Hot Off the Press: Do Emergency Department–based Predischarge Educational Interventions for Adult Asthma Patients Improve Outcomes?

The World Health Organization estimates that about 334 million people worldwide suffer from asthma (http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf). In the United States, over 22,000 people suffer from asthma, which accounts for about 1.8 million emergency department (ED) visits annually (http://www.cdc.gov/asthma/most_recent_data.htm). While two-thirds of ED asthma patients are discharged, one in five experience an asthma relapse within 14 days.1 The ED is uniquely positioned to improve the quality of asthma care,2 but high quality evidence to support ED educational interventions is lacking. The most recent Cochrane review on “ED educational interventions” for adult asthma exacerbations noted a reduction in hospital readmissions (relative risk [RR] = 0.50; 95% confidence interval [CI] = 0.27 to 0.91). However, ED relapse rates, cost, symptom improvement, and quality of life were not improved.3 Another Cochrane review regarding chronic disease management programs for asthma included collaboration with a primary care physician (PCP) and demonstrated significant improvements in quality of life, asthma severity scores, and lung function tests.4 There is no evidence to date, however, that directly examines the effect of timely PCP follow-up after an asthma exacerbation and its outcomes. Despite the lack of high-quality evidence, current asthma exacerbation guidelines recommend follow-up with a PCP, highlighting the significance of the partnership between the patient and PCP, patient education, and guided self-management.5 This systematic review of randomized controlled studies evaluated any asthma-related educational interventions that occurred within 1 week of the index ED visit for asthma. “Educational interventions” included post-ED phone call reminders to predischarge asthma care packages that included the entire course of steroids, inhalers, and transportation vouchers for the follow-up appointment, to a simple fax from the ED to the PCP office. The studies compared the effectiveness of the interventions to usual care, defined as discharge instructions and prescriptions for medications. The primary outcome was the percentage of PCP office follow-up visits. The secondary outcomes were percentage of unscheduled revisits to the office or ED for asthma relapse, admissions, time to first PCP follow-up visit, and time to first relapse. The authors also evaluated the fidelity of the educational interventions. Overall, this is a high-quality systematic review that adheres to the Preferred Reporting for Systematic Reviews and Meta-Analyses reporting guidelines. However, this systematic review is limited by the lack of high-quality studies. In addition, available research may have limited external validity, as all of the studies used nonclinical personnel to educate patients; nonclinical personnel resources are not often available in most EDs. All of the studies occurred in the United States and Canada, which may not be accurately extrapolated to other nation's healthcare systems. Finally, the primary outcome (PCP follow-up) is a surrogate for more meaningful, patient-centered outcomes of asthma recovery and sustained health. Educational interventions improved the primary outcome, post-ED PCP visits, in all five studies (RR = 1.6, 95% CI = 1.31 to 1.87) compared to usual care with a number needed to treat (NNT) of 6 (95% CI = 4 to 11) for one patient to follow up with his or her PCP who otherwise would not have followed up. Although no significant differences in any of the secondary outcomes were observed with education, a trend toward benefit was observed for each outcome favoring asthma education as opposed to usual care: asthma relapse (RR = 1.3, 95% CI = 0.82 to 1.98), time to asthma relapse (median = 45 days vs. 28 days), or time to first PCP visit (median = 45 days vs. 16 days). One study reported more patients with a written “asthma action plan” and higher quality of life scores at 6 months following ED education. The inconsistency and lack of outcome reporting on many of the secondary outcomes precluded performing meta-analysis. Using the Treatment Fidelity Assessment Grid the authors found that none of the trials used any behavioral adaption theory for their educational intervention. Specifically, details about educator training and the consistency of intervention delivery to participants were lacking, so the systematic review authors could not evaluate “fidelity” across studies. Shared decision-making (SDM) is an essential skill in the practice of medicine and patient education is a key component of effective SDM.6 Variations between practice environments and patient populations, resources, personnel, health literacy, and other factors make ED predischarge interventions difficult to implement. To improve predischarge care and related patient-centered outcomes, we must understand the effectiveness of such interventions. This systematic review indicates an acceptable NNT to promote asthma patients’ follow-up, but secondary outcomes that may be more clinically relevant (relapse rate, admissions, ED returns) did not significantly improve with enhanced predischarge patient education. It is plausible that increasing PCP follow-up rates increases cost and healthcare utilization without improving asthma related morbidity, so the value and effective components of follow-up PCP care for asthma must also be quantified.7 Furthermore, none of the educational interventions reported using an established, reproducible theoretical framework or model8 to implement behavioral change, an essential component of implementation research.9 Failure to use theoretical frameworks to promote patient follow-up may be related to the systematic review authors’ challenges measuring the fidelity of each intervention. Fidelity measures how consistently and with what depth study subjects receive an intervention, in essence a measure of dosing.10 More consistent reporting of fidelity would permit more meaningful comparisons of the rigor, timing, engagement, and clarity with which educational interventions are applied by bedside providers. Asthma education regarding warning signs, medical management, follow-up recommendations, and reasons for return to the ED are important component of quality emergency care. However, the evidence supporting efforts to reduce asthma related morbidity like preventable readmission, symptom relapse, or return ED visits remains unclear. Limited evidence supports patient education to improve PCP follow-up rates. Further research is required to define the most effective predischarge education and intervention strategies (both in the ED and in PCP follow-up) that reduce preventable asthma morbidity.

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