Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA.
BMJ Qual Saf. 2021 Nov;30(11):876-883. doi: 10.1136/bmjqs-2020-012292. Epub 2021 Jan 19.
Community hospitals, which care for most hospitalised children in the USA, may be vulnerable to declines in paediatric care quality when quality improvement (QI) initiatives end. We aimed to evaluate changes in care quality in community hospitals after the end of the Pathways for Improving Paediatric Asthma Care (PIPA) national QI collaborative.
We conducted a longitudinal cohort study during and after PIPA. PIPA included 45 community hospitals, of which 34 completed the 12-month collaborative and were invited for extended sustainability monitoring (total of 21-24 months from collaborative start). PIPA provided paediatric asthma pathways, educational materials/seminars, QI mentorship, monthly data reports, a mobile application and peer-to-peer learning opportunities. Access to pathways, educational materials and the mobile application remained during sustainability monitoring. Charts were reviewed for children aged 2-17 years old hospitalised with a primary diagnosis of asthma (maximum 20 monthly per hospital). Outcomes included measures of guideline adherence (early bronchodilator administration via metered-dose inhaler (MDI), secondhand smoke screening and referral to smoking cessation resources) and length of stay (LOS). We evaluated outcomes using multilevel regression models adjusted for patient mix, using an interrupted time-series approach.
We analysed 2159 hospitalisations from 23 hospitals (68% of eligible). Participating hospitals were structurally similar to those that dropped out but had more improvement in guideline adherence during the collaborative (29% vs 15%, p=0.02). The end of the collaborative was associated with a significant initial decrease in early MDI administration (81%-68%) (adjusted OR (aOR) 0.26 (95% CI 0.15 to 0.42)) and decreased rate of referral to smoking cessation resources (2.2% per month increase to 0.3% per month decrease) (aOR 0.86 (95% CI 0.75 to 0.98)) but no significant changes in LOS or secondhand smoke screening.
The end of a paediatric asthma QI collaborative was associated with concerning declines in guideline adherence in community hospitals.
在美国，大多数住院儿童都由社区医院照顾，当质量改进（QI）计划结束时，这些医院可能会面临儿科医疗质量下降的风险。我们旨在评估 Pathways for Improving Paediatric Asthma Care（PIPA）国家 QI 合作结束后社区医院的护理质量变化。
我们在 PIPA 期间和之后进行了一项纵向队列研究。PIPA 包括 45 家社区医院，其中 34 家完成了为期 12 个月的合作，并受邀进行了延长的可持续性监测（从合作开始后总共 21-24 个月）。PIPA 提供了儿科哮喘途径、教育材料/研讨会、QI 指导、每月数据报告、移动应用程序和同行学习机会。在可持续性监测期间，仍然可以获得途径、教育材料和移动应用程序。对因哮喘（每家医院最多每月 20 例）这一主要诊断住院的 2-17 岁儿童的图表进行了审查。结果包括指南遵守情况的衡量标准（通过计量吸入器（MDI）进行早期支气管扩张剂治疗、二手烟筛查和转介至戒烟资源）和住院时间（LOS）。我们使用多水平回归模型评估了结果，该模型根据患者组合进行了调整，采用了中断时间序列方法。
我们分析了来自 23 家医院的 2159 例住院病例（占合格病例的 68%）。参与医院在结构上与退出的医院相似，但在合作期间指南的遵守程度有所提高（29%比 15%，p=0.02）。合作结束与早期 MDI 治疗的显著初始下降相关（81%-68%）（调整后的比值比（aOR）0.26（95%CI 0.15-0.42）），以及转介至戒烟资源的比例下降（每月增加 2.2%至每月减少 0.3%）（aOR 0.86（95%CI 0.75-0.98）），但 LOS 或二手烟筛查没有显著变化。
儿科哮喘 QI 合作结束与社区医院指南遵守情况的令人担忧的下降有关。
