SGEM#142: We Need Asthma Education

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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. 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

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.

Author’s 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:

The clinical question is sensible and answerable. Yes
The search for studies was detailed and exhaustive. Yes
The primary studies were of high methodological quality. No
The assessment of studies were reproducible. Yes
The outcomes were clinically relevant. Unsure
There was low statistical heterogeneity for the primary outcomes. Yes
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.

Patient 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.

There 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

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.
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.
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.
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.
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 author’s 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:

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