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In a 2002-2004 study involving children with recurrent visits to an urban emergency department (ED) for asthma treatment, researchers “found that a single follow-up visit to a comprehensive ED-based asthma clinic resulted in significant and clinically relevant improvements in care and outcomes in a high-morbidity pediatric population.”
Investigators from George Washington University and the Albert Einstein College of Medicine studied 488 participants who were predominately African-American with 62% reporting that the ED was their usual source of treatment for asthma. Children in the intervention group were scheduled to have a follow-up appointment with a physician and an asthma educator two to fifteen days after being released from the ED. The sixty to ninety minute sessions, which took place in the ED on weekday mornings, covered “asthma self-monitoring and management, environmental modification and trigger control, and linkages and referrals to ongoing primary care.”
“The average total number of unscheduled asthma visits was 40% lower among children in the intervention group.”
Of the children enrolled in the intervention group, 71% went to their follow-up visit. The clinic supplied all attendees with a pillow cover, a mattress pad and an individualized asthma treatment plan. Many also received prescriptions for inhaled corticosteroids (97%) and leukotriene antagonists (40%). Subsequent to the appointment, every participant’s primary care physician (PCP), insurance asthma case manager and school nurse received an account of the follow-up session and a copy of the asthma treatment plan. Children in the control group did not have a follow-up visit, but were given a pamphlet on asthma.
After adjusting for demographic and other differences between the two groups, the researchers found that after one month the intervention group was 53% more likely than the control group to use a written asthma plan. They were also significantly more likely to use mattress pads and pillow covers, to have no daily smoking inside the home and to use inhaled corticosteroids and leukotriene antagonists. The difference between the two groups continued after six months for some of these measures, including the use of inhaled corticosteroids. However, the intervention group was not more likely to name a PCP as their primary source of asthma care.
Researchers also studied participants’ use of care over a six-month follow-up period. The average total number of unscheduled asthma visits was 40% lower among children in the intervention group (1.39 vs. 2.34, adjusted for demographics and other variables). In particular, they had 46% less visits to the ED (0.64 vs. 1.19). However, the investigators did not find statistically significant differences in the number of hospital admissions or scheduled visits with a PCP for asthma.
“After one month, children in the intervention group were 74% more likely to have experienced no functional limitations in their quality of life, but only 33% more likely after 6 months.”
After one month, children in the intervention group were 74% more likely to have experienced no functional limitations in their quality of life during the prior four weeks. They were also significantly more likely to be free of daytime and nighttime symptoms over a two week period (67% and 23% more likely, respectively). After six months, however, differences between the two groups had declined; the intervention group was only 33% more likely to have no limitations in quality of life and the prevalence of daytime and nighttime symptoms was no longer significantly different.
Since the intervention did not increase patients’ interaction with their PCPs, the authors expressed concern that it could have “negatively impacted the role of the PCPs by establishing an effective ED-based system for short term asthma management.” Nevertheless, the intervention did have a positive impact on behavior and outcomes, and the researchers identified several factors that may have contributed this success. The sessions were individualized, covered a broad range of issues and occurred in a familiar setting. Also, the families were approached during an ED visit, a time when they were particularly receptive to ways to improve care.
Source: Teach, Stephen J., MD, MPH, et al., Improved Asthma Outcomes in a High-Morbidity Pediatric Population, Archives of Pediatrics and Adolescent Medicine. Vol. 160, Pgs. 535-541.
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