Original Contributions
A randomized, controlled trial of a simple emergency department intervention to improve the rate of primary care follow-up for patients with acute asthma exacerbations*,**,*

Presented at the Society for Academic Emergency Medicine annual meeting, Boston, MA, May 1999.
https://doi.org/10.1067/mem.2001.116593Get rights and content

Abstract

Study Objective: We determined whether a simple emergency department intervention improves the likelihood of primary care provider (PCP) follow-up after ED discharge for an acute asthma exacerbation. Methods: This randomized, controlled clinical trial was conducted in an urban university-based ED. Participants were patients with asthma between the ages of 16 and 45 years who were treated and discharged from the ED. The study intervention was usual care or an intervention that consisted of a free 5-day course of prednisone, vouchers for transportation to and from their PCP, and a 48-hour telephone reminder to make an appointment with their PCP. The main outcome was whether the patient received follow-up care as determined by PCP contact at 4 weeks. Results: One hundred ninety-two patients with asthma were enrolled over 8 months; 178 (93%) had complete follow-up. The intervention and control groups were similar with regard to age, sex, ethnicity, or years of education. The 2 groups were also comparable with respect to multiple measures of baseline access/barriers to care and severity of ED exacerbation. Patients receiving the intervention were significantly more likely to follow up with their PCP than control patients (relative risk 1.6; 95% confidence interval [CI] 1.1, 2.4). When adjusted for other factors influencing PCP follow-up care (ethnicity, prior PCP relationship, insurance status, regular car access), intervention patients were more likely to follow up with their PCP (odds ratio 3.1; 95% CI 1.5, 6.3). Conclusion: Providing medication, transportation vouchers, and a telephone reminder to make an appointment increased the likelihood that discharged patients with asthma obtained PCP follow-up. [Baren JM, Shofer FS, Ivey B, Reinhard S, DeGeus J, Stahmer SA, Panettieri R, Hollander JE. A randomized, controlled trial of a simple emergency department intervention to improve the rate of primary care follow-up for patients with acute asthma exacerbations. Ann Emerg Med. August 2001;38:115-122.]

Introduction

Asthma continues to be one of the most prevalent chronic diseases, affecting at least 5% of the US population with annual health care costs exceeding $6 billion.1 Emergency departments play a large role in the care of patients with asthma, with approximately 2 million visits annually in the United States.1, 2 Dependence on the ED as a site for episodic, crisis-oriented asthma care has been viewed as a marker for increased morbidity and is associated with poor self-management practices.3, 4, 5 Increased utilization of the ED by some patients with asthma also has been linked to inadequate health insurance. However, underutilization of preventive primary care services and reliance on ED services cannot be fully explained by financial barriers.6 Many asthmatic patients who are reliant on ED care actually have primary care providers (PCPs).6, 7, 8, 9, 10

Effective and timely outpatient care of asthma prevents adverse asthma outcomes and reduces hospitalization and ED visits.11, 12, 13, 14, 15 Follow-up after an acute asthma exacerbation requiring hospitalization has been associated with a reduction in subsequent hospital admissions and improvement in asthma symptoms.16 As a result, the 1997 National Asthma Education and Prevention Program (NAEPP) Guidelines Expert Panel Report-2 recommends close PCP follow-up by instructing patients to make an appointment within 3 to 5 days after an ED visit.17

Several studies have proposed methods to enhance ED–PCP linkage for patients with asthma. Strategies including ED-based asthma education, scheduling of appointments for patients before ED discharge, distribution of medications, and improved communication between primary care physicians and the ED have been proposed.18, 19, 20 Few studies have tested specific interventions in a systematic fashion. We performed a randomized, controlled trial to determine whether a simple, inexpensive, 3-part ED intervention would increase the likelihood of PCP follow-up for patients treated and discharged from the ED for an acute asthma exacerbation. We hypothesized that patients receiving this intervention would be more likely to have PCP follow-up than the control patients who received usual discharge care.

Section snippets

Materials and methods

This study was a prospective randomized, controlled trial of a simple ED intervention to improve the rate of PCP follow-up for patients with acute asthma exacerbations. The study was conducted in the ED of the Hospital of the University of Pennsylvania, an urban tertiary care center with an annual patient census of approximately 47,000 visits. There is no observation or short-stay unit available at the study institution for the extended ED care of asthmatic patients. The study was approved by

Results

During the study period, 218 patients were evaluated in the ED. Review of ED logs identified 21 of the 218 eligible patients were not enrolled, leaving 197 patients who met the inclusion criteria. Three patients refused enrollment, and 2 patients were mistakenly enrolled in an incorrect group. Therefore, 192 patients entered the study protocol (98 in the intervention group and 94 in the control group). These data are consistent with the anticipated 80% enrollment rate. Patients who met study

Discussion

Our study demonstrated that a simple 3-part ED intervention given to discharged asthmatic patients resulted in an increased rate of follow-up with PCPs compared with discharged asthmatic patients who did not receive the intervention. This difference in PCP follow-up between intervention and control patients remained statistically significant even after adjustment for other factors associated with enhanced follow-up, including prior relationship with a PCP.

Because our study design used a

Acknowledgements

Author contributions: JMB, SAS, and RP conceived the study, designed the trial, and obtained research funding. JMB, BI, SR, JD, and JEH supervised the conduct of the trial, subject recruitment, and data collection. JMB, BI, SR, JD, and FSS managed the data including quality control. JMB, FSS, RP, and JEH provided statistical advice, study design, and data analysis. JMB, FSS, BI, and JEH wrote the draft of manuscript. JMB, FSS, SAS, RP, and JEH revised the manuscript. JMB takes responsibility

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    *

    Author contributions are provided at the end of this article.

    **

    Supported by grants from the American Lung Association– Southeastern Pennsylvania Chapter.

    *

    Address for reprints: Jill M. Baren, MD, Department of Emergency Medicine, Hospital of the University of Pennsylvania, Ground Ravdin, 3400 Spruce Street, Philadelphia, PA 19102; 215-662-6917,fax 215-662-3953;,E-mail [email protected].

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