Low Rates of Controller Medication Initiation and Outpatient Follow-up After Emergency Department Visits for Asthma
Andrews AL, Teufel RJ 2nd, Basco WT Jr
J Pediatr. 2012;160:325-330
Background. The current recommendations regarding initiation of controller medications in children seen in the emergency department (ED) for exacerbation of asthma are confusing. For example, in the United States, the National Heart, Lung, and Blood Institute's (NHLBI) 2007 guidelines recommend that practitioners consider starting controllers upon ED discharge, but it is not a firm recommendation. By contrast, the Global Initiative for Asthma (GINA) guidelines, used more commonly in Europe, make a clear recommendation to initiate inhaled corticosteroids after an ED visit for asthma exacerbation. Finally, the Healthcare Effectiveness Data and Information Set (HEDIS) criteria consider any child with asthma who experiences an ED visit for asthma exacerbation as a "persistent asthmatic," and therefore in need of a controller.
Multiple previous studies have shown that ED use is a marker for future asthma exacerbations.[4,5,6] However, current practice in the United States largely promotes the approach that it is the role of primary care providers to begin asthma controller medications after an ED visit. Many ED providers feel uncomfortable starting a chronic medication in a patient with whom they do not have a long-term relationship.
Methods. The investigators used 2007-2009 Medicaid data from 1 state to determine the proportion of children seen in the ED for asthma exacerbation who received a controller medication or attended an outpatient follow-up appointment after the ED visit. The patients were 2-18 years old and were identified using accepted asthma visit and diagnosis codes. Patients with exercise-induced asthma and those with certain chronic medical diseases were eliminated. Investigators also excluded children who were admitted to the hospital after their emergency department visit. In the absence of exact dates, insurance claims sequence numbers were used to determine if children received prescriptions for controllers. A child was classified as having received a controller if a pharmacy claim for a controller appeared in the dataset during the same month as the ED visit or the subsequent month. Similarly, any outpatient, nonemergency department follow-up visit in the month of the ED visit or the subsequent month was considered an appropriate ED follow-up visit. Investigators defined severity of asthma using the frequency of inhaled beta-agonist prescription claims. Children who had 6 or more short-acting beta-agonist prescription dispensing events in 12 months were classified as "severe asthmatics."
Findings. The analysis cohort included 3435 children with a mean age of 8.5 years. Boys comprised 57% of the cohort, and 76% were of racial or ethnic minorities. Slightly more than two-thirds of the children lived in urban areas, and 10% were classified as "severe asthmatics." Only 18% of children received inhaled corticosteroids after the ED visit. When "controllers" were classified as any inhaled corticosteroid or leukotriene antagonists, the frequency of controller dispensing after the ED visit increased to 28%. Only 12% of the children had an appropriate follow-up visit within 2 months of the ED visit, and 5.2% of the children had both a follow-up visit and received inhaled corticosteroids after the ED visit. Attending an outpatient follow-up visit was associated with having received an inhaled corticosteroid in the ED, with 44% of children who made at least 1 outpatient follow-up visit receiving an inhaled corticosteroid compared with 29% of those who did not make an outpatient follow-up visit.
In multivariable analyses, patients in the middle age group (7-12 years) were more likely to receive controllers or attend follow-up visits compared with the younger age stratum (2-6 years) or those 13 years and older. Children with severe asthma were much more likely to receive a controller after their ED visit, with an adjusted odds ratio of 3.2 (95% confidence interval, 2.5-4.0), and children who lived in rural areas were less likely to receive a controller medication after ED visits. Similarly, in the model for predicting follow-up appointments, the 7-12 age group was more likely to have a follow-up appointment, as were children with severe asthma. A similar pattern held for the combined outcome of inhaled corticosteroids plus follow-up appointment.
The investigators concluded that fewer than 20% of the children seen in the ED for an asthma exacerbation were dispensed a prescription for inhaled corticosteroids, and only 12% attended follow-up visits. They suggest that ED visits for asthma should be recognized as potential markers for poorly controlled asthma, and consideration should be given to increasing the prescription of controllers in the acute care environment.
In the interest of full disclosure, I should point out that I am the senior author on this manuscript. This is the first paper of which I am an author that I have reviewed for Medscape, but this study seemed appropriate. Asthma is one of the top 2 or 3 chronic medical conditions in childhood, on the basis of either the percentage of children affected or healthcare-related costs. Although we hypothesized that relatively low percentages of children would receive measures of preventive care after an ED visit for asthma, we did not expect such low percentages, particularly the finding that barely 5% of children received both inhaled steroids and a follow-up visit. This suggests that ED visits have tremendous potential to become much more aggressive in the treatment of asthma.
Practitioners can reflect on what these data might mean for their own patients and consider how they view an emergency department visit for asthma. Although there are many reasons why a child may show up in the emergency department with an asthma exacerbation (some of which may not relate to the chronicity of the child's symptoms), ED use is a marker for future asthma exacerbation when viewed on a population basis. Therefore, this seems to be a good patient population to target for more aggressive asthma management. It is also important to emphasize that the Medicaid data contained only prescriptions that were dispensed, so our findings may represent an underestimate of the percentage of children who were prescribed an inhaler or other controller after the ED visit. Nevertheless, the very low rates suggest that reluctance to provide the prescription and failure to fill the prescription both contribute to the problem.
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Cite this: William T. Basco. Emergency Department Visits for Asthma in Children - Medscape - Apr 19, 2012.