Emergency Department Allies: A Controlled Trial of Two Emergency Department–Based Follow-up Interventions to Improve Asthma Outcomes in Children

Abstract

OBJECTIVE. We sought to study the impact of emergency department (ED)-based intensive primary care linkage and initiation of asthma case management on long-term, patient-oriented outcomes for children with an asthma exacerbation.METHODS. Our study was a randomized, 3-arm, parallel-group, single-blind clinical trial. Children aged 2 through 17 years treated in a pediatric ED for acute asthma were randomly assigned to standard care (group 1), including patient education, a written care plan, and instructions to follow up with the primary care provider within 7 days, or 1 of 2 interventions. Group 2 received standard care plus assistance with scheduling follow-up, while group 3 received the above interventions, plus enrollment in a case management program.OUTCOMES. The primary outcome was the proportion of children having an ED visit for asthma within 6 months. Other outcomes included change in quality-of-life score and controller-medication use.RESULTS. Three hundred fifty-two children were enrolled; 78% completed followup, 69% were black, and 70% had persistent asthma. Of the children, 37.8% had a subsequent ED visit for asthma, with no difference among the treatment groups (group 1: 38.4%; group 2, 39.2%; group 3, 35.8%). Children in all groups had a substantial, but similar, increase in their quality-of-life score. Controller-medication use increased from 69.4% to 81.4%, with no difference among the groups.CONCLUSION. ED-based attempts to improve primary care linkage or initiate case management are no more effective than our standard ED care in improving subsequent asthma outcomes over a 6-month period. A STHMA, WHICH AFFECTS Ͼ6 million US children, is a chronic disease marked by acute exacerbations that account for much of the associated morbidity. 1-3 Much of the care of these acute flare-ups is provided in emergency departments (EDs), with Ͼ728 000 ED visits for childhood asthma in 2000. 1 Because the ED is a frequent source of care for patients with asthma, it may have a role in chronic disease management as well. 4 A 2002 publication by an expert panel outlined multiple policy recommendations to improve childhood asthma outcomes. 5 Three of these recommendations focused on improving access to and quality of asthma health care services, improving primary asthma care, and providing case management (CM) for high-risk asthmatic children.Linkage between the ED and the source of primary asthma care has been the subject of some investigation. In 1997, the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 2 6 emphasized the importance of ongoing preventive care and follow-up with a primary care provider (PCP) after acute care treatment in reducing asthma morbidity. However, although NAEPP guidelines recommend follow-up with a PCP within 3 to 5 days of an acute asthma exacerbation, numerous studies have demonstrated low rates of compliance with this recommendation. 7,8 A variety of strategies have been found to improve the rate of post-ED care follow-up, including scheduling of fo...

Distances to Emergency Department and to Primary Care Provider’s Office Affect Emergency Department Use in Children

“…Once the patient is in the ED, there have been mixed results in trying to improve subsequent continuity of care with the PCP. 14,15 This study adds to the growing literature that demonstrates that there are more than just financial barriers to access to primary care that need to be evaluated. [16][17][18] …”

Emergency Department-Based Care Transitions for Pediatric Patients: A Systematic Review

“…The interventions could be generally classified into the following categories: educational support (face-to-face, video-based, or telephonic), 24,27,28,31,37,38,42,43 appointment scheduling, 27 -30, 42, 45 telephonic reminders, 27 -30, 42, 45 ED-based discharge instructions, 28,36,40,45 monetary incentives, 37,38 text message reminders, 34 providing PCP information, 40 nurse support line, 33 mailed reminders, 43 therapeutic sessions, 24,29 and case management program 28 ( Table 2). …”

“…29,30,37,38,43,45 We also investigated the time of administration of the interventions (ie, during the visit, after the visit [eg, within 24-48 hours]). Interventions were administered during the ED visit in 3 studies 27,28,36 and after the ED visit in 3 others. 26,33,34 In the remaining 10 studies, interventions were administered both during and after the ED visit (ie, involving multicomponent intervention).…”

“…In the remaining 5 studies (4 of which included patients with asthma and 1 with minor illnesses), 27,28,37,43,45 ED-based care transition interventions had little or no effect on ED readmissions (RR, 1.02 [95% CI, 1.02-1.15]) ( Fig 5). Results were generally consistent across the included studies (I 2 = 0).…”

Follow-up after acute asthma episodes: What improves future outcomes?

“…[19][20][21] Outcomes evaluated in all 3 studies were also comprehensive, including medical utilization and quality-of-life parameters. The intervention in the study by Castro et al 19 used a multifaceted approach consisting of 7 key elements: (1) nurse's suggestion of simplification or consolidation of the patient's medical regimen to the primary physician (based on National Asthma Education and Prevention Program II guidance); (2) daily completion of an asthma care flow sheet; (3) asthma education in accordance with patient education, cultural beliefs, and motivation; (4) psychosocial support and screening for professional counseling; (5) individualized asthma self-management plans; (6) social service professional consultations for discharge planning facilitation; and (7) outpatient follow-up through telephone contact, home visits, and follow-up appointments with the primary care physician.…”