Impact of Emergency Department Asthma
Management Strategies on Return Visits in
Children: A Population Based Study
Astrid Guttmann1,2,3,4 Brandon Zagorski1 Michael Schull1,4,5 Asma
Razzaq1 Geoff Anderson1,4
1
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario
3 Department of Paediatrics, Faculty of Medicine, University of Toronto
4 Department of Health Policy, Management and Evaluation, University of Toronto
5 Department of Emergency Medicine, University of Toronto
2 Division
Enhancing the effectiveness of health care
for Ontarians through research
Disclosures
• Research funded by the Ontario
•
•
Hospital Report Research
Collaborative
Salary Support for Dr.’s Austin and
Guttmann from the Canadian
Institute for Health Research
No conflicts to declare
Background
• Emergency Departments (EDs) play
•
an
important role in the care of children with
asthma
Steady rise in ED visits for asthma

>750,000 visits in US (2004)
• Many guidelines for overall management
•
of acute exacerbations
? Best strategies for implementing
guideline care
Research Objectives
1) Describe the current asthma
management strategies for children
employed by EDs in the province of
Ontario
2) Test which strategies have an
impact on 72 hour return visits in
children -- performance measure
Methods
• Population-based cohort study
Comprehensive administrative heath
and survey data from all 152 EDs in
Ontario, Canada
 Cohort: all children ages 2 - 17 years
who had a visit to an ED for asthma
(April 2003 to March 2005)
 Outcome: Unplanned return visit within
72 hours

ED Resources and Asthma
Management Strategies
• ED Survey









Training of frontline staff
Pediatrician for consultation
Short stay unit
Guidelines
Preprinted, standardized order sheet
Discharge instructions
Trained personnel in asthma education
Routine PFTs
Dispense aerochambers
Analysis
• Clustered logistic regression model (GEE)
controlling for


patient factors
• age, gender, SES, triage score, history of admission
hospital factors
• propensity to admit, type (academic, large and small
community), volume of asthma patients (all ages)

Subgroup Analyses
• Training of frontline staff
• PFTs
Results
• 32, 996 children with at least one visit for
•
•
•
asthma in the 2 year study period
Academic and large community hospitals
tended to see younger and sicker children
Overall return visit rate 5.6% (7.1% in the
small community hospitals)
Subsequent admission rate of 16.6% in
those returning
Distribution of Emergency Department Strategies
and Resources by Hospital Type *
Hospital Type
Number of
Strategies
Academic
(N=12)
Large
Community
(N=70)
Small
Community
(N=70)
All
(N=152)
0
3 (4.3)
1 (1.4)
4 (2.6)
Up to 2
Strategies
4 (33.3)
8 (11)
23 (32.9)
35 (23)
3-4 Strategies
4 (33.3)
32 (46)
33 (47.1)
69 (45.4)
5 or more
Strategies
4 (33.3)
27 (39)
23 (18.6)
44 (28.9)
None
* 100% response rate
Adjusted Odds Ratios of Return Visits by Hospital
Strategy/Resources
Hospital Strategy/Resources
Odds Ratio
(95%CI)
p Value
Short stay unit
1.17 (0.99, 1.38)
0.06
Access to a Pediatrician
0.64 (0.52, 0.79)
<0.001
Pre-printed discharge instructions
0.99 (0.83, 1.19)
0.95
Pre-printed order sheets
0.68 (0.55, 0.85)
< 0.001
Routine use of peak flow testing
0.93 (0.79, 1.10)
0.40
Trained personnel in asthma
teaching
0.96(0.78,1.18)
0.68
Ability to dispense aerochambers
0.87 (0.70, 1.08)
0.21
Availability of asthma guidelines
0.96 (0.80, 1.16)
0.70
Return Visit Rate by Number of
Effective Strategies* Used
Strategies
Hospitals with the
Number of Key
Strategies (N=152)
Return Visit
Rate (%)
No.(%)
Neither
95(63)
6.9
Pediatrician for
Consultation only
31(20)
5.4**
Order Sheet Only
9(6)
5.4***
17(11)
4.4**
Both
*Access to pediatricians, pre-printed order sheets
** p<0.001 ***p<0.05
Main Findings
• 2 Strategies associated with reduced
recidivism
Preprinted, standardized order pathway
 Access to pediatricians

• No difference between EDs with pediatrician
as frontline physicians vs those available
for consults
Mechanism of effect of strategies
• Standardized order sheets
Dosing of appropriate medications
 Assessment criteria
 Follow up plans

• Access to pediatrician for
consultation

?guideline care, more time for
teaching/counselling?
Limitations
• No verification of survey data
• Did not account for follow up
• Testing different constructs
•

Order sheets, discharge instructions
Ecologic exposures

Pediatrician, PFT’s
Strengths and Conclusions
• Complete response rate
• Population-based sample of children
•
across different settings/providers
Effectiveness of interventions
• Pre-printed/standardized order sheet
Feasible, inexpensive
 Currently only used by minority of EDs
