Improving Quality of Asthma Care After Emergency Department Discharge: Evidence Before Action
Article Outline
- Introduction
- The urgency to consider new approaches
- The need for evidence before adopting new approaches
- References
- Copyright
Introduction
Asthma is a common chronic disease, and exacerbations due to a variety of causes are problematic1 and expensive for the health care system.2, 3 Many patients with the most severe exacerbations present to the emergency department (ED); however, most patients are treated, improve symptomatically, and then are discharged. Despite this seeming improvement before discharge, relapse is common and return to normal quality of life is often delayed or never achieved.4, 5, 6 Given the nature of this disease, repeat visits are common for many patients, and many providers and researchers (including Singer et al7 in this issue of Annals) have identified the ED as an “ideal” setting for interventions to improve the quality of chronic asthma management.
The urgency to consider new approaches
In an accompanying editorial, Singer et al7 propose emergency physicians adopt a more “nontraditional” management approach by prescribing inhaled corticosteroid anti-inflammatory agents and delivering asthma education. They claim that this approach is intuitive, evidence-based, and relatively easy to implement and that their case is sufficiently strong that we should all be doing this now as part of usual care. If this approach is so obvious and so ready for prime time, why aren't more emergency physicians doing it? There are a variety of reasons. First, there are a variety of possible “anti-inflammatory” agents from which to choose (eg, systemic and inhaled corticosteroids, leukotriene receptor antagonists, and combinations of inhaled corticosteroids and long-acting beta-agonists); however, not all have been proven to be effective in acute asthma. Most evidence supports the use of systemic corticosteroids4 and inhaled corticosteroid agents for postdischarge patients5, 8; however, additional evidence is still required to determine what other treatments are needed. For example, which patients required the inhaled corticosteroid and long-acting beta-agonist combination after ED care is still unclear. Moreover, these agents are expensive and available only to patients who have drug plan coverage or financial security. A prescription written but not dispensed might make emergency physicians feel better; however, it has not served the patient well. In addition, there is much literature on the choices made, and resultant adverse consequences, when patients with restricted income must choose among medications or choose between multiple medications and other necessities.9
Second, asthma education in the ED would be expensive (in terms of time and opportunity costs relative to what the ED as a whole might need to give up) and patchy. Moreover, there is fairly limited evidence to guide the delivery of this intervention, and the risk-benefit ratio is unknown. Given the evidence base for systemic and inhaled corticosteroids, the evidence cited by Singer et al7 to support educational interventions is sparse at best. The 2 studies they use to support their asthma education recommendations are a “before-after” study of 30 patients compared with historical controls10 and a structured nurse-specialist model with multiple planned visits back at the ED and ongoing contact between visits.11 The former is hardly supportive evidence, and the latter is not what most of us would consider simple asthma education. Indeed, there is little evidence that providing a written action plan with simple instruction in the ED is effective or that education can be delivered effectively in the ED at the time of the acute visit. All of these educational efforts still consume financial and human resources, take energy away from other initiatives, and like any other health care intervention, have the potential to be expensive and ineffective or even cause harm.
The need for evidence before adopting new approaches
Clearly, we all agree with the basic principle that we ought to do more for patients with acute asthma; however, evidence to direct our actions is currently lacking and precludes widespread adoption of the approach suggested by Singer et al7 at this time. We believe emergency physicians should adopt a paradigm of focusing on acute and subacute asthma management. The first step in this process is to increase the seemingly and alarmingly low rates of inhaled corticosteroid prescribing in this setting. By incorporating systemic and inhaled corticosteroids into their practice, emergency physicians are providing patients with the best opportunity to regain control. In the setting where patients cannot afford care of this kind, innovative programs for funding, free samples, and enhanced ED care are worthy of further study. To access these programs, emergency physicians will need to become more cognizant of how much these new medications will cost the patient in front of them, and they will need to develop facility in asking the question: “Are you going to be able to afford another $40 to $70 a month (depending on the agent) to pay for this new inhaler?”
Because so many people use the ED for the delivery of routine asthma care, such novel approaches might put a halt to the revolving door we currently see. This may be even more important for those patients who do not have clear links to primary care providers. Emergency physicians should further focus their considerable interest and attention in asthma on determining what is best practice for patients through higher quality, more innovative, and more collaborative research efforts. The argument would be that research should drive what we do in medication delivery (inhaled corticosteroids+systemic corticosteroids versus inhaled corticosteroids+long-acting beta-agonists+systemic corticosteroids versus systemic corticosteroids alone; shot gun versus tailored). Researching these questions (rather than adopting seemingly good ideas without solid evidence) also has the additional advantage that enrolled trial patients will be guaranteed better follow-up and, perhaps, medication access—at least for the duration of the study.
Secondly, we propose emergency physicians promote, rather than actually perform, formal asthma education. For all of the pleas to perform asthma education in the ED, the evidence base for this recommendation is surprisingly shallow. In one Cochrane Review, Gibson et al12 found limited asthma information to be of little value. There was some evidence to suggest this reduced ED visits; however, although somewhat encouraging, this is hardly sufficient to justify wide-scale adoption as part of usual care. Conversely, the same group found asthma self-management that involves self-monitoring (eg, peak expiratory flow or symptoms), coupled with regular medical review and a written action plan, improves health outcomes for adults with asthma.13 Moreover, recent evidence suggests that doubling the dose of inhaled corticosteroids, the core of the action plan approach, was ineffective in preventing exacerbations.14 Rather than have EDs haphazardly adopt time-consuming, variable, perhaps ineffective, and certainly expensive educational programs, once again we are presented with an opportunity to make the choices simpler and the evidence for those choices more appropriate. For example, while many would promote a discharge plan for ED patients, should we also discuss “action plans,” focus on medication delivery and trigger avoidance, and provide a “1-800” number for ongoing counseling and outreach advice? Should we perform formal ED asthma education or refer patients to an asthma educator whose career is focused on the delivery techniques designed to maximize results? What approach would be most effective, is decanting the ED and preventing repeat visits necessarily an unqualified good, and what are the costs of each approach? Limited research has been performed to determine if education can be effectively delivered in this setting, whether it could be transferred to another setting, or whether using innovative delivery techniques (eg, video, computer-based, Web-interactive) that don't overwhelm an already taxed ED staff might be effective. Finally, for patients who have no primary care follow-up and in settings where resources are scarce, the delivery of asthma education is more difficult, but should still be driven by research evidence. The evidentiary standard for our prescriptions of the dose, duration, and delivery of asthma education should be no different than our demands for evidence about drugs and devices: action cannot precede evidence.
Efforts to facilitate follow-up for chronic diseases are an often-neglected area of emergency care. Several studies have been completed examining intensive efforts to improve patient follow-up with their primary care providers after ED visits for asthma.15, 16 Both studies demonstrated small-to-modest improvements in follow-up visits; however, these interventions are likely not generalizable to most EDs, had no long-term impact on asthma control, and may not actually be cost-effective compared with usual care. We regularly assess, treat, and discharge a variety of diseases for which education and follow-up are necessary and appropriate. For example, apart from asthma, other chronic and costly conditions such as chronic obstructive pulmonary disease, diabetes mellitus, and heart failure represent diseases where needs are similarly great, ED visits are all too common, and demand for services would be high. Decisions on which chronic diseases receive educational interventions in the ED will be difficult; alternative and innovative approaches for congested EDs are required.
Recently, we reported a simple strategy of secondary prevention after ED discharge for patients with distal wrist fractures.17 Rather than advocate that emergency physicians initiate evidence-based treatment with bisphosphonates (drugs associated with a 50% reduction in future fracture and safety profiles and ease of administration similar to inhaled corticosteroids) for patients that they never intended to see again on a regular basis, we developed a program to facilitate linkage between fracture patients and their primary care providers and tested it in an ED-based controlled trial. Discharge information and counseling to both patients and their providers, delivered by nurses and orthopedic technicians and endorsed by local opinion leaders, resulted in a remarkable improvement in osteoporosis screening and treatment.17 The delivery was inexpensive, easily performed, and engaged a potentially underutilized partner for delivery. More to the point, this program did not require busy emergency physicians or nurses to take on more clinical or medicolegal responsibility for patients with whom they do not enjoy a continuous patient-physician relationship. Similar approaches should be examined in the ED setting for other chronic diseases, including asthma. In addition, many primary care providers have difficulty tracking their patients, especially when they present to the ED. Enhanced communications between ED and primary care providers may actually be possible with the availability and expansion of electronic health records and ED information systems18—and again, these quality improvement approaches (in terms of dose, timing, frequency, content, and specific conditions) can be tested in controlled studies before widespread implementation or well-intended infliction.
In conclusion, in many ways, we have made tremendous strides in our understanding of asthma and in the care we can now provide to patients suffering with this disease. Efforts to restore asthma control can and will continue to provide patients with hope for a better quality of life. The challenge, however, is to design approaches that are based on evidence, that are both safe and efficacious in a variety of settings, and that are reasonably cost-effective. The emergency research community owes that to both patients and clinical colleagues who are looking to us for direction.
References
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- . Trends in the cost of illness for asthma in the United States, 1985-1994. J Allergy Clin Immunol. 2000;106:493–499
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- A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. Resp Med. 2000;94:900–908
- Limited (information only) patient education programs for adults with asthma. (Cochrane Review) In: The Cochrane Library, Issue 4. Chichester, United Kingdom: John Wiley & Sons, Ltd; 2004;
- Self-management education and regular practitioner review for adults with asthma. (Cochrane Review) In: The Cochrane Library, Issue 3. Chichester, United Kingdom: John Wiley & Sons, Ltd; 2004;
- Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet. 2004;363:271–275
- Randomized controlled trial of two simple ED interventions to improve the rate of primary care follow-up for patients with acute asthma: 6-month follow-up results. [abstract] Acad Emerg Med. 2002;9:211
- . Effects of increased primary care access on process of care and health outcomes among patients with asthma who frequent emergency departments. Am J Med. 2004;11:479–483
- Increasing the detection and treatment of osteoporosis in patients who present to an emergency department with a wrist fracture. Ann Intern Med. 2004;141:366–373
- A randomized, controlled trial of clinical information shared from another institution. Ann Emerg Med. 2004;39:14–23
Funding and support: Dr. Rowe is supported as a Canada Research Chair in Emergency Airway Diseases through the Canadian Institutes of Health Research. Dr. Majumdar is supported as a Population Health Investigator through the Alberta Heritage Foundation for Medical Research and a New Investigator from the Canadian Institutes of Health Research. Dr. Rowe has received funding for research and/or speaking from the following companies: Abbott (Chicago, IL), AstraZeneca (Mississauga, Ontario, Canada), Aventis (Montreal, Quebec, Canada), Boehringer-Ingelheim Corporation (Ridgefield, CT), and GlaxoSmithKline (Mississauga, Ontario, Canada); however, he is neither a paid employee nor a consultant for any of these companies and has no financial interests in these companies. Dr. Majumdar has no conflicts of interest, financial or otherwise, to disclose.Reprints not available from the authors.
PII: S0196-0644(04)01742-1
doi:10.1016/j.annemergmed.2004.11.026
© 2005 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
Refers to article:
- A Call for Expanding the Role of the Emergency Physician in the Care of Patients With Asthma , 06 January 2005
