title: Comparison of US emergency department acute asthma care quality: 1997-2001 and 2011-2012.
abstract: BACKGROUND
  It remains unclear whether the quality of acute asthma care in US emergency departments (EDs) has improved over time.
  
  
  OBJECTIVE
  We investigated changes in concordance of ED asthma care with 2007 National Institutes of Health guidelines, identified ED characteristics predictive of concordance, and tested whether higher concordance was associated with lower risk of hospitalization.
  
  
  METHODS
  We performed chart reviews in ED patients aged 18 to 54 years with asthma exacerbations in 48 EDs during 2 time periods: 1997-2001 (2 prior studies) and 2011-2012 (new study). Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores at the patient and ED levels; these scores ranged from 0 to 100.
  
  
  RESULTS
  The analytic cohort comprised 4039 patients (2119 from 1997-2001 vs 1920 from 2011-2012). Over these 16 years, emergency asthma care became more concordant with level A recommendations at both the patient and ED levels (both P < .001). By contrast, concordance with non-level A recommendations (peak expiratory flow measurement and timeliness) decreased at both the patient (median score, 75 [interquartile range, 50-100] to 50 [interquartile range, 33-75], P < .001) and ED (mean score, 67 [SD, 7] to 50 [SD, 16], P < .001) levels. Multivariable analysis demonstrated ED concordance was lower in Southern and Western EDs compared with Midwestern EDs. After adjusting for severity, guideline-concordant care was associated with lower risk of hospitalization (odds ratio, 0.37; 95% CI, 0.26-0.53).
  
  
  CONCLUSIONS
  Between 1997 and 2012, we observed changes in the quality of emergency asthma care that differed by level of guideline recommendation and substantial interhospital and geographic variations. Greater concordance with guideline-recommended management might reduce unnecessary hospitalizations.
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Electronic address: khasegawa1@partners.org.
authors.forename: Kohei
authors.initials: K
authors.lastname: Hasegawa
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Ashley F
authors.initials: AF
authors.lastname: Sullivan
authors.affiliation: Harvard Interfaculty Initiative in Health Policy, Cambridge, Mass.
authors.forename: Yusuke
authors.initials: Y
authors.lastname: Tsugawa
authors.affiliation: Novartis Pharmaceuticals, East Hanover, NJ.
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Turner
authors.affiliation: Novartis Pharmaceuticals, East Hanover, NJ.
authors.forename: Susan
authors.initials: S
authors.lastname: Massaro
authors.affiliation: Department of Emergency Medicine, Weill Cornell Medical College, New York, NY.
authors.forename: Sunday
authors.initials: S
authors.lastname: Clark
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Chu-Lin
authors.initials: CL
authors.lastname: Tsai
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Camargo
mesh_terms: D000328:Adult; D001249:Asthma / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000592:standards*; D004638:Emergency Treatment / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care / Q000592:standards*; D014481:United States
keywords: Acute asthma; concordance; emergency department; guideline; hospitalization; quality of care; regional variation; time trend