A 9-year-old Black male with 4 asthma hospitalizations in the last year was admitted to the PICU for noninvasive ventilation for an asthma exacerbation. Upon stabilization, he was transferred to a general pediatrics unit where he was discharged after education about the importance of adherence to his current controller regimen. Though providers had documented appropriate controller use in the setting of his poorly controlled asthma, adjustment of his controller medication had been deferred to outpatient follow-up during each admission, which did not occur.
Although approximately 8% of US children have a diagnosis of asthma, only about 1 in 20 of these children require hospitalization for their asthma each year.1 Of those hospitalized, there are persistent racial disparities, with Black children nearly 3 times more likely to be hospitalized than white children.2 Even more concerning, data from 2020 reveal that compared with white children, Black children are nearly 10 times more likely to die of asthma.3 In the last several decades, there have been robust improvements in the range of novel therapeutic options for chronic asthma management, as well as robust evidence supporting the efficacy and effectiveness of more standard therapies, such as daily inhaled corticosteroid (ICS) use and single maintenance and reliever therapy.4 These improvements in chronic management have coincided with reductions in asthma hospitalization disparities in the early 2000s.5 Despite this progress, up to 20% of children hospitalized with asthma were rehospitalized within a year and racial and ethnic disparities in these rates persist.6 Compared with outpatient asthma management, inpatient pharmacological management has not changed in decades. Thus, interventions to improve inpatient care have focused on expediting and standardizing existing pharmacological management and only a few inpatient interventions have included enhancing guideline-concordance of chronic asthma medication regimens.7–11 This raises an important value question: what are hospitalists’ responsibilities to improving the quality and equity of longitudinal asthma care?
The rise of pediatric hospitalists over the last several decades has led to improvements in the consistency and efficiency of inpatient care. Prior efforts to improve asthma care by hospitalists focused on standardization of acute exacerbation treatment through development and implementation of inpatient asthma pathways, which led to increases in the use of recommended medications and decreased length of hospital stay, healthcare costs, and hospital readmissions.7,10,11 The tradeoff for this increased focus on the quality of inpatient care was a potential desynchrony between inpatient and outpatient care.12 As a response to this, in the last decade or so, there has been an increased focus on transition from inpatient to outpatient care, including efforts to facilitate discharge medication filling, outpatient practitioner follow-up, and bundles of these services.13–15
These represent steps in the right direction toward greater accountability for longitudinal quality and equity during an inpatient admission, yet there are often missed hospital opportunities to adjust a patient’s chronic asthma medication management to better align with evidence-based and guideline consistent care. Though prior studies have demonstrated that 50% of children hospitalized for asthma have persistent disease and that posthospitalization ICS fill is associated with lower odds of readmission up to 90 days, only 37% of Medicaid-insured children had an ICS prescription fill shortly after hospitalization.8,16 Although we are not aware of any studies quantifying inpatient chronic medication step-up, emerging evidence for its infrequency includes a recent inpatient quality improvement initiative that highlighted appropriateness of controller medication prescription on discharge as an important area for improvement.17 Similarly, when prompted about barriers to guideline-recommended step-up to single maintenance and reliever therapy, a hospitalist focus group noted deferral of chronic medication changes to the primary care provider as a primary barrier to inpatient step-up.18 This recent work demonstrates an opportunity for hospitalists to improve the quality and equity of the longitudinal asthma care.
In 2012, the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association sponsored an expert round table discussion regarding the future of pediatric hospital medicine.19 Quality was identified as 1 of the 4 initiatives of the specialty, with hospitalists identified as having an important role within the delivery of high-value care. Value is often defined as quality over cost with the 6 domains of healthcare quality defined as effective, safe, timely, patient-centered, equitable, and efficient.20 We argue that hospitalists could enhance the value they contribute to at least 3 of these domains, effectiveness, timeliness, and equitability, by “stepping up” their longitudinal care for hospitalized children with asthma.
Effective
In 2020, the National Heart Lung and Blood Institute released the “2020 Focused Updates to the Asthma Management Guidelines” that built upon the 2007 guidelines. Evidence supporting step-wise pharmacologic therapy for long-term asthma management in reducing asthma symptoms and exacerbations is clear.21 The 2007 guidelines recommended assessing asthma risk, as well as impairment using validated tools (ie, Asthma Control Test, etc), to inform decisions to step-up long-term pharmacologic therapy.22 When a child experiences an asthma hospitalization, their asthma risk increases and if the hospitalization represents the second systemic corticosteroid course in the last year, the guidelines recommend stepping up asthma care. There is a clear benefit to partnering with primary care providers who will manage a patient’s asthma following an acute hospitalization. However, when an adjustment to pharmacologic therapy is indicated based on lack of effectiveness of the current therapy and evidence-based guidelines, hospitalists and primary care providers need only to communicate. Similar to other chronic conditions, such as uncontrolled hyperglycemia in a patient with Type 1 diabetes, the question in many cases is not whether we should adjust chronic management, but when and who should do it.
For our 9-year-old patient, we have clear evidence of high-risk asthma in the setting of reported good medication adherence; therefore, stepped up therapy is indicated for management of his chronic disease.
Timely
Deferring indicated medication management changes until hospital follow-up unnecessarily delays appropriate care. A patient admitted to the ICU or with multiple inpatient admissions should serve as a red flag to healthcare providers and systems that additional, time-sensitive support – in the form of medication change, care coordination, and/or necessary psychosocial care – is indicated. As part of the standard hospital admission process, pediatric hospitalists obtain a focused asthma history, including prior systemic steroids courses and impairment symptoms before this exacerbation. They, therefore, have the information needed to inform current pharmacologic decisions, as well as the provision of additional psychosocial resources, at the time of admission.
Inpatient chronic medication management deferral assumes not only that the patient will be able to access timely outpatient care (see Equitable, below), but that that care will be with a provider with sufficient familiarity or time with the child and caregiver to revisit the history already evoked by the hospitalist. Because mean hospital length of stay for patients admitted for an asthma exacerbation is 2.2 days and hospital follow-up visits are approximately 15 minutes and may occur with providers other than the child’s primary care provider, hospitalists may be in a better position to adequately assess control, educate families on pharmacologic adjustments, and obtain specialist input, if necessary.23,24 Hospitalists also have the benefit of a bevy of additional resources, partnering with colleagues in nursing, respiratory therapy, pharmacy, social work, and case management to coordinate both education and resources (ie, medication filling, prior authorization, housing condition assessment, etc) during the admission. Lastly, the pediatric rate of missed inpatient discharge follow-up visits ranges from 28% to 62%.25 Therefore, deferral of chronic medication management is often a missed opportunity for timely care.
For our patient, stepping up his chronic asthma medication while inpatient, in conjunction with utilization of resources such as medication filling and interdisciplinary education, would have decreased delays to receiving guideline consistent care.
Equitable
Lastly, deferring decisions on chronic medication management to outpatient follow-up may perpetuate asthma disparities. As stated earlier, Black children experience higher rates of asthma emergency department visits, hospitalization, and death, and children from low socioeconomic households are more likely to have persistent asthma.5,26,27 Furthermore, prior work has demonstrated that barriers related to social inequity, such competing demands for basic needs and lack of stable transportation, result in missed pediatric visits.28 This places these patients at risk for continued morbidity because of uncontrolled asthma.
The impact of “sitting on” uncontrolled asthma extends into the child’s education and family unit. Childhood asthma is a leading cause of chronic disease-related school absenteeism in the United States, resulting in lower academic performances, particularly among minority children.29 The impact of absenteeism extends into the family unit, resulting in an estimated unit $719.1 million in parents’ self-reported loss of productivity.30 Both inadequate schooling and healthcare are risk factors identified to make it difficult to rise out of poverty, creating a vicious cycle from childhood to adulthood.31 Though the causes of asthma disparities are multifactorial, hospitalists have the opportunity to offer evidence-based and guideline consistent care to not only improve asthma care, but prevent downstream, far reaching, negative consequences of uncontrolled asthma for both the patient and their family.
Multiple barriers related to social inequity prevented our patient from outpatient follow up. Providing inpatient adjustment of his chronic asthma medication would have reduced drivers of known disparities.
Next steps
For our 9-year-old male patient, adjustments to his chronic asthma medication therapy were deferred to the ambulatory setting during all of his hospitalizations, leading to poorly controlled asthma for approximately 1 year, requiring 6 courses of systemic steroids. Inpatient adjustment of his chronic medication regimen would have been effective, timely, and equitable and would have provided him the evidence-based and guideline consistent care that he deserves and may have prevented his multiple readmissions.
Further studies should assess the respective roles and perspectives of pediatric hospitalists and primary care providers in optimizing and individualizing longitudinal pharmacologic management of pediatric asthma. However, we encourage pediatric hospitalists to partner with their primary care colleagues and lean into effective, timely, and equitable longitudinal management decisions for patients admitted for asthma exacerbation. Hospitalists are well positioned to address gaps in the implementation of evidence-based and guideline consistent care of asthma; it is time for us to step up.
FUNDING: This work was supported by the National Institutes of Health (grant no. K23HL136842 to C.C.K.).
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
Drs Pumphrey and Kenyon conceptualized this manuscript and drafted the initial manuscript; and all authors reviewed and revised the manuscript and approved the final manuscript as submitted.
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