Improving Pediatric Asthma Care andOutcomes Across Multiple HospitalsFlory Nkoy, MD, MS, MPHa, Bernhard Fassl, MDa, Bryan Stone, MD, MSa, Derek A. Uchida, MDa, Joseph Johnson, MDb,Carolyn Reynolds, MS, APRNb, Karen Valentine, MStatb, Karmella Koopmeiners, RN, MSb, Eun Hea Kim, BAa, Lucy Savitz, PhDb,Christopher G. Maloney, MD, PhDa

abstract BACKGROUND AND OBJECTIVES: Gaps exist in inpatient asthma care. Our aims were toassess the impact of an evidence-based care process model (EB-CPM) 5 yearsafter implementation at Primary Children’s Hospital (PCH), a tertiary carefacility, and after its dissemination to 7 community hospitals.

METHODS: Participants included asthmatics 2 to 17 years admitted at 8 hospitalsbetween 2003 and 2013. The EB-CPM was implemented at PCH betweenJanuary 2008 and March 2009, then disseminated to 7 community hospitalsbetween January and June 2011. We measured compliance using a compositescore (CS) for 8 quality measures. Outcomes were compared betweenpreimplementation and postimplementation periods. Confounding wasaddressed through multivariable regression analyses.

RESULTS: At PCH, the CS increased and remained at .90% for 5 years afterimplementation. We observed sustained reductions in asthma readmissions(P = .026) and length of stay (P , .001), a trend toward reduced costs(P = .094), and no change in hospital resource use, ICU transfers, or deaths.The CS also increased at the 7 community hospitals, reaching 80% to 90% andpersisting .2 years after dissemination, with a slight but not significantreadmission reduction (P = .119), a significant reduction in length of stay(P , .001) and cost (P = .053), a slight increase in hospital resource use(P = .032), and no change in ICU transfers or deaths.

CONCLUSIONS: Our intervention resulted in sustained, long-term improvement inasthma care and outcomes at the tertiary care hospital and successfuldissemination to community hospitals.

Asthma is the most common reason forpreventable emergency department(ED) and hospital admissions amongchildren in the United States.1–3 In2009, .679 000 children with asthmawere admitted to the ED or hospital.1

Readmission rates of children to the EDor hospital are high and are associatedwith substantial health care costs.2–4

Despite a major burden, significantgaps exist between the evidence of bestasthma care practices and the actualcare for children hospitalized withasthma.5–8 Multiple qualityimprovement (QI) efforts to improveinpatient asthma care for children have

been reported, but a positive impact onasthma outcomes is often notdemonstrated.3,9–18 No data existabout the sustainability or long-termimpact of QI interventions.Furthermore, most of the successfulpediatric inpatient asthmainterventions are implemented ata tertiary care pediatric centers, withlittle information available aboutdissemination to communityhospitals.19–23

We previously reported suboptimalasthma care quality at PrimaryChildren’s Hospital (PCH),8 a tertiarycare children’s hospital, and

aDepartment of Pediatrics, University of Utah, Salt Lake City,Utah; and bIntermountain Healthcare, Salt Lake City, Utah

Dr Nkoy conceptualized and designed the study,drafted the initial manuscript, and oversaw theanalysis; Drs Fassl, Stone, Uchida, Johnson, Savitz,and Maloney, Ms Reynolds, and Ms Koopmeinersparticipated in the concept and design,interpretation of data, and review of the manuscript;Ms Valentine coordinated and supervised datacollection, participated in data analysis, andcritically reviewed the manuscript; Ms Kimcoordinated and supervised data collection andcritically reviewed the manuscript; and all authorsapproved the final manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2015-0285

DOI: 10.1542/peds.2015-0285

Accepted for publication Jun 11, 2015

Address correspondence to Flory L. Nkoy, MD, MS,MPH, Primary Children’s Medical Center, Division ofPediatric Inpatient Medicine, University of UtahSchool of Medicine, 100 North Medical Drive, SaltLake City, UT 84113. E-mail: flory.nkoy@hsc.utah.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,1098-4275).

Copyright © 2015 by the American Academy ofPediatrics

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a significant improvement in qualityof care with reduction in asthmareadmissions 2 years afterimplementation of an evidence-basedasthma care process model(EB-CPM).21

Because of suboptimal baselineasthma care quality findings atcommunity hospitals and the desireto improve care throughout theregion, the specific aims of this studywere twofold: to evaluate the 5-year(or long-term) impact after EB-CPMimplementation at PCH and todetermine the impact ofdisseminating the EB-CPM to7 community hospitals. Specifically,we sought to assess changes frombaseline in provider compliance withevidence-based (EB) asthma inpatientquality measures and asthmahospitalization outcomes. Ourprimary outcome was 6-month ED orhospital asthma readmission,consistent with our previous work,21

and the current aim to assess long-term EB-CPM impact at PCH.Secondary outcomes were length ofstay (LOS), costs, hospital resourceuse, ICU transfer after inpatientadmission, and death.

METHODS

Setting

Our study included 8 IntermountainHealthcare hospitals. IntermountainHealthcare is a regional, not-for-profitintegrated health care deliverysystem, with 22 hospitals and160 clinics and urgent care facilitieslocated in Utah and southeasternIdaho,24 providing health care to∼1 680 000 patients. IntermountainHealthcare serves ∼60% of Utah’s 2.8million residents and 85% of Utah’schildren.25 Participating hospitalsinclude a 289-bed freestandingtertiary care children’s hospital (PCH)located in a major metropolitan area,staffed by pediatric hospitalists andsubspecialists, and both urban andrural general community hospitalswith pediatric wards, staffed by

general pediatricians and familyphysicians with limited pediatricresources.

PCH is affiliated with the Departmentof Pediatrics at the University of Utahand serves as a tertiary care pediatricreferral hospital for Utah and4 surrounding states (Wyoming,Nevada, Idaho, and Montana). The7 Utah community hospitals wereAmerican Fork Community Hospitalin American Fork, Dixie RegionalHospital in St George, LoganCommunity Hospital in Logan, McKayDee Hospital in Ogden, RivertonCommunity Hospital in Riverton, UtahValley Regional Medical Center inProvo, and Valley View Hospital inCedar City. Overall, the 8 hospitalsprovide care to ∼700 asthmaticchildren each year and serve bothurban (PCH, Riverton, McKay Dee,and Utah Valley) and rural (AmericanFork, Dixie, Valley View, and Logan)populations. The IntermountainHealthcare privacy and University ofUtah institutional review boardsapproved the study.

Planning the Intervention

EB-CPM implementation at PCH wasdescribed previously.21 Wedisseminated the EB-CPM to7 community hospitals by using theReplicating Effective Programsframework.26 We securedIntermountain Healthcare leadershipsupport, which led to prioritization ofour project as one of theorganizational clinical goals,identified local hospital physicianchampions, and assembleda multidisciplinary implementationteam with representatives from eachhospital, including physicianchampions; nursing, respiratorytherapy, and pharmacist leaders;hospital administrators; and QI staff.We obtained baseline compliancedata for each hospital, which showedsuboptimal asthma care, and sharedthese data with hospital clinical andadministrative leaders. We securedlocal administrative leadershipsupport, ensured buy-in of local

clinical staff (physicians, nurses,respiratory therapists, andpharmacists) through education andtraining, and adapted the PCHtraining manual and decision supporttools to fit local needs to facilitateEB-CPM integration into workflow.

The Intervention (Asthma EB-CPM)

Asthma EB-CPM Description

The EB-CPM was designed tostandardize asthma care and supporthospital compliance with EB asthmaquality measures.8 The EB-CPMincluded decision support tools(admission and discharge ordersets), with the followingcomponents: a standardizedassessment of both acute andchronic asthma severity and control,recommendations for acute care andchronic asthma control, algorithmsfor escalating and weaning fromalbuterol and oxygen, criteria forspecialist consultation, criteriafor pediatric ICU transfer, criteriafor discharge, and a standardizedtemplate and checklist to facilitatecare transition to the primary careprovider, including a written asthmaaction plan, patient and parentcompetency-oriented asthmaeducation modeled on the HomeManagement Plan of Care,27 andalgorithm-based stepwiseadjustment of controller therapy.28

Implementation and Dissemination ofthe EB-CPM

We began EB-CPM implementation21

at PCH in January 2008 and completedit in March 2009 by usinga Plan–Do–Study–Act rapid cycleapproach.29,30 To ensure EB-CPMsustainability at PCH, we replaced thepaper-based discharge order set withan electronic discharge process,21,31

allowing automated informationexchange and care continuity withprimary care providers.28 The EB-CPMdissemination to community hospitalsstarted in January 2011 and wascompleted in June 2011. We providedon-site education and training ofclinical and administrative staff and

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data feedback during monthlymeetings with participating hospitalrepresentatives. Feedback data werealso shared with local hospital clinicaland administrative staff by localphysician champions. Finally, weprovided ongoing technical assistanceto physician champions and theirteams for troubleshooting theimplementation process.

Planning the Study

We used 8 EB quality measures fromour previous work to evaluate theEB-CPM impact.8 These included4 measures to assess compliancewith EB treatments for acuteexacerbations: (1) documented acuteasthma severity on admission, (2) useof quick reliever medications in thehospital, (3) use of systemiccorticosteroid medication in thehospital, and (4) restricted use ofipratropium bromide to ,24 hoursafter admission. They also included4 measures to assess compliance withEB measures intended to decreasereadmission risk: (5) documentedasthma education, (6) documenteddegree of chronic asthma control, (7)use of appropriate controller therapyprescription based on degree ofasthma control, and (8) documentedasthma action plan at discharge, withinstructions on how to recognize andavoid triggers and with follow-upappointment date and time.

Data Collection

This was a QI study of children aged 2to 17 years, discharged fromparticipating hospitals betweenJanuary 1, 2003, and December 31,2013, with the InternationalClassification of Diseases, NinthRevision primary diagnostic code ofasthma (493.xx). Data collectionincluded compliance with the 8quality measures and associatedasthma outcomes and was completedmanually for quality measures 1, 5, 6,7, and 8, and electronically (using theIntermountain Healthcare enterprisedata warehouse [EDW])32 for qualitymeasures 2, 3, and 4. Manual

collection of compliance metricswas facilitated by creation of a Web-based data collection form, anddata collection sources includedphysician and nursing documentationand medication administrationrecords.

The EDW was used to collect outcomevariables including asthmareadmission (ED revisit or hospitalreadmission with a primary diagnosisof asthma) at any of 22 Intermountainhospitals, hospital LOS in hours,variable hospitalization cost (directcost), hospital relative resource units(RRUs) used, ICU transfer within24 hours of admission, and death.Hospitalization cost was inflationadjusted for 2013. RRU isa standardized value adjusted forinflation and local market factors toallow comparison of resource usebetween hospitals and across years,reflecting the relative intensity ofresources used for each hospitalcharge.33 Finally, we used the EDW toretrieve demographic and othercovariates, including age, gender, race,insurance, calendar month ofhospitalization, and severity of illness(SOI) using All Patient RefinedDiagnosis Related Groups.34

For PCH, asthma discharges betweenJanuary 2003 and March 2009were defined as baseline(before implementation) withpostimplementation dischargesbetween April 2009 and December2013. For community hospitals,asthma discharges between January2003 and June 2011 were used asbaseline, with postimplementationdischarges including those betweenJuly 2011 and December 2013.

We included baseline data back to2003 to take into account anypreexisting secular trends.

Baseline data were collectedretrospectively andpostimplementation dataprospectively. For each patient, werecorded whether the care teamwas compliant with each measure(1 = yes and 0 = no). Individual

measure compliance per patient wassummed (ranging from 0 to 8) andused to calculate averagecompliance with individualmeasures and an average compositescore35 per hospital.

Data Analysis

We compared patient characteristicsbetween preimplementation andpostimplementation periods usingx2 for categorical and Wilcoxon t testfor continuous variables. We assessedchanges in compliance, by using thecomposite score, at PCHindependently and at communityhospitals as a group because oflimited sample size at individualcommunity hospitals. We used the“patient average” (cumulativepercentage of quality measuresachieved for each patient) method tocalculate the composite score.35 Weused statistical process control chartsto visually assess changes over timein 6-month asthma readmission andLOS between the preimplementationand postimplementation periods. Logtransformation was applied to LOS,cost, and RRU data, and log-linearregression analysis was used tocompare these outcomes betweenpreimplementation andpostimplementation periods. Thesemodels were adjusted for covariates.Finally, we used Fisher’s exact test toassess the EB-CPM impact on PICUtransfer.

RESULTS

There were 3510 children withasthma discharged from PCHand 1721 from community hospitalsduring the study period: 46.7%(1640/3510) and 74.3% (1279/1721)during preimplementation and53.3% (1870/3510) and25.7% (442/1721) during thepostimplementation period,respectively. Table 1 comparesdemographic characteristicsbetween preimplementation andpostimplementation populations. AtPCH, we noted significant differences

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in age, gender, race or ethnicity,insurance, and severity of illness(more severe after implementation).The community hospitals showeddifferences in race or ethnicity only,with similar severity of illnessbetween implementation periods.

Quality of Asthma Care

Baseline compliance as measured bythe composite score was low andhighly variable across hospitals, with

45% at PCH and 25% to 58% atcommunity hospitals (Fig 1). Afterimplementation at PCH, averagecompliance with the composite scoreincreased and was sustained at.90% for 5 years. Improvement ofthe composite score was rapid acrossthe 7 community hospitals, reaching80% to 99% within 6 months andremaining in this range over a 2-yearfollow-up period. Except for use ofquick relievers and systemic

corticosteroids, which had nearoptimal baseline compliance at allsites, increased compliance withindividual quality measuresfollowed different patterns at PCH(Supplemental Fig 4) and communityhospitals (Supplemental Fig 5), withPCH showing progressiveimprovement with individualmeasures overall, whereas theimprovement was rapid atcommunity hospitals.

TABLE 1 Patient Demographic Characteristics

PCH

Characteristics Category Before Implementation(January 2003–March 2009),

n = 1640 (46.7%)

After Implementation(April 2009–December 2013),

n = 1870 (53.3%)

P

Admit age, y, average (SD) 5.5 (3.5) 5.8 (3.5) ,.001Gender, n (%)

Male 914 (55.7%) 1119 (59.8%) .014Female 726 (44.3%) 751 (40.2%)

Race or ethnicity, n (%)White 1178 (71.8%) 1250 (66.8%) ,.001Hispanic 282 (17.2) 187 (10.0%)Other 140 (8.5%) 397 (21.2%)Unknown 40 (2.4%) 36 (1.9% %)

Insurance, n (%)Medicaid 449 (27.4%) 635 (33.9%) ,.001Private 1094 (66.7%) 1140 (60.9%)Self-pay 97 (5.9%) 95 (5.1%)

Severity of illness, n (%)1 1128 (68.8%) 1204 (64.4%) .0012 403 (24.6%) 466 (24.9%)3 94 (5.7%) 172 (9.2%)4 15 (0.9%) 28 (1.5%)

Community Hospitals

Characteristics Category Before Implementation(January 2003–June 2011),

n = 1279 (74.3%)

After Implementation(July 2011–December 2013),

n = 442 (25.7%)

P

Admit age, y, average (SD) 5.8 (3.7) 5.9 (3.7) ,.001Gender, n (%)

Male 721 (60.6%) 307 (57.8%) .279Female 469 (39.4%) 224 (42.2%)

Race or ethnicity, n (%)White 1032 (80.7%) 333 (75.3%) ,.001Hispanic 139 (10.9%) 4 (0.9%)Other 68 (5.3%) 72 (4.2%)Unknown 40 (3.1%) 33 (7.5%)

Insurance, n (%)Medicaid 332 (27.9%) 157 (29.6%) .551Private 809 (67.9%) 357 (67.2%)Self-pay 49 (4.1%) 17 (3.2%)

Severity of illness, n (%)a

1 832 (69.9%) 387 (72.9%) .2602 328 (27.6%) 132 (24.9%)3 30 (2.5%) 11 (2.1%)4 0 (0.0%) 1 (0.2%)

a Severity of illness: 1 = minor, 2 = moderate, 3 = major, and 4 = extreme.

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Outcomes

The average asthma readmission rateat PCH significantly reduced afterimplementation when analyzed byregression analysis, and thisreduction was sustained for 5 yearsafter implementation (Fig 2). Averageasthma readmission rate atcommunity hospitals showed a smallbut not statistically significant

reduction after implementation(Fig 3). Table 2 summarizes results of

regression analyses comparing

hospitalization outcomes

(readmission, LOS, cost, and RRU)

between the preimplementation and

postimplementation periods and

provides odds ratios (ORs) or b

coefficients (b) with 95% confidence

intervals.

At PCH, we found a significantreduction in asthma readmission (OR0.81; P = .026) and LOS (b 20.08;P , .001) and a nonsignificantreduction in costs (b 20.04; P = .094)(Table 2). Overall, improved asthmaoutcomes occurred without anyincrease in hospital resource use andno change in PICU transfer or death.At community hospitals, we founda nonsignificant trend towardreduced asthma readmission (OR0.76; P = .119) and a significantreduction in LOS (b 20.24; P , .001)and cost (b20.05; P =.053) (Table 2).Contrary to PCH, we observeda slight and significant increase inresource use at community hospitals(b 0.05; P = .032) and, again, nochange in PICU transfer or death.Supplemental Figs 6 and 7 showstatistical process control chartsdepicting changes in LOS at PCH andcommunity hospitals.

DISCUSSION

We demonstrated a high andsustained compliance with qualitymeasures and a persisting reductionin asthma readmissions over 5 yearsat a tertiary care hospital after theEB-CPM implementation. We alsofound a significant reduction in LOSwith a trend toward reduction inhospitalization costs. At communityhospitals, our study showedsuccessful EB-CPM dissemination,with improved compliance withquality measures and early evidenceof improved asthma outcomes. Wefound a trend toward asthmareadmission reduction anda significant reduction in LOS andhospitalization costs; however,improvements at communityhospitals occurred with a slightincrease in hospital resource use.

At both the tertiary care andcommunity hospitals, baselinecompliance with inpatient asthmaquality measures targetingreadmission prevention was generallylow. This finding is consistent withprevious studies reporting

FIGURE 1Composite scores of the 8 quality measures at each hospital. This figure shows that implementationof the EB-CPM started early at PCH (PC) and the beginning of 2011 at other community hospitals. PCHachieved optimal adherence (.80%) in 2008, and this high adherence was maintained through theend of 2013, whereas community hospitals had a short time (only 2 years) with optimal adherencewith the composite score. AF, American Fork Community Hospital; DX, Dixie Regional Hospital; LG,Logan Community Hospital; MK, McKay Dee Hospital; RV, Riverton Community Hospital; UV, Utah ValleyRegional Medical Center; VV, Valley View Hospital.

FIGURE 26-Month asthma readmission rates: PCH. Significant and sustained reduction in 6-month asthmareadmission rates after EB-CPM implementation. CL, central line; LCL, lower control limit; UCL, uppercontrol limit.

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suboptimal care with regard tointerventions targeting preventionof subsequent asthmahospitalizations.5,7,8,36–39 EB-CPMimplementation resulted in improvedcare quality, including markedimprovement in compliance withquality measures targeting asthmareadmission prevention, acrossdiverse inpatient settings.

We observed a significant andsustained reduction in asthmareadmission at the tertiary carehospital but only a trend towardreduction in asthma readmission atcommunity hospitals. It is likely that

the small number of patients at thecommunity hospitals did not providesufficient statistical power to detecta significant reduction in readmission,and an extended postimplementationobservation period will probablyresult in a significant change.

Finally, we found a slight increase inresource use at community hospitals,whereas resource use at PCH did notchange. This finding highlights thefact that the demand to achieve andsustain high compliance with qualitymeasures may require more hospitalresource use. However, a reduction inhospital resource use may occur over

time as community hospitals becomefamiliar with the new process.

Several factors contributed to thesuccess of our interventions,including administrative leadershipsupport with prioritization of ourproject, QI culture within theIntermountain Healthcareorganization, buy-in and support oflocal physician champions, use of anelectronic discharge process, and theEB-CPM design itself, includingasthma education and decisionsupport tools integrated into theclinical workflow to facilitatecompliance.40–42

To our knowledge, this is the firststudy to report long-termcompliance with EB inpatientasthma care measures andpersisting positive impact on asthmaoutcomes after implementation of anEB-CPM. Our study is also unique inreporting successful disseminationof the intervention to diversecommunity hospital settings, withimproved compliance with inpatientasthma care measures andoutcomes.

Our study has several limitations.First, the tertiary care hospital (PCH)admitted most children (67%) withasthma, and the sample size atindividual community hospitals wassmall. It was not possible to evaluatethe EB-CPM effects at the individual

FIGURE 36-Month asthma readmission rates: community hospitals. Slight but not significant reduction in6-month asthma readmission rates after EB-CPM implementation. CL, central line; UCL, upper controllimit.

TABLE 2 Regression Analysis of Outcomes: PCH

Variable BeforeImplementation

AfterImplementation

Odds Ratio or b 95% ConfidenceInterval

P

PCH

6-mo readmission rate, % (SD) 16.4 (37.0) 13.6 (34.3) 0.81a 0.67, 0.97 .026LOS, h, median (IQR) 49 (35–77) 45 (33–69) 20.08 20.13, 20.04 ,.001Hospitalization costs, adjusted for 2013 dollars, median (IQR)b 1816.8 (1300.5–2614.2) 1703.6 (1144.9–2894.6) 20.04 20.08, 0.01 .094RRU, median (IQR) 22.6 (16.4–33.6) 22.6 (15.5–39.3) 0.03 20.02, 0.07 .218

Community Hospitals

6-mo readmission rate, % (SD) 13.8 (34.5) 11.5 (31.9) 0.76a 0.54, 1.07 .119LOS, h, median (IQR) 44 (33–59) 35 (24–48) 20.24 20.29, 20.18 ,.001Hospitalization costs, adjusted for 2013 dollars, median (IQR) 1556.9 (1157.4–2121.2) 1484.7 (1009.8–2066.3) 20.05 20.10, 20.001 .053RRU, median (IQR) 22.3 (16.9–29.8) 22.9 (16.8–31.7) 0.05 0.00, 0.10 .032

Analysis was controlled for age, gender, race, insurance, severity. and month. IQR, interquartile ratio.a Odds ratio.b Direct or variable costs related to inpatient asthma care.

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community hospital level. Second, weused the EDW data to track asthmareadmissions at any of the 22Intermountain Healthcare hospitals.Although Intermountain Healthcarecovers 85% of pediatric care in thestate, we may have missedreadmissions at non–IntermountainHealthcare facilities. The impact ofthis is unknown but unlikely tochange our results. Third,implementation and disseminationreceived leadership support fromIntermountain Healthcare and wasfacilitated by organizational changesat each facility to support compliance.The impact of leadership support andorganizational change is difficult toestimate. Efforts to disseminate theEB-CPM to facilities outsideIntermountain Healthcare may faceadditional challenges, although webelieve that our approach43 todissemination can be appliedanywhere.

Fourth, our EB-CPM is complex. Inour analysis we did not determinethe individual effect of EB-CPMcomponents on asthma outcomes.Fifth, the EB-CPM was introducedinto a dynamic real-world clinicalsetting in which many otherunmeasured variables may haveaffected the results, such as changesin access to asthma care,socioeconomic barriers to care, andimprovements in the quality ofasthma care resulting fromintroduction of the 2007 asthmaguidelines. However, Fig 1 showssuboptimal compliance with qualitymeasures at community hospitalsthat persisted ∼4 years after the2007 asthma guideline publicationand changed only after EB-CPMimplementation in 2011. We alsobelieve that including insurancetype, age, gender, race, underlying

asthma severity, and calendar monthin our adjusted analysis at leastpartially addressed unmeasuredconfounding factors. Sixth, weincluded SOI as a confounding factorin our regression analyses. SOI is animperfect marker of illness severityat presentation. It is also a reflectionof diagnoses coded and resourceuse.

Seventh, our study populationincluded only children with a primarydiagnosis of asthma, identifiedelectronically through the EDW, andwould exclude children with asthmadischarged with another primarydiagnosis, such as viral pneumonia.However, a review of our datasuggested that including only thosewith a primary diagnosis of asthmacaptures the great majority of cases.44

Lastly, previous studies have reportedthe effect of organizational factors onimplementation of QI interventionsand provider compliance with EBcare.42,45–47 Specifically, success of animplementation strategy is a functionof the relationship between thenature of the evidence, the context inwhich the proposed change isimplemented, and the methodsthrough which change isfacilitated.48–51 Our future planincludes assessing organizationalfactors associated with successfulimplementation and dissemination ofEB-CPMs. We hope to identify keyfactors that can be addressed tofacilitate implementation anddissemination of an EB interventionto more broadly improve asthma careand outcomes.

CONCLUSIONS

Our results showed not onlyimproved asthma care and outcomesbut also long-term sustainability of

the EB-CPM impact at PCH, a tertiarycare children’s hospital, andsuccessful dissemination to 7community hospitals, with evidenceof improvement in both the qualityof asthma care and clinical outcomes.Our study demonstrates thepotential use of EB-CPMs to achievesustained improvement in asthmacare and outcomes in varioushospital settings.

ACKNOWLEDGMENTS

We acknowledge the medical,nursing, respiratory therapy, andadministrative staff at participatinghospitals for their efforts anddiligence during the implementationand dissemination of the EB-CPM.We also thank the Pediatric ClinicalProgram leadership, includingDr Ed Clark and Ms CarolynReynolds, as well as Dr Brent Jamesof the Intermountain Institute forHealthcare Delivery Research fortheir support for this project. Finally,Dr Nkoy has full access to all thedata in the study and takesresponsibility for the integrity of thedata and accuracy of the dataanalysis.

ABBREVIATIONS

CS: composite scoreEB: evidence-basedEB-CPM: evidence-based care

process modelED: emergency departmentEDW: enterprise data warehouseLOS: length of stayOR: odds ratioPCH: Primary Children’s HospitalQI: quality improvementRRU: relative resource unitSOI: severity of illness

FINANCIAL DISCLOSURE: Drs Nkoy, Stone, and Fassl received salary and travel support through an Agency for Healthcare Research and Quality (AHRQ) grant.

Dr Maloney, Ms Koopmeiners, and Ms Kim received salary support through an AHRQ grant. The remaining authors have no financial relationships relevant to this

article to disclose.

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FUNDING: Supported by grant 1R18HS018166-01A1 from the Agency for Healthcare Research and Quality (AHRQ) to Drs Nkoy, Stone, and Fassl. Regarding funding

sources outside the scope of work for this publication, Drs Nkoy, Stone, Fassl, and Maloney are also supported by grant 1R18HS018678-01A1 (Improving Post-

Hospital Transitions and Ambulatory Care for Children With Asthma) from the AHRQ. Dr Stone is also supported by award KM1CA156723 from the National Cancer

Institute. None of the sponsors participated in design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation,

review, or approval of the manuscript. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the AHRQ or the

National Institutes of Health.

POTENTIAL CONFLICT OF INTEREST: Drs Nkoy, Fassl, Stone, and Maloney have a patent pending for an electronic tool (electronic AsthmaTracker) developed to support

asthma self-monitoring and management in children. The other authors have indicated they have no potential conflicts of interest to disclose.

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DOI: 10.1542/peds.2015-0285 originally published online November 2, 2015; 2015;136;e1602Pediatrics 

Christopher G. MaloneyReynolds, Karen Valentine, Karmella Koopmeiners, Eun Hea Kim, Lucy Savitz and

Flory Nkoy, Bernhard Fassl, Bryan Stone, Derek A. Uchida, Joseph Johnson, CarolynImproving Pediatric Asthma Care and Outcomes Across Multiple Hospitals

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Christopher G. MaloneyReynolds, Karen Valentine, Karmella Koopmeiners, Eun Hea Kim, Lucy Savitz and

Flory Nkoy, Bernhard Fassl, Bryan Stone, Derek A. Uchida, Joseph Johnson, CarolynImproving Pediatric Asthma Care and Outcomes Across Multiple Hospitals

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ISSN: . 60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since . Pediatrics is owned, published, and trademarked by the Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

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