complete them would significantly reduce lung deposition of medication. While past studies did evaluate both MDIs and discuss the devices, our study is the first to report difference in problems with technique between SM and SMP. As asthma educational interventions are developed and/or implemented, it is important to stress that different steps in inhaler technique are being missed in those using a mask versus mouthpiece.
The limitations of this study include that it was at a single center with a primarily urban and English-speaking population; however, this study population reflects the racial diversity of pediatric asthma patients. Further studies may explore the reproducibility of these findings at multiple centers and with non-English-speaking families. This study included younger patients than in some previous publications investigating asthma; however, all patients met the criteria for asthma diagnosis and this age range is reflective of patients presenting for inpatient asthma care. Furthermore, because of our daytime research hours, 59% of patients were excluded because a primary caregiver was not available. It is possible that these families have decreased access to inpatient asthma educators as well and may be another target group for future studies. Finally, a large proportion of parents had a college education or greater in our sample. However, there was no association within our analysis between parental education level and inhaler proficiency.
The findings from this study indicate that continued efforts are needed to establish that inhaler technique is adequate for all families regardless of their educational status or socioeconomic background, especially for adolescents and in the setting of poor asthma control. Furthermore, our findings support that inhaler technique education may be beneficial in the inpatient setting and that acute care settings can provide a valuable “teachable moment.”14,15
CONCLUSION
Errors in inhaler technique are prevalent in pediatric inpatients with asthma, primarily those using a mouthpiece device. Educational efforts in both inpatient and outpatient settings have the potential to improve drug delivery and therefore asthma control. Inpatient hospitalization may serve as a platform for further studies to investigate innovative educational interventions.
Acknowledgments
The authors thank Tina Carter for her assistance in the recruitment and data collection and Ashley Hull and Susannah Butters for training the study staff on the use of the asthma checklist.
Disclosures
Dr. Gupta receives research grant support from the National Institutes of Health and the United Healthcare Group. Dr. Gupta serves as a consultant for DBV Technology, Aimmune Therapeutics, Kaleo & BEFORE Brands. Dr. Gupta has received lecture fees/honorariums from the Allergy Asthma Network & the American College of Asthma, Allergy & Immunology. Dr. Press reports research support from the Chicago Center for Diabetes Translation Research Pilot and Feasibility Grant, the Bucksbaum Institute for Clinical Excellence Pilot Grant Program, the Academy of Distinguished Medical Educators, the Development of Novel Hospital-initiated Care Bundle in Adults Hospitalized for Acute Asthma: the 41st Multicenter Airway Research Collaboration (MARC-41) Study, UCM’s Innovation Grant Program, the University of Chicago-Chapin Hall Join Research Fund, the NIH/NHLBI Loan Repayment Program, 1 K23 HL118151 01, NIH NLBHI R03 (RFA-HL-18-025), the George and Carol Abramson Pilot Awards, the COPD Foundation Green Shoots Grant, the University of Chicago Women’s Board Grant, NIH NHLBI UG1 (RFA-HL-17-009), and the CTSA Pilot Award, outside the submitted work. These disclosures have been reported to Dr. Press’ institutional IRB board. Additionally, a management plan is on file that details how to address conflicts such as these which are sources of research support but do not directly support the work at hand. The remaining authors have no conflicts of interest relevant to the article to disclose.
Funding
This study was funded by internal grants from Ann and Robert H. Lurie Children’s Hospital of Chicago. Dr. Press was funded by a K23HL118151.
Many studies have shown that improved control can be achieved for most children with asthma if inhaled medications are taken correctly and adequately.1-3 Drug delivery studies have shown that bioavailability of medication with a pressurized metered-dose inhaler (MDI) improves from 34% to 83% with the addition of spacer devices. This difference is largely due to the decrease in oropharyngeal deposition,1,4,5 and therefore, the use of a spacer with proper technique has been recommended in all pediatric patients.1,6
Poor inhaler technique is common among children.1,7 Previous studies of children with asthma have evaluated inhaler technique, primarily in the outpatient and community settings, and reported variable rates of error (from 45% to >90%).8,9 No studies have evaluated children hospitalized with asthma. As these children represent a particularly high-risk group for morbidity and mortality,10,11 the objectives of this study were to assess errors in inhaler technique in hospitalized asthmatic children and identify risk factors for improper use.
METHODS
As part of a larger interventional study, we conducted a prospective cross-sectional study at a tertiary urban children’s hospital. We enrolled a convenience sample of children aged 2-16 years admitted to the inpatient ward with an asthma exacerbation Monday-Friday from 8 AM to 6 PM. Participants were required to have a diagnosis of asthma (an established diagnosis by their primary care provider or meets the National Heart, Lung, and Blood Institute [NHLBI] criteria1), have a consenting adult available, and speak English. Patients were excluded if they had a codiagnosis of an additional respiratory disease (ie, pneumonia), cardiac disease, or sickle cell anemia. The Institutional Review Board approved this study.
We asked caregivers, or children >10 years old if they independently use their inhaler, to demonstrate their typical home inhaler technique using a spacer with mask (SM), spacer with mouthpiece (SMP), or no spacer (per their usual home practice). Inhaler technique was scored using a previously validated asthma checklist (Table 1).12 Certain steps in the checklist were identified as critical: (Step 1) removing the cap, (Step 3) attaching to a spacer, (Step 7) taking six breaths (SM), and (Step 9) holding breath for five seconds (SMP). Caregivers only were also asked to complete questionnaires assessing their literacy (Brief Health Literacy Screen [BHLS]), confidence (Parent Asthma Management Self-Efficacy scale [PAMSE]), and any barriers to managing their child’s asthma (Barriers to Asthma Care). Demographic and medical history information was extracted from the medical chart.
Inhaler technique was evaluated in two ways by comparing: (1) patients who missed more than one critical step with those who missed zero critical steps and (2) patients with an asthma checklist score <7 versus ≥7. While there is a lot of variability in how inhaler technique has been measured in past studies, these two markers (75% of steps and critical errors) were the most common.8
We assessed a number of variables to evaluate their association with improper inhaler technique. For categorical variables, the association with each outcome was evaluated using relative risks (RRs). Bivariate P-values were calculated using chi-square or Fisher’s exact tests, as appropriate. Continuous variables were assessed for associations with each outcome using two-sample t-tests. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression analyses. Using a model entry criterion of P < .10 on univariate tests, variables were entered into a multivariable logistic regression model for each outcome. Full models with all eligible covariates and reduced models selected via a manual backward selection process were evaluated. Two-sided P-values <.05 were considered statistically significant.
RESULTS
Participants
From October 2016 to June 2017, 380 participants were assessed for participation; 215 were excluded for not having a parent available (59%), not speaking English (27%), not having an asthma diagnosis (ie, viral wheezing; 14%), and 52 (14%) declined to participate. Therefore, a total of 113 participants were enrolled, with demonstrations provided by 100 caregivers and 13 children. The mean age of the patients overall was 6.6 ± 3.4 years and over half (55%) of the participants had uncontrolled asthma (NHLBI criteria1).
Errors in Inhaler Technique
The mean asthma checklist score was 6.7 (maximum score of 10 for SM and 12 for SMP). A third (35%) scored <7 on the asthma checklist and 42% of participants missed at least one critical step. Overall, children who missed a critical step were significantly older (7.8 [6.7-8.9] vs 5.8 [5.1-6.5] years; P = .002). More participants missed a critical step with the SMP than the SM (75% [51%-90%] vs 36% [27%-46%]; P = .003), and this was the most prominent factor for missing a critical step in the adjusted regression analysis (OR 6.95 [1.71-28.23], P = .007). The most commonly missed steps were breathing normally for 30 seconds for SM, and for SMP, it was breathing out fully and breathing away from the spacer (Table 1). Twenty participants (18%) did not use a spacer device; these patients were older than those who did use a spacer (mean age 8.5 [6.7-10.4] vs 6.2 [5.6-6.9] years; P = .005); however, no other significant differences were identified.
Demographic, Medical History, and Socioeconomic Characteristics
Overall, race, ethnicity, and insurance status did not vary significantly based on asthma checklist score ≥7 or missing a critical step. Patients in the SM group who had received inpatient asthma education during a previous admission, had a history of pediatric intensive care unit (PICU) admission, and had been prescribed a daily controller were less likely to miss a critical step (Table 2). Parental education level varied, with 33% having a high school degree or less, but was not associated with asthma checklist score or missing critical steps. Parental BHLS and parental confidence (PAMSE) were not significantly associated with inhaler proficiency. However, transportation-related barriers were more common in patients with checklist scores <7 and more missed critical steps (OR 1.62 [1.06-2.46]; P = .02).
Nearly half of the participants in this study missed at least one critical step in inhaler use. In addition, 18% did not use a spacer when demonstrating their inhaler technique. Despite robust studies demonstrating how asthma education can improve both asthma skills and clinical outcomes,13 our study demonstrates that a large gap remains in proper inhaler technique among asthmatic patients presenting for inpatient care. Specifically, in the mouthpiece group, steps related to breathing technique were the most commonly missed. Our results also show that inhaler technique errors were most prominent in the adolescent population, possibly coinciding with the process of transitioning to a mouthpiece and more independence in medication administration. Adolescents may be a high-impact population on which to focus inpatient asthma education. Additionally, we found that a previous PICU admission and previous inpatient asthma education were associated with missing fewer critical steps in inhaler technique. This finding is consistent with those of another study that evaluated inhaler technique in the emergency department and found that previous hospitalization for asthma was inversely related to improper inhaler use (RR 0.55, 95% CI 0.36-0.84).14 This supports that when provided, inpatient education can increase inhaler administration skills.
Previous studies conducted in the outpatient setting have demonstrated variable rates of inhaler skill, from 0% to approximately 89% of children performing all steps of inhalation correctly.8 This wide range may be related to variations in the number and definition of critical steps between the different studies. In our study, we highlighted removing the cap, attaching a spacer, and adequate breathing technique as critical steps, because failure to complete them would significantly reduce lung deposition of medication. While past studies did evaluate both MDIs and discuss the devices, our study is the first to report difference in problems with technique between SM and SMP. As asthma educational interventions are developed and/or implemented, it is important to stress that different steps in inhaler technique are being missed in those using a mask versus mouthpiece.
The limitations of this study include that it was at a single center with a primarily urban and English-speaking population; however, this study population reflects the racial diversity of pediatric asthma patients. Further studies may explore the reproducibility of these findings at multiple centers and with non-English-speaking families. This study included younger patients than in some previous publications investigating asthma; however, all patients met the criteria for asthma diagnosis and this age range is reflective of patients presenting for inpatient asthma care. Furthermore, because of our daytime research hours, 59% of patients were excluded because a primary caregiver was not available. It is possible that these families have decreased access to inpatient asthma educators as well and may be another target group for future studies. Finally, a large proportion of parents had a college education or greater in our sample. However, there was no association within our analysis between parental education level and inhaler proficiency.
The findings from this study indicate that continued efforts are needed to establish that inhaler technique is adequate for all families regardless of their educational status or socioeconomic background, especially for adolescents and in the setting of poor asthma control. Furthermore, our findings support that inhaler technique education may be beneficial in the inpatient setting and that acute care settings can provide a valuable “teachable moment.”14,15
CONCLUSION
Errors in inhaler technique are prevalent in pediatric inpatients with asthma, primarily those using a mouthpiece device. Educational efforts in both inpatient and outpatient settings have the potential to improve drug delivery and therefore asthma control. Inpatient hospitalization may serve as a platform for further studies to investigate innovative educational interventions.
Acknowledgments
The authors thank Tina Carter for her assistance in the recruitment and data collection and Ashley Hull and Susannah Butters for training the study staff on the use of the asthma checklist.
Disclosures
Dr. Gupta receives research grant support from the National Institutes of Health and the United Healthcare Group. Dr. Gupta serves as a consultant for DBV Technology, Aimmune Therapeutics, Kaleo & BEFORE Brands. Dr. Gupta has received lecture fees/honorariums from the Allergy Asthma Network & the American College of Asthma, Allergy & Immunology. Dr. Press reports research support from the Chicago Center for Diabetes Translation Research Pilot and Feasibility Grant, the Bucksbaum Institute for Clinical Excellence Pilot Grant Program, the Academy of Distinguished Medical Educators, the Development of Novel Hospital-initiated Care Bundle in Adults Hospitalized for Acute Asthma: the 41st Multicenter Airway Research Collaboration (MARC-41) Study, UCM’s Innovation Grant Program, the University of Chicago-Chapin Hall Join Research Fund, the NIH/NHLBI Loan Repayment Program, 1 K23 HL118151 01, NIH NLBHI R03 (RFA-HL-18-025), the George and Carol Abramson Pilot Awards, the COPD Foundation Green Shoots Grant, the University of Chicago Women’s Board Grant, NIH NHLBI UG1 (RFA-HL-17-009), and the CTSA Pilot Award, outside the submitted work. These disclosures have been reported to Dr. Press’ institutional IRB board. Additionally, a management plan is on file that details how to address conflicts such as these which are sources of research support but do not directly support the work at hand. The remaining authors have no conflicts of interest relevant to the article to disclose.
Funding
This study was funded by internal grants from Ann and Robert H. Lurie Children’s Hospital of Chicago. Dr. Press was funded by a K23HL118151.
1. Expert Panel Report 3: guidelines for the diagnosis and management of asthma: full report. Washington, DC: US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute; 2007. PubMed
2. Hekking PP, Wener RR, Amelink M, Zwinderman AH, Bouvy ML, Bel EH. The prevalence of severe refractory asthma. J Allergy Clin Immunol. 2015;135(4):896-902. doi: 10.1016/j.jaci.2014.08.042. PubMed
3. Peters SP, Ferguson G, Deniz Y, Reisner C. Uncontrolled asthma: a review of the prevalence, disease burden and options for treatment. Respir Med. 2006;100(7):1139-1151. doi: 10.1016/j.rmed.2006.03.031. PubMed
4. Dickens GR, Wermeling DP, Matheny CJ, et al. Pharmacokinetics of flunisolide administered via metered dose inhaler with and without a spacer device and following oral administration. Ann Allergy Asthma Immunol. 2000;84(5):528-532. doi: 10.1016/S1081-1206(10)62517-3. PubMed
5. Nikander K, Nicholls C, Denyer J, Pritchard J. The evolution of spacers and valved holding chambers. J Aerosol Med Pulm Drug Deliv. 2014;27(1):S4-S23. doi: 10.1089/jamp.2013.1076. PubMed
6. Rubin BK, Fink JB. The delivery of inhaled medication to the young child. Pediatr Clin North Am. 2003;50(3):717-731. doi:10.1016/S0031-3955(03)00049-X. PubMed
7. Roland NJ, Bhalla RK, Earis J. The local side effects of inhaled corticosteroids: current understanding and review of the literature. Chest. 2004;126(1):213-219. doi: 10.1378/chest.126.1.213. PubMed
8. Gillette C, Rockich-Winston N, Kuhn JA, Flesher S, Shepherd M. Inhaler technique in children with asthma: a systematic review. Acad Pediatr. 2016;16(7):605-615. doi: 10.1016/j.acap.2016.04.006. PubMed
9. Pappalardo AA, Karavolos K, Martin MA. What really happens in the home: the medication environment of urban, minority youth. J Allergy Clin Immunol Pract. 2017;5(3):764-770. doi: 10.1016/j.jaip.2016.09.046. PubMed
10. Crane J, Pearce N, Burgess C, Woodman K, Robson B, Beasley R. Markers of risk of asthma death or readmission in the 12 months following a hospital admission for asthma. Int J Epidemiol. 1992;21(4):737-744. doi: 10.1093/ije/21.4.737. PubMed
11. Turner MO, Noertjojo K, Vedal S, Bai T, Crump S, Fitzgerald JM. Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med. 1998;157(6 Pt 1):1804-1809. doi: 10.1164/ajrccm.157.6.9708092. PubMed
12. Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med. 2011;26(6):635-642. doi: 10.1007/s11606-010-1624-2. PubMed
13. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003;326(7402):1308-1309. doi: 10.1136/bmj.326.7402.1308. PubMed
14. Scarfone RJ, Capraro GA, Zorc JJ, Zhao H. Demonstrated use of metered-dose inhalers and peak flow meters by children and adolescents with acute asthma exacerbations. Arch Pediatr Adolesc Med. 2002;156(4):378-383. doi: 10.1001/archpedi.156.4.378. PubMed
15. Sockrider MM, Abramson S, Brooks E, et al. Delivering tailored asthma family education in a pediatric emergency department setting: a pilot study. Pediatrics. 2006;117(4 Pt 2):S135-144. doi: 10.1542/peds.2005-2000K. PubMed
1. Expert Panel Report 3: guidelines for the diagnosis and management of asthma: full report. Washington, DC: US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute; 2007. PubMed
2. Hekking PP, Wener RR, Amelink M, Zwinderman AH, Bouvy ML, Bel EH. The prevalence of severe refractory asthma. J Allergy Clin Immunol. 2015;135(4):896-902. doi: 10.1016/j.jaci.2014.08.042. PubMed
3. Peters SP, Ferguson G, Deniz Y, Reisner C. Uncontrolled asthma: a review of the prevalence, disease burden and options for treatment. Respir Med. 2006;100(7):1139-1151. doi: 10.1016/j.rmed.2006.03.031. PubMed
4. Dickens GR, Wermeling DP, Matheny CJ, et al. Pharmacokinetics of flunisolide administered via metered dose inhaler with and without a spacer device and following oral administration. Ann Allergy Asthma Immunol. 2000;84(5):528-532. doi: 10.1016/S1081-1206(10)62517-3. PubMed
5. Nikander K, Nicholls C, Denyer J, Pritchard J. The evolution of spacers and valved holding chambers. J Aerosol Med Pulm Drug Deliv. 2014;27(1):S4-S23. doi: 10.1089/jamp.2013.1076. PubMed
6. Rubin BK, Fink JB. The delivery of inhaled medication to the young child. Pediatr Clin North Am. 2003;50(3):717-731. doi:10.1016/S0031-3955(03)00049-X. PubMed
7. Roland NJ, Bhalla RK, Earis J. The local side effects of inhaled corticosteroids: current understanding and review of the literature. Chest. 2004;126(1):213-219. doi: 10.1378/chest.126.1.213. PubMed
8. Gillette C, Rockich-Winston N, Kuhn JA, Flesher S, Shepherd M. Inhaler technique in children with asthma: a systematic review. Acad Pediatr. 2016;16(7):605-615. doi: 10.1016/j.acap.2016.04.006. PubMed
9. Pappalardo AA, Karavolos K, Martin MA. What really happens in the home: the medication environment of urban, minority youth. J Allergy Clin Immunol Pract. 2017;5(3):764-770. doi: 10.1016/j.jaip.2016.09.046. PubMed
10. Crane J, Pearce N, Burgess C, Woodman K, Robson B, Beasley R. Markers of risk of asthma death or readmission in the 12 months following a hospital admission for asthma. Int J Epidemiol. 1992;21(4):737-744. doi: 10.1093/ije/21.4.737. PubMed
11. Turner MO, Noertjojo K, Vedal S, Bai T, Crump S, Fitzgerald JM. Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med. 1998;157(6 Pt 1):1804-1809. doi: 10.1164/ajrccm.157.6.9708092. PubMed
12. Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med. 2011;26(6):635-642. doi: 10.1007/s11606-010-1624-2. PubMed
13. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003;326(7402):1308-1309. doi: 10.1136/bmj.326.7402.1308. PubMed
14. Scarfone RJ, Capraro GA, Zorc JJ, Zhao H. Demonstrated use of metered-dose inhalers and peak flow meters by children and adolescents with acute asthma exacerbations. Arch Pediatr Adolesc Med. 2002;156(4):378-383. doi: 10.1001/archpedi.156.4.378. PubMed
15. Sockrider MM, Abramson S, Brooks E, et al. Delivering tailored asthma family education in a pediatric emergency department setting: a pilot study. Pediatrics. 2006;117(4 Pt 2):S135-144. doi: 10.1542/peds.2005-2000K. PubMed
© 2019 Society of Hospital Medicine