PURPOSE OF THE STUDY.
To determine the clinical outcomes and cost-effectiveness of 3 inhaled corticosteroid (ICS) delivery options for children with asthma treated in and discharged from the emergency department (ED).
A hypothetical cohort of children with asthma being discharged from the ED introduced into each arm of the decision tree analysis.
A cost-effectiveness decision analysis model was designed by using a decision tree to compare 3 ED-based ICS delivery options: (1) usual care (recommending outpatient follow-up), (2) prescribe (uniformly prescribing ICS), and (3) dispense (uniformly dispensing ICS). Accounting for expected follow-up rates, prescription filling, and medication compliance, the investigators compared projected rates of ED relapse visits and hospitalizations within 1 month of ED visits across all 3 arms; 100 children in each group. Direct and indirect costs were compared.
The model predicts that the rate of return to ED per 100 patients within 1 month of ED visit was 10.6 visits for the usual care arm, 9.4 visits for the prescription arm, and 8.4 visits for the medication-dispensing arm. Rates of hospitalization per 100 patients were 2.4, 2.2, and 1.9, respectively. Direct costs per 100 patients for each arm were $23 000, $20 800, and $19 100, respectively. Including indirect costs related to missed parental work, total costs per 100 patients were $27 100, $22 000, and $20 100, respectively. Total costs savings per 100 patients comparing the usual care arm with the medication dispensing arm was $7000.
This decision analysis model suggests that uniform prescribing or dispensing of ICS at the time of ED visit for asthma may lead to fewer ED visits and hospital admissions within 1 month of the sentinel ED visit and provides a substantial cost-savings overall.
Eureka! This is a common sense investigation with expected outcomes and recommendations that should be implemented. How many times are asthmatic children with asthma discharged from the ED with a prescription for oral corticosteroids but without prescribing or dispensing an ICS as an on-going asthma controller therapy? Although ICSs are the recommended therapy for persistent asthma, they continue to be underprescribed and a minority of patients receives ICSs after acute ED visits for asthma. Although the Global Initiative for Asthma guidelines unequivocally state that children with asthma seen in the ED qualify as persistent and should be started on controller medications, National Heart, Lung, and Blood Institute guidelines do not make clear recommendations in this regard. This investigation implemented a decision analysis model to demonstrate that the uniform dispensing of ICS at the time of ED discharge for children with acute asthma exacerbations reduces subsequent acute care visits for asthma and yields a significant cost-savings per patient.
- Copyright © 2013 by the American Academy of Pediatrics