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SGEM#142: We Need Asthma Education

SGEM#142: We Need Asthma Education

Podcast Link: SGEM142
Date: January 5th, 2016

Guest Skeptics: Dr. Chris Carpenter is from Washington University, Deputy Editor of Academic Emergency Medicine and faculty member of Emergency Medical Abstracts.

Dr. Brian Rowe is a Professor, Department of Emergency Medicine, at the University of Alberta. He is a Canadian Research Chair in Evidence-Based Emergency Medicine and is also co-editor of the Cochrane Collaboration Airway Review Group.

Dr. Cristina Villa-Roel is a physician with a MSc in Clinical Epidemiology who is nearing the completion of her PhD at the School of Public Health at the University of Alberta. She is interested in improving the quality of life for patients with asthma by coordinating transitions in care between the emergency department and the primary care setting through the delivery of comprehensive and evidence-based care. Her research is supported by the Canadian Institutes for Health Research (CIHR) in partnership with the Knowledge Translation branch.

Case: A 21 year old with asthma since he was five years old and a prior intubation when he was eight presents to your emergency department with wheezing that is improved with two short (5 mg Albuterol) nebulizer treatments + Prednisone. He is eagerly awaiting discharge home when you note that he has had 15 visits to your emergency department for asthma exacerbations over the last 12 months.  You ask him if he is following up with his primary care provider and filling the asthma medication prescriptions that he receives at each emergency department visit. He notes that he has no primary care provider with whom to follow-up, no money to pay for prescriptions, and no transportation to get to either a doctor’s office or the pharmacy. You wonder if anything can be done from the emergency department to keep this patient at home with minimal asthma symptoms for a prolonged period while facing these social and financial barriers.

Dr. Briam Rowe

Dr. Brian Rowe

Background: Asthma is a common presentation to the emergency department. Listen to Dr. Brian Rowe discuss the following:

  • Asthma’s impact on the health care system
  • Asthma’s impact on the individual
  • What happens to most emergency department patients who present with asthma
  • What the guidelines say about post-emergency department discharge
  • Patient education and teachable moments in the emergency department

Clinical Question: Can an educational intervention done in the emergency department prior to discharge improve follow-up with primary care providers in asthma patients?


Dr. Cristina Villa-Roel

Dr. Cristina Villa-Roel

Reference: Villa-Roel et al. Effectiveness of Educational Interventions to Increase Primary Care Follow-Up for Adults Seen in the Emergency Department for Acute Asthma: A Systematic Review and Meta-Analysis. AEM Dec 2016.

  • Population: Original studies of adult patients discharged from the emergency department after treatment for asthma exacerbation.
  • Intervention: Randomized controlled studies (or controlled studies) of any asthma-related educational intervention occurring within one week of the index emergency department visit for asthma. Interventions ranged from post-emergency department phone call reminding patients of follow-up appointment (or arranging follow-up appointment), 5-day course of steroids + transport voucher, fax from emergency department to primary care provider with tailored asthma care recommendations, and/or “asthma action plan” constructed in emergency department with patient prior to discharge.
  • Comparison: All studies evaluated the effectiveness of educational interventions compared to usual care (discharge instructions + medication prescriptions at discretion of the treating emergency physician).
  • Outcome:
    • Primary outcome: Percentage of primary care provider (family physician, general practitioner, general internist, nurse) office follow-up visits.
    • Secondary outcomes: Percentage of unscheduled revisits to the office or emergency department for asthma relapse, hospital admissions, time to first primary care provider office visit, time to first relapse. The authors also attempted to evaluate the fidelity of the reported educational interventions.

Authors Conclusions:  “ED-directed educational interventions targeting either patients or providers increase the chance of having office follow-up visits with PCPs after asthma exacerbations. Their impact on health-related outcomes (e.g., relapse and admissions) remains unclear.

Quality Checklist for Therapeutic Systematic Reviews:

  1. checklistThe clinical question is sensible and answerable. Yes
  2. The search for studies was detailed and exhaustive. Yes
  3. The primary studies were of high methodological quality. No
  4. The assessment of studies were reproducible. Yes
  5. The outcomes were clinically relevant. Unsure
  6. There was low statistical heterogeneity for the primary outcomes. Yes
  7. The treatment effect was large enough and precise enough to be clinically significant. Unsure

Key Results: Five eligible studies totaling 825 patients were identified, all from the U.S. (2) or Canada (3). The risk of bias across studies was qualified as “unclear”, mostly due to the possibility of selective outcome reporting secondary to the lack of registered protocols or full-text publications. The authors were unable to assess the risk of publication bias due to the small number of eligible studies.

Using the Treatment Fidelity Assessment Grid, the authors noted that none of the trials used any behavioral adaptation theory for their educational intervention. In addition, details about the educator training protocols and methods to ensure participant receipt of the educational materials were largely lacking. None of the studies assessed patient compliance with individual recommendations from the educational intervention.

  • Primary Outcome: Post-emergency department primary care provider follow-up was improved compliance with the educational intervention RR=1.6 (95% CI: 1.31-1.87) with minimal statistical heterogeneity (I2 = 0%)

NNT of 6 for one patient to follow-up with their primary care provider after emergency department encounter.


  • Secondary Outcomes: No significant differences were noted between the educational intervention and usual care for
    • asthma relapse (RR 1.3; 95% CI 0.82-1.98),
    • time to asthma relapse (median 45 days in the educational arm vs. 28 days in the usual care arm),
    • time to first primary care provider visit (median 18 days in education arm vs. 16 days in the usual care arm)
    • admission rate (RR 0.51; 95%CI 0.24-1.06)
    • Most studies reported no difference in medication compliance between their comparison groups.

One study reported more patients with a written asthma action plan (46% vs. 25%) and higher quality-of-life scores in the educational arm at 6-months follow-up.

Screen Shot 2015-04-25 at 3.11.12 PMPatient education is the basis for effective and meaningful shared decision making. Unfortunately, emergency department providers manage patients with widely varying levels of health literacy (Carpenter et al, Griffey et al, and McNaughton et al) everyday in chaotic settings with scant access to personnel or resources that enable focused pre-discharge educational efforts.

Nonetheless, enhancing pre-discharge care must be a priority for efficient, patient- centric emergency department operations for medical, psychiatric, surgical, and trauma patients.

Therefore, understanding the effectiveness of pre-discharge interventions in asthma patients provides valuable lessons for researchers, clinicians, and educators across multiple conditions.

This systematic review suggests that a variety of pre- or immediate post-discharge patient-focused interventions improve primary care provider follow-up rates (Disease Oriented Outcomes) without compelling evidence of reduced asthma relapse rates, emergency department returns, or hospital admissions (Patient Oriented Outcomes).

Differentiating these outcomes is important because increasing follow-up rates (NNT = 6) drives up healthcare costs and resource utilization, which should derive improved health via less asthma-related morbidity, but this cause-effect relationship has yet to be established.

five+fingersThere were a number of limitations to this study that we discussed with the authors. Here are five issues and their responses. Listen to the podcast to hear the full responses from Dr. Rowe and Dr. Villa-Roel

  1. Labor Intensive: The studies used non-clinical personnel to perform the educational intervention (trained research assistants, study coordinators, or research nurses). Using resources that are not widely available in most EDs limits the external validity of research findings so more pragmatic research designs will be needed in the future.
    • Author’s Response: That is an excellent point. Emergency physicians and most nurses likely don’t have the time (nor the training) to accomplish this. Ideally, the use of clinical resources available in the emergency department (e.g., specialized nurses, respiratory therapists) or health professional liaisons in transitions of care (e.g., asthma educators, pharmacists, nurse practitioners) should be guided by the needs of patients and local primary care providers.
  2. Theoretical framework: None of the studies reported a theoretical framework for the educational intervention. Adapting behavior is complex and implementation science mandates use of an established framework to guide these interventions.
    • Author’s Response: That is correct. The unclear theoretical foundation of many educational trials in asthma has been strongly criticized; difficulties in replication and limited applicability may be associated with this issue.
      • In addition, implementation science frameworks indicate the need to contemplate, measure, and report cultural capacity for change, essential stakeholders and opinion leaders, intervention adaptability, and sustainability, none of which was evaluable in this systematic review.
    • Author’s Response: That is also correct and it is unfortunate that we couldn’t summarize these elements in our article. Clearly, these steps should be performed before implementation; however, in their defense the authors may have completed this work prior to starting the trial and just not reported it. The identification of potential facilitators/barriers for implementation contributes to incorporating evidence into practice particularly when aiming an improvement of self-care and professional practices.
  3. Fidelity of the Intervention: None of the studies reported fidelity of the intervention. What I mean by that is the vigor, timing, engagement and clarity of the asthma education. There was not enough detail to differential which interventions were effective vs. ineffective.
    • Author’s Response: In our article, we made considerable efforts to describe the fidelity of the interventions; however, we failed to identify detailed fidelity information. Consequently, we called for standardized description and evaluation of the proposed interventions in future reports. Analyses focused on one or more of the fidelity domains could reveal important changes in effect sizes.
  4. Health Literacy: The NNT was 6 for the intervention but none of the studies reported whether patients understood or followed the ED educational recommendations. Nor did they assess what happened during the PCP office follow-up visit. Better understanding these events will be essential to establishing a cause-effect relationship between ED education efforts and patient-oriented outcomes.
    • Author’s Response: The issue of literacy needs to be determined BEFORE the intervention is implemented and was not reported in these trials. We are similarly concerned that simply being seen by a PCP is as effective as seeing a PCP with and interest and training in asthma education. The effectiveness of the intervention does depend to some degree on the skills and resources available to PCPs at the time of the follow-up.
  5. Texting: What about using technology for the asthma education and encourage follow-up? You could text asthma information while at the same time reminding patients of their primary care provider follow-up.
    • Author’s Response: Texting has been shown to be an effective delivery method for educational interventions; however, you need to consider your “target population” and the purpose of your intervention. We have learned lots from engaging patients and knowledge users (PCPs) in our research initiatives in asthma and from exploring their perceived needs and expectations. In our research, patients appear to prefer having one-on-one discussions, and text was not a preferred method. We concur; however, this is an area, which deserves more focused attention.

Comment on authors conclusion compared to SGEM Conclusion: A variety of emergency department educational interventions appear to improve primary care provider follow-up rates, but which interventions applied to which patients in what settings remain nebulous. The external validity of these findings in emergency departments without dedicated research personnel is unknown, as is the link between asthma education and asthma-related morbidity in the months following an asthma exacerbation episode of care.


SGEM Bottom Line: Educating asthma patients about warning signs, acute medical management, follow-up recommendations, and indications to return to the emergency department for re-evaluation are important components of quality emergency care. Available studies indicate that a variety of pre- or immediate post-discharge efforts by research personnel improve primary care provider follow-up rates, but whether these efforts reduce short-term asthma-related morbidity (relapsing symptoms, emergency department returns, hospitalization) remains unproven.


 Case Resolution: You explain the diagnosis, prescriptions, symptoms to monitor/return to emergency department for, and rationale for engaged primary care team with the patient – and then ask him to explain these elements of his asthma care back to you. Next, the emergency department Social Worker is able to provide the patient with a new inhaler and 4 day course of steroids plus a cab voucher for his follow-up appointment, which the emergency department Case Manager has scheduled with the Medicine clinic. You discharge the patient hoping that his next emergency department visit is many months to years away, and perhaps unrelated to his asthma.

Clinically Application: Working with my nurse educator, our emergency department develops a nurse-led asthma discharge education protocol that includes teach-back understanding of asthma care received in the emergency department, prescriptions provided, indications for each prescription, available primary care provider, and access to transportation for both prescriptions and primary care provider office follow-up.

What do I tell my patient? Asthma is a common lung disease. An asthma attack can happen throughout your life. Sometimes we are able to find what triggered the attack (cold, weather changes, medication changes, exposure to smoke or chemicals), but often we cannot. If you understand your asthma better you can have less attacks, which could be less severe. This can mean fewer trips to the emergency department, better quality of life, less sick days lost from work and even prevent you from being admitted to hospital. Our asthma nurse is going to talk with you about:

  1. What would mean your asthma is getting worse
  2. How to treat your asthma if it is getting worse
  3. What treatments you received in the emergency department today
  4. When you should follow-up with your primary care provider?
  5. What situations you should return immediately to the emergency department?

Keener Kontest: Last week’s winner was David Hedman. David knew British sailors were called “limey” because of the lime juice added to their watered-down rum to prevent scurvy.

Listen to the podcast to hear this weeks’ question. Send your answer to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will win the cool skeptical prize.


Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.


Conferences:

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  • Salim R. Rezaie

    Hey Ken….great podcast as always and even more important topic…Hope my summary slide did the post some justice. 🙂

    Salim

    • TheSGem

      Thank you Salim as always for helping to cut the knowledge translation window down from over 10 years to less than 1 year.

  • Chris Rueda-Clausen

    Great podcast, Love the PinkFloyd Touch!!!. Interesting that the most primitive and fundamental of all interventions in health care (EDUCATION) has been neglected so badly and for so long. Glad to hear that standardized methods to assess and implement educative strategies are being implemented and tested in this field. Great perspective as a model to be implemented in many other high cost high recurrence chronic diseases.
    Chris

    • Cristina Villa-Roel

      Chris, Thanks for your positive comments! I agree, this is a critical area that needs more attention. We have learnt lots from this review. I am positive that we will be able to report in a more detailed and standardized way the results of an educational trial that our group has been working on over the last few years. Looking forward to see how our results contribute to this evidence synthesis!
      Cristina

  • Ali Martha

    Hi, interesting article, wondering if you have any comments about the communication barriers for education, language in particular… how do you know that the patient is understanding the content and the information that is delivered?
    Regards
    Ali.

    • SAEM EBM IG

      Ali: Excellent points! I’ll be interested to hear the authors’ response to these queries, too. Our research has demonstrated that low health literacy is a significant issue in the urban ED (http://pmid.us/24673669 and http://pmid.us/24673670). “Teach Back”, which is one method of ensuring patient comprehension real-time, is not completely effective in ED settings (http://pmid.us/26617669), so it will be important for future asthma patient education researchers to include health literacy and some assessment of comprehension (and probably knowledge retention through the course of the asthma exacerbation) in weighing the value of ED discharge asthma education efforts. Chris Carpenter

    • Cristina Villa-Roel

      Hi Ali, those are key factors that may influence the results of studies such the ones included in our systematic review. We are not aware that there was a baseline evaluation of health literacy in the included trials. Ideally, this should be done before testing interventions so that the results can be adjusted by the potential differences in this factor.

  • Melissa Xuan

    I am a pharmacy student
    we do a lot of education in asthmatic patients. feel like our interventions in education has not been appreciated or even considered in most studies. I believe that our work teaching people how to deal with dear diseases can be very important in improving outcomes. Great job
    C

    • SAEM EBM IG

      Melissa: Interesting — thanks for sharing! At our ED I’m unaware if our Pharmacists doing any asthma patient education, but now I’ll check. What sort of education do your Pharmacists do for ED asthma patients and when are the Pharmacists available? Are the Pharmacists engaged on all discharged asthma patients or based upon some trigger? Are there published studies from the world of Pharmacy that highlight the value of the Pharmacists’ role in educating ED asthma patients? I wonder how many ED’s have access to Pharmacists to perform pre-discharge asthma education? Chris Carpenter

    • Cristina Villa-Roel

      Thanks Melissa for sharing your thoughts! In our aim to improve our research designs we have considered patients and physicians perceptions about the ideal content and delivery methods of educational interventions in acute asthma. Both have recognized the importance of health professional liaisons (e.g., asthma educators, respiratory therapists, pharmacists) which I think is VERY valuable and informative. However, our survey participants seem to prefer having this education after their ED visit (manuscript in progress). Will have a look at the literature to see if there is evidence supporting this specific role for pharmacists.

  • Alex Ferreira

    Emergency Doctors never have time, they don’t event talk to you.
    but nurses are awesome! Any videos or resources in the internet that you recommend to educate patients with Asthma. Any resources in Portuguese?
    Thanks.

    • Cristina Villa-Roel

      Alex, thanks for your comment! The potential role of nurses and other health professionals such as respiratory therapists and pharmacists (specially those with training/special interest in asthma) is enormous and not only in the busy ED setting. Their monitoring, education and support after the ED visit may have an important impact on health-realated outcomes and on the quality of life of patients with asthma. Will consult the asthma educator of our group (who happens to be a nurse!) to see if there are any resources we can recommend.

  • This is one of the topics that is really important but is often overlooked (and will probably never receive big grant funding to investigate!)

    Education is difficult – both of HCPs and Patients. I have argued that the interface and interaction with education (http://www.jeehp.org/DOIx.php?id=10.3352/jeehp.2015.12.35) is important but rarely part of an evaluative framework. What I mean is the reasons you choose to access (interface) with education are very important to your engagement with it. Many attending EDs won’t be expecting to ‘learn’ something and may not be keen to engage with anything but treatment. Or the converse may be true – the patient may be desperate to stop re-presentation. Either way their interpretation of the education is affected (?biased) by this. Secondly the interaction with education is important. The means of delivery is of relevance (http://bmjopen.bmj.com/content/5/12/e008280.abstract) and yet it is difficult to control this is a single study

    Ultimately the ED visit is only a short moment in a patients health care journey. It is sad that in the same way we consider a patient journey for treatment (from primary to secondary and sometimes tertiary care) we do not do the same for health education and promotion i.e. we rarely link with our community or hospital colleagues to provide unified and consistent information.

    All the best – nice paper and nice review 🙂

    • Cristina Villa-Roel

      Thanks Damian-all good and realistic points. We did actually get funding from the Canadian Institutes for Health research (CIHR) to assess the effectiveness of ED-directed interventions in acute asthma. This systematic review was one of the projects that helped us identifying the gaps that we could potentially address in our trial. We are currently finishing data collection and are looking forward to analyzing/disseminating the results.

      • Great work on getting the grant and really look forward to the outcome your study!

  • Lauren Westafer

    This is an excellent reminder that discharge instructions are really a “procedure” as the process theoretically involves everything from having a mental script, to discussing risks/benefits with patients, to eating up time in the Emergency Department. I can see that many other conditions could benefit from standardized processes like this one, the unfortunate reality is that even our nurses, RTs, residents are taxed for time based on the huge number of patients (and even a cab voucher would be a dream at our shop). Definitely seems worth a systemic overhaul.

    • Cristina Villa-Roel

      I agree Lauren! Only by standardizing the components and delivery methods of non-pharmacological interventions (in asthma and other conditions), we will be able to compare their effectiveness. A critical step before the implementation of evidence-based interventions!

  • SAEM EBM IG

    I spoke with one of the pharmacists who specializes in emergency department pharmacy today and learned something interesting.

    “We have regulatory barriers in Missouri that preclude ‘To Go’ medications. It is my understanding (interpretation passed along to me) that non-pharmacy dispensing from the ED should not occur. If you have a discharge/retail pharmacy that could dispense/label at discharge then it could be feasible. Key stakeholders have noticed (no great data, just observed in some cases) scenarios where patients will
    latch onto processes like this and then abandon any interest in engaging in primary care utilization.”

    How would Drs. Villa-Roel and Rowe recommend overcoming these regulatory barriers and perceptions of misuse of ED “To Go” medications that may improve patient compliance and thereby reduce asthma morbidity and recurrence?

    Any ideas from Melissa or others to overcome these obstacles from a Pharmacists’ perspective?

    Chris

  • Laura Andrea Rodríguez Villami

    Congratulations! I really love the topic and the discussion derived from your paper! Education is increasingly taking a central role in health-related interventions but its importance, successful characteristics, quality, and effectiveness are barely studied. That’s the case with asthma. Despite being one the most common chronic respiratory disease worldwide, the paper evidenced the few number of controlled trials addressing education interventions. I’m wondering about the quality of the denominated “educational interventions”. I know the paper examined the adherence to the proposed intervention but, beyond the adherence, I’m wondering about the quality itself.. delivery (including language and communication as Ali Martha said), frequency, personnel training, etc. Do you know any study addressing quality of the educational interventions and its impact on the intervention results?
    Thanks, great work!.
    Laura

    • Cristina Villa-Roel

      Thanks Laura for your comments! We made an attempt to describe the Fidelity of the educational interventions tested in the individual studies. Treatment Fidelity refers to the methodological strategies used to monitor the reliability and validity of behavioural interventions. As we have discussed in this blog, the description of the components that were evaluated in the individual studies (theory congruence, provider training, treatment implementation, receipt and enactment) was very poor; that limited our analyses and discussion. Some of the authors of this paper have attempted to evaluate the impact of these components on effect estimates: (Ospina MB, Villa-Roel C, Rowe BH. Reporting of
      intervention fidelity in systematic reviews of asthma education. 23rd Cochrane
      Colloquium. Vienna (Austria) [Oct 3 – 7, 2015].)

  • DGM

    Really enjoying your podcasts 🙂

    Minor point:

    Dr Rowe said that asthma is about twice as common in children as adults – the stats don’t bare this out.

    In the US around 1 in 10 children have asthma and 1 in 12 adults have asthma. (http://www.cdc.gov/vitalsigns/asthma/

    Similarly, in the UK around 1 in 11 children have asthma and 1 in 12 adults have asthma.(https://www.asthma.org.uk/about/media/facts-and-statistics/)

    Is this a common misconception, or have I misunderstood the statistics?

    • Brian Rowe

      The question is an important one because estimates vary widely and are almost always associated with warnings that the numbers/percentages should be used with caution. In Canada, that is the approximate proportion. For example, 15.6% of children
      ages 4-11 been diagnosed with asthma, 11.7% of adolescents ages 12-19 have been diagnosed with asthma and ~8% of adults have been diagnosed with asthma.

      It really depends on the definition used (e.g., MD diagnosis, survey, etc), the country/region, culture (higher in some African American populations in USA than Caucasians), poverty and the age breakdowns. Overall, it’s safe to say the prevalence of asthma is
      high as a chronic disease and higher in children than adults. Readers should obtain local data and use that when applying the results to their populations.

  • Joe Benedict

    Thank you, SGEM, for covering an important topic in improving care of patients presenting to the Emergency Department with asthma exacerbation.

    Providing patient-centered and effective discharge counseling is a challenge for all Emergency Departments for many of the reasons mentioned in this podcast, covered in the literature, and experienced by practitioners every day.

    Leveraging technology can help to overcome some of these barriers and challenges. For example, caregivers for pediatric patients presenting to the ED for common complaints, including asthma, reported increased knowledge and satisfaction with their discharge information if provided with video instruction along with printed materials (Bloch et. Al. Ped Em Care. June, 2013).

    Many institutions, such as my own, have available technology in the form of video interpretive devices that could be co-opted to provide video discharge instructions relatively easy. Overall, video modules could be an effective intervention to provide meaningful discharge counseling for patients with asthma and many other conditions.

    • Cristina Villa-Roel

      Since our paper summarized the evidence behind Emergency Department (ED)-directed interventions targeting either adult patients or providers, we cannot comment on pediatric educational
      interventions. Moreover, the study focused on their effectiveness in
      increasing primary care provider follow-up visits after asthma exacerbations. None of the included studies evaluated technology or devices (e.g., in the form of videos, applications, games) as delivery methods for the proposed educational interventions. Interestingly, in our engagement activities with adult patients who have visited the ED for asthma exacerbations, value has been given to “one-on-one” interactions with health care providers for activities like guidance on the proper use of spacer devices. Rigorous evaluations need to be conducted in order to clarify the effectiveness of technology delivery methods for asthma education in adults who visit the ED for acute asthma.

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