Inhaled corticosteroids should be initiated before discharge from the emergency department in patients with persistent asthma

Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care

BACKGROUND

Guidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations.

OBJECTIVE

We sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians.

METHODS

This was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering.

RESULTS

Among 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99-12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08-3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51-0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62-0.91) or no insurance (OR 0.54; 95% CI 0.35-0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period.

CONCLUSIONS

An ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.

Dispensing inhalers to patients with chronic obstructive pulmonary disease on hospital discharge: Effects on prescription filling and readmission

PURPOSE

The effects of dispensing inhalers to patients with chronic obstructive pulmonary disease (COPD) on hospital discharge were evaluated.

METHODS

Data were collected in 2011-12 for patients with COPD who had hospital orders for the study inhalers (preintervention group) and after implementation of the multidose medication dispensing on discharge (MMDD) service (2013-14) (postintervention group). The primary objective of this study was to assess inhaler adherence and readmission rates before and after MMDD implementation. Adherence was defined as filling the discharge prescription for the multidose inhaler at a Harris Health pharmacy within three days of discharge or having at least seven days of medication left in an inhaler from a previous prescription that was filled or refilled before hospital admission. All patients in the postintervention group were considered adherent, since every patient was given the remainder of his or her multidose inhaler when discharged.

RESULTS

Data from 620 patients (412 in the preintervention group, 208 in the postintervention group) were collected. During the preintervention time period, 88 of 412 patients were readmitted within 30 days compared with 18 of 208 patients during the postintervention period (p < 0.001). The intervention was associated with a significant reduction in 30-day readmissions (p = 0.0016) and 60-day readmissions (p = 0.0056).

CONCLUSION

A targeted pharmacy program to provide COPD patients being discharged from the hospital with the multidose inhalers they had used during hospitalization was associated with improved medication adherence, as measured by prescription filling behavior, and reduced rates of 30- and 60-day hospital readmissions.

Prescription habits for preventative medications among pediatric emergency department physicians at an inner-city teaching hospital

INTRODUCTION

As asthma presentation is episodic, patients with acute exacerbations often present in the emergency department (ED) where preventative regimen may not always be addressed. Addressing initiation and modification of controller medications in the setting of an acute exacerbation may facilitate improved asthma control and decrease the frequency of ED visits, particularly so for families who receive most of their asthma management in the ED. However, this aspect has not yet been explored.

METHODS

We reviewed a random sample of 363 charts, 10% of the total number of asthmatic children, aged 2-18, seen from January to December 2007 in the pediatric ED of an urban teaching hospital located in Bronx, NY, USA. We quantified the frequency of modification of the preventative regimen and the influence of seasons on this practice.

RESULTS

Of these 363 children, 42.4% of patients were not previously on a controller medication. Of these, 9.7% were started on a new controller medication, with a significantly higher percent occurring in the summer months. Of those that were previously on a controller medication, 2.87% were started on a new controller medication and 0.95% had their controller medication dose increased. However, the regimen was not adjusted in 14.3% that had been seen four or more times in the preceding 2 years. Of the total 363 children, 78.5% were discharged from the ED on a short course of oral steroids, and this was not part of their preventative regimen. Only four charts had physician-documented asthma severity classification.

CONCLUSIONS

We found that the preventative regimen was modified in only 0.9-2% of all asthmatic children seen in an urban ED whereas 78.5% were started on systemic steroids. Asthma severity was evaluated in a very small number of patients. Because modification of preventative regimen requires appropriate asthma severity classification, the inclusion of asthma severity classification as part of routine ED evaluation may encourage physicians to address controller medications in persistent asthmatics.

Multicenter study of chronic asthma severity among emergency department patients with acute asthma

OBJECTIVE

The initiation of controller therapy for asthma depends on chronic asthma severity. To facilitate initiation of inhaled corticosteroids (ICSs), the preferred controller therapy, in the emergency department (ED), the objective of the study was to describe chronic asthma severity, as defined by the national asthma guidelines, among children presenting to the ED with acute asthma.

METHODS

Investigators at 14 U.S. sites prospectively enrolled consecutive children 2–17 years presenting to the ED with acute asthma. Three factors (daytime symptoms, nighttime symptoms, and medication usage) were used to categorize children into four chronic asthma severity groups: intermittent, mild persistent, moderate persistent or severe persistent.

RESULTS

This multistate cohort of 311 children had a mean age of 7.7 years, was 51% Black, and 89% had a primary care provider (PCP). Regarding chronic severity, 18% were intermittent and 82% persistent: 37% mild persistent, 24% moderate persistent, and 20% severe persistent. Chronic severity groups did not differ by demographics or PCP status. Patients with persistent asthma were more likely to report moderate-severe asthma symptoms (58% versus 19%; p < .001), poor asthma control (2% versus 18%; p = .002), and more ED visits (median, 2 versus 1; p < .001) in the past year. The groups did not differ in acute asthma severity, ED treatment, or admission rate. Rate of discharge prescription for ICSs was low, albeit higher among children with persistent asthma (24% versus 4%; p = .003).

CONCLUSIONS

The high prevalence of persistent asthma among ED patients exceeds the prevalence reported previously, and supports ED initiation of ICS, as recommended by national guidelines.

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).