July 9, 2012 — Emergency departments (EDs) that use evidence-based standardized protocols (EBSPs) to treat children with asthma have similar rates of hospital admissions as EDs that do not use EBSPs, according to a new Canadian study. The findings were published online July 9 in the Archives of Pediatric Adolescent Medicine.
The retrospective population-based cohort study, led by Patricia Li, MD, from the Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Quebec, Canada, evaluated 46,510 ED visits for children with asthma (age, 2 - 17 years) between April 2006 and March 2009. The primary outcome evaluated was hospital admission at the time of the index ED visit. Secondary outcomes were ED return visits and outpatient follow-up visits within 7 days among patients who were not admitted.
The researchers found that 9.1% of children were admitted to the hospital at the time of the initial visit. Among those not admitted, 4.2% had high-acuity return visits and 17.4% had outpatient follow-up visits within 7 days. Of the 146 EDs included in the evaluation, 70.5% did not use standardized protocols (SPs) for treating pediatric asthma. In a multivariable analysis, the study authors found that there was no significant association between the use of SPs and outcomes.
The researchers analyzed data from 31,138 children with a diagnosis of asthma who had an unplanned visit to an ED for asthma-related problems. The authors categorized EDs as using EBSPs, other SPs, or no protocol when treating children with asthma. SP formats included preprinted orders, clinical practice guidelines, medical directives, and clinical pathways and "were categorized as having evidence-based content if they contained practices supported by the best level of evidence (A, if available)."
The researchers adjusted for patient-level covariates, including sex, age, and neighborhood income quintile. Asthma severity and chronicity were adjusted using the Canadian Triage and Acuity Scale triage score of the index ED visit as well as history of asthma ED visits in the preceding 2 years. The investigators also evaluated hospital-level covariates, including location, hospital type, and pediatric asthma patient volume.
"The failure to demonstrate a significant effect of SPs may be explained in part by the quality and implementation of EBSPs," Dr. Li and colleagues write.
"Several nonrandomized trials for asthma SPs in the ED have demonstrated improved processes of care (such as prescribing steroids and discharge planning) but few have shown improved asthma outcomes," the study authors write.
The authors also note that despite improvements in processes of care, EBSPs may not improve outcomes because of the complexity and chronicity of a disease such as asthma, particularly when addressing treatment in an acute care setting.
The researchers acknowledge study limitations such as the observational design, which impeded the ability to establish causality. In addition, they could not assess the extent to which treating clinicians actually implemented SPs.
"With increasing policies and programs mandated to enhance quality of care, our findings point to the need for mechanisms to update the content and ensure widespread dissemination of SPs, but likely, effective implementation will continue to be an important research and policy need," conclude the study authors.
The work of the lead author for this study is supported by an Academic Pediatric Association/Agency for Healthcare Research and Quality Young Investigator Award. Other authors' work is supported by the Dales Award, University of Toronto, the Canadian Institutes of Health Research New Investigator Award, and a Canadian Child Health Clinician Scientist Career Enhancement Program Award. The Pediatric Outcomes Research Team is supported by a grant from the Hospital for Sick Children Foundation. In addition, this study was performed at the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. The authors have disclosed no relevant financial relationships.
Arch Pediatr Adolesc Med. Published online July 9, 2012. Full text
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