Randomized controlled trial of emergency department interventions to improve primary care follow-up for patients with acute asthma

The Transition of Care Between Emergency Department and Primary Care: An Integrative Systematic Review

AIMS

To identify the barriers and enablers of effective transitions of care between the emergency department and primary care providers.

BACKGROUND

Successful patient care transitions from the emergency department to primary care providers are important because this process has implications for the quality, patient safety, and cost of patient care. Failure in follow-up consultations with primary care can result in representations to the emergency department, which can impact negative emergency department operational issues throughout the entire hospital.

DESIGN AND METHODS

An integrative systematic review was reported according to PRISMA guidelines. The reviewers followed a systematic review protocol registered with PROSPERO (CRD42022316165). A search strategy was applied to extract articles from included databases: CINAHL, MEDLINE, PsycINFO, Scopus, ProQuest Nursing and Allied Health databases. Articles were assessed using a predetermined eligibility criterion. Quality assessment and a narrative synthesis were conducted.

RESULTS

Of the 1200 articles screened, 25 studies were included. Four additional articles were identified from reference lists. The range of study designs included: four qualitative, three mixed methods and 22 quantitative studies. A total of 291,012 patients were represented. Successful care transition was enhanced by access to insurance, ease of payment methods, effective communication, prior booked primary care provider appointments and access to transportation. Many patients experienced financial toxicity, and the shortfall between fees charged and rebates provided was found to influence primary care provider follow-up compliance.

CONCLUSION

Future recommendations to provide safe and effective transitions of care would be to optimise supported self-management for patients and deliver timely and clear communication with standardised discharge documentation to be shared between the emergency department and primary care providers.

RELEVANCE FOR CLINICAL PRACTICE

There is no one-size-fits-all approach to delivering safe care transitions between emergency department and primary care providers, and future research should target high-risk groups.

TRIAL REGISTRATION

Prospero: CRD42022316165.

Risk Factors for Loss to Follow-up of Elderly Patients After Hip Fracture Surgery: A Retrospective Cohort Study

Introduction

Non-attendance with scheduled postoperative follow-up visits remains a common issue in orthopaedic clinical research. The objective of this study was to identify the risk factors associated with loss to follow-up among elderly patients with hip-fracture postoperatively.

Methods

A retrospective analysis of 1-year post-surgery was performed on patients aged over 60 years who underwent hip-fracture surgery from January 2017 to March 2019. Based on their completion of the appointed follow-up schedule, the patients were classified into 2 groups: the Loss to Follow-up (LTFU) Group and the Follow-up (FU) Group. Clinical outcomes were evaluated by Functional Recovery Score (FRS) questionnaires. Telephone interviews were conducted with patients lost to follow-up to determine the reasons for non-attendance. A comparative analysis of baseline characteristics between the 2 groups was implemented, with further exploration of statistical differences through logistic regression.

Results

A total of 992 patients met the inclusion criteria were included in this study, of which 189 patients, accounting for 19.1%, were lost to follow-up 1 year postoperatively. The mean age of the patients in the LTFU Group was 82.0 years, significantly higher than the 76.0 years observed in the FU Group (P < 0.001). The FRS for the LTFU Group was marginally higher than that of the FU group (84.0 vs 81.0), with no significant difference (P = 0.060). Logistic regression analysis identified several significant predictors of noncompliance, including advanced age at surgery, femoral neck fracture, hip arthroplasty, long distance from residence to hospital, and the reliance on urban-rural public transportation for reaching the hospital.

Conclusion

Postoperative follow-up loss was prevalent among elderly patients with hip fractures. Our study indicated a constellation of risk factors contributing to noncompliance, including advanced age, transportation difficulties, long travel distance, femoral neck fracture and hip arthroplasty surgery.

A Systematic Review of HIV Pre-exposure Prophylaxis (PrEP) Implementation in U.S. Emergency Departments: Patient Screening, Prescribing, and Linkage to Care

In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is limited data available, however, describing the incorporation of HIV prevention initiatives in U.S. EDs. Over the last decade, HIV pre-exposure prophylaxis (PrEP) has significantly changed the HIV prevention landscape globally and very little is known about the provision of PrEP in U.S. EDs. To address this gap in the literature, we conducted a systematic review of peer-reviewed quantitative studies and conference abstracts spanning July 2012 - October 2022. Of 433 citations, 11 articles and 13 abstracts meet our inclusion criteria, representing 18 unique studies addressing PrEP screening, prescribing, and/or linkage to PrEP care.Most studies describe screening processes to identify PrEP-eligible patients (n = 17); most studies leveraged a patient's STI history as initial PrEP eligibility screening criteria. Fewer studies describe PrEP prescribing (n = 2) and/or linkage to PrEP care (n = 8).Findings from this systematic review highlight the potential for U.S. EDs to increase PrEP uptake among individuals at risk for HIV infection. Despite a growing number of studies exploring processes for incorporating PrEP into the ED setting, such studies are small-scale and time limited. Models providing prescribing PrEP in the ED show higher initiation rates than post-discharge engagement models. Electronic health record (EHR)-based HIV screening is valuable, but post-ED linkage rates are low. Our findings emphasize the need to establish best practices for initiating and supporting prevention effective PrEP use in the ED setting.

Effect of the Telemedicine Enhanced Asthma Management Through the Emergency Department (TEAM-ED) Program on Asthma Morbidity: A Randomized Controlled Trial

OBJECTIVE

To test the effectiveness of a telemedicine-based program in reducing asthma morbidity among children who present to the emergency department (ED) for asthma, by facilitating primary care follow-up and promoting delivery of guideline-based care.

STUDY DESIGN

We included children (3-12 years of age) with persistent asthma who presented to the ED for asthma, who were then randomly assigned to Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED) or enhanced usual care. TEAM-ED included (1) school-based telemedicine follow-ups, completed by a primary care provider, (2) point-of-care prompting to promote guideline-based care, and 3) an opportunity for 2 additional telemedicine follow-ups. The primary outcome was the mean number of symptom-free days (SFDs) over 2 weeks at 3, 6, 9, and 12 months.

RESULTS

We included 373 children from 2016 through 2021 (participation rate 68%; 54% Black, 32% Hispanic, 77% public insurance; mean age, 6.4 years). Demographic characteristics and asthma severity were similar between groups at baseline. Most (91%) TEAM-ED children had ≥1 telemedicine visit and 41% completed 3 visits. At 3 months, caregivers of children in TEAM-ED reported more follow-up visits (66% vs 48%; aOR, 2.07; 95% CI, 1.28-3.33), preventive asthma medication actions (90% vs 79%; aOR, 3.28; 95% CI, 1.56-6.89), and use of a preventive medication (82% vs 69%; aOR, 2.716; 95% CI, 1.45-5.08), compared with enhanced usual care. There was no difference between groups in medication adherence or asthma morbidity. When only prepandemic data were included, there was greater improvement in SFDs over time for children in TEAM-ED vs enhanced usual care.

CONCLUSIONS

TEAM-ED significantly improved follow-up and preventive care after an ED visit for asthma. We also saw improved SFDs with prepandemic data. The lack of overall improvement in morbidity and adherence indicates the need for additional ongoing management support.

TRIAL REGISTRATION

NCT02752165.

Feasibility of text message follow-up for pediatric asthma care after an emergency department visit

Background: Many children seen in the Emergency Department (ED) for asthma do not follow-up with their primary care provider. Text messaging via short message service (SMS) is a ubiquitous, but untested means of providing post-ED asthma follow-up care.Objective: To evaluate responses to an asthma assessment survey via SMS following an ED visit and estimate the likelihood of response by sociodemographic and clinical characteristics. Methods: We recruited 173 parents of children 2-17 years-old presenting for ED asthma care to receive a follow-up text (participation rate: 85%). One month later, parents received via SMS a 22-item survey that assessed asthma morbidity. We assessed response rates overall and by various sociodemographic and clinical characteristics, including age, parental education, and indicators of asthma severity.Results: Overall, 55% of parents (n = 95) responded to the SMS survey. In multivariable logistic regression (MLR), parents who graduated high school had a four-fold higher response rate compared to parents with less than a high school degree (OR: 4.05 (1.62, 10.13)). More parents of children with oral steroid use in the prior 12 months responded to survey items (OR: 2.53 (1.2, 5.31)). Reported asthma characteristics included: 48% uncontrolled, 22% unimproved/worse, 21% with sleep disruption, and 10% who were hospitalized for asthma.Conclusions: Text messaging may be a viable strategy to improve post-ED asthma assessment and to identify children with persistent symptoms in need of enhanced care or modification of care plans.

Understanding interventions delivered in the emergency department targeting improved asthma outcomes beyond the emergency department: an integrative review

OBJECTIVES

The emergency department (ED) represents a place and moment of opportunity to provide interventions to improve long-term asthma outcomes, but feasibility, effectiveness and mechanisms of impact are poorly understood. We aimed to review the existing literature on interventions that are delivered in the ED for adults and adolescents, targeting asthma outcomes beyond the ED, and to code the interventions according to theory used, and to understand the barriers and facilitators to their implementation.

METHODS

We systematically searched seven electronic databases and research registers, and manually searched reference lists of included studies and relevant reviews. Both quantitative and qualitative studies that reported on interventions delivered in the ED which aimed to improve asthma outcomes beyond management of the acute exacerbation, for adolescents or adults were included. Methodological quality was assessed using the Mixed Methods Appraisal Tool and informed study interpretation. Theory was coded using the Theoretical Domains Framework. Findings were summarised by narrative synthesis.

RESULTS

12 articles were included, representing 10 unique interventions, including educational and medication-based changes (6 randomised controlled trials and 4 non-randomised studies). Six trials reported statistically significant improvements in one or more outcome measures relating to long-term asthma control, including unscheduled healthcare, asthma control, asthma knowledge or quality of life. We identified limited use of theory in the intervention designs with only one intervention explicitly underpinned by theory. There was little reporting on facilitators or barriers, although brief interventions appeared more feasible.

CONCLUSION

The results of this review suggest that ED-based asthma interventions may be capable of improving long-term outcomes. However, there was significant variation in the range of interventions, reported outcomes and duration of follow-up. Future interventions would benefit from using behaviour change theory, such as constructs from the Theoretical Domains Framework.

PROSPERO REGISTRATION NUMBER

CRD 42020223058.

Utilization of the emergency department as a routine source of care among children with asthma

Objective: To describe characteristics of children with persistent asthma in the ED who receive most of their healthcare in emergency settings; and determine whether recent asthma experiences or historic patterns of care are associated with identifying the ED as a typical location for care.Methods: We conducted a sub-analysis of baseline data from Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED), an RCT of children (3-12 years) presenting to the ED with persistent asthma (2016-2020). Caregivers identified reasons for seeking emergency care, including if their child received most overall healthcare in the ED ('ED Care'; primary outcome) or not ('Other Care'). Independent variables included demographics, recent symptoms and quality of life (QOL), and historic preventive care and healthcare use. We compared responses between ED Care and Other Care groups using bivariate and multivariate analyses.Results: We analyzed data for 355 children (31% ED Care, 69% Other Care). Compared with Other Care, ED Care respondents were more likely to identify the ED as the closest source of healthcare; report fewer symptom nights but a poorer quality of life; and describe the ED as a usual place for sick care, despite most having a PCP.Conclusions: Many children with asthma use the ED as a typical source of healthcare, and are distinguished by need for proximity, poorer caregiver QOL, and historic patterns of care-seeking. Efforts to improve timely access to outpatient care and reinforce the role of PCP-directed asthma management, such as through telemedicine, may reduce preventable morbidity including ED visits.

Predictors of outpatient follow-up care after adult emergency department asthma visits and association with 30-day outcomes

Objective: Guidelines recommend outpatient follow-up after emergency department visits for asthma, but factors related to rates of follow-up among the adult population are understudied. We sought to describe patient and community-level predictors of outpatient follow-up after an index ED visit for asthma and evaluate the association between outpatient follow-up visits and subsequent ED revisits.Methods: We conducted a retrospective observational cohort study of adult patients with emergency departments visits for asthma. The primary predictor was time to outpatient follow-up visit within 30 days of the index ED visit. The primary outcome was all-cause ED revisit within 30 days of the index ED visit. Cox proportional hazards regression was utilized to test the association between time to outpatient follow-up and hazard of ED revisit within 30 days.Results: Time to outpatient follow-up visit within 30 days was not significantly associated with hazard of 30-day ED revisit for asthma (HR 1.05; 95% CI 0.69-1.61). However, male patients (HR 1.45; 95% C 1.11-1.89) and smokers (HR 1.67; 95% CI 1.22-2.29) were significantly more likely to have an ED revisit.Conclusion: Younger, Black patients with Medicaid were less likely to receive follow-up care relative to older patients insured by Medicare. While follow-up visits were not associated with 30-day revisit rates, differences by age, race, and insurance status suggest disproportionate barriers to accessing care. Future research may target these subgroups to improve transitions of care after an ED visit for asthma.

Asthma outcomes in pediatric patients with 30-day follow-up after an asthma hospitalization in a Medicaid-managed care program

BACKGROUND

National asthma guidelines recommend an outpatient follow-up after hospitalization for asthma. Our aim is determine if a follow-up visit within 30 days after an asthma hospitalization impacts risk for re-hospitalization and emergency department visits for asthma within the following year.

METHODS

This was a retrospective cohort study of claims data of Texas Children's Health Plan (a Medicaid managed care program) members age 1 to <18 years and hospitalized for asthma between January 1, 2012, and December 31, 2018. Primary outcomes were days to re-hospitalization and emergency department visit between 30 days and 365 days following the index hospitalization.

RESULTS

We identified 1,485 children age 1 to <18 years hospitalized for asthma. Comparing those with a 30 day follow-up to those without, there was no difference in days to re-hospitalization (adjusted hazard ratio 1.23, 95% Confidence Interval (CI) 0.74-2.06) or emergency department visit for asthma (aHR 1.08, 95% CI 0.88-1.33). Inhaled corticosteroid and short acting beta agonist dispensing were greater in the group completing the 30 day follow-up (means of 2.8 and 4.8 respectively for those with follow-up, 1.6 and 3.5 respectively for those without, p < 0.0001).

CONCLUSION

Having a follow-up outpatient visit within 30 days of an asthma hospitalization is not associated with a decrease in asthma re-hospitalization or emergency department visit in the 30-365 day period following the index hospitalization. Non-adherence to regular use of inhaled corticosteroid medication was high in both groups. These findings suggest need for improvement in the quality and quantity of post hospital asthma follow-up.

Role of Health Equity Research and Policy for Diverse Populations Requiring Hand Surgery Care

Health equity requires allocation of resources to eliminate the systematic disparities in health, imposed on marginalized groups, which adversely impact outcomes. A socioecological approach is implemented to elucidate the role of health equity research and policy for underrepresented minority and socioeconomically disadvantaged populations. Through investigation of the individual, community, institution, and public policy, we investigate problems and propose solutions to ensure fair and just treatment of all patients requiring hand surgery.

Veteran knowledge, perceptions, and receipt of care following visits to VA emergency departments for ambulatory care sensitive conditions

OBJECTIVE

Receipt of follow-up care after emergency department (ED) visits for chronic ambulatory care sensitive conditions (ACSCs)-asthma, chronic obstructive pulmonary disease, heart failure, diabetes, and/or hypertension-is crucial. We assessed Veterans' follow-up care knowledge, perceptions, and receipt of care after visits to Veterans Health Administration (VA) EDs for chronic ACSCs.

METHODS

Using explanatory sequential mixed methods, we interviewed Veterans with follow-up care needs after ACSC-related ED visits, and manually reviewed ED notes, abstracting interviewees' documented follow-up needs and care received.

RESULTS

We interviewed and reviewed ED notes of 35 Veterans, 12-27 (mean 19) days after ED visits. Follow-up care was completely received/scheduled in 20, partially received/scheduled in eight, and not received in seven Veterans. Among those who received care, it was received within specified time frames half the time. However, interviewees often did not recall these time frames or reported them to be longer than specified in the ED notes. Veterans who had not yet received or scheduled follow-up care commonly did not recall follow-up care instructions, believed that they did not need this care since they were not currently having symptoms, or thought that such care would be difficult to obtain due to appointment unavailability and/or difficulties communicating with follow-up care providers. Among the 28 Veterans in whom all or some follow-up care had been received/scheduled, for 25 cases VA staff reached out to the Veteran or the appointment was scheduled prior to or during the ED visit.

CONCLUSIONS

VA should prioritize implementing processes for EDs to efficiently communicate Veterans' needs to follow-up care providers and systems for reaching out to Veterans and/or arranging for care prior to Veterans leaving the ED. VA should also enhance practices using multimodal approaches for educating Veterans about recommended ED follow-up care and improve mechanisms for Veterans to communicate with follow-up care providers.

Follow-Up After Asthma Emergency Department Visits and Its Relationship With Subsequent Asthma-Related Utilization

OBJECTIVE

To assess the association between follow-up after an asthma-related emergency department (ED) visit and the likelihood of subsequent asthma-related ED utilization.

METHODS

Using data from California Medicaid (2014-2016), and Vermont (2014-2016) and Massachusetts (2013-2015) all-payer claims databases, we identified asthma-related ED visits for patients ages 3 to 21. Follow-up was defined as a visit within 14 days with a primary care provider or an asthma specialist.

OUTCOME

asthma-related ED revisit after the initial ED visit. Models included logistic regression to assess the relationship between 14-day follow-up and the outcome at 60 and 365 days, and mixed-effects negative binomial regression to assess the relationship between 14-day follow-up and repeated outcome events (# ED revisits/100 child-years). All models accounted for zip-code level clustering.

RESULTS

There were 90,267 ED visits, of which 22.6% had 14-day follow-up. Patients with follow-up were younger and more likely to have commercial insurance, complex chronic conditions, and evidence of prior asthma. 14-day follow-up was associated with decreased subsequent asthma-related ED revisits at 60 days (5.7% versus 6.4%, P < .001) and at 365 days (25.0% versus 28.3%, P < 0.001). Similarly, 14-day follow-up was associated with a decrease in the rate of repeated subsequent ED revisits (66.7 versus 77.3 revisits/100 child-years; P < 0.001).

CONCLUSIONS

We found a protective association between outpatient 14-day follow-up and asthma-related ED revisits. This may reflect improved asthma control as providers follow the NHLBI guideline stepwise approach. Our findings highlight an opportunity for improvement, with only 22.6% of those with asthma-related ED visits having 14-day follow-up.

Features of successful interventions to improve adherence to inhaled corticosteroids in children with asthma: A narrative systematic review

INTRODUCTION

Nonadherence to inhaled corticosteroids (ICSs) in children with asthma leads to significant morbidity and mortality. Few adherence interventions have been effective and little is known about what contributes to intervention effectiveness. This systematic review summarizes the efficacy and the characteristics of effective interventions.

METHODS

Six databases were systematically searched on October 3, 2020 for randomized control trials measuring adherence to ICS in children with asthma. A narrative synthesis was conducted focusing on intervention efficacy and study reliability. Intervention content was coded based on the National Institute for Health and Care Excellence guidelines for medicines adherence (the Perceptions and Practicalities Approach, PAPA) and behavior change techniques (BCTs), to determine the effective aspects of the intervention.

RESULTS

Of 240 studies identified, 25 were eligible for inclusion. Thirteen of the 25 studies were categorized as being highly reliable. Nine of the 13 interventions were effective at increasing adherence and 6 of those met the criteria for a PAPA intervention. Techniques targeting perceptions and practicalities in successful interventions included rewards, reminders, feedback and monitoring of adherence, pharmacological support, instruction on how to take their ICS/adhere, and information about triggers for symptoms and nonadherence.

CONCLUSION

Adherence interventions in children with asthma have mixed effectiveness. Effective intervention studies were more frequently of higher quality, were tailored to individuals' perceptual and practical adherence barriers, and used multiple BCTs. However, due to the small number of included studies and varying study design quality, conclusions drawn here are preliminary. Future research is needed to test a PAPA-based intervention with a rigorous study design.

Emergency Department Patient Navigator Program Demonstrates Reduction in Emergency Department Return Visits and Increase in Follow-up Appointment Adherence

BACKGROUND

An estimated 56% of emergency department (ED) visits are avoidable. One motivation for return visits is patients' perception of poor access to timely outpatient care. Efforts to facilitate access may help reduce preventable ED visits. We aimed to analyze whether an ED patient navigator (PN) program improved adherence with outpatient appointments and reduced ED return visits.

METHODS

We performed a retrospective analysis of patients evaluated and discharged from two EDs from October 2016 to December 2019. Using propensity score matching, an intervention case group was matched against two control groups - patients similar to the case group who presented either (1) pre-PN intervention or (2) post-PN intervention and did not receive intervention. The four outcomes included 72-h return ED visits, 30-day return ED visits, overall ED utilization, as well as the intervention group's adherence rates to PN-scheduled outpatient appointments. From 482,896 charts, propensity matching led to a total of 14,295 patients in each group.

RESULTS

PN intervention decreased both acute and subacute ED return visits. Compared to both pre-PN and post-PN controls, navigated patients had a decrease in 72-h and 30-day return visits from 2% to 1% and 7% to 4% (p < 0.001) respectively. Navigated patients also had outpatient appointment adherence rates of 74-80% compared to the estimated national average of 25-56%. While there was no difference in mean ED utilization between the intervention group and pre-PN control group, mean ED utilization was found to be higher in the intervention group compared to the post-PN control group with 0.62 visits compared to 0.38 mean visits (p < 0.001).

CONCLUSIONS

By facilitating access to post-ED care, PNs may reduce avoidable ED utilization and improve outpatient follow-up adherence. While overall ED utilization did not change, this may be due to the overall vulnerability of the navigated group which is the goal PN intervention group.

Assessment of Predictor Factors Associated with Multiple Emergency Department Attendance with Asthma Attack: A Qualitative and Multicentric Prospective Observational Study

Purpose

Identified factors associated with multiple emergency department (ED) visits (≥) for asthma, which is associated with death.

Patients and Methods

We first conducted a qualitative study. We invited French-speaking adults (≥18 years old) with a diagnosis of asthma for more than 6 months. The identified concepts were transcribed into items. A Delphi method allowed for selecting items for a self-reported questionnaire. In an observational multicentric cross-sectional quantitative study, the resulting 20-item questionnaire and 12-item General Health Questionnaire, exploring psychological distress, were administered to adults visiting an ED for asthma exacerbation. Multivariable logistic regression was used to assess factors associated with ED visits.

Results

Data saturation was obtained after 8 patient interviews. Patients who came to the ED seemed unfamiliar with their illness or treatments but were concerned by the disease. The questionnaire was administered to 182 patients. On multivariable logistic regression, multiple and systematic ED visits were associated with asthma exacerbation (adjusted odds ratio (aOR) = 6.89, 95% confidence interval [CI]: 2.25–21.09), asthma perceived as a handicap (aOR=3.19, 95% CI: 1.55–6.57) and reported atopy (OR=2.09, 95% CI: 1.03–4.26). High educational level and lack of maintenance inhaled corticosteroids were protective for multiple ED visits.

Conclusion

Inadequate medical care is frequent in patients attending the ED for an asthma exacerbation, associated with strong psychological impact. Questioning the reasons for consulting the ED may help quickly identify patients requiring asthma education and improve their referral.

Feasibility of a Brief Intervention to Increase Rapid Primary Care Follow-Up Among African American Patients With Uncontrolled Diabetes

The management of diabetes, like many other chronic conditions, depends on effective primary care engagement. Patients with diabetes without a usual source of care have a higher risk of uncontrolled disease, hospitalizations, and early death. Our objective was to study the effect of a brief intervention to help patients in medically underserved areas obtain rapid primary care follow-up appointments following hospitalization. We performed a pilot pragmatic randomized controlled trial of adult patients with uncontrolled diabetes who had been admitted to one of three hospitals in the Memphis, TN, area. The enhanced usual care arm received a list of primary care clinics, whereas the intervention group had an appointment made for them preceding their index discharge. Patients in both groups were evaluated for primary care appointment attendance within seven and fourteen days of index discharge. In addition, we examined barriers patients encounter to receiving rapid primary care follow-up using a secret shopper approach to assess wait times when calling primary care offices. Twelve patients were enrolled with six in each trial arm. Baseline demographics, access to medical care, and health literacy were similar across the groups. Primary care follow-up was also similar across the groups; no improvements in follow-up rates were seen in the group receiving assistance with making appointments. Identified barriers to making primary care follow-up appointments included inability to schedule an urgent appointment, long hold times when calling doctor’s offices and lack of transportation. Additionally, hold times when calling primary care offices were found to be excessively long in the medically underserved areas studied. The study demonstrates the feasibility of providing patient assistance with scheduling rapid primary care follow-up appointments at the time of discharge and the potential to improve care transitions and access to primary care among patients living in medically underserved areas. Larger pragmatic trials are needed to further test alternative approaches for insuring rapid primary care follow-up in vulnerable patients with ambulatory care-sensitive chronic conditions.

How scheduling systems with automated appointment reminders improve health clinic efficiency

Missed clinic appointments or no-shows burden health care systems through inefficient use of staff time and resources. Scheduling software with automatic appointment reminders shows promise to improve clinics' management through timely cancellations and re-scheduling, but at-scale evidence is missing. We study a nationwide text message appointment reminder program in Chile implemented at primary care clinics for patients with chronic disease. Using longitudinal clinic-level data, we find that the program did not change the number of visits by chronic patients eligible to receive the reminder but visits from other patients ineligible to receive reminders increased by 5.0% in the first year and 7.4% in the second. Clinics treating more chronic patients and those with a relatively younger patient population benefited more from the program. Scheduling systems with automatic appointment reminders were effective in increasing clinics' ability to care for more patients, likely due to timely cancellations and re-scheduling.

Impact of integrated care coordination on pediatric asthma hospital presentations

INTRODUCTION

Frequent asthma attacks in children result in unscheduled hospital presentations. Patient centered care coordination can reduce asthma hospital presentations. In 2016, The Sydney Children's Hospitals Network launched the Asthma Follow up Integrated Care Initiative with the aim to reduce pediatric asthma emergency department (ED) presentations by 50% through developing and testing an integrated model of care led by care coordinators (CCs).

METHODS

The integrated model of care was developed by a multidisciplinary team at Sydney Children's Hospital Randwick (SCH,R) and implemented in two phases: Phase I and Phase II. Children aged 2-16 years who presented ≥4 times to the ED of the SCH,R in the preceding 12 months were enrolled in Phase I and those who had ≥4 ED presentations and ≥1 hospital admissions with asthma attack were enrolled in Phase II. Phase I included a suite of interventions delivered by CCs including encouraging parents/carers to schedule follow-up visits with GP post-discharge, ensuring parents/carers are provided with standard asthma resource pack, offering referrals to asthma education sessions, sending a letter to the child's GP advising of the child's recent hospital presentation and coordinating asthma education webinar for GPs. In addition, in Phase II CCs sent text messages to parents/carers reminding them to follow-up with the child's GP. We compared the change in ED visits and hospital admissions at baseline (6 months pre-enrolment) and at 6-and 12-months post-enrolment in the program.

RESULTS

During December 2016-January 2021, 160 children (99 in Phase I and 61 in Phase II) were enrolled. Compared to baseline at 6- and 12-months post-enrolment, the proportion of children requiring ≥1 asthma ED presentations reduced by 43 and 61% in Phase I and 41 and 66% in Phase II. Similarly, the proportion of children requiring ≥1 asthma hospital admissions at 6- and 12-months post-enrolment reduced by 40 and 47% in Phase I and 62 and 69% in Phase II.

CONCLUSION

Our results support that care coordinator led integrated model of asthma care which enables integration of acute and primary care services and provides families with asthma resources and education can reduce asthma hospital presentations in children.

Ambulante Entlassung aus der Notfallstation

Die Entlassung aus der Notfallstation in die ambulante Weiterbehandlung stellt den größten Teil des „outflow“ aus den Notfallstationen dar. Um die steigende Anzahl der Patienten sicher in die ambulante Betreuung zu entlassen, sollte der Entlassungsprozess ebenso wie Diagnostik und Therapie einen Platz im Behandlungsplan einnehmen. Werden die Maßnahmen zur Sicherung einer guten Kommunikation und Instruktion der Patienten vor der Entlassung richtig umgesetzt, können Patientensicherheit und medizinisches Outcome verbessert werden. Diese Strategie unterstützt eine patientenzentrierte Behandlung und reduziert oftmals eine ungeplante Wiedervorstellung und folglich Gesundheitskosten. Der nachfolgende Text basiert auf der Veröffentlichung „Improving the emergency department discharge process: environmental scan report“ des Armstrong Institute for Patient Safety and Quality an der der Johns Hopkins University School of Medicine für die Agency for Healthcare Research and Quality in den Vereinigten Staaten. Hier werden Begriffe definiert, die eine qualitativ hochwertige Entlassung ausmachen; welche Risikofaktoren eine qualitativ schlechte Entlassung verursachen können und welche Maßnahmen die Qualität der Entlassung erhöhen. Natürlich sollte man dabei die Unterschiede im Setting und im Gesundheitssystem sowie der Notfallstationen bedenken und an die eigenen Gegebenheiten anpassen.

Insurance Status and Disparities in Outpatient Care after Traumatic Injuries of the Hand: A Retrospective Cohort Study

BACKGROUND

Hand-injured patients seen in the emergency department can often be followed as outpatients for definitive care and rehabilitation. Many face barriers to continuing care in the outpatient setting that impact quality of care delivery. The authors aimed to evaluate patterns of outpatient follow-up after initial emergency department evaluation of traumatic hand injuries, identify factors associated with poor follow-up, and suggest areas for improvement.

METHODS

In this retrospective cohort study, the authors reviewed records of adult patients with acute hand injuries referred for outpatient follow-up after initial plastic surgery consultation in the emergency department of a single urban Level I trauma center over a 12-month period (n = 300). Patients were grouped by insurance (i.e., no insurance, Medicaid, Medicare, or private). Outcomes included completion of outpatient follow-up, hand therapy participation, and emergency department return visits.

RESULTS

Factors significantly associated with failure to follow up included male sex (OR, 3.58; 95 percent CI, 1.57 to 8.16), uninsured status (OR, 3.47; 95 percent CI, 1.48 to 8.16), Medicaid insurance (OR, 4.46; 95 percent CI, 1.31 to 15.25), and lack of a driver's license (OR, 3.35; 95 percent CI, 1.53 to 7.34). Hand therapy attendance and unexpected emergency department return visits also varied significantly by insurance type (p < 0.001).

CONCLUSIONS

There is a significant disparity in the use of outpatient care after emergency department visits for acute hand injuries. Uninsured and Medicaid-insured patients are significantly less likely to initiate recommended hand specialty follow-up, and significantly less likely to complete follow-up even when established with an outpatient clinic. Future research should evaluate targeted interventions for at-risk patients.

Spreading the Veterans Health Administration's emergency department rapid access clinics (ED-RAC) innovation: Role of champions and local contexts

BACKGROUND

Champions frequently facilitate change in healthcare, but the literature lacks specificity regarding champion activities and interactions with local contexts. The Veterans' Health Administration (VA) Emergency Department (ED) Rapid Access Clinic (ED-RAC) initiative used champions to spread an innovation aimed at achieving timely specialty follow-up care for ED patients. We assessed the roles champions and local contexts played in successful ED-RAC spread in the initiative's first year.

METHODS

Our mixed method formative evaluation included serial questionnaires, fieldnotes from meetings, and champion interviews. We analyzed qualitative data from spread site rapid and non-rapid implementers, assessing champion and contextual factors.

RESULTS

Among 24 participating VA sites, 11 were rapid implementers (i.e., implemented ED-RAC in first year), 13 were not. Site champions at rapid sites described crossing multiple organizational units to get tasks accomplished (e.g., gaining buy-in, requesting resources); champions at non-rapid sites experienced inter-departmental communication challenges and competing demands. Champions at rapid and non-rapid sites encountered similar context-related barriers (e.g. scheduling complexities) and facilitators (e.g. enthusiastic buy-in), but differed in leadership and resource barriers.

CONCLUSIONS

Identifying site champions was not enough to assure rapid innovation spread. Interdependencies between ED-RAC implementation requirements (e.g., boundary spanning, resources) and champion and contextual factors helped explain variations in progress.

IMPLICATIONS

Tailoring spread support to champion and contextual factors may facilitate more rapid spread of innovations.

Management of Asthma Exacerbations in the Emergency Department

Asthma exacerbations occur across a wide spectrum of chronic severity; they contribute to millions of emergency department (ED) visits in both children and adults every year. Management of asthma exacerbations is an important part of the continuum of asthma care. The best strategy for ED management of an asthma exacerbation is early recognition and intervention, continuous monitoring, appropriate disposition, and, once improved, multifaceted transitional care that optimizes subacute and chronic asthma management after ED discharge. This article concisely reviews ED evaluation, treatment, disposition, and postdischarge care for patients with asthma exacerbations, based on high-quality evidence (eg, systematic reviews from the Cochrane Collaboration) and current international guidelines (eg, the National Asthma Education and Prevention Program Expert Panel Report 3, Global Initiative for Asthma, and Australian guidelines). Special populations (young children, pregnant women, and the elderly) also are addressed. Despite advances in asthma science, there remain many important evidence gaps in managing ED patients with asthma exacerbation. This article summarizes several of these controversial areas and challenges that merit further investigation.

Association between attendance at outpatient follow-up appointments and blood pressure control among patients with hypertension

Objective

The aim of this study was to assess the impact of regularity in treatment follow-up appointments on treatment outcomes among hypertensive patients attending different healthcare settings in Islamabad, Pakistan. Additionally, factors associated with regularity in treatment follow-up were also identified.

Methods

A cross-sectional study was undertaken in selected primary, secondary and tertiary healthcare settings between September, 2017 and December, 2018 in Islamabad, Pakistan. A structured data collection form was used to gather sociodemographic and clinical data of recruited patients. Binary logistic regression analyses were undertaken to determine association between regularity in treatment follow-up appointments and blood pressure control and to determine covariates significantly associated with regularity in treatment follow-up appointments.

Results

A total of 662 patients with hypertension participated in the study. More than half 346 (52%) of the patients were females. The mean age of participants was 54 ± 12 years. Only 274 (41%) patients regularly attended treatment follow-up appointments. Regression analysis found that regular treatment follow-up was an independent predictor of controlled blood pressure (OR 1.561 [95% CI 1.102–2.211; P = 0.024]). Gender (OR 1.720 [95% CI 1.259–2.350; P = 0.001]), age (OR 1.462 [CI 95%:1.059–2.020; P = 0.021]), higher education (OR 1.7 [95% CI 1.041–2.778; P = 0.034]), entitlement to free medical care (OR 3.166 [95% CI 2.284–4.388; P = 0.0001]), treatment duration (OR 1.788 [95% CI 1.288–2.483; P = 0.001]), number of medications (OR 1.585 [95% CI 1.259–1.996; P = 0.0001]), presence of co-morbidity (OR 3.214 [95% CI 2.248–4.593; P = 0.0001]) and medication adherence (OR 6.231 [95% CI 4.264–9.106; P = 0.0001]) were significantly associated with regularity in treatment follow-up appointments.

Conclusion

Attendance at follow-up visits was alarmingly low among patients with hypertension in Pakistan which may explain poor treatment outcomes in patients. Evidence-based targeted interventions should be developed and implemented, considering local needs, to improve attendance at treatment follow-up appointments.

Asthma Across Childhood: Improving Adherence to Asthma Management from Early Childhood to Adolescence

Asthma affects nearly 6 million US children. Throughout childhood, children undergo a series of biological, developmental, and psychosocial changes. Thus, factors influencing a child's asthma management differ across 3 essential stages-early childhood (0-5 years), school-aged years (5-12 years), and adolescence (12-18 years)-and require varied intervention by parents, school personnel, clinicians, and the children themselves. Because asthma care in children is characterized by fluctuations in severity and coordination among many stakeholders, optimal asthma control is difficult to achieve in this young population. Challenges in childhood asthma management are reflected in the low rates of children's adherence to medication regimes. Although pharmacological and biological factors addressing age in physicians' treatment choices are well outlined, age-specific approaches to patient-provider communication and asthma-related interventions are also important in improving quality of life for patients with pediatric asthma.

Providing individualized written asthma action plans during the pediatric emergency department visit

Introduction: Among children presenting to the pediatric emergency department (PED) with an asthma exacerbation, the objective was to determine if creating an individualized written asthma action plan (WAAP) during the PED visit, when compared with standard discharge instructions, led to fewer asthma-related unplanned return visits up to three months after the PED visit. Secondary outcomes included rates of routine follow up with a healthcare provider, asthma control scores and caregiver confidence measures.Methods: Children ages 2-17 who presented to the PED with an asthma exacerbation and did not already have a WAAP were randomized to receive discharge instructions including a WAAP versus standard discharge instructions. The WAAP was ordered by the physician and reviewed with families by a respiratory therapist as part of a brief educational session during the PED visit. Parents completed follow-up surveys at one and three months after the PED visit.Results: 91 families were enrolled and 83/91 (91%) completed at least one follow-up survey. Fewer families in the WAAP group reported an unplanned visit to a healthcare provider during the follow-up period [WAAP 7/39 (18%), Control 17/44 (39%), p = 0.038]. Inhaled corticosteroids were prescribed more commonly in the WAAP group [WAAP 29/45 (64%), Control 15/46 (33%), p = 0.002]. There was no difference in rates of routine follow-up visits, asthma control scores or caregiver confidence measures during the follow-up period.Conclusions: Families who were provided a written asthma action plan during their pediatric emergency department visit for an asthma exacerbation reported fewer unplanned visits during the subsequent three months.

Visto, Pero No Escuchado: A Qualitative Arm of a Mixed-Methods Study of Puerto Rican Children With Asthma

INTRODUCTION

Communication among health care providers, caregivers, and children with asthma is challenging and sometimes may exclude the child. This may result in delay in recognizing and responding appropriately to asthma symptoms. The purpose was to conduct focus groups among Puerto Rican children with asthma on communication with their health care provider about their asthma symptoms.

METHOD

The qualitative arm (focus groups) of a mixed-method explanatory sequential study that was used to view communication with their health care provider through the lens of a group of Puerto Rican children. The sample included Puerto Rican children ages 8 to 12 years with asthma (N = 23). The goal was to develop a child illness representation questionnaire.

RESULTS

The perspective of children with asthma provided enriched information to influence the development of instrument subscale on communication. The children were often not heard during a clinical visit. Most of the children express fear of their health care provider.

CONCLUSIONS

Although this was a small sample, there were indications that children would like to opportunity to tell the story about their experience with having asthma. Further research will lead to the next step toward developing and computing a reliable measure that includes the child in a discussion during a clinical visit.

Children with Asthma and Communication with Healthcare Provider: Instrument Development

PURPOSE

Communication among healthcare providers, caregivers and children with asthma is challenging and sometimes may exclude the child. This may result in delay in recognizing and responding appropriately to asthma symptoms. The purpose was to test an instrument's subscale for content validity related to communication with the healthcare provider by examining age appropriateness, readability and clarity for children with asthma.

DESIGN AND METHODS

This was a mixed method explanatory sequential design to examine age appropriateness, readability and clarity for a 15-item subscale of an instrument for children. The qualitative arm (focus groups) was used to enrich the questionnaire. The sample included children ages 8 to 12 with asthma (N = 25).

RESULTS

The perspective of children with asthma provided enriched information to influence the development of instrument subscale on communication.

CONCLUSIONS

The subscale revealed internal consistency with Cronbach Alpha 0.85. One of the children reported that using the term "provider" was clearer as oppose to healthcare provider. Children participating in the study found readable and clear. A readability analysis revealed the items were readable at a 6th grade level.

PRACTICE IMPLICATION

Although the instrument is designed for primary care providers (physicians, nurse practitioners, physician assistants), the information gained from this pilot increases understanding about including the child in a triadic discussion. Further research will lead to next step toward computing reliability of the full measure and a factor analysis.

Identifying patient-centered outcomes for children with cancer and their caregivers when they seek care in the emergency department

BACKGROUND

Children with cancer have high utilization of the emergency department (ED), but little is known about which outcomes are most important to them and their caregivers when they seek care in the ED.

PROCEDURE

A qualitative evaluation of ED experience for children with cancer and their caregivers was performed using self-reported interactive toolkits. Eligible participants included children with cancer (ages 11-19) and caregivers of children with cancer whose child received cancer therapy within the last year and had an ED visit within the last 2 years. Eligible participants received toolkits by mail and received incentives if they completed the toolkit. Toolkits were transcribed, thematically coded, and iteratively analyzed using Nvivo 11.0 software.

RESULTS

There were 26 toolkits received-seven by children aged 11-17 years and 19 by caregivers (11 with children aged 2-7 years, eight with children aged 11-17 years). About half were from within 1 h of their treating institution. The most important outcomes to this population included system-level issues (eg, cleanliness of space, timeliness of evaluation) and oncology-provider- and ED-provider-level issues (eg, ability to access port-a-caths, quality of communication). Participants also identified outcomes that were within the control of the patient/caregiver, such as improving their sense of preparedness.

CONCLUSION

The important outcomes to children with cancer and their caregivers when they seek care in the ED are distinct from current quality metrics. Future research should focus on the development and validation of a patient-centered outcomes tool.

General practitioner consultation after a visit to the emergency department: an observational study

BACKGROUND

Some studies have demonstrated an association between poor continuity of care, high likelihood of 'inappropriate' use of emergency departments (EDs) and avoidable hospitalization. However, we lack data concerning primary care use after an ED visit.

OBJECTIVE

Identify the determinants of a visit to the general practitioner (GP) after an ED visit.Methods.

DESIGN

Observational study (single-centre cohort).

SETTING

One emergency department in Paris, France.

SUBJECTS

All adult patients who presented at the ED and were discharged.

MAIN OUTCOME MEASURE

We collected data by the use of a standardized questionnaire, patients' medical records and a telephonic follow-up. Descriptive analyses were performed to compare individuals with and without a GP. Then, for those with a GP, multivariate logistic regression was used to identify the determinants of the GP consultation.

RESULTS

We included 243 patients (mean age 45 years [±19]); 211 (87%) reported having a GP. Among those who reported having a GP, 52% had consulted their GP after the ED visit. Not having a GP was associated with young age, not having complementary health insurance coverage, and being single. GP consultation was associated with increasing age [adjusted odds ratios (aOR) = 1.03], poor self-reported health status (aOR = 2.25), medical complaints versus traumatic injuries (aOR = 2.24) and prescription for sick note (aOR = 5.74).

CONCLUSION

Not having a GP was associated with factors of social vulnerability such as not having complementary health insurance coverage. For patients with a GP, consultation in the month after an ED visit seems appropriate, because it was associated with poor health status and medical complaints.

[Asthma exacerbations in adults: Preventing and treat]

Exacerbations of asthma are still responsible for 900 deaths per year in France, most of which are considered preventable. They have a major impact on the quality of life of patients and are responsible for a large part of the socio-economic cost of asthma in France. Exacerbations of asthma can be partly prevented by inhaled corticosteroid treatment as controller therapy, at a dose adapted to the level of control of symptoms and the management of aggravating factors. Every patient should benefit from a written action plan that allows them to start oral corticosteroid therapy as soon as possible during an exacerbation. The treatment combines short-acting bronchodilators with systemic corticosteroids. Systemic antibiotic therapy has no place in the treatment of exacerbations. The patient must be seen early in the course of an exacerbation of asthma to review all of his follow-up.

Improving allergy office scheduling increases patient follow up and reduces asthma readmission after pediatric asthma hospitalization

BACKGROUND

Pediatric asthma is a major contributor to emergency room utilization and hospital readmission rates.

OBJECTIVE

To develop an allergy department‒based intervention to improve follow-up appointment scheduling processes for pediatric asthma patients after discharge for asthma exacerbation.

METHODS

This quality improvement study was conducted in the allergy clinic of an urban, tertiary children's hospital. Children receiving subspecialty allergy care for asthma were included into the intervention group during the intervention period. The quality improvement intervention consisted of 3 attempts by telephone to reach the family to schedule the follow-up appointment. If this was unsuccessful or if the appointment was not kept, then a reminder letter was sent to the family. The primary outcome of interest in this study was the percent of postdischarge follow-up appointments scheduled within 30 days of discharge. Secondary outcomes measured were the percent of allergy appointments attended within 30 days of discharge and the 30-day hospital readmission rate.

RESULTS

Demographics did not differ significantly between the intervention and baseline preintervention year. The initial baseline scheduled allergy follow-up visit rate was 48.8 ± 13.3% of patients discharged per month. This increased to an overall rate of 75.7 ± 20.1% patients scheduling allergy follow-up within 30 days of discharge during the intervention year. We also observed a significant increase in attended allergy visits 30 days postdischarge from 35.5 ± 15.6% in year 1 to 53.9 ± 25.5% during the intervention year and a significant decrease in the 30-day readmission rate on the allergy service.

CONCLUSION

These data suggests that minor changes in allergy practice organization can significantly affect posthospitalization follow-up rates and decrease asthma readmission rates.

Development and Pilot Testing of a Computerized Asthma Kiosk to Initiate Chronic Asthma Care in a Pediatric Emergency Department

OBJECTIVES

Emergency department (ED) visits are an opportunity to initiate chronic asthma care. Ideally, this care should be implemented in a fashion that limits utilization of scarce ED resources. We developed, iteratively refined, and pilot tested the feasibility of a computerized asthma kiosk to (1) capture asthma information, (2) deliver asthma education, and (3) facilitate guideline-based chronic asthma management.

METHODS

The following are the 4 phases of this study: (1) developing the content and structure of a computerized asthma kiosk, (2) iterative refinement through heuristic testing by human-computer interface experts, (3) usability testing with ED providers (n = 4) and caregivers of children with asthma (n = 4), and (4) pilot testing the kiosk with caregivers (n = 31) and providers in the ED (n = 18). Outcome measures for the pilot-testing phase were the proportion of ED providers who prescribed long-term controller medication (LTCM) and asthma action plans (AsAPs) and the proportion of children who took LTCMs and attended primary care providers follow-up.

RESULTS

After kiosk development and refinement, pilot implementation resulted in LTCMs prescribing and AsAP provision for 19 (61%) of 31 and 17 (55%) of 31 patients, respectively. Before kiosk use, the proportion of the 18 ED providers who reported prescribing LTCM was 1 (5%) of 18, and providing AsAPs was 0 (0%) of 18. Eighteen (58%) of the 31 caregivers reported that their children used LTCMs after kiosk use and 13 (42%) of 31 reported following up with the primary care provider within 1 month of the ED visits.

CONCLUSIONS

A rigorously developed asthma kiosk showed promise for initiating chronic asthma care in the ED.

Telephoned, Texted, or Typed Out: A Randomized Trial of Physician-Patient Communication After Emergency Department Discharge

BACKGROUND

Novel means of emergency department (ED) post-discharge communication-telephone callbacks and text messages-are increasingly being utilized to facilitate patient-oriented outcomes, such as ED revisits, patient adherence, and satisfaction.

OBJECTIVE

The primary measure of interest is the rate of ED revisits in the week after discharge. The secondary measures of interests are rate of primary medical doctor (PMD) or specialist physician contact in the week after discharge and patient satisfaction.

METHODS

Pilot randomized controlled trial with three groups: usual discharge; usual care + phone call 48 h after discharge asking if patients wanted to speak with a physician; or usual care + text message 48 h after discharge asking if patients wanted to speak with a physician. All participants received a 1-week assessment of patient satisfaction. ED revisit and contact with PMD or specialist physician within 7 days of discharge were obtained from electronic medical record and analyzed using χ² test.

RESULTS

Two hundred and fifty-one patients were enrolled and randomized (66 control, 103 phone, 82 text). Although the three groups did not show a statistically significant difference, the phone and text groups had similar and lower proportions of patients revisiting the ED (>50% reduction) and calling or visiting their PMD or specialist physician (approximately 30% reduction) than the control group (χ² = 4.57, degrees of freedom [df] = 2, p = 0.10; χ² = 1.36, df = 2, p = 0.51). There was no difference in patient satisfaction (χ² = 2.88, df = 2, p = 0.24).

CONCLUSIONS

Patients who are contacted for ED follow-up by phone and text, though perhaps not more satisfied, may tend to revisit the ED and contact their PMD or specialty physician less often than patients receiving standard written discharge instructions. However, this pilot study is underpowered, so larger randomized studies are needed to confirm.

Comparing Ran-Out Status of Inhaled Short-Acting Beta-Agonists in Emergency Department Patients with Acute Asthma: 1996-1998 versus 2015-2017

BACKGROUND

Medication nonadherence, including running out of inhaled asthma medications, is an important problem.

OBJECTIVE

The objective of this study was to examine the changes in the proportion of adults with acute asthma who ran out of their short-acting beta-agonist (SABA) inhalers before presenting to the emergency department (ED) between 1996--1998 and 2015-2017.

METHODS

We analyzed data from prospective multicenter observational cohort studies of ED adult patients (aged 18-54 years) with acute asthma. Within the same 3 EDs, we performed a structured interview during 2 time periods: 1996-1998 and 2015-2017. We fitted multivariable models to compare ran-out status between the 2 periods, adjusting for the baseline patient demographics, socioeconomic status, chronic asthma factors, and health care utilization factors. We further adjusted for the presence of a written action plan-an intervenable factor.

RESULTS

The analytic cohort comprised 353 patients (150 from the 1996-1998 studies and 203 from the 2015-2017 study). Over the approximately 20-year period, the proportion of patients who ran out of SABA inhalers increased (18% in 1996-1998 vs 26% in 2015-2017). In the multivariable model, compared with patients in 1996-1998, those in 2015-2017 had a significantly higher risk of running out of their SABA inhalers (adjusted odds ratio [OR] 2.01; 95% confidence interval [CI] 1.06-3.81; P = .03). With further adjustment for the presence of a written action plan, this difference attenuated (adjusted OR 1.66; 95% CI 0.75-3.68; P = .21).

CONCLUSIONS

Between 1996 and 2017, the proportion of ED patients with asthma who ran out of SABA inhalers significantly increased. The increase was explained, at least partially, by a lack of a written action plan.

Care transition interventions for children with asthma in the emergency department

The emergency department (ED) is a critical point of identification and treatment for some of the most high-risk children with asthma. This review summarizes the evidence regarding care transition interventions originating in the ED for children with uncontrolled asthma, with a focus on care coordination and self-management education. Although many interventions on care transition for pediatric asthma have been tested, only a few were actually conducted in the ED setting. Most of these targeted both care coordination and self-management education but ultimately did not improve attendance at follow-up appointments with primary care providers, improve asthma control, or reduce health care utilization. Conducting any ED-based intervention in the current environment is challenging because of the many demands on ED providers and staff, poor communication within and outside of the medical sector, and caregiver/patient burden. The evidence to date suggests that ED care transition interventions should consider expanding beyond the ED to bridge the multiple sectors children with asthma navigate, including health care settings, homes, schools, and community spaces. Patient-centered approaches may also be important to ensure adequate intervention design, enrollment, retention, and evaluation of outcomes important to children and their families.

Inhaled corticosteroid prescribing in a pediatric emergency department: Sustained success and prescription filling rates

OBJECTIVE

To determine if improvement in Inhaled Corticosteroid (ICS) prescribing in the pediatric emergency department (PED) can be sustained after transition from intense intervention to low-intervention phase, and to determine ICS fill rates.

METHODS

A Quality Improvement (QI) project began in Aug 2012. Results through Feb 2014 were previously published. In Feb 2014 interventions were scaled back to determine the sustainability of QI success. Eligible patients included children aged 2-17 seen in the PED for asthma between Feb 2014 and Sept 2016. The primary change when moving to the low-intervention phase was stopping monthly attending feedback. The primary outcome was the proportion of patients who were prescribed an ICS at the time of PED discharge. The secondary objective of this study was to determine the proportion of patients who filled their ICS prescription in the 6 months following Emergency Department (ED) visit.

RESULTS

The goal rate of ICS prescribing was 75%. After transition to the low-intervention phase, the ICS prescribing rate was maintained at a median of 79% through Sept 2016. ICS fill rate in the first 30 days following ED visit was 89%, although this quickly fell to below 40% for months 2-6.

CONCLUSIONS

The ICS prescribing rate remained the goal of 75% over a 2.5-year period after transition to a low-intervention phase. High ICS fill rates immediately after ED visit have been demonstrated. However, rapid decline in these rates over subsequent months suggests a need for future efforts to focus on long-term ICS adherence among children with ED visits for asthma.

Development of a Patient-centered Outcome Measure for Emergency Department Asthma Patients

BACKGROUND

Measuring outcomes of emergency care is of key importance, but current metrics, such as 72-hour return visit rates, are subject to ascertainment bias, incentivize overtesting and overtreatment at initial visit, and do not reflect the full burden of disease and morbidity experienced at home following ED care. There is increasing emphasis on including patient-reported outcomes, but the existing patient-reported measures have limited applicability to emergency care.

OBJECTIVE

The objective was to identify concepts for inclusion in a patient-reported outcome measure for ED care and assess differences in potential concepts by health literacy.

METHODS

A three-phase qualitative study was completed using freelisting and semistructured interviewing for concept identification, member checking for concept ranking, and cognitive interviewing for question development. Participants were drawn from three tertiary care EDs. Parents of patients (pediatric) or patients (adult) with asthma completed a demographic survey and an assessment of health literacy. Phase 1 participants also completed a freelisting exercise and qualitative interview regarding the definition of success following ED discharge. Phase 2 participants completed a member checking survey based on concepts identified in Phase 1. Phase 3 was a pilot of trial questions based on the highest-ranked concepts from Phase 2.

RESULTS

Phase 1 enrolled 22 adult patients and 37 parents of pediatric patients. Phase 2 enrolled 41 adult patients and 200 parents. Phase 3 involved 15 parents. Across all demographic/literacy groups, Phase 1 participants reported return to usual activity and lack of asthma symptoms as the most important markers of success. In Phase 2, symptom improvement, medication use and access, and asthma knowledge were identified as the most important components of the definition of post-ED discharge success. Phase 3 resulted in five questions for the proposed measure.

CONCLUSIONS

A stepwise qualitative process can identify, rank, and formulate questions based on patient-identified concepts for inclusion in a patient-reported outcome measure for ED discharge. The four key concepts identified for inclusion: symptom improvement, medication access, correct medication use, and asthma knowledge are not measured by existing quality metrics.

The Transition of Care Between Emergency Department and Primary Care: A Scoping Study

OBJECTIVES

Patients with chronic diseases are often forced to seek emergency care for exacerbations. In the face of large predicted increases in the prevalence of chronic diseases, there is increased pressure to avoid hospitalizing these patients at the end of the ED visit, if they can obtain the care they need in the outpatient setting. We performed this scoping study to provide a broad overview of the published literature on the transition of care between ED and primary care following ED discharge.

METHODS

We performed a MEDLINE search of English-language articles published between 1990 and March 2015. We created a data-charting form a priori of the search. Papers were organized into themes, with new themes created when none of the existing themes matched the paper. Papers with multiple themes were assigned preferentially to the theme that was consistent with their primary objectives. We created a descriptive numerical summary of the included studies.

RESULTS

Of 1,138 titles, there were 252 potentially relevant abstracts, and among those 122 met criteria for full paper review. An additional 11 papers were acquired from reference review. From the 133 papers, 85 were included in the study. The papers were categorized into seven themes. These included Follow-up compliance and its predictors (38 studies), Telephone calls to discharged ED patients (15 studies), ED navigators (14 studies), The current system (nine studies), Ways to alert primary care providers (PCPs) of the ED visit (seven studies), and Patient views and PCP information requirements (one each). In the Follow-up compliance and predictors theme, the two most frequently identified significant predictors for increasing the frequency of follow-up care were the provision of a follow-up appointment time prior to ED departure and the presence of health insurance. Follow-up telephone calls to patients resulted in better follow-up rates, but increased ED return visits in some studies. In the current system patients themselves are the conduit, and the barriers to follow-up care can be high. E-mail and/or electronic medical record alerts to the PCP are relatively new, and no studies limited the alerts to patients who had a defined need for follow-up care.

CONCLUSIONS

A plethora of work has been published on the transition of care from ED to primary care. To decrease hospitalizations among the upcoming wave of patients with chronic diseases, it appears that the two most efficient areas to target are a primary care follow-up appointment system and health insurance. Further research is needed in particular to identify the patients who actually need follow-up care and to develop information technology solutions that can be effectively implemented within the current emergency healthcare system.

New views on global child health: global solutions for care of vulnerable children in the United States

PURPOSE OF REVIEW

This paper provides a brief overview of the current landscape of global child health and the impact of social determinants on the world's children. In the United States (US), global child health (GCH) has increasingly been highlighted as a priority area by national organizations, such as the National Academy of Medicine and American Academy of Pediatrics, as well as individual pediatricians committed to ensuring the health of all children regardless of geographic location. Although GCH is commonly used to refer to the health of children outside of the US, here, we highlight the recent call for GCH to also include care of US vulnerable children. Many of the lessons learned from abroad can be applied to pediatrics domestically by addressing social determinants that contribute to health disparities.

RECENT FINDINGS

Using the 'three-delay' framework, effective global health interventions target delays in seeking, accessing, and/or receiving adequate care. In resource-limited, international settings, novel health system strengthening approaches, such as peer groups, community health workers, health vouchers, cultural humility training, and provision of family-centered care, can mitigate barriers to healthcare and improve access to medical services.

SUMMARY

The creative use of limited resources for pediatric care internationally may offer insight into effective strategies to address health challenges that children face here in the US. The growing number of child health providers with clinical experience in resource-limited, low-income countries can serve as an unforeseen yet formidable resource for improving pediatric care in underserved US communities.

Emergency Department-Based Care Transitions for Pediatric Patients: A Systematic Review

CONTEXT

Successful care transitions between emergency departments (EDs) and outpatient settings have implications for quality, safety, and cost of care.

OBJECTIVE

To investigate the effectiveness of ED-based care transition interventions in achieving outpatient follow-up among pediatric patients.

DATA SOURCES

Medline, Embase, CINAHL, Cochrane Library, trial registers, and reference lists of relevant articles.

STUDY SELECTION AND DATA EXTRACTION

Eligible studies included randomized controlled trials of ED-based care transition interventions involving pediatric patients (aged ≤18 years). Study selection, data extraction, and risk of bias assessment were performed in duplicate and independent manner. Study results were pooled for meta-analysis by using a random effects model.

RESULTS

Sixteen randomized controlled trials, comprising 3760 patients, were included in the study. Most interventions were single-site (n = 14), multicomponent (n = 12), and focused on patients with asthma (n = 8). Pooling data from 10 studies (n = 1965 patients) found moderate-quality evidence for a relative increase of 29% in outpatient follow-up with interventions compared with routine care (odds ratio, 1.58 [95% confidence interval, 1.08-2.31]). Successful interventions included structured telephone reminders, educational counseling on follow-up, and appointment scheduling assistance. There was low-quality evidence when pooling data from 5 studies (n = 1609 participants) that exhibited little or no beneficial effect of interventions on ED readmissions (risk ratio, 1.02 [95% confidence interval, 0.91-1.15]).

LIMITATIONS

All studies were conducted in urban US hospitals which makes generalization of the results to rural settings and other countries difficult.

CONCLUSIONS

ED-based care transition interventions are effective in increasing follow-up but do not seem to reduce ED readmissions. Further research is required to investigate the mechanisms that affect the success of these interventions.

Primary Care Follow-up After Emergency Department Visits for Routine Complaints: What Primary Care Physicians Prefer and What Emergency Department Physicians Currently Recommend

OBJECTIVES

Given that the vast majority of pediatric patients that present to the emergency department (ED) are discharged home after their visit, one issue for study is the appropriate recommendations for follow-up after the ED visit. Numerous PubMed searches using various keywords revealed a gap in the literature regarding the desires of primary care physicians (PCPs) concerning follow-up after ED visits. This study was conducted to determine how pediatric emergency medicine (PEM) physicians' recommendations for follow-up align with the desires of (PCPs) for follow-up after ED visits.

METHODS

An electronic survey was distributed to pediatric emergency physicians at one community-based academic institution regarding current recommendations for follow-up with PCPs for 12 common diagnoses seen in the ED. A similar survey was sent to pediatricians in the same community inquiring about their desires for follow-up after their patients are seen in the ED for the same diagnoses.

RESULTS

Completion rates for the survey were 40/40 (100%) for PEM physicians and 78/145 (54%) for pediatricians. In 11/12 of the diagnoses included, PEM physicians recommended a statistically significant (P < 0.05) closer follow-up than desired by the PCPs.

CONCLUSIONS

Recommendations for follow-up made by PEM physicians and desired by PCPs vary significantly. Overall, PEM physicians recommend closer follow-up than desired by PCPs for low acuity complaints. Closing of this gap may allow for a better allocation of resources and consistency of care.

Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit

OBJECTIVE

The goal of this report is to review available modalities for assessing and managing acute asthma exacerbations in pediatric patients, including some that are not included in current expert panel guidelines. While it is not our purpose to provide a comprehensive review of the National Asthma Education and Prevention Program (NAEPP) guidelines, we review NAEPP-recommended treatments to provide the full range of treatments available for managing exacerbations with an emphasis on the continuum of care between the ER and ICU.

DATA SOURCES

We searched PubMed using the following search terms in different combinations: asthma, children, pediatric, exacerbation, epidemiology, pathophysiology, guidelines, treatment, management, oxygen, albuterol, β2-agonist, anticholinergic, theophylline, corticosteroid, magnesium, heliox, BiPAP, ventilation, mechanical ventilation, non-invasive mechanical ventilation and respiratory failure. We attempted to weigh the evidence using the hierarchy in which meta-analyses of randomized controlled trials (RCTs) provide the strongest evidence, followed by individual RCTs, followed by observational studies. We also reviewed the NAEPP and Global Initiative for Asthma expert panel guidelines.

RESULTS AND CONCLUSIONS

Asthma is the most common chronic disease of childhood, and acute exacerbations are a significant burden to patients and to public health. Optimal assessment and management of exacerbations, including appropriate escalation of interventions, are essential to minimize morbidity and prevent mortality. While inhaled albuterol and systemic corticosteroids are the mainstay of exacerbation management, escalation may include interventions discussed in this review.

Outcomes of follow-up care after an emergency department visit among pediatric asthmatics in the military health system

BACKGROUND AND OBJECTIVES

Asthma exacerbations frequently trigger emergency department (ED) visits. Guidelines recommend timely follow-up after an ED visit for asthma, however, other studies have questioned the quality of follow-up care and their effect on subsequent ED utilization. We evaluated follow-up care on asthma outcomes in pediatric asthmatics enrolled in the Military Health System (MHS) after an ED visit for asthma.

METHODS

This retrospective study utilized MHS data to evaluate 2-17-year-old persistent asthmatics with an ED visit for asthma between 2010-2012. Demographics, medication dispensing, and subsequent asthma related ED and hospital utilization were compared between those with or without a 28-day follow-up appointment.

RESULTS

10,460 of 88,837 persistent asthmatics met inclusion criteria for an asthma ED visit. 4,964 (47.5%) had ≥ 1 follow-up visit. In the 29-365 days after their ED visit, 21.1% of the follow-up cohort required an ED re-visit compared to 24.0% of the patients without follow-up. Follow-up care was associated with a reduction in ED re-visits (adjusted hazard ratio 0.86; 95% confidence interval 0.79, 0.93). Controller medications were dispensed to 76.0% of the follow-up cohort within 90 days of their ED visit compared to 49.7% in the group without follow-up.

CONCLUSIONS

Despite universal access to healthcare, less than half of pediatric MHS asthma patients had follow-up within 28 days of an ED visit. Those with follow-up were more likely to fill a controller medication within 90 days post-ED visit, and less likely to have an asthma ED re-visit in the subsequent year.

Transitional care clinics for follow-up and primary care linkage for patients discharged from the ED

OBJECTIVES

Transitional care clinics (TCCs) represent one strategy to facilitate follow-up and primary care linkage for patients with no regular source of care who are discharged from the emergency department (ED). We assessed factors associated with completion of TCC follow-up among these patients and characterized their subsequent ED use.

METHODS

Retrospective study of 660 randomly sampled patients with a scheduled appointment to a TCC at time of ED discharge. Patient- and visit-level characteristics were abstracted from the medical records of these patients and linked to a state visit database to characterize ED use after referral. Multiple logistic regression was used to determine factors associated with completion of follow-up and subsequent ED utilization.

RESULTS

Half (50%) of the patients completed their follow-up appointment with a mean follow-up time of 6.9days. Non-English language (odds ratio [OR], 2.21; confidence interval [CI], 1.30-3.75) was the only factor associated with improved follow-up; however, patients who were homeless (OR, 0.42; CI, 0.26-0.66) had a substance use history (OR, 0.68; CI, 0.45-1.00), and those with more baseline ED visits (OR, 0.94 per additional ED visit; CI, 0.89-0.99) were significantly less likely to complete follow-up. After adjusting for demographic, clinical, and visit-level characteristics, patients who completed their appointment had significantly fewer ED visits in the subsequent year compared to patients who did not complete their appointment (mean, 2.3 vs 3.3 visits; difference, -1.0 visits in subsequent calendar year; CI for difference, -1.2 to -0.7).

CONCLUSION

Transitional care clinics represent a promising strategy to improve the continuity of care for emergency patients and may reduce unnecessary ED use.

Effectiveness of Educational Interventions to Increase Primary Care Follow-up for Adults Seen in the Emergency Department for Acute Asthma: A Systematic Review and Meta-analysis

OBJECTIVES

Patients with asthma commonly present to emergency departments (ED) with exacerbations. Asthma guidelines recommend close follow-up with a primary care provider (PCP) after ED discharge; however, this linkage is often delayed or absent. The objective of this study was to assess whether ED-directed educational interventions improve office follow-up with PCPs after ED discharge for acute asthma.

METHODS

Comprehensive literature searches were conducted in seven electronic databases (1946 to 2014). Randomized controlled clinical trials examining the effectiveness of educational interventions to increase office follow-up with a PCP were included. Study quality was determined using the Cochrane risk of bias tool; fidelity of the interventions was assessed using the Treatment Fidelity Assessment Grid. Using study data, risk ratios (RRs),and the number needed to treat for benefit (NNTB) with 95% confidence intervals (CI) were calculated using random-effects models.

RESULTS

From 427 potentially relevant studies, five (n = 825) were included. The overall risk of bias was unclear, and the description of intervention fidelity varied across the studies. Educational interventions targeting either patients or PCPs led to a greater likelihood of having primary care follow-up after ED discharge (RR = 1.6; 95% CI = 1.31 to 1.87; I(2)  = 0%). The number needed to treat for benefit was six (95% CI = 4 to 11). No significant benefit was observed in reductions of relapses (RR = 1.3; 95% CI = 0.82 to 1.98; I(2)  = 23%) and admissions (RR = 0.51; 95% CI = 0.24 to 1.06; I(2)  = 0%). Due to the small number of studies for each comparison, publication bias was not formally assessed.

CONCLUSIONS

ED-directed educational interventions targeting either patients or providers increase the chance of having office follow-up visits with PCPs after asthma exacerbations. Their impact on health-related outcomes (e.g., relapse and admissions) remains unclear.

Experiences, Functioning and Needs of Low-Income African American Mothers of Children With Asthma

The purpose of this proposed study was to explore experiences, needs and functioning of low-income, African American caregivers of children with asthma in order to better understand symptom management.

METHOD

A qualitative, descriptive design was used. A purposive sampling technique was used to screen 32 caregivers of children with asthma, and 15 caregivers agreed to participate.

RESULTS

Three main themes were identified: managing the symptoms; cultural beliefs and values; and culturally competent health care provider.

CONCLUSION

For the caregivers culture disparity is not just about access to health services but instead the healthcare providers' understanding of the complexity of symptoms management.