Inhaled corticosteroids for asthma: are ED visits a missed opportunity for prevention?

Inhaled corticosteroids prescriptions increased in the ED for recurrent asthma exacerbations by automated electronic reminders in the ED

Objective: The objective of this study was to evaluate the impact of an electronic alert on the prescription rate of inhaled corticosteroids (ICS) by ED providers for poorly controlled persistent asthmatic children.Methods: Study subjects included asthmatic patients age 4-18 presenting to the ED at Phenix Children's Hospital between February 9, 2018 and December 4, 2018, with a history of at least two previous ED visits for acute exacerbation of asthma within 365 days, no active ICS prescription within 90 days, and free from developmental delay, bronchopulmonary dysplasia due to prematurity, cystic fibrosis, sickle cell disease, and/or interstitial ling disease. Patients meeting these criteria triggered an electronic alert prompting the medical provider to prescribe ICS or indicate reason for not prescribing. Instruction on the alert was provided to ED attending physicians and residents by email and through several educational sessions held prior to the implementation.Results: Among 62 patients without prior ICS who were discharged home from the ED, ICS was prescribed for 48 (77%). No statistically significant differences were detected in baseline characteristics between patients discharged home from the ED with and without ICS prescription. While ICS was prescribed by a larger proportion of physicians (56%) compared to residents (42%), statistical significance was not reached. For the 14 (33%) patients who were discharged home without ICS, no reason was provided to indicate why ICS were not prescribed.Conclusion: An electronic alert incorporated into the ED workflow to populate a discharge order set is effective to initiate asthma controller medication for poorly controlled pediatric patients. Additional data describing reasons for not prescribing ICS can further refine recommendations for ICS prescriptions, and provide a comprehensive strategy to support clinical decision for pediatric asthma control in acute care settings.

Evaluation of pharmacotherapy of obstructive airway diseases in the Montenegrin outpatient care: comparison with two Scandinavian countries

BACKGROUND

This study is aimed at evaluating the pharmacotherapy of obstructive airway diseases (OAD) in the Montenegrin outpatient care (MOC) in 2010.

METHODS

Data on the reimbursed drugs which were prescribed during the reference period were obtained from the National Database that was established within the Health Insurance Fund of Montenegro in 2004. We have applied the standard pharmacoepidemiologic methodology with the defined daily dose (DDD) along with the Anatomical Therapeutic Chemical (ATC) classification of drugs. Clinical entities of OAD were classified according to the International Classification of Diseases (ICD-Revision X).

RESULTS

Prescribing and the subsequent use of drugs for OAD (ATC code R03) in 2010 was 18.18 DDD/1000inhabitants/day, much lower than in some developed countries. Fenoterol/ipratropium and salmeterol/fluticasone fixed combinations had the highest utilisation level, accounting for more than 50% of all OAD drugs. About 90% of OAD drugs were prescribed for COPD and asthma.

CONCLUSIONS

Obtained results indicate that there are still large differences in OAD drug utilisation in MOC when compared with developed countries, but also some improvement in pharmacological approach to the pharmacotherapy of OAD in comparison to the earlier period.

Improving asthma management among African-American children via a community health worker model: findings from a Chicago-based pilot intervention

OBJECTIVES

Asthma affects 25-30% of children living in certain disadvantaged Chicago neighborhoods, a rate twice the national prevalence (13%). Children living in poor, minority communities tend to rely heavily on the emergency department (ED) for asthma care and are unlikely to be properly medicated or educated on asthma self-management. A pilot project implemented and evaluated a community health worker (CHW) model for its effectiveness in reducing asthma morbidity and improving the quality of life among African-American children living in disadvantaged Chicago neighborhoods.

METHODS

Trained CHWs from targeted communities provided individualized asthma education during three to four home visits over 6 months. The CHWs also served as liaisons between families and the medical system. Seventy children were enrolled into the pilot phase between 15 November 2004 and 15 July 2005, of which 96% were insured by Medicaid and 54% lived with a smoker. Prior to starting, the study was approved by an institutional review board. Data on 50 children (71.4%) who completed the entire 12-month evaluation phase were analyzed using a before and after study design.

RESULTS

Findings indicate improved asthma control. Specifically, symptom frequency was reduced by 35% and urgent health resource utilization by 75% between the pre- and post-intervention periods. Parental quality of life also improved by a level that was both clinically and statistically significant. Other important outcomes included improved asthma-related knowledge, decreased exposure to asthma triggers, and improved medical management. The intervention was also shown to be cost-effective, resulting in an estimated $5.58 saved per dollar spent on the intervention.

CONCLUSIONS

Findings suggest that individualized asthma education provided by a trained, culturally competent CHW is effective in improving asthma management among poorly controlled, inner-city children. Further studies are needed to affirm the findings and assess the model's generalizability.

Predictors of uncontrolled asthma in adult and pediatric patients: analysis of the Asthma Control Characteristics and Prevalence Survey Studies (ACCESS)

BACKGROUND

Despite the availability of effective asthma treatments and evidence-based management guidelines focusing on asthma control, many patients have asthma that is inadequately controlled. The objective of this analysis was to identify risk factors for uncontrolled asthma among adult and pediatric patients.

METHODS

Two cross-sectional surveys assessing asthma control status were conducted between January 25 and May 2, 2008, among adult and pediatric patients with asthma. Participants completed a self-administered questionnaire including demographics, medical history, and current asthma medication use. In addition, participants completed either the Asthma Control Test (ACT) or Childhood ACT (C-ACT). Uncontrolled asthma was defined as a score of < or = 19 on the ACT or C-ACT. Multiple logistic regression was used to identify factors related to uncontrolled asthma.

RESULTS

A sample of 64 primary care provider sites (35 for adults and 29 for pediatric patients) across the United States enrolled. One study enrolled 2238 adults (aged > or = 18 years) and the other 2429 children (aged 4-17 years) with asthma. The patients were visiting their health care provider for a scheduled appointment for any reason. The overall prevalence of uncontrolled asthma was 58% and 46% in adult and pediatric patients, respectively. Multivariate analysis identified predictors of uncontrolled asthma in both adults and children including self-reported asthma severity, lack of adherence, and recent history of cold, flu, or sinus infection. The predictors of uncontrolled asthma seen only in adults were less education, insurance status, current smoker, body mass index (BMI) >30 kg/m(2), and history of gastroesophageal symptoms. The predictors of uncontrolled asthma seen only in children were female aged 12-17 years, caregiver unemployment, and history of asthma exacerbation.

CONCLUSIONS

A high proportion of patients with asthma seen in primary care settings are not well controlled. Recognition of specific predictors can signal who may be at higher risk of uncontrolled asthma and provide the opportunity for early interventions.

Assessing Primary Care Physician's Beliefs and Attitudes of Asthma Exacerbation Treatment and Follow-Up

Objective:

The objective of this survey was to assess adult primary care physicians’ and pediatricians’ perceptions of asthma exacerbation management, including beliefs concerning the discharge of patients from the emergency department (ED) following asthma exacerbations.

Methods:

This was a cross-sectional survey of primary care physicians (PCPs) treating adult or pediatric patients. Surveys were mailed to physicians and included questions on how PCPs define an exacerbation, how they are notified and how they followed-up with their patients who experienced exacerbations.

Results:

A total of 189 physicians were targeted in this survey, with 124 (65%) returning a completed survey. The majority of physicians agreed that an exacerbation included worsening asthma requiring a course of oral corticosteroids (83%). However, ≥70% of physicians agreed that an exacerbation could also include events which did not require OCS. Overall, 71% of PCPs believed that the majority of their patients’ asthma exacerbations were treated in the doctor’s office with only 6% believing the majority were treated in the ED. Over 90% of PCPs surveyed said they scheduled a follow-up with their patients “all or most of the time” when notified of an ED visit for an asthma exacerbation. Of the adult PCPs surveyed, 20% said they were never notified when one of their patients received treatment in the hospital because of an asthma exacerbation, whereas only 10% of pediatricians said they were never notified. The majority of PCPs surveyed (79%) indicated that if a controller medication was warranted, the ED staff should initiate treatment at time of discharge.

Conclusions:

This study showed that healthcare providers may not share a common definition of an asthma exacerbation. In addition, most physicians believe that the majority of exacerbations are treated in their office or at home. Further, most agreed that if a controller medication was warranted, the ED or urgent care staff should initiate treatment.

Inhaled corticosteroids should be initiated before discharge from the emergency department in patients with persistent asthma

National and International Guidelines concur that inhaled corticosteroids (ICS) are the preferred long-term maintenance drug therapy for mild persistent asthma for all ages. For moderate and severe persistent asthma, ICS are essential to optimal management, often concurrent with other key therapies. Despite strong evidence and consensus guidelines, ICS are still underused. While some patients who are treated in the emergency department (ED) have intermittent asthma, most have persistent asthma and need ICS for optimum outcomes. Failure to initiate ICS at this critical juncture often results in subsequent lack of ICS therapy. Along with a short course of oral corticosteroids, ICS should be initiated before discharge from the ED in patients with persistent asthma. Although the NIH/NAEPP Expert Panel Report 3 suggests considering the prescription of ICS on discharge from the ED, The Global Initiative for Asthma (GINA) 2008 guidelines recommend initiation or continuation of ICS before patients are discharged from the ED. The initiation of ICS therapy by ED physicians is also encouraged in the emergency medicine literature over the past decade. Misdiagnosis of intermittent asthma is common; therefore, ICS therapy should be considered for ED patients with this diagnosis with reassessment in follow-up office visits. To help ensure adherence to ICS therapy, patient education regarding both airway inflammation (show airway models/colored pictures) and the strong evidence of efficacy is vital. Teaching ICS inhaler technique, environmental control, and giving a written action plan are essential. Lack of initiation of ICS with appropriate patient education before discharge from the ED in patients with persistent asthma is common but unfortunately associated with continued poor patient outcomes.

Adding long-acting beta-agonists to inhaled corticosteroids after discharge from the emergency department for acute asthma: a randomized controlled trial

BACKGROUND

Relapses of asthma following emergency department discharge can be reduced with oral and inhaled corticosteroids (ICSs), but the benefits of long-acting beta-agonists (LABAs) are unclear.

OBJECTIVES

To determine whether the addition of a LABA reduces relapses in patients with acute asthma.

METHODS

This was a randomized, controlled, double-blind trial of 137 patients, aged 18-55 years, conducted in four Canadian EDs. Patients receiving high-dose ICSs or oral corticosteroids, and those who were medically unstable, were excluded. Patients were randomized to either fluticasone 1,000 microg/day with salmeterol 100 microg/day or fluticasone 1,000 microg/day alone. All patients were discharged on seven days of oral prednisone. The main outcome measure was relapse at 21 days.

RESULTS

Both groups had similar baseline characteristics. After 21 days, seven of 69 patients (10.1%) treated with fluticasone/salmeterol and ten of 68 patients (14.7%) treated with fluticasone experienced a relapse (p = 0.42). Prior intubation, female gender, and prior use of ICSs were associated with relapse. There were no clinically or statistically significant differences in overall quality of life and individual domain scores. Fluticasone/salmeterol improved quality of life (p < 0.05) and relapses (24% to 13%; p = 0.35) in patients receiving ICSs at the time of emergency admission.

CONCLUSIONS

Outpatient treatment with a short course of systemic corticosteroids combined with ICSs is adequate for most patients with asthma discharged from the emergency department; those already receiving ICS agents may benefit from ICS/LABA combination therapy to improve quality of life. Larger studies are needed to confirm the role of inhaled LABAs in acute asthma.

No symptoms, no asthma: the acute episodic disease belief is associated with poor self-management among inner-city adults with persistent asthma

OBJECTIVE

Asthma morbidity and mortality is highest among inner-city populations. Suboptimal beliefs about the chronicity of asthma may perpetuate poor asthma control among inner-city asthmatics. This study sought to characterize beliefs about the chronicity of disease and its correlates in a cohort of inner-city adults with persistent asthma.

DESIGN

Prospective, longitudinal, observational cohort study.

PATIENTS

One hundred ninety-eight adults hospitalized with asthma over a 12-month period at an inner-city teaching hospital.

MEASUREMENTS

Sociodemographics, clinical history, disease beliefs, and self-management behaviors were collected by interview. Information on self-reported use of inhaled corticosteroids (ICS), peak flowmeters, and regular asthma visits was collected during hospitalization, and 1 month and 6 months after discharge.

RESULTS

This cohort was predominantly low income and nonwhite, with high rates of prior intubation, oral steroid use, and emergency department visits and hospitalizations. Overall, 53% of patients believed they only had asthma when they were having symptoms, what we call the no symptoms, no asthma belief. Men patients, those > or = 65 years old, and those with no usual place of care had greater odds of having the no symptoms, no asthma belief, and those receiving oral steroids all or most of the time or with symptoms most days had half the odds of having this belief (p < 0.05 for all). The no symptoms, no asthma belief was negatively associated with beliefs about always having asthma, having lung inflammation, or the importance of using ICS, and was positively associated with expecting to be cured. The acute disease belief was associated with one-third lower odds of adherence to ICS when asymptomatic at all three time periods (p < 0.02 for all).

CONCLUSION

The single question, "Do you think you have asthma all of the time, or only when you are having symptoms?" can efficiently identify patients who do not think about or manage their asthma as a chronic disease.

Emergency physicians' prescribing of asthma controller medications

OBJECTIVES

To determine the frequency with which emergency department (ED) physicians prescribe long-term controller medications (LTCMs) for children with asthma, to assess ED physicians' awareness of and level of agreement with national guidelines for LTCM use, and to identify criteria ED physicians use to prescribe LTCMs and barriers to the use of LTCMs.

METHODS

A survey of all physician members of the American Academy of Pediatrics Section on Emergency Medicine who provide care for children in an ED was performed.

RESULTS

Surveys were returned by 391 (50%) of 782 physicians. The majority (80%) indicated that fewer than one half of children with persistent asthma were using LTCMs on ED arrival. Although 99% believe that children with persistent asthma should be treated with LTCMs, <20% provide LTCMs for the majority of such children at ED discharge. For 49%, the main reason for not prescribing these medications was the belief that this was the role of the primary care provider or asthma specialist. Practice setting, prior training, and annual patient volume were not associated significantly with prescribing LTCM. Patient's age and likelihood of compliance and physician's belief in efficacy and concerns about adverse effects were not important criteria in the decision to begin LTCM.

CONCLUSIONS

ED physicians often encounter children with persistent asthma who are not receiving LTCMs, they believe in the efficacy and safety of LTCMs, and they think that children with persistent disease should be treated with LTCMs, but they prescribe LTCMs infrequently.

Inadequate follow-up controller medications among patients with asthma who visit the emergency department

STUDY OBJECTIVE

The purpose of this study is to determine the frequency with which primary care physicians add inhaled corticosteroids to the regimen of asthmatic patients after a visit to the emergency department (ED) among patients not previously prescribed inhaled corticosteroids and to determine the rate at which inhaled corticosteroids prescribed in the ED were continued by primary care physicians.

METHODS

We conducted a structured retrospective cohort study using electronic medical record review of consecutive patients aged 6 to 45 years, treated for acute asthma exacerbation (International Classification of Diseases, Ninth Revision code 493.00 through 493.99) in the ED during a specified 6-month period, and followed up for 1 year. The patients' first ED visit for asthma exacerbation during the study period was considered the index visit for purposes of this study.

RESULTS

Six hundred twenty-nine patients met study inclusion criteria, 414 of whom were not previously receiving inhaled corticosteroid therapy. On ED or hospital discharge, 99 (24%) of these 414 patients were prescribed an inhaled corticosteroid. Of these 99 patients, 37 patients had a primary care follow-up visit within 6 months, with 4 receiving an inhaled corticosteroid dose change and no patients having the inhaled corticosteroids discontinued. Of the 315 patients not prescribed an inhaled corticosteroid on ED or hospital discharge, 128 had a primary care follow-up visit within 6 months, with 32 (25%) patients having an inhaled corticosteroid added to their therapeutic regimen. After primary care follow-up, only 69 (42%) of the 165 patients treated in clinic were receiving an inhaled corticosteroid for control of their asthma. Patients without insurance (odds ratio 0.14; 95% confidence interval 0.027 to 0.71) and patients initially discharged home from the ED (odds ratio 0.17; 95% confidence interval 0.05 to 0.53) were much less likely to receive inhaled corticosteroids at follow-up on multivariate logistic regression adjusting for race, sex, insurance status, and initial disposition.

CONCLUSION

Primary care physicians infrequently add controller medications (inhaled corticosteroids) at follow-up to the regimen of asthmatic patients after a visit to the ED. Emergency physicians should be encouraged to evaluate chronic asthma burden among patients presenting with exacerbation, educate asthmatic patients, and prescribe controller medications, such as inhaled corticosteroids, for those with persistent symptoms.

Quality and access to care among a cohort of inner-city adults with asthma: who gets guideline concordant care?

STUDY OBJECTIVES

Asthma morbidity is highest among inner-city populations. This study measured whether quality and access to care over time was concordant with National Asthma Education and Prevention Program (NAEPP) guidelines. It also identified factors associated with NAEPP guideline-concordant care.

DESIGN

A prospective, observational cohort study.

SETTING

An urban academic medical center.

PATIENTS

A consecutive cohort of 198 inner-city adults hospitalized for asthma.

MEASUREMENTS

Detailed information about sociodemographics, asthma history, access to care, history of the current exacerbation, prescription and use of inhaled corticosteroids (ICS) and beta-agonists, and other elements of NAEPP-concordant care (spacers, metered-dose inhaler [MDI] technique, peak flow meters, and action plans) was collected during the index admission and 1 month and 6 months after discharge.

RESULTS

In this predominantly low-income, nonwhite cohort, while 92% of patients had insurance and 80% had a usual source of care, 73% reported delays in seeking care. ICS were prescribed for 77% of patients prior to hospital admission, 83% at 1 month, and 67% at 6 months. Adherence with other NAEPP recommendations were 89% for receipt of MDI instruction, 68% for spacers, 80% for peak flow meters, 31% for written action plans for worsening, and 22% for written plans for attacks. In multivariate analysis, greater asthma severity and having a usual source of care increased the odds of receiving ICS, spacers, and peak flow meters. Care by a specialist increased the odds of receiving action plans. Patients who spoke mostly Spanish were less likely to be given spacers or action plans.

CONCLUSION

Baseline problems with quality and access to care persisted over time. Better systems of care are needed to ensure that high-risk patients receive an appropriate step-up in the quality of ongoing asthma care.

How appropriate is asthma therapy in general practice?

High association between burden of asthma and inadequate disease control make asthma management a major public health issue. We studied asthma management practices of general practitioners (GPs) in France to describe drug therapy and more specifically, to identify correlates of antibiotic prescriptions, a marker of inappropriate asthma management. Patients with persistent asthma aged 17-50 years were evaluated in a 12-month retrospective study using a computerized GPs database (Thales) and a patient survey, in which patients reported hospital contacts, use of oral corticosteroids and recent asthma symptoms. Therapy was described and the correlates of antibiotic prescriptions in the previous year were identified using multivariate logistic regression. During the study period, 16.4% of 1038 patients received one or more prescriptions of theophylline, 31.3% long-acting beta-agonists and 61.6% inhaled corticosteroids. Rates of prescription of antibiotics, expectorants, antihistamines, antitussives and nasal corticosteroids were 57.6, 42.0, 33.0, 19.9, and 14.4%, respectively. In parallel, 15% of patients reported at least one hospital contact for asthma and 43.1% used oral corticosteroids. Antibiotic prescriptions were more likely co-prescribed in patients using expectorants [odds ratio (OR) = 13.0, 95% confidence interval (CI) = 8.5-19.8] and antitussives (OR = 6.5, 95% CI = 3.7-11.6). Moreover, patients using courses of oral corticosteroids, and often visiting their GP (more than four times) during the study period were more likely to receive antibiotics. The results were unchanged when analyses were restricted to non-smokers and younger patients (< or = 40 years). Asthma management was sub-optimal among asthma patients treated by general practitioners in France. Antibiotics, expectorants, antihistamines, antitussives and nasal corticosteroids were commonly prescribed while asthma controllers were under-used.

Inpatient management of asthma in the Chicago suburbs: the Suburban Asthma Management Initiative (SAMI)

BACKGROUND

Assessment of inpatient asthma management has generally been limited to urban settings, including Chicago, which is known for its high asthma morbidity and mortality. Previously published data have been based on survey methodology. The Suburban Asthma Consortium (SAC) sought to obtain patient-based data unique to the Chicago suburbs to improve asthma care in those areas.

OBJECTIVE

To evaluate current inpatient asthma management based on the 1997 National Asthma Education and Prevention Program (NAEPP).

DESIGN

Retrospective chart review of all hospitalized patients 3-65 years bearing asthma-related ICD-9 codes for fiscal year 2002 in community, nonteaching hospitals in Chicago suburbs.

RESULTS

Nine hundred two cases were submitted from seven hospitals. The majority ( > or = 75%) received inhaled bronchodilators, systemic steroids, oxygen and pulse oximetry. Antibiotic use (67%), chest radiography (85%), complete blood count (77%), and electrolytes (59%) appeared excessive in view of NAEPP recommendations. Peak flow monitoring (PFM) was recorded on admission in 45% of patients 5 years old and older; 52% had PFM during hospitalization. Thirty-eight percent of patients were taking ICS prior to admission; of those not on ICS, only 12% were newly diagnosed asthmatics. Overall, 51% of patients were discharged with ICS. Patients were more likely to receive ICS at discharge if they had required intensive care (ICU), had been on ICS prior to admission, were referred to an asthma specialist while hospitalized, or were insured. Patients with Medicare/Medicaid (MC/MA) had more repeat emergency visits and hospitalizations, longer lengths of stay, and received less ICS at discharge. Depending on the parameter, 41% or less patients received discharge planning education and were not more likely to have received education if in the ICU. Results ranged significantly between hospitals for most parameters (p < 0.05 or less).

CONCLUSION

Study subjects received appropriate acute therapy and oxygen monitoring, but there was a divergence from NAEPP recommendations regarding PFM, ICS use, antibiotics, and laboratory evaluation. Patients receiving MC/MA experienced higher morbidity and received less ICS. Discharge asthma education was suboptimal for most hospitals. Most parameters demonstrated significantly wide practice variations between hospitals. Peak flow monitoring and patient education findings differed significantly from those in survey-conducted studies.

Use of inhaled corticosteroids following discharge from an emergency department for an acute exacerbation of asthma

BACKGROUND

Most patients who have an asthma exacerbation leading to a visit to an emergency department (ED) will benefit from treatment with inhaled corticosteroids (ICS) at discharge. We investigated whether asthmatic children and adolescents were receiving ICS after discharge from the ED and identified the characteristics of patients and physicians associated with their use.

METHODS

A cohort of 4042 asthmatic patients aged 5-17 years was selected from the administrative database of the Regie de l'assurance maladie du Quebec between 1997 and 1999. The proportion of patients using ICS 1, 3, and 6 months after ED discharge was estimated. Using GEE models the independent contribution of sociodemographic variables, markers of asthma severity, prior use of healthcare services and ICS, and physician characteristics was investigated on the likelihood of using ICS after ED discharge.

RESULTS

68% of children and 51% of adolescents had a valid prescription for ICS in the month following discharge. At 6 months after discharge the corresponding figures were 77% and 60%. The strongest predictors of ICS use were age, with adolescents being less likely to use ICS than children (OR 0.49; 95% CI 0.43 to 0.56), prior use of ICS (OR 2.28; 95% CI 2.00 to 2.61), and filling a prescription for oral corticosteroids in the month following discharge (OR 2.29; 95% CI 2.03 to 2.58). However, patients who had an ED visit or a hospital admission for asthma during the 6 months before discharge were not more likely to use ICS after discharge.

CONCLUSION

A large proportion of patients with clear markers of uncontrolled or severe asthma did not have a valid prescription for an ICS after discharge from the ED.

Children's use of emergency departments for asthma: persistent barriers or acute need?

Our objective was to explore, in a predominantly Latino inner-city population, why caregivers bring their children with asthma to the ED (emergency department). We conducted bilingual parent surveys and medical chart abstractions of a consecutive ED sample consisting of 234 children with asthma (69% Latino; 54% Spanish-speaking) and their caregivers. Outcome measures included: (1) the acute need for ED services based on objective physiological measures, (2) the extent to which these children experienced barriers to quality primary care for asthma before the ED visit, and (3) the relative importance caregivers assigned to worsening symptoms versus perceived barriers to non-ED care when deciding to bring their child to the ED. Most children had moderate or severe asthma attacks. In the prior month, only 33% went to a primary care provider, 83% had used a bronchodilator, and 63%, an age-appropriate spacer device. Seventy-five percent of caregivers cited perceived acute need, instead of barriers to primary care, as the most important reason for using the ED. This perception of acute need was associated with moderate or severe asthma attacks according to objective physiological measures, after controlling for health and sociodemographic characteristics. Children with asthma who use the ED encounter barriers to primary care, but caregivers' perception of acute need--validated by independent measures of attack severity--dominates caregivers' decision to use the ED. Ensuring continuity of care for children with asthma would involve not only improving various aspects of access to and quality of primary non-ED care--including parent education about early recognition and treatment of asthma attacks--but also providing families with practical low-cost alternatives for 24-hour care and assuring linkages between the ED and sources of primary care.

Relationship between asthma medication and antibiotic use

STUDY OBJECTIVES

Increasing morbidity due to asthma and antimicrobial resistance among human pathogens are both major public-health concerns. Numerous studies describe the overuse of antibiotics in general populations and underuse of anti-inflammatory medications by asthmatic patients. However, little is known about the relationship between asthma medication and antibiotic use in asthmatics. Specifically, we tested the hypothesis that higher use of bronchodilator and anti-inflammatory medication by asthmatics, as a marker of problematic asthma, is associated with greater antibiotic use. We also test the hypothesis that physicians who are low prescribers of anti-inflammatory medications are high prescribers of antibiotics.

DESIGN

We conducted a retrospective cohort study evaluating asthma medication and antibiotic use by children and adults with asthma and the prescribing of these medications by primary-care physicians.

SETTING/PATIENTS

Subjects were continuously enrolled asthma patients aged 6 to 55 years receiving care in an urban, group-model, health maintenance organization.

INTERVENTIONS

None.

MEASUREMENT AND RESULTS

Main outcome measures were (1) antibiotic use by asthmatics stratified by low, moderate, and high bronchodilator use; (2) antibiotic use by asthmatics stratified by no, intermittent, and long-term anti-inflammatory use; and (3) correlation between physician-level anti-inflammatory agent to bronchodilator ratio (AIF:BD) and their rate of antibiotic prescribing. We found that (1) high bronchodilator users received 1.72 antibiotics per person-year (95% confidence interval [CI], 1.62 to 1.83), whereas low bronchodilator users received 1.23 antibiotics per person-year (95% CI, 1.19 to 1.27; p < 0.0001); (2) long-term users of anti-inflammatory agents received 1.85 antibiotics per person-year (95% CI, 1.76 to 1.95), whereas those not receiving an anti-inflammatory agent received 0.95 antibiotics per person-year (95% CI, 0.90 to 1.00; p < 0.0001); and (3) despite variations in physician AIF:BDs and antibiotic prescribing, respectively, these measures were not correlated.

CONCLUSIONS

Antibiotic use and asthma medication use are positively associated in a cohort of asthma patients. Greater effort is needed to define the appropriate role of antibiotics in asthma management.

Characteristics and correlates of asthma knowledge among emergency department users in Harlem

We constructed a questionnaire to assess asthma knowledge, assessed its psychometric properties, and examined its association with demographic characteristics, psychosocial factors, and disease severity and management in 375 adults following an asthma-related emergency department visit. Overall knowledge was poor but varied widely among respondents. Better knowledge was related to younger age, higher education, and less severe disease. Chance-orientated health locus of control and low self-esteem were associated with lower asthma knowledge. Better knowledge was associated with better disease management. We conclude that asthma education can lead to improved disease outcomes, and psychosocial factors need to be considered when designing interventions for asthma education.

Asthma therapy in the observation unit

The management of asthma is a commonly encountered clinical problem. There have been major advances in the treatment of asthma, including an increase in the drugs available for treatment, as well as in knowledge of the pathophysiology of the disease. Despite these advances, however, the prevalence, morbidity, and mortality for asthma have shown a disturbing upward trend over the past few decades. Experience with the OU management of asthma has shown many advantages: decreased inpatient hospitalization, better quality of life for patients, higher patient satisfaction, cost-effectiveness, and effective patient care. It is estimated that 60% to 70% of asthmatic patients could be treated in an ED observation unit instead of in an inpatient hospital ward. There is a tremendous opportunity for the OU management of asthma to improve patient care, as well as decrease costs, thereby reducing asthma morbidity and mortality.

Randomized trial of inhaled flunisolide versus placebo among asthmatic patients discharged from the emergency department

STUDY OBJECTIVE

Inhaled corticosteroids (ICs) improve airflow and decrease symptoms in patients with chronic asthma. We examined whether high-dose inhaled flunisolide would have similar benefits after an emergency department visit for acute asthma.

METHODS

Over a 16-month period at one inner-city ED, we documented 551 eligible patients (acute asthma; age 18 to 50 years; no ICs in past week; no oral corticosteroids in past month; and peak expiratory flow rate [PEFR] <70% of predicted value after first beta-agonist treatment); 104 patients agreed to participate. At ED discharge, all patients were given prednisone 40 mg/d for 5 days and inhaled beta-agonists as needed and were randomly assigned to receive high-dose inhaled flunisolide 2 mg/d (n=51) or placebo (n=53). Patients were telephoned daily and asked to return for PEFR measurement at 3, 7, 12, 21, and 24 days.

RESULTS

Despite precautions, 28% (16 receiving flunisolide and 13 receiving placebo) of patients were completely lost to follow-up, 2 patients had only one follow-up (day 3), 2 patients receiving flunisolide withdrew because of medication-related bronchospasm, and 4 patients in each group experienced relapse. Among the 63 remaining patients, we found no difference between flunisolide and placebo at day 24 follow-up in percent predicted PEFR (87% versus 83% on day 24, P =.36; difference 4%, 95% confidence interval [CI] -5% to 13%). Nocturnal wheezing and nocturnal albuterol inhaler use was higher among patients receiving flunisolide than those receiving placebo on day 24 (48% versus 18% for nocturnal wheezing, P =.01; mean difference 30%, 95% CI 11% to 49%; 3.8 versus 1.4 nocturnal albuterol puffs, P =.03; mean difference 2.4 puffs, (95% CI 0.2 to 4). Levels of dyspnea, cough, and overall well-being were similar between the flunisolide and placebo groups.

CONCLUSION

Addition of high-dose inhaled flunisolide to standard therapy does not benefit inner-city patients with acute asthma in the first 24 days after ED discharge. Airway inflammation during acute asthma may require higher doses or more potent anti-inflammatory agents.