PEDIATRICS Vol. 117 No. 3 March 2006, pp. 821-827 (doi:10.1542/peds.2005-0962)
Emergency Physicians' Prescribing of Asthma Controller Medications
a Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
b Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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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.
Key Words: long-term controller medication • emergency department • asthma
Abbreviations: LTCM—long-term controller medication • ED—emergency department • NAEPP—National Asthma Education and Prevention Program • ICS—inhaled corticosteroid • AAP—American Academy of Pediatrics • PCP—primary care provider • PEM—pediatric emergency medicine
The marked increase in asthma prevalence since 1980,1 as well as increases in asthma-related mortality rates,2 hospitalizations,2 disability,3 and cost,4 have led to the development of practice guidelines such as the National Asthma Education and Prevention Program (NAEPP) guidelines for the diagnosis and management of asthma published by the National Heart, Lung, and Blood Institute.5,6 These guidelines define persistent asthma and recommend that infants and children of all ages with persistent disease be treated daily with a long-term controller medication (LTCM), preferably an inhaled corticosteroid (ICS). However, the guidelines do not state explicitly that emergency department (ED) physicians should identify children with persistent asthma or initiate LTCM therapy for them. In fact, in one study, just one third of ED physicians who care primarily for adults reported routinely prescribing an ICS at ED discharge.7 This issue has not been well studied in children.
Traditionally, the role of ED physicians in caring for patients with acute asthma exacerbations has been to provide emergency treatment and then to arrange follow-up visits with a primary care provider (PCP) for ongoing preventive care. The efficacy of preventive care in improving outcomes such as ED visits and hospitalizations is well documented.8–11 However, linkage between ED and PCP visits is often poor. Researchers from the National Cooperative Inner City Asthma Study estimated that only one half of children visited a PCP within 1 month after an ED asthma visit.12 The NAEPP recommends that children see their PCP for follow-up care within 5 days after an ED visit for asthma; in previous work, we reported that just 23% of children met this standard.13 Furthermore, 22% of adults reported the ED as their usual source of asthma prescriptions.14 Therefore, there are subsets of patients with asthma who primarily have contact with physicians only during ED visits for acute asthma exacerbations. This may explain, in part, why as many as 73% of children with persistent asthma do not use LTCM on a daily basis.15
The short-term16,17 and long-term10,11,18–20 benefits of LTCMs are well established, and there is accumulating evidence supporting the safety of these medications.20–22 Therefore, ED physicians may be ready to expand their role to include initiating LTCM therapy for select children. The purpose of this study was to describe the frequency with which ED physicians prescribe LTCMs for children with persistent asthma who are being discharged from the ED after treatment for acute asthma. In addition, we assessed ED physicians' awareness of and level of agreement with national guidelines for LTCM use and we determined the criteria used by them to prescribe LTCMs and the barriers to their use.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Population Surveyed
Study participants were physicians who, as of March 2004, were members of the American Academy of Pediatrics (AAP) Section on Emergency Medicine and who cared for children in an ED setting. Mailing labels with the names and addresses of these physicians were purchased from Medical Marketing Service (Carol Stream, IL).
Physicians were told in writing that the hospital's institutional review board had approved the study and that their responses would remain confidential and would not be linked to their names. Practitioners who indicated that they did not care for pediatric patients in the ED were asked to indicate so and to return their uncompleted surveys. Similarly, individuals who did not wish to complete the survey were asked to indicate so and return it. All others were instructed to describe their clinical practice patterns when caring for children with asthma in the ED.
Survey Instrument
The initial questions in the self-report survey sought demographic information about the participants and data regarding their level of training, experience, and practice setting. The remaining questions sought information about the participants' awareness of the NAEPP guidelines and details regarding the circumstances under which they prescribe LTCMs. Questions were in multiple-choice format and, when appropriate, an opportunity to write an open-ended response was provided. Also, a sample scenario was presented under 2 different circumstances, ie, the patient is 2 years of age or the patient is 15 years of age, as follows. A 2 (or 15)-year-old child with a history of frequent asthma symptoms is about to be discharged from the ED, after treatment for an asthma exacerbation. She does not take LTCMs. In your role as an ED physician, how frequently do you or the resident you are supervising prescribe LTCM for such a child (never, rarely [1–10%], sometimes [11–25%], often [26–50%], or usually [>50%])?
For standardization and clarity, the following survey terms were defined for participants: LTCMs: ICS, leukotriene modifiers, including montelukast (Singulair; Merck & Co, West Point, PA), zafirlukast (Accolate; AstraZeneca Pharmaceuticals LP, Wilmington, DE), and zileuton (Zyflo; Abbott Laboratories, Inc, Abbott Park, IL), mast cell stabilizers, including nedocromil and cromolyn (Intal; Monarch Pharmaceuticals, Bristol, TN), long-acting orally administered or inhaled ß2-receptor agonists, including salmeterol (Serevent; GlaxoSmithKline, Research Triangle Park, NC), combination medications, including fluticasone/salmeterol (Advair; GlaxoSmithKline, Research Triangle Park, NC), and theophylline; pediatric patients: patients 0 to 18 years of age; care for: provide medical treatment directly or supervise treatment by a resident; frequent asthma symptoms: symptoms 
3 days per week or 3 nights per month. The term frequent asthma symptoms was used in the survey for the benefit of practitioners who did not know the definition of persistent asthma.
Survey Methods
Before the first mailing in April 2004, the survey was pilot-tested by a group of 20 pediatric emergency medicine (PEM) physicians and revisions were made on the basis of their suggestions. Each survey was coded with a number to track respondents and was mailed with an addressed, postage-paid, return envelope. In July 2004, a second mailing was sent to nonrespondents. In September 2004, when no new surveys had been returned for 2 weeks, the study's data collection phase ended.
Statistical Analyses
There were 782 members of the AAP Section on Emergency Medicine in March 2004. Study data were analyzed with SPSS 12.0 software (SPSS, Chicago, IL). The 
2 test or Fisher's exact test was used to test the significance of the differences between categorical variables, and Student's t test was used for continuous data. Statistical significance was set at P < .05.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The survey was mailed to 782 physicians and was returned by 391 (50%). Of those, 43 indicated that they do not care for children in an ED setting and 11 indicated that they did not wish to complete the survey, leaving 337 surveys that were analyzed.
Table 1 describes the study participants and their practice settings and characteristics. The majority of respondents were board-certified in pediatrics and PEM and had completed fellowship training, and 120 (36%) had completed residency training within the past decade.
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Although 272 physicians (81%) know the definition of persistent asthma, as stated by the NAEPP, just 228 (68%) ask questions routinely to determine whether a child with an asthma exacerbation has persistent asthma. Eighty percent of physicians indicated that less than one half of children with persistent asthma were already using LTCMs at the time of ED arrival.
Almost all physicians (334 physicians [99%]) think that children with a history of frequent asthma symptoms should be maintained on LTCMs, and almost all (334 physicians [99%]) believe in the long-term benefits of LTCMs. Physicians' awareness of (know the definition of persistent asthma) and agreement with (belief that children with persistent asthma symptoms should be taking LTCMs) the guidelines as they pertain to LTCM use for persistent asthma were analyzed on the basis of practice setting and level of training (Table 2). These variables were not associated significantly with awareness or agreement, with 1 exception; significantly more physicians who had not completed fellowship training knew the definition of persistent asthma.
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Figure 1 indicates the frequency with which physicians, faced with the scenario detailed above, would prescribe a LTCM for either a 2- or 15-year-old patient. Although the distribution of answers did differ significantly (P < .001) in favor of prescribing a LTCM for the older child, the differences were small. For example, 47% would never or rarely prescribe a LTCM for the 2-year-old child, compared with 42% for the 15-year-old youth. Prescribing practices for patients of different ages were also analyzed on the basis of practice setting and training (Table 3). These factors had little effect on prescribing practices, although physicians who had completed residency training >10 years ago were significantly more likely than others to prescribe a LTCM for a 15-year-old with persistent asthma.
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The patient's frequency of asthma symptoms was cited by 43% of physicians as the most important factor in deciding whether to prescribe a LTCM. Other criteria cited as the most important factor included the frequency of ED visits for asthma (12%), the severity of the acute asthma exacerbation (7%), and the frequency of hospitalizations for asthma (7%). Table 4 shows the barriers cited by physicians for cases in which they do not provide LTCMs. Of these, believing that this was the role of the PCP or asthma specialist rather than the ED physician was the most commonly cited factor, indicated by approximately one half of respondents. This was so even though the vast majority (334 physicians [99%]) of physicians either instruct the child's caretaker to follow up with the PCP after the ED visit or make contact with the PCP during the ED visit, to arrange follow-up care.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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We found that ED physicians commonly encounter children with persistent asthma who are not being treated with LTCMs. Furthermore, there was a high degree of awareness of national guidelines recommending use of LTCMs for these children, and virtually every surveyed physician believed that such children should receive LTCMs. However, when presented with case scenarios of children with frequent asthma symptoms, fewer than 1 in 5 physicians stated that they would provide LTCMs for the majority of such children.
Working in a university-based children's hospital, being fellowship trained, and recently completing residency were used as proxies for being academically oriented and/or being trained when guidelines were being developed and disseminated. For the most part, these factors did not influence significantly physicians' awareness or prescribing habits (Tables 2 and 3). In fact, a significantly greater proportion of physicians who had not completed fellowship training knew the definition of persistent asthma. We had hypothesized that, because of concerns about growth suppression, physicians would be less inclined to prescribe a LTCM for a 2-year-old child, compared with a 15-year-old child. Although we did note a statistically significant difference in prescribing patterns based on patient age (Fig 1), the absolute differences were not substantial. Furthermore, the likelihood of compliance, belief in efficacy, and concerns about adverse effects were not important criteria in the decision to begin LTCM therapy. The most common reasons for not prescribing these medications were the belief that it was the role of the PCP or asthma specialist to do so and the inability of ED physicians to provide long-term follow-up care (Table 4).
ED physicians who prescribe LTCMs such as ICSs at ED discharge could have either of 2 management goals. They might wish to improve long-term asthma outcomes for children with persistent asthma and/or they might be seeking short-term benefits that might result in lower rates of relapse to the ED. Although many studies have shown LTCMs to be efficacious in the management of asthma,8–11,17–24 perhaps the best data proving the long-term efficacy of ICSs comes from the Childhood Asthma Management Program Research Group.10 In that multicenter study, 1041 children 5 to 12 years of age were assigned randomly to daily treatment with budesonide, nedocromil, or placebo for 4 to 6 years. Those treated with budesonide had a 43% lower rate of hospitalizations, a 45% lower rate of urgent visits to a caretaker, a 43% lower rate of prednisone use, and a reduced need for albuterol and other asthma medications, compared with the placebo group. As stated in national guidelines, "strong evidence from clinical trials has established that ICS improve control of asthma for children with mild or moderate persistent asthma."6
Regarding the short-term efficacy of ICSs after ED discharge, the preponderance of evidence seems to favor their use, although most studies have been performed among adults. Rowe et al16 randomly assigned 188 adults to receive high-dose budesonide or placebo after an ED visit for asthma. All subjects were also treated with prednisone for 7 days. After 21 days, one half as many in the ICS group had experienced an ED relapse and those in the budesonide group had better symptom scores and less need for rescue treatment with ß-receptor agonists. Also, among 635 patients 5 to 60 years of age, those prescribed ICSs after ED discharge had 45% fewer relapse ED visits, compared with nonusers.17 Brenner et al25 failed to demonstrate that the use of flunisolide among adults had any efficacy in the first 24 days after ED discharge. However, that study had several limitations, including the use of a medium, not high, daily ICS dose, a follow-up rate of just 72%, and a compliance rate of just 56%.25
Just 4 physicians (1%) cited concerns about adverse effects as the main reason for not prescribing LTCMs, which reflects a good understanding of recent literature.10,20,22,26 Agertoff and Pedersen22 found that children with asthma who had been treated with long-term ICS therapy achieved normal adult height, and Bisgaard et al20 found no effect on growth for preschoolers treated with a ICS for 1 year. As stated by the NAEPP, "strong evidence from clinical trials following children for up to 6 years shows that the use of ICS at recommended doses does not have frequent, clinically significant, or irreversible effects on any outcomes reviewed."6
At our own institution, we found that 64% of a convenience sample of children with acute asthma had persistent disease.27 Furthermore, in our prior work, we noted that, among the cohort with persistent disease, just 21% of patients were using an ICS daily,27 whereas other investigators found that just 26% to 39% of patients were taking antiinflammatory medication daily.28–30 Cabana et al31 reported barriers among general pediatricians to prescribing daily ICS therapy. These barriers included concerns about long-term safety, lack of awareness of efficacy and dosing, and parental fear of corticosteroids. To our knowledge, ours is the first study that attempts to identify barriers that ED physicians face when considering the use of LTCMs, and none of the barriers described by Cabana et al31 was an important factor for the ED physicians. Pathman et al32 stated that, in order for physicians to comply with practice guidelines, they must become aware, agree intellectually, decide to adopt, and then adhere. Physicians in this study were aware of national guidelines calling for PCPs to prescribe LTCMs when appropriate and agreed with the guidelines to a great extent but did not adopt them into their own practices. Other ED physicians, with less knowledge of NAEPP definitions and recommendations, may be even less inclined to prescribe LTCMs; therefore, these data may underestimate overall prescribing rates.
This study was subject to limitations inherent with surveys. One half of those surveyed did not respond, and it is possible that responders and nonresponders differed in their use of LTCMs. However, if it is assumed that those with a strong interest in asthma were more likely to respond, then the low rates of use reported here may in fact overestimate what occurs in actual practice among all physicians. The survey was pilot-tested to assess clarity, accuracy, and comprehensiveness. However, the validity of the results depends on respondents' recall and honesty. Attempts were made to limit recall bias by asking questions related to current practice. It was not possible to target and to question all emergency providers for children, including those who were not members of the AAP; we do not know how their responses might have compared with those of the surveyed group. We did attempt to maximize the generalizability of the data by including physicians from across the nation and from various practice settings, as well as those with and without fellowship training. Also, we specifically sought to survey physicians who cared for children in an ED setting, to determine prevailing practices in the treatment of children with asthma.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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It is well established that LTCMs, especially ICSs, are both efficacious and safe for the chronic treatment of children with persistent asthma. What is less well defined is what role, if any, ED physicians should have in initiating this therapy. The NAEPP guidelines state that medications used after an ED visit should include inhaled ß-receptor agonists and orally administered systemic corticosteroids, but there is no recommendation that LTCM therapy should be initiated at this stage.5,6 Some authors are now calling for emergency physicians to consider strongly the initiation of ICS therapy at ED discharge,33 whereas others are discouraging widespread adoption of this approach pending more data.34 The failure to prescribe LTCMs after an ED visit for asthma may represent a lost opportunity to intervene on behalf of an at-risk population.
The present data show that ED physicians commonly encounter children with persistent asthma who are not being treated with LTCMs, they are aware of national guidelines recommending the use of LTCMs for such children, and they believe in the efficacy of LTCMs. However, only a small proportion of the children who potentially would benefit from LTCMs are receiving them at ED discharge. This, combined with inconsistent PCP follow-up care,12,13 is contributing to the underutilization of LTCMs for children with persistent asthma. Perhaps if future versions of the NAEPP guidelines address specifically the role of ED physicians in prescribing LTCMs, a greater proportion of children with persistent asthma would be treated with preventive medications.
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ACKNOWLEDGMENTS |
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This work was supported with an unrestricted educational grant from AstraZeneca.
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FOOTNOTES |
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Accepted Jul 19, 2005.
Address correspondence to Richard J. Scarfone, MD, FAAP, Division of Emergency Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104. E-mail: scarfone{at}email.chop.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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