A tool to organize instructions at discharge after treatment of asthmatic children in an emergency department

Predicting Continuity of Asthma Care Using a Machine Learning Model: Retrospective Cohort Study

Continuity of care (COC) has been shown to possess numerous health benefits for chronic diseases. Specifically, the establishment of its level can facilitate clinical decision-making and enhanced allocation of healthcare resources. However, the use of a generalizable predictive methodology to determine the COC in patients has been underinvestigated. To fill this research gap, this study aimed to develop a machine learning model to predict the future COC of asthma patients and explore the associated factors. We included 31,724 adult outpatients with asthma who received care from the University of Washington Medicine between 2011 and 2018, and examined 138 features to build the machine learning model. Following the 10-fold cross-validations, the proposed model yielded an accuracy of 88.20%, an average area under the receiver operating characteristic curve of 0.96, and an average F1 score of 0.86. Further analysis revealed that the severity of asthma, comorbidities, insurance, and age were highly correlated with the COC of patients with asthma. This study used predictive methods to obtain the COC of patients, and our excellent modeling strategy achieved high performance. After further optimization, the model could facilitate future clinical decisions, hospital management, and improve outcomes.

A Scoping Review of Emergency Department Discharge Risk Stratification

INTRODUCTION

Although emergency department (ED) discharge presents patient-safety challenges and opportunities, the ways in which EDs address discharge risk in the general ED population remains disparate and largely uncharacterized. In this study our goal was to conduct a review of how EDs identify and target patients at increased risk at time of discharge.

METHODS

We conducted a literature search to explore how EDs assess patient risk upon discharge, including a review of PubMed and gray literature. After independently screening articles for inclusion, we recorded study characteristics including outcome measures, patient risk factors, and tool descriptions. Based on this review and discussion among collaborators, major themes were identified.

RESULTS

PubMed search yielded 384 potentially eligible articles. After title and abstract review, we screened 235 for potential inclusion. After full text and reference review, supplemented by Google Scholar and gray literature reviews, we included 30 articles for full review. Three major themes were elucidated: 1) Multiple studies include retrospective risk assessment, whereas the use of point-of-care risk assessment tools appears limited; 2) of the point-of-care tools that exist, inputs and outcome measures varied, and few were applicable to the general ED population; and 3) while many studies describe initiatives to improve the discharge process, few describe assessment of post-discharge resource needs.

CONCLUSION

Numerous studies describe factors associated with an increased risk of readmission and adverse events after ED discharge, but few describe point-of-care tools used by physicians for the general ED population. Future work is needed to investigate standardized tools that assess ED discharge risk and patients' needs upon ED discharge.

Discharge communication practices in pediatric emergency care: a systematic review and narrative synthesis

BACKGROUND

The majority of children receiving care in the emergency department (ED) are discharged home, making discharge communication a key component of quality emergency care. Parents must have the knowledge and skills to effectively manage their child's ongoing care at home. Parental fatigue and stress, health literacy, and the fragmented nature of communication in the ED setting may contribute to suboptimal parent comprehension of discharge instructions and inappropriate ED return visits. The aim of this study was to examine how and why discharge communication works in a pediatric ED context and develop recommendations for practice, policy, and research.

METHODS

We systematically reviewed the published and gray literature. We searched electronic databases CINAHL, Medline, and Embase up to July 2017. Policies guiding discharge communication were also sought from pediatric emergency networks in Canada, USA, Australia, and the UK. Eligible studies included children less than 19 years of age with a focus on discharge communication in the ED as the primary objective. Included studies were appraised using relevant Joanna Briggs Institute (JBI) checklists. Textual summaries, content analysis, and conceptual mapping assisted with exploring relationships within and between data. We implemented an integrated knowledge translation approach to strengthen the relevancy of our research questions and assist with summarizing our findings.

RESULTS

A total of 5095 studies were identified in the initial search, with 75 articles included in the final review. Included studies focused on a range of illness presentations and employed a variety of strategies to deliver discharge instructions. Education was the most common intervention and the majority of studies targeted parent knowledge or behavior. Few interventions attempted to change healthcare provider knowledge or behavior. Assessing barriers to implementation, identifying relevant ED contextual factors, and understanding provider and patient attitudes and beliefs about discharge communication were identified as important factors for improving discharge communication practice.

CONCLUSION

Existing literature examining discharge communication in pediatric emergency care varies widely. A theory-based approach to intervention design is needed to improve our understanding regarding discharge communication practice. Strengthening discharge communication in a pediatric emergency context presents a significant opportunity for improving parent comprehension and health outcomes for children.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42014007106.

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.

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.

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.

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.

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.

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.

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.

Home use of albuterol for asthma exacerbations

BACKGROUND

To reduce symptoms and emergency department (ED) visits, the National Asthma Education and Prevention Program (NAEPP) guidelines recommend early treatment of acute asthma symptoms with albuterol and oral corticosteroids. Yet, ED visits for asthma are frequent and often occur several days after onset of increased symptoms, particularly for children from low-income, urban neighborhoods.

OBJECTIVES

To describe home use of albuterol and identify factors associated with appropriate albuterol use.

METHODS

A total of 114 caregivers in the intervention group of a randomized trial to reduce emergent care for low-income, urban children completed a structured telephone interview with an asthma nurse to evaluate home management of their child's acute asthma symptoms. Interviews lasted approximately 20 minutes and were conducted from November 5, 2003, through September 30, 2005. Albuterol use as reported by caregivers was categorized as appropriate or inappropriate based on NAEPP recommendations.

RESULTS

Albuterol use for worsening asthma symptoms was categorized as appropriate for only 68% of caregivers and was more likely if the children had an ED visit or hospitalization for asthma in the prior year. The remaining 32% of caregivers used albuterol inappropriately (overtreatment or undertreatment). Appropriate albuterol use was not associated with caregiver report of having an asthma action plan (AAP) or a recent primary care physician visit to discuss asthma maintenance care.

CONCLUSIONS

Caregivers reported that they would use albuterol to treat their child's worsening asthma symptoms, but many described inappropriate use. Detailed evaluation of proper albuterol use at home may provide insight into how health care professionals can better educate and support parents in their management of acute exacerbations and more effective use of AAPs.

Association between skin testing in the pediatric emergency department and adherence to follow-up in children with asthma

BACKGROUND

Efforts to enroll inner-city asthmatic children into continuity care after a pediatric emergency department (PED) visit are frequently unsuccessful. Providing parents with documentation of their child's allergic status and how this can be used to tailor an asthma management plan may improve adherence to scheduled continuity appointments.

OBJECTIVE

To determine whether skin testing children during PED visits for wheezing and providing parents with skin test results improves adherence to follow-up visits.

METHODS

A convenience sample of children aged 2 to 12 years with asthma who presented to the PED with wheezing were eligible. Enrolled children were randomized to group 1 (no skin test) or group 2 (skin test). At discharge, both groups scheduled asthma clinic appointments for within 1 week. Children in group 2 underwent skin testing with standard allergens, and parents were given documentation of skin test results. Adherence was assessed by computer confirmation of the patient's asthma clinic visit.

RESULTS

Seventy-seven children were enrolled: 39 in group 1 and 38 in group 2. The mean age was 7 years; 69% had mild intermittent asthma. Twenty-four percent of children (9 of 38) in group 1 vs 46% (17 of 37) in group 2 were followed up in the asthma clinic (P < .05). Children in group 2 were 2.6 (95% confidence interval, 1.02-6.65) times more likely to keep appointments compared with children in group 1.

CONCLUSIONS

Parents who receive evidence in the PED of their child's allergic status and probable relationship to the child's asthma are more likely to adhere to scheduled continuity visits.

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

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

Asthma coaching in the pediatric emergency department

OBJECTIVES

Coaching and monetary incentives have been used to modify medical behavior of individuals with several chronic diseases, including asthma. The authors performed a randomized, controlled trial of an intervention combining asthma coaching during an emergency department (ED) visit for asthma, and monetary incentive to improve follow-up with primary care providers (PCP).

METHODS

Subjects were parents of children 2-12 years of age, with Medicaid or no medical insurance, receiving treatment for asthma in the ED. The primary outcome was a verified PCP visit for asthma within two weeks of the index ED visit. All parents received 15 dollars for their time in the ED. Parents in the intervention group were told that they would receive an additional 15 dollars monetary incentive if a PCP visit was completed. The coach engaged in a dialogue with the parent during the ED visit, and discussed the importance and advantages of seeking follow-up care with the child's PCP. All parents received the usual discharge instructions, including advice to see the PCP within three days.

RESULTS

The authors enrolled 92 parents; outcome data were available for 86 (42 controls, 50 intervention). Demographic characteristics were similar in both groups. There was no significant difference in the proportion of patients who had follow-up PCP visits between the intervention (22.0%; 95% confidence interval [95% CI] = 11.5% to 36.0%) and control (23.8%; 95% CI = 12.0% to 39.4%) groups (p = 0.99).

CONCLUSIONS

An intervention combining asthma coaching during acute ED visits and a monetary incentive to return for a PCP visit does not appear to increase follow-up with the PCP.

A randomized clinical trial of clinician feedback to improve quality of care for inner-city children with asthma

CONTEXT

Barriers impede translating recommendations for asthma treatment into practice, particularly in inner cities where asthma morbidity is highest.

METHODS

The purpose of this study was to test the effectiveness of timely patient feedback in the form of a letter providing recent patient-specific symptoms, medication, and health service use combined with guideline-based recommendations for changes in therapy on improving the quality of asthma care by inner-city primary care providers and on resultant asthma morbidity. This was a randomized, controlled clinical trial in 5- to 11-year-old children (n = 937) with moderate to severe asthma receiving health care in hospital- and community-based clinics and private practices in 7 inner-city urban areas. The caretaker of each child received a bimonthly telephone call to collect clinical information about the child's asthma. For a full year, the providers of intervention group children received bimonthly computer-generated letters based on these calls summarizing the child's asthma symptoms, health service use, and medication use with a corresponding recommendation to step up or step down medications. We measured the number and proportion of scheduled visits resulting in stepping up of medications, asthma symptoms (2-week recall), and health care use (2-month recall).

RESULTS

In this population, only a modest proportion of children whose symptoms warranted a medication increase actually had a scheduled visit to reevaluate their asthma treatment. However, in the 2-month interval after receipt of a step-up letter, 17.1% of the letters were followed by scheduled visits in the intervention group compared with scheduled visits 12.3% of the time by the control children with comparable clinical symptoms. Asthma medications were stepped up when indicated after 46.0% of these visits in the intervention group compared with 35.6% in the control group, and when asthma symptoms warranted a step up in therapy, medication changes occurred earlier among the intervention children. Among children whose medications were stepped up at any time during the 12-month study period, those in the intervention group experienced 22.1% fewer symptom days and 37.9% fewer school days missed. The intention-to-treat analysis showed no difference over the intervention year in the number of symptom days, yet there was a trend toward fewer days of limited activity and a significant decrease in emergency department visits by the intervention group compared with controls. This 24% drop in emergency department visits resulted in an intervention that was cost saving in its first year.

CONCLUSIONS

Patient-specific feedback to inner-city providers increased scheduled asthma visits, increased asthma visits in which medications were stepped up when clinically indicated, and reduced emergency department visits.

Delivering tailored asthma family education in a pediatric emergency department setting: a pilot study

OBJECTIVE

Many children are brought to the pediatric emergency department (ED) with acute asthma symptoms. Emergency asthma care is costly, and many ED visits may be preventable. Families often do not have written asthma action plans and lack asthma self-management skills. This study tests a tailored self-management intervention delivered in the ED for families of children with asthma. The primary hypotheses were that the intervention group would have greater confidence to manage asthma 14 days postintervention and more well-asthma visits and fewer urgent care/ED visits at 9 and 12 months.

METHODS

This randomized intervention/usual-care study was part of a larger ED asthma surveillance project in 4 urban pediatric ED sites. Asthma educators used a computer-based resource to tailor the intervention messages and provide a customized asthma action plan and educational summary. Children with acute asthma were enrolled during an ED visit, and follow-up telephone interviews were conducted during the next 9 months. The ED clinician classified the child's acute and chronic severity.

RESULTS

To date, 464 subjects aged 1 to 18 years have been enrolled. The ED clinicians reported that 46% had intermittent and 54% had persistent chronic severity with 51% having mild acute severity episodes. The confidence level to prevent asthma episodes and keep them from getting worse was significantly higher in the intervention group at 14 days postintervention. More subjects in the intervention group reported well-asthma visits by 9 months. Return ED visits were significantly lower in the intervention group in those with intermittent asthma. Twelve-month follow-up is in process.

CONCLUSIONS

The tailored ED self-management intervention demonstrates significant effects on caregiver self-confidence and well-visit follow-up. Additional evaluation is needed to determine what impact this intervention has long-term.

Refinement of an instrument to evaluate parental attitudes about follow-up care after an acute emergency department visit for asthma

INTRODUCTION

Prompt follow-up after emergency department (ED) care for asthma allows the primary care provider (PCP) and family to review factors that led to the ED visit, update current care plans, and plan for prevention of future exacerbations.

METHODS

The Initial Questionnaire to assess parental impressions of Pros and Cons of follow-up was administered to parents who brought their children to the ED for treatment of an acute asthma exacerbation (N = 309). After a planned interim analysis, 19 new items were generated, and this Expanded Questionnaire was given to 198 parents. Principal Component Analysis (PCA) was used to identify well-defined items and discard ambiguous and confusing items.

RESULTS

PCA of the Expanded Questionnaire revealed 18 of 43 items related to four dimensions of parents' Pros and Cons for obtaining follow-up care. Four distinct categories were identified: two Pros and two Cons. Pro items related to practical things parents get from a follow-up visit and to positive parental beliefs about follow-up care. Con items emphasized practical considerations that make it difficult to go to a follow-up visit and identified the misconception that follow-up is not necessary for asymptomatic children. In addition, two distinct clusters of parents were identified: those that value and those that do not value follow-up care.

CONCLUSION

We developed an 18-item measure that assesses Pros and Cons of follow-up care for asthma following emergency care, which has four reliable factors: Pro Practical, Pro Attitude, Con Practical, and Con Attitude. This questionnaire may help guide interventions to change perceptions of the need for follow-up. Attention to increasing Pros among those who are reluctant to attend follow-up care may be especially effective.

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

OBJECTIVE

To improve follow-up with primary care providers after acute Emergency Department (ED) asthma visits for children from low-income urban families.

STUDY DESIGN

A prospective, randomized, controlled trial evaluated combined telephone asthma coaching and monetary incentive. The primary outcome was asthma-planning visits with primary care providers within 15 days of index ED visits. The subjects were urban parents whose children were treated for asthma in the ED and had Medicaid or no insurance.

RESULTS

We enrolled 527 parents (264 control and 263 intervention). There was a significant difference ( P < .0001) between the intervention (35.7%) and control (18.9%) groups in the proportion of children who had asthma-planning visits and decreased mean nights/days with asthma symptoms by 4.36 intervention and 3.31 control at 2 weeks. The proportions of children with asthma-planning visits and acute asthma care visits during the 16-day to 6-month period were similar for both groups.

CONCLUSIONS

Telephone coaching and a monetary incentive significantly increased the proportion of low-income urban parents who brought their children for asthma-planning visits, and decreased asthma symptoms shortly after asthma ED visits. The intervention did not increase subsequent asthma-planning visits or decrease ED visits or hospitalizations.

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.