Chest
Volume 115, Issue 4, April 1999, Pages 919-927
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Clinical Investigations
Asthma
Prospective Multicenter Study of Relapse Following Treatment for Acute Asthma Among Adults Presenting to the Emergency Department

https://doi.org/10.1378/chest.115.4.919Get rights and content

Study objective

To identify factors associated with relapse following treatment for acute asthma among adults presenting to the emergency department (ED).

Design

Prospective inception cohort study performed during October 1996 to December 1996 and April 1997 to June 1997, as part of the Multicenter Asthma Research Collaboration.

Setting

Thirty-six EDs in 18 states.

Patients

ED patients, aged 18 to 54 years, with physician diagnosis of acute asthma. For the present analysis, we restricted the cohort to patients sent home from the ED (n = 971), then further excluded patients with comorbid respiratory conditions (n = 32). This left 939 eligible subjects to have follow-up data.

Interventions

None.

Measurements and results

Two weeks after being sent home from the ED, patients were contacted by telephone. A relapse was defined as an urgent or unscheduled visit to any physician for worsening asthma symptoms during the 14-day follow-up period. Complete follow-up data were available for 641 patients, of whom 17% reported relapse (95% confidence interval, 14 to 20). There was no significant difference in peak expiratory flow rate (PEFR) between patients who suffered relapse and those who did not. In a multivariate logistic regression analysis (controlling for age, gender, race, and primary care provider status), patients who suffered relapse were more likely to have a history of numerous ED (odds ratio [OD] 1.3 per 5 visits) and urgent clinic visits (OR 1.4 per 5 visits) for asthma in the past year, use a home nebulizer (OR 2.2), report multiple triggers of their asthma (OR 1.1 per trigger), and report a longer duration of symptoms (OR 2.5 for 1 to 7 days).

Conclusion

Among patients sent home from the ED following acute asthma therapy, 17% will have a relapse and PEFR does not predict who will develop this outcome. By contrast, several historical features were associated with increased risk. Further research should focus on ways to decrease the relapse rate among these high-risk patients. The clinician may wish to consider these historical factors when making ED decisions.

Section snippets

Subjects

This study combines data from two prospective cohort studies performed during October 1996 to December 1996 and April 1997 to June 1997, respectively, as part of the Multicenter Asthma Research Collaboration (MARC).17 This study was designed prospectively to evaluate a number of aspects of ED asthma care, including relapse. Using a standardized protocol, investigators at 36 EDs in 18 states provided 24 h/d coverage for a median of 2 weeks and enrolled 1,281 patients with acute asthma. All

Results

During the study period, 1,301 patients were discharged from the ED with a diagnosis of asthma; 939 of these patients were evaluated for the study. The patients who were not enrolled did not differ from the study population by either age or gender. A total of 641 patients sent home from the ED had complete follow-up data. These patients, compared with those not contacted by telephone (n = 297), did not differ significantly according to age, asthma medications used in past 4 weeks, number of

Discussion

This study confirms previous findings that a substantial proportion of patients treated in the ED suffer a relapse within days to weeks after ED discharge. Although there is no common definition of an “acceptable” relapse rate, 17% certainly represents a high failure rate. In this study, we have confirmed that easily ascertainable historical features define patients at highest risk. Since the National Asthma Education and Prevention Program guidelines allow for physician discretion in the

MARC Steering Committee

Carlos A. Camargo, Jr., MD, FCCP (Chair); Rita K. Cydulka, MD; Michael A. Gibbs, MD; Robert A. Silverman, MD; and Janice L. Zimmerman, MD, FCCP.

Operations Committee and Data Coordinating Center

Carlos A. Camargo, Jr., MD, FCCP (Chair); George T. Mathew; Leo T. Mayer; Anita K. Singh; and Prescott G. Woodruff, MD—all at Massachusetts General Hospital, Boston, MA.

Principal Investigators at the 36 Participating Sites

C.A. Bethel (Mercy Hospital, Philadelphia, PA); L. Bielory (University Hospital, Newark, NJ); M.P. Blanda (Summa Health System, Akron, OH); B.E. Brenner (Brooklyn Hospital Center,

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  • Cited by (0)

    Drs. Woodruff and Camargo are supported by grants HL-07427 and HL-03533, respectively, from the National Institutes of Health (Bethesda, MD). The Multicenter Asthma Research Collaboration is supported by unrestricted grants from Glaxo-Wellcome Inc (Research Triangle Park, NC) and Monaghan Medical Corporation (Syracuse, NY).

    A complete list of the MARC Investigators is located in Appendix1.

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