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Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative
  1. Sarah Schechter1,
  2. Sravya Jaladanki2,
  3. Jonathan Rodean3,
  4. Brittany Jennings4,
  5. Marquita Genies5,
  6. Michael D Cabana6,7,
  7. Sunitha Vemula Kaiser1,2
  1. 1Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
  2. 2Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
  3. 3Children's Hospital Association, Lenexa, Kansas, USA
  4. 4American Academy of Pediatrics, Itasca, Illinois, USA
  5. 5Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  6. 6Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
  7. 7Children's Hospital at Montefiore (CHAM), Bronx, New York, USA
  1. Correspondence to Dr Sarah Schechter, Department of Pediatrics, University of California San Francisco, San Francisco, CA 94158, USA; sarah.schechter{at}


Background 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.

Methods 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.

Results 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.

Conclusions The end of a paediatric asthma QI collaborative was associated with concerning declines in guideline adherence in community hospitals.

  • paediatrics
  • implementation science
  • quality improvement

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  • Contributors Conception and design: SVK, BJ and MC. Data acquisition: community hospital site leaders, Value in Inpatient Pediatrics, SVK. Analysis: JR. Interpretation: all authors. Writing: SS and SK. Revision: all authors.

  • Funding This study was funded by the Agency for Healthcare Research and Quality (R03 HS027041).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Institutional Review Board at the University of California, San Francisco.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. Deidentified participant data are available from the corresponding author (ORCID 0000-0003-2243-8268) on reasonable request. Reuse is not permitted.

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