Comparison of emergency room asthma care to National Guidelines

Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review

A gap between guidelines or protocols and clinical practice often exists, which may result in patients not receiving appropriate care. Therefore, the objectives of this systematic review were (1) to give an overview of professionals' adherence to (inter)national guidelines and protocols in the emergency medical dispatch, prehospital and emergency department (ED) settings, and (2) to explore which factors influencing adherence were described in studies reporting on adherence. PubMed (including MEDLINE), CINAHL, EMBASE and the Cochrane database for systematic reviews were systematically searched. Reference lists of included studies were also searched for eligible studies. Identified articles were screened on title, abstract and year of publication (≥1990) and were included when reporting on adherence in the eligible settings. Following the initial selection, articles were screened full text and included if they concerned adherence to a (inter)national guideline or protocol, and if the time interval between data collection and publication date was <10 years. Finally, articles were assessed on reporting quality. Each step was undertaken by two independent researchers. Thirty-five articles met the criteria, none of these addressed the emergency medical dispatch setting or protocols. Median adherence ranged from 7.8-95% in the prehospital setting, and from 0-98% in the ED setting. In the prehospital setting, recommendations on monitoring came with higher median adherence percentages than treatment recommendations. For both settings, cardiology treatment recommendations came with relatively low median adherence percentages. Eight studies identified patient and organisational factors influencing adherence. The results showed that professionals' adherence to (inter)national prehospital and emergency department guidelines shows a wide variation, while adherence in the emergency medical dispatch setting is not reported. As insight in influencing factors for adherence in the emergency care settings is minimal, future research should identify such factors to allow the development of strategies to improve adherence and thus improve quality of care.

Multicenter analysis of quality indicators for children treated in the emergency department for asthma

OBJECTIVE

To test the hypothesis that an association exists between process and outcome measures of the quality of acute asthma care provided to children in the emergency department.

METHODS

Investigators at 14 US sites prospectively enrolled consecutive children 2 to 17 years of age presenting to the emergency department with acute asthma. In models adjusted for variables commonly associated with the quality of acute asthma care, we measured the association between 7 measures of concordance with national asthma guideline-recommended processes and 2 outcomes. Specifically, we modeled the association between 5 receipt/nonreceipt process measures and successful discharge and the association between 2 timeliness measures and admission.

RESULTS

In this cohort of 1426 patients, 62% were discharged without relapse or ongoing symptoms (successful discharge), 15% were discharged with relapse or ongoing symptoms, and 24% were admitted. The composite score for receipt of all 5 receipt/nonreceipt process measures was 84%, and for timeliness measures, 57% receive a timely corticosteroid and 92% a timely β-agonist. Our adjusted models showed no association between process and outcome measures, with 1 exception: timely β-agonist administration was associated with admission, likely reflecting confounding by severity rather than a true process-outcome association.

CONCLUSIONS

We found no clinically significant association between process and outcome quality measures in the delivery of asthma-related care to children in a multicenter study. Although the quality of emergency department care does not predict successful discharge, other factors, such as outpatient care, may better predict outcomes.

Emergency department management of pediatric asthma at a university teaching hospital

BACKGROUND

Asthma is a major health problem and the most frequent cause of chronic illness and emergency department (ED) visits in children. Limited data examining the ED management of pediatric asthma within university teaching hospitals across the US exist.

OBJECTIVE

To compare the ED management of children (aged 1-17 y) with asthma at a university teaching hospital using National Asthma Education and Prevention Program (NAEPP) guidelines.

METHODS

All cases of pediatric asthma that presented to the University of California, San Francisco, Medical Center ED between October 1, 2003, and October 31, 2004, were included. Patients who required hospital admission were excluded. Data pertaining to patient demographics, primary diagnosis, pharmacologic management, diagnostic tests performed, and follow-up plans were abstracted and compared with NAEPP guidelines issued in 1997 and updated topics released in 2002.

RESULTS

A total of 141 cases were identified. Mean patient age was 5.8 years. Most (61.7%) patients were male and of African American ethnicity (31.9%). Asthma severity was typically mild (66.7%) or moderate (29.1%). In persons at least 6 years of age (n = 58), peak expiratory flow rate (PEFR) was performed in 25.9% of cases. Pulse oximetry, however, was always performed. Based on NAEPP guidelines, beta-agonists and corticosteroids should have been used, but were not, in 2.8% and 31.9% of cases, respectively. At discharge, no corticosteroid prescription was given in 40.4% of the cases, no written action plan was prepared in 80.1% of the cases, no formal device training was administered in 67.3% of cases, and no peak flow meter was provided for persons at least 6 years of age in 50.0% of cases.

CONCLUSIONS

NAEPP guidelines were met in all patients regarding pulse oximetry and in most patients with respect to the use of beta-agonists. Improvements could be made, however, in the use of corticosteroids in the ED; in performing PEFR measurements for persons at least 6 years of age upon arrival; and in providing formal device training, a written action plan, prescriptions for steroids, and peak flow meters at discharge.

Clinical measures associated with FEV1 in persons with asthma requiring hospital admission

OBJECTIVE

We sought to determine the association of select clinical measures of asthma severity with percent predicted forced expiratory volume in one-second (%FEV1).

METHODS

We studied a prospective cohort of adult subjects (N = 129) with asthma exacerbations requiring hospital admission. Clinical data was acquired, including medical and social history, symptoms, vital signs, physical assessment, and spirometry. Predictor variables for this study included manually determined pulsus paradoxus (PP), percent predicted peak expiratory flow rate (%PEFR) and accessory muscle use. The outcome measure was %FEV1. Multiple linear regression analyses were performed to determine the independent associations between predictor variables and %FEV1.

RESULTS

In univariate analysis, %PEFR correlated with %FEV1 (rho = 0.77, P < .001) and PP correlated negatively with %FEV1 (rho = - 0.384, P < .001). %FEV1 was significantly lower in participants with accessory muscle use (Median %FEV1 = 37.5%, IQR: 27.0-49.0) than in those without accessory muscle use (Median %FEV1= 55.0%, IQR: 39.0-69.0), (P = .004). In multivariable analysis including the covariates %PEFR, accessory muscle use, PP, age, sex, heart rate and respiratory rate, %PEFR (P < .0001) and accessory muscle use (P = .003) remained significantly associated with %FEV1, whereas PP did not (P = .52).

Effect of a clinical pathway on the hospitalisation rates of children with asthma: a prospective study

AIM

To determine the effect of implementing a clinical pathway, using evidence-based clinical practice guidelines, for the emergency care of children and adolescents with asthma.

METHODS

A prospective, before-after, controlled trial was conducted, which included patients aged 1-18 years who had acute exacerbations of asthma treated in a tertiary care paediatric emergency department. Data were collected for identical 2-month seasonal periods before and after implementation of the clinical pathway to determine hospitalisation rate and other outcomes. For 2 weeks after emergency visits, the rate at which patients returned to emergency care for worsening asthma was evaluated. A multidisciplinary panel, using national guidelines and a systematic review, developed the pathway.

RESULTS

267 patients were studied. The rate of hospitalisation was significantly lower in the post-implementation group (10/74; 13.5%) than in the pre-implementation control group (53/193; 27.5%; p = 0.02; number needed to treat 7.1). All reduction in hospitalisation occurred in children with moderate to severe asthma exacerbation. After implementation of the clinical pathway, the rate of administration of oral corticosteroids to patients with moderate or severe exacerbations increased from 71% to 92% (p = 0.01), and significantly more patients received beta2-agonists in the first hour (p = 0.02). No significant change in relapse to acute care occurred within 2 weeks (p = 0.19).

CONCLUSIONS

An evidence-based clinical pathway for children and adolescents with moderate to severe exacerbations of acute asthma markedly decreases their rate of hospitalisation without increased return to emergency care.

Emergency department as the main source of asthma care

Many asthma patients use the emergency department (ED) as the sole source of asthma care. This is considered inadequate and poor practice. This prospective study revealed that young age, lack of evening clinic, forgetting to keep the appointment, conflicting priorities of daily life, and easy access to the ED on an as-needed basis for urgent care, medications, and prescriptions, and failure to use inhaled corticosteroids were significant while lack of insurance or access to asthma clinic were not significant factors in exclusive use of the ED. Establishing ED asthma education programs or an after hours asthma clinic may alleviate the practice.

Inadequate follow-up controller medications among patients with asthma who visit the emergency department

STUDY OBJECTIVE

The purpose of this study is to determine the frequency with which primary care physicians add inhaled corticosteroids to the regimen of asthmatic patients after a visit to the emergency department (ED) among patients not previously prescribed inhaled corticosteroids and to determine the rate at which inhaled corticosteroids prescribed in the ED were continued by primary care physicians.

METHODS

We conducted a structured retrospective cohort study using electronic medical record review of consecutive patients aged 6 to 45 years, treated for acute asthma exacerbation (International Classification of Diseases, Ninth Revision code 493.00 through 493.99) in the ED during a specified 6-month period, and followed up for 1 year. The patients' first ED visit for asthma exacerbation during the study period was considered the index visit for purposes of this study.

RESULTS

Six hundred twenty-nine patients met study inclusion criteria, 414 of whom were not previously receiving inhaled corticosteroid therapy. On ED or hospital discharge, 99 (24%) of these 414 patients were prescribed an inhaled corticosteroid. Of these 99 patients, 37 patients had a primary care follow-up visit within 6 months, with 4 receiving an inhaled corticosteroid dose change and no patients having the inhaled corticosteroids discontinued. Of the 315 patients not prescribed an inhaled corticosteroid on ED or hospital discharge, 128 had a primary care follow-up visit within 6 months, with 32 (25%) patients having an inhaled corticosteroid added to their therapeutic regimen. After primary care follow-up, only 69 (42%) of the 165 patients treated in clinic were receiving an inhaled corticosteroid for control of their asthma. Patients without insurance (odds ratio 0.14; 95% confidence interval 0.027 to 0.71) and patients initially discharged home from the ED (odds ratio 0.17; 95% confidence interval 0.05 to 0.53) were much less likely to receive inhaled corticosteroids at follow-up on multivariate logistic regression adjusting for race, sex, insurance status, and initial disposition.

CONCLUSION

Primary care physicians infrequently add controller medications (inhaled corticosteroids) at follow-up to the regimen of asthmatic patients after a visit to the ED. Emergency physicians should be encouraged to evaluate chronic asthma burden among patients presenting with exacerbation, educate asthmatic patients, and prescribe controller medications, such as inhaled corticosteroids, for those with persistent symptoms.

[Consistency of clinical practice with the scientific evidence in the management of childhood asthma]

INTRODUCTION

There is substantial inconsistency between the evidence available on the management of childhood asthma and its application in practice.

OBJECTIVE

To evaluate the degree of appropriateness of current management of childhood asthma.

MATERIAL AND METHODS

We performed a structured review of the articles published on appropriateness in the recent biomedical literature (last 5 years). Methodological analysis and qualitative synthesis were performed.

RESULTS

Twenty-three articles were identified that reflected the following problems: insufficient documentation on trigger factors, evolution of pulmonary function and symptoms, inadequate guidelines on the treatment of exacerbations, inadequate use of inhaler devices, insufficient use of anti-inflammatory drugs, unjustified heterogeneity in the selection of anti-inflammatory drugs, lack of correlation between severity and level of treatment, lack of written guidelines on customized self-management, unjustified use of antibiotics, and lack of pulmonary function testing devices.

CONCLUSIONS

The management of childhood asthma should be reviewed since a large number of decisions made in clinical practice are not always based on valid scientific evidence.

Multi-colored simplified asthma guideline reminder: why pragmatic asthma tools are needed in real-world practice

Asthma is a chronic disease that is highly prevalent around the world with increasing societal and economic burden. National Asthma Educational and Preventive Program (NAEPP) and Global Initiative for Asthma (GINA) are evidence-based documents designed to help clinicians make appropriate decisions for their patients and to reduce undesirable variation in the care of asthmatic patients. It is a generally accepted fact that asthma specialists achieved better and improved asthma outcomes for their patients when compared with primary care physicians (PCPs). These outcome differences are somewhat related to PCPs' poor adherence to published NAEPP guidelines. Multi-Colored Simplified Asthma Guideline Reminder (MSAGR) is the first user-friendly single-sheet convenient asthma tool designed for clinicians after barriers to the poor adherence to asthma guidelines in primary care settings were identified. Voluntary acceptance and utilization of MSAGR resulted in fewer emergency room visits and hospitalizations for their patients. General acceptance of MSAGR (more than 1 million copies requested by clinicians globally), and overwhelming positive comments by asthma care providers, strongly advocate a need for real-time, pragmatic clinical tools not only in asthma, but also in other chronic diseases such as chronic obstructive pulmonary disease, diabetes mellitus, hypertension, and depression, etc. In this brief review, we discuss how clinicians, patients, and payers are utilizing these simplified asthma tools to improve asthma care in their community.

Evaluation of a program aimed at increasing referrals for asthma education of patients consulting at the emergency department for acute asthma

BACKGROUND

Emergency department (ED) visits for asthma may reflect poor asthma control, often due to insufficient asthma education and medical follow-up. However, few patients consulting an ED for asthma are referred for education.

AIMS

To describe a model for automatic referral to educational interventions targeting patients consulting at the ED for acute asthma, to demonstrate how this model can be integrated into current care, and to increase referrals for asthma education.

METHODS

The program combines a short ED-based educational intervention with the goal of motivating patients and their families to pursue an educational program with an automatic referral to an asthma education center (AEC) after agreement with ED physicians. The program was implemented in nine acute care centers with a high number of ED visits for asthma. The main study parameter was the number of patients referred to an AEC after 4 months of program implementation, as compared with 4 months before. In addition, we assessed potential barriers to successfully establishing the program.

RESULTS

In the first 4 months of the program, 1,104 patients were referred to an AEC, compared with 110 for the same period the year before; 106 patients (15%) patients could not be contacted, 114 patients (16.1%) refused the intervention, 488 patients (68.9%) made appointments, and 346 patients (48.9%, or 72.8% of scheduled patients) honored their appointments.

CONCLUSION

We describe a model of educational intervention for asthmatic patients consulting at the ED. We found that ED professionals can motivate patients to attend an asthma education program and that an automatic referral process is well accepted by ED staff. Such intervention can help to reduce asthma-related morbidity, but local barriers to implementation of such program should be addressed.

Measuring asthma disparities in Hispanics: adherence to the national guidelines for asthma treatment in emergency departments in Puerto Rico

BACKGROUND

Puerto Rico has the highest prevalence of asthma in the United States. Currently, there are no data on actual care given to asthmatic patients.

OBJECTIVE

To determine the prevalence of documented adherence to the 1997 National Asthma Education Prevention Program guidelines regarding care given in emergency departments (EDs) in Ponce, Puerto Rico.

METHODS

A case series was conducted using 6,002 ED records with a physician-based diagnosis of asthma for 1999 through 2001.

RESULTS

A history of asthma attack was documented in 82.0% of the cases and in all age groups. In-home beta-agonist use was recorded in only 5.7% of the medical records. Documentation of previous admissions to the ED and the intensive care unit were found in 3.5% and 0.33% of the records, respectively. Nocturnal symptoms before the ED visit were found in only 6.4% of the records, and asthma treatment at home was found in 39.9%. Accessory muscle retraction was documented in 99.1% of the cases, and oxygen saturation was found in 23.2%. Treatment with nebulized beta-agonist was found in 72.1% of the records, and intravenous or oral corticosteroid use was found in 84.1%. Follow-up appointments were detected in 64.8% of the cases, and referrals to specialists were given in only 5.3%. Rate ratios between our data and those of other researchers indicate that there are geographical differences in compliance with the guidelines.

CONCLUSION

Of the variables tested, only one had acceptable levels of compliance, as evidenced in the patient's records, indicating that there are alarming differences in ED evaluation and treatment compared with the 1997 National Asthma Education Prevention Program guidelines.

Standardized protocol improves asthma management in emergency department

This study assessed, 30 months after its initiation, the impact of a standardized asthma management program designed to facilitate the implementation of asthma management guidelines in a tertiary teaching hospital adult emergency department. The program was initiated in a stepwise manner: first, a retrospective baseline audit; followed by generation of local guidelines; validation of these guidelines by all staff involved; distribution of the guidelines; a second practice audit; use of these results to further improve the program; feedback to the staff; twice-yearly information meetings; and a new audit 2 years later. The main results were a significant improvement in history taking (p < 0.001), increased use of serial airflow measurements (p < 0.001), increased steroid use (p < 0.001), and better documentation of follow-up arrangements (p < 0.01). Several tests of questionable value were no longer prescribed routinely. The improvements persisted after 2.5 years. In contrast, there was no improvement in the proportion of medical files that contained records of discharge prescriptions for outpatients. Implementation of locally agreed guidelines resulted in a marked improvement in several aspects of asthma management in an emergency department; the program must be pursued to maintain and further improve quality of care.

Acute asthma among adults presenting to the emergency department: the role of race/ethnicity and socioeconomic status

OBJECTIVES

To investigate racial/ethnic differences in acute asthma among adults presenting to the emergency department (ED), and to determine whether observed differences are attributable to socioeconomic status (SES).

DESIGN

Prospective cohort studies performed during 1996 to 1998 by the Multicenter Airway Research Collaboration. Using a standardized protocol, researchers provided 24-h coverage for a median duration of 2 weeks per year. Adults with acute asthma were interviewed in the ED and by telephone 2 weeks after hospital discharge.

PARTICIPANTS

Sixty-four North American EDs.

RESULTS

A total of 1,847 patients were enrolled into the study. Black and Hispanic asthma patients had a history of more hospitalizations than did whites (ever-hospitalized patients: black, 66%; Hispanic, 63%; white, 54%; p < 0.001; patients hospitalized in the past year: black, 31%; Hispanic, 33%; white, 25%; p < 0.05) and more frequent ED use (median use in past year: black, three visits; Hispanic, three visits; white, one visit; p < 0.001). The mean initial peak expiratory flow rate (PEFR) was lower in blacks and Hispanics (black, 47%; Hispanic, 47%; white, 52%; p < 0.001). For most factors, ED management did not differ based on race/ethnicity. After accounting for several confounding variables, blacks and Hispanics were twice as likely to be admitted to the hospital. Blacks and Hispanics also were more likely to report continued severe symptoms 2 weeks after hospital discharge (blacks, 24%; Hispanic, 31%; white, 19%; p < 0.01). After adjusting for sociodemographic factors, the race/ethnicity differences in initial PEFR and posthospital discharge symptoms were markedly reduced.

CONCLUSION

Despite significant racial/ethnic differences in chronic asthma severity, initial PEFR at ED presentation, and posthospital discharge outcome, ED management during the index visit was fairly similar for all racial groups. SES appears to account for most of the observed acute asthma differences, although hospital admission rates were higher among black and Hispanic patients after adjustment for confounding factors. Despite asthma treatment advances, race/ethnicity-based deficiencies persist. Health-care providers and policymakers might specifically target the ED as a place to initiate interventions designed to reduce race-based disparities in health.

Accident and emergency departments are still failing to assess asthma severity

OBJECTIVES

To quantify the documentation of vital signs in children attending accident and emergency (A&E) for asthma and to assess whether indicators of severity were used appropriately.

METHODS

Records of all children aged 3 to 14 attending A&E for the treatment of asthma in four London hospitals over a three month period were examined for documentation of heart rate, respiratory rate, peak expiratory flow rate, oxygen saturation, and fraction of inspired oxygen. The relation between severity indicators and whether the child was admitted or not was examined.

RESULTS

There were 255 attendances in 229 children. Heart rate, respiratory rate, and oxygen saturation were recorded on most attendances (94.5%, 85.5%, and 96.8%) but fraction of inspired oxygen and peak flow were recorded in few children (48.6% and 48.5%). Heart rate and respiratory rate were higher and oxygen saturation lower in children who were admitted compared with those who were not.

CONCLUSIONS

Assessment of airways obstruction is inadequate in children but when measured may be used appropriately to guide admission. There is a need for interventions to improve assessment of children attending A&E for asthma.

Factors associated with emergency department use in asthma: acute care interventions improving chronic disease outcomes

OBJECTIVE

To provide a literature review of the factors associated with childhood asthma-related emergency department (ED) visits and to identify elements of effective ED interventions that reduce the frequency of childhood ED visits while increasing primary health care utilization.

DATA SOURCE

English Medline articles from 1990 that cross-referenced with the terms asthma, emergency, intervention, pediatric, and/or acute care. Experts in the field of allergy and asthma were also consulted.

STUDY SELECTION

Childhood asthma interventions in the ED.

RESULTS

Factors associated with childhood asthma-related ED visits include being impoverished, being exposed to allergens, receiving Medicaid or lacking insurance, being noncompliant with self-management skills, and having an African-American heritage. Other minorities may also be at risk, but further investigation is required to determine the extent. Attempts to link the patient to primary health care by the ED staff resulted in increased adherence to followup care.

CONCLUSIONS

The ED provides an opportunity to help patients and families deal with asthma to improve their quality of life. Further, current studies demonstrate that the ED is an appropriate setting for an intervention that links the patient back to the primary health care provider. More research is needed on the appropriate educational messages to be delivered in ED. Also, barriers to followup care and regular use of a primary health care provider need to be identified so that future intervention designs can address these issues.

Multicolored simplified asthma guideline reminder (MSAGR) for better adherence to national/global asthma guidelines

BACKGROUND

Clinicians in general have not widely and consistently used asthma guidelines in their practices around the world. This study identifies reasons for the poor adherence to asthma guidelines by primary care physicians (PCPs), and simultaneously introduces multicolored simplified asthma guideline reminder (MSAGR) as a practical tool to enhance adherence to asthma guidelines.

METHODS

Sixty-nine PCPs were given a simple, one-page, fill-in-the-blank questionnaire on the classification of asthma severity as defined in National Asthma Education and Prevention Program guidelines, using patients' symptoms, peak expiratory flow rate (PEFR)/forced expiratory volume in 1 second (FEV1) value, PEFR variability, and step therapy based on asthma severity. Also, they were given a questionnaire on barriers to using asthma guidelines and MSAGR for evaluation. In one targeted community, free copies of MSAGR were made available to PCPs, and data on emergency room visits and hospitalization of asthmatic patients were analyzed.

RESULTS

Of the PCPs, 16% correctly classified mild, intermittent asthma, 13% mild, persistent asthma, 8% moderate, persistent asthma, and 8% severe, persistent asthma based on the combined patient's symptoms, PEFR or FEV1 value and PEFR variability as defined in National Asthma Education and Prevention Program guidelines. One hundred percent of the PCPs chose inhaled beta2-agonists as quick relief medication. Fifty percent of the PCPs chose inhaled steroids, leukotriene antagonists, oral theophylline, and long acting beta-agonists in various combinations for different severity of asthma. Eighty percent of the physicians failed to select the appropriate dosages of inhaled steroids for different severities of asthma. Ninety-five percent of PCPs reported that MSAGR made using the guidelines easier for them. In the targeted community, asthma-related emergency room visits decreased 22.5% and hospitalizations by 26.9%.

CONCLUSIONS

This is the first study that identified the reasons for poor adherence to asthma guidelines by PCPs, and introduced MSAGR as a practical "low-tech" tool to promote better adherence to asthma guidelines. MSAGR presents patient-specific recommendations, based on asthma guidelines in a user-friendly format that can save the physician time in real-world primary care settings, where such information is often needed instantly. The overwhelming majority of PCPs strongly agreed that MSAGR helped them recall the classification of asthma severity in a timely manner, to inquire about various triggers, and to use step therapy accurately and confidently. In one targeted community, MSAGR helped clinicians in primary care settings to achieve better asthma outcomes and to reduce both emergency room visits and hospitalizations.

Asthma severity and adequacy of management in accident and emergency departments in France: a prospective study

BACKGROUND

Recent guidelines have enabled doctors to establish accident and emergency department management strategies for acute asthma on the basis of severity of exacerbations at presentation. However, there is no available information on acute asthma patients classified according to severity of disease. Our aim was to describe the severity of such exacerbations at presentation, and the adequacy of treatment and management.

METHODS

We did a 12-month multicentre cross-sectional observational cohort study in adult patients with acute asthma who attended one of 37 accident and emergency departments in France. The doctors who examined the patients obtained information using a formatted chart. We classified exacerbations according to severity (life-threatening, severe, or mild to moderate), on the basis of clinical findings and peak expiratory flow value, as defined by currently used guidelines.

FINDINGS

Of 3772 patients with acute asthma, 975 (26%) had life-threatening attacks, 1834 (49%) had severe exacerbations without life-threatening features, and 963 (26%) had mild to moderate exacerbations. Initial treatment included nebulised b2 agonists, anticholinergics, and systemic corticosteroids in 3492 (93%), 1841 (49%), and 2252 (60%), respectively. According to severity classification, anticholinergics were used in 494 (51%), 913 (50%), and 434 (45%) of patients in life-threatening, severe, and mild to moderate exacerbations groups, respectively; corticosteroids were given in 666 (68%), 1117 (61%), and 468 (49%), respectively. The overall admission rate was 54.2%, and mean stay was 6.1 (SD 6.0) days. Patients were admitted in 747 (77%), 1018 (55%), and 278 (29%) of cases in life-threatening, severe, and mild to moderate groups, respectively. Three patients died in hospital.

INTERPRETATION

Acute asthma exacerbations are often life-threatening in patients who attend accident and emergency departments, and management of patients is not ideal, mainly because of underuse of corticosteroids and inappropriate admission rates according to severity.

Effect of allergist intervention on patient-centered and societal outcomes: allergists as leaders, innovators, and educators

Atopic disorders, which afflict millions of Americans and hundreds of millions worldwide, are at epidemic levels with concomitant increases in morbidity and mortality. Environmental and lifestyle changes over the past three to five decades are proposed causes for this pandemic and as such present major burdens to reverse. The scope of allergy practice bridges directly on this challenge. Allergy as a specialty is a major leader in developing effective strategies to confront this epidemic. Allergists have made major contributions to the understanding of the risk factors, immunology, pathophysiology, immunomodulation, and prevention of atopic and immunologic disorders. Allergist epidemiologists and clinicians have helped develop and implement national and international guidelines in the recognition, management, and prevention of asthma and rhinitis. Allergist clinical researchers are active in (1) outcomes research that demonstrates convincingly the value of allergy as a specialty in asthma, allergic rhinitis, anaphylaxis, drug and food allergy, and other atopic disorders, (2) National Institutes of Health clinical trials that will form the basis for the future treatment of asthma and allergic disease, and (3) pharmaceutical trials that evaluate new, effective, and safe medication to treat atopic disease. Allergist educators, comprising academic and practicing allergists, supported by allied health professionals, national associations, and affiliated lay organizations, provide comprehensive education to fellows, residents, colleague physicians, media, the public, and patients. Documentation of the value of allergists in improving patient-centered and societal outcomes in their core domain, allergy, is the appropriate final topic contribution in the important series "New millennium: The conquest of allergy."

The pathobiology of acute asthma

Acute bronchial asthma is a common problem with immense medical and economic impacts. It is estimated that this disease affects 12 to 14 million people in the United States with costs in excess of $6 billion per year. Most of the morbidity and all of the mortality of asthma tends to be associated with acute exacerbations, and treatment of these events accounts for the majority of expenditures in money and health care resources. Unfortunately, the factors that contribute to the destabilization of asthma are rarely studied and much of the pathogenesis and pathobiology of acute asthma remains unknown. This article examines these issues and suggests treatment for acute asthma.