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PREVENTING ASTHMA-RELATED ED READMISSION
EDMONTON, ALBERTA—Continued use of inhaled corticosteroids initially given during emergency department (ED) visits for acute asthma may significantly decrease the number of subsequent visits, two new studies confirm.[1,2]
Asthma accounts for almost two million ED visits annually. About 30% of asthma patients treated in the ED will have a relapse in symptoms. Don D. Sin, MD, MPH, Assistant Professor of Medicine at the University of Alberta, noted that once a relapse occurs, the risk of asthma-related morbidity and mortality rises sharply.
STEROIDS VERSUS NO STEROIDS
Dr. Sin and his colleague S. F. Paul Man, MD, analyzed ED discharge data from 1,293 patients ranging in age from 5 to 60 years who were admitted to the ED because of asthma-related symptoms between April 1, 1997, and March 31, 2001. The use of all asthma medications was recorded for each patient.[1]
During the four-year study, 658 patients received no inhaled corticosteroids. Of the 459 patients who were given inhaled corticosteroids, 241 received low-dose, 96 received medium-dose, and 122 received high-dose therapy.
Four hundred sixty-two patients had subsequent ED visits for asthma. Patients who used inhaled corticosteroids following initial ED discharge had a 45% lower risk of a subsequent ED visit than did nonusers. Low-dose corticosteroid therapy was as effective as higher doses in reducing the risk of a subsequent ED visit.
The effectiveness of inhaled corticosteroids was independent of the other medications administered. For example, inhaled corticosteroids markedly lowered the risk of a subsequent ED visit in patients who had received at least one dose from a bronchodilator. A similar pattern was observed in patients given oral corticosteroids.
In an
interview with RESPIRATORY REVIEWS,
Dr. Sin said that the beneficial effect of inhaled corticosteroids
on relapse rates was expected. However, he added, “What
was surprising was that more than 50% of patients did
not receive inhaled corticosteroids during the [study] period,
despite being in an emergency department.”
INHALED OR SYSTEMIC CORTICOSTEROIDS?
Marcia Edmonds, MD, MSc, and colleagues conducted a meta-analysis that included data from six placebo-controlled trials that studied patients treated in the ED for acute asthma.[2]
Two of the six trials evaluated treatment with inhaled plus systemic corticosteroids versus systemic corticosteroids plus placebo. The other four trials studied inhaled corticosteroids versus placebo.
The most beneficial effect on pulmonary function was found in the groups who received either the highest (18 mg of flunisolide) or the lowest (200 µg of beclomethasone) doses of inhaled corticosteroids. However, because of the small number of studies available for analysis, not enough data existed to allow the authors to form a conclusion about the beneficial effects of inhaled corticosteroids on pulmonary function.
In the studies in which inhaled and systemic corticosteroids were compared with systemic corticosteroids alone, the addition of inhaled therapy appeared to lower hospital admission rates, but the results did not reach significance. When results from all six studies were pooled, however, they showed a 55% reduction in hospital readmission after the use of inhaled corticosteroids following the initial visit to the ED.
LOW DOSES ARE AS EFFECTIVE AS HIGHER ONES
The findings of Drs. Sin and Man concur with those of Dr. Edmonds and colleagues. Drs. Sin and Man commented that some physicians believe “more is better” when it comes to the use of inhaled corticosteroids in asthma. However, both studies detected evidence suggesting that low doses are effective in reducing relapse rates leading to ED readmission.
Both studies found that inhaled corticosteroids introduced in the ED resulted in a decrease in hospital admission for acute asthma exacerbations. According to Dr. Sin, “Some physicians still are not prescribing [inhaled corticosteroids] despite the overwhelming evidence that these medications reduce morbidity in asthma.”
PATIENT EDUCATION NECESSARY
Even if an inhaled corticosteroid is prescribed, however, patients may not fill their prescriptions. “They may feel that these medications are not particularly helpful, they may be fearful of the side effects of ‘steroids,’ or the medications may be too expensive,” said Dr. Sin.
With education and reinforcement, many patient concerns can be addressed and overcome, but Dr. Sin noted that this is easier said than done. “In a busy primary care practice, the educational component of therapy is usually missing. Patients generally receive a prescription and nothing else.” There is a missed opportunity in the ED for getting patients started on inhaled corticosteroid therapy.
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A
Parents’-Eye View of Follow-up Care
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St.
Louis—A
recent study suggests that low-income, urban parents
would seek follow-up care for their asthmatic children
after an ED visit if that care were easier to obtain.[1]
Previous research has shown that although more than
90% of urban children have a source of primary
medical care, approximately 75% of their families
do not use it for asthma management. Instead, children
are brought to the ED for care.
Sharon Smith, MD, Assistant Professor of Pediatrics
at Washington University School of Medicine, St. Louis,
told RESPIRATORY REVIEWS, “Most parents in our
community view asthma as an episodic illness. They
are aware that their child has asthma, but treatment
is sought only when their child is symptomatic.”
Dr. Smith and colleagues created a questionnaire
that covered parental perceptions of the pros and
cons of follow-up care. It contained 41 statements
considered to be reasons for or against seeking follow-up
asthma care. One hundred forty-seven parents were
asked to rate the statements on a scale of 1 to 5
(5 = “extremely important” and 1 =
“not important”).
Statements were grouped into four categories: information
pro, attitudinal pro, information con, and attitudinal
con.
OBSTACLES TO SEEKING CARE
Results showed that barriers to care occur on many
levels—both practical and ideological. For example,
one parent may be influenced by his or her negative
beliefs about the need for asthma care, whereas another
may be influenced by logistical problems, such as
finding transportation or a baby-sitter. Both of these
cons, though unrelated, have the same negative effect
on follow-up behavior.
Dr. Smith, who is also an emergency physician at
St. Louis Children’s Hospital, noted that most
primary care physicians are aware that parents have
barriers to care. She adds, however, “I am not
sure if they fully appreciate how this impacts a family’s
ability or desire to seek follow-up or regular asthma
care.”
Although the con items on this questionnaire were
not given high ratings, the observed low level of
follow-up care among this group suggests that parents
do not know or appreciate the benefits of follow-up
care. However, the high ratings given to the pro items
suggest that parents believe that follow-up care can
help their child.
WHAT’S
A DOCTOR TO DO?
“I think the most important thing a primary
care provider can do to improve follow-up visits is
to educate the office staff about the importance of
and need for follow-up care,” Dr. Smith remarked.
“Many parents in our study reported that it was
difficult to make an appointment on short notice,
and some office staff told parents that if their child
had no symptoms they did not need to be seen.”
According to Dr. Smith, most ED physicians will treat
a child’s acute symptoms and send the child home
with appropriate instructions and medication for the
next few days. This does not address long-term management,
however. “How do parents treat the child’s
asthma after the ED visit?” she asked. “Well,
in our experience, most parents go back to treating
the child as they did before the ED visit.”
Dr. Smith noted that if a child gets sick enough
to require an ED visit, then there is a problem with
that child’s home management plan or action plan.
“A follow-up visit provides an opportunity to
review the child’s medications and action plan
as well as help educate the parents about early recognition
of an impending exacerbation. This would help prevent
another ED visit.”
—Gale Jurasek
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Reference
1. Smith SR, Highstein GR, Jaffe DM, et al. Parental
impressions of the benefits (pros) and barriers (cons)
of follow-up care after an acute emergency department
visit for children with asthma. Pediatrics.
2002;110:323-330.
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—Gale
Jurasek
References
1. Sin DD, Man SFP. Low-dose inhaled corticosteroid therapy
and risk of emergency department visits for asthma. Arch
Intern Med. 2002;162:1591-1595.
2. Edmonds ML, Camargo CA Jr, Pollack CV Jr, Rowe BH. The
effectiveness of inhaled corticosteroids in the emergency
department treatment of acute asthma: a meta-analysis. Ann
Emerg Med. 2002;40:145-154.
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