Program

Feb 24, 2010

OVERVIEW

This brief
Emergency Department-based intervention is designed to assist families of
children with asthma to better manage their child’s asthma. Two variations of
the program have been developed and evaluated. In one program, study staff
assisted families in scheduling a follow-up appointment with a primary care
physician while still in the emergency department. In the modified program,
study staff presented families, while still in the emergency department, with a
brief video discussing asthma and asthma management and sent reminder postcards
to schedule a follow-up appointment with a primary care physician. In an
evaluation of the first version of the program, patients in the treatment group
were more likely to have a follow-up physician visit; but no impacts were found
on return visits to the emergency department for asthma or using a daily asthma
controller medication. In an evaluation of the modified program, there were no
impacts on following-up with a primary care physician, asthma symptoms, asthma
quality of life, and subsequent asthma-related emergency department visits or
hospitalizations.

DESCRIPTION OF PROGRAM

Target population: Children with asthma residing in the inner-city.

This brief
emergency department-based intervention is designed to assist families of
children with asthma in scheduling a follow-up appointment with a primary care
provider prior to their discharge from the emergency department. Study staff are
stationed in the emergency department between 8 AM and 12 midnight, seven days a
week. Together with the parent/guardian, study staff attempt to call a primary
care physician to schedule an asthma follow-up appointment for the family. If
unable to schedule an appointment prior to discharge from the emergency
department, study staff offer to continue attempting to schedule a follow-up
appointment or, if parents are available during the daytime, study staff setup a
conference call so that staff and parents can, together, attempt to schedule an
asthma follow-up appointment with a primary care physician. In addition, when an
appointment is made, study staff fax copies of emergency department medical
records to the primary care physician for the follow-up visit.

Based on an
evaluation of this program (Zorc et al,, 2003), adjustments were made (Zorc et
al,, 2009), which now focus more on addressing beliefs and barriers to receiving
asthma follow-up care rather than scheduling a follow-up appointment with a
primary care physician. In the modified program, three components are included.
While in the emergency department, a brief video is shown to families depicting
other families with children with well-controlled asthma discussing beliefs and
misconceptions about asthma and asthma follow-up care (such as, “What is
asthma?”; “How can asthma be controlled?”; and, “What are the benefits of
controlling asthma?”). A reminder postcard is mailed to families to schedule a
follow-up appointment with a primary care physician and discuss ways to control
asthma. Also, if children are screened to have “persistent” asthma, families are
mailed these results.

EVALUATION(S) OF PROGRAM

Zorc JJ,
Scarfone RJ, Li Y, Hong T, Harmelin M, Grunstein L, Andre JB. (2003). Scheduled
Follow-up After a Pediatric Emergency Department Visit for Asthma: A Randomized
Trial. Pediatrics, 111(3):495-502.

Evaluated
population:
A total of 278 children between 2 and 18 years of age were
enrolled in the study. The average age was approximately eight years. Among
study participants, 62% were male, 94% were black, 62% were insured through
Medical Assistance, 55% had two or more emergency department
visits/hospitalizations for asthma-related problems within the past year, and
70% had baseline “persistent” asthma symptoms.

Approach:
Families were enrolled in the study while still in the emergency department.
Children were approached for the study if they met the following criteria: 2-18
years of age; family resides within Philadelphia, PA; two or more previous
medical visits for asthma in which bronchodilators were prescribed; acute
respiratory symptoms requiring emergency department treatment with
bronchodilators; child not admitted to the hospital for further treatment or
observation; and the family had a telephone and an English speaker in the home.
Children were randomly assigned to the intervention group (n=139) or the control
group (n=139). Control group participants were given standard discharge
instructions to follow-up with their primary care physician within three to five
days after the emergency department visit.

Participants were
assessed on demographic characteristics and asthma history and treatment.
Between four and six weeks after the emergency department visit, a telephone
interview was conducted with study participants, using a validated survey
instrument. Families were assessed on the participant’s symptoms since the
emergency department visit, date of follow-up, interventions that had taken
place, and, if applicable, reason(s) for no primary care physician follow-up.
Copies of medical records for each visit were reviewed, where possible, to
confirm information collected during telephone interviews.

Results:
Four weeks after the emergency department visit, participants in the
intervention group were significantly more likely to report a return to baseline
health and seeing a primary care physician compared with the control group.
There were no significant differences between the two study groups on a return
visit to the emergency department, missing school, parents/guardians missing
work, and using a daily controller medication.

An analysis of a
subset of intervention (n=68) and control (n=67) participants for subsequent
primary care physician visits and asthma-related emergency department visits and
hospitalizations one year after the intervention found no significant
differences in the number of primary care physician visits and asthma-related
emergency department visits. However, the intervention group was significantly
more likely than the control group to have an asthma-related hospitalization one
year after the emergency department-based intervention.

The authors note
study staff expressed difficulty in scheduling appointments for families while
in the emergency department, especially after physician office hours.

Zorc JJ, Chew A,
Allen JL, Shaw K. (2009). Beliefs and Barriers to Follow-up After an Emergency
Department Asthma Visit: A Randomized Trial. Pediatrics, 124(4):
1135-1142.

Evaluated
population:
A total of 433 children between 1 and 18 years of age were
enrolled in the study, with a mean age of seven years. The majority of study
participants were male (62%), approximately 94% were black, and more than
two-thirds were insured through Medical Assistance. In addition, 50% of study
participants had baseline “persistent” asthma symptoms.

Approach:
Families were enrolled in the study while still in the emergency department. The
same inclusion criteria were used for this study as in the Zorc et al. (2003)
study, except children could be between 1 and 18 years of age. Children were
randomly assigned to the intervention group (n=217) or the control group
(n=216). Control group participants were given standard discharge instructions
to follow-up with their primary care physician within three to five days after
the emergency department visit.

Parents/guardians
were assessed on the benefits and barriers to follow-up care prior to leaving
the emergency department. In addition, parents/guardians were contacted, via
telephone, at one, three, and six months after the emergency department visit to
assess: child’s symptoms since emergency department visit, date of follow-up
care, subsequent asthma-related emergency department visits, interventions that
had taken place, and asthma quality of life. Copies of medical records for each
visit were reviewed, where possible, to confirm information collected during
telephone interviews.

Results: At
follow-up assessments, there were no differences between the two study groups
for following-up with a primary care physician, asthma symptoms, asthma quality
of life, and subsequent asthma-related emergency department visits and
hospitalization.

At the end of the
emergency department visit, intervention families expressed more positive
beliefs, compared with those in the control group, about whether children who
regularly visit their primary care physician have fewer emergency department
visits, miss fewer days of school, or have fewer asthma symptoms. However, these
findings did not remain at the three-month follow-up period.

SOURCES FOR MORE INFORMATION

References:

Zorc JJ, Chew A,
Allen JL, Shaw K. (2009). Beliefs and Barriers to Follow-up After an Emergency
Department Asthma Visit: A Randomized Trial. Pediatrics, 124(4):
1135-1142.

Zorc JJ, Scarfone
RJ, Li Y, Hong T, Harmelin M, Grunstein L, Andre JB. (2003). Scheduled Follow-up
After a Pediatric Emergency Department Visit for Asthma: A Randomized Trial. Pediatrics, 111(3):495-502.

KEYWORDS: Children
(3-11), Urban, Black/African-American, Parent Training/Education, Health
Status/Conditions, Attendance, Clinic/Provider-Based.

Program information last updated on 2/24/10.