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Scheduled follow-up after a pediatric emergency department visit for asthma: a randomized trial
Joseph J Zorc1, Richard J Scarfone, Yuelin Li
1Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pennsylvania School of Medicine and the Children's Hospital of Philadelphia, PA 19104-4399, USA. zorc@email.chop.edu
Insights
Scheduling primary care provider appointments during emergency department visits improved follow-up rates for urban children with asthma. However, most appointments couldn't be made in the ED, indicating a need for better emergency department to primary care linkage.
Area of Science:
- Pediatric Emergency Medicine
- Public Health
- Asthma Management
Background:
- Primary care provider (PCP) follow-up is crucial after emergency department (ED) visits for pediatric asthma.
- Previous studies show low PCP follow-up rates among urban children with asthma.
- Effective strategies are needed to improve continuity of care and asthma management.
Purpose of the Study:
- To determine if scheduling PCP appointments during ED visits improves follow-up rates for urban children with asthma.
- To assess the intervention's impact on short-term health outcomes.
- To evaluate the effect on controller medication use.
Main Methods:
- A randomized trial involving children (2-18 years) treated for acute asthma in an urban children's hospital ED.
- Intervention group received assistance scheduling PCP appointments during the ED visit or via phone.
- Outcomes included PCP visits, asthma morbidity, and controller medication use at 4 weeks post-ED visit.
Main Results:
- Intervention subjects were more likely to follow up with their PCP (64% vs. 46%) compared to controls.
- The median time to the next PCP visit was significantly shorter for the intervention group (13 vs. 54 days).
- No significant differences were observed in return ED visits, missed school/work, or controller medication use between groups.
Conclusions:
- Scheduling PCP appointments during ED visits enhances follow-up for urban children with asthma.
- Directly scheduling appointments in the ED was successful for only a minority of patients.
- Additional interventions are necessary to strengthen the link between ED care and primary care for pediatric asthma.
Objectives:
Follow-up with a primary care provider (PCP) is recommended after an emergency department (ED) visit for asthma to assess clinical status and develop a management plan to improve future care. However, previous ED-based studies of urban children with asthma have reported low follow-up rates. The objective of this study was to determine whether scheduling an appointment at the time of an ED visit improves PCP follow-up for urban children. A secondary goal was to assess the effect of this intervention on short-term health outcomes and the use of recommended preventive controller medications.
Methods:
This randomized trial enrolled a convenience sample of children who were 2 to 18 years old and discharged after treatment for acute asthma in an urban children's hospital ED. Both intervention and control subjects were instructed to follow up with their PCP within 3 to 5 days. Study staff assisted intervention subjects to call their PCP from the ED and schedule an appointment. When follow-up could not be scheduled, assistance continued after ED discharge by telephone until an appointment date was confirmed. Study outcomes included PCP visits, asthma-related morbidity, and daily use of preventive medication 4 weeks after the ED visit. Outcomes were assessed by telephone interview and confirmed by PCP record review.
Results:
A total of 278 eligible subjects were enrolled over 8 months; intervention and control groups were similar by demographic variables and PCP type as well as by asthma history, symptoms, and previous medication use. Only 38% of subjects reported using a daily controller medication, although 70% described persistent asthma symptoms for which these are recommended. For the intervention group, follow-up appointments were successfully obtained during the ED visit for 24% of subjects; when unsuccessful, a median of 3 telephone calls (range: 1-14) were needed to confirm that an appointment had been scheduled. During the 4 weeks after the ED visit, intervention subjects were more likely than controls to follow up with their PCP (64% vs 46%; relative probability for follow-up: 1.4; 95% confidence interval: 1.1-1.7). Study groups did not differ in return ED visits, missed school or work, or the percentage reporting daily use of a controller medication (58% vs 54%) 4 weeks after the ED visit. The median time to the next PCP visit was shorter among intervention subjects (13 vs 54 days).
Conclusions:
Scheduling an appointment after an ED visit increased the likelihood that urban children with asthma would follow up with a PCP. An appointment could not be obtained during the ED visit for most children. Other interventions are needed to improve linkage between ED and primary care for asthma and to improve the use of controller medications.