Comparison of Canadian versus American emergency department visits for acute asthma

Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care

BACKGROUND

Guidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations.

OBJECTIVE

We sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians.

METHODS

This was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering.

RESULTS

Among 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99-12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08-3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51-0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62-0.91) or no insurance (OR 0.54; 95% CI 0.35-0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period.

CONCLUSIONS

An ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.

Characteristics of medicine use for children with asthma in China: a nationwide population-based study

OBJECTIVE

To analyze the asthma medication use in Chinese children of different age groups, regions, and levels of cities in China, based on the 2015 Healthcare Insurance Data in China.

METHODS

The China Healthcare Insurance Research Association (CHIRA) database was searched for children from 0 to 14 years old diagnosed as asthma based on the "J45" and "J46" coded in ICD-10. A cross-sectional study design was employed.

RESULTS

A total of 308,550 children were identified, all of whom were treated under the coverage of healthcare insurance. Among them, 2,468 children were eligible for inclusion in the present study. Compared with the current status of asthma care in European and American countries, under the guidelines for the diagnosis and treatment of asthma in China, the use percentages of ICS and short-acting β2 receptor agonist in children with asthma in China were lower, but the use percentages of oral corticosteroids, long-acting β2 receptor agonist, and theophylline (especially intravenous theophylline) were higher, especially in the Central and West China.

CONCLUSION

The asthma medication use was attributed to many factors, thus efforts are still needed to further popularize the GINA programs and China's guidelines for asthma diagnosis and treatment, especially in the Central and West China.

A comparison of post-transplant renal function in pre-emptive and post-dialysis pediatric kidney transplant recipients

PURPOSE

Little is known regarding post-transplant renal function following pediatric pre-emptive KT. Therefore, this study aims to determine whether there is a difference in 1 year post-transplant renal function outcomes between pre-emptive and post-dialysis KT in pediatric transplant recipients.

METHODS

A retrospective review of patients who underwent kidney transplant at our institution between 2000 and 2015 was performed. Kidney transplant recipients were divided into four groups: pre-DD, post-DD, pre-LD, and post-LD. The clinical outcomes, measured in eGFR (mL/min/1.73 m² ), acute rejection episodes within 1 year, and hospitalization within 1 year were compared to between groups in their respective donor types (pre-DD vs post-DD; pre-LD vs post-LD).

RESULTS

The 324 patients were identified (21 pre-DD, 151 post-DD, 54 pre-LD, and 98 post-LD). Post-DD group had more females (P = 0.018) and post-operative complications (P = 0.023), although there was no difference in complications requiring intervention (P = 0.129). Post-LD patients were more likely to be females (P = 0.017) and those with intrinsic renal (non-urological/structural) ESRD etiology (P = 0.003). The 1-year eGFR was similar between pre-DD and post-DD groups (70.3 [IQR 53.5-88.5] vs 74.3 [IQR 62.3-90.5], P = 0.613), as well as pre-LD and post-LD groups (66.6 [IQR 47.8-73.7] vs 63.9 [IQR 55.0-77.1], P = 0.600). There were no significant differences in rates of acute rejection episodes or hospitalization within 1 year of transplantation for in LD/DD groups.

CONCLUSION

There is no significant difference in renal function at 1 year post-transplant in pediatric patients receiving pre-emptive or post-dialysis kidney transplants.

Care of acute conditions and chronic diseases in Canada and the United States: Rapid systematic review and meta-analysis

This study tested the hypothesis that socioeconomically vulnerable Canadians with diverse acute conditions or chronic diseases have health care access and survival advantages over their counterparts in the USA. A rapid systematic review retrieved 25 studies (34 independent cohorts) published between 2003 and 2018. They were synthesized with a streamlined meta-analysis. Very low-income Canadian patients were consistently and highly advantaged in terms of health care access and survival compared with their counterparts in the USA who lived in poverty and/or were uninsured or underinsured. In aggregate and controlling for specific conditions or diseases and typically 4 to 9 comorbid factors or biomarkers, Canadians' chances of receiving better health care were estimated to be 36% greater than their American counterparts (RR=1.36, 95% CI 1.35-1.37). This estimate was significantly larger than that based on general patient or non-vulnerable population comparisons (RR=1.09, 95% CI 1.08-1.10). Contrary to prevalent political rhetoric, three studies observed that Americans experience more than twice the risk of long waits for breast or colon cancer care or of dying while they wait for an organ transplant (RR=2.36, 95% CI 2.09-2.66). These findings were replicated across externally valid national studies and more internally valid, metropolitan or provincial/state comparisons. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more modest Canadian advantages. The Affordable Care Act ought to be fully supported including the expansion of Medicaid across all states. Canada's single payer system ought to be maintained and strengthened, but not through privatization.

Prioritizing Systemic Corticosteroid Treatments to Mitigate Relapse in Adults With Acute Asthma: A Systematic Review and Network Meta-analysis

OBJECTIVES

While systemic corticosteroids (SCS) are widely used to prevent relapse in adults with acute asthma discharged from the emergency department, the most effective route of administration is unclear. The objective of this review was to examine the effectiveness of SCS in adults and to identify the most effective route of SCS to preventing relapse.

METHODS

A search was conducted to identify randomized controlled trials comparing the effectiveness of intramuscular (IM) or oral (PO) short-course or long-course corticosteroids to prevent relapse in adults with acute asthma. Two independent reviewers judged study relevance, inclusion, and risk of bias. Pooled statistics were calculated as risk ratios (RR) and odds ratios (OR) with 95% confidence intervals (CI) and credibility intervals (CrI) using a random-effects model. A Bayesian network meta-analysis was performed for indirect comparisons of SCS to placebo. Probability of best (PB) analysis was reported for comparisons between the routes of administration.

RESULTS

Thirteen studies of moderate quality were included. Four studies compared SCS to placebo, in which SCS significantly reduced relapse (RR = 0.43; 95% CI = 0.25 to 0.74). In the network meta-analysis, a significant reduction in relapse within 10 days of discharge was found in adults receiving IM (OR = 0.21; 95% CrI = 0.05 to 0.73) and PO long-course (OR = 0.31; 95% CrI = 0.09 to 0.95) corticosteroids. Relapse rates between PO short-course corticosteroids and placebo were not statistically significantly different (OR = 0.37; 95% CrI = 0.04 to 3.38). PB analysis favored IM corticosteroids (62%) followed by PO short-course (20.3%) and PO long-course (14.1%) corticosteroids.

CONCLUSIONS

The network analysis identified IM corticosteroids and PO long-course corticosteroids as the most effective strategies to prevent relapse among adults with acute asthma, compared to PO short-course corticosteroids. The lack of significant findings with PO short-course corticosteroids is likely due to the paucity of research. Further comparative studies are required to determine the safety and effectiveness of briefer PO SCS treatment options in adults.

Factors associated with relapse in adult patients discharged from the emergency department following acute asthma: a systematic review

A significant proportion of patients discharged from the emergency department (ED) with asthma exacerbations will relapse within 4 weeks. This systematic review summarises the evidence regarding relapses and factors associated with relapse in adult patients discharged from EDs after being treated for acute asthma. Following a registered protocol, comprehensive literature searches were conducted. Studies tracking outcomes for adults after ED management and discharge were included if they involved adjusted analyses. Methodological quality was assessed using the Newcastle–Ottawa Scale (NOS) and the Risk of Bias (RoB) Tool. Results were summarised using medians and IQRs or mean and SD, as appropriate. 178 articles underwent full-text review and 10 studies, of various methodologies, involving 32 923 patients were included. The majority of the studies were of high quality according to NOS and RoB Tool. Relapse proportions were 8±3%, 12±4% and 14±6% at 1, 2 and 4 weeks, respectively. Female sex was the most commonly reported and statistically significant factor associated with an increased risk of relapse within 4 weeks of ED discharge for acute asthma. Other factors significantly associated with relapse were past healthcare usage and previous inhaled corticosteroids (ICS) usage. A median of 17% of patients who are discharged from the ED will relapse within the first 4 weeks. Factors such as female sex, past healthcare usage and ICS use at presentation were commonly and significantly associated with relapse occurrence. Identifying patients with these features could provide clinicians with guidance during their ED discharge decision-making.

Is cognitive function a concern in independent elderly adults discharged home from the emergency department in Canada after a minor injury?

OBJECTIVES

To describe the cognitive functioning of independent community-dwelling elderly adults visiting the emergency department (ED) for minor injuries and at 3- and 6-month follow-up assessments and to document the occurrence of falls, return to the ED, and hospital visits over time according to cognitive level.

DESIGN

Prospective cohort study.

SETTING

Three Canadian EDs.

PARTICIPANTS

Individuals aged 65 and older who were independent in basic activities of daily living, visiting the ED for minor injuries, and discharged home within 48 hours (N = 320).

MEASUREMENTS

Participants completed the Montreal Cognitive Assessment (MoCA). New falls involving pain and ED or hospital visits were documented at 3 and 6 months.

RESULTS

At baseline, 62.4% of participants scored below the recommended cutoff of 26 on the MoCA, suggesting cognitive dysfunction, and 22.9% scored below a more-stringent cutoff of 21. MoCA scores had improved significantly at 3 and 6 months. Items showing the most improvement were delayed recall and verbal fluency. Persons with MoCA scores of less than 21 reported significantly more new falls and hospital visits 3 to 6 months after injury.

CONCLUSION

Cognition is not optimal in many community-dwelling elderly adults visiting an ED for a minor injury, which may affect their capacity to comprehend, recall, and adhere to medical recommendations after their injury and put them at risk of further negative health events such as falls.

Systemic corticosteroids for the treatment of asthma exacerbations during and outside of pregnancy in an acute-care setting

BACKGROUND

Asthma exacerbations are common during pregnancy with a prevalence as high as 51.9% among women with severe asthma.

OBJECTIVE

To compare the treatment of asthma exacerbations in an acute-care setting during and outside of pregnancy.

METHODS

We formed a cohort of women who sought medical care for an asthma exacerbation at a teaching hospital during or in the year preceding pregnancy, between 1998 and 2008. An exacerbation was composed of one or more medical encounters in an acute-care setting (hospital-based outpatient clinic, emergency department, or during hospitalization). Data were retrieved from medical charts and health administrative databases. We compared the use of systemic corticosteroids (SCSs) during and outside of pregnancy with a Cox proportional hazards model.

RESULTS

The cohort was formed of 39 women who had 40 exacerbations during and 39 exacerbations outside of pregnancy. Use of SCSs to treat exacerbations was less frequent (adjusted hazard ratio: 0.51; 95% CI: 0.31-0.84) during pregnancy. Moreover, upon the first medical encounter related to the exacerbation, SCSs, when administered, were given less frequently to women when pregnant than when non-pregnant (83% vs. 100%). The SCS prescription was filled at the community pharmacy 65% and 67% of the time when it was prescribed at discharge to women when pregnant than when non-pregnant, respectively.

CONCLUSION

We observed a reduced and delayed use of SCSs for the treatment of asthma exacerbations in women when pregnant than when non-pregnant, with similar numbers of women in both conditions filling their SCSs prescription in pharmacies.

A local perspective to asthma management in the accident and emergency department in Malta

AIM

This study was performed to assess the management of adult patients presenting to the Mater Dei Hospital Accident and Emergency (A&E) department with acute asthma.

SUBJECTS AND METHODS

Asthmatic patients age 14 or older who presented to A&E department between January and October 2010 with asthma exacerbations were included. Data were collected from the clinical notes and analyzed.

RESULTS

A total of 244 patients (67.2% females) were included, 126 (51.6%) were admitted, 97 (39.8%) discharged and 21 (8.6%) discharged themselves against medical advice. There was a decline in the presentations between January and July, followed by an upward trend until October (P = 0.42). Pulse oximetry was performed in 207 patients (84.8%), arterial blood gases in 133 (54.5%), peak expiratory flow rate in 106 (43.4%) and chest radiography in 206 (84.4%) patients. The respiratory rate was documented in 151 (61.8%), heart rate in 204 (83.6%) and ability to complete sentences in 123 (50.4%) patients. One hundred and ninety six patients (80.3%) were given nebulized bronchodilators, 103 (42.2%) intravenous corticosteroids, 7 (2.87%) oral corticosteroids, 109 (44.7%) oxygen, 28 (11.5%) antibiotics and 9 (3.69%) magnesium. Systemic corticosteroids and antibiotics were more commonly prescribed to patients admitted (P < 0.001).

CONCLUSION

Management of acute asthma in Malta requires optimization in order to compare with international guidelines.

Clinical, economic, and humanistic burden of asthma in Canada: a systematic review

BACKGROUND

Asthma, one of the most common chronic respiratory diseases, affects about 3 million Canadians. The objective of this study is to provide a comprehensive evaluation of the published literature that reports on the clinical, economic, and humanistic burden of asthma in Canada.

METHODS

A search of the PubMed, EMBASE, and EMCare databases was conducted to identify original research published between 2000 and 2011 on the burden of asthma in Canada. Controlled vocabulary with "asthma" as the main search concept was used. Searches were limited to articles written in English, involving human subjects and restricted to Canada. Articles were selected for inclusion based on predefined criteria like appropriate study design, disease state, and outcome measures. Key data elements, including year and type of research, number of study subjects, characteristics of study population, outcomes evaluated, results, and overall conclusions of the study, were abstracted and tabulated.

RESULTS

Thirty-three of the 570 articles identified by the clinical and economic burden literature searches and 14 of the 309 articles identified by the humanistic burden literature searches met the requirements for inclusion in this review. The included studies highlighted the significant clinical burden of asthma and show high rates of healthcare resource utilization among asthma patients (hospitalizations, ED, physician visits, and prescription medication use). The economic burden is also high, with direct costs ranging from an average annual cost of $366 to $647 per patient and a total annual population-level cost ranging from ~ $46 million in British Columbia to ~ $141 million in Ontario. Indirect costs due to time loss from work, productivity loss, and functional impairment increase the overall burden. Although there is limited research on the humanistic burden of asthma, studies show a high (31%-50%) prevalence of psychological distress and diminished QoL among asthma patients relative to subjects without asthma.

CONCLUSIONS

As new therapies for asthma become available, economic evaluations and assessment of clinical and humanistic burden will become increasingly important. This report provides a comprehensive resource for health technology assessment that will assist decision making on asthma treatment selection and management guidelines in Canada.

Validation of the modified Vesikari score in children with gastroenteritis in 5 US emergency departments

OBJECTIVES

The burden of acute gastroenteritis (AGE) in US children is substantial. Research into outpatient treatment strategies has been hampered by the lack of easily used and validated gastroenteritis severity scales relevant to the populations studied. We sought to evaluate, in a US cohort, the reliability, construct validity, and generalizability of a gastroenteritis severity scale previously derived in a Canadian population, the modified Vesikari score (MVS).

METHODS

We conducted a prospective, cohort, clinical observational study of children 3 to 48 months of age with acute gastroenteritis presenting to 5 US emergency departments. A baseline MVS score was determined in the emergency department, and telephone follow-up 14 days after presentation was used to assign the follow-up MVS. We determined reliability using inter-item correlations; construct validity via principal component factor analysis; cross-sectional construct validity via correlations with the presence of dehydration, hospitalization, and day care and parental work absenteeism; and generalizability via score distribution among sites.

RESULTS

Two hundred eighteen of 274 patients (80%) were successfully contacted for follow-up. Cronbach α was 0.63, indicating expectedly low internal reliability because of the multidimensional properties of the MVS. Factor analysis supported the appropriateness of retaining all variables in the score. Disease severity correlated with dehydration (P < 0.001), hospitalization (P < 0.001), and subsequent day care (P = 0.01) and work (P < 0.001) absenteeism. The MVS was normally distributed, and scores did not differ among sites.

CONCLUSIONS

The MVS effectively measures global severity of disease and performs similarly in varying populations within the US health care system. Its characteristics support its use in multisite outpatient clinical trials.

Predicting hospitalization in children with acute asthma

BACKGROUND

Acute asthma is one of the most common medical emergencies in children. Appropriate assessment/treatment and early identification of factors that predict hospitalization are critical for the effective utilization of emergency services.

OBJECTIVE

To identify risk factors that predict hospitalization and to compare the concordance of the Modified Pulmonary Index Score (MPIS) with the Global Initiative for Asthma (GINA) guideline criteria in terms of attack severity.

METHODS

The study population was composed of children aged 5-18 years who presented to the Emergency Departments (ED) of the tertiary reference centers of the country within a period of 3 months. Patients were evaluated at the initial presentation and the 1(st) and 4(th) hours.

RESULTS

Of the 304 patients (median age: 8.0 years [interquartile range: 6.5-9.7]), 51.3% and 19.4% required oral corticosteroids (OCS) and hospitalization, respectively. Attack severity and MPIS were found as predicting factors for hospitalization, but none of the demographic characteristics collected predicted OCS use or hospitalization. Hospitalization status at the 1(st) hour with moderate/severe attack severity showed a sensitivity of 44.1%, specificity of 82.9%, positive predictive value of 38.2%, and negative predictive value of 86.0%; for MPIS ≥ 5, these values were 42.4%, 85.3%, 41.0%, and 86.0%, respectively. Concordance in prediction of hospitalization between the MPIS and the GINA guideline was found to be moderate at the 1(st) hour (κ = 0.577).

CONCLUSION

Attack severity is a predictive factor for hospitalization in children with acute asthma. Determining attack severity with MPIS and a cut-off value ≥ 5 at the 1(st) hour may help physicians in EDs. Having fewer variables and the ability to calculate a numeric value with MPIS makes it an easy and useful tool in clinical practice.

Trends in asthma-related direct medical costs from 2002 to 2007 in British Columbia, Canada: a population based-cohort study

Background

Asthma-related health resource use and costs may be influenced by increasing asthma prevalence, changes to asthma management guidelines, and new medications over the last decade. The objective of this work was to analyze direct asthma-related medical costs, and trends in total and per-patient costs of hospitalizations, physician visits, and medications.

Methods

A cohort of asthma patients from British Columbia (BC), Canada, was created. Asthma patients were identified using a validated case definition. Costs for hospitalizations, physician visits, and medications were calculated from billing records (in 2008 Canadian dollars). Trends in total and per-patient costs over the study period were analyzed using Generalized Linear Models.

Results

398,235 patients satisfied the asthma case definition (mid-point prevalence 8.0%). Patients consumed $315.9 million (M) in direct asthma-related health resources between 2002 and 2007. Hospitalizations, physician visits, and medication costs accounted for 16.0%, 15.7% and 68.2% of total costs, respectively. Cost of asthma increased from $49.4 M in 2002 to $54.7 M in 2007. Total annual costs attributable to hospitalizations and physician visits decreased (−39.8% and −25.5%, respectively; p<0.001), while medication costs increased (+38.7%; p<0.001).

Interpretation

This population-based analysis shows that the total direct cost of asthma in BC has increased since 2002, mainly due to a rise in asthma prevalence and cost of medication. Combination therapy with inhaled corticosteroids/long-acting beta-agonists has become a significant component of the cost of asthma. Although billing records capture only a fraction of the true burden of asthma, the simultaneous increase in medication costs and reductions in hospitalization and physician visit costs provides valuable insight for policy makers into the shifts in asthma-related resource use.

Minimal difference in the prevalence of asthma in the urban and rural environment

Multiple risk factors can be modified to decrease asthma incidence. It is important to understand early risks to decrease exposure to harmful conditions in the environment that can trigger asthma which may not be clinically evident in children until they reach adulthood. A retrospective literature review of articles on the prevalence of asthma in the urban versus rural environment was initiated in order to understand the effect of the environment on asthma. The urban-living effect is a global problem in the face of growing population, industrialization and pollution. The socioeconomic dichotomy in the urban versus rural environment also affects access and quality of health care.

Articles reviewed had differences in the urban versus rural prevalence of asthma. However, further analysis of specific risk factors and socioeconomic trends that increased susceptibility to asthma was the same in these studies. Some rural areas may have similar environmental and socioeconomic issues that place them at the same risk for the development of asthma as their urban counterparts.

Urban locations generally tend to have the prototype environment that can lead to the predisposition of asthma. Ultimately, the incidence of asthma can be decreased if these environmental and socioeconomic issues are addressed. However, every effort is needed from the level of the individual to the community at large.

Patient, practice and organisational influences on asthma control: observational data from a national study on primary care in the United Kingdom

BACKGROUND

Achieving asthma control is central to optimising patient quality of life and clinical outcome. Contemporary models of chronic disease management across a variety of countries point to the importance of micro, meso and macro level influences on patient care and outcome. However, asthma outcomes research has almost invariably concentrated on identifying and addressing patient predictors. Little is known about higher level organisational influences.

OBJECTIVE

This paper explores the contribution of organisational factors on poor asthma control, allowing for patient factors, at three organisational levels: the individual patient, local service deliverers, and strategic regional providers.

DESIGN, SETTING AND PARTICIPANTS

Prospective cross-sectional observational cohort study of 64,929 people with asthma from 1205 primary care practices spread throughout the United Kingdom (UK). Patient clinical data were recorded during a routine asthma review.

METHOD

Data were analysed using simple descriptive, multiple regression and complex multi-level modelling techniques, accounting for practice clustering of patients.

RESULTS

Poor asthma control was associated with areas of higher deprivation [regression coefficient 0.026 (95% confidence intervals 0.006; 0.046)] and urban practice [-0.155 (-0.275; -0.035)] but not all local and regional variation was explained by the data. In contrast, patient level predictors of poor control were: short acting bronchodilator overuse [2.129 (2.091; 2.164)], days-off due to asthma [1.203 (1.148; 1.258)], PEFR<80 [0.76 (0.666; 0.854)], non-use of a self-management plan (SMP) [0.554 (0.515; 0.593)], poor inhaler technique [0.53 (0.475; 0.585)], poor medication compliance [0.385 (-0.007; 0.777)], and gender [0.314 (0.281; 0.347)]. Pattern of medication use, smoking history, age, body mass index (BMI), and health service resource use were also significant factors for predicting control.

CONCLUSIONS

Targeting of health service resource requires knowledge of the factors associated with poor control of asthma symptoms. In the UK the contribution of local and regional structures appears minimal in explaining variation in asthma outcomes. However, unexplained variation in the data suggests other unrecorded factors may play a part. While patient personal characteristics (including self-management plan use, inhaler technique, medication compliance) appear to be the predominant influence the complex nature of the disease means that some, perhaps more subtle, influences are affecting the variability at all levels and this variance needs to be explored. Further research in other international contexts is required to identify the likely applicability of these findings to other health care systems.

Pediatric primary care services in Manitoba: is the health of the next generation of children at risk?

OBJECTIVES

Physician resource planning is an important part of health policy, but to date there are no studies measuring the primary care service needs of a particular population. The aim of this study was to project the expected provision of physician services for the pediatric population of one Canadian province for 2020.

METHODS

A novel standardized measure of physician service provision, the equivalent services measure, was developed using mathematical modeling. Population projections and past use of services were used to calculate the projected service needs for the pediatric population of Manitoba.

RESULTS

Despite projecting a small increase in the pediatric population (2.8%), our model predicted a decrease of 13.4% in the services that would be provided.

CONCLUSIONS

The findings of this study indicate that the health of future generations of children may be at risk. Further research is needed to determine the effect of the reduction in pediatric service provision on the health of the pediatric population.

A case study and state of science review: private versus public healthcare financing

Medicare is a popular program in Canada that offers universal access to medically-necessary healthcare services for all Canadians through a public insurance plan in each province. In spite of its popularity, healthcare privatization has been debated, often over concerns about wait times for healthcare services. A case report focused on the 2005 Supreme Court's response to the "Chaoulli v. Quebec" challenge of the Quebec law banning the purchase of private health insurance for publicly-insured services is presented, along with findings from a state of science review to determine if there would be any benefit from adopting the United States model of private health insurance. This review reveals private health insurance would have significant negative implications, especially by creating inequity in healthcare access for low-income groups. Further study is needed to determine whether Canada's publicly-funded healthcare system would benefit in any way from increased private financing.

Asthma diagnosis and management

Asthma is a chronic inflammatory airway disease that is commonly seen in the emergency department (ED). This article provides an evidence-based review of diagnosis and management of asthma. Early recognition of asthma exacerbations and initiation of treatment are essential. Treatment is dictated by the severity of the exacerbation. Treatment involves bronchodilators and corticosteroids. Other treatment modalities including magnesium, heliox, and noninvasive ventilator support are discussed. Safe disposition from the ED can be considered after stabilization of the exacerbation, response to treatment and attaining peak flow measures.

Direct health care costs associated with asthma in British Columbia

BACKGROUND

A better understanding of health care costs associated with asthma would enable the estimation of the economic burden of this increasingly common disease.

OBJECTIVE

To determine the direct medical costs of asthma-related health care in British Columbia (BC).

METHODS

Administrative health care data from the BC Linked Health Database and PharmaNet database from 1996 to 2000 were analyzed for BC residents five to 55 years of age, including the billing information for physician visits, drug dispensations and hospital discharge records. A unit cost was assigned to physician/emergency department visits, and government reimbursement fees for prescribed medications were applied. The case mix method was used to calculate hospitalization costs. All costs were reported in inflation-adjusted 2006 Canadian dollars.

RESULTS

Asthma resulted in $41,858,610 in annual health care-related costs during the study period ($331 per patient-year). The major cost component was medications, which accounted for 63.9% of total costs, followed by physician visits (18.3%) and hospitalization (17.8%). When broader definitions of asthma-related hospitalizations and physician visits were used, total costs increased to $56,114,574 annually ($444 per patient-year). There was a statistically significant decrease in the annual per patient cost of hospitalizations (P<0.01) over the study period. Asthma was poorly controlled in 63.5% of patients, with this group being responsible for 94% of asthma-related resource use.

CONCLUSION

The economic burden of asthma is significant in BC, with the majority of the cost attributed to poor asthma control. Policy makers should investigate the reason for lack of proper asthma control and adjust their policies accordingly to improve asthma management.

Admissions to Canadian hospitals for acute asthma: a prospective, multicentre study

BACKGROUND

Asthma exacerbations constitute one of the most common causes of emergency department (ED) attendance in most developed countries. While severe asthma often requires hospitalization, variability in admission practices has been observed.

OBJECTIVE

To describe the factors associated with admission to Canadian hospitals for acute asthma after ED treatment.

METHODS

Subjects 18 to 55 years of age treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview (n=695) and telephone interview two weeks later.

RESULTS

The median age of the patients was 30 years, and the majority were women (62.8%). The admission rate was 13.1% (95% CI 10.7% to 15.8%). Admitted patients were older, more often receiving oral or inhaled corticosteroids at presentation, and more frequently receiving systemic corticosteroids and magnesium sulphate in the ED. Similar proportions received beta-2 agonists and/or ipratropium bromide within 1 h of arrival. On multivariable analyses, factors associated with admission included age, previous admission in the past two years, more than eight beta-2 agonist puffs in the past 24 h, a Canadian Triage and Acuity Score of 1 to 2, a respiratory rate of greater than 22 breaths/min and an oxygen saturation of less than 95%.

CONCLUSION

The admission rate for acute asthma from these Canadian EDs was lower than reported in other North American studies. The present study provides insight into practical factors associated with admission for acute asthma and highlights the importance of history and asthma severity markers on ED decision making. Further efforts to standardize ED management and expedite admission decision-making appear warranted.

Can an evidence-based guideline reminder card improve asthma management in the emergency department?

Objective

Asthma is the most common chronic disease in children. Previous studies described significant variations in acute asthma management in children. This study was conducted to examine whether asthma management in the pediatric emergency department (ED) was improved through the use of an evidence-based acute asthma care guideline reminder card.

Methods

The Pediatric Acute Asthma Management Guideline (PAMG) was introduced to the ED of a pediatric tertiary care hospital in Ontario, Canada. Medical charts of 278 retrospective ED visits (January–December 2002) and 154 prospective visits (July 2003–June 2004) were reviewed to assess changes in acute asthma management such as medication treatment, asthma education, and discharge planning. Logistic and linear regressions were used to determine the effect of PAMG on asthma management in the ED. The propensity score method was used to adjust for confounding.

Results

During the implementation of PAMG, patients who visited the ED were more likely to receive oral corticosteroids (Adjusted Odds Ratio [AOR] = 2.26, 95% CI: 1.63–3.14, p < 0.0001) and oxygen saturation reassessment before ED discharge (AOR = 2.02, 95% CI: 1.45–2.82, p < 0.0001). They also received 0.23 (95% CI: 0.03–0.44, p = 0.0283) more doses of bronchodilator in the first hour of ED stay. Improvements in asthma education and discharge planning were noted, but the changes were not statistically significant.

Conclusions

After the implementation of an evidence-based guideline reminder card, medication treatment for acute asthma in the ED was significantly improved; however, asthma education and discharge planning remained unchanged. Future efforts on promoting guideline-based practice in the ED should focus on these components.

The treatment of pediatric gastroenteritis: a comparative analysis of pediatric emergency physicians' practice patterns

OBJECTIVES

Acute gastroenteritis is a very common emergency department (ED) diagnosis accounting for greater than 1.5 million outpatient visits and 200,000 hospitalizations annually among children in the United States. Although guidelines exist to assist clinicians, they do not clearly address topics for which evidence is new or limited, including the use of antiemetic agents, probiotics, and intravenous (IV) fluid rehydration regimens. This study sought to describe the ED treatments administered to children with acute gastroenteritis and to compare management between Canadian and U.S. physicians practicing pediatric emergency medicine (PEM).

METHODS

Members of PEM research networks located in Canada and the United States were invited to participate in a cross-sectional, Internet-based survey. Participants were included if they are attending physicians and provide care to patients <18 years of age in an ED.

RESULTS

In total, 235 of 339 (73%) eligible individuals responded. A total of 103 of 136 Canadian physicians (76%) report initiating oral rehydration therapy (ORT) in children with moderate dehydration, compared with 44 of 94 (47%) of their U.S. colleagues (p<0.001). The latter more often administer antiemetic agents to children with vomiting (67% vs. 45%; p=0.001). American physicians administer larger IV fluid bolus volumes (p<0.001) and over shorter time periods (p=0.001) and repeat the fluid boluses more frequently (p<0.001). Probiotics are routinely recommended by only 35 of 230 respondents (15%).

CONCLUSIONS

The treatment of pediatric gastroenteritis varies by geographic location and differs significantly between Canadian and American PEM physicians. Oral rehydration continues to be underused, particularly in the United States. Probiotic use remains uncommon, while ondansetron administration has become routine. Children frequently receive IV rehydration, with the rate and volume administered being greater in the United States.

A population-based study of emergency department presentations for asthma in regions of Alberta

OBJECTIVE

We describe the epidemiology of asthma presentations to emergency departments (EDs) for 3 main regions in the province of Alberta.

METHODS

We used a comprehensive ED database to identify ED visits in Alberta from April 1999 to March 2005. We linked the visits to other provincial administrative databases to obtain all data on follow-up encounters for asthma during that period. Information extracted included demographics, regions of residence (Edmonton, Calgary or non-major urban [NMU]), timing of ED visits, and subsequent visits to non-ED settings. Data analysis included descriptive summaries and directly standardized visit rates.

RESULTS

During the 6-year study period, 93 146 patients made 199 991 ED visits for asthma. Crude rates in 2004/05 were 7.9/1000, 6.5/1000 and 15.4/1000 in the Edmonton, Calgary and NMU regions, respectively. The Edmonton and Calgary regions had consistently lower visit rates than the NMU regions. The ED visits were followed by low rates of follow-up visits in a variety of non-ED settings, at different intervals.

CONCLUSION

Asthma is a relatively common presenting problem in Alberta EDs. This study identified relatively stable rates of presentation during the study period, and variation among regions in terms of age and sex. This study provides further understanding of the variation associated with ED presentation and indicates possible targets for specific interventions to reduce asthma-related ED visits.

Asthma care pathways in the emergency department

PURPOSE OF REVIEW

The purpose of this review is to describe recent evidence of the efficacy and effectiveness of clinical pathways for the assessment and management of severe acute asthma in children and adults in the emergency department (ED). The review will highlight examples of successful knowledge translation initiatives and their ability to support adherence to Best Practice Guidelines.

RECENT FINDINGS

Recent studies reveal that management of pediatric and adult asthma in the ED setting often differs from that which is recommended in clinical practice guidelines. Single and multicenter North American studies have consistently found care gaps. Barriers to adherence to evidence-based management guidelines are numerous. Care pathways are knowledge translation tools that provide a means of applying knowledge translation principles to overcome these barriers, integrate guidelines into practice and optimize patient outcomes. Evidence from a recent Ontario multicenter asthma clinical pathway initiative is highlighted, demonstrating increased adherence to certain aspects of ED care, improved patient recollection of teaching done in the ED and increased referral rates. These findings strengthen the evidence supporting the development and implementation of standardized evidence-based asthma clinical pathways.

SUMMARY

Gaps between current and best practices persist for the management of asthma in children and adults in North American EDs. There is robust evidence in support of ED asthma clinical pathways to optimize asthma care and outcomes in this setting.

Multicentre evaluation of an emergency department asthma care pathway for adults

OBJECTIVE

We sought to determine whether a standardized emergency department (ED) asthma care pathway (ACP) for adults would be accepted by ED staff, improve adherence to Canadian ED asthma management guidelines and improve patient outcomes.

METHODS

Ten Ontario hospital EDs (5 intervention, 5 control) participated in a 5-month pre-post intervention study. Emergency department management, admissions, repeat ED visits and ED length of stay were compared between sites and by ACP use versus nonuse at intervention sites.

RESULTS

The ACP was used in 101 of 383 visits (26.4%) at 5 intervention sites. Use of the ACP varied significantly between sites, ranging from 6% to 60% (p < 0.001). When compared with control sites, there were significant increases in the use of metered dose inhalers (MDIs), inhaled steroids, referrals, documentation of teaching, patient recollection of teaching (all with a p < 0.001) and oxygen (p = 0.001). Use of peak expiratory flow rate (PEFR) measurements decreased in both intervention and control sites. Increased PEFR documentation and systemic steroid use in the ED and on discharge were only found in patients who were on the ACP at intervention sites. Admissions increased from 3.9% to 9.4% at intervention sites in contrast to control sites, where they remained fairly stable (p = 0.016), but did not differ by ACP use. The length of stay for discharged patients increased by a mean of 16 minutes for ACP patients at intervention sites (p = 0.002). There were no statistically significant differences in repeat ED visits.

CONCLUSION

Adoption of a standardized ED ACP for adults is highly variable. Despite modest uptake, which averaged 26%, beneficial changes in specific aspects of asthma care delivery were found, notably in referrals and recollection of teaching done during the ED visit, without a substantial increase in ED length of stay. These changes may lead to improvements in outcomes, such as reduced relapse rates, which this study was not designed or powered to detect. Provincial and national implementation strategies that address barriers to clinical pathway adoption are warranted and have the potential to improve adherence to guidelines and outcomes for asthma patients.

Asynchrony between left and right lungs in acute asthma

BACKGROUND

Asthma is a disease of air flow obstruction. Transmitted sounds can be analyzed in detail and may shed light upon the physiology of asthma and how it changes over time. The goals of this study were to use a computerized analytic acoustic tool to evaluate respiratory sound patterns in asthmatic patients during acute attacks and after clinical improvement and to compare asthmatic profiles with those of normal individuals.

METHODS

Respiratory sound analysis throughout the respiratory cycle was performed on 22 symptomatic asthma patients at the time of presentation to the emergency department (ED) and after clinical improvement. Fifteen healthy volunteers were analyzed as a control group. Vibrations patterns were plotted. Right and left lungs were analyzed separately.

RESULTS

Asthmatic attacks were found to be correlated with asynchrony between lungs. In normal subjects, the inspiratory and expiratory vibration energy peaks (VEPs) occurred almost simultaneously in both lungs; the time interval between right and left expiratory VEPs was 0.006 +/- 0.012 seconds. In symptomatic asthmatic patients on admission, the time interval between right and left expiratory VEPs was 0.14 +/- 0.09 seconds and after clinical improvement the interval decreased to 0.04 +/- 0.04 seconds. Compared to healthy volunteers, asynchrony between two lungs was increased in asthmatics (p < 0.05). The asynchrony was significantly reduced after clinical improvement (p < 0.05).

CONCLUSIONS

Respiratory sound analysis demonstrated significant asynchrony between right and left lungs in asthma exacerbations, a finding which, to our knowledge, has never been reported to date. The asynchrony is significantly reduced with clinical improvement following treatment.

Comparison of Canadian versus United States emergency department visits for chronic obstructive pulmonary disease exacerbation

INTRODUCTION

Despite the frequency of emergency department (ED) visits for chronic obstructive pulmonary disease (COPD) exacerbation, little is known about practice variation in EDs.

OBJECTIVES

To examine the differences between Canadian and United States (US) COPD patients, and the ED management they receive.

METHODS

A prospective multicentre cohort study was conducted involving 29 EDs in the US and Canada. Using a standard protocol, consecutive ED patients with COPD exacerbations were interviewed, their charts reviewed and a two-week telephone follow-up completed. Comparisons between Canadian and US patients, as well as their treatment and outcomes, were made. Predictors of antibiotic use were determined by multivariate logistic regression.

RESULTS

Of 584 patients who had physician-diagnosed COPD, 397 (68%) were enrolled. Of these, 63 patients (16%) were from Canada. Canadians were older (73 years versus 69 years; P=0.002), more often white (97% versus 65%; P<0.001), less educated (P=0.003) and more commonly insured (P<0.001) than the US patients. US patients more commonly used the ED for their usual COPD medications (17% versus 3%; P=0.005). Although Canadian patients had fewer pack-years of smoking (45 pack-years versus 53 pack-years; P=0.001), current COPD medications and comorbidities were similar. At ED presentation, Canadian patients were more often hypoxic and symptomatic. ED treatment with inhaled beta-agonists (approximately 90%) and systemic corticosteroids (approximately 65%) were similar; Canadians received more antibiotics (46% versus 25%; P<0.001) and other treatments (29% versus 11%; P=0.002). Admission rates were similar in both countries (approximately 65%), although Canadian patients remained in the ED longer than the US patients (10 h versus 5 h, respectively; P<0.001).

CONCLUSIONS

Overall, patients with acute COPD in Canada and the US appear to have similar history, ED treatment and outcomes; however, Canadian patients are older and receive more aggressive treatment in the ED. In both countries, the prolonged length of stay and high admission rate contribute to the ED overcrowding crisis facing EDs.

Asthma presentations by adults to emergency departments in Alberta, Canada: a large population-based study

BACKGROUND

Asthma is a widespread disease with a prevalence of approximately 7 to 10% in adults. Exacerbations are common in the emergency department (ED) setting. The objective of this study was to describe the epidemiology of asthma presentations to EDs made by adults in the province of Alberta, Canada.

METHODS

The Ambulatory Care Classification System of Alberta and provincial administrative databases were used to obtain all ED encounters for asthma during 6 fiscal years (April 1999 to March 2005). Information extracted included demographics, ED visit timing, and subsequent visits to non-ED settings. Data analysis included descriptive summaries and directly standardized visit rates.

RESULTS

There were 105,813 ED visits for asthma made by 48,942 distinct adults, with an average of 2.2 visits per individual. Most patients (66%) had only one asthma-related ED visit. Female patients (61.2%) presented more commonly than male patients. The gender- and age-standardized visit rates declined from 9.7/1,000 in 1999/2000 to 6.8/1,000 in 2004/2005. The welfare and Aboriginal subsidy groups had larger age-specific ED visits rates than other populations. Important daily, weekly, and monthly trends were observed. Hospital admission occurred in 9.8% of the cases; 6.4% had a repeat ED visit within 7 days. Overall, 67.4% of individuals had yet to have a non-ED follow-up visit by 1 week. The estimated median time to the first follow-up visit was 19 days (95% confidence interval, 18 to 21).

CONCLUSIONS

Asthma is a common presenting problem in Alberta EDs, and further study of these trends is required to understand the factors associated with the variation in presentations. The important findings include an overall decrease in the rates of presentation over the study period, disparities based on age, gender, and socioeconomic/cultural status, and the low rate of early follow-up. Targeted interventions could be implemented to address specific groups and reduce asthma-related visits to Alberta EDs.

Relapse after emergency department discharge for acute asthma

OBJECTIVES

The objectives were to determine patient and treatment-response factors associated with relapse after emergency department (ED) treatment for acute asthma.

METHODS

Subjects aged 18-55 years who were treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview and telephone contact 2 weeks later.

RESULTS

Of 695 enrolled patients, 604 (86.9%) were discharged from the ED; follow-up was available in 529 (87.5%); 63% were female and the median age was 29 years. Most patients were discharged on oral (70.8%) and inhaled (60.1%) corticosteroids (CS); 2-week treatment adherences were 93.3 and 80.9%, respectively. Relapse occurred in 9.2% at 1 week (95% confidence interval [CI] = 7.1% to 12.0%) and 13.9% (95% CI = 11% to 17%) at 2 weeks. In multivariable modeling, factors associated with relapse were ethnicity (risk ratio [RR] white = 0.66; 95% CI = 0.52 to 0.83); female gender (RR = 1.57; 95% CI = 1.14 to 2.09); any ED visits in the past 2 years (RR = 1.47; 95% CI = 1.18 to 1.80); ever admitted for asthma treatment (RR = 1.83; 95% CI = 1.09 to 2.84); use of combined inhaled CS plus long-acting beta(2)-agonists (RR = 1.39; 95% CI = 1.07 to 1.78) and of oral CS (RR = 1.35; 95% CI = 1.12 to 1.59) at the time of ED presentation.

CONCLUSIONS

Ethnicity (white), female gender, prior ED visits and admissions for asthma, and recent treatments (especially oral CS) were associated with asthma relapse, which remains relatively common. Future research is required to target this high-risk group.