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Cherney K, Bulloch B, Mecham C, Drewek R, Mirea L. Inhaled corticosteroid prescriptions in the ED for recurrent asthma using IT clinical decision support: revisit after cessation of an incentive program. J Asthma 2021; 59:1621-1626. [PMID: 34293262 DOI: 10.1080/02770903.2021.1959927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The objective of this study was to assess whether inhaled corticosteroid (ICS) prescription rates for patients with poorly controlled asthma presenting to the emergency department (ED) remained high with a clinical support system in place, after a financial incentive program ended. This study is the second phase of a previous study done at our institution. The first phase demonstrated that the introduction of an electronic alert system advising providers to prescribe ICS to patients with poorly controlled asthma, along with a financial incentive, increased ICS prescription rates from 2% to 77%. Clinical support systems are necessary to improve control for patients with asthma, as prescribing ICS in the ED has not previously been standard of care. METHODS This retrospective study identified 96 eligible patients during the study period of January 1, 2019 to December 31, 2019. Subjects included patients aged 4-18 with at least two ED visits for asthma within 365 days and no recent ICS prescription. For subjects meeting these criteria, an electronic alert activated, advising the provider to prescribe ICS. RESULTS ICS prescription rate without the incentive remained high at 0.74 (0.59, 0.86) and was not significantly different than the rate with the incentive of 0.77 (0.65, 0.87), with p value 0.82. No significant differences were detected in baseline characteristics between patients discharged with and without an ICS prescription. CONCLUSIONS This study confirmed that an electronic alert advising ICS prescription in the ED for patients with recurrent asthma visits is effective, even without a financial incentive.
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Affiliation(s)
- Krystal Cherney
- Medical Education Department, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Blake Bulloch
- Pediatric Emergency Medicine Department, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Cherisse Mecham
- Pediatric Emergency Medicine Department, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Rupali Drewek
- Pediatric Pulmonary Department, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Lucia Mirea
- Statistics Department, Phoenix Children's Hospital, Phoenix, AZ, USA
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Farmer A, Mirea L, Carter J, Rank M, Bulloch B, Vaidya V, Drewek R. Inhaled corticosteroids prescriptions increased in the ED for recurrent asthma exacerbations by automated electronic reminders in the ED. J Asthma 2019; 57:1140-1144. [PMID: 31226000 DOI: 10.1080/02770903.2019.1635152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Adam Farmer
- Medical Education Department, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Lucia Mirea
- Statistics Department, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Jodi Carter
- Pediatric Hospitalist, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Matthew Rank
- Allergy, Asthma and Clinical Immunology, Mayo Clinic Phoenix, Scottsdale, AZ, USA
| | - Blake Bulloch
- Department of Pediatric Emergency Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Vinay Vaidya
- Department of Pediatric Intensive Care Unit, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Rupali Drewek
- Pediatric Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, USA
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Schuh S, Zemek R, Plint A, Black KJL, Freedman S, Porter R, Gouin S, Johnson DW. Practice patterns in asthma discharge pharmacotherapy in pediatric emergency departments: a pediatric emergency research Canada study. Acad Emerg Med 2012; 19:E1019-26. [PMID: 22978728 DOI: 10.1111/j.1553-2712.2012.01433.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The objective was to examine utilization of β2 agonists via metered dose inhalers with oral and inhaled corticosteroids (ICS) at discharge in children with acute asthma. METHODS This was a retrospective medical record review at six pediatric emergency departments (EDs) of otherwise healthy children 2 to 17 years of age discharged with acute asthma. Data were extracted on history, disease severity, and pharmacotherapy used in the ED and at discharge. The primary outcome was the proportion of children prescribed "comprehensive therapy," i.e., albuterol via metered dose inhaler (MDI) with oral and ICS. RESULTS The overall rate of comprehensive therapy was 382 of 654 (58%), which varied from 30% to 84% (p < 0.0001). A total of 570 of 575 children discharged on albuterol received MDIs. Although the rates of prescriptions for oral and ICS were both 80%, only 58% of patients without ICS on arrival were offered ICS at discharge. There was significant variation in the rates of all discharge pharmacotherapies across centers. The independent predictors of comprehensive therapy were daytime presentation (odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.05 to 2.67) and "intensive stabilization" (OR = 2.33, 95% CI = 1.29 to 2.67). Seventeen patients (2.6%) were prescribed antibiotics. Children were more likely to receive antibiotics if they had moderate to severe exacerbations (OR = 2.8) or received a chest radiograph (OR = 8.4). CONCLUSIONS The overwhelming majority of children discharged from Canadian pediatric EDs with acute asthma are prescribed inhaled albuterol via MDIs. Although the corticosteroid use at discharge is higher than previously reported, utilization of new prescriptions for ICS may not be optimal. Children presenting during daytime to EDs receiving intensive stabilization are more likely to receive the albuterol/oral steroid/ICS combination.
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Affiliation(s)
- Suzanne Schuh
- Department of Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Schuh S, Dick PT, Stephens D, Hartley M, Khaikin S, Rodrigues L, Coates AL. High-dose inhaled fluticasone does not replace oral prednisolone in children with mild to moderate acute asthma. Pediatrics 2006; 118:644-50. [PMID: 16882819 DOI: 10.1542/peds.2005-2842] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Inhaled corticosteroids are not as effective as oral corticosteroids in school-aged children with severe acute asthma. It is uncertain how inhaled corticosteroids compare with oral corticosteroids in mild to moderate exacerbations. PRIMARY OBJECTIVE The purpose of this work was to determine whether there is a significant difference in the percentage of predicted forced expiratory volume in 1 second in children with mild to moderate acute asthma treated with either inhaled fluticasone or oral prednisolone. METHODS This was a randomized, double-blind controlled trial conducted between 2001 and 2004 in a tertiary care pediatric emergency department. We studied a convenience sample of 69 previously healthy children 5 to 17 years of age with acute asthma and forced expiratory volume in 1 second at 50% to 79% predicted value; 41 families refused participation. Albuterol was given in the emergency department and salmeterol was given after discharge to all patients, as well as either 2 mg of fluticasone via metered dose inhaler and valved holding chamber in the emergency department plus 500 microg twice daily via Diskus for 10 doses after discharge (fluticasone group, N = 35) or 2 mg/kg of oral prednisolone in the emergency department plus 5 daily doses of 1 mg/kg of prednisolone after discharge (prednisolone group, N = 34). We measured a priori defined absolute change in percent predicted forced expiratory volume in 1 second from baseline to 4 and 48 hours in the 2 groups. RESULTS. At 240 minutes, the forced expiratory volume in 1 second increased by 19.1% +/- 12.7% in the fluticasone group and 29.8% +/- 15.5% in the prednisolone group. At 48 hours, this difference was no longer significant (estimated difference: 4.0 +/- 3.4; P = .14). The relapse rates by 48 hours were 12.5% and 0% in the fluticasone group and prednisolone group, respectively. CONCLUSION Airway obstruction in children with mild to moderate acute asthma in the emergency department improves faster on oral than inhaled corticosteroids.
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Affiliation(s)
- Suzanne Schuh
- Division of Paediatric Emergency Medicine, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8.
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Butterfoss FD, Major DA, Clarke SM, Cardenas RA, Isaacman DJ, Mason JD, Clements DL. What providers from general emergency departments say about implementing a pediatric asthma pathway. Clin Pediatr (Phila) 2006; 45:325-33. [PMID: 16703155 DOI: 10.1177/000992280604500404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The goal of this study was to assess institutional climate and providers' readiness to adopt pediatric pathways for asthma treatment and management. Twelve focus groups were held with 24 physicians/physicians' assistants, 20 nurses, and 17 emergency medical technicians from emergency departments in 4 general hospitals from July to October 2002. Positive experience with previous pathways, open communication and buy-in from clinicians and administrators, comprehensive training on pathways, and adapting standards to fit specific emergency department environments were identified as necessary elements for pathway adoption. Providers were optimistic about successfully implementing an asthma pathway (95%) and supportive of pathway implementation (87%).
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Abstract
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.
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Affiliation(s)
- Richard J Scarfone
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Akoglu S, Topacoglu H, Karcioglu O, Cimrin AH. Do the residents in the emergency department appropriately manage patients with acute asthma attack? A study of self-criticism. Adv Ther 2004; 21:348-56. [PMID: 15856858 DOI: 10.1007/bf02850099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The objective of this study was to investigate the management of patients with asthma attack admitted to the emergency department (ED) in terms of compliance with international guidelines. The records of patients with asthma who were admitted to a university-based ED between December 2001 and December 2002 were evaluated. A total of 72 cases with available data were evaluated retrospectively. Twenty-six patients (36.1%) were admitted more than once during the study period. The number of multiple admissions ranged from 2 (15 patients, 20.0%) to 11 (2 patients, 2.8%). Peak expiratory flow (PEF) measurements were recorded in 17 patients (23.6%) on presentation. Pulse and respiratory rates were recorded in 70 (97.0%) and 67 patients (93.0%), respectively. Thirty-four patients (47.2%) underwent chest x-ray; results were normal in most patients. Salbutamol was the most commonly used drug as first-line therapy. Ipratropium bromide (inhaled) and systemic corticosteroids were added to the salbutamol in 47 (65.2%), 42 (58.4%), and 32 patients (44%), respectively. Pulmonologists were consulted in only 7 cases (9.7%). Thirty patients (43.4%) were prescribed corticosteroids on discharge. The role of functional parameters in determining asthma severity and monitoring treatment effects should be emphasized in clinical practice. Finally, more prevalent use of management guidelines will help determine their usefulness.
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Affiliation(s)
- Sebahat Akoglu
- Department of Pulmonary Medicine, Mustafa Kemal University Medical School, Hatay, Turkey
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Edmonds ML, Camargo CA, Pollack CV, Rowe BH. The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis. Ann Emerg Med 2002; 40:145-54. [PMID: 12140492 DOI: 10.1067/mem.2002.124753] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Inhaled corticosteroids (ICSs) are of proven benefit in the treatment of chronic asthma; however, their role in the management of acute asthma is unclear. METHODS We performed a systematic review of randomized controlled trials involving children or adults treated in the emergency department for acute asthma with or without the addition of ICSs. Outcome measures included hospital admission, pulmonary function tests, and side effects. RESULTS Seven trials were selected for inclusion in the primary analyses. ICSs versus placebo were compared; data were not available on 1 of these trials. In the remaining 6 trials, a total of 352 patients were studied (179 ICS-treated and 173 non-ICS-treated patients). Two trials compared ICSs plus systemic corticosteroids versus placebo plus systemic corticosteroids; 4 trials compared ICSs versus placebo. Patients treated with ICSs were less likely to be admitted to the hospital (odds ratio 0.30; 95% confidence interval [CI] 0.16 to 0.57) and showed small improvements in peak expiratory flows (weighted mean difference 8%; 95% CI 3% to 13%) Overall, the treatment was well tolerated, with few reports of adverse side effects. A secondary analysis compared ICSs alone versus systemic corticosteroids alone; in the 4 included trials, significant heterogeneity between the study results for admission rates precluded meaningful pooling of admission data. CONCLUSION There is evidence of decreased admission rates for patients with acute asthma treated with ICSs. However, there is insufficient evidence that ICS therapy results in clinically important changes in pulmonary function when used in acute asthma, and there is insufficient evidence that ICSs alone are as effective as systemic corticosteroids.
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Affiliation(s)
- Marcia L Edmonds
- Division of Emergency Medicine, University of Alberta, and Capital Health Authority, Edmonton, Alberta, Canada
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