An emergency department–based follow-up clinic can improve asthma outcomes
Article Outline
- Teach SJ, Crain EF, Quint DM, Hylan ML, Joseph JG. Improved asthma outcomes in a high-morbidity pediatric population: Results of an emergency department–based randomized clinical trial. Arch Pediatr Adolesc Med 2006;160:535-41
- References
- Copyright
Teach SJ, Crain EF, Quint DM, Hylan ML, Joseph JG. Improved asthma outcomes in a high-morbidity pediatric population: Results of an emergency department–based randomized clinical trial. Arch Pediatr Adolesc Med 2006;160:535-41
Question Among a high-morbidity pediatric population, does an emergency department (ED)–based asthma follow-up clinic improve outcomes?
Design Randomized clinical trial.
Setting Emergency department of an urban pediatric medical center.
Participants 488 children, aged 1 to 17 years, with active asthma.
Intervention Children were randomized to a single follow-up clinic visit focusing on asthma self-monitoring and management, environmental modification and trigger control, and linkages and referrals to ongoing care.
Outcomes The primary outcome measure was unscheduled visits for acute asthma care. Secondary outcomes included compliance with a medical plan and asthma quality of life.
Main Results Of the children assigned to the follow-up clinic, 172 of 244 (71%) attended. After 6 months, children in the clinic group had fewer unscheduled visits for asthma (1.39 vs 2.34, relative risk [RR] = 0.60), greater likelihood of action plan use (61% vs 40%, number needed to treat [NNT] = 5), recent daily inhaled corticosteroid use (64% vs 33%, NNT = 4), and spacer use (49% vs. 27%, NNT = 5), compared with children in the control group. There were no differences in hospitalizations or identification and contact with a primary care provider for asthma care.
Conclusions An ED-based, follow-up asthma clinic decreased unscheduled asthma care, while improving asthma self-management.
Commentary Although asthma is managed by primary care physicians, because of its unpredictable nature, it is often treated by ED physicians. Bridging the gap between primary and emergency care is a focus of recent research.1, 2 This well-done study suggests that a single follow-up visit at a novel ED-based asthma clinic can improve self-management, quality of life, and ED use. However, there are a couple of concerns that arise if one were to apply this model more broadly. First, the percentage of subjects who identified (49%) or scheduled visits with their primary care provider (PCP) (2 visits/6 months) was no different between the 2 groups. Additionally, the intervention has potential to weaken the PCP-patient relationship by replacing it with ED-based follow-up. Without PCP involvement, it may be difficult to sustain improvements beyond 6 months.2 Finally, the study took place in a large pediatric ED (over 72,000 visits per year). Smaller settings may not have the volume or economy of scale to make such a follow-up asthma clinic feasible or cost-effective. This important study suggests a novel approach to “jump start” asthma management in the ED. Still, the results need to be replicated in different settings, with different personnel and with stronger links to the PCPs and subspecialists who are crucial components in the continuum of comprehensive asthma care.
References
PII: S0022-3476(06)00808-0
doi:10.1016/j.jpeds.2006.08.035
© 2006 Mosby, Inc. All rights reserved.
