PEDIATRICS Vol. 118 No. 6 December 2006, pp. 2394-2401 (doi:10.1542/peds.2006-0871)
ARTICLE |
Initiation of Maintenance Antiinflammatory Medication in Asthmatic Children in a Pediatric Emergency Department
a Divisions of Allergy/Immunology
b Emergency Medicine, Department of Pediatrics, University at Buffalo School of Medicine and Biomedical Sciences, Women and Children's Hospital of Buffalo, Buffalo, New York
c Center for Patient Quality, Women and Children's Hospital of Buffalo, Buffalo, New York
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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BACKGROUND. Despite National Asthma Education and Prevention Program guidelines recommending the use of daily controller medication in patients with persistent asthma, less than half of children requiring emergency department treatment for asthma exacerbations are receiving antiinflammatory therapy.
OBJECTIVE. The purpose of this study was to evaluate a pediatric emergency department–based intervention designed to affect the prescribing practices of primary care physicians to better comply with national asthma guidelines. The intervention involved initiating maintenance antiinflammatory therapy in children with an asthma exacerbation who met guidelines for persistent disease but were not on antiinflammatory medications.
METHODS. Guardians of children 2 to 18 years of age presenting to the pediatric emergency department with an asthma exacerbation were asked to complete an asthma survey. Patients were classified into severity categories. Those with persistent disease not on antiinflammatory medications were given a 2-week supply of medication and were instructed to follow-up with their primary care physicians to obtain a prescription for the antiinflammatory medication. Patient adherence information was obtained through telephone calls, pharmacy claims data, and physician office records.
RESULTS. Forty-seven of 142 patients met criteria and were enrolled in the intervention. Seven patients were lost to follow-up. Of the remaining 40 patients, 28 followed-up with their primary care physician. Of these patients, 75% were continued on an antiinflammatory medication. Primary care physicians were significantly more likely to continue an antiinflammatory prescription in patients with severe persistent asthma (88.9% vs 68.4% of mild- or moderate-persistent asthmatics). Of the 28 patients who followed-up with their primary care physician, 13 had a prescription written, dispensed, and reported using the medication at the time of follow-up.
CONCLUSIONS. Pediatric emergency department physicians can successfully partner with primary care physicians to implement national guidelines for children requiring maintenance antiinflammatory asthma therapy. Patient nonadherence continues to be a significant barrier for asthma management.
Key Words: asthma • emergency department • inhaled antiinflammatory agents • compliance • guideline adherence
Abbreviations: NAEPP—National Asthma Education and Prevention Program • PCP—primary care physician • ED—emergency department • PED—pediatric emergency department • WCHOB—Women and Children's Hospital of Buffalo
The National Asthma Education and Prevention Program (NAEPP) guidelines from 1991, 1997, and 2002 recommend the use of daily long-term control medication, specifically antiinflammatory therapy, in all patients with persistent asthma.1,2 The efficacy of maintenance antiinflammatory therapy in asthma has been well established on the basis of measures of lung function,3 symptoms scores, and reduction in emergency department (ED) visits and hospitalization.4 Although primary care physicians (PCPs) acknowledge awareness of the national guidelines regarding treatment of persistent asthma,5,6 overreliance on short-term control agents and underuse of antiinflammatory agents still occurs.7,8 Less than half of children requiring ED treatment for asthma exacerbations are receiving antiinflammatory therapy as recommended by the NAEPP.9,10
Nationally, children with asthma account for >550000 ED visits each year.11 In 2000, of the 25429 patients between the ages of 2 and 18 seen in the pediatric emergency department (PED) at the Women and Children's Hospital of Buffalo (WCHOB), 2.4% had a diagnosis of asthma. A 1999 survey of 137 children with asthma seen in the WCHOB PED demonstrated underuse of inhaled steroids, with only 48% of patients with persistent asthma on an antiinflammatory medication.12
Although current emergency management of asthma exacerbations focuses on prompt relief of bronchoconstriction with the use of short-acting ß-agonists, oral or intravenous steroids, and anticholinergics,13 the ED is an effective place to initiate maintenance antiinflammatory therapy during an asthma exacerbation. The benefits of initiating maintenance therapy in the ED depend on a strong physician-patient partnership with the primary care physician (PCP) in treating and monitoring chronic asthma.1 Therefore, it would be essential to involve the PCP in the decision-making process for initiation of antiinflammatory therapy in the ED.
The primary objective of this study was to evaluate a PED-based intervention designed to create a new role for the PED physician in asthma management. In addition, this study attempted to affect the prescribing practices of PCPs to better comply with NAEPP guidelines by initiating maintenance antiinflammatory therapy in children who present to the PED with an asthma exacerbation and who meet the guidelines for persistent disease in hopes that the PCPs would continue the medications.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Study participants included children, ages 2 to 18 years, presenting to the PED with asthma-related symptoms between June 2002 and May 2004. A convenience sample of 142 patients presenting to the PED with complaints of "asthma," "wheeze," "shortness of breath," "difficulty breathing," or "reactive airway disease" were screened by respiratory therapists and trained medical students for inclusion into the intervention. Enrollment took place with the help of trained student research assistants from November 2002 to February 2004 at peak times in the PED (eg, 5–11 PM). All patients were considered for enrollment during these blocks of time based on research personnel capacity.
Patients' parents or guardians answered a 3-page questionnaire addressing demographics and family history, pharmacy information, identification of PCP and asthma specialist, past asthma history, perceived asthma triggers, perceived asthma severity, asthma management plan, and medication adherence questions. The interviewer obtained written consent from the patient's guardian, as well as assent by all patients >6 years of age for those patients meeting intervention criteria and enrolled in the study. An asthma-severity classification for each patient was determined by the interviewer and confirmed by one of the authors using a modification of the 1997 NAEPP criteria for persistent asthma, in which we took into account ED visits, hospitalizations, and oral steroid bursts in the 6 months before initial interview.
Exclusion criteria included age <2 or 
19 years of age; other chronic pulmonary conditions (eg, cystic fibrosis, bronchopulmonary dysplasia) or congenital heart disease; asthmatic patients already on maintenance antiinflammatory treatment; patients in status asthmaticus resulting in hospitalization; and asthmatic patients without persistent symptoms (intermittent asthma).
On discharge from the ED, patients were given a 2-week sample of an antiinflammatory medication by a PED attending physician using an algorithm based on patient age and asthma severity, shown how to use the medication if an inhaler, and instructed to follow-up with their PCP within 7 days for a prescription of the antiinflammatory medication. Mild-persistent asthmatic children were discharged with either a leukotriene modifier (montelukast) or low-dose inhaled corticosteroid. Patients with moderate-persistent classification were discharged on an inhaled corticosteroid, and severe-persistent patients were discharged on an inhaled corticosteroid, with or without the addition of montelukast. Selection of the exact discharge regimen was decided on by the attending PED physician based on the patient's age and severity score. The inhaled corticosteroids used were fluticasone with a spacer device or budesonide by turbohaler for children >6 years of age, and budesonide by nebulization for children <6 years. Children in the 6- to 8-year range could be discharged with any of the above choices depending on the children's ability to use the various delivery systems.
Before discharge with the sample medications, the patient's PCP was called to discuss the patient's diagnosis of persistent asthma and to obtain their approval for the addition of an antiinflammatory medication as part of the study. A letter outlining the treatment plan and decision process for determining severity of asthma was faxed to the patient's PCP on the morning after the PED visit, both for patients in the intervention group and those not eligible for intervention.
Trained medical students, with a goal follow-up time of 2 to 4 weeks after their PED visit, telephoned parents or guardians of patients in the intervention group. The telephone interviews addressed follow-up with the primary physician, whether an antiinflammatory prescription was given, and whether that prescription was filled and was currently being used by the patient. Students confirmed the medication name, pharmacy name, and telephone number at the time of the telephone interview by having the parent or guardian read the label of the medications given by the PCP.
All PCP office records that could be obtained were reviewed for patients enrolled in the intervention. PCP office staff was provided with the patients' signed consent forms.
The patients' pharmacy records were obtained for the time period from 1 year before the intervention until 1 year postintervention. Pharmacies were provided with the patients' signed consent forms, which discussed the use of pharmacy records in the study.
All data analyses were conducted by using SPSS 11.5 (SPSS Inc, Chicago, IL) and SAS (SAS Institute, Inc, Cary, NC) (for verification purposes only). Differences between percentages in every contrast noted were assessed for significance by t (pairwise contrasts) or 
2 tests, as appropriate.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Of the 142 patients with asthma that were screened, 47 patients with a diagnosis of persistent asthma between the ages of 2 and 18 met criteria for the study and gave written consent by the parent or guardian (and assent when appropriate) for enrollment. Of the 95 patients not enrolled, 18 patients were categorized as mild intermittent asthma, and 64 patients were already on antiinflammatory medication, eg, inhaled steroids or leukotriene modifiers for asthma. Two patients were not enrolled because their ED visit resulted in hospitalization. Two patients met criteria for the study, but declined the intervention, and were therefore not enrolled. For 9 patients, there were errors in the classification or enrollment process that led to them not receiving the intervention, although they were eligible (Fig 1). Table 1 shows the demographic data on the 47 patients enrolled in the intervention. The patient population was primarily from the inner city, with 68% being black and 66% on Medicaid insurance.
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Three approaches were used together to confirm whether patients followed-up with their PCP, received a prescription for maintenance antiinflammatory medication, and filled the prescription. The first approach used was telephone interviews. Twenty-six follow-up telephone interviews were completed of 47 patients enrolled in the intervention. The reasons for uncompleted telephone interviews included incorrect or disconnected telephone numbers and no response to multiple calls for interview. Median time to telephone follow-up was 2 months, with a range of 1 week to 7 months postintervention. Time to telephone follow-up was 7 months for 1 patient and 6 months for 2 patients. The other 23 patients with follow-up telephone interviews were contacted within 3 months after the original intervention.
In the second approach, we used pharmacy records to confirm prescription filling, which were obtained for 33 of 47 patients enrolled in the intervention. The reasons for not obtaining pharmacy records included no known pharmacy at initial PED visit (and failure to update pharmacy by telephone interview), and no records for the patient at the pharmacy identified by the parent or guardian.
Finally, all PCP office records that could be obtained (20 of 47) were reviewed for patients enrolled in the intervention. The reasons for not obtaining office records included incorrect or no PCP identified by parent or guardian at initial PED visit or inability to obtain access to charts at private PCP offices.
In aggregate, incorporating all 3 methods, we were able to obtain follow-up data on 40 of 47 patients who were enrolled in the intervention and discharged from the PED with an antiinflammatory controller medication. Unfortunately, no single method was adequate to completely confirm patient and PCP compliance. However, when all 3 methods were used they often complemented each other. For example, pharmacy data alone could not tell us whether a patient who had no antiinflammatory prescription filled had ever received a prescription from the PCP or followed-up with the PCP in the first place. PCP office records were able to confirm if the patient was seen in follow-up and had a prescription written but not if they then went on to fill it. Although telephone interviews had the potential to confirm each stage of follow-up, they were prone to recall bias. Whenever possible, we confirmed information obtained through telephone interview with information obtained from pharmacy records and PCP's office records. In 4 of 40 patients, telephone follow-up could not be confirmed with either PCP office records or pharmacy data. In 3 of these cases, the parent or guardian read the patient's antiinflammatory prescription information to the interviewer, and in 1 case, the patient's guardian reported that no follow-up visit with the PCP was ever initiated.
Seven patients were lost to follow-up because of disconnected or incorrect telephone numbers, no response to multiple follow-up calls, and/or unidentified pharmacy. The subsequent analysis was completed using the remaining 40 enrolled patients on whom follow-up data are available.
Twenty-eight (70.0%) of 40 patients followed-up with their PCP, as verified by patient telephone calls and office records from the PCP. The PCP continued the patients' antiinflammatory medication for 21 patients (75.0% of those that followed-up with their PCP). Follow-up data on patients who received prescriptions from their PCP were obtained for 20 of 21 patients (1 patient was lost to follow-up at this stage because of a disconnected telephone number and unidentified pharmacy). Seven of these 20 patients did not fill the prescription received from their PCP. Of patients who followed-up with their PCP, 13 (46.4%) of 28 had a prescription written and dispensed, and were reported to be using the medication at the time of telephone follow-up (eg, complete adherence). Therefore, only 32.5% of the original 40 patients not lost to follow-up continued on a long-term antiinflammatory controller after their initial intervention in the PED.
Of the severe-persistent asthmatic patients, 6 (54.5%) of 11 continued the intervention, versus 6 (27.3%) of 22 with moderate-persistent, and 1 (14.3%) of 7 with mild-persistent (Fig 2) asthma. Therefore, asthma severity was a significant predictor of continuation of therapy, because severe-persistent asthmatic patients were significantly more likely to continue therapy than either moderate-persistent (P < .01) or mild-persistent (P < .001) asthmatic patients. The difference in continuation rate between moderate- and mild-persistent asthmatic patients approached significance (P < .06).
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When looking at the individual steps toward adherence to the intervention, severe-persistent asthmatic children were more likely to follow-up with their primary physician (9 [81.8%] of 11) than moderate-persistent (15 [68.2%] of 22; P < .01) or mild-persistent (4 [57.1%] of 7; P < .01) asthmatic children (Fig 3). The difference between mild- and moderate-persistent asthmatic patients was not statistically significant at this step in the follow-up. PCPs were significantly more likely to continue an antiinflammatory prescription after our intervention in patients with severe-persistent asthma (8 [88.9%] of 9) compared with those with moderate asthma (10 [66.7%] of 15; P < .001) or compared with moderate and mild combined (13 [68.4%] of 19; P < .01) (Fig 4). Severe-persistent asthmatic patients were also more likely to fill a prescription for antiinflammatory medications (6 [85.7%] of 7) than moderate-persistent (6 [60%] of 10; P < .001) or mild-persistent (1 [33.3%] of 3; P < .001) asthmatic patients, and moderate-persistent asthmatic patients were more likely to fill a prescription than mild-persistent asthmatic patients (P < .01) (Fig 5). Table 2 summarizes the relationship between asthma severity and adherence at all steps after the intervention.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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One of the major goals of this study was to educate the PCP and change prescribing habits by encouraging the use of maintenance antiinflammatory medication in children with persistent asthma. However, this process depended on several variables including the return of the patient to see the PCP after the ED visit, the PCP handing the patient or guardian a prescription, and the patient actually filling the prescription at a pharmacy. Thus, adherence to the intervention entailed several steps, with active involvement of both the patient or guardian and the PCP. In this study, despite an active intervention including dispensing of sample medication, as well as verbal and written contact with the patient's PCP at the onset of the intervention, adherence to the intervention was still low. Of those patients placed on appropriate sample medications through our intervention, just under one-third were continuing long-term maintenance antiinflammatory medications.
Despite being given verbal and written instruction to schedule a follow-up appointment, only 28 (70%) of 40 patients in the intervention attended a follow-up visit with their PCP after their PED visit. These data were comparable to that found by the National Cooperative Inner-City Asthma Study, in which appointments for follow-up after ED visit were kept by 60% of patients who were told specifically to call for an appointment.14
The stage at which the poorest adherence to our intervention occurred was filling prescriptions for the antiinflammatory medication. Only 65% of patients who received a prescription from their PCP filled that prescription in the pharmacy. Adherence rates to long-term therapy among patients with many chronic conditions are disappointingly low, dropping most dramatically after the first 6 months of therapy.15 This holds true for pediatric asthma populations, in which studies of patient adherence demonstrate that patients are using their long-term control medications less than 40% to 60% of the time, according to pharmacy records16 and electronic monitoring.8,17 The reasons behind controller medication nonadherence are multidimensional and include poor parental understanding of therapy,18 concerns about safety or value of controller medications,19 family and parental psychosocial stressors,20 and lack of motivation or forgetfulness by the patient.21
Although many patients failed to comply with the intervention by not following-up with their PCP or not filling prescriptions written by their PCP, there were also a number of patients who were not continued on an antiinflammatory controller medication by their PCP. Twenty-five percent of the intervention patients (7 of 28) who saw their PCP in follow-up were not continued on an antiinflammatory medication despite communication by the PED staff of treatment recommendations. None of the 7 patients had the same PCP.
The reasons behind this PCP nonadherence were not known, because a follow-up discussion with the PCPs by the investigators was not incorporated into this study. Some PCPs may have disagreed with having patients started on controller medication in the ED setting. This study did involve a call to the PCP at time of enrollment to obtain permission to start a controller medication, but many of the study patients went to group practices where the on-call physician contacted at time of enrollment was not the same physician seeing the patient in follow-up. Secondly, the PCP may have disagreed with the asthma-severity classification determined in the PED, a copy of which was faxed to the PCP. Classification in this study was based on 6-month parental recall, which may have conflicted with the PCP's office records or with parental recall of symptoms in the setting of the PCP visit. In addition to these barriers specific to our study, it has been shown previously that pediatricians may not comply with NAEPP guidelines for the use of daily inhaled corticosteroids because of lack of awareness, familiarity or agreement, lack of confidence in dosing and recognizing contraindications, and lack of outcome expectancy or concern about steroid adverse effects.22 A recent study demonstrated that targeted physician education on asthma management guidelines could improve chronic asthma care in pediatric patients.23
In our study, both the patients' families and PCP were more likely to comply with the intervention in patients with more severe disease. At each step of follow-up with the intervention, there was a direct relationship between severity classification and adherence to the intervention. Patients with milder disease were less likely to follow-up or fill prescriptions. PCPs were less likely to write a prescription for patients with mild or moderate disease compared with those with severe disease. A similar observation was made by Cabana et al.24 Two thirds of children did not receive an outpatient follow-up visit for asthma within 30 days of their ED asthma visit. Those patients that did have follow-up after their ED visit were more likely to have a repeat ED asthma visit within 1 year. Thus, in our study patients with more severe asthma adhered to the intervention the best, which as pointed out by Cabana and colleagues may have reduced their risk for a repeat visit to the ED for asthma exacerbation. Although this correlation between compliance and disease severity has been shown previously in both adult asthmatic patients25 and in children,26 it remains a serious misconception that antiinflammatory controller medication is less important in mild-persistent disease. In mildly-to-moderately asthmatic children, there is improved long-term lung function in those that receive inhaled corticosteroid treatment early in the course compared with those with later initiation of treatment.3
The ED has not traditionally been used to initiate maintenance asthma medications. A recent survey of ED physicians found that although 99% of these physicians agree that children with persistent asthma should be on long-term controller medication, <20% provide a long-term controller at discharge from the ED for an asthma-related visit.27
Farber and Oliveria28 recently described a PED-based intervention to improve chronic asthma management in a population of children presenting to the PED with an asthma exacerbation. After an intervention consisting of asthma education, a written asthma action plan, and a prescription for an asthma controller medication and a quick-relief medication, 39% of patients in the intervention group continued the controller medication after the PED visit compared with 11% of patients in the control group. In their study, patients with both intermittent and persistent disease were included in the intervention, and >20% of the intervention group was already receiving inhaled antiinflammatory medication before the initiation of the intervention.
In contrast with the study by Farber and Oliveria, our intervention was designed, in part, to target changes in PCP behavior as well as patient adherence. We, therefore, dispensed sample antiinflammatory medications to our enrolled patients rather than a prescription for a maintenance antiinflammatory medication. This allowed our study to shift the responsibility of writing a prescription for a maintenance medication to the PCP and to bypass the negative effect of the patient viewing the PED as its primary prescribing entity. We did not verify measures of improved health for treated children, which was beyond the scope of our study.
Limitations of our study included the lack of a control group, reliance on the parent or guardian reporting in determining asthma severity and tracking follow-up, long recall time required of the parent or guardian at time of telephone follow-up, and significant loss of patients to follow-up. Although our study had no control group, historical controls from our PED population at WCHOB show that 48% of patients presenting to the PED with persistent asthma were not on maintenance antiinflammatory medications.12 Therefore, we felt that the continuation of maintenance antiinflammatory medications by almost one third of our intervention patients represents an important step toward increased adherence to the NAEPP guidelines.
Although telephone follow-up was initially attempted 2 to 4 weeks after the initial intervention, several patients could not be reached in a timely manner. Attempts continued up to 7 months after the intervention. Three patients could be contacted by telephone for the first time at 6 to 7 months after the initial PED visit. Asking guardians to recall follow-up with a PCP after this long interval could increase recall bias in these cases. In 1 case, we were able to obtain both PCP office records and pharmacy data to confirm information obtained. In the second case, we obtained PCP office records but no pharmacy data. In the third case, the telephone interview was the only follow-up information we were able to obtain.
Many patients were lost to follow-up during the various steps of our study, attributable in large part to the inner-city demographics of our patient population. At the time of telephone follow-up, many telephone numbers were disconnected or had incorrect numbers. By the time of attempted 6- to 12-month telephone follow-ups, all but 5 patients had disconnected the telephone numbers that we had previously used at the initial telephone follow-up. In addition, the pharmacies that patients initially named at the time of their interview had only short periods of active use for these patients when we reviewed pharmacy records 1 year postintervention. Likely, patients were frequently changing pharmacies, because even albuterol refills are not in the pharmacy records for a whole year's period of time. This made an analysis of compliance with refilling the maintenance controller medication over the year postintervention virtually impossible.
More than a decade after initial asthma management guidelines were published, the literature is filled with interventions aimed at both patients and providers to increase compliance with the guidelines and reduce asthma morbidity. There is a need to proactively consider alternative approaches to achieving control of pediatric asthma, because there continues to be a large percentage of patients who are managed suboptimally. Our study details a novel approach using the PED to initiate maintenance therapy in persistent asthmatic patients, which is easily generalizable to both the PED and the general ED with a subset of pediatric patients.
Although under ideal circumstances, a maintenance antiinflammatory medication should be initiated by the PCP, the PED physician can successfully partner with the PCP to implement national guidelines for children requiring chronic asthma therapy. To keep the physician-patient partnership intact, it is important to encourage prompt patient follow-up with the PCP after discharge and identify the PCP as the patient's physician for asthma management and medication refills, rather than the ED.
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ACKNOWLEDGMENTS |
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Dr Augustine was supported by a summer student research grant from the American Academy of Allergy, Asthma & Immunology.
We thank the University at Buffalo medical students who helped enroll patients and performed follow-up telephone calls. We also thank the Visiting Nurses Association and the PED attending physicians, residents, nursing staff and respiratory therapists at WCHOB for their help.
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FOOTNOTES |
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Accepted Jul 24, 2006.
Address correspondence to Heather K. Lehman, MD, Division of Allergy and Immunology, Department of Pediatrics, Women and Children's Hospital of Buffalo, 219 Bryant St, Buffalo, NY 14222. E-mail: hkm{at}buffalo.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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