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

A profile of U.S. asthma centers, 2006

BACKGROUND

Asthma is a significant public health problem that results in 1.8 million annual emergency department (ED) visits. Many ED visits may be prevented with specialized asthma care.

OBJECTIVE

To describe US asthma centers with a long-term goal of exploring their potential role in improving outcomes for ED patients with acute asthma.

METHODS

We conducted initial online surveys in 2004. One survey identified asthma centers and their directors through reports by emergency medicine researchers and fellowship directors (allergy/immunology, pulmonary, and critical care) at US hospitals. A second survey asked asthma center directors to describe their asthma center. Follow-up surveys were conducted 2 years later in 2006.

RESULTS

Eighty-seven (49%) of the 177 hospitals surveyed have asthma clinics. Although spirometry was available on the day of the visit at all asthma centers surveyed in 2006, only 21% (95% confidence interval, 11 %-34%) of sites reported that at least 90% of visits per week included a spirometry test. Only one quarter (26%; 95% confidence interval, 15%-40%) of asthma centers reported that at least 90% of patients undergo a skin or blood test for environmental allergens during 1 of their visits. Half of center directors (53%) were unsure of the approximate number of annual ED visits for acute asthma at their hospital. No significant measured changes were noted in asthma centers between 2004 and 2006.

CONCLUSIONS

Asthma centers are heterogenous, with different services available. Although challenges remain, collaboration between EDs and asthma centers may contribute to improved asthma outcomes and merits further study.

Improving asthma communication in high-risk children

Few child asthma studies address the specific content and techniques needed to enhance child communication during asthma preventive care visits. This study examined the content of child and parent communications regarding their asthma management during a medical encounter with their primary care provider (PCP). The majority of parents and children required prompting to communicate symptom information to the PCP during the clinic visit. Some high-risk families may require an asthma advocate to ensure that the clinician receives an accurate report of child's asthma severity and asthma control to ensure prescribing of optimal asthma therapy.

Outcome measures for asthma disease management

PURPOSE OF REVIEW

Many interventions have been undertaken in managing asthma in a population-based framework. The identification of successful interventions would guide policy implementation to improve outcomes in patient morbidity and mortality and healthcare costs.

RECENT FINDINGS

Several studies have focussed on emergency room interventions in asthma management. Many support the existence of the "teachable moment" to lead to interventions that are effective. Other popular interventions are community-based educational programmes, targeting clinician and patient behavior modification. In some cases, it is unclear how these interventions impact patient-specific outcomes such as quality of life, symptom-free days, or missed days of school or work as these were not measured. Most studies separate patients on the basis of age (adults versus children), adding yet another level of complexity to the development of useful interventions.

SUMMARY

Several of the interventions failed to show a significant improvement of patient-centered asthma outcomes when they were measured. This was despite an improvement in surrogate measures, such as attendance of follow-up appointments. Many studies did not (or were not designed to) show a durable response. Further research is needed to understand this chronic disease and devise effective interventions with appropriate outcomes for measuring their effectiveness.

Education interventions for adults who attend the emergency room for acute asthma

BACKGROUND

The use of educational and behavioural interventions in the management of chronic asthma have a strong evidence base. There may be a role for educative interventions following presentation in an emergency setting in adults.

OBJECTIVES

To assess the effectiveness of educational interventions administered following an acute exacerbation of asthma leading to presentation in the emergency department.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register. Study authors were contacted for additional information. Searches are current to November 2006.

SELECTION CRITERIA

Randomised, parallel group trials were eligible if they recruited adults (> 17 years) who had presented at an emergency department with an acute asthma exacerbation. The intervention of interest was any educational intervention (for example, written asthma management plan).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Twelve studies involving 1954 adults were included. Education significantly reduced subsequent admission to hospital (relative risk 0.50; 95% confidence interval 0.27 to 0.91); however, did not significantly reduce the risk of re-presentation at emergency departments (ED) the study follow up (relative risk 0.69; 95% confidence interval 0.40 to 1.21). The lack of statistically significant differences between asthma education and control groups in terms of peak flow, quality of life, study withdrawal and days lost were hard to interpret given the low number of studies contributing to these outcomes. One study from the early 1990s measured cost and found no difference for total costs and costs related to physician visits and admissions to hospital. If data were restricted to emergency department treatment, education led to lower costs than control.

AUTHORS' CONCLUSIONS

This review found that educational interventions applied in the emergency department reduce subsequent asthma admissions to hospital. The interventions did not significantly reduce ED re-presentations; while the trend in effect favours educational interventions, the pooled results were not statistically significant. The impact of educational intervention in this context on longer term outcomes relating to asthma morbidity is unclear. Priorities for additional research in this area include assessment of health-related quality of life, lung function assessment, exploration of the relationship between socio-economic status and asthma morbidity, and better description of the intervention assessed.

Childhood asthma in the emergency department: trends, challenges, and opportunities

Acute exacerbations of childhood asthma are frequently managed in the emergency department (ED). ED-based surveillance and intervention projects highlight the limitations and challenges of acute and chronic childhood asthma management. Because a significant number of asthmatic children currently receive and will likely continue to seek acute asthma care in the ED, provision of asthma education and initiation of controller medication therapy during the ED visit, although controversial, may contribute to improving asthma outcomes and eventually to reducing the burden of asthma on our overcrowded EDs.