Inpatient Quality Improvement Interventions for Asthma: A Meta-analysis

Abstract

CONTEXT: Despite the availability of evidence-based guidelines for the management of pediatric asthma, health care utilization remains high. OBJECTIVE: Systematically review the inpatient literature on asthma quality improvement (QI) and synthesize impact on subsequent health care utilization. DATA SOURCES: Medline and Cumulative Index to Nursing and Allied Health Literature (January 1, 1991–November 16, 2016) and bibliographies of retrieved articles. STUDY SELECTION: Interventional studies in English of inpatient-initiated asthma QI work. DATA EXTRACTION: Studies were categorized by intervention type and outcome. Random-effects models were used to generate pooled risk ratios for health care utilization outcomes after inpatient QI interventions. RESULTS: Thirty articles met inclusion criteria and 12 provided data on health care reutilization outcomes. Risk ratios for emergency department revisits were: 0.97 (95% confidence interval [CI]: 0.06–14.47) <30 days, 1.70 (95% CI: 0.67–4.29) for 30 days to 6 months, and 1.22 (95% CI: 0.52–2.85) for 6 months to 1 year. Risk ratios for readmissions were: 2.02 (95% CI: 0.73–5.61) for <30 days, 1.68 (95% CI: 0.88–3.19) for 30 days to 6 months, and 1.27 (95% CI 0.85–1.90) for 6 months to 1 year. Subanalysis of multimodal interventions suggested lower readmission rates (risk ratio: 1.49 [95% CI: 1.17–1.89] over a period of 30 days to 1 year after the index admission). Subanalysis of education and discharge planning interventions did not show effect. LIMITATIONS: Linkages between intervention and outcome are complicated by the multimodal approach to QI in most studies. CONCLUSIONS: We did not identify any inpatient strategies impacting health care reutilization within 30 days of index hospitalization. Multimodal interventions demonstrated impact over the longer interval.