Impact of clinical pathways and practice guidelines on the management of acute exacerbations of bronchial asthma

Chest. 1998 Jan;113(1):28-33. doi: 10.1378/chest.113.1.28.


Objectives: In 1990, it was estimated that approximately 1% of all US health-care costs (approximately $6.2 billion) were spent on asthma-related health expenses. Of this, hospitalization charges alone exceeded $2.6 billion. Practice guidelines and clinical pathways are being developed to standardize the management of acute asthma with the aim of improving care and safely reducing health-care costs. In this report, we evaluate the impact of an asthma pathway developed and instituted at a large community-based teaching hospital. This pathway was evidence based and was developed by a multidisciplinary group.

Methods: The study was conducted during a 6-month period in 1995, while a similar period in 1994 was used as a historical control period. Data collected included patient demographics, hospital admission and discharge peak expiratory flow rates, pulse oximetry measurements, length of stay, conversion from hand-held nebulizer to metered-dose inhaler, use of corticosteroids within 24 h of hospitalization, and conversion of i.v. steroids to oral steroids.

Results: A total of 42 patients were enrolled during the study period. Of these, 19 were placed on the pathway, while 23 were not treated according to the pathway. There were 38 patients in the 1994 historical control period. For 1995, there was no significant difference between the pathway and nonpathway groups with regard to the length of stay (4.4+/-3.3 vs 3.2+/-2.3 days; p > 0.05), hospital discharge peak expiratory flow rates (324 vs 286 L/min; p > 0.05), or use of steroids (100% vs 91%; p > 0.05). However, a significant increase in conversion from hand-held nebulizer to metered-dose inhaler was noted in the pathway group (68% vs 34%; p < 0.05). The data from 1994 compared to 1995 pathway were similar in that there was no difference in the length of stay (3.4+/-2.1 vs 4.4+/-3.3 days; p > 0.05) and/or use of steroids (92% vs 100%; p > 0.05), while a significant increase in hand-held nebulizer to metered-dose inhaler conversion was observed for the 1995 pathway group (68% vs 26%; p=0.002).

Conclusions: We conclude that although the asthma pathway did not significantly reduce length of stay, it was associated with a significant increase in hand-held nebulizer to metered-dose inhaler conversion, resulting in a substantial cost savings of $288,000/year.

MeSH terms

  • Acute Disease
  • Anti-Asthmatic Agents / administration & dosage
  • Anti-Asthmatic Agents / economics
  • Asthma / diagnosis
  • Asthma / drug therapy*
  • Asthma / economics
  • Critical Pathways* / economics
  • Critical Pathways* / organization & administration
  • Critical Pathways* / standards
  • Female
  • Glucocorticoids / administration & dosage
  • Glucocorticoids / economics
  • Health Care Costs / standards
  • Health Care Costs / trends
  • Hospitalization / economics
  • Hospitalization / trends
  • Humans
  • Male
  • Middle Aged
  • Nebulizers and Vaporizers
  • Practice Guidelines as Topic
  • Respiratory Function Tests
  • Retrospective Studies
  • Severity of Illness Index
  • Treatment Outcome


  • Anti-Asthmatic Agents
  • Glucocorticoids