Asthma is a disease entity that all emergency department (ED) providers are expected to be able to manage both quickly and effectively. This is especially true in the pediatric population, where asthma is both the most common chronic disease of childhood and a leading reason for children to present to the ED.
In addition to mainstay therapies like beta-agonist inhalers and systemic steroids, the National Asthma Education and Prevention Program Guidelines also recommend that ED physicians “consider” initiating controller therapies like inhaled corticosteroids (ICS) at discharge. The thought process being that initiating these controller medications in the ED may decrease relapse rates, improve outcomes, and can be continued long-term by primary providers. Despite this, prescription of inhaled corticosteroids in the ED remain low.
Would prescribing such controller medications lead to an increased likelihood of continued use in the future?
In the pediatric population, is prescription of an inhaled corticosteroid at ED discharge, following a visit for asthma, associated with an increased rate of continued use of an inhaled corticosteroid as an outpatient?
Patients aged 1-18 years with persistent asthma defined as greater than 2 previous wheezing episodes treated with b-agonists; persistent symptoms as defined by the Pediatric Asthma Control Tool; plan for ED discharge; and an identified primary care provider for follow-up. Conducted at an urban academic children’s hospital ED.
Intervention subjects received a 1-month prescription for an inhaled corticosteroid (fluticasone or budesonide by age) in addition to standard asthma therapy and instructions given to all patients
Received standardized asthma education, an asthma action plan, and recommendation for primary care provider follow-up within 5 days
Primary: Occurrence of a patient filling a subsequent prescription for inhaled corticosteroid from their primary care provider
Secondary: Occurrence of asthma symptoms and measures of functional disability, asthma-related quality of life, and follow-up with a primary care provider
Single-center Randomized, Non-blinded, Controlled Trial
Inpatient or observation admission; previous ICU admission for asthma; contraindications to beta-agonists or systemic or inhaled steroids; comorbid chronic lung, sickle cell, heart disease, or immunodeficiency; lack of English-speaking guardian or a telephone for follow-up; and previous enrollment
- 147 patients randomized to the 2 treatment groups
- Intervention (prescribed ICS in ED), n = 71
- Control (No ICS prescription), n = 76
- Study was powered to demonstrate a proportion difference of 0.25 between control and intervention groups. With power set to 80%, a total sample size of 132 was needed.
- Primary endpoint: Had a PCP ICS prescription filled
- Overall: 19.0% (28/147)
- Intervention = 21.1% vs Control = 17.1%
- Absolute difference 4% (relative rate = 1.24; 95% CI 0.63 to 2.41)
- No statistically significant difference
- *53.5% of intervention group filled their ED ICS prescription
- Secondary Endpoint: Asthma symptoms, quality of life, follow-up
- 2 fewer days of daytime SOB and nighttime cough in intervention group @ 2 weeks
- No difference between groups in rate of PCP follow-up, functional limitations or quality of life
- First randomized controlled trial in children examining short-term outcomes after controller medication initiation during ED Asthma visit.
- Clinically relevant outcomes
- Randomization performed well
- Single urban center – may not be generalizable
- 30 % loss to follow up by telephone @ 8 weeks
- No blinding to patients or physicians
- Possibility patients received follow up prescriptions other than from PCP
“There was no difference in the proportion of patients who filled a primary care provider prescription after ED initiation of an inhaled corticosteroid. The intervention was associated with reduced reported symptoms but did not affect other asthma outcomes or primary care provider follow-up.”
Prescribing inhaled corticosteroids in the ED did not correlate with increased proportion of patients who filled PCP prescriptions. While reported symptoms were reduced, the unblinded nature of the intervention may have influenced this outcome.
Potential Impact To Current Practice
This study does not impact current practice. The choice to initiate inhaled corticosteroids in pediatric population remains up to the discretion of the ED provider.
ED prescription of ICS alone did not increase primary care provider prescription of an ICS. Further research may be directed at morbidity/mortality benefits, repeat ED presentations or other short-term effects on symptoms of ICS initiation in the ED.