Improving follow-up for children with asthma after an acute Emergency Department visit

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.

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.

Ambulatory follow-up among publicly insured children discharged from the emergency department

BACKGROUND

While children discharged from the emergency department (ED) are frequently advised to follow up with ambulatory care providers, the extent to which this occurs is unknown. We sought to characterize the proportion of publicly insured children who have an ambulatory visit following ED discharge, identify factors associated with ambulatory follow-up, and evaluate the association of ambulatory follow-up with subsequent hospital-based health care utilization.

METHODS

We performed a cross-sectional study of pediatric (<18 years) encounters during 2019 included in the IBM Watson Medicaid MarketScan claims database from seven U.S. states. Our primary outcome was an ambulatory follow-up visit within 7 days of ED discharge. Secondary outcomes were 7-day ED return visits and hospitalizations. Logistic regression and Cox proportional hazards were used for multivariable modeling.

RESULTS

We included 1,408,406 index ED encounters (median age 5 years, IQR 2-10 years), for which a 7-day ambulatory visit occurred in 280,602 (19.9%). Conditions with the highest proportion of 7-day ambulatory follow-up included seizures (36.4%); allergic, immunologic, and rheumatologic diseases (24.6%); other gastrointestinal diseases (24.5%); and fever (24.1%). Ambulatory follow-up was associated with younger age, Hispanic ethnicity, weekend ED discharge, ambulatory encounters prior to the ED visit, and diagnostic testing performed during the ED encounter. Ambulatory follow-up was inversely associated with Black race and ambulatory care-sensitive or complex chronic conditions. In Cox models, ambulatory follow-up was associated with a higher hazard ratio (HR) of subsequent ED return (HR range 1.32-1.65) visit and hospitalization (HR range 3.10-4.03).

CONCLUSIONS

One-fifth of children discharged from the ED have an ambulatory visit within 7 days, which varied by patient characteristics and diagnoses. Children with ambulatory follow-up have a greater subsequent health care utilization, including subsequent ED visit and/or hospitalization. These findings identify the need to further research the role and costs associated with routine post-ED visit follow-up.

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.

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.

Hypertension in an Emergency Department Population in Moshi, Tanzania; A Qualitative Study of Barriers to Hypertension Control

BACKGROUND

Sub-Saharan Africa has a high prevalence of hypertension with a low rate of awareness, treatment adherence, and control. The emergency department (ED) may represent a unique opportunity to improve hypertension screening, awareness, and linkage to care. We conducted a qualitative study among hypertensive patients presenting to the ED and their healthcare providers to determine barriers to hypertension care and control.

METHODS

In northern Tanzania, between November and December 2017, we conducted three focus group discussions among patients with hypertension presenting to the emergency department and three in-depth interviews among emergency department physicians. In our study, hypertension was defined as a single blood pressure of ≥160/100 mm Hg or a two-time average of ≥140/90 mm Hg. Barriers to care were identified by thematic analysis applying an inductive approach within the framework method.

RESULTS

We enrolled 24 total patients into three focus groups and performed three in-depth interviews with individual providers. Thematic analysis identified two major domains: 1) patient knowledge, attitudes, and practices, and 2) structural barriers to hypertension care. Four major themes emerged within the knowledge, attitudes, and practices domain, including disease chronicity, provider communication, family support, and fear-based attitudes. Within the structural domain, several themes emerged that identified barriers that impeded hypertension follow-up care and self-management, including cost, access to care, and transportation and wait time.

CONCLUSION

Patients and physicians identified multiple barriers and facilitators to hypertension care. These perspectives may be helpful to design emergency department-based interventions that target blood pressure control and linkage to outpatient care.

Pediatric Emergency Department Return Visits Within 72 Hours: Caregivers' Motives and Analysis of Ethnic and Primary Language Disparities

OBJECTIVES

In the United States, approximately 2.2% to 5% of children discharged from the emergency department (ED) return within 72 hours. There is limited literature examining caregivers' reasons for return to the ED, and none among Hispanics and Spanish-speaking caregivers. We sought to examine why caregivers of pediatric patients return to the ED within 72 hours of a prior ED visit, and assess roles of ethnicity and primary language.

METHODS

A previously validated survey was prospectively administered to caregivers returning to the ED within 72 hours of discharge at a freestanding, tertiary care, children's hospital over a 7-month period. Reasons for return to the ED, previous ED discharge processes, and events since discharge were summarized according to Hispanic ethnicity, and English or Spanish language preference, and compared using the Fisher exact test.

RESULTS

Among 499 caregiver surveys analyzed, caregivers returned mostly because of no symptom improvement (57.5%) and worsening condition (35.5%), with no statistically significant differences between Hispanic/non-Hispanic ethnicity, or English/Spanish preference. Most (85.2%) caregivers recalled reasons to return to the ED. Recall of expected duration until symptom improvement was significantly higher among Hispanic (60.4%) versus non-Hispanic (52.1%) (P = 0.003), and for Spanish- (68.9%) versus English-speaking (54.6%) (P = 0.04), caregivers.

CONCLUSIONS

Most caregivers returned to the ED because their child's condition was not better or had worsened. Ethnicity and language were not associated with variations in reasons for return. Non-Hispanic and English-speaking caregivers were less likely to recall being informed of time to improvement and may require additional intervention.

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.

Outcomes from a pilot patient-centered hospital-to-home transition program for children hospitalized with asthma

OBJECTIVE

To evaluate a multi-component hospital-to-home (H2H) transition program for children hospitalized with an asthma exacerbation.

METHODS

A pilot prospective randomized clinical trial of guideline-based asthma care with and without a patient-centered multi-component H2H program among children enrolled in K-8^th grade on Medicaid hospitalized for an asthma exacerbation. H2H program includes 5 components: medications in-hand at discharge, school-based asthma therapy (SBAT) for controller medications, referral for home trigger assessments, communication with the primary care provider (PCP), and patient navigator support. Primary outcomes included feasibility and acceptability. Secondary outcomes included healthcare utilization, asthma morbidity, and caregiver quality of life.

RESULTS

A total of 32 children were enrolled and randomized. Feasibility outcomes in the intervention group included: medications in-hand at discharge (100%); SBAT for controller medication initiated (100%); home visit referrals made (100%) and home visits completed within 4 weeks of discharge (44%); PCP communication (100%); patient navigator communication at 3 days (81.3%) and 14 days (46.7%). Acceptability outcomes in the intervention group included: 87.5% of families continued SBAT, and 87.5% of families reported it was extremely helpful to have the home visit referral. Adjusting for baseline differences in age, asthma severity and control, there was no significant difference in healthcare utilization outcomes.

CONCLUSION

These pilot data suggest that comprehensive care coordination initiated during the inpatient stay is feasible and acceptable. A larger trial is justified to determine if the intervention may reduce healthcare utilization for urban, minority children with asthma.

Tuberculosis household accompaniment to improve the contact management cascade: A prospective cohort study

Background

Appropriate management of people exposed in the home to tuberculosis is essential to prevent morbidity. These household contacts, particularly children, should receive preventive therapy to prevent them from falling ill. However, few people receive preventive therapy worldwide. We sought to determine whether a community-based accompaniment intervention could improve tuberculosis contact management.

Methods

We conducted a prospective cohort study of household contacts of tuberculosis patients who initiated treatment during September 2015-June 2016 in Lima, Peru. Enrolled households received an intervention comprising home visits, transport vouchers, assistance coordinating evaluation procedures, and adherence support during preventive therapy. To evaluate the impact of the intervention, we conducted retrospective chart reviews of all patients initiating treatment during 6-month baseline and intervention periods.

Results

We enrolled 314 household contacts of 109 index patients. Of these, 283 (90%) completed evaluation, and 4 (1%) were diagnosed with tuberculosis. Preventive therapy was prescribed for 35/38 (92%) contacts 0–19 years old who were eligible under Peruvian guidelines. Preventive therapy was also prescribed for 6/26 (23%) contacts with unknown eligibility due to lack of a tuberculin skin test (TST), and 20/69 (29%) who were ineligible either because of a negative TST result or exposure to a drug-resistant or extrapulmonary case. Of the 61 contacts who were prescribed preventive therapy, 57 (93%) initiated treatment, and 51 (91%) completed treatment. The proportion of contacts who completed evaluation increased from 42% during the baseline period to 71% during the evaluation period (risk ratio [RR] = 1.73, 95% confidence interval [95% CI]: 1.41–2.13). The proportion of contacts who initiated preventive therapy increased from 15% to 40% (RR = 2.45, 95% CI: 1.42–4.22).

Conclusion

Accompaniment of TB patient households greatly improved the evaluation of household contacts for TB and increased the use of preventive therapy.

Family Caregiver Marginalization is Associated With Decreased Primary and Subspecialty Asthma Care in Head Start Children

BACKGROUND

Urban minority children are at risk for poor asthma outcomes and might not receive appropriate primary or subspecialty care. We hypothesized that preschool children with asthma whose caregivers reported more barriers to care would be less likely to have seen their primary care provider (PCP) or an asthma subspecialist and more likely to have had a recent emergency department (ED) visit for asthma.

METHODS

The Barriers to Care Questionnaire (BCQ) is used to measure expectations, knowledge, marginalization, pragmatics, and skills. We assessed asthma control using the Test for Respiratory and Asthma Control in Kids and these outcomes: PCP visits for asthma in the past 6 months, subspecialty care (allergist or pulmonologist) in the past 2 years, and ED visits in the past 3 months.

RESULTS

Three hundred ninety-five caregivers (96% African-American, 82% low-income, 96% Medicaid) completed the BCQ. Sixty percent (n = 236) of children had uncontrolled asthma, 86% had seen a PCP, 23% had seen a subspecialist, and 29% had an ED visit. Barriers related to marginalization were associated with decreased likelihood of PCP (odds ratio [OR], 0.95; P = .014) and subspecialty visits (OR, 0.92; P = .019). Overall BCQ score was associated with decreased likelihood of subspecialty care (OR, 0.98; P = .027). Barriers related to expectations, knowledge, pragmatics, and skills were not associated with any of the care outcomes.

CONCLUSIONS

Among low-income, predominantly African-American preschool children with asthma, primary and subspecialty care were less likely if caregivers reported past negative experiences with the health care system (marginalization). Clinicians who serve at-risk populations should be sensitive to families' past experiences and should consider designing interventions to target the most commonly reported barriers.

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.

Disseminability of computerized cognitive training: Performance across coaches

Cogmed is a computerized cognitive intervention utilizing coaches who receive standardized instruction in analyzing training indices and tailoring feedback to remotely monitor participant's performance. The goal of this study was to examine adherence, satisfaction, and efficacy of Cogmed across coaches. Survivors of pediatric brain tumors and acute lymphoblastic leukemia (N = 68) were randomized to intervention (Cogmed) or waitlist control. The intervention group was matched with one of two coaches. Cognitive assessments were completed before and after intervention, and participants and caregivers in the intervention group completed satisfaction surveys. T-tests showed no differences in adherence across coaches (number of sessions completed p = .38; d = .32). Noninferiority statistics were not consistently equivalent for satisfaction, but equivalence was supported for caregiver perceptions of pragmatic utility and participant perceptions of logistical ease of Cogmed. Equivalence was not consistently suggested for cognitive outcomes, but was supported on measures tapping relevant cognitive domains (attention, working memory, processing speed, academic fluency). This study suggests adherence can be maintained across coaches. While aspects of satisfaction and cognitive outcomes were equivalent, the possible influence of coach-based variables cannot be ruled out. Findings highlight challenges in standardizing the coaching component of multicomponent computerized interventions and the need for ongoing research to establish dessiminability.

Parental Management of Discharge Instructions: A Systematic Review

CONTEXT

Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for adverse outcomes. Parents' ability to manage discharge instructions has not been examined before in a systematic review.

OBJECTIVE

To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions.

DATA SOURCES

We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017).

STUDY SELECTION

We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated.

DATA EXTRACTION

Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form.

RESULTS

Sixty-four studies met inclusion criteria; most (n = 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (n = 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (n = 3), restrictions (n = 2), or equipment (n = 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED, n = 5; inpatient, n = 0).

LIMITATIONS

The studies were primarily observational in nature.

CONCLUSIONS

Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.

Development and implementation of an emergency department telephone follow-up system

Implementing a telephone follow-up system after a patient's emergency department (ED) visit is challenging, but it may improve patient safety and care. This study's objective was to describe the development and implementation of a comprehensive ED telephone follow-up system over a 9-year period. Discharged patients who received a follow-up telephone call within 48 hours of their ED visit included all pediatric patients, those who left without being seen by a provider, and any adult patient with a "high-risk chief complaint," which was defined as a headache, visual problem, chest pain, dyspnea, abdominal pain, syncope, trauma, and neurological-related problems. There were 127 524 cases that met criteria to receive a follow-up call, with 138 331 attempted calls being made and 46 114 (36.2%) cases successfully followed up. Forty-two percent of pediatric cases and 16% of patients who left without being seen were successfully contacted with a follow-up call; 1.6% of cases were referred to the CQI Committee. In the 9 years prior and after implementation of this follow-up system, there were 3.5 (95% confidence interval [CI] = 2.1-5.9) and 2.5 (95% CI = 1.3-4.5) medical malpractice lawsuits per 100 000 ED patient visits, respectively; this represented a 28.6% reduction. A comprehensive telephone follow-up program can be developed and implemented utilizing available resources.

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.

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.

Pediatric Emergency Department Return: A Literature Review of Risk Factors and Interventions

BACKGROUND AND OBJECTIVE

Children discharged from emergency departments (EDs) are often at risk for ED return. The objective was to identify risk factors and interventions to mitigate or prevent ED return among this patient population.

METHODS

Structured literature review of PubMed and clinicaltrials.gov was conducted to identify relevant studies. Inclusion criteria were studies evaluating ED returns by identifying risk factors and interventions in the pediatric population. Emergency department return was defined as returning to the ED within 1 year after initial visit. Abstract and full text articles were reviewed, and data were abstracted by 2 independent authors.

RESULTS

A total of 963 articles were screened and yielded 42 potential relevant articles involving pediatric population. After full text review, a total of 12 articles were included in the final analysis (6 on risk factors and 6 on interventions). Risk factors for pediatric ED return included behavioral/psychiatric problems, younger age, acuity of illness, medical history of asthma, and social factors. Interventions included computer-generated instructions, postdischarge telephone coaching, ED-made appointments, case management, and home environment intervention. Emergency department-made appointments and postdischarge telephone coaching plus monetary incentive improved outpatient follow-up rate but not ED return. Home environment assessment coupled with case management reduced ED returns specifically among asthma patients.

CONCLUSIONS

Several patient and visit characteristics can help predict children at risk for ED return. Although some interventions are successful at improving postdischarge follow-up, most did not reduce ED returns.

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.

Asthma-related emergency department use: current perspectives

Asthma is one of the most common chronic pediatric diseases. Patients with asthma often present to the emergency department for treatment for acute exacerbations. These patients may not have a primary care physician or primary care home, and thus are seeking care in the emergency department. Asthma care in the emergency department is multifaceted to treat asthma patients appropriately and provide quality care. National and international guidelines exist to help drive clinical care. Electronic and paper-based tools exist for both physicians and patients to help improve emergency, home, and preventive care. Treatment of patients with asthma should include the acute exacerbation, long-term management of controller medications, and controlling triggers in the home environment. We will address the current state of asthma research in emergency medicine in the US, and discuss some of the resources being used to help provide a medical home and improve care for patients who suffer from acute asthma exacerbations.

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.

Innovations in health information technologies for chronic pulmonary diseases

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic obstructive lung disorders in the US that affect over 49 million people. There is no cure for asthma or COPD, but clinical guidelines exist for controlling symptoms that are successful in most patients that adhere to their treatment plan. Health information technologies (HITs) are revolutionizing healthcare by becoming mainstream tools to assist patients in self-monitoring and decision-making, and subsequently, driving a shift toward a care model increasingly centered on personal adoption and use of digital and web-based tools. While the number of chronic pulmonary disease HITs is rapidly increasing, most have not been validated as clinically effective tools for the management of disease. Online communities for asthma and COPD patients are becoming sources of empowerment and support, as well as facilitators of patient-centered research efforts. In addition to empowering patients and facilitating disease self-management, HITs offer promise to aid researchers in identifying chronic pulmonary disease endotypes and personalized treatments based on patient-specific profiles that integrate symptom occurrence and medication usage with environmental and genomic data.

Unmet Needs at the Time of Emergency Department Discharge

OBJECTIVES

Emergency department (ED) discharge requires conveying critical information in a time-limited and distracting setting. Limited health literacy may put patients at risk of incomplete comprehension, but the relationship between discharge communication needs and health literacy has not been well defined. The goal of this study was to characterize the variation in needs and preferences regarding the ED discharge process by health literacy and identify novel ideas for process improvement from parents and patients.

METHODS

This was an in-depth qualitative interview study in two EDs using asthma as a model system for health communication. Adult patients and parents of pediatric patients with an asthma exacerbation and planned discharge were enrolled using purposive sampling to balance across literacy groups at each site. Interviews were audiotaped, transcribed, coded independently by two team members, and analyzed using a modified grounded theory approach. Interviews were conducted until thematic saturation was reached in both literacy groups at each site.

RESULTS

In-depth interviews were completed with 51 participants: 20 adult patients and 31 pediatric parents. The majority of participants identified barriers related to ED providers, such as use of medical terminology, and systems of care, such as absence of protected time for discharge communication. Patients with limited health literacy, but not those with adequate literacy, identified conflicting information between health care sources as a barrier to successful ED discharge.

CONCLUSIONS

Participants across literacy groups and settings identified multiple actionable areas for improvement in the ED discharge process. These included the use of simplified/lay language, increased visual learning and demonstration, and the desire for complete information. Individuals with limited literacy may particularly benefit from increased attention to consistency.

Poor asthma education and medication compliance are associated with increased emergency department visits by asthmatic children

BACKGROUND:

Acute exacerbations of bronchial asthma remain a major cause of frequent Emergency Department (ED) visits by pediatric patients. However, other factors including psychosocial, behavioural and educational, are also reportedly associated with repetitive ED visits. Therefore, it is necessary to determine whether such visits are justifiable.

OBJECTIVE:

The objective of this cross-sectional study was to identify risk factors associated with visits to ED by asthmatic children.

METHODS:

Asthmatic children (n = 297) between 1-17 years old were recruited and information collected at the time of visiting an ED facility at two major hospitals.

RESULTS:

Asthmatic patients visited the ED 3.9 ΁ 3.2 times-per-year, on average. Inadequately controlled asthma was perceived in 60.3% of patients. The majority of patients (56.4%) reported not receiving education about asthma. Patients reflected misconceptions about the ED department, including the belief that more effective treatments are available (40.9%), or that the ED staff is better qualified (27.8%). About half of patients (48.2%) visited the ED because of the convenience of being open 24 hours, or because they are received immediately (38.4%). Uncontrolled asthma was associated with poor education about asthma and/or medication use. Patients educated about asthma, were less likely to stop corticosteroid therapy when their symptoms get better (OR:0.55; 95% CI:0.3-0.9; P = 0.04).

CONCLUSION:

This study reports that most patients had poor knowledge about asthma and were using medications improperly, thus suggesting inefficient application of management action plan. Unnecessary and frequent visits to the ED for asthma care was associated with poor education about asthma and medication use. Potential deficiencies of the health system at directing patients to the proper medical facility were uncovered and underline the necessity to improve education about the disease and medication compliance of patients and their parents/guardians.

A randomized trial exploring the effect of a telephone call follow-up on care plan compliance among older adults discharged home from the emergency department

OBJECTIVES

Older patients discharged from the emergency department (ED) have difficulty comprehending discharge plans and are at high risk of adverse outcomes. The authors investigated whether a postdischarge telephone call-mediated intervention by a nurse would improve discharge care plan adherence, specifically by expediting post-ED visit physician follow-up appointments and/or compliance with medication changes. The second objectives were to determine if this telephone call intervention would reduce return ED visits and/or hospitalizations within 35 days of the index ED visit and to determine potential cost savings of this intervention.

METHODS

This was a 10-week randomized, controlled trial among patients aged 65 and older discharged to home from an academic ED. At 1 to 3 days after each patient's index ED visit, a trained nurse called intervention group patients to review discharge instructions and assist with discharge plan compliance; placebo call group patients received a patient satisfaction survey call, while the control group patients were not called. Data collection calls occurred at 5 to 8 days and 30 to 35 days after the index ED visits for all three groups. Chi-square or Fisher's exact tests were performed for categorical data and the Kruskal-Wallis test examined group differences in time to follow-up.

RESULTS

A total of 120 patients completed the study. Patients were 60% female and 72% white, with a mean age of 75 years (standard deviation [SD] ± 7.58 years). Intervention patients were more likely to follow up with medical providers within 5 days of their ED visits than either the placebo or the control group patients (54, 20, and 37%, respectively; p = 0.04). All groups performed well in medication acquisition and comprehension of medication indications and dosage. There were no differences in return visits to the ED or hospital within 35 days of the index ED visit for intervention patients, compared to placebo or control group patients (22, 33, and 27%, respectively; p = 0.41). An economic analysis showed an estimated 70% chance that this intervention would reduce total costs.

CONCLUSIONS

Telephone call follow-up of older patients discharged from the ED resulted in expedited follow-up for patients with their primary care physicians. Further study is warranted to determine if these results translate into improved patient outcomes, decreased return ED visits or hospital admissions, and cost savings resulting from this intervention.

Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children

OBJECTIVES

To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children.

METHODS

We prospectively enrolled 2-10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP "Acute Asthma" visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP.

RESULTS

One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5 ± 2.3 (standard deviation), range 0-10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2 ± 2.8; range 1-18. The mean number of PCP Acute Asthma visits/child was 0.7 ± 1.6; range 0-11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI -0.018, 0.06).

CONCLUSIONS

Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.

Quality improvement methods improve inhaled corticosteroid prescribing in the emergency department

OBJECTIVE

Inhaled corticosteroids (ICS) are underutilized among persistent asthmatics. Because of low outpatient follow-up rates after Emergency Department (ED) visits, children are unlikely to be prescribed ICS by their primary care physician after an acute exacerbation. ED physicians have the opportunity to contribute to the delivery of preventive care in the acute care setting. Our objective was to evaluate if quality improvement (QI) methods could improve the rate of ICS initiation at ED discharge.

METHODS

Within the Pediatric ED (PED) at a tertiary children's hospital, QI methods were used to encourage ICS prescribing at the time of ED discharge. Interventions focused on education at both the attending physician and resident level, process improvements designed to streamline prescribing, and directed provider feedback. This involved multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed monthly to determine ICS prescribing rates. The effect of our interventions on prescribing rate was tracked over time using a run chart.

RESULTS

Following our interventions, the ICS initiation rate for children seen in and discharged home from the ED with an acute asthma exacerbation increased from a baseline median rate of 11.25% to a median rate of 79% representing a significant, non-random improvement. The ICS initiation rate has been sustained for 8 months over our goal rate of 75%.

CONCLUSIONS

This study demonstrates that QI methods can be used to increase inhaled corticosteroid initiation rate at the time of ED discharge and, thus, improve the delivery of preventive asthma care in the acute care setting.

Frequent attenders to the ED: patients who present with repeated asthma exacerbations

BACKGROUND

Asthma has been reported as one of the main causes of frequent attendance to the emergency department (ED), and many of those visits are potentially preventable. Understanding the characteristics of frequent attender (FA) patients with asthmatic exacerbations will help to identify factors associated with frequent attendance and improve case management. The aim of this study is to describe the characteristics of FA who present multiple times to the ED for asthma exacerbations.

METHODS

This study was a retrospective review of cases presented to Singapore General Hospital ED in 2010. Patients who attended the ED for 4 times or more with at least 1 visit attributable to asthma exacerbations in 2010 were included. They were then categorized as FA with multiple exacerbations (FAME) and those with fewer exacerbations.

RESULTS

Of 105616 ED patients, 155 patients attending the ED in 2010 were identified as FA with asthma, and 26 (17%) of these patients were classified as FAME, resulting in 213 visits (45% of total visits). Compared with FA with fewer exacerbations group, FAME were more likely to be men (P = .002), unemployed (P < .000), bad debtors (P = .045), substance abusers (P = .022), previously known to medical social workers (P = .002), and were found to spend a longer amount of time in the ED (>6 hours) (P = .03).

CONCLUSION

We found that a small number of FAME patients accumulated a large number of ED visits and spent a significantly longer time in the ED. This group tended to be males with social, financial, and addiction problems.

Asthma update

Asthma continues to be one of the most common reasons for emergency department visits and a leading cause of hospitalization. Acute management involves severity-based treatment of bronchoconstriction and underlying airway inflammation. Optimal treatment has been defined and standardized through randomized controlled trials, systematic reviews, and consensus guidelines. Implementation of clinical practice guidelines may improve clinical, quality, and safety outcomes. Asthma morbidity is disproportionately high in poor, urban, and minority children. Children treated in emergency departments commonly have persistent chronic severity, significant morbidity, and infrequent follow-up and primary asthma care, and prescription of inhaled corticosteroids is appropriate.

Initiating inhaled steroid treatment for children with asthma in the emergency room: current reported prescribing rates and frequently cited barriers

OBJECTIVE

The objective of this study was to determine how frequently emergency department (ED) physicians prescribe inhaled corticosteroids (ICSs) and describe commonly cited barriers.

METHODS

We surveyed members of the American Academy of Pediatrics Section on Emergency Medicine between May and August 2011. Demographic data were collected. Using the knowledge-attitude-behavior model for barriers to physician guideline adherence, we asked 20 Likert scale questions regarding barriers to ICS prescribing. Our primary outcome was reported frequency of ICS prescribing. We defined frequent prescribers as those who prescribe ICS more than 25% of the time. Logistic regression models were built for each barrier category and identified barriers that predict infrequent prescribing.

RESULTS

Two hundred seven (19.5%) of the 1062 surveyed responded; 75.8% report prescribing ICS 25% of the time or less. For knowledge, those who agreed that the National Heart, Lung, and Blood Institute guidelines are not clear regarding the ED physician's role were less likely to be frequent prescribers compared with those who disagreed (adjusted odds ratio [OR], 0.31; 95% confidence interval [CI], 0.11-0.90). For attitude, those who agreed it is not the role of the ED physician to prescribe long-term medications were less likely to be frequent prescribers (adjusted OR, 0.12; 95% CI, 0.04-0.37). For behavior, those who agreed they do not routinely start long-term medications because they cannot see patients in follow-up were less likely to be frequent prescribers (adjusted OR, 0.21; 95% CI, 0.07-0.58).

CONCLUSIONS

Emergency department physicians report low rates of ICS prescribing. Commonly cited barriers include unclear guidelines, believing that long-term medication prescribing is not within their role, and inability to see patients in follow-up. Addressing guideline discrepancies may improve preventive care delivery in the ED.

Parental education on asthma severity in the emergency department and primary care follow-up rates

Asthma is the most prevalent chronic condition affecting children and a common chief complaint in emergency departments (EDs). We aimed to improve parents' understanding of their child's asthma severity on accessing our pediatric ED for an acute asthma exacerbation. A retrospective chart review was conducted to determine outpatient follow-up rates from our ED in 2010-2011. In an attempt to educate parents at ED discharge about their child's asthma severity at presentation, we included a visual severity scale on their discharge instructions. Postdischarge telephone interviews were completed to determine postintervention follow-up rates. Asthma follow-up rates at 1 week improved from 20.8% to 50% after intervention. This difference was statistically significant after controlling for age and clinical asthma score with logistic regression (P < .0001). Offering predischarge education about a child's initial asthma severity is a simple intervention that significantly improved follow-up rates for children seen in the ED for asthma exacerbation.

Challenges in providing preventive care to inner-city children with asthma

Although the scientific understanding of the pathophysiology of asthma and the quality of asthma therapies have significantly improved over the past 30 years, asthma morbidity remains high and preventive care low for inner-city children. This article focuses on 4 major challenges to providing preventive care (family and patient attitudes and beliefs, lack of access to quality medical care, psychosocial factors, environmental factors) based on prior evidence and the authors' observation of these challenges in research with inner-city children with asthma over the past decade. Cost issues related to preventive care are addressed, and recommendations provide for pediatric nurses.

A cost-effectiveness analysis of inhaled corticosteroid delivery for children with asthma in the emergency department

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of 3 inhaled corticosteroid (ICS) delivery options for children with asthma treated in and discharged from the emergency department (ED).

STUDY DESIGN

We conducted cost-effectiveness analysis using a decision tree to compare 3 ED-based ICS delivery options: usual care (recommending outpatient follow-up), prescribe (uniformly prescribing ICS), and dispense (uniformly dispensing ICS). Accounting for expected follow-up rates, prescription filling, and medication compliance, we compared projected rates of ED relapse visits and hospitalizations within 1 month of ED visit across all 3 arms. Direct and indirect costs were compared.

RESULTS

The model predicts that the rate of return to ED per 100 patients within 1 month of the ED visit was 10.6 visits for the usual care arm, 9.4 visits for the prescription arm, and 8.4 visits for the medication-dispensing arm. Rates of hospitalization per 100 patients were 2.4, 2.2, and 1.9, respectively. Direct costs per 100 patients for each arm were $23,400, $20,800, and $19,100, respectively. Including indirect costs related to missed parental work, total costs per 100 patients were $27,100, $22,000, and $20,100, respectively. Total cost savings per 100 patients comparing the usual care arm with the medication dispensing arm was $7000.

CONCLUSIONS

This decision analysis model suggests that uniform prescribing or dispensing of ICS at the time of ED visit for asthma may lead to a decreased number of ED visits and hospital admissions within 1 month of the sentinel ED visit and provides a substantial cost-savings.

Factors associated with completion of a behavioral intervention for caregivers of urban children with asthma

BACKGROUND

Rates of preventive follow-up asthma care after an acute emergency department (ED) visit are low among inner-city children. We implemented a novel behavioral asthma intervention, Pediatric Asthma Alert (PAAL) intervention, to improve outpatient follow-up and preventive care for urban children with a recent ED visit for asthma.

OBJECTIVE

The objective of this article is to describe the PAAL intervention and examine factors associated with intervention completers and noncompleters.

METHODS

Children with persistent asthma and recurrent ED visits (N = 300) were enrolled in a randomized controlled trial of the PAAL intervention that included two home visits and a facilitated follow-up visit with the child's primary care provider (PCP). Children were categorized as intervention completers, that is, completed home and PCP visits compared with noncompleters, who completed at least one home visit but did not complete the PCP visit. Using chi-square test of independence, analysis of variance, and multiple logistic regression, the intervention completion status was examined by several sociodemographic, health, and caregiver psychological variables.

RESULTS

Children were African-American (95%), Medicaid insured (91%), and young (aged 3-5 years, 56%). Overall, 71% of children randomized to the intervention successfully completed all home and PCP visits (completers). Factors significantly associated with completing the intervention included younger age (age 3-5 years: completers, 65.4%; noncompleters, 34.1%; p < .001) and having an asthma action plan in the home at baseline (completers: 40%; noncompleters: 21%; p = .02). In a logistic regression model, younger child age, having an asthma action plan, and lower caregiver daily asthma stress were significantly associated with successful completion of the intervention.

CONCLUSIONS

The majority of caregivers of high-risk children with asthma were successfully engaged in this home and PCP-based intervention. Caregivers of older children with asthma and those with high stress may need additional support for program completion. Further, the lack of an asthma action plan may be a marker of preexisting barriers to preventive care.

Low rates of follow-up with primary care providers after pediatric emergency department visits for respiratory tract illnesses

OBJECTIVES

We sought to determine diagnosis-specific rates of follow-up with primary care providers (PCPs) after emergency department (ED) visits for respiratory tract illnesses. We hypothesized that follow-up rates would be higher among patients with acute infectious illnesses than among those with asthma.

METHODS

This was a retrospective cohort study of a random sample of patients aged 0 to 12 years discharged over a 12-month period from an urban, tertiary care pediatric ED with 4 different respiratory tract illnesses (asthma, bronchiolitis, croup, and pneumonia). Primary care provider follow-up was examined for associations with sociodemographic and clinical factors and with subsequent ED visits.

RESULTS

Rates of follow-up in the overall cohort were low: 23.6% (95% confidence interval, 19.7-27.4) by 7 days and 40.5% (95% confidence interval, 36.0-44.9) by 30 days. Compared with patients with asthma, the relative risks (RRs) of follow-up within 7 and 30 days were significantly higher among patients with bronchiolitis and pneumonia, but not with croup. For the cohort as a whole, the RR of follow-up within 7 and 30 days significantly decreased for each 1-year increase in age, and the RR of follow-up within 7 days significantly increased with the provision of explicit ED discharge instructions recommending follow-up. Among patients with asthma, follow-up with PCPs within 30 days was not associated with decreased ED visits for asthma over the following year.

CONCLUSIONS

Rates of PCP follow-up were globally low but significantly higher for patients with acute infectious illnesses, for younger patients, and for those receiving explicit ED discharge instructions.

Follow-up care after an emergency department visit for asthma and subsequent healthcare utilization in a universal-access healthcare system

OBJECTIVES

To describe the follow-up care within 28 days of an emergency department (ED) visit for asthma and to determine the association of follow-up visits within 28 days with ED re-visits and hospital admissions in the subsequent year.

STUDY DESIGN

Population-based retrospective cohort study of children with asthma aged 2-17 years treated in an ED in Ontario, Canada between April 14, 2006 and February 28, 2009. Multiple linked health administrative datasets and Cox proportional hazard multivariable survival models were used to test the association of characteristics of 28-day follow-up visits with 1-year outcomes.

RESULTS

The final cohort consisted of 29391 children, of whom 32.8% had follow-up, 6496 (22.1%) had an ED re-visit, and 801 (2.7%) had a hospital admission. Having a follow-up visit was not associated with ED re-visit or hospitalizations (hazard ratio 0.98; 95% CI 0.93, 1.03 and hazard ratio 1.06; 95% CI 0.92, 1.23, respectively). Younger children and those with indices of more severe acute or chronic asthma were more likely to have ED re-visits and hospitalizations. Other follow-up care characteristics (number of visits, type of physician providing care) were not associated with outcomes.

CONCLUSIONS

Despite a universal healthcare setting, most children did not access follow-up care after an ED visit for asthma, and those that did had no associated benefit in terms of reduced ED re-visits and hospitalizations in the subsequent year.

Low rates of controller medication initiation and outpatient follow-up after emergency department visits for asthma

OBJECTIVE

To determine what proportion of patients who are seen in an emergency department (ED) for asthma receive inhaled corticosteroids or attend follow-up appointments.

STUDY DESIGN

This was a retrospective cohort study of 2007-2009 South Carolina Medicaid data. Enrollees aged 2-18 years who had an ED visit for asthma were included. Patients admitted for asthma or with an inhaled corticosteroid claim in the 2 months before the month of the ED visit were excluded. Covariates were sex, race, age, rural residence, and asthma severity. Outcome measures were a prescription for an inhaled corticosteroid filled within the 2 months after the ED visit and attendance at a follow-up appointment within the 2 months after the ED visit.

RESULTS

A total of 3435 patients were included. Out of the study cohort, 57% were male, 76% were of a minority race/ethnicity, 69% lived in an urban areas, 18% had inhaled corticosteroid use, and 12% completed follow-up. Multivariate analyses demonstrated that patients with severe asthma were more likely to receive an inhaled corticosteroid (OR, 2.9; 95% CI, 2.3-3.7) and attend a follow-up appointment (OR, 2.0; 95% CI, 1.5-2.6). Patients aged 2-6 years and those aged >12 years were less likely to attend follow-up (OR, 0.71; 95% CI, 0.56-0.90 and OR, 0.62; 95% CI, 0.47-0.83, respectively) (all models P < .0001).

CONCLUSION

Children with asthma seen in the ED have low rates of inhaled corticosteroid use and outpatient follow-up. This indicates a need for further interventions to increase the use of inhaled corticosteroids in response to ED visits.

Effective discharge communication in the emergency department

Communication at discharge is an important part of high-quality emergency department (ED) care. This review describes the existing literature on patient understanding and implementation of discharge instructions, discusses previous interventions aimed at improving the discharge process, and recommends best practices and future research. MEDLINE and Cochrane databases were searched, using combinations of key terms. Literature from both the adult and pediatric ED populations was reviewed. Multiple reports have shown deficient comprehension at discharge, with patients or parents frequently unable to report their diagnosis, management plan, or reasons to return. Interventions to improve discharge communication have been, at best, moderately successful. Patients need structured content, presented verbally, with written and visual cues to enhance recall. Written instructions need to be provided in the patient's language and at an appropriate reading level. Understanding should be confirmed before the patient leaves the ED. Further research is needed to describe the optimal content, channel, and timing for the ED discharge process and the relationship between discharge process and outcomes.

Home-based educational interventions for children with asthma

BACKGROUND

While guidelines recommend that children with asthma should receive asthma education, it is not known if education delivered in the home is superior to usual care or the same education delivered elsewhere. The home setting allows educators to reach populations (such as the economically disadvantaged) that may experience barriers to care (such as lack of transportation) within a familiar environment.

OBJECTIVES

To perform a systematic review on educational interventions for asthma delivered in the home to children, caregivers or both, and to determine the effects of such interventions on asthma-related health outcomes. We also planned to make the education interventions accessible to readers by summarising the content and components.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register of trials, which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearched respiratory journals and meeting abstracts. We also searched the Education Resources Information Center database (ERIC), reference lists of trials and review articles (last search January 2011).

SELECTION CRITERIA

We included randomised controlled trials of asthma education delivered in the home to children, their caregivers or both. In the first comparison, eligible control groups were provided usual care or the same education delivered outside of the home. For the second comparison, control groups received a less intensive educational intervention delivered in the home.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, assessed trial quality and extracted the data. We contacted study authors for additional information. We pooled dichotomous data with fixed-effect odds ratio and continuous data with mean difference (MD) using a fixed-effect where possible.

MAIN RESULTS

A total of 12 studies involving 2342 children were included. Eleven out of 12 trials were conducted in North America, within urban or suburban settings involving vulnerable populations. The studies were overall of good methodological quality. They differed markedly in terms of age, severity of asthma, context and content of the educational intervention leading to substantial clinical heterogeneity. Due to this clinical heterogeneity, we did not pool results for our primary outcome, the number of patients with exacerbations requiring emergency department (ED) visit. The mean number of exacerbations requiring ED visits per person at six months was not significantly different between the home-based intervention and control groups (N = 2 studies; MD 0.04; 95% confidence interval (CI) -0.20 to 0.27). Only one trial contributed to our other primary outcome, exacerbations requiring a course of oral corticosteroids. Hospital admissions also demonstrated wide variation between trials with significant changes in some trials in both directions. Quality of life improved in both education and control groups over time.A table summarising some of the key components of the education programmes is included in the review.

AUTHORS' CONCLUSIONS

We found inconsistent evidence for home-based asthma educational interventions compared to standard care, education delivered outside of the home or a less intensive educational intervention delivered at home. Although education remains a key component of managing asthma in children, advocated in numerous guidelines, this review does not contribute further information on the fundamental content and optimum setting for such educational interventions.

A randomized controlled trial of parental asthma coaching to improve outcomes among urban minority children

OBJECTIVES

To investigate whether asthma coaching decreases emergency department (ED) visits and hospitalizations and increases outpatient asthma monitoring visits.

DESIGN

Randomized controlled trial.

SETTING

Urban tertiary care children's hospital.

PARTICIPANTS

Primary caregivers (hereafter referred to as parents) of children aged 2 to 10 years with asthma who have Medicaid insurance coverage and are urban residents who were attending the ED for acute asthma care.

INTERVENTION

Eighteen months of participating in usual care (control group) vs receiving coaching focused on asthma home management, completion of periodic outpatient asthma monitoring visits, and development of a collaborative relationship with a primary care provider (intervention group).

MAIN OUTCOME MEASURES

The primary outcome was ED visits. Secondary outcomes were hospitalizations and asthma monitoring visits (nonacute visits focused on asthma care). Outcomes were measured during the year before and 2 years after enrollment.

RESULTS

We included 120 intervention parents and 121 control parents. More children of coached parents had at least 1 asthma monitoring visit after enrollment (relative risk [RR], 1.21; 95% confidence interval [CI], 1.04-1.41), but proportions with at least 4 asthma monitoring visits during 2 years were low (20.0% in the intervention group vs 9.9% in the control group). Similar proportions of children in both study groups had at least 1 ED visit (59.2% in the intervention group vs 62.8% in the control group; RR, 0.94; 95% CI, 0.77-1.15) and at least 1 hospitalization (24.2% in the intervention group vs 26.4% in the control group; 0.91; 0.59-1.41) after enrollment. An ED visit after enrollment was more likely if an ED visit had occurred before enrollment (RR, 1.46; 95% CI, 1.16-1.86; adjusted for study group), but risk was similar in both study groups when adjusted for previous ED visits (1.02; 0.82-1.27).

CONCLUSION

This parental asthma coaching intervention increased outpatient asthma monitoring visits (although infrequent) but did not decrease ED visits.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00149500.

Recruitment and retention of patients into emergency medicine clinical trials

The emergency medicine (EM) and prehospital environments are unlike any other clinical environments and require special consideration to allow the successful implementation of clinical trials. This article reviews the specific issues involved in EM clinical trials and provides strategies from EM and non-EM trials to maximize recruitment and retention. While the evidence supporting some of these strategies is deficient, addressing recruitment and retention issues with specific strategies will help researchers deal with these issues in their funding applications and in turn develop the necessary infrastructure to participate in EM clinical trials.

Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control

RATIONALE

An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial.

OBJECTIVES

We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department.

METHODS

We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, β(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control.

MEASUREMENTS AND MAIN RESULTS

Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes.

CONCLUSIONS

Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).

Make an M-PACT on asthma: rapid identification of persistent asthma symptoms in a pediatric emergency department

OBJECTIVE

To develop and validate a brief assessment instrument for persistent asthma symptoms in a pediatric emergency department (ED) population.

METHODS

Parents of children aged 1 to 18 years being discharged home after treatment for acute asthma in an urban children's hospital completed a 6-item screen for persistent symptoms that had been developed from national guidelines and previously validated. During a follow-up phone call 4 weeks after the ED visit, the instrument was repeated. An 8-item asthma-related quality-of-life (ARQOL) instrument was also administered at both times to assess construct validity. Item analysis assessed the performance of individual items and their combination versus the full instrument.

RESULTS

Four hundred thirty-three children were enrolled, and 361 patients (83%) had complete data. Sensitivity and predictive value were calculated for the full screen and combination of items in detecting persistent symptoms at baseline and follow-up. A 3-item version included symptoms with activity, symptoms at night, and need for rescue albuterol. This version was 96% sensitive (95% confidence interval, 92-99) for persistent symptoms compared with the 6-item screen, and 69% (95% confidence interval, 62-76) of the participants continued to report persistent symptoms 4 weeks after the visit. For both screens, subjects with persistent symptoms had significantly worse ARQOL score at baseline and follow-up.

CONCLUSIONS

A brief screen can identify persistent symptoms in pediatric ED patients with good sensitivity compared with a longer instrument. Most of these patients will continue to report persistent symptoms and reduced ARQOL score 1 month after the ED visit and may be candidates for additional interventions in the ED to improve long-term asthma care.