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Impact of Emergency Department Asthma Management Strategies on Return Visits in

Children: A Population Based Study

Astrid Guttmann1,2,3,4 Brandon Zagorski1 Michael Schull1,4,5 Asma Razzaq1 Geoff Anderson1,4

1 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.2 Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario 3 Department of Paediatrics, Faculty of Medicine, University of Toronto4 Department of Health Policy, Management and Evaluation, University of Toronto5 Department of Emergency Medicine, University of Toronto

Disclosures

• Research funded by the Ontario Hospital Report Research Collaborative

• Salary Support for Dr.’s Austin and Guttmann from the Canadian Institute for Health Research

• No conflicts to declare

Background

• Emergency Departments (EDs) play an important role in the care of children with asthma

• Steady rise in ED visits for asthma >750,000 visits in US (2004)

• Many guidelines for overall management of acute exacerbations

• ? Best strategies for implementing guideline care

Research Objectives

1) Describe the current asthma management strategies for children employed by EDs in the province of Ontario

2) Test which strategies have an impact on 72 hour return visits in children -- performance measure

Methods

• Population-based cohort study Comprehensive administrative heath

and survey data from all 152 EDs in Ontario, Canada

Cohort: all children ages 2 - 17 years who had a visit to an ED for asthma (April 2003 to March 2005)

Outcome: Unplanned return visit within 72 hours

ED Resources and Asthma Management Strategies

• ED Survey Training of frontline staff Pediatrician for consultation Short stay unit Guidelines Preprinted, standardized order sheet Discharge instructions Trained personnel in asthma education Routine PFTs Dispense aerochambers

Analysis

• Clustered logistic regression model (GEE) controlling for patient factors• age, gender, SES, triage score, history of admission

hospital factors• propensity to admit, type (academic, large and small

community), volume of asthma patients (all ages) Subgroup Analyses • Training of frontline staff

• PFTs

Results

• 32, 996 children with at least one visit for asthma in the 2 year study period

• Academic and large community hospitals tended to see younger and sicker children

• Overall return visit rate 5.6% (7.1% in the small community hospitals)

• Subsequent admission rate of 16.6% in those returning

Distribution of Emergency Department Strategies and Resources by Hospital Type *

Hospital Type

Number of Strategies

Academic (N=12)

Large Community

(N=70)

Small Community

(N=70)

All

(N=152)

None 0 3 (4.3) 1 (1.4) 4 (2.6)

Up to 2 Strategies

4 (33.3) 8 (11) 23 (32.9) 35 (23)

3-4 Strategies 4 (33.3) 32 (46) 33 (47.1) 69 (45.4)

5 or more Strategies

4 (33.3) 27 (39) 23 (18.6) 44 (28.9)

* 100% response rate

Adjusted Odds Ratios of Return Visits by Hospital Strategy/Resources

Hospital Strategy/Resources Odds Ratio

(95%CI)p Value

Short stay unit 1.17 (0.99, 1.38) 0.06

Access to a Pediatrician 0.64 (0.52, 0.79) <0.001

Pre-printed discharge instructions 0.99 (0.83, 1.19) 0.95

Pre-printed order sheets 0.68 (0.55, 0.85) < 0.001

Routine use of peak flow testing 0.93 (0.79, 1.10) 0.40

Trained personnel in asthma teaching

0.96(0.78,1.18) 0.68

Ability to dispense aerochambers 0.87 (0.70, 1.08) 0.21

Availability of asthma guidelines 0.96 (0.80, 1.16) 0.70

Return Visit Rate by Number of Effective Strategies* Used

Strategies Hospitals with the Number of Key

Strategies (N=152)

Return Visit

Rate (%)

No.(%)

Neither 95(63) 6.9

Pediatrician for Consultation only

31(20) 5.4**

Order Sheet Only 9(6) 5.4***

Both 17(11) 4.4**

*Access to pediatricians, pre-printed order sheets

** p<0.001 ***p<0.05

Main Findings

• 2 Strategies associated with reduced recidivism Preprinted, standardized order pathway Access to pediatricians

•No difference between EDs with pediatrician as frontline physicians vs those available for consults

Mechanism of effect of strategies

• Standardized order sheets Dosing of appropriate medications Assessment criteria Follow up plans

• Access to pediatrician for consultation ?guideline care, more time for

teaching/counselling?

Limitations

• No verification of survey data

• Did not account for follow up

• Testing different constructs Order sheets, discharge instructions

• Ecologic exposures Pediatrician, PFT’s

Strengths and Conclusions

• Complete response rate

• Population-based sample of children across different settings/providers

• Effectiveness of interventions

• Pre-printed/standardized order sheet Feasible, inexpensive Currently only used by minority of EDs